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Unwillingly to School.
  1. ANTONY COX, Professor of child and adolescent psychiatry

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    Unwillingly to School. 4th Ed. Edited by Ian Berg and Jean Nursten. (Pp 312; £20 paperback.) Gaskell/Royal College of Psychiatrists, 1996. ISBN 0-902241-89-3 .

    Jack Kahn was one of the most loved and respected child psychiatrists of recent years. The third edition of Unwillingly to School, which he edited with Jean Nursten, was published in 1981. Like its predecessors it focused predominantly on the pattern of school non-attendance associated with anxiety that is usually called school refusal. The vast majority of school non-attendance is ostensibly because of physical illness and short lived. Of the more persistent patterns and those for which social or psychopathology has been more clearly demonstrated school refusal is the least common, truancy being much more frequent in community surveys.

    Ian Berg has joined Jean Nursten to edit the 4th edition ofUnwillingly to School. It commemorates and is a tribute to Jack Kahn, and although it appropriately includes four chapters from the previous edition on which he was the only or lead author, the scope has been broadened to include aspects of the whole range of school non-attendance. For example, adult sequelae of truancy are reported from the National Child Development Study, the Cambridge Study in Delinquent Development, and the American Epidemiologic Catchment Area Study. Chronic disease and school non-attendance is also addressed with new contributions from child psychiatric and educational psychology perspectives; however, most of the treatment described appears focused on school refusal.

    There is a most striking contrast between the depressing and indeed appalling longer term sequelae of those who have truanted and the relatively benign outcome of a 20–30 year follow up study of Swedish urban children with school refusal. This contrast is matched by sensitive and perceptive descriptions of the treatment of school refusal and the depressing situation with regard to truancy and withdrawal. Incidentally, withdrawal—school non-attendance with which parents collude—receives relatively little attention. With regard to truancy it is considered that the Children Act 1989 has largely drawn the teeth of the courts and research into schools has been much better at describing differences between them in their effectiveness than in bringing about school improvement. It is notable that the most psychosocially disabled group in Farrington’s report of later life outcomes of truants in the Cambridge Study are the delinquent truants who in their school years were particularly notable for lack of concentration and impulsivity. Although the odds ratios were particularly high for this group on these two factors, they commonly had higher odds ratios on almost all the factors that distinguished both non-delinquent truants and delinquent non-truants.

    For all forms of school non-attendance there is a challenge. Jack Kahn himself recognised that most problems in this area cannot be addressed by specialist child and adolescent mental health services. Indeed a significant proportion of truants are not thought to have any psychological and psychiatric disorders.

    Secondly the importance of early prevention, particularly in truancy, is highlighted. One particular gap should be mentioned, namely the lack of contribution from a clinical psychologist and this is reflected in less detailed or broad ranging accounts of cognitive and behavioural approaches and a failure to emphasise sufficiently the importance of educational cognitive assessment.

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