Brit. J. Psychiat. (1976), 128, 80—5
The Outcome of Adolescent School Phobia By IAN BERG, ALAN BUTLER
and GABRIELLE
HALL
Summary. A hundred-and-twenty-five school phobic youngsters had been treated in a psychiatric in-patient unit for young adolescents of secondary school age over a seven-year period; a hundred of them were reviewed on average three years after discharge. About a third of cases were found to have improved little; they had persistent severe symptoms of emotional disturbance and continuing social impairment. Another third had improved appreciably and were affected by neurotic symptoms rather than social impairment. The remaining third had improved substantially or completely. School attendance difficulties had remained in about half of all cases. Subsequent difficulties in going to work were less pronounced. The best predictor of outcome was clinical state on discharge. High intelligence also emerged as a significant predictor of poor outcome. Five girls and a boy had already developed severe and persistent agoraphobic difficulties when reviewed. It was found that severe school phobia in early adolescence resembled adult affective disorders in some clinical features and in outcome.
PROCEDURE
INTRODUCTION The sample
This is a report of a follow-up study carried out on youngsters previously treated for school phobia in a hospital in-patient unit. One hundred of them were reviewed about three years after discharge. The features of many of these cases have been described previously (Berg, Nichols and Pritchard, 1969; Berg and McGuire, 1971; Berg, Butler and McGuire, 1972;
Berg
and
McGuire,
1974;
Berg,
Efforts were made to contact all cases of school phobia that had been treated as in-patients at High Lands Adolescent Unit in the years 1965 to 1972 indusively. There were 125 children in all. Thirty of the i oo successfully reviewed cases attended out patient clinics, where the youngster was interviewed by a psychiatrist (I.B.) and the mother was seen by a psychiatric social worker (A.B. or G.H.). The other 70 were visited at home by one or two of the
Butler
and Pritchard, 1974; Berg and Collins, 1974). It seems likely that youngsters who suffer from school phobia are more prone to agoraphobia or other neurotic disorders in later life (Berg, Marks, McGuire and Lipsedge, 1974; Tyrer and Tyrer, 1974). The aim of the investigation was to see how disturbed, in terms of psychiatric symptoms and failure to make a satisfactory adjustment, these school-phobic children remained throughout the period of follow-up, and to relate outcome to some clinical features ascertained at the time of discharge.
three
social
workers
attached
to the Unit
where
the
mother was interviewed usually in the presence of the youngster. Of those 25 who could not be reviewed, five could not be traced or had moved away from the district and the remainder
refused further contact.
A ques
tionnaire was sent to the last-known general practi tioner of these 25 cases that could not be followed-up directly. The questions were: i. Did he/she continue
to attend school normally after he/she left the Unit? 2. Was there any subsequent
difficulty
with
work?
3. Did he/she attend a psychiatiist? 4. Did he/she come to you for nervous problems? For purposes of comparison the same questionnairewas also sent to So
BY IAN
BERG,
ALAN
BUTLER
AND
GABRIELLE
8i
HALL
a random sample of 25 of the hundred youngsters
nent factor analysis.The
reviewed. There were i 2 replies in the first group and 15 in the second.
account for 6i per cent of total variance was the best weighted combination of outcome ratings measuring
Reliabiit,
improvement. Standardized component scores were converted into whole number subscale scores lying alonga nine-point scale(—I@2 to —¿o@8 = 1,
A standard form* was completed during the interview. It covered psychiatric symptoms and
—¿0@7to +01
—¿0@ =
2,
= 4, +o@8to
firstgeneral component
—¿0@2to +O@2 +I@2
=
=
5, +I@3t0
3, +01
to
+11
= 6,
adjustment. A picture of the clinical state over the interval since discharge was built up retrospectively.
+i@8 to +2@2
The proportion of time ill (incapacitating symptoms
+3@2
with
slightly improved
time of discharge (namely age, sex,socialdass, full
moderate
scale IQ and length of stay in hospital) were then used to carry out a multiple regression analysis with the outcome subscale as the criterion.
marked
(marked
social impairment),
symptoms
with
mild
or
social
impairment), much improved (mild or moderate symptoms with minimal social impairment) and well (absence of symptoms and normal social adjust ment) was estimated and recorded as described by Kerr, Roth, Schapira and Gurney (1972). Two of the social workers carried out ,@ joint interviews
in the youngsters'
homes. One asked the
=
g).
7, +21
Items
to +21
of information
= 8, +2@8 to available
at the
RESULTS
Cases not reviewed Comparisons
between
the
i oo followed-up
above were identical. In three cases one duration category was different. In only one rating was
cases and those 25 who were not able to be seen, revealed no significant differences as far as age, sex, social class, length of stay in the Unit and full scale IQ were concerned. Comparisons
sevent,
between
questions and both made independent ratings. In 15 instances
the
severity/duration
of disturbance
grossly
estimates
disparate
outlined
between
the
the 12 cases not reviewed
and
the 15
two estimates. The psychiatrist's ratings of the youngster and the
youngsters reviewed, using questionnaire data obtained from general practitioners, are shown socialworker'sratingsof the mother were also in Table I. compared
in 25 instances.
Fifteen
ratings
were
identical. In seven cases slight duration differences were present.
In three
there
were differences
severity; the children tended to underestimate difficulties. The composite r was o@9.
of
T@ai@aI Frequency of difficulties after discharge:
their
12
cases
reviewed
and
15
cases
taken from the 100 youngsters
The data derived from the responses of mothers to the follow-up interviews was converted into three measuring
improvement
direction and positively correlated.
in
a
comparison of
followed-up,
on
repliesto a questionnairesent to the generalpractitioners of 25 casesnot reviewedand a randomsampleof 25
Analysis of data
variables
not
positive
This was done in
the way described by Kerr, Roth, Schapira and Gurney (1972). The first variable was well scores, the second was well plus muchimprovedscores, and the third was well plus much improved plus slightly improved
reviewed
School quent doctor work atten for psychia atten dance neurotic tristSaw dance problemCasesproblemSubse problemSaw notreviewed3225fl=I2@esreviewed3326fl
scores. Percentages of time spent in the clinical states corresponding to these variableswere changed into
integers on an eight-point 1—10 per
cent
=
scale (o per cent
2@ 11—25 per
cent
=
=
3; 26—50 per
cent = 4, 51—75 per cent = 5; 76—90 per cent = 6, 91—99 per cent
= 7, ioo per cent
=
15
= 8). The results
were punched on cards for analysis on the Leeds University I.C.L. I96oA computer using a standard system of programs (Hamilton, McGuire and Good man, 1965). The data on the three variables described were correlated and subjected to a principal compo * Copies of this form are available from I.B. on request.
Clinical outcome For the sake of convenience,the ioo cases reviewed are described in four groups of de creasing severity. There were no significant differences (P > 0.05) between mean ages on
82
@
THE
OUTCOME
OF ADOLESCENT
interview (which varied between i6 and i 7.5 years) or mean durations of follow-up (which varied between 2 5 and 3 . 5 years) of the four groups. Group I comprises
i 7 youngsters
who were
rated as ill some part of the follow-up period. This was the worst affected group. Two of them
were rated as ill all the time and six were found to be ill over 50 per cent of the time. None of this group had managed to resume regular attendance at an ordinary day school. Only
SCHOOL
PHOBIA
time.
Eleven
were slightly improved less than
50
cent
per
of the
time
and
27 were
in the
muck
improved category more than 50 per cent of the time. Half the group had school attendance difficulties. About one in ten had work problems. Between a quarter and a fifth had very limited social contacts and stayed in excessively. Two thirds had persistent neurotic symptoms, cluding those of anxiety, depression obsessions. Two had received out-patient
in and psy
chiatric treatment.
Group 4 comprises 2 7 youngsters who were well all the time (n = i 7) or over @oper cent greatdealand had few or no friends. Four girls of the follow-up period (n = io). A fifth of the group had some school attendance difficulties. and a boy had suffered from persistent and Less than a tenth had problems going to work. marked agoraphobic symptoms; two of these Even fewer had either difficulties with staying had received out-patient treatment over a long in or limited social contacts. Some depressive period. Five others had received psychiatric problems occurred in three youngsters, anxiety treatment. Two had been admitted to hospital symptoms in two and obsessional difficulties in with depressive conditions; one of them had two. None had received psychiatric treatment. been given ECT. Two youngsters with severe schizoid personality traits had also been admit Course ted to psychiatric hospitals; one had been The proportion of youngsters considered well diagnosed schizophrenic. The fifth, a girl, had doubled from i 8 per cent at discharge to 38 per an incapacitating neurotic illness with obses cent after four years. However, the proportion sional features; she had received out-patient of cases categorized as ill remained at just over psychiatric treatment. nine least
had worked relatively normally for at six months. Most stayed in the house a
10 per
Group 2 comprises i 8 youngsters who were never considered disturbed enough to be rated as ill but who were found to be only slightly improved for more than 50 per cent of the time. Half of those who were of school age during the follow-up period had marked school attendance difficulties. Of those past school leaving age, a quarter were unable to work normally
thirds
for a span
of the
of at least
group
had
six months.
very
limited
Two
had
mainly
Group 3 comprises not
sufficiently
anxiety
symptoms.
38 youngsters
disturbed
to be
who were
categorized
throughout
the
Just
50
per
cent
of
follow-up
period.
sex differences the
ioo
in
successfully
followed-up cases did not change over the follow-up period. Of these, I 7 (13 boys and 4 girls) were rated as well, 21 (i 3 boys and 8 girls) were much improved, i 0 (5 boys and 5 girls) were slightly improved and 2 (both girls) were ill allthetime.
social
contacts. A thirdstayedin excessively. Two girls had received regular psychiatric treatment as out-patients; in one case this was for marked and persistent agoraphobic symptoms. Three girls had predominantly depressive symptoms, one girl had obsessional symptoms and four youngsters
cent
There were no significant these respects (Fig. i).
as
either ill or slightly improved more than half the
Prediction of outcome
The outcome 3@2,
standard
subscale had a mean value of deviation
2@0.
The
multiple
correlation coefficient R was o 49. It was found to be highly significant (P
The Outcome of Adolescent School Phobia By IAN BERG, ALAN BUTLER
and GABRIELLE
HALL
Summary. A hundred-and-twenty-five school phobic youngsters had been treated in a psychiatric in-patient unit for young adolescents of secondary school age over a seven-year period; a hundred of them were reviewed on average three years after discharge. About a third of cases were found to have improved little; they had persistent severe symptoms of emotional disturbance and continuing social impairment. Another third had improved appreciably and were affected by neurotic symptoms rather than social impairment. The remaining third had improved substantially or completely. School attendance difficulties had remained in about half of all cases. Subsequent difficulties in going to work were less pronounced. The best predictor of outcome was clinical state on discharge. High intelligence also emerged as a significant predictor of poor outcome. Five girls and a boy had already developed severe and persistent agoraphobic difficulties when reviewed. It was found that severe school phobia in early adolescence resembled adult affective disorders in some clinical features and in outcome.
PROCEDURE
INTRODUCTION The sample
This is a report of a follow-up study carried out on youngsters previously treated for school phobia in a hospital in-patient unit. One hundred of them were reviewed about three years after discharge. The features of many of these cases have been described previously (Berg, Nichols and Pritchard, 1969; Berg and McGuire, 1971; Berg, Butler and McGuire, 1972;
Berg
and
McGuire,
1974;
Berg,
Efforts were made to contact all cases of school phobia that had been treated as in-patients at High Lands Adolescent Unit in the years 1965 to 1972 indusively. There were 125 children in all. Thirty of the i oo successfully reviewed cases attended out patient clinics, where the youngster was interviewed by a psychiatrist (I.B.) and the mother was seen by a psychiatric social worker (A.B. or G.H.). The other 70 were visited at home by one or two of the
Butler
and Pritchard, 1974; Berg and Collins, 1974). It seems likely that youngsters who suffer from school phobia are more prone to agoraphobia or other neurotic disorders in later life (Berg, Marks, McGuire and Lipsedge, 1974; Tyrer and Tyrer, 1974). The aim of the investigation was to see how disturbed, in terms of psychiatric symptoms and failure to make a satisfactory adjustment, these school-phobic children remained throughout the period of follow-up, and to relate outcome to some clinical features ascertained at the time of discharge.
three
social
workers
attached
to the Unit
where
the
mother was interviewed usually in the presence of the youngster. Of those 25 who could not be reviewed, five could not be traced or had moved away from the district and the remainder
refused further contact.
A ques
tionnaire was sent to the last-known general practi tioner of these 25 cases that could not be followed-up directly. The questions were: i. Did he/she continue
to attend school normally after he/she left the Unit? 2. Was there any subsequent
difficulty
with
work?
3. Did he/she attend a psychiatiist? 4. Did he/she come to you for nervous problems? For purposes of comparison the same questionnairewas also sent to So
BY IAN
BERG,
ALAN
BUTLER
AND
GABRIELLE
8i
HALL
a random sample of 25 of the hundred youngsters
nent factor analysis.The
reviewed. There were i 2 replies in the first group and 15 in the second.
account for 6i per cent of total variance was the best weighted combination of outcome ratings measuring
Reliabiit,
improvement. Standardized component scores were converted into whole number subscale scores lying alonga nine-point scale(—I@2 to —¿o@8 = 1,
A standard form* was completed during the interview. It covered psychiatric symptoms and
—¿0@7to +01
—¿0@ =
2,
= 4, +o@8to
firstgeneral component
—¿0@2to +O@2 +I@2
=
=
5, +I@3t0
3, +01
to
+11
= 6,
adjustment. A picture of the clinical state over the interval since discharge was built up retrospectively.
+i@8 to +2@2
The proportion of time ill (incapacitating symptoms
+3@2
with
slightly improved
time of discharge (namely age, sex,socialdass, full
moderate
scale IQ and length of stay in hospital) were then used to carry out a multiple regression analysis with the outcome subscale as the criterion.
marked
(marked
social impairment),
symptoms
with
mild
or
social
impairment), much improved (mild or moderate symptoms with minimal social impairment) and well (absence of symptoms and normal social adjust ment) was estimated and recorded as described by Kerr, Roth, Schapira and Gurney (1972). Two of the social workers carried out ,@ joint interviews
in the youngsters'
homes. One asked the
=
g).
7, +21
Items
to +21
of information
= 8, +2@8 to available
at the
RESULTS
Cases not reviewed Comparisons
between
the
i oo followed-up
above were identical. In three cases one duration category was different. In only one rating was
cases and those 25 who were not able to be seen, revealed no significant differences as far as age, sex, social class, length of stay in the Unit and full scale IQ were concerned. Comparisons
sevent,
between
questions and both made independent ratings. In 15 instances
the
severity/duration
of disturbance
grossly
estimates
disparate
outlined
between
the
the 12 cases not reviewed
and
the 15
two estimates. The psychiatrist's ratings of the youngster and the
youngsters reviewed, using questionnaire data obtained from general practitioners, are shown socialworker'sratingsof the mother were also in Table I. compared
in 25 instances.
Fifteen
ratings
were
identical. In seven cases slight duration differences were present.
In three
there
were differences
severity; the children tended to underestimate difficulties. The composite r was o@9.
of
T@ai@aI Frequency of difficulties after discharge:
their
12
cases
reviewed
and
15
cases
taken from the 100 youngsters
The data derived from the responses of mothers to the follow-up interviews was converted into three measuring
improvement
direction and positively correlated.
in
a
comparison of
followed-up,
on
repliesto a questionnairesent to the generalpractitioners of 25 casesnot reviewedand a randomsampleof 25
Analysis of data
variables
not
positive
This was done in
the way described by Kerr, Roth, Schapira and Gurney (1972). The first variable was well scores, the second was well plus muchimprovedscores, and the third was well plus much improved plus slightly improved
reviewed
School quent doctor work atten for psychia atten dance neurotic tristSaw dance problemCasesproblemSubse problemSaw notreviewed3225fl=I2@esreviewed3326fl
scores. Percentages of time spent in the clinical states corresponding to these variableswere changed into
integers on an eight-point 1—10 per
cent
=
scale (o per cent
2@ 11—25 per
cent
=
=
3; 26—50 per
cent = 4, 51—75 per cent = 5; 76—90 per cent = 6, 91—99 per cent
= 7, ioo per cent
=
15
= 8). The results
were punched on cards for analysis on the Leeds University I.C.L. I96oA computer using a standard system of programs (Hamilton, McGuire and Good man, 1965). The data on the three variables described were correlated and subjected to a principal compo * Copies of this form are available from I.B. on request.
Clinical outcome For the sake of convenience,the ioo cases reviewed are described in four groups of de creasing severity. There were no significant differences (P > 0.05) between mean ages on
82
@
THE
OUTCOME
OF ADOLESCENT
interview (which varied between i6 and i 7.5 years) or mean durations of follow-up (which varied between 2 5 and 3 . 5 years) of the four groups. Group I comprises
i 7 youngsters
who were
rated as ill some part of the follow-up period. This was the worst affected group. Two of them
were rated as ill all the time and six were found to be ill over 50 per cent of the time. None of this group had managed to resume regular attendance at an ordinary day school. Only
SCHOOL
PHOBIA
time.
Eleven
were slightly improved less than
50
cent
per
of the
time
and
27 were
in the
muck
improved category more than 50 per cent of the time. Half the group had school attendance difficulties. About one in ten had work problems. Between a quarter and a fifth had very limited social contacts and stayed in excessively. Two thirds had persistent neurotic symptoms, cluding those of anxiety, depression obsessions. Two had received out-patient
in and psy
chiatric treatment.
Group 4 comprises 2 7 youngsters who were well all the time (n = i 7) or over @oper cent greatdealand had few or no friends. Four girls of the follow-up period (n = io). A fifth of the group had some school attendance difficulties. and a boy had suffered from persistent and Less than a tenth had problems going to work. marked agoraphobic symptoms; two of these Even fewer had either difficulties with staying had received out-patient treatment over a long in or limited social contacts. Some depressive period. Five others had received psychiatric problems occurred in three youngsters, anxiety treatment. Two had been admitted to hospital symptoms in two and obsessional difficulties in with depressive conditions; one of them had two. None had received psychiatric treatment. been given ECT. Two youngsters with severe schizoid personality traits had also been admit Course ted to psychiatric hospitals; one had been The proportion of youngsters considered well diagnosed schizophrenic. The fifth, a girl, had doubled from i 8 per cent at discharge to 38 per an incapacitating neurotic illness with obses cent after four years. However, the proportion sional features; she had received out-patient of cases categorized as ill remained at just over psychiatric treatment. nine least
had worked relatively normally for at six months. Most stayed in the house a
10 per
Group 2 comprises i 8 youngsters who were never considered disturbed enough to be rated as ill but who were found to be only slightly improved for more than 50 per cent of the time. Half of those who were of school age during the follow-up period had marked school attendance difficulties. Of those past school leaving age, a quarter were unable to work normally
thirds
for a span
of the
of at least
group
had
six months.
very
limited
Two
had
mainly
Group 3 comprises not
sufficiently
anxiety
symptoms.
38 youngsters
disturbed
to be
who were
categorized
throughout
the
Just
50
per
cent
of
follow-up
period.
sex differences the
ioo
in
successfully
followed-up cases did not change over the follow-up period. Of these, I 7 (13 boys and 4 girls) were rated as well, 21 (i 3 boys and 8 girls) were much improved, i 0 (5 boys and 5 girls) were slightly improved and 2 (both girls) were ill allthetime.
social
contacts. A thirdstayedin excessively. Two girls had received regular psychiatric treatment as out-patients; in one case this was for marked and persistent agoraphobic symptoms. Three girls had predominantly depressive symptoms, one girl had obsessional symptoms and four youngsters
cent
There were no significant these respects (Fig. i).
as
either ill or slightly improved more than half the
Prediction of outcome
The outcome 3@2,
standard
subscale had a mean value of deviation
2@0.
The
multiple
correlation coefficient R was o 49. It was found to be highly significant (P
