Absence from school and mental health

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.

Adapting a coach-assisted web-based intervention for parents of adolescents who refuse school: qualitative study with users of the Partners in Parenting Plus programme

BACKGROUND

School refusal is a heterogenous problem which typically emerges in adolescence and co-occurs with internalising disorders. A substantial proportion of adolescents do not respond to existing treatment modalities; thus, novel, effective intervention options are needed. Partners in Parenting Plus (PiP+) is a coach-assisted, web-based intervention designed to empower parents to respond to adolescent internalising disorders.

AIMS

To conduct a process evaluation of PiP+ and identify programme adaptations required to meet the needs of parents of adolescents who refuse school.

METHOD

Semi-structured interviews were conducted with 14 Australian mothers who had: (a) received the PiP+ programme (not tailored for school refusal) during a prior research trial; and (b) reported that their adolescent was refusing school during their participation in PiP+. Inductive thematic analysis was used to analyse interview transcripts.

RESULTS

Participants were 41-53 years old (M = 47.8) and parenting adolescent children aged 14-17 years (M = 14.9). Three themes illustrated how PiP+ features met or could better meet the needs of parents of adolescents who were refusing school: (a) feeling heard, supported and respected; (b) relevance to me and my context; and (c) seeing positive changes. Participants had favourable views of PiP+, especially coached components. Participants requested programme enhancements to better meet the needs of parents of neurodiverse adolescents and discussed the impact of cumulative help-seeking 'failures' on self-efficacy and locus of control.

CONCLUSIONS

PiP+ was highly acceptable to the majority of parents navigating the issue of school refusal. This has implications for the enhancement of coach-assisted parenting interventions and the context-specific adaptation of PiP+ for school refusal.

Chinese clients' experiences throughout family therapy for school-refusing adolescents: A multiperspectival interpretative phenomenological analysis

OBJECTIVE

This study aimed to explore Chinese clients' experiences with family dynamic change throughout family therapy for school refusal and the interventions adolescents and their parents identified as useful during family therapy.

METHODS

A multiperspective interpretative phenomenology analysis (IPA) was adopted. Thirty-two participants from 11 Chinese families with school-refusing adolescents were recruited after completing family therapy at the hospitals. Semistructured interviews were conducted with the families, and the transcripts were analyzed.

RESULTS

Four main superordinate themes emerged: reshaping healthy family boundaries, building a harmonious family atmosphere, learning to cooperate and fight against stress, and achieving individual growth.

CONCLUSION

Our analysis suggested that changes in school-refusing adolescents through family therapy consisted of multilevel factors. These factors influence the reversal of adolescents' school refusal. Some targeted interventions for Chinese adolescents who refuse school are discussed and suggested.

The relationship between depressive and anxious symptoms and school attendance among adolescents seeking psychological services in a public general hospital in China: a cross-sectional study

BACKGROUND

School attendance problems (SAPs), whether absenteeism or dropout, are strongly associated with poor outcomes for adolescents. We examined multiple variables that influence SAPs to identify potential leverage points for improving school attendance.

METHODS

Self-reported SAPs and demographic information was collected from 392 adolescents in adolescents presenting to the general hospital for psychological services. PHQ-9 and GAD-7 were applied to assess the severity of depressive and anxious symptoms. We constructed logistic regression analysis and the Chi-Square Automatic Interaction Detection (CHAID) segmentation analysis via SPSS Decision Tree to identifying risk factors for the development of SAPs in adolescents.

RESULTS

SAPs were self-reported by 252 (64.3%) adolescents. The SAPs group and non-SAPs group showed a significant difference in age, PHQ9 total scores, GAD7 total scores, schools, siblings, residence, parental marital quality, general health, regular exercise, and regular diet. A post hoc comparison between the two groups showed that the frequency of SAPs was significantly higher in the moderately-severe and severe depressive groups compared with other three groups (none, mild, moderate). The frequency of SAPs in severe anxious groups was significantly different from the none-anxious group. According to the binary logistic regression analysis, the depressive severity, siblings, residence, marital quality of parents, general health, and regular diet were correlated with the SAPs among adolescents. The adjusted OR of SAPs according to moderately-severe depressive symptoms was 10.84 (95%CI: 1.967-59.742) and severe depressive symptoms was 6.659 (95%CI: 1.147-38.666). In the decision tree model, PHQ-9 severity was extracted as the first splitting variable, with regular exercise and residence as the second, and siblings as the third. The ROC curves for predicting SAPs showed a fair diagnostic accuracy of the model with AUCs of CHAID model (0.705,95%CI:0.652-0.759, P = 0.000) and logistic regression model (0.777,95%CI:0.729-0.824, P = 0.000).

CONCLUSION

Our study provides insights into the associations between depressive symptoms and poor school attendance and identifies a number of risk factors associated with SAPs. Effective intervention by mental health practitioners, more attention by policy makers, and further research in this area are urgently needed for adolescents.

Developmental Issues Associated with Adolescent School Refusal and Cognitive-Behavioral Therapy Manuals

It is important to consider developmental issues when addressing school refusal (SR) in adolescence. Referral rates appear to be higher among adolescents relative to children, and treatment appears to be less effective among adolescents. This paper provides an in-depth review of developmental issues associated with adolescent SR and treatment via cognitive-behavioral therapy (CBT). It begins by considering the reasons for the higher referral and poorer treatment outcomes, including the higher level of absenteeism in adolescence, higher rates of concurrent social anxiety disorder and depressive disorder, and the developmental challenges inherent to adolescence. Such challenges include increased academic and social demands in the secondary-school environment, and increasing autonomy which may contribute to family conflict. These developmental issues may potentiate and exacerbate an adolescent's difficulty attending school, make it difficult for families to cope, and complicate practitioners' efforts to provide effective treatment for SR. Further, the review describes CBT manuals for SR and the extent to which they are developmentally sensitive. There are five CBT manuals, which vary in their sensitivity to developmental issues. Various multimodal treatments employ interventions in addition to CBT, such as medication or inpatient treatment, to address the complexity of SR in adolescence. Nevertheless, nonresponse to treatment for adolescent SR ranges from one-third to two-thirds of youths. Attention thus needs to be given to ways of improving treatment outcomes.

A Systematic Review of Somatic Symptoms in School Refusal

OBJECTIVE

School refusers often display somatic symptoms that are temporally related to school attendance. The aim of this systematic review is to summarize characteristics and causes of somatic symptoms and their management in the context of school refusal. Findings of this review may help clinicians in their daily practice.

METHODS

PubMed and PsycINFO databases were systematically searched (according to PRISMA guidelines) for articles mentioning somatic symptoms in school refusal by May 2020. Among 1025 identified studies, 148 were included.

RESULTS

Unspecific somatic symptoms were frequently the first complaints in school refusal. Abdominal pain, headache, nausea, vomiting, muscular or joint ache, diarrhea, dizziness, fatigue, and palpitation were the most commonly encountered symptoms and were usually not accounted for by an identifiable physical disease. Anxiety was the most recurrent etiology found, but physicians' lack of awareness about psychological comorbidities often delayed psychological/psychiatric referral. Successful therapies consisted of dialectical behavior therapy, anxiety management through relaxation/breathing training, and ignoring the somatic symptoms.

CONCLUSIONS

Somatic symptoms in school refusal are frequent but poorly understood. Their management could include interventions targeting anxiety, psychotherapies such as emotional awareness and expression therapy, third-wave behavioral therapies, and psychoeducation. A multidisciplinary approach through strengthened collaboration between school staff, physicians, and psychologists/psychiatrists is needed to improve well-being in children who experience somatic symptoms as related to school avoidance.

Common health conditions in childhood and adolescence, school absence, and educational attainment: Mendelian randomization study

Good health is positively related to children's educational outcomes, but relationships may not be causal. Demonstrating a causal influence would strongly support childhood and adolescent health as important for education policy. We applied genetic causal inference methods to assess the causal relationship of common health conditions at age 10 (primary/elementary school) and 13 (mid-secondary/mid-high school) with educational attainment at 16 and school absence at 14-16. Participants were 6113 children from the Avon Longitudinal Study of Parents and Children (ALSPAC). Exposures were symptoms of attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), depression, asthma, migraines and BMI. Genetic liability for these conditions and BMI was indexed by polygenic scores. In non-genetic, multivariate-adjusted models, all health conditions except asthma and migraines were associated with poorer attainment and greater school absence. School absence substantially mediated effects of BMI (39.9% for BMI at 13) and migraines (72.0% at 10), on attainment with more modest mediation for emotional and neurodevelopmental conditions. In genetic models, a unit increase in standardized BMI at 10 predicted a 0.19 S.D. decrease (95% CI: 0.11, 0.28) in attainment at 16, equivalent to around a 1/3 grade lower in all subjects, and 8.7% more school absence (95% CI:1.8%,16.1%). Associations were similar at 13. Genetic liability for ADHD predicted lower attainment but not more absence. Triangulation across multiple approaches supports a causal, negative influence on educational outcomes of BMI and ADHD, but not of ASD, depression, asthma or migraine. Higher BMI in childhood and adolescence may causally impair educational outcomes.

Multifamily Therapy for Adolescents With School Refusal: Perspectives of the Adolescents and Their Parents

Introduction: School refusal is an important public health concern in adolescent psychiatry increasing over the past several years (5% of child and adolescent psychiatry consultations in France). Multifamily therapy has developed over 30 years. Its efficacy is validated in adult, child and adolescent psychiatry, including for children at risk of school exclusion. In this study, we aimed to explore the adolescents and their parent's experience of a multifamily therapy treatment of school refusal with a qualitative method. Materials and Methods: This qualitative study is based on an Interpretative Phenomenological Analysis approach. We conducted 15 semi-structured interviews, participants were adolescents (n = 6) and their parents (n = 9) who experienced multifamily therapy in an adolescent department in Paris. Data analysis was performed independently by two researchers. Results: For the six families, school was a source of suffering, system paralysis and social exclusion. Families reported painful emotions and separation anxiety. For teenagers, multifamily therapy increased self-confidence and allowed group experience. For parents, it gave support and relieved from feelings of stigmatization and guilt. Parents became more aware of their adolescent's suffering and their insight. They all considered that multifamily therapy improved intra-family communication and expression of emotion. Participants highlighted the benefits of intergenerational interactions, activities, group and guidance from therapists. Discussion: Multifamily therapy uses therapeutic tools from both family therapy (joining, resonance, family competence, and metacommunication) and group therapy (use of media, identity device, and mirror reactions). Parents expect school solutions from multifamily therapy and question how psychiatric treatment can deal with school, school refusal being therefore understood as a social functioning disorder.

Association Between Parenting and School Refusal Among Elementary School Children in Japan: Results From A-CHILD Longitudinal Study

Objective: The aim of this study was to examine the association between parenting, including the parent-child interaction and child maltreatment in the first grade (6-7 years old), and school refusal in the second (7-8 years old) and fourth (9-10 years old) grades among elementary school children in Japan. Methods: Data were from the Adachi Child Health Impact of Living Difficulty (A-CHILD) longitudinal study conducted in 2015, 2016, and 2018 in Adachi City, Tokyo, Japan. A questionnaire was distributed to all the first-grade school children (N = 5,355) in 2015. Of the total 4,291 valid children (response rate: 80.1%), 3,590 and 3,070 children were followed up to the second and fourth grades, respectively. Caregivers responded to the questionnaire on the parent-child interaction and child maltreatment, including neglect, physical abuse, and psychological abuse in the first grade and school refusal in the second and fourth grades. We conducted multiple imputation for missing data. Multivariate logistic regression model was used for this analysis adjusting for child mental health in the first grade and sociodemographic characteristics. Results: Prevalence of school refusal was 1.8% (n = 64) in the second grade and 2% (n = 60) in the fourth grade. We found no association of the parent-child interaction and child maltreatment in the first grade and with school refusal in the second and fourth grades, respectively, after adjusting for covariates. Conclusions: Parenting, such as the parent-child interaction and child maltreatment, may not be associated with school refusal among elementary school children. Further longitudinal research is needed to elucidate other factors, such as peer relationships and school environment, which can affect school refusal.

Practitioner Review: School refusal: developments in conceptualisation and treatment since 2000

BACKGROUND

A generation has passed since the literature on the conceptualisation, assessment and treatment of school refusal was reviewed in this journal (Elliott, ). In the light of considerable gaps in the literature, identified at that time, and growing international interest, the current paper sought to identify progress subsequently made this century.

METHODS

We open with discussion of continuing conceptual uncertainty as to whether school refusal should incorporate both truancy and absenteeism marked by anxiety and distress. We then consider progress in treatment, and conclude by examining prognosis and subsequent adult functioning. In selecting intervention studies for review, our primary focus has been upon RCTS, systematic reviews and meta-analyses.

RESULTS

The literature review indicates that, since the turn of the century, there has been little substantial advance in knowledge that can guide practitioners. Many of the issues raised in the 1999 paper, in particular, conceptual confusion over this heterogeneous condition, a dearth of rigorous RCT designs, limited knowledge of underlying mechanisms and uncertainty as to the long-term effects of specific forms of intervention, are little clearer than before.

CONCLUSIONS

While several sound publications are available to guide intervention for school refusal, there is a continuing need for rigorous studies that can provide evidence to support individualised and tailored responses to an incapacitating problem with many causes and manifestations. While a multisystemic response to intervention approach is considered attractive, the practicalities of operating this across disparate professional borders are likely to present a long-term challenge.

A Systematic Review of Pharmacologic Treatments for School Refusal Behavior

OBJECTIVE

School refusal is an important pediatric problem with significant negative short- and long-term outcomes. Specific psychosocial treatments appear effective in reducing school refusal, but many children do not respond to these treatments. Although systematic reviews have examined the efficacy of psychological interventions for school refusal, no systematic reviews on pharmacological interventions exist.

METHODS

We conducted a comprehensive literature search of MEDLINE, PsycINFO, Scopus, and Embase for randomized controlled trials (RCTs) or quasi-experimental pharmacologic trials in children and adolescents with school refusal reported in English or Spanish until July 1, 2017. Two authors screened study titles and abstracts for eligibility. Data regarding the population, intervention, comparison, and outcomes for each trial were extracted and reported. Effect sizes for school attendance are presented.

RESULTS

The search identified 6 articles, including 7 trials (6 RCTs and 1 open label) and 306 youths. Pharmacologic treatments investigated for school refusal included antidepressants (imipramine, clomipramine, and fluoxetine) and benzodiazepines (alprazolam). All pharmacotherapies studied had pretreatment to posttreatment improvements on school refusal, depression, and anxiety symptoms. However, included trials were severely underpowered and did not demonstrate significant improvement compared to placebo.

CONCLUSIONS

Data regarding pharmacological treatments for school refusal are sparse. Most trials in this area were conducted before development of newer antidepressants, were underpowered, and have significant methodological limitations that are characteristic of the time in which they were conducted. This systematic review highlights the need for more trials with newer pharmacologic agents, larger sample sizes, and improved systematic assessments of school refusal and comorbidities. School refusal represents an important functional outcome for many children, especially those with anxiety and depression. Future pharmacologic studies of anxiety and depression in children may benefit from incorporating specific school refusal measures as secondary outcomes.

Maternal mental illness and mother-child relations

Interest in the relationship between mother-child interactions and mental health has two sources: awareness of the importance of correct parenting in personal development; and the exploration of postnatal mental illness.

Physical Activity and School Absenteeism Due to Illness in Adolescents

BACKGROUND

Knowledge about the beneficial role of physical activity (PA) for health and school performance is growing. Studies investigating the link between PA and school absenteeism due to illness are lacking. Therefore, we investigated associations between habitual PA and school absenteeism due to illness in adolescents and explored whether mental health and cardiovascular fitness mediated this association.

METHODS

We studied 328 students in grades 7 and 9 (mean age 13.8 years; 49% boys). The PA was measured objectively by an ActivPAL3™ accelerometer attached on the thigh during 1 full week (24 hours/day). Depressive symptoms and self-esteem were self-reported by the Center for Epidemiologic Studies Depression Scale (CES-D) and Rosenberg Self-Esteem Scale, respectively, and included as a proxy for mental health in the analyses. Cardiovascular fitness was measured by the 20-m shuttle-run test. School absenteeism due to illness data was provided by the school administration.

RESULTS

The PA was not significantly associated with school absenteeism, though there was an indirect association between PA and school absenteeism by cardiovascular fitness.

CONCLUSIONS

Cardiovascular fitness mediates the association between PA and school absenteeism due to illness. Thus, cardiovascular fitness of students should be improved to reduce school absenteeism due to illness.

Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial

This study investigates whether the augmentation of cognitive behavior therapy (CBT) with fluoxetine improves outcomes in anxious school refusing adolescents (11-16.5 years). Sixty-two participants were randomly allocated to CBT alone, CBT + fluoxetine or CBT + placebo. All treatments were well tolerated; with one suicide-attempt in the CBT + placebo group. All groups improved significantly on primary (school attendance) and secondary outcome measures (anxiety, depression, self-efficacy and clinician-rated global functioning); with gains largely maintained at 6-months and 1-year. Few participants were anxiety disorder free after acute treatment. During the follow-up period anxiety and depressive disorders continued to decline whilst school attendance remained stable, at around 54 %. The only significant between-group difference was greater adolescent-reported treatment satisfaction in the CBT + fluoxetine group than the CBT alone group. These results indicate the chronicity of school refusal, and the need for future research into how to best improve school attendance rates.

Chronic Fatigue Syndrome in Children and Adolescents: A Review Article

Clinicians have been describing individuals with chronic fatigue states for over 100 years, although chronic fatigue syndrome is often regarded as a modern disease. The aetiology of chronic fatigue syndrome is uncertain. For young individuals with chronic fatigue syndrome there are neither reliable prevalence figures nor scientific evidence concerning the effectiveness of treatments. Information obtained from research into adult individuals with chronic fatigue syndrome may be helpful but is not necessarily directly applicable to children and adolescents. Developmental factors and the influence of other family members on the course of the disorder in young sufferers should be considered. The uncertainties surrounding chronic fatigue syndrome should not deter child and adolescent mental health workers from becoming involved in the assessment and management of individual patients. The mainstay of treatment is rehabilitation with an emphasis on gradually increasing activities. Considerable attention will need to be given to engaging the young people and their families and working effectively with a multidisciplinary team. If mental health workers do not become involved in treating young people with chronic fatigue syndrome there is a risk that psychological factors will not be addressed and that chronic functional impairment will ensue.

Adverse Prenatal, Perinatal and Neonatal Experiences in Children with Anxiety Disorders

This study examined the incidence of adverse prenatal, perinatal, and neonatal experiences amongst children with anxiety disorders, and the relationship to clinical symptomology and functional impairment in treatment-seeking children (N = 107) with a primary anxiety disorder. Anxious children had higher rates of reported maternal prescription medication use during pregnancy, maternal smoking and illness during pregnancy and neonatal complications (including neonatal intensive care and feeding issues) compared with population base rates and non-affected children. Almost one-third had early problems with sleep. Developmental problems were common with more than half having at least one area of delay. More than three quarters of anxious children had a first-degree family member with a psychiatric history. There were several associations between neonatal complications and subsequent clinical symptomology, including attention deficit hyperactivity disorder and depressive comorbidity, anxiety severity and functional impairment. Findings suggest higher rates of perinatal complications in anxious children.

The downward spiral of mental disorders and educational attainment: a systematic review on early school leaving

BACKGROUND

Most psychiatric disorders present symptom patterns that cause severe impairment on the emotional, cognitive and social level. Thus, adolescents who suffer from a mental disorder risk finding themselves in a downward spiral caused by the reciprocal association of psychological symptoms and negative school experiences that may culminate in early school leaving. In addition to previous collective work that mainly focused on school refusing behaviour among children and was presented as an expert's opinion, the following systematic review fills the knowledge gap by providing a structured overview of the bidirectional association between mental health and secondary school dropout based on a sound methodology and with a particular focus on mediating factors.

METHODS

Four electronic databases were searched from January 1990 until June 2014. Selected references were assessed for study details, main results, mediating factors and methodological limitations. Standardized risk of bias assessment was conducted.

RESULTS

Mood and anxiety disorders seemed to have a less consequential direct effect on early school leaving than substance use and disruptive behaviour disorders. The association between externalizing disorders and educational attainment was even stronger when the disorder occurred early in life. On the other hand, internalizing disorders were reported to develop as a consequence of school dropout. Only few studies had addressed gender differences, with discrepant results. Socio-economic background, academic achievement and family support were identified as significant mediating factors of the association between mental disorders and subsequent educational attainment.

CONCLUSIONS

Findings suggested a strong association between mental health and education, in both directions. However, most studies focused on mediating factors that could not be targeted by intervention programs.

Ten year follow-up of children with school refusal

Objectives: To assess school refusal (school phobia) outcome in adult life.

Method: A 10 year follow-up used questionnaires completed by the target group of young adults and their parents and telephone interviews with their parents. Comparison groups were used.

Results: Psychiatric disorder was present in 30 % and caseness in a further 20%.

Conclusions: There is a need to identify interventions with long lasting effectiveness in this childhood disorder.

A newly identified group of adolescents at "invisible" risk for psychopathology and suicidal behavior: findings from the SEYLE study

This study explored the prevalence of risk behaviors (excessive alcohol use, illegal drug use, heavy smoking, reduced sleep, overweight, underweight, sedentary behavior, high use of Internet/TV/videogames for reasons not related to school or work, and truancy), and their association with psychopathology and self-destructive behaviors, in a sample of 12,395 adolescents recruited in randomly selected schools across 11 European countries. Latent class analysis identified three groups of adolescents: a low-risk group (57.8%) including pupils with low or very low frequency of risk behaviors; a high-risk group (13.2%) including pupils who scored high on all risk behaviors, and a third group ("invisible" risk, 29%) including pupils who were positive for high use of Internet/TV/videogames for reasons not related to school or work, sedentary behavior and reduced sleep. Pupils in the "invisible" risk group, compared with the high-risk group, had a similar prevalence of suicidal thoughts (42.2% vs. 44%), anxiety (8% vs. 9.2%), subthreshold depression (33.2% vs. 34%) and depression (13.4% vs. 14.7%). The prevalence of suicide attempts was 5.9% in the "invisible" group, 10.1% in the high-risk group and 1.7% in the low-risk group. The prevalence of all risk behaviors increased with age and most of them were significantly more frequent among boys. Girls were significantly more likely to experience internalizing (emotional) psychiatric symptoms. The "invisible" group may represent an important new intervention target group for potentially reducing psychopathology and other untoward outcomes in adolescence, including suicidal behavior.

Externalizing and internalizing syndromes in relation to school truancy among adolescents in high-risk urban schools

INTRODUCTION

To examine the relationship between externalizing/internalizing syndromes and school truancy among Form Four (10th grade) students attending "high-risk" schools in Kuala Lumpur.

METHODS

This is a cross-sectional study conducted upon 16-year-old adolescents attending three high-risk schools in Kuala Lumpur. A total of 373 students completed self-administered questionnaires on the sociodemographic variables and externalizing/internalizing syndromes. The number of truant-days per student during the study period was obtained from the school records.

RESULTS

The mean internalizing score, externalizing score and total problem score of those who were truant were found to be significantly higher (P < 0.05) than those who were non-truant. Multiple logistic regressions showed externalizing syndrome (odds ratio [OR] = 1.044; confidence interval [CI] = 1.012-1.078, P = 0.018) significantly predicts truancy but not the internalizing syndrome. Two other psychosocial factors, namely, having divorced parents (OR = 2.495, CI = 1.058-5.886, P = 0.037) and did not understand or were uncertain of the purpose of schooling (OR = 2.621, CI = 1.265-5.433, P = 0.010) were also showed to be stronger predictors of truancy compared to externalizing/internalizing syndromes.

DISCUSSION

Truancy has significant association to externalizing syndrome, in addition to other significant psychosocial variables like parental and schooling factors. This finding indicated the need for comprehensive assessment of students presenting with truant behavior, including the identification of associated psychological and behavioral problems which highlights the roles of mental health professionals in tackling truancy.

School dropouts: examining the space of reasons

BACKGROUND

Dropping out of school is a worldwide phenomenon with drastic mental health consequences for children, families and society. AIM AND MATERIALS METHODS: This study examines school dropouts in one district in Kerala with an emphasis on looking at multiple reasons for the problem.

RESULTS

The most common "reason" was various Physical disorders (80, 21.8%) followed by Mental Retardation (77, 20.9%). Child labour (Employment) came last (30, 8.1%) as a "reason" while financial issues constituted 50 (13.6%). Family issues accounted for 63 (17.1%) and School-related issues 68 (18.5%).

CONCLUSION

This study highlights the need to examine a space of reasons for this phenomenon with active involvement and coordination of multiple agencies to examine and support getting children back to school and prevent dropouts.

Effectiveness of integrated psychological therapy (IPT) for schizophrenia patients: a research update

Standardized recovery criteria go beyond symptom remission and put special emphasis on personal and social functioning in residence, work, and leisure. Against this background, evidence-based integrated approaches combining cognitive remediation with social skills therapy show promise for improving functional recovery of schizophrenia patients. Over the past 30 years, research groups in 12 countries have evaluated integrated psychological therapy (IPT) in 36 independent studies. IPT is a group therapy program for schizophrenia patients. It combines neurocognitive and social cognitive interventions with social skills and problem-solving approaches. The aim of the present study was to update and integrate the growing amount of research data on the effectiveness of IPT. We quantitatively reviewed the results of these 36 studies, including 1601 schizophrenia patients, by means of a meta-analytic procedure. Patients undergoing IPT showed significantly greater improvement in all outcome variables (neurocognition, social cognition, psychosocial functioning, and negative symptoms) than those in the control groups (placebo-attention conditions and standard care). IPT patients maintained their mean positive effects during an average follow-up period of 8.1 months. They showed better effects on distal outcome measures when all 5 subprograms were integrated. This analysis summarizes the broad empirical evidence indicating that IPT is an effective rehabilitation approach for schizophrenia patients and is robust across a wide range of sample characteristics as well as treatment conditions. Moreover, the cognitive and social subprograms of IPT may work in a synergistic manner, thereby enhancing the transfer of therapy effects over time and improving functional recovery.

Social anxiety level in Turkish adolescents

Social phobia is a mental disorder characterized by extreme and consistent fear of meeting new people, scrutiny in a variety of performance and/or interactional situations. The aim of this study was to investigate the level of self-reported social anxiety in a community sample of Turkish adolescents and the relationship between social anxiety and some sociodemographic parameters. This study was a school-based cross-sectional study. Students in grades 6-8 (aged 10-16) from 12 schools in Kocaeli/Turkey were screened by the Social Anxiety Scale for Adolescents (SAS-A). The correlations of sociodemographic parameters with the SAS-A scores were examined. Data from a sample of 1,713 students (865 boys 50.4% and 848 girls 49.5%) were analyzed. A significant gender difference in the SAS-A points was found. Boys reported higher SAS-A total and subscale scores (except social avoidance and distress-general subscale score) than did girls. A significant negative correlation was found between socioeconomic status and social anxiety level. SAS-A scores were higher in those with a low socioeconomic level, and who were going to rural schools. The result of this study showed that social phobic symptoms among Turkish adolescents were more severe in boys. Some factors such as low socioeconomic level, and going to a rural school had impact on the SAS-A scores. As the impairment in the school-domain was reported to be quite high, professionals and teachers need to recognize social anxiety in adolescents, so that help can be offered to overcome the difficulties social phobia causes.

The Effect of Pupil Absenteeism on Literacy and Numeracy in the Primary School

Although school psychologists are involved in dealing with the problem of pupil absenteeism at both the individual child and whole school level, one of the possible reasons for their involvement, namely the belief that significant absence from school has an effect on attainments, is actually founded on weak evidence. The literature review presented in this article revealed that, in order to determine the effect of absence on attainments, no satisfactory study had hitherto been conducted in which attainments had been measured before and after a period of absence. However, the results of longitudinal research partially conducted by the present author, reported in this article, do show that absence from school has a significant effect on primary school attainments. In particular, it was found that an absence of half a year between the ages of 7- and 11-years-of-age resulted in a reduction of 0.7 of a year and 1 year in reading and mathematics test scores respectively. The article ends with a consideration of the kind of research which still needs to be conducted in order to provide school psychologists with the information they need to deal successfully with pupil absenteeism problems.

Academic attainment: a predictor of psychiatric disorders?

AIM

Poor academic performance can reflect the neurobiological abnormalities underlying schizophrenia and has been suggested as a premorbid marker for the disorder. However, it is not clear as to how academic performance compares as a marker for other mental disorders. The objective of this study was to examine whether educational attainment is a candidate marker for certain psychiatric disorders.

METHODS

Using a retrospective cohort design, we compared the early educational performance of 6957 National Service male conscripts. The presence of mental illness was assessed using the Composite International Diagnostic Interview. Academic performance was assessed using the results of a standardized national examination after 6 years of primary education.

RESULTS

Adjusting for ethnicity, the scores from this examination revealed that those with schizophrenia spectrum disorders scored significantly lower than those without any mental illness.

CONCLUSIONS

Poor educational attainment predicts the onset of schizophrenia spectrum disorders and could be a possible predictor for this specific group of mental illness.

Cognitive remediation: a promising tool for the treatment of schizophrenia

Cognitive remediation is a type of treatment added recently to the range of tools available to therapists. It includes a number of miscellaneous methods that aim to correct some of the cognitive impairments observed in schizophrenia. These cover the fields of target attention, memory and executive deficits, as well as impaired social cognition. Cognitive remediation acts as a complement to medication and psychological therapies, which constitute the core methods of treatment for schizophrenia. The present paper reviews the state of the art in cognitive remediation. The principle underlying this innovative therapeutic approach is the enhancement of the cognitive resources of patients with schizophrenia in order to improve their cognitive functions, social skills and in some cases alleviate some of the symptoms of the disease. Several programs developed within the past two decades (e.g., IPT, CRT, NEAR, CET, NET, CRT and CAT) are becoming more widely used. Their efficacy on neurocognition and on functional outcome has been demonstrated, with inconstant continuation of benefit after completion of treatment. The sustainability of the cognitive and functional improvements following completion of these programs has to be further studied. Other programs aimed at acting upon altered social cognition (one of the critical facets of schizophrenia) are still in the experimental stages, but the results obtained so far are encouraging. A preliminary study has also demonstrated the effectiveness of board games in improving cognitive functioning, which seems to be a highly promising therapeutic avenue owing to its ease of use.

Associations of health risk behaviors with school absenteeism. Does having permission for the absence make a difference?

BACKGROUND

Nearly 10% of students enrolled in US public schools are absent daily. Although previous research has shown associations of school absenteeism with participation in risk behaviors, it is unclear if these associations vary by whether the absence was excused. The purpose of this study was to examine the associations of health risk behaviors with being absent from school with and without permission among high school students.

METHODS

During spring 2004, questionnaires similar to the Youth Risk Behavior Survey questionnaire were completed by 4517 ninth- and eleventh-grade students. Responses to items assessing frequency of school absences during the past 30 days for any reason and without permission were combined to create a variable coded as absent on: 0 days; > or =1 day, all with permission (WP); and > or =1 day, at least 1 day without permission (WOP). Logistic regression analyses controlling for gender, grade, and race/ethnicity examined the association of risk behaviors with absenteeism.

RESULTS

Controlling for demographic variables, compared to students who were absent 0 days, students who were absent WP had significantly higher odds of engaging in 25 of 55 risk behaviors examined and students who were absent WOP had significantly higher odds of engaging in 43 of the 55 behaviors. Students who were absent WOP also had approximately twice the odds of engaging in risk behaviors compared to students who were absent WP.

CONCLUSIONS

School absenteeism, with and without permission, is associated with risk behaviors. Schools should recognize absenteeism for any reason as a warning sign for a variety of risk behaviors.

Absenteeism Rates in Students Receiving Services for CDs, LDs, and EDs: A Macroscopic View of the Consequences of Disability

Purpose

Elevated levels of absenteeism have been reported for students receiving special education services, especially students with learning disabilities (LDs) and emotional disturbances (EDs). In contrast, little is known about absenteeism rates associated with students with communication disorders (CDs).

Method

Archival records of student attendance for the 1997–2001 academic years from a mid-sized urban school district in the Intermountain West were used to examine absenteeism rates in students receiving services for CDs, LDs, and EDs. Two cohort samples were generated (K–4th grade and 5th–9th grade).

Results

Students with CDs displayed absenteeism rates that were comparable to those of students receiving general education. Significant group and group × grade effects were found. Students in the LD and ED groups displayed elevated levels of absenteeism, especially at Grade 9.

Conclusion

The outcomes of this study support the characterization of the socioemotional concomitants associated with CDs as being typologically different and exerting a weaker influence on student’s health levels than those associated with either LDs or EDs.

Le refus scolaire

Pediatrician are often questioned by school refusal which relies on a wide range of psychopathological features and necessitates specific approaches. This disabling condition remains underestimated and is still increasing. A poor prognosis associated with a prolonged school absence is the common hallmark of school refusals, regardless of its heterogeneity. Its seriousness warrants early identification and prompt intervention by childhood healthcare professionals, teachers and social workers. A specialized treatment is needed, closely linked with families and school. Promising developments come from a functional rather than symptomatic concept of school refusal. They offer tailored interventions which fit the clinical diversity of school refusals. After a brief historical summary and current definitions of school refusal, the authors review the main clinical features and comorbidity before taking up treatment modalities.

Fobia social em uma amostra de adolescentes

Este estudo relata a prevalência e o impacto na escolaridade da fobia social em uma amostra de adolescentes da cidade de São Paulo, SP, Brasil. O Inventário de Fobia Social (SPIN) foi administrado em 116 estudantes adolescentes de 5ª, 6ª, 7ª e 8ª séries de ambos os sexos. A prevalência da fobia social foi de 7,8% na amostra de adolescentes, com maior incidência entre estudantes do sexo feminino, com idade entre 12 e 15. O impacto negativo na escolaridade foi grande, aproximadamente 89% dos adolescentes com fobia social repetiram o ano na escola ao menos uma vez.

Who are the kids who self-harm? An Australian self-report school survey

OBJECTIVE

To determine the prevalence and types of deliberate self-harm (DSH) in adolescents, and associated factors.

DESIGN

A cross-sectional questionnaire study.

PARTICIPANTS AND SETTING

3757 of 4097 Year 10 and Year 11 students (91.7%) from 14 high schools on the Gold Coast, Queensland, during September 2002.

MAIN OUTCOME MEASURES

DSH behaviour, including descriptions of the last act, psychological symptoms, recent stressors, coping styles, help-seeking behaviour, lifestyle choices, and self-prescribing of medications.

RESULTS

233 students (6.2%) met the criteria for DSH in the previous 12 months, with DSH more prevalent in females than males (OR, 7.5; 95% CI, 5.1-10.9). The main methods were self-cutting (138 respondents; 59.2%) and overdosing with medication (69 respondents; 29.6%). Factors associated with DSH included similar behaviours in friends or family, coping by self-blame, and self-prescribing of medications. Most self-harmers did not seek help before or after their most recent action, with those who did primarily consulting friends.

CONCLUSIONS

DSH is common in Australian youth, especially in females. Preventive programs should encourage young people to consult health professionals in stressful situations.

Factors related to school absenteeism in adolescents with recurrent headache

OBJECTIVE

To examine possible risk and protective factors for school absenteeism among adolescents referred to a hospital-based behavioral treatment program.

DESIGN

Data obtained from intake interviews, screening questionnaires, and baseline headache diaries of 283 consecutive adolescents referred for behavioral treatment of recurrent headache were reviewed for demographics, length of headache history, headache type, current headache activity, symptoms of anxiety and depression, perceived self-efficacy regarding headache control, school performance, participation in extracurricular activities, and school absenteeism. The study population was divided into 2 groups at the median number of days missed due to headache in the previous 6 months that school was in session. Adolescents who missed 2 or less days of school due to headache (low absenteeism) were compared with those who missed more than 2 days (high absenteeism).

RESULTS

Compared with the low absenteeism group, the high absenteeism group had higher scores on the Children's Depression Inventory (8.7 +/- 6.5 versus 6.8 +/- 6.2, P <.05) and lower academic performance (2.1 +/- 1.0 versus 1.7 +/- 0.8, P <.0001). The 2 groups were not statistically different in age, sex, length of headache history, type of headache, current headache frequency or intensity scores, anxiety scores, self-efficacy ratings, or participation in extracurricular activities.

CONCLUSIONS

In a referred population, students who missed more school due to headache had higher depression scores and lower academic performance than students who missed less school. A directional relationship, however, cannot be implied from these results. Future studies should investigate the complex relationship between recurrent adolescent headache, potential risk or protective factors, and school absenteeism.

The impact of anxiety disorders on educational achievement

Anxiety disorders typically have an age of onset in childhood and adolescence, resulting in significant disability in social and occupational functioning. Epidemiological evidence suggests that persons with psychiatric disorders and perhaps especially social phobia are at increased risk for premature withdrawal from school [Am. J. Psychiatry 157 (2000) 1606]. In order to further determine the impact of anxiety disorders on school functioning and/or premature withdrawal from school, 201 patients meeting DSM-IV criteria for a primary anxiety disorder completed a school leaving questionnaire as well as self-report measures of anxiety, depression, and social adjustment. About 49% (n = 98) reported leaving school prematurely and 24% of those indicated that anxiety was the primary reason for this decision. Patients who had left school prematurely were significantly more likely to have a lifetime diagnosis of generalized social phobia, a past history of alcohol abuse/dependence and a greater number of lifetime diagnoses than those who completed their desired level of education. This study suggests that anxiety disorders, and perhaps especially generalized social phobia, are associated with premature withdrawal from school. Further studies are required to determine methods for early identification and treatment of anxiety disorders in school aged children to enable these students to reach their full potential.

School refusal and psychiatric disorders: a community study

OBJECTIVE

To examine the association between anxious school refusal and truancy and psychiatric disorders in a community sample of children and adolescents using a descriptive rather than etiological definition of school refusal.

METHOD

Data from eight annual waves of structured psychiatric interviews with 9- to 16-year-olds and their parents from the Great Smoky Mountains Study were analyzed.

RESULTS

Pure anxious school refusal was associated with depression (odds ratio [OR] = 13, 95% confidence interval [CI] 3.4, 42) and separation anxiety disorder (OR = 8.7, 95% CI 4.1, 19). Pure truancy was associated with oppositional defiant disorder (OR = 2.2, 95% CI 1.2, 4.2), conduct disorder (OR = 7.4, 95% CI 3.9, 14), and depression (OR = 2.6, 95% CI 1.2, 56). Of mixed school refusers (children with both anxious school refusal and truancy), 88.2% had a psychiatric disorder. They had increased rates of both emotional and behavior disorders. Specific fears, sleep difficulties, somatic complaints, difficulties in peer relationships, and adverse psychosocial variables had different associations with the three types of school refusal.

CONCLUSIONS

Anxious school refusal and truancy are distinct but not mutually exclusive and are significantly associated with psychopathology, as well as adverse experiences at home and school. Implications of these findings for assessment, identification, and intervention for school refusal are discussed.