J. Paediafr. Child Health (1992) 28, 41 1-41 3

Annotation

School refusal N. J. KING’ and 6. J. TONGE2 ’Faculty of Education, School of Graduate Studies, Monash University and ‘Centre for Developmental Psychiatry, Monash Medical Centre, Clayton, Victoria, Australia

While school attendance can be a rewarding and satisfying experience for children, there are times when it produces fear or apprehension. Separation from parents is anxiety producing for many young children attending school. School itself can be a foreboding and strange place, and in the mind of the young child, inhabited by imaginary creatures and unknown dimensions.’ These fears diminish as the child develops in cognitive sophistication and undergoes desensitization to the feared aspects of school. Socio-evaluative fears such as talking to a group or class, taking tests and getting bad marks become more prominent in older children and adolescent^.'^^ For the vast majority of children, these school-related fears do not translate into high school absenteeism.’ However for a small proportion of children the prospect Of separation from parents and/or facing anxiety inducing situations at school is so distressing that they refuse to attend school. This problem is labelled ‘school refusal’ or ‘school phobia’, although we prefer the former term because it allows for the heterogeneity of the problem. School refusal is a serious problem as the child‘s social and educational development may be jeopardized. In addition school refusers are at risk in adult life in terms of employment difficulties and severe psychiatric disorders such as a g ~ r a p h o b i a .In ~ the clinical literature, school refusal is differentiated from truancy.’ This latter group of children refuse to attend or abscond from school for reasons unrelated to anxiety about school attendance. These children are usually not at home throughout the school day and may in fact engage in stealing, antisocial and destructive behaviours.

AETIOLOGY The aetiology of school refusal is complex with many factors contributing to the problem. Some children probably have a constitutional or inborn vulnerability which places them at risk for the development of emotional disturbance. In particular, much research has focused on temperament as a determinant

Correspondence: N. J. King, Faculty of Education, School of Graduate Studies, Monash University, Clayton, Vic. 3168, Australia. N. J. King, BA, PhD, Senior Lecturer. B. J. Tonge. MB, BS, MD, DPM. MRC Psych, FRANZP, Cert. Child Psych., RANZCP, Head of Monash University Centre for Developmental Psychiatry. Accepted for publication 16 December 1991.

of childhood psychopathology. A follow-up study of ‘temperamentally difficult’ children found that such children display a high level of psychopathology in home and school setting^.^ Stressful life events at home and/or school invariably precipitate school refusal. In a review of 50 school refusal cases Hersov6 noted the following precipitants: change of school (19 cases); the death, departure or illness of a parent-usually the mother (nine cases); and an illness, accident or operation which led to the child spending a period away from school either in hospital or at home (five cases). No clear precipitating factor could be found in 17 cases. Whether or not school refusers actually experience a greater number of stressors than is normal for children remains to be shown empirically. Familial influences also contribute to the aetiology of school refusal. Sometimes parents and/or other family members have a history of school refusal.’ Psychiatric illness also has been documented in parents of school ref user^.^,^ Further, school avoidance invariably leads to increased parental attention as well as relieving maternal loneliness. An important gap in the literature concerns family dynamics, an area that might be studied using self-report questionnaires and behavioural observations of family interactions.

CLINICAL DESCRIPTION The clinical features of school refusal include: (i) severe difficulties in attending school, often amounting to prolonged absence; (ii) severe emotional upset on being faced with the prospect of going to school, which may include complaints of physical illness such as headache and stomach pain for which there is no organic cause; (iii) staying at home when the child should be at school, with the knowledge of parents: and (iv) absence of significant antisocial behaviour such as stealing, lying and destructiveness.’0 School refusers often meet the criteria for a psychiatric diagnosis as outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorder (DSM111 -R).” Of special relevance to school refusal are the anxiety disorders of childhood and adolescence including separation anxiety disorder, avoidant disorder, and overanxious disorder. School refusers may qualify for other diagnoses such as simple phobia, social phobia, panic disorder, depression and adjustment disorder. In a recent investigation of 63 anxiety-based school refusers, Last and Strauss found that there were two primary diagnostic subgroups of school refusers-separation anxious

N. J. King and B. J. Tonge

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and phobic.'2 Phobic school refusers had a later age of onset and showed more severe school refusal than separation anxious school refusers. For many years, depression has been reported to be fairly common in school refusal. Bernstein and Garfinkel examined the overlap of affective disorders in a group of 26 early adolescent, chronic school ref user^.'^ Sixty-nine per cent of the adolescents met DSM-111 criteria for an affective disorder (depression), 62% met criteria for anxiety disorder and 50% met criteria for both depressive and anxiety disorders. Obviously the presence of depression and suicidal ideationlacts have important implications for clinical management.

EPIDEMIOLOGY School refusal has a low prevalence among school-aged children. In a recent review, it was estimated that school refusal is seen in approximately 5% of all clinic-referred children and 1% of all school-aged ~ h i 1 d r e n . School l~ refusal can occur throughout the entire range of school years, although it appears that there are major peaks at certain ages. Reporting on research findings in the United Kingdom, Blagg has observed major peaks in the onset of school refusal at 5-6 years of age, 11-12 years of age and then again in early adole~cence.'~ Inconsistent findings have been reported concerning the sex ratio for school refusal, although some authorities believe that school refusal is equally common in both sexes.' Contrary to early opinion that school refusal is more likely to occur in children of above average intelligence, school refusal occurs in children across the normal distribution of intelligence and at all levels of achievement. Finally, school refusal occurs in children from families of all socio-economic levels. In Australia, Lang has reported a study on a group of severe school refusers who were matched to a group of regular school attenders.I6 In contrast to the findings of researchers in other countries, school refusing children had lower levels of education and were functioning at lower levels of intelligence than controls. Their parents tended to be older, less intelligent, had completed less years of education and were of lower socio-economic status than the parents of regular school attending children. Inconsistent findings on the epidemiological aspects of school are probably attributable to the various criteria used to define school refusal, as well as sampling bias.

CLINICAL MANAGEMENT Research advances on the treatment of school refusal have taken place fairly slowly, as might be expected in view of the sampling and ethical problems in conducting controlled investigations. The modest progress that has been made is confined to behaviour modification and pharmacotherapy. In relation to behaviour modification, graduated and rapid behavioural strategies have been used successfully in the treatment of school refusal. Illustrative of the graduated approach, Garvey and Hegrenes treated a 10 year old school refuser using a real-life desensitization p r ~ g r a m m e .The ' ~ programme consisted of 12 steps, the first of which involved sitting in a car In front of the school with the therapist. Examples of the other steps included getting onto the footpath, entering the school and sitting in the classroom. After 3 weeks of daily exposure to fear-eliciting stimuli. the child resumed a normal school routine. Miller and

his colleagues have reported the only controlled evaluation of desensitization in the treatment of school refusal.'* Their feelings support the efficacy of desensitization, although methodological limitations have been noted about the study.' A more confronting behavioural treatment strategy, sometimes referred to as 'flooding', involves having the child immediately resume full-time school attendance by starting and finishing the school day just like his or her peers. This procedure entails escorting the child to school and ignoring temper tantrums and complaints of illness. The rationale for this treatment is that through exposure and blocking escape, the child's excessive anxiety will dissipate (extinction).Some British researchers have shown that this approach is both effective and cost-efficient compared with alternate treatment service^.'^ Medication is only very rarely indicated, with a small dose of a major tranquillizer (such as thioridazine) being used for the first few days back at school. If the fear is overwhelming and chronic, a course of imipramine given at night, in consultation with a psychiatrist, may be therapeutic. Gittelman-Klein and Klein have reported a double-blind placebo-controlled study supporting the efficacy of imipramine in the treatment of school refusal.20However, parents of the children were also advised on the use of behavioural strategies thus making it difficult to determine the operative variable in their treatment package. Some concern has been expressed about the high doses of imipramine used in the Gittelman-Klein and Klein study (dose range 100-200 mglday). Cardiotoxicity and death has been reported with tricyclic antidepressants in the absence of other side effects which might prompt dose reduction. Therefore, initial and follow-up electrocardiograph monitoring during treatment is indicated, particularly when doses of imipramine of 5 mg/kg per day or greater are used. Plasma imipramine levels of 125-250 ng/mL are regarded as the therapeutic and safe range for the treatment of depression in childrenz' Fear of side effects is probably responsible for the negative perceptions of caregivers towards medication in the treatment of school refusal.22

REFERENCES Ollendick T. H., Mayer J. A. School phobia. In: Turner S. M. ed. Behavioral Theories and Treatment of AnxiefF Plenum, New York. 1984; 367-441. Granell de Aldaz E.. Vivas E.. Gelfand D. M.. Feldman L. Estimatingthe prevalence of school refusal and school-related fears. A Venezuelan sample. J. New Menf.Dis. 1984; 172: 722-9. King N. J., Ollier K.. laucone R. et a/. Fears of children and adolescents: A cross-sectional Australian study using the Revised-Fear Survey Schedule for Children. J. Child Psycho/. Psychiatry 1989; 30: 775-84. Berg I., Marks I., McGuire R., Lipsedge M. School phobia and agoraphobia. Psycho/. Med. 1974; 4:428-34. Maziade M.. Caperaa P.. Laplante 8. et a/.Value of difficult tempera-

ment among 7-year-olds in the general population for predicting psychiatric diagnosis at age 12. Am. J. Psychiatry 1985; 142: 943-6. Hersov L. A. Refusal to go to school. J. Child Psycho/. Psychiatry 1960; 1: 137-45.

Granell de Aldaz E., Feldman L., Vivas E., Gelfand D. M. Characteristics of Venezuelan school refusers: Toward the development of a high-risk profile. J. New Menf. Dis. 1987; 175:402-7. Berg I., Butler A,, Pritchard J. Psychiatric illness in the mothers of school-phobic adolescents. Br. J. Psychiatry 1974; 125: 466-7. Gittelman-Klein R. Psychiatric characteristics of the relatives of school-phobic children. In: Sankar D. V. S. ed. Mental Healfh in Children, Vol. 1. PJD Publications,New York. 1975; 325-34.

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10 Berg I., Nichols K.,Pritchard C. School phobia-its classification and relationship to dependency. J. Child Psycho/. Psychiatry 1969; 10: 123-41. 11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders- Ill-R. Washington, DC. 1987. 12 Last C. G., Strauss C. C. School refusal in anxiety-disordered children and adolescents. J. Am. Acad. Child Adol. Psychiatry 1990; 29: 31 -5. 13 Bernstein G. A,, Garfinkel B. D. School phobia: The overlap of affective and anxiety disorders. J. Am. Acad. Child Psychiatry 1986; 25: 235-41. 14 Burke A. E., Silvermann W. The prescriptive treatment of school refusal. Clin. Psychol. Rev. 1987; 7: 353-62. 15 Blagg N. School Phobia and its Treatment. Croom Helm, London. 1987. 16 Lang M. School refusal: an empirical study and system analysis. Aust. J. Fam. Ther. 1982: 3: 93-107.

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17 Garvey W. P., Hegrenes J. R. Desensitization techniques in the treatment of school phobia. Am. J. Orfhopsychiatry1966; 36: 147-52. 18 Miller L. C., BarretlC. L.. Hampe E., Noble H. Comparison of reciprocal inhibition, psychotherapy and waiting list control for phobic children. J. Abnorm. Psychol. 1972; 79: 269-79. 19 Blagg N. R.. Yule W. The behavioural treatment of school refusal -A comparative study. Behav. Res. Ther. 1984; 22: 119-27. 20 Gittelman-Klein R., Klein D. F. Controlled imipramine treatment of school phobia. Arch. Gen. Psychiatry 1971; 25: 204-7. 21 Preskorn S. M.,Weller E. B.. Weller R. A,, Glotzbach E.Plasma levels of imipramine and adverse effects in children. Am. J. Psychiatry 1983; 140: 1332-5. 22 Gullone E.. King N. J. Acceptability of alternative treatments for school refusal: Evaluations by students, caregivers and professionals. Br. J. Educ. Psycho/. 1991; 61: 346-54.

School refusal.

J. Paediafr. Child Health (1992) 28, 41 1-41 3 Annotation School refusal N. J. KING’ and 6. J. TONGE2 ’Faculty of Education, School of Graduate Stud...
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