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M. S. Thambirajah examines the troubling plight of those who fear school

Craig is a Year 7 pupil whose school attendance started falling in the second term of his first year in secondary school. It began with reluctance to attend school and odd complaints of tummy pains and feeling sick in the mornings at the time of going to school. Initially, he was thought to be suffering from a tummy bug and his doctor provided medical certificates to cover his school absence. Over the next few weeks, his distress in the mornings worsened and he was missing two to three days of school each week. On the days he managed to get to class, he initially felt light headed and thought he was going to faint, but after the first few hours he was able to settle down and join in the lessons. However, the problem would repeat itself the next day. On one occasion, he was sent home because he had become so distraught that he seemed physically ill.

He usually started worrying about attending school the previous night and by the morning he was shaking, sweating and close to panic. He begged his mother to keep him off school and when she tried to be firm with him, he retorted that she did not love him. When allowed to stay at home, he would settle down after one or two hours. On weekends, he was his usual happy and carefree self.

As the weeks went by, getting him out the house in the mornings became more and more difficult and he soon stopped going to school altogether. Teachers were baffled by his school non-attendance. Craig was considered to be academically bright, he had a good group of friends and he liked school. He was one of the well-behaved pupils in his class.

Most teachers may recall having come across children like Craig at some time in their career. Often misunderstood and frequently mismanaged, such children belong to a group of school non-attenders known as school refusers. School refusal is the contemporary term used to describe a condition where a child has difficulties attending school on account of severe emotional distress during their time in school. School phobia, school avoidance and emotionally based school refusal are some of the alternative terms used to describe it.

The hallmark of this group is the severe emotional distress they exhibit at the prospect of attending school, and many indeed have an emotional disorder. They tend to show internalising problems, such as fear, misery, anxiety and worry, for no obvious reason. Reluctance to separate from parents is common in younger children, while social anxiety is more common in adolescents. This characteristic of school refusal stands in stark contrast to truancy, in which school non-attendance is a part of general defiant and oppositional behaviour (externalising problems). Although the distinction between the two groups is not absolute, it is important to differentiate between them: the child with school refusal is invariably a good student; the truant is a poor student. Truants openly acknowledge their dislike of school; school refusers wish they could attend. The truant usually avoids both home and school, whereas the school refuser stays at home. Moreover, truants fabricate excuses to cover up their absence, while the child with school refusal draws attention to their inability to leave home or stay in school.

There are no accurate figures for the prevalence of school refusal as the Department for Children, Schools and Families (DCSF) collects figures only for unauthorized pupil absentees, a much larger group than school refusers. Most epidemiological studies have come from mental health literature. These study findings, extrapolated from referrals to clinics, suggest that school refusal occurs in approximately five per cent of all school-age children (Last & Strauss, 1990). Overall, though, the more widely accepted prevalence rate for school refusal is between one and two per cent (King & Bernstein, 2001).

School refusal is equally common in boys and girls. In terms of age groups, there appear to be three peaks that correspond with key transition periods: five to six years (school entry), eleven to twelve years (transfer to secondary school) and around fourteen years.

One of the pernicious features of school refusal is that, once the process has begun, a vicious cycle of increasing anxiety and escalating school avoidance is established very rapidly. Avoiding a feared situation only increases the anxiety when you have to face it the next time. Also, for the child, being away from school has its positive consequences. Over time (of more than a few weeks), the school attendance difficulties become more entrenched. Moreover, prolonged school absence creates secondary complications as the child falls behind with school work, loses contact with peers and friends and becomes socially isolated. In many, there is severe loss of self-confidence and self-esteem. The young person may become chronically anxious at the thought of going out of the house and, in severe cases, become practically home bound. Many education professionals tend to underestimate the long-term prognosis for these children. Longitudinal follow up studies show that in adulthood they have more mental health problems (mainly anxiety disorders and clinical depression), greater social difficulties and are less independent than peers (Flakierska-Praquin et al., 1997). This is in addition to the adverse consequences of loss of education.

Because of the self-reinforcing nature of school refusal, early identification is of the utmost importance if we are to manage it successfully. The main principle of management is to get the child to attend school in a planned, gradual manner in order to overcome his or her anxiety. This may require flexible arrangements about time off from the classroom, a gradual return to school on a cut down time table and, in very severe cases, the judicious use of a pupil referral unit for a limited period of time. It is crucial that parents are involved and that the problem is handled sympathetically. Since the causation of school refusal is multi-factorial, involving issues relating to the school, the family and the child, it is important to identify the particular contributory factors in each individual case.

While schools and education welfare services often do a great deal of work with these young people to get them back to school, much more needs to be done to improve the situation. Although the category of school refusers has been recognized by education and health professionals for more than 75 years, it has been ignored in official statistics. Current methods of data collection by the DCSF subsume the category of school refusal within the unauthorized school absences group. Policy makers do not seem to have caught up with research findings. School refusal needs to be recognized as a separate condition and recorded and documented separately. The first precondition for any change is to recognize the nature of the problem, and this should happen at the top, at the level of policy makers. Indeed, such an approach may also help with attaining targets for school non-attendance.

Further information

Dr M. S. Thambirajah is a consultant child and adolescent psychiatrist, with a special interest in school refusal, working in Dudley and Walsall Mental Health Partnership Trust:
www.dwmh.nhs.uk

He works closely with the Shepwell Centre, a pupil referral unit in Walsall and is the author of several books, including Understanding School Refusal: a handbook for professionals in education, health and social care (Thambirajah M. S., Grandison, K. & De-Hays, L., 2008) published by Jessica Kingsley Publishers.


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