Journal of Autism and Developmental Disorders, VoL 21, No. L 1991
School Refusal in Pervasive Developmental Disorders I Hiroshi Kurita 2
National Institute of Mental Health, NCNP, Japan, lchikawa, Japan
Of 135 autistic and~or mentally retarded youngsters, 30 with pervasive developmental disorders and 2 with nonautistic mental retardation showed school refusal according to its modified definition. School refusal was significantly more frequent in other PDDs than in nonautistic mental retardation. The intellectual level was significantly higher in PDD children with school refusal than those without it. A certain level of mental development and obsessive tendency appear necessary for PDD children to develop school refusal. In order to treat school refusal in PDD, it is important to make school a pleasant place to go and to encourage the child to attend.
Attending school is undoubtedly an important part of the life of autistic and/or mentally retarded children. As a matter of fact, the importance of school for those children has been understood so far with regard to its function to educate them. At first glance, it may appear contradictory to discuss school refusal in autistic and/or mentally retarded children in view of historical studies on school refusal. Broadwin (1932) noted that previous school performance and conduct of school phobics had been fair. Johnson, Falstein, Szurek, and Svendsen (1941) stated that the majority of their eight school-phobic children had superior intelligence. Rodriguez, Rodriguez, 1This study was supported in part by a Grant-in-Aid for General Scientific Research (No. 63480263) from the Ministry of Education, Science and Culture of Japan. The author thanks Hide Adachi and Hiroko Taniguchi in the Child Guidance Center affiliated with the National Welfare Foundation for Disabled Children in Tokyo for their assistance in data collection. 2Address all correspondence to Hiroshi Kurita, Division of Developmental Disorders, National Institute of Mental Health, NCNP, Japan, 1-7-3 Konodai, Ichikawa, Chiba 272, Japan.
0162-3257~1/0300-0001506.50/0O 1991PlcnumPublishingCorporation
2
Kurita
and Eisenberg (1959) found that none of 41 school phobics tested below the dull normal range and half fell into the bright to superior levels of intelligence. Hersov (1960) reported that the mean IQ of 106.4 in 50 children with school refusal did not differ significantly from that of control children. Coolidge, Brodie, and Feeney (1964) noted that a median IQ in 36 school-phobic children was 113, well above average on national norms. Berg, Collins, McGuire, and O'Melia (1975) concluded that poor educational attainment is not an important causal factor of school phobia. Although Adams, McDonald, and Huey (1966) noted school phobics of borderline or mild mental retardation, the majority of earlier researchers do not appear to have considered an explicit intellectual deficit frequently accompanying school refusal or school refusal frequently emerging in the developmentally retarded. There has been no systematic study of school refusal in autistic conditions even in Japan where autism and school refusal have been two major themes in the field of child psychiatry. The prevalence of autism in Japan is about 1.3/1,000 children (roughly three times the rate reported in the US and European countries) according to recent epidemiological studies (Sugiyama & Abe, 1989; Tanoue, Oda, Asano, & Kawashima, 1988). The occurrence of school refusal is increasing recently in Japan (Koizumi, 1990). Based on case reports, Kurita (1987, 1988) suggested that going to school per se could become a problem for some autistic children, and Kobayashi (1985) noted that school refusal was an imminent problem in 3 of 60 autistic children aged 12 to 17 years at the time of his follow-up study. Based on personal experiences, I do not think school refusal is rare among children with pervasive developmental disorders (PDD). It is also my contention that to identify school refusal among P D D children is a matter of definition and of clinical experiences with PDD. A combination of two common features of P D D (i.e., a certain level of mental development, which is not enough for adaptation in a class but sufficient to perceive a stressful situation at school, and obsessive tendency, which makes an otherwise transient behavior continue) may be an important basis of school refusal in some P D D children (Kurita, 1987, 1988). Also, PDD, a relatively new concept, is a major category in developmental disorders with a prevalence of 1.0 to 1.5/1,000 children (two to three times higher than that of infantile autism in the US and European countries) according to DSM-III-R (American Psychiatric Association, 1987). For all of these reasons, school refusal in P D D seems worthy of study. This report is an attempt to clarify school refusal in P D D based on its modified definition.
School Refusal in PDD
3
METHOD
Definition Since school refusal is not a disorder as such in DSM-III (American Psychiatric Association, 1980) but a clinical state or symptom complex, it has been used somewhat differently in its content and extent from author to author. Probably its dearest definition is its diagnostic criteria delineated by Berg, Nichols, and Pritchard (1969): (a) severe difficulty in attending s c h o o l - o f t e n amounting to prolonged absence; (b) severe emotional upset--shown by such symptoms as excessive fearfulness, undue tempers, misery, and complaints of feeling ill without obvious organic cause being faced with the prospect of giong to school; (c) staying at home with the knowledge of their parents, when they should be at school, at some stage in the course of the disorder; and (d) absence of significant antisocial disorders, such as stealing, lying, wandering, destructiveness, and sexual misbehavior. However, these criteria are not directly applicable to the developmentally disabled, especially to those who cannot verbalize their feelings about school attendance. In addition, criteria requiring the severity of symptoms are not suitable to detect mild cases. In order to detect school refusal widely among the developmentally disabled, the present author redefined school refusal by relaxing the conditions on the severity of symptoms in the criteria of Berg et al. (1969) as follows: (a) absence from school because of reluctance to attend, which is expressed in words or attitudes, without a justifiable reason such as a physical disease or an accident; (b) staying at home with the knowledge of parents, when children should be at school, and (c) no significant antisocial disorders while absent.
Subjects Subjects were 135 autistic and/or mentally retarded elementary, junior high, high school children, and graduates (mean age = 13.5 -+ 4.9 years; 111 male and 24 female), who had consecutively attended the Child Guidance Center affiliated with the National Welfare Foundation for Disabled Children in Tokyo from 1987 to 1989. Detailed clinical evaluation of children there was introduced elsewhere (Kurita, 1985). In short, a child psychiatrist, a pediatric neurologist, a psychologist, and a social worker participated in history taking, clinical examinations, and making the diagnosis on the children. Several questionnaires on the development and abnormal behavior of children to be filled out by parents were administered.
Kurita
4
According to DSM-III diagnoses determined on the basis of these examinations and data, the 135 children were divided into two groups [i.e., pervasive developmental disorders (PDD) including residual states regardless of whether they have a concomitant diagnosis of mental retardation or not, and mental retardation without an additional diagnosis of PDD]. The P D D group consisted of 110 children and adolescents (mean age = 13.2 +- 4.3 years; 97 male and 13 female) including 75 with infantile autism and 35 with other pervasive developmental disorders ( O P D D ) (i.e., childhood onset pervasive developmental disorders and atypical pervasive developmental disorders). The mental retardation group included 25 youngsters (mean age = 14.9 _+ 6.9 years; 14 male and 11 female). Ages did not differ significantly between PDD and mental retardation groups. In the 135 subjects, mean lengths of preschool education (e.g., nursery, kindergarten) and school education from elementary to hig h school were 2.7 -+ 0.9 years and 6.3 -+ 3.6 years, respectively. In 110 of the 135 subjects, an IQ was measured on the Japanese version of the Stanford-Binet or the WISC-R. In 2, a developmental quotient (DQ) on a Japanese developmental schedule, the Tsumori's Mental Developmental Scale, consisting of 438 items rated on the basis of an interview with a child's caretaker, was used for an IQ, because the DQ was correlated with the IQ on the Japanese version of the Stanford-Binet with a value of r = .77 (Shimizu, Senda, Someya, Ohta, & Kawasaki, 1987). Based on the IQ, intellectual levels were classified into three categories: mild retardation and over (IQ > 50), moderate retardation (50 > IQ >_.35), and severe retardation and below (IQ < 35). In the other 23 for whom an IQ was not obtained, the three grades were clinically estimated by a psychologist. The intellectual level did not differ significantly between PDD and mental retardation, though it tended to be higher in O P D D than in infantile autism.
Procedure
In each of the 135 subjects, a history of school refusal as defined and other items were requested from parents by a social worker at the time of first or follow-up observation, using a questionnaire devised by the author. The social worker was blind to the membership of the child in the DSM-III diagnostic groups. (The questionnaire written in Japanese is available from the author upon request.) The questionnaire consisted of 45 items: demography and family backgrounds [e.g., the number of and order in sibs, parental highest education level, types of father's occupation (in three categories; white-collar, blue,collar, and self-employed)]; maternal neuroticism (i.e.,
5
School Refusal in PDD Table 1. Frequency of School Refusal by Diagnoses
No. (%) of cases by type of school attendence Diagnosis*
n
School refusal
No school refusal
IA OPDD MR
75 35 25
16 (21.3) 14 (40.0) 2 (8.0)
59 (78.7) 21 (60.0) 23 (92.0)
X2(2, N = 135) = 8.78, p < .05 *IA, infantile autism including residual states; OPDD, other pervasive developmental disorders (i.e., childhood onset pervasive developmental disorders and atypical pervasive developmental disorders) including residual states; MR, mental retardation without an additional diagnosis of pervasive developmental disorders.
oversolicitousness, anxiety, and overprotectiveness) clinically judged on a 3-point scale (severe, moderate, and mild or weak); medical history, a history of school refusal as defined rated on a 3-point scale (having had, having shown unwillingness to attend but having never been absent, and having never had); age at onset of the first school refusal; a precipitating factor; degree of resistance against parental attempts to have the child go; a total duration of absence.
RESULTS
Incidence of School Refusal by Diagnosis Of the 135 autistic and/or mentally retarded children and adolescents, 32 (23.7%) had shown school refusal as defined; 38 (28.1%) were reported to have shown unwillingness to go to school that did not result in school refusal. All of their mothers admitted that they encouraged the children to go to school as much as possible. Table I shows a significant association between diagnoses and school refusal. The lengths in years of preschool and school education did not differ significantly between those with and without school refusal in all of the three diagnostic groups. The frequency of school refusal was significantly higher in O P D D than mental retardation (Fisher's test p < .01). School refusal tended to be more frequent in PDD as a whole (27.3%) than in mental retardation (8.0%) (Fisher's test p < .10). In 17 PDD and 6 mentally retarded adolescents who had finished school either by graduation or quitting, the frequency of school refusal was also higher in PDD (47.1%) than in mental retardation (16.7%), though the difference did not reach statistical significance. The frequency of school
6
Kurita
Table II. Thirty PDD Cases with School Refusal
Case no.
Age (years) and place at the 1st onset b
Inducing factor
Sex
Dx ~
I 2 3
M M M
OPDD OPDD OPDD
4
M
IA
13.0: NJH 11.0: SPS 7.3: SC of NPS 11,4: NPS
5 6
M F
IA OPDD
15.8: NHS 8.6: NPS
7
M
OPDD
14.1: NJH
8 9 l0 11
M F M M
OPDD IA OPDD IA
16.0: 17.1: 16.7: 11.3:
12
M
OPDD
8.2: NPS
13
M
IA
14
M
IA
15 16
M M
IA IA
10.5: SC of NPS 7.4: SC of NPS 10.8: NPS 14.7: SC of NJH
17 18
M F
OPDD OPDD
19
M
IA
10.9: NPS
20
M
IA
21 22
M F
IA OPDD
10.2: SC of NPS 5,4: N 9.8: NPS
23
F
IA
4.0: K
24
M
OPDD
6.5: N
25 26
M F
IA IA
SHS SHS SHS SPS
5.3: K 4.3: K
Total absence (days)
IQ
None Teasing School sports Teasing
60 30
School Refusal in Pervasive Developmental Disorders I Hiroshi Kurita 2
National Institute of Mental Health, NCNP, Japan, lchikawa, Japan
Of 135 autistic and~or mentally retarded youngsters, 30 with pervasive developmental disorders and 2 with nonautistic mental retardation showed school refusal according to its modified definition. School refusal was significantly more frequent in other PDDs than in nonautistic mental retardation. The intellectual level was significantly higher in PDD children with school refusal than those without it. A certain level of mental development and obsessive tendency appear necessary for PDD children to develop school refusal. In order to treat school refusal in PDD, it is important to make school a pleasant place to go and to encourage the child to attend.
Attending school is undoubtedly an important part of the life of autistic and/or mentally retarded children. As a matter of fact, the importance of school for those children has been understood so far with regard to its function to educate them. At first glance, it may appear contradictory to discuss school refusal in autistic and/or mentally retarded children in view of historical studies on school refusal. Broadwin (1932) noted that previous school performance and conduct of school phobics had been fair. Johnson, Falstein, Szurek, and Svendsen (1941) stated that the majority of their eight school-phobic children had superior intelligence. Rodriguez, Rodriguez, 1This study was supported in part by a Grant-in-Aid for General Scientific Research (No. 63480263) from the Ministry of Education, Science and Culture of Japan. The author thanks Hide Adachi and Hiroko Taniguchi in the Child Guidance Center affiliated with the National Welfare Foundation for Disabled Children in Tokyo for their assistance in data collection. 2Address all correspondence to Hiroshi Kurita, Division of Developmental Disorders, National Institute of Mental Health, NCNP, Japan, 1-7-3 Konodai, Ichikawa, Chiba 272, Japan.
0162-3257~1/0300-0001506.50/0O 1991PlcnumPublishingCorporation
2
Kurita
and Eisenberg (1959) found that none of 41 school phobics tested below the dull normal range and half fell into the bright to superior levels of intelligence. Hersov (1960) reported that the mean IQ of 106.4 in 50 children with school refusal did not differ significantly from that of control children. Coolidge, Brodie, and Feeney (1964) noted that a median IQ in 36 school-phobic children was 113, well above average on national norms. Berg, Collins, McGuire, and O'Melia (1975) concluded that poor educational attainment is not an important causal factor of school phobia. Although Adams, McDonald, and Huey (1966) noted school phobics of borderline or mild mental retardation, the majority of earlier researchers do not appear to have considered an explicit intellectual deficit frequently accompanying school refusal or school refusal frequently emerging in the developmentally retarded. There has been no systematic study of school refusal in autistic conditions even in Japan where autism and school refusal have been two major themes in the field of child psychiatry. The prevalence of autism in Japan is about 1.3/1,000 children (roughly three times the rate reported in the US and European countries) according to recent epidemiological studies (Sugiyama & Abe, 1989; Tanoue, Oda, Asano, & Kawashima, 1988). The occurrence of school refusal is increasing recently in Japan (Koizumi, 1990). Based on case reports, Kurita (1987, 1988) suggested that going to school per se could become a problem for some autistic children, and Kobayashi (1985) noted that school refusal was an imminent problem in 3 of 60 autistic children aged 12 to 17 years at the time of his follow-up study. Based on personal experiences, I do not think school refusal is rare among children with pervasive developmental disorders (PDD). It is also my contention that to identify school refusal among P D D children is a matter of definition and of clinical experiences with PDD. A combination of two common features of P D D (i.e., a certain level of mental development, which is not enough for adaptation in a class but sufficient to perceive a stressful situation at school, and obsessive tendency, which makes an otherwise transient behavior continue) may be an important basis of school refusal in some P D D children (Kurita, 1987, 1988). Also, PDD, a relatively new concept, is a major category in developmental disorders with a prevalence of 1.0 to 1.5/1,000 children (two to three times higher than that of infantile autism in the US and European countries) according to DSM-III-R (American Psychiatric Association, 1987). For all of these reasons, school refusal in P D D seems worthy of study. This report is an attempt to clarify school refusal in P D D based on its modified definition.
School Refusal in PDD
3
METHOD
Definition Since school refusal is not a disorder as such in DSM-III (American Psychiatric Association, 1980) but a clinical state or symptom complex, it has been used somewhat differently in its content and extent from author to author. Probably its dearest definition is its diagnostic criteria delineated by Berg, Nichols, and Pritchard (1969): (a) severe difficulty in attending s c h o o l - o f t e n amounting to prolonged absence; (b) severe emotional upset--shown by such symptoms as excessive fearfulness, undue tempers, misery, and complaints of feeling ill without obvious organic cause being faced with the prospect of giong to school; (c) staying at home with the knowledge of their parents, when they should be at school, at some stage in the course of the disorder; and (d) absence of significant antisocial disorders, such as stealing, lying, wandering, destructiveness, and sexual misbehavior. However, these criteria are not directly applicable to the developmentally disabled, especially to those who cannot verbalize their feelings about school attendance. In addition, criteria requiring the severity of symptoms are not suitable to detect mild cases. In order to detect school refusal widely among the developmentally disabled, the present author redefined school refusal by relaxing the conditions on the severity of symptoms in the criteria of Berg et al. (1969) as follows: (a) absence from school because of reluctance to attend, which is expressed in words or attitudes, without a justifiable reason such as a physical disease or an accident; (b) staying at home with the knowledge of parents, when children should be at school, and (c) no significant antisocial disorders while absent.
Subjects Subjects were 135 autistic and/or mentally retarded elementary, junior high, high school children, and graduates (mean age = 13.5 -+ 4.9 years; 111 male and 24 female), who had consecutively attended the Child Guidance Center affiliated with the National Welfare Foundation for Disabled Children in Tokyo from 1987 to 1989. Detailed clinical evaluation of children there was introduced elsewhere (Kurita, 1985). In short, a child psychiatrist, a pediatric neurologist, a psychologist, and a social worker participated in history taking, clinical examinations, and making the diagnosis on the children. Several questionnaires on the development and abnormal behavior of children to be filled out by parents were administered.
Kurita
4
According to DSM-III diagnoses determined on the basis of these examinations and data, the 135 children were divided into two groups [i.e., pervasive developmental disorders (PDD) including residual states regardless of whether they have a concomitant diagnosis of mental retardation or not, and mental retardation without an additional diagnosis of PDD]. The P D D group consisted of 110 children and adolescents (mean age = 13.2 +- 4.3 years; 97 male and 13 female) including 75 with infantile autism and 35 with other pervasive developmental disorders ( O P D D ) (i.e., childhood onset pervasive developmental disorders and atypical pervasive developmental disorders). The mental retardation group included 25 youngsters (mean age = 14.9 _+ 6.9 years; 14 male and 11 female). Ages did not differ significantly between PDD and mental retardation groups. In the 135 subjects, mean lengths of preschool education (e.g., nursery, kindergarten) and school education from elementary to hig h school were 2.7 -+ 0.9 years and 6.3 -+ 3.6 years, respectively. In 110 of the 135 subjects, an IQ was measured on the Japanese version of the Stanford-Binet or the WISC-R. In 2, a developmental quotient (DQ) on a Japanese developmental schedule, the Tsumori's Mental Developmental Scale, consisting of 438 items rated on the basis of an interview with a child's caretaker, was used for an IQ, because the DQ was correlated with the IQ on the Japanese version of the Stanford-Binet with a value of r = .77 (Shimizu, Senda, Someya, Ohta, & Kawasaki, 1987). Based on the IQ, intellectual levels were classified into three categories: mild retardation and over (IQ > 50), moderate retardation (50 > IQ >_.35), and severe retardation and below (IQ < 35). In the other 23 for whom an IQ was not obtained, the three grades were clinically estimated by a psychologist. The intellectual level did not differ significantly between PDD and mental retardation, though it tended to be higher in O P D D than in infantile autism.
Procedure
In each of the 135 subjects, a history of school refusal as defined and other items were requested from parents by a social worker at the time of first or follow-up observation, using a questionnaire devised by the author. The social worker was blind to the membership of the child in the DSM-III diagnostic groups. (The questionnaire written in Japanese is available from the author upon request.) The questionnaire consisted of 45 items: demography and family backgrounds [e.g., the number of and order in sibs, parental highest education level, types of father's occupation (in three categories; white-collar, blue,collar, and self-employed)]; maternal neuroticism (i.e.,
5
School Refusal in PDD Table 1. Frequency of School Refusal by Diagnoses
No. (%) of cases by type of school attendence Diagnosis*
n
School refusal
No school refusal
IA OPDD MR
75 35 25
16 (21.3) 14 (40.0) 2 (8.0)
59 (78.7) 21 (60.0) 23 (92.0)
X2(2, N = 135) = 8.78, p < .05 *IA, infantile autism including residual states; OPDD, other pervasive developmental disorders (i.e., childhood onset pervasive developmental disorders and atypical pervasive developmental disorders) including residual states; MR, mental retardation without an additional diagnosis of pervasive developmental disorders.
oversolicitousness, anxiety, and overprotectiveness) clinically judged on a 3-point scale (severe, moderate, and mild or weak); medical history, a history of school refusal as defined rated on a 3-point scale (having had, having shown unwillingness to attend but having never been absent, and having never had); age at onset of the first school refusal; a precipitating factor; degree of resistance against parental attempts to have the child go; a total duration of absence.
RESULTS
Incidence of School Refusal by Diagnosis Of the 135 autistic and/or mentally retarded children and adolescents, 32 (23.7%) had shown school refusal as defined; 38 (28.1%) were reported to have shown unwillingness to go to school that did not result in school refusal. All of their mothers admitted that they encouraged the children to go to school as much as possible. Table I shows a significant association between diagnoses and school refusal. The lengths in years of preschool and school education did not differ significantly between those with and without school refusal in all of the three diagnostic groups. The frequency of school refusal was significantly higher in O P D D than mental retardation (Fisher's test p < .01). School refusal tended to be more frequent in PDD as a whole (27.3%) than in mental retardation (8.0%) (Fisher's test p < .10). In 17 PDD and 6 mentally retarded adolescents who had finished school either by graduation or quitting, the frequency of school refusal was also higher in PDD (47.1%) than in mental retardation (16.7%), though the difference did not reach statistical significance. The frequency of school
6
Kurita
Table II. Thirty PDD Cases with School Refusal
Case no.
Age (years) and place at the 1st onset b
Inducing factor
Sex
Dx ~
I 2 3
M M M
OPDD OPDD OPDD
4
M
IA
13.0: NJH 11.0: SPS 7.3: SC of NPS 11,4: NPS
5 6
M F
IA OPDD
15.8: NHS 8.6: NPS
7
M
OPDD
14.1: NJH
8 9 l0 11
M F M M
OPDD IA OPDD IA
16.0: 17.1: 16.7: 11.3:
12
M
OPDD
8.2: NPS
13
M
IA
14
M
IA
15 16
M M
IA IA
10.5: SC of NPS 7.4: SC of NPS 10.8: NPS 14.7: SC of NJH
17 18
M F
OPDD OPDD
19
M
IA
10.9: NPS
20
M
IA
21 22
M F
IA OPDD
10.2: SC of NPS 5,4: N 9.8: NPS
23
F
IA
4.0: K
24
M
OPDD
6.5: N
25 26
M F
IA IA
SHS SHS SHS SPS
5.3: K 4.3: K
Total absence (days)
IQ
None Teasing School sports Teasing
60 30
