School Refusal Flashcards
Assessment
Because children with school refusal present with a wide variety of clinical symptoms, a comprehensive evaluation is recommended. School refusal is a complex problem, and physicians must allocate a sufficient amount of time to the patient to make an accurate assessment and recommend effective interventions.
Often, more than one appointment is needed.
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, associated stressors, school history, peer relationships, family Interviews with family, individual interviews with child and parents, medical history, physical exam, history of onset and development of school refusal sx, associated stressors, social hx, peer relationships, family functioning, psych hx, substance use hx, collaboration with school staff functioning, psychiatric history, 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. These tools may be used by a physician, but because of time constraints, a school psychologist or mental health counsellor should administer these scales whenever possible. 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. Although these scales are used frequently in children with school refusal, their clinical usefulness in developing effective treatment strategies has not been demonstrated.
Treatment
The primary treatment goal for children with school refusal is early return to school. Physicians should avoid writing excuses for children to stay out of school unless a medical condition makes it necessary for them to stay home. Treatment also should address comorbid psychiatric problems, family dysfunction, and other contributing problems. A multimodal, collaborative team approach should include the physician, child, parents, school staff, and mental health professional. Treatment options include education and consultation, behaviour strategies, family interventions, and possibly pharmacotherapy. 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.
Behaviour approaches for the treatment of school refusal are 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.
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).
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.
Early return to school, address comorbid psychiatric problems, family dysfunction. Multimodal collaborative team approach… 1) behavioural approaches- exposure based treatments and include systematic desensitisation (graded exposure to the school environment), relaxation training, emotive imagery, contingency management, social skills training, cognitive behavioural therapy 2) traditional educational and supportive therapy-informational presentations and supportive psychotherapy
Family functioning
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 single- parent families), and problems with family members’ rigidity and cohesiveness also have been identified.
Associated psychiatric disorder
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.
