School refusal: epidemiology and management

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.

Childhood Reading Ability and Pain in Childhood Through to Midlife

Dyslexia and pain have recently been shown to correlate on a genetic level, but there has been little exploration of this association on the phenotypic level despite reports of increased pain in Attention Deficit Hyperactivity Disorder, which commonly co-occurs with dyslexia. In this study we test for an association between reading ability, which is the primary feature of dyslexia, and pain both in childhood and adulthood. Logistic regression modeling was used to test associations between reading ability in childhood and pain from childhood to midlife in a large UK birth cohort; the 1958 National Child Development Study. Associations were found between poor childhood reading ability and increased headache and abdominal pain in childhood, and between poor childhood reading ability and headache, eye pain, back pain, and rheumatism in adulthood. Mediation analyses indicated that socioeconomic status (defined by employment) fully mediated the association between poor reading ability in childhood and back pain at age 42. By contrast, the association between reading ability and eye pain acted independently of socioeconomic status. Different mechanisms were thus indicated for the association of reading with different pain types, including manual labor and a potential shared biological pathway. PERSPECTIVE: This study found a relationship between poor reading ability in childhood and pain in childhood and adulthood. Those with reading difficulties should be monitored for pain symptoms. Future research may uncover shared biological mechanisms, increasing our understanding of pain and potential treatments.

Psychological characteristics and emotional difficulties underlying school refusal in adolescents using functional near-infrared spectroscopy

BACKGROUND

This study aims to explore the psychological characteristics, related emotional problems and potential NIR brain function mechanism of adolescents who refuse to attend school.

METHODS

The study included 38 adolescents (12-18 years old) who were not attending school and 35 healthy controls (12-18 years old) who are attending school regularly. Participants completed (1) general demographics, (2) Eysenck Personality Questionnaire (EPQ), (3) Zung Self-Rating Depression Scale (SDS), (4) Zung Self-Rating Anxiety Scale (SAS), and (5) Symptom Checklist-90 (SCL-90). In addition to the clinical tests, participants completed functional near-infrared spectroscopy (fNIRS). Mental health, personality, and emotional state were evaluated in both groups to explore the differences and to understand the underlying mechanisms of school refusal during adolescence.

RESULTS

Adolescents who did not attend school had higher neuroticism scores on the Eysenck Personality Questionnaire than healthy controls (p(FDR) < 0.001), introversion and concealment scores were lower than those of healthy controls (p(FDR) < 0.001), there was no significant difference in psychoticism scores between groups. SDS, SAS, SCL-90 scores and factor scores were higher than those of healthy control group (p(FDR) < 0.001), NIR functional brain imaging was different from healthy control group in the 12 and 27 channels (p(FDR) = 0.030, p(FDR) = 0.018), and no difference was found in the remaining channels (p(FDR) > 0.05). There were statistically significant differences in age and gender between the adolescents who refused school and the control group (p(FDR) < 0.001).

CONCLUSION

School refusal adolescents are relatively introverted and sensitive and need more attention in daily life. Although the adolescents' emotional problems did not reach the diagnostic criteria of depressive disorder and anxiety disorder, their scores were still higher than those of the control group, suggesting that we should pay more attention to their emotional problems in order to better help them return to school. Using fNIRS, it was found that abnormalities in frontal lobe regions in adolescents with school refusal behaviors, which would contribute to early diagnosis and timely intervention of school refusal behaviors.

Modifiable Parent Factors Associated with Child and Adolescent School Refusal: A Systematic Review

School refusal is a complex problem that refers to difficulty attending/remaining at school due to emotional distress about attendance. Despite its occurrence being associated with negative outcomes, many are unresponsive to the current treatment options. While parent factors have a key role to play in school refusal, they are not adequately addressed in existing treatments. Further research is needed to consolidate understanding and implement new treatments. Employing the PRISMA method, this review aims to identify modifiable parent factors associated with child and/or adolescent school refusal. Eight studies met inclusion criteria from which nine factors were identified. Factors found to be associated with school refusal included: parent psychopathology, family functioning and maternal overprotection (communication subdomain). Other factors such as maternal overprotection (affection, assistance and travel subdomains) and parental self-efficacy had weak or inconsistent results warranting further investigation. Overall, findings call for action in this field that has sparse and dated literature.

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).

School Refusal in Immigrants and Ethnic Minority Groups: A Qualitative Study of Adolescents' and Young Adults' Experiences

BACKGROUND

School refusal is one cause of school absenteeism along with truancy, and the two can be difficult to distinguish. School absenteeism behaviors among students in transcultural situations (immigrants or children of immigrants) and from ethnic minority groups are subject to misdiagnosis and decreased access to care. To improve the care provided, this exploratory study addresses the experience of adolescents and young adults engaging in school refusal, from immigrant and ethnic minority groups.

METHODS

Sixteen participants between the ages of 16 and 20 years old presenting with school refusal were interviewed for this qualitative study. All participants were either immigrants, children of immigrants, or from an ethnic minority group. We conducted a qualitative analysis based on Interpretative Phenomenological Analysis.

RESULTS

Participants experienced school refusal as a loss of identity and as a failure to achieve what was perceived as parental expectations of success, which triggered feelings of worthlessness, shame, and guilt. The loss of a peer group, namely their classmates, as a result of school absenteeism was experienced as a marginalization from the larger society. Although participants denied having personally experienced racism, some of them recalled their parents experiencing racism at school.

CONCLUSION

School refusal complicates identity construction, autonomy, and integration into society. For adolescents and young adults from immigrant and ethnic minority backgrounds, it also triggers guilt, transgenerational traumatic memories, and the fear of marginalization. In addition to validated therapies for school refusal, sociological, intersectional, and cross-cultural tools would be a valuable addition to treatment.

What Contributes to the Development and Maintenance of School Refusal in Chinese Adolescents: A Qualitative Study

Objective: Although, there has been a growing number of studies on school refusal in Western cultures, the underlying factors that contribute to school refusal in Chinese adolescents remain unclear. This study aimed to better understand why Chinese adolescents refuse to go to school and to further interpret what they want to express through their school refusal behaviors. Methods: We performed a qualitative study using an interpretative phenomenological analysis. Twenty adolescents with school refusal experiences were recruited from the clinical psychology department of two mental health hospitals in Shanghai, China. They participated in semistructured, face-to-face in-depth interviews. The interviews were transcribed verbatim and analyzed according to the guidelines of interpretative phenomenological analysis. Findings: Five main superordinate themes emerged from data analysis: (a) competition-oriented social environment; (b) family living space dominated by conflicts; (c) personal living space lacking meaningful support; (d) conflict between the pros and cons of being labeled with a psychiatric diagnosis; and (e) reintegration in school life. Conclusions: Our analysis emphasized the complex interacting effects of the social environment, family interpersonal conflicts, personal psychological factors and mental health complaints on the development and maintenance of Chinese adolescents' school refusal. These factors contributed to school refusal at each level and influenced each other's effects on school refusal behaviors. Therefore, interventions for Chinese teenagers with school refusal may need to integrate strategies that inspire reorganization and changes in different ecosystems, such as strategies related to government policy, peer relationships, family systems and individual inner dynamics.

Longitudinal Effects of the Pandemic and Confinement on the Anxiety Levels of a Sample of Spanish Children in Primary Education

(1) Background: The psychological effects of confinement due to the SARS-CoV-2 virus pandemic on children are only partially known. In Madrid, Spain, children suffered a strict confinement for 10 weeks and they returned to school under conditions that were far from normal. This work assesses the effects of the pandemic on the anxiety levels of a group of children living in Madrid. (2) Methods: Children were aged 6 to 11 years (N = 215). A self-report measure of anxiety was completed by participants at two time-points: (1) a few months before the beginning of the pandemic and (2) 1 year later. A smaller subgroup of participants also completed the measure during the confinement period (n = 60). (3) Results: A comparison of these three measures shows that the children’s anxiety was reduced during confinement, and that one year later these levels continue below those registered before the start of the pandemic. (4) Conclusions: These results contradict some previous studies, which found an increase in children’s anxiety as a result of confinement and the pandemic. The discussion considers protective and vulnerability factors in the context of the pandemic, which may affect children’s levels of anxiety.

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.

Types and correlates of school non-attendance in students with autism spectrum disorders

School non-attendance in autism spectrum disorders has received very little attention to date. The study aimed to provide a comprehensive description of school non-attendance in students with autism spectrum disorders. Through an online survey, parents of 486 children (mean age: 11 years) reported on school attendance over 1 month and reasons for instances of non-attendance. On average, students missed 5 days of school of a possible 23 days. Persistent non-attendance (absent on 10%+ of available sessions) occurred among 43% of students. School non-attendance was associated with child older age, not living in a two-parent household, parental unemployment and, especially, attending a mainstream school. School refusal accounted for 43% of non-attendance. School exclusion and school withdrawal each accounted for 9% of absences. Truancy was almost non-existent. Non-problematic absenteeism (mostly related to medical appointments and illness) accounted for 32% of absences. Non-problematic absenteeism was more likely among those with intellectual disability, school refusal was more likely among older students and school exclusion was more likely among students from single-parent, unemployed and well-educated households. Findings suggest that school non-attendance in autism spectrum disorders is a significant issue, and that it is important to capture detail about attendance patterns and reasons for school non-attendance.

The Mediator Role of Academic Resilience in the Relationship of Anxiety Sensitivity, Social and Adaptive Functioning, and School Refusal With School Attachment in High School Students

School has an important function in providing the environment for young people to acquire many skills and knowledge required by contemporary life, but the problems of attachment to school and problematic attendance all over the world reveal an increasing statistic. It is thought that some negative processes such as anxiety sensitivity, social and adaptive functioning, and school refusal can affect this problem. On the other hand, it is considered that the academic resilience of young people has an important protective function in terms of these risk factors. For this purpose, the mediator role of academic resilience between anxiety sensitivity, social and adaptive functioning, and school refusal and school attachment were examined in a Turkish sample of 452 high school students. In the process of data collection, the school refusal assessment scale, social and adaptive functioning scale, and academic resilience scale were adapted and used in the Turkish culture. In the data analysis, the structural equation model was used to determine the direct and indirect predictive effects between the variables. The results of the study showed that academic resilience fully mediated the relationship between anxiety sensitivity and school attachment, whereas it partially mediated the relationship between social and adaptive functioning and school refusal and school attachment. Based on the results of the study, it was evaluated that high academic resilience has a strong protective function against the problems of negative school attachment and problematic school absenteeism among young people, and this finding was discussed within the context of literature.

Towards a comprehensive assessment of school absenteeism: development and initial validation of the inventory of school attendance problems

School attendance problems (SAPs) become manifest in many ways and are associated with multiple risk factors, calling for comprehensive assessment methods. This study documents the development of the inventory of school attendance problems (ISAP), which assesses both the quality and the function of a broad spectrum of SAPs by first asking students with SAPs to rate the intensity of symptoms prior to or at school and then to rate their impact on school attendance. An empirically generated pool of 124 items was analyzed (explorative factor analysis) using a clinical sample of N = 245 students with SAPs (53.5% male; M_age: 14.4). The Youth Self Report (YSR), a German version of the School Refusal Assessment Scale (SRAS), and the extent of school absenteeism were used to determine construct validity. The resulting 48 items loaded on 13 factors. The 13 scales assess internalizing and externalizing symptoms (Depression, Social Anxiety, Performance Anxiety, Agoraphobia/Panic, Separation Anxiety, Somatic Complaints, Aggression, School Aversion/Attractive Alternatives) as well as emotional distress due to problems in the school or family context (Problems with Teachers, Dislike of the Specific School, Problems with Peers, Problems Within the Family, Problems with Parents). All scales showed good internal consistencies. Their correlations with the YSR and the SRAS indicated convergent and discriminant validity. Positive associations between most of the scales and the extent of school absenteeism were obtained. Although preliminary, these results support the usefulness of the ISAP for a comprehensive assessment of SAPs in clinical settings.

Migrant Parents of Adolescents With School Refusal: A Qualitative Study of Parental Distress and Cultural Barriers in Access to Care

Introduction: School refusal is an important problem in adolescent psychiatry. However, little is known about the experience of school refusal among minority youth (migrants and minority ethnic groups). This study assesses how parents of various cultural backgrounds experience their adolescents' school refusal. Method: This qualitative study is based on interviews of 11 parents of teenagers diagnosed with school refusal at three adolescent outpatient mental health units in Paris and its suburbs. Interpretative phenomenological analysis was used for the thematic investigation. Results: The analysis found four themes: (i) confronting school and school refusal distresses parental representations; (ii) school refusal as a failure of the family's obligation to succeed after migration; (iii) representations of school that fluctuate with time since arrival: idealization, followed by mistrust and disappointment in the inequalities, even the racism; (iv) solutions envisioned for school refusal, confronting the healthcare system, stigma, and, again, inequality. Conclusion: All parents question their parenting choices when their children become school refusers. However, when families belong to minority groups, school refusal calls into question parents' relations with the French school system and their immigration choices. At the same time, the construction of a multicultural identity for children and adolescents in transcultural situations requires them to strike a balance between two worlds, and school refusal endangers this delicate negotiation. Subsequent misunderstandings can lead clinicians to misdiagnose school refusal as truancy. Clinicians must take the parents' culture and migration history into account to minimize the risk of complete failure of treatment for school refusal and the ensuing inequality of care and opportunity that can result.

School Refusal Behavior in Indian Children: Analysis of Clinical Profile, Psychopathology and Development of a Best-Fit Risk Assessment Model

OBJECTIVES

School refusal is seen as an emergency in child psychiatry and various risk factors have been analyzed. Children who present with school refusal have been shown to have several associated psychiatric comorbidities. However, risk assessment of psychiatric comorbidities is lacking, particularly in the Indian context. The authors aimed to study the sociodemographic profile and associated psychopathology in children with school refusal. They compared the prevalence rates of psychiatric illnesses to that of the community. A best-fit model for risk assessment of psychopathology was formulated.

METHODS

Past records of children aged 5-16 y, who presented with school refusal in the period from June 2013 through June 2015 to authors' Child Guidance Clinic were studied and their sociodemographic details, symptoms and diagnoses were obtained. Chi square test of proportion was used to compare the prevalence rates between the study population and community. Multinomial analysis was used to elucidate a best-fit model of risk assessment.

RESULTS

School refusal was seen in 3.6% of children. 77.8% of the children had a psychiatric diagnosis, most common being depression (26.7%), followed by anxiety (17.7%). Prevalence of psychiatric disorders was significantly higher in the study population than community (p < 0.05). A best-fit model of 4 factors: academic difficulties, adjustment problems at school, behavioral problems and parental conflicts is suggested (p < 0.05).

CONCLUSIONS

School refusal is associated with significant psychopathology, most commonly depression, followed by anxiety. The best-fit model for risk assessment can predict the likelihood of psychopathology and help in early diagnosis.

[Adolescent sleep disorders associated with school absenteeism: The child and adolescent psychiatrist is often crucial for effective management in sleep consultation]

INTRODUCTION

Adolescent sleep is characterized by a physiological delayed sleep phase disorder frequently exacerbated by the intensive use of information and communication technologies. The sleep restriction thus induced during schooling has consequences on the physical and psychological health of the adolescent. On the other hand, the sleep complaint may correspond to psychiatric disorders in the adolescent. Thus, when this complaint is associated with school absenteeism, the management of sleep alone is often insufficient. In order to understand the reason for this inefficiency, we wanted to better characterize the profile of these adolescents.

METHOD

We have developed a somnological and psychiatric "screening kit" resulting in a management decision tree. This kit was tested in 2017 as part of joint consultations at the Lyon Sleep Center in adolescents who presented a complaint of sleepiness or insomnia associated with school absenteeism.

RESULTS

These preliminary results on 11 patients show the predominance of a delayed sleep phase syndrome or an absence of sleep diagnosis associated in more than 90 % of cases with anxiety-depressive difficulties ranging from the mood depressive disorder to the school refusal behavior and underlying anxiety disorders. Somatization is also common.

CONCLUSION

These first data seem to confirm the need for a child and adolescent psychiatric assessment to deal with the psychological difficulties of these adolescents in parallel with their sleep complaint so as to offer them the best chances of improvement, re-schooling and social insertion.

Adolescent mental health and behavioural predictors of being NEET: a prospective study of young adults not in employment, education, or training

BACKGROUND

Young adults who are not in employment, education, or training (NEET) are at risk of long-term economic disadvantage and social exclusion. Knowledge about risk factors for being NEET largely comes from cross-sectional studies of vulnerable individuals. Using data collected over a 10-year period, we examined adolescent predictors of being NEET in young adulthood.

METHODS

We used data on 1938 participants from the Victorian Adolescent Health Cohort Study, a community-based longitudinal study of adolescents in Victoria, Australia. Associations between common mental disorders, disruptive behaviour, cannabis use and drinking behaviour in adolescence, and NEET status at two waves of follow-up in young adulthood (mean ages of 20.7 and 24.1 years) were investigated using logistic regression, with generalised estimating equations used to account for the repeated outcome measure.

RESULTS

Overall, 8.5% of the participants were NEET at age 20.7 years and 8.2% at 24.1 years. After adjusting for potential confounders, we found evidence of increased risk of being NEET among frequent adolescent cannabis users [adjusted odds ratio (ORadj) = 1.74; 95% confidence interval (CI) 1.10-2.75] and those who reported repeated disruptive behaviours (ORadj = 1.71; 95% CI 1.15-2.55) or persistent common mental disorders in adolescence (ORadj = 1.60; 95% CI 1.07-2.40). Similar associations were present when participants with children were included in the same category as those in employment, education, or training.

CONCLUSIONS

Young people with an early onset of mental health and behavioural problems are at risk of failing to make the transition from school to employment. This finding reinforces the importance of integrated employment and mental health support programmes.

Individual characteristics of students with autism spectrum disorders and school refusal behavior

This study compared social, executive, emotional, and behavioral characteristics of students with autism spectrum disorder who did and did not display school refusal behavior. The participants were 62 students with autism spectrum disorder without intellectual disability aged 9-16 years attending inclusive schools. Parents first completed questionnaires assessing social and executive functioning as well as emotional and behavioral problems. They then documented their child's school refusal behavior for a period of 20 days. Compared to students without school refusal behavior (n = 29), students with school refusal behavior (n = 33) were significantly less socially motivated; displayed more deficits in initiating tasks or activities, in generating ideas, responses, or problem-solving strategies; and displayed more withdrawn and depressive symptoms. Assessing social and executive functioning, as well as emotional problems, may help professionals provide tailored interventions for students with autism spectrum disorder and school refusal behavior, which will further be valuable in recognizing characteristics associated with school refusal behavior.

School Phobia

School phobia is a serious disorder affecting up to 5% of elementary and middle school children. Long-term consequences include academic failure, diminished peer relationships, parental conflict, and development of additional psychiatric disorders. Hiding behind such common physical symptoms as headaches, stomachaches, and fatigue, school phobia evades diagnosis with ease. Unraveling the problem of school phobia is challenging for the school nurse and is complicated by an overall lack of knowledge regarding the serious potential outcomes. The purpose of this article is to define school phobia, differentiate it from truancy, and highlight some interventions useful in the treatment of this increasingly common and potentially serious disorder.

[School absenteeism: Preliminary developments and maintaining persisting challenges]

A first step when considering school absenteeism is to understand the meaning and definition of the term. School absenteeism encompasses several terms such as school refusal, truancy and school phobia, all of which have been used inconsistently and confusingly in the past. Furthermore, the question of how many days of absence can be seen as problematic remains unclear. Due to these definitional problems, available data is inconsistent. Therefore, the prevalence rates of school absenteeism can only be estimated (about 5 % of all students). School absenteeism affects not only individual students, but also family, school and society structures. In order to establish appropriate support and intervention programs, a multimodal as well as an individual approach should be considered to address this interdependency. The primary goal, however, should be the students’ resumption of a regular school attendance, which requires a strong cooperation between parents, schools, youth welfare services and psychotherapeutic offers. If therapeutic interventions are required, it is highly recommended to start with outpatient treatment. If school attendance still remains irregular an inpatient treatment should follow.

Fifteen-minute consultation for a child not attending school: a structured approach to school refusal

Paediatric consultations in school refusal cases need to explore the presenting medical symptoms and discuss with families any psychological function of the problems that have led to non-attendance. Understanding possible reinforcements of the child's avoidant behaviour, liaising with school and reassurance of the parents are often enough to manage the situation. However, more chronic and persistent refusal often require support from an extended team around the child, often requiring input from mental health professionals. Behavioural strategies are the recommended approach to improve school attendance and to tackle the underlying anxiety or depression, or both, that may be the root cause of their non-attendance.

School refusal behavior in South Korean first graders: A prospective observational community-based study

Refusing to attend school is a serious problem that could lead to psychopathology. We aimed to: (1) prospectively observe the actual development of school refusal behavior according to a history of separation anxiety symptoms (SAS) and (2) explore factors for predicting school refusal behavior in children who were just beginning primary school. The participants were 277 children, aged 6-7 years, who were expected to enter primary school in 2 months. The parents were surveyed about the child׳s history of SAS and their behavior. The children were questioned about anxiety symptoms. The children were surveyed about whether school refusal behavior developed or not after they entered primary school. Of the 248 children who responded to the follow-up survey, 7.66% of children met the criteria for school refusal behavior during the 3 months after entering school. We found no significant differences in the occurrence of school refusal behavior according to the children׳s SAS history. Familial risk factors for school refusal behavior included low parental educational level and a working mother. School refusal behavior by first graders cannot be fully explained by the expression of SAS and could be implicated in a more complex psychopathology.

ADad 8: School Phobia and Anxiety Disorders among adolescents in a rural community population in India

OBJECTIVE

School Phobia (SP), although is not a formal psychiatric diagnosis, is widely prevalent debilitating phenomenon with a gamut of underlying psychiatric conditions in an overwhelming majority of cases. This study documents the prevalence, symptom presentation and the relationship between the various subtypes of Anxiety Disorders (AD) and School Phobia.

METHODS

In a prospective community survey of 500 adolescents, independent raters administered the Screen for Child Anxiety Related Emotional Disorders and Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime to identify SP and subtype of AD respectively. Descriptive statistics for the prevalence and symptom presentation, Spearman's Correlation test, Independent t tests, on-way ANOVA and Chi-square tests were done to compare the prevalence and severity of School Phobia among various age groups and gender. Univariate and multivariate analyses were done for documenting the relationship between the School Phobia and Anxiety Disorders.

RESULTS

School Phobia was noted in 4.8% of adolescents. Although age was related to SP, gender, school grade the adolescent was attending and family structure were not related to SP. Somatic symptoms were more often noted than cognitive-emotional symptoms among adolescents with SP. Panic Disorder (OR = 8.62), Social Anxiety Disorder (OR = 8.63), and Separation Anxiety Disorder (OR = 6.26), were significantly related to SP.

CONCLUSIONS

School Phobia is noted in a significant proportion of adolescents in the community. Anxiety Disorder is a major underlying factor resulting in SP. Community and clinical intervention and service models should include anxiety alleviation methods in adolescents with School Phobia.

How to identify students for school-based depression intervention: can school record review be substituted for universal depression screening?

PROBLEM

Early identification and intervention are critical for reducing the adverse effects of depression on academic and occupational performance. Cost-effective approaches are needed for identifying adolescents at high depression risk. This study evaluated the utility of school record review versus universal school-based depression screening for determining eligibility for an indicated depression intervention program implemented in the middle school setting.

METHODS

Algorithms derived from grades, attendance, suspensions, and basic demographic information were evaluated with regard to their ability to predict students' depression screening scores.

FINDINGS

The school information-based algorithms proved poor proxies for individual students' depression screening results. However, school records showed promise for identifying low, medium, and high-yield subgroups on the basis of which efficient screening targeting decisions could be made.

CONCLUSIONS

Study results will help to guide school nurses who coordinate indicated depression intervention programs in school settings as they evaluate options of approaches for determining which students are eligible for participation.

School avoidance from the point of view of child and adolescent psychiatry: symptomatology, development, course, and treatment

BACKGROUND

A considerable percentage of children and adolescents who avoid school have mental illnesses. This article reviews the typical manifestations, classification, development, course, and treatment of school-avoiding behavior.

METHODS

Based on a selective review of recent literature, we present findings on the psychopathologically relevant features of school-avoiding children and adolescents, including psychiatric diagnoses, developmental, family-related, and psychological test variables. The emphasis is placed on our own studies of the subject.

RESULTS

Although the evidence from the studies that have been performed to date is not definitive, the available findings show that school avoidance is associated with poor mental health and with unfavorable consequences onward into adulthood. Its causes include a number of individual and social stressors that place excessive demands on the affected children and adolescents and lead them to avoid school as a coping attempt.

CONCLUSIONS

Many preventive and therapeutic interventions are now available, but the existing measures need to be better coordinated, and more effort needs to be directed to the early recognition and treatment of school-avoiding behavior. Physicians should consider the possibility of mental illness. Rather than writing sick notes or prescribing mother-child treatments at health resorts, which rather tend to sustain the problem, they should refer patients promptly to a child and adolescent psychiatrist.

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.

Evaluation of child therapy and caregiver training in the treatment of school refusal

OBJECTIVE

To evaluate the relative efficacy of (1) child therapy, (2) parent/teacher training, and (3) the combination of child therapy and parent/teacher training in the treatment of anxiety-based school refusal.

METHOD

Sixty-one school-refusing children (aged 7-14 years) from throughout Melbourne, Australia, were randomized to a child therapy program, a parent and teacher training program, or a combination of the two. Children were assessed before and after treatment, and at 4.5-month follow-up, by means of attendance records, self-report of emotional distress and self-efficacy, parent and teacher reports of emotional distress, and clinician ratings of overall functioning.

RESULTS

Statistically and clinically significant pretreatment-posttreatment change occurred for each group. Immediately posttreatment, child therapy appeared to be the least effective in increasing attendance. By follow-up, the attendance and adjustment of those in the child therapy group equalled that of children whose parents and teachers were involved in treatment, whether on their own (parent/teacher training) or together with their children (combined child therapy and parent/teacher training).

CONCLUSION

Contrary to expectations, combined child therapy and parent/teacher training did not produce better outcomes at posttreatment or follow-up.