School refusal an emergency in child psychiatry

1. SCHOOL REFUSAL
PRESENTOR – DR DHAYASUDHAN(PG Resident in
Psychiatry)

2. OVERVIEW
• Introduction
• Etiology and risk factors
• Epidemiology
• Clinical features with associated psychiatric condition
• Assessment
• Management
• References

3. INTRODUCTION
• School life is the most exciting period in one’s life
• It is the time when one learns the first lessons of socialization
• School placement and regular attendance is considered essential for the overall
development of a child
• Refusing to attend school can be detrimental in many ways
• School refusal is defined as ‘child motivated refusal to attend or difficulties remaining
in school for the entire day’ [Kearney et al]

4. INTRODUCTION
• School refusal is not a Diagnostic and Statistical Manual of Mental Disorders (DSM–
5) diagnosis
• School refusal describes the disorder of a child who refuses to go to school on a
regular basis or has problems staying in school
• It is a symptom that can be associated with several other diagnoses
• Children may avoid school to cope with stress or fear for a vast number of reasons
• It is a challenge for children, families, and school personnel
• Failing to attend school has significant short and long-term effects on children's
social, emotional, and educational development

5. Berg crieteria :
(a) reluctance or refusal to attend school, often leading to prolonged absences
(b) staying at home during school hours with parents’ knowledge rather than
concealing the problem from parents
(c) experience of emotional distress at the prospect of attending school (e.g., somatic
complaints, anxiety, and unhappiness)
(d) absence of severe antisocial behavior
(e) parental efforts to secure their child’s attendance at school

6. • school refusal comes under category of school avoidance , under which truancy is
also there
• it is necessary that school refusal to be differentiated with truancy

7. SCHOOL REFUSAL
1)Severe emotional distress about attending
school manifests as anxiety, temper
tantrums, depression, or somatic symptoms
2)Parents are aware of absence; the child
often tries to persuade parents to allow him
or her to stay home
3)Antisocial behaviors such as juvenile
delinquency are not notably seen
4)Children usually stay home during school
hours
TRUANCY
1)Excessive anxiety or fear about attending
school are not commonly seen; rather child
often tries to conceal absence from parents
2)Antisocial behavior such as delinquent and
disruptive acts, for example, lying and
stealing, are frequent in the company of
antisocial peers.
3)The child frequently does not stay home
during school hours.
4)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

8. ETIOLOGY
• It is difficult to determine the number of children that experience school refusal
• A common statistic cited by organizations that advocate for increased mental health
awareness say school refusal affects 2% to 5% of all school-age children
• If the child has been home for a while, for example during summer vacation, another
holiday break, or brief illness, it may trigger the problem
•A stressful event like the death of a pet or relative or moving to a new house may also
precipitate the condition.
•When a child does not want to go to school often say they are sick
•When they wake up in the morning, they complain of having a headache,
stomachache, or a sore throat

9. • If someone allows them to stay home, the “illness” might go away, but it comes
back the next morning before school
• Some children may have crying spells or temper tantrums

10. RISK FACTORS
• School refusal is a complex problem that is multiply determined by a broad range of
risk factors, which interact with each other and change over time
• These may operate as predisposing, precipitating, and/or perpetuating factors

11. • Several authors have summarized the risk factors identified in the school refusal literature,
differentiating between
i. individual factors (e.g., behavioral inhibition, fear of failure, low self-efficacy, and physical
illness)
ii. family factors (e.g., separation and divorce, parent mental health problems,
overprotective parenting style, and dysfunctional family interactions)
iii. school factors (e.g., bullying, physical education lessons, transition to secondary school,
and structure of the school day)
iv. community factors (e.g., increasing pressure to achieve academically, inconsistent
professional advice
v. inadequate support services

12. EPIDEMOLOGY
• Approximately 2% to 5% of all school-aged children have school refusal
• The incidence is similar between boys and girls
• Although school refusal occurs at all ages, it is more common in children ages 5 to 6
and 10 to 11 years of age
• The longer a child is out of school, the harder it is to return
• No socioeconomic differences have been noted
• Nayak et al reported that children studying in English medium and those from
nuclear family have higher rates of school refusal

13. CLINICAL FEATURES
• The onset of school refusal symptoms usually is gradual
• Symptoms may begin after a holiday or illness
• Some children have trouble going back to school after weekends or vacations
• Stressful events at home or school, or with peers may cause school refusal
• Some children leave home in the morning and develop difficulties as they get closer
to school, then are unable to proceed and Other children refuse to make any effort to
go to school

14. • Presenting symptoms include fearfulness, panic symptoms, crying episodes, temper
tantrums, threats of selfharm, and somatic symptoms that present in the morning
and improve if the child is allowed to stay home
• The longer the child stays out of school, the more difficult it is to return
• Stressful life events like moving or starting a new school, among others may
trigger School Refusal. Other reasons include the child’s fear a parent being harmed
once they are in school or fear that they may not do well in school, or they may be
afraid of another student

16. • Short-term sequelae include poor academic performance, family difficulties, and
problems with peer relationships
•Long-term consequences may include academic underachievement, employment
difficulties, and increased risk for psychiatric illness

18. ASSOCIATED PSYCHIATRIC CONDITION
• School refusal is not a formal psychiatric diagnosis
• children with school refusal may suffer from significant emotional distress, especially
anxiety and depression
• Children with school refusal usually present with anxiety symptoms, and adolescents
have symptoms associated with anxiety and mood disorders
• The most common comorbid psychiatric disorders include separation anxiety, social
phobia, simple phobia, panic disorder, post-traumatic stress disorder, major
depressive disorder, dysthymia, and adjustment disorder

21. • School refusal should be considered a heterogeneous and multicausal syndrome
• School avoidance may serve different functions depending on the individual child
• These may include avoidance of specific fears provoked by the
a. school environment (e.g., test-taking situations, bathrooms, cafeterias, teachers),
b. escape from aversive social situations (e.g., problems with classmates or teachers)
c. separation anxiety
d. attention-seeking behaviors (e.g., somatic complaints, crying spells) that worsen
over time if the child is allowed to stay home

22. FAMILY FUNCTIONING
• Problems with family functioning contribute to school refusal in children
• Parents of children with school avoidance and separation anxiety have an increased
rate of panic disorder and agoraphobia
• Dysfunctional family interactions that correlate with school refusal include
overdependency, detachment with little interaction among family members, isolation
with little interaction outside the family unit, and a high degree of conflict
• Communication problems within families, problems in role performance (especially
in single-parent families), and problems with family members’ rigidity and
cohesiveness also have been identified

23. ASSESMENT
• comprehensive evaluation is recommended
• complex problem, and physicians must allocate a sufficient amount of time to the
patient to make an accurate assessment

25. ASSESMENT
In a school setting:
Initial assessment by teacher
Frequency of absences
Intensity of avoidance behavior while at school (nurse visits, calls home, grades,
class participation)
Resistance to Intervention by teacher needs help from mental health
professional

26. PSYCHOLOGICAL ASSESMENT
Assessment done by using structured or semi structured interview schedule &
specific objective tests/scales
Interview with child
Interview with parents
Interview with family
Interview with teacher/teacher’s reports
Complete medical history
If necessary referral to primary Care Provider to do physical examination and
investigation to rule out underlying medical conditions

28. INTERVENTION IN SCHOOL REFUSAL
• It is important to get the child back to school
•Youngster with SRB usually fall behind in their class work
• Youngster with poor academic competence are certainly at risk for dropout.
• Poor peer relationship
• School/legal conflicts
• Work/collage avoidance and adult psychological/psychiatry disorder may result
•The potential long-term effects are serious for a child who has persistent fears.
•These children may develop panic/anxiety disorder as adults
• The child may develop serious educational/social problem if away from school friends for
extended period of time

29. MANAGEMENT
• The goals in treating school refusal :
a) To facilitate the child’s returning to normal functioning
b) To make the child tolerate normal separation from caregivers without distress or
impairment of functioning.
c) To make the child attend school consistently without subjective experience of
distress.
• Often rewards may be added for the child who stays in school

30. MANAGEMENT
• Treatment also should address comorbid psychiatric problems, family dysfunction,
and other contributing problems
• children who refuse to go to school often present with physical symptoms, the
physician may need to explain that the problem is a manifestation of psychologic
distress rather than a sign of illness
•A multimodal, collaborative team approach should include the physician, child,
parents, school staff, and mental health professional

31. MANAGEMENT
• A range of empirically supported exposure-based treatment options is available in
the management of school refusal
• Providers may provide psychoeducational support for the child and parents, monitor
medications, and help with a referral to more intensive psychotherapy
• Cognitive behavior therapy
• Educational-support therapy
• Pharmacotherapy
• parent-teacher interventions

32. • Treatment strategies must take into account the severity of symptoms, comorbid
diagnosis, family dysfunction, and parental psychopathology
• When a child is younger and displays minimal symptoms of fear, anxiety, and
depression , working directly with parents and school personnel without direct
intervention with the child may be sufficient treatment
•If the child’s difficulties include prolonged school absence, comorbid psychiatric
diagnosis, and deficits in social skills, child therapy with parental and school staff
involvement is indicated

33. • Behavior treatments include relaxation training, systematic desensitization (that
is graded exposure to the school environment), emotive imagery, social skills training,
and contingency management

34. • CBT in school refusal :
• Cognitive behavior therapy (CBT) is a very structured strategy during with a therapist
offers specific instructions for children to enable and gradually increase their
exposure to the school environment
• children are encouraged to confront their fears, and they are taught how to modify
negative thoughts
• CBT provides solutions to current problems and provides tools to change unhelpful
thoughts and behaviors

35. • CBT attempts to restructure the child’s thoughts and behaviours into a more adaptive
framework.
•If any Specific fear behavioural techniques such as systematic desensitization,
exposure and operant behavioural techniques have been found to be effective.
•Identification and recognition of anxiety and associated phenomena are central to
successful behaviour change.
•Modelling, role playing, relaxation techniques as well as reward systems for behaviour
change are frequently used as components of behavioural and cognitive behaviour
therapies

36. • ERP in school refusal :
• ERP focuses on gradual exposures to anxiety-inducing stimuli and situations. It is
usually performed in the most anxiety-producing situations so that the individual can
confidently proceed in the therapy

37. • DBT in school refusal :
• Dialectical behavior therapy (DBT) is also effective in treating anxiety and school
refusal
• It is based on 4 skill modules which include 2 sets of acceptance-oriented skills
(mindfulness and distress tolerance) and 2 sets of change-oriented skills (emotion
regulation and interpersonal effectiveness)
• Treatment addresses comorbid psychiatric problems, family dysfunction, and other
contributing problems

38. • If a child who refuses to go to school has presented with physical symptoms, the
physician should explain that signs of physical illnesses are the manifestation of
psychologic distress rather than a physical illness
• A collaborative team approach with multimodal facilities which include the
physician, child, parents, school staff, and other mental health professionals should be
applied
• Physicians should avoid writing a non-judicial excuse note for children to stay out of
school unless a medical condition makes it mandatory for them to stay home

39. PHARMACOTHERAPHY
• Pharmacologic treatment of school refusal should be used in conjunction with
behavioral or psychotherapeutic interventions, not as the sole intervention
• Interventions that help children develop skills to master their difficulties prevent a
recurrence of symptoms after medication is discontinued

40. PHARMACOTHERAPHY
• Selective serotonin reuptake inhibitors (SSRIs) have replaced tricyclic antidepressants as the
first-line pharmacologic treatment for anxiety disorders in children
• Although there are there are few controlled, double-blind studies of SSRI use in children; the
data suggest that SSRIs are effective and safe in the treatment of childhood anxiety disorders
• Clinically, SSRIs are used frequently used to treat school refusal
• Fluvoxamine and sertraline are approved for use in anxiety disorder in children
• Sertraline can be started at an initial dose of 12.5 to 25 mg per day for a minimum of 7 days
and titrated up to 50 mg per day in increments of 12.5 mg (child) or 25 to 50 mg (adolescent)
per week
• If adequate clinical response is not seen after 6 to 8 weeks of treatment, subsequent trials
should be tried following dose increases of 12.5 mg per day for children and 25 to 50 mg per
day for adolescents to a maximum of 200 mg per day

41. • Benzodiazepines can be used on a short-term basis for children with severe school
refusal
• Benzodiazepine may be added with an SSRI to target acute symptoms of anxiety. It
should be discontinued once the SSRI has had time to produce beneficial effects as
there is a risk for addiction and side-effects. There are many side effects of
benzodiazepines such as sedation, behavior disinhibition, and cognitive impairment
that should keep in mind

42. EDUCATION SUPPORT THERAPHY
• Traditional educational and supportive therapy has been shown to be as effective as
behavior therapy for the management of school refusal
• It is a combination of informational presentations and supportive psychotherapy
• Children are encouraged to talk about their fears and identify differences between
fear, anxiety, and phobias
• Children are given information to help them overcome their fears about attending
school
• They are given written assignments that are discussed at follow-up sessions

43. • Children keep a daily diary to describe their fears, thoughts, coping strategies, and
feelings associated with their fears
• Unlike cognitive behavior therapy, children do not receive specific instructions on
how to confront their fears, nor do they receive positive reinforcement for school
attendance

44. • Child therapy involves individual sessions that incorporate
I. relaxation training (to help the child when he or she approaches the school
grounds or is questioned by peers)
II. cognitive therapy (to reduce anxiety-provoking thoughts and provide coping
statements)
III. social skills training (to improve social competence and interactions with peers)
IV. desensitization (e.g., graded in vivo exposure, emotive imagery, systematic
desensitization)

45. PARENT-TEACHER INTERVENTION
• Parental involvement and caregiver training are critical factors in enhancing the
effectiveness of behavior treatment
• Behavior interventions appear to be equally effective with or without direct child
involvement
• School attendance and child adjustment at post-treatment follow-up are the same
for children who are treated with child therapy alone and for children whose parents
and teachers are involved in treatment
• Parent-teacher interventions include clinical sessions with parents and consultation
with school personnel

46. Parents are given behavior-management strategies
• escorting the child to school
•providing positive reinforcement for school attendance
•decreasing positive reinforcement for staying home (e.g., watching television while
home from school)

47. • Parents also benefit from cognitive training to help reduce their own anxiety and
understand their role in helping their children make effective changes
• School consultation involves specific recommendations to school staff to prepare for
the child’s return
a) use of positive reinforcement
b) academic, social, and emotional accommodations

48. FAMILY THERAPHY
• Includes the assessment of family functioning and facilitating communication to
change dysfunctional patterns of communication and interactional patterns within
the family
• These maladaptive patterns may serve to maintain the child feeling unable to
separate from attachment figures
• Certain maladaptive patterns within the family may cause the family to encourage
the child in the sick role
• It is also essential to deal with the mental health/substance abuse issues of the
parents which might be influencing the child’s school refusal

49. • Parents are often encouraged to assess & find out the possible reasons for school
refusal in the children.
•Parents should be made aware of the cause & possible ways of dealing with such
causes.
•Parents should also encourage the child to talk about his or her feelings & fears

50. REFERNCES
• School Refusal in Children and Adolescents ; Am Fam Physician 2003;68:1555-
60,1563-4 ; WANDA P. FREMONT
• School Refusal Behavior in Indian Children ; Indian journal of pediatrics ; 2018 ; Ajita
Nayak & Bijal Sangoi & Hrishikesh Nachane
• Outcome of Children with School Refusal ; Indian Journal of Pediatrics, Volume 74—
April, 2007 ; Mukesh Prabhuswamy, Shoba Srinath, Satish Girimaji and Shekhar
Seshadri
• Treatment for School Refusal Among Children and Adolescents: A Systematic Review
and Meta-Analysis ; Brandy R. Maynard ; sagepub.com/journalsPermissions.nav
• school refusal statpearls ; ncbi bookshelf ; MDS Kawskar 2018