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School refusal is a condition characterised by reluctance and often outright refusal to go to school in a child who: (1) seeks the comfort and security of home, preferring to remain close to parental figures, especially during school hours; (2) displays evidence of emotional upset when faced with the prospect of having to attend school, although this may only take the form of unexplained physical symptoms; (3) manifests no severe antisocial tendencies, apart from possible aggressiveness when attempts are made to force school attendance; and (4) does not attempt to conceal the problem from parents.1
Boys and girls are equally affected and there is no relationship to social class. Neither is there any relationship with intellectual or academic ability. The youngest in a family of several children is more likely to be affected and parents are often older than would otherwise be expected. It can affect a school child of any age, but young teenagers at about the time of transition from primary to secondary school are more likely to develop school refusal. Although uncommon in the general population, it forms a not inconsiderable proportion of referrals to child mental health services. Onset tends to be gradual, with increasing problems in facing up to leaving home to go to school, but it may occur suddenly after time away from school because of illness or holidays, it may occur after some upsetting event, or just come on without any obvious reason. There may be no associated social impairment, but there often is, including staying home excessively and avoiding contact with other children.2 The problem has been called ‘home-bound school absence’.3
School refusal can sometimes occur without any accompanying disorder classifiable on currently used systems of classification. On the International Classification of Diseases, 10th revision (ICD-10),4 a frequent disorder linked to school refusal is separation anxiety disorder (F93.0), although one of the criteria for saying that this disorder exists is school refusal, but there are several other disorders mostly involving anxiety and depression that may be present: for example, phobic disorder of childhood (F93.1), social anxiety disorder of childhood (F93.2), agoraphobia without panic disorder (F40.0), mild depressive episode (F32.0), and adjustment disorder (F41). More than one of these may coexist, a situation described as comorbidity.5
The problem is clearly one of school refusal when the criteria in the definition above are present and symptoms of anxiety and depression are very evident. Physical symptoms that are clearly manifestations of emotional upset when they are limited to school mornings include tummy ache, frequency of micturition, anorexia, diarrhoea, pallor, and headache. Less clear cut vague physical symptoms, without a cause being found, sometimes occur not so obviously related to having to go to school, but the fact of excessive school absence and the child’s unwillingness to make an effort to attend school suggest the diagnosis. The name ‘masquerade syndrome’ has been given to the situation where school refusal masquerades as physical illness.3 The condition may be thought to be ME.
It is important to convince child and parents that the problem is a pathological emotional reaction to leaving home and/or going to school and not some undiagnosed physical disorder. It is also important to convince them that, despite any anxiety/mood disorder, return to school will substantially improve matters. Early return to school is the treatment of choice. To accomplish this, the child needs a great deal of help in the form of coordinated action on the part of family, school, community workers, and the medical profession. Any physical investigations required to exclude a physical cause for symptoms should be speedily completed and the family encouraged not to pursue the search for physical illness as an explanation for the problem.6 Referral to mental health services for children will be required if return to normal school attendance cannot be achieved in a reasonable period of time or if psychiatric symptoms persist when it is. Medication has no part to play in the treatment of school refusal.
The long term outcome is very good, in so far as school refusers in later life only tend to suffer from minor problems of anxiety and/or depression, and possibly some reluctance to leave home and set up their own families.7 8 However, if it not satisfactorily managed, it can persist for months or even years. In the short term the main problem of school refusal is the loss of education.
Absence from school
In both Britain and the United States the average amount of time a child takes off school is only a few days a year. Most children are away because of illness and occasionally family or religious holidays; the acceptable reasons for being off. Obviously, severely ill children may be absent because of hospital treatment, but it is surprising how little time may be taken off school by some children with quite severe physical disabilities.9 10
There is a legal requirement for children to be appropriately educated. When children are off school for long periods without adequate explanation, it is possible for parents to prosecuted in the magistrates’ court. This is not done very often and any fines that are imposed are frequently very small. In exceptional circumstances, children can be taken to a juvenile court because of failing to attend school and an educational supervision order may be made. With previous legislation, children could be taken to court under care proceedings and this could be quite effective in getting children back to school and keeping them out of trouble in other ways.9 It seems unlikely that the present procedures, which exclude failure to attend school as grounds for care proceedings, and only allow juvenile court magistrates to put regular contact with a social worker from the education welfare department on a more formal basis, will have the same effect in improving school attendance as the old ones did.11 12
Strictly speaking, truancy is said to occur when children stay off school and attempt to conceal the fact from their parents. Under these circumstances, it is best estimated by information obtained from the school. Typically, this kind of school attendance problem is associated with antisocial conduct such as disruptiveness in school, aggressive behaviour, staying out excessively, stealing, lying, and destructiveness. Truancy persisting for six months is one criterion for saying that an ICD-10 conduct disorder exists. Boys predominate and there are frequently educational difficulties. There is often social disadvantage and poor relationships with more normal children.2
The term truancy is often used to refer to unwarranted absence from school more generally.13 Girls are affected as much as or more than boys. There may not be any psychiatric disorder. Severe social disadvantage is usually evident. There may be little or no support at home to help a child maintain normal school attendance. Sometimes it is evident that parents are quite irresponsible where school attendance is concerned and make feeble excuses, suggesting that there is a degree of parentally condoned absence from school.
There needs to be a coordinated approach to the problem of truancy on the part of educational, social, medical, and psychological services. Academic needs require attention. Coordination between home, school, and those otherwise involved is important. Behavioural methods employed in the clinic can sometimes help when social and educational aspects are less significant and conduct problems are more important.13
Truancy is quite a strong predictor of antisocial tendencies in adult life, particularly when there are associated childhood conduct problems and severe social disadvantage.14
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