School refusal

Question 1

epidemiology

Answer 1

Approximately 1 to 5% of all school-aged children have school refusal. The rate is similar between boys and

girls. Although school refusal occurs at all ages, it is more common in children five, six, 10, and 11 years of
age. No socioeconomic differences have been noted.

Question 2

clinical features

Answer 2

The onset of school refusal symptoms usually is gradual. Symptoms may begin after a holiday or illness.
Some children have trouble going back to school after weekends or vacations. Stressful events at home or
school or with peers may cause school refusal. Some children leave home in the morning and develop
difficulties as they get closer to school, then are unable to proceed. Other children refuse to make any effort
to go to school.
Presenting symptoms include fearfulness, panic symptoms, crying episodes, temper tantrums, threats of
self-harm, and somatic symptoms that present in the morning and improve if the child is allowed to stay
home. The longer the child stays out of school, the more difficult it is to return.
Short-term sequelae include poor academic performance, family difficulties, and problems with peer
relationships. Long-term consequences may include academic underachievement, employment difficulties,
and increased risk for psychiatric illness.

Question 3

Psychiatric comorbidities

Answer 3

School refusal is not a formal psychiatric diagnosis. However, children with school refusal may suffer from
significant emotional distress, especially anxiety and depression. Children with school refusal usually present
with anxiety symptoms, and adolescents have symptoms associated with anxiety and mood disorders. The
most common comorbid psychiatric disorders include separation anxiety, social phobia, simple phobia, panic
disorder, post-traumatic stress disorder, major depressive disorder, dysthymia, and adjustment disorder.
School refusal should be considered a heterogeneous and multicausal syndrome. School avoidance may
serve different functions depending on the individual child. These may include avoidance of specific fears
provoked by the school environment (e.g. test-taking situations, bathrooms, cafeterias, and teachers),
escape from aversive social situations (e.g. problems with classmates or teachers), separation anxiety, or
attention-seeking behaviours (e.g. somatic complaints, crying spells) that worsen over time if the child is
allowed to stay home.

Question 4

Family functioning

Answer 4

Problems with family functioning contribute to school refusal in children; however, few studies have
systematically evaluated and measured these problems. Parents of children with school avoidance and
separation anxiety have an increased rate of panic disorder and agoraphobia.
Dysfunctional family interactions that correlate with school refusal include overdependency, detachment with
little interaction among family members, isolation with little interaction outside the family unit, and a high
degree of conflict. Communication problems within families, problems in role performance (especially in singleparent
families), and problems with family members’ rigidity and cohesiveness also have been identified

Question 5

Assessment

Answer 5

The evaluation should include interviews with the family and individual interviews with the child and parents.
Assessment should include a complete medical history and physical examination, history of the onset and
development of school refusal symptoms (following illness/vacation), associated stressors (bullying, tests), school history, peer relationships, family functioning (contributes to cause, worsen), psychiatric history (comorbid phobia/depression/PTSD/OCD often associated) substance abuse history, and a mental status examination. Identification of
specific factors responsible for school avoidance behaviours is important. Collaboration with school staff in
regards to assessment and treatment is necessary for successful management. School personnel can
provide additional information to aid in assessment, including review of attendance records, report cards,
and psychoeducational evaluations

Several psychological assessment tools (e.g. teacher and parent rating scales, self-report measures,
clinician rating scales) have been developed to provide additional information about the child’s general
functioning at home and at school.

Generalised scales (e.g. Child Behaviour Checklist, Teacher’s Report Form) identify areas of difficulties.
Specific rating scales assess for symptoms and severity of psychiatric problems, including anxiety and
depression

Question 6

Treatment

Answer 6

Primary goal is early return to school
Avoid writing excuses for children to stay out of school unless medical reason warrants it
Multimodal, collaborative team approach-> doctor, child, parent, school staff, MH professional

1. Education and consultation:
   Traditional educational and supportive therapy has been shown to be as effective as behaviour therapy
   for the management of school refusal. Educational-support therapy is a combination of informational
   presentations and supportive psychotherapy. Child therapy involves individual sessions that incorporate
   relaxation training (to help the child when he or she approaches the school grounds or is questioned by
   peers), cognitive therapy (to reduce anxiety-provoking thoughts and provide coping statements), social skills
   training (to improve social competence and interactions with peers), and desensitisation (e.g. graded in vivo
   exposure, emotive imagery, systematic desensitisation).
2. Behaviour strategies: primarily exposure-based treatments and include systematic desensitisation (i.e. graded exposure to the school environment), relaxation training, emotive imagery, contingency management, and social skills training. Cognitive behaviour therapy is a highly structured approach that includes specific instructions for children to help gradually increase their exposure to the school environment.
3. Family interventions:
   Parental involvement and caregiver training are critical factors in enhancing the effectiveness of behaviour
   treatment. Parent-teacher interventions include clinical sessions with parents and consultation with school
   personnel. Parents are given behaviour-management strategies such as escorting the child to school,
   providing positive reinforcement for school attendance, and decreasing positive reinforcement for staying
   home (e.g. watching television while home from school). Parents also benefit from cognitive training to help
   reduce their own anxiety and understand their role in helping their children make effective changes. School
   consultation involves specific recommendations to school staff to prepare for the child’s return, use of
   positive reinforcement, and academic, social, and emotional accommodations
4. Possible pharmacotherapy:
   inconclusive data

When a child is younger and
displays minimal symptoms of fear, anxiety, and depression, working directly with parents and school
personnel without direct intervention with the child may be sufficient treatment. If the child’s difficulties
include prolonged school absence, comorbid psychiatric diagnosis, and deficits in social skills, child therapy
with parental and school staff involvement is indicated.

Question 7

formulate and provide adequate information about school refusal

Answer 7

utilising a Biopsychosocial approach, and/or identifying relevant predisposing (especially genetic, developmental and attachment issues), precipitating perpetuating (e.g family dynamics and climate including absence of contingency management from parents, lack of empathy or understanding by the father, the child’s poor anxiety management skills and predisposing anxious
disposition) and protective factors

Good prognosis

Question 8

Management overview (OSCE)

Answer 8

Biopsychosocial model including psychoeducation
about anxiety for the child and the parents, psychological input which may include anxiety management skills
for the child (with the parents knowing what they are to support the child in using them), peer relational skills
building for the child, consideration of family intervention/therapy which includes the father and/or
behavioural programme e.g. hierarchy development and graded exposure, behavioural contingencies
(rewards and consequences). Mentions no need for medication. Must mention involving the school and
working with the family especially the father.