School refusal and isolation: The perspectives of five adolescent school refusers in London, UK

"I felt shamed and blamed": an exploration of the parental lived experience of school distress

Introduction

School Distress refers to a child or young person's (CYP) difficulty attending school due to the extreme emotional distress associated with school attendance. Limited research exists on the impact of School Distress on the parents/carers supporting these CYP.

Methods

Using a case-control, concurrent embedded mixed-method design, we explored this lived experience. 947 parents of CYP with School Distress completed a bespoke on line questionnaire, alongside two control parent groups (n=149, n=25) and one professional group (n=19).

Results

Findings revealed a devastating impact on the mental health of parents, with parents displaying significantly heightened daily anxiety and significantly lower mood during, but not before, their children's school attendance difficulties. In addition, parents with children experiencing School Distress reported significantly higher negative emotion states and significantly lower positive emotion states. Parents also reported overwhelmingly negative treatment from professionals, including being disbelieved or blamed for their child's difficulties, threatened with fines and court action, and disempowered by the actions of professionals surrounding their child. Significant, deleterious impacts were also evident across all aspects of their lives, including their careers, finances, and other children. Perhaps unsurprisingly, half of these parents reported developing a new mental health condition since their child's difficulties began, with the experience itself rated as the second most threatening potential life event, superseded only by the death of a first-degree relative (including a child or spouse). On the other hand, professionals working with CYP with School Distress did not experience these deleterious mental health or wider life consequences. Despite understanding how threatening the experience is for parents, they were often quick to blame parents for their children's difficulties. Professionals, like parents, expressed frustration with the lack of help available for these CYP and their families.

Discussion

This study highlights a bleak, adversarial, and lonely picture for parents of CYP struggling to attend school. More specifically, the findings depict a system rife with parental blame; a system that appears to isolate parents through hostile, threatening, and punitive actions. A wider lack of societal understanding of the experience of School Distress further compounds this dearth of support for parents, placing parental mental health in further peril.

School refusal behavior in children and adolescents: a five-year narrative review of clinical significance and psychopathological profiles

The aim of the study was to explore the clinical significance of school refusal behavior, its negative impact on psychological well-being of children and adolescents and its relationship with the most common psychopathological conditions during childhood and adolescence (e.g. neurodevelopmental disorders, psychiatric disorders). School refusal behavior refers to a distressing condition experienced by children and adolescents that compromise regular school attendance and determine negative consequences on mental health and adaptive functioning. A narrative review of the literature published between January 2019 and March 2023 was conducted. Ten studies (n = 10) were included from a literature search of the electronic databases PubMed, CINAHL, PsycInfo, MedLine, and Cochrane Library. The results indicate that school refusal is highly present in neurodevelopmental disorders such as autism and attention-deficit/hyperactivity disorder due to the presence of behavioral problems and deficits in communication skills. As for psychiatric disorders, school refusal appears to be highly common in anxiety disorders, depressive disorders, and somatic symptoms. We also found that school refusal behavior may be associated with various emotional and behavioral conditions that act as risk factors. Especially, but are not limited to, it may be associated with a diminished self-concept, exposure to cyberbullying, specific affective profiles and excessive technology usage. Our results indicate that school refusal is a condition with many clinical facets. It can be attributed to both vulnerability factors, both temperamental and relational, and to various psychopathological conditions that differ significantly from each other, such as neurodevelopmental disorders and psychiatric disorders. Recognizing these aspects can improve the implementation of patient-tailored therapeutic interventions that are consequently more likely to produce effective outcomes. The therapeutic intervention should facilitate the recognition of cognitive biases regarding school as a threatening environment, while regulating negative emotions associated with school attendance. Additionally, therapeutic intervention programs linked to social skill training and problem-solving training, conducted directly within the school setting, can enhance children's abilities to cope with academic performance and social relationships, ultimately preventing school refusal.

School distress and the school attendance crisis: a story dominated by neurodivergence and unmet need

Background

The Covid-19 pandemic has brought into sharp focus a school attendance crisis in many countries, although this likely pre-dates the pandemic. Children and young people (CYP) struggling to attend school often display extreme emotional distress before/during/after school. We term this School Distress. Here we sought to elucidate the characteristics of the CYP struggling to attend school in the United Kingdom.

Methods

Using a case-control, concurrent embedded mixed-method research design, 947 parents of CYP with experience of School Distress completed a bespoke online questionnaire (February/March 2022), alongside an age-matched control group (n = 149) and a smaller group of parents who electively home-educate (n = 25).

Results

In 94.3% of cases, school attendance problems were underpinned by significant emotional distress, with often harrowing accounts of this distress provided by parents. While the mean age of the CYP in this sample was 11.6 years (StDev 3.1 years), their School Distress was evident to parents from a much younger age (7.9 years). Notably, 92.1% of CYP currently experiencing School Distress were described as neurodivergent (ND) and 83.4% as autistic. The Odds Ratio of autistic CYP experiencing School Distress was 46.61 [95% CI (24.67, 88.07)]. Autistic CYP displayed School Distress at a significantly earlier age, and it was significantly more enduring. Multi-modal sensory processing difficulties and ADHD (among other neurodivergent conditions) were also commonly associated with School Distress; with School Distress CYP having an average of 3.62 NDs (StDev 2.68). In addition, clinically significant anxiety symptomology (92.5%) and elevated demand avoidance were also pervasive. Mental health difficulties in the absence of a neurodivergent profile were, however, relatively rare (6.17%). Concerningly, despite the striking levels of emotional distress and disability reported by parents, parents also reported a dearth of meaningful support for their CYP at school.

Conclusion

While not a story of exclusivity relating solely to autism, School Distress is a story dominated by complex neurodivergence and a seemingly systemic failure to meet the needs of these CYP. Given the disproportionate number of disabled CYP impacted, we ask whether the United Kingdom is upholding its responsibility to ensure the "right to an education" for all CYP (Human Rights Act 1998).

Interview-Based Qualitative Descriptive Study on Risk Factors of School Withdrawal among Elementary School Children

With increasing school refusal among elementary school children, we qualitatively examined the associated factors. Elementary school teachers underwent semi-structured interviews, and the data generated were analyzed using SCAT. We conducted interviews with 27 teachers (18 men, nine women) responsible for children refusing to attend school. We analyzed verbatim transcripts of the interviews and abstracted six constructs for school refusal: underdeveloped interpersonal skills; families having difficulty in supporting their children to attend school; low self-esteem; diverse views on school refusal; tenuous relationships among local community members; and an environment where games and media are easily accessible. Children refusing to attend school may be unable to relate well to other people owing to underdeveloped interpersonal skills, and they may have low self-esteem. Regarding the home environment of children who are not positive about school life, living in families having difficulty in supporting their children to attend school may make the children less likely to do so. Because of tenuous relationships with local community members, there has been a decline in the involvement of people around children other than family members in encouraging school attendance. Recently, diverse views on school refusal have been accepted; increasingly, parents and children are likely to choose to spend time outside school. An environment in which games and media are easily accessible may make it easy to relate to other people without attending school, undermining the need for school attendance.