Читать книгу Overcoming School Refusal - Joanne Garfi - Страница 7
ОглавлениеSchool refusal is a complex issue that is stressful for the child, their family and the school. The more time a child is away from school, the more difficult it is for the child to resume normal school life. If school refusal becomes an ongoing issue it can negatively impact the child’s social and educational development.
Children who develop school refusal display severe emotional and cognitive stress in the face of attending school. While it is a well established behavioural condition, it is not recognised as a disorder in its own right within the main diagnostic tool used by psychologists and psychiatrists to reliably diagnose disorders — the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).1 There is, however, a consensus in the literature that school refusal is characterised by absences from school that can be over extended periods of time, periodic, general tardiness or repeated missed classes. It is driven by intense feelings of anxiety that can arise from a variety of causes, which we will discuss further in future chapters.
In contrast to the issue of truancy, an anxious child who refuses to attend school does so because they are genuinely distressed. A school refuser will often attempt to get up in the morning, put on their uniform, have breakfast and may even make it to the car or the school drop-off zone but when the time comes to take those fateful last steps they either become angry and defiant or tearful and distressed. The school refuser makes no secret of their inability to attend school. They will often say that they want to go to school but can’t.
This is in marked contrast to the truant whose absences are not anxiety-based and who hides the fact that they are not attending school. Unlike the school refuser the truant will engage in alternate behaviours when not at school, such as spending the day with friends, shopping or walking the streets of the city.
Parents of school refusers often report overt anxiety symptoms shortly after the child gets home from school. Parents report a variety of symptoms including moodiness, aggressive outbursts, unwillingness to complete homework, reduced appetite, excessive worry, changes in sleep patterns and reluctance to engage in bedtime routines as it signals the end of the day and the imminent start of another school day. These symptoms are often worse on Sunday nights and a day or two before the beginning of a new school term as the child has had several days away from school and has had time to distance themselves from the anxiety associated with going to school. Many parents dread the beginning of a new term for this very reason.
Anxiety and school refusal
In order to best understand school refusal we must have a solid understanding of child anxiety. Up to 80% of school refusers meet criteria for some form of anxiety disorder whether it be separation anxiety, generalised anxiety or social anxiety.2
According to the DSM-5, anxiety is the anticipation of future threat, while fear is the emotional response to a real or perceived imminent threat. Although these two states overlap they also differ in that fear is more often associated with surges of autonomic arousal necessary for the fight or flight response, while anxiety is more often associated with muscle tension and vigilance in preparation for a future danger. While anxiety disorders (separation anxiety disorder, generalised anxiety disorder and social anxiety disorder) have a high rate of comorbidity, they can be differentiated by examination of the types of situations that are feared or avoided. Separation anxiety is at its core a fear of being separated from a significant person who is believed to offer comfort, safety and support. Social anxiety is characterised by marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Generalised anxiety disorder, on the other hand, is characterised by excessive worrying about a number of events or activities. For the purposes of simplicity I will use the umbrella term ‘anxiety disorder’ throughout this book and where necessary will venture into specific anxiety disorders as the need arises.
Anxiety disorder is a commonly occurring mental health disorder that affects approximately 14% of the population3 or one in seven people, which means that we all know at least one or two people who suffer with this disorder. Its severity can range from mild (where the person can still attend school/work), right through to severe (where the person is challenged to leave their home). It is characterised by persistent, excessive worry that hinders logical thinking and action. Individuals with anxiety disorder typically overestimate the perceived danger in situations and become either overly cautious or avoidant. In the case of school refusal, the child has often experienced a negative situation at school (i.e., bullying, failed assessment task) and avoids a reoccurrence of the incident by avoiding school. The longer the child is away the greater the perceived danger becomes causing symptoms to become ever more severe. Symptoms as listed in the DSM-5 are typically characterised by restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
This does not mean that the remaining 86% of the population are anxiety-free as anxiety is part of everyday life. Think, for example, of the last time you attended the dentist or entered a meeting with your employer, which you suspected, would not end well. That dread, that hollow sick feeling in your stomach, the clammy hands, the racing thoughts, the tightness in your throat and chest, is your body telling you that your anxiety is on the rise and that you are not coping. Anxiety can also be triggered by everyday occurrences like the traffic on the way to work, arguments with our loved ones, and children who will not get ready for school. For most people (86%) these feelings of distress/anxiety/stress will subside once the situation is resolved but for some (14%) this return to equilibrium is not easily achieved. For these people everything that goes wrong in their day (no matter how small) adds to the existing high levels of anxiety until eventually the body can take no more and a panic attack ensues. Yep that’s right: a panic attack doesn’t just come out of nowhere, it is a result of persistent anxiety that builds and results in an abrupt surge of intense fear or discomfort that leads to panic symptoms. So, your child’s frenzied tantrum at 8am has been building for hours and sometimes even days. A panic attack is the body’s way of saying ‘too much stress, can’t manage it any more, let’s get rid of it’. That is why, after a panic attack, the sufferer often reports feeling tired, sleepy and worn out. A panic attack is the emotional equivalent of a pressure cooker with a blocked outlet valve.
Now imagine these intense feelings in a child who has been worried about going to school since the day before (obvious signs of not coping often begin around dinner time) and suddenly it’s not surprising that they lash out at the well-meaning parent or carer who is trying to get them to school. Fear (which is what the child feels when they’re told they’re going to school) provokes a fight, flight, or freeze response. The child will either argue back, lash out and flee to their room or the playground area, (if at school), or say nothing and have rivers of tears flowing down their cheeks. This is normally where parents become frustrated, angry or completely disheartened and eventually give into the child’s pleas resulting in another day off school and more feelings of failure for everyone involved. Every day that a parent or caregiver gives into the child’s pleas and reasons for not attending school, we reinforce their fear and teach the child that the louder they scream, the harder they plead and the more plausible their reasons, the more likely we are to give in. This does not mean that the child is innately devious or manipulative, they are simply using whatever is at their disposal to achieve their desired goal: not going to school and hence reducing their level of distress. Rather than allowing this self-destructive behaviour to continue we, as service providers and parents, need to provide the child with the knowledge and skills to recognise their symptoms of anxiety and manage them in a way that empowers and rebuilds self-esteem.
A good analogy of this would be teaching a child to swim. Initially the child is afraid of the water, especially if they have had a bad experience, and may cry and cling to the parent as they enter the water. Their instincts are to hold on to their carer for dear life. If the carer does not encourage the child to begin to let go, it is highly likely that the child will never learn to swim and may in fact develop a real fear of water. However, if the carer reassures the child and tolerates their cries and praises even the slightest of achievements the child begins to believe that they are capable. Progress will, of course, be very slow but if every time the carer gets into the pool there is an expectation that the child will pick up where they left off the last lesson progress will begin to occur.
Just as the swimmer is slowly encouraged and expected to master their water skills so must we expect the school refuser to return to school. It is important that we all understand that the school refuser will not miraculously get up one day having mastered their anxiety and gladly go to school. Learning to master their anxiety symptoms comes from learning what anxiety is, how it presents, what can be done to control it and real-life exposure that is done at a pace the child can handle. Just like the swimmer, we must always expect that the following day will be a slight improvement on the day before. This is how empowerment and self-esteem is built no matter what the challenge may be.
Returning a child to school can be a monumental task taking enormous time and energy on the part of parents, teachers, psychologists and of course the child (who may initially not like any of these people very much). The early stages of returning a child to school can be a thankless and heart wrenching ordeal but an integrated team approach can produce positive, long-term outcomes as I have evidenced in my 30 years as a psychologist.
What does school refusal look like?
Let’s look at an example of school refusal compiled from multiple case studies:
Jacqui is an 11-year-old girl who has attended the same primary school for 6 years. She has a good group of friends, gets on well with teachers and is doing well academically. Six months prior to referral Jacqui injures her foot resulting in surgery and approximately three months off school.
During her recuperation, Jacqui is forced to stop her beloved dancing and limit outings with friends as walking becomes a challenge. In an effort to support Jacqui, her mother (Bianca) takes time off work. For the first time since beginning school Jacqui spends most days with Bianca while her siblings are at school. Bianca reports that Jacqui remained in touch with friends via social media and telephone calls but had very little face-to-face contact during her time away from school.
As Jacqui’s injury improved Bianca began leaving Jacqui with family and friends so she could return to work. This coincided with Jacqui reporting tummy upsets, headaches and nausea immediately after dinner on days when her mother was due to go to work the following morning. Jacqui would beg her mother not to go to work. To her mother’s credit she never gave in to Jacqui’s pleas but did admit to feeling very guilty and sad at having to leave her.
Just as Jacqui began to settle into staying with grandparents or family friends, her physiotherapist announced that a return to school would be achievable within a week or two. Almost immediately Jacqui’s symptoms worsened ten-fold. Her parents reported uncontrolled bouts of anger, tears, tummy upsets, headaches, broken sleep and variable appetite.
The night before her scheduled return to school Jacqui complains of aches and pains, sore tummy, difficulty breathing and sleeping. By the time Jacqui is woken the following morning she is red-eyed and crying uncontrollably, begging and pleading with her parents to give her ONE more day at home. She assures them that the following day will be different and that she just needs the day to adjust. But guess what? The next day was no better, nor the day after that, nor the week after that. When I met Jacqui she had been absent from school for a total of two school terms.
The three major factors of school refusal — FEAR + ANXIETY + AVOIDANCE — are well illustrated in this case example. Jacqui develops a fear of returning to school following an injury. But why did the fear develop? Let’s think carefully about what happened when Jacqui injured herself: she lost face-to-face contact with friends, stopped dancing, missed school work, developed bad habits (i.e., not needing to follow a morning routine), and got loads of attention from mum while she was recovering. Returning to school became a challenge because Jacqui had lost self-confidence and experienced lots of secondary gains that made being at home comfortable and nonchallenging. She did not believe she could return to school because she had missed so much schoolwork, lost contact with her peers and was afraid she could not fit in as she had before her accident.
Once fear sets in anxiety quickly follows and grows exponentially as anxiety is fed by fear. In fact, anxiety is, at its very root, a fear of fear (in other words, Jacqui became afraid of being afraid). Once fear and anxiety are present, avoidance is highly likely to develop, as no-one (irrespective of age or gender) will willingly place themselves in a situation that provokes fear and anxiety.
Once in place, school refusal is driven by one or more of the following reasons:
• Avoiding situations that evoke negative emotions. ‘If I don’t go to school I don’t need to explain my absence or feel stupid because I’ve missed so much work’.
• Escape from negative social and/or evaluative situations. For example, bullying or receiving exam results.
• Attention seeking. ‘When I don’t go to school mum stays home with me or I go to grandma’s house and everyone wants to know what’s wrong with me’.
• Rewards. ‘Once I’m home I don’t have to do schoolwork, I can watch TV, eat whatever I like and keep in touch with friends using social media’.
Determining what ‘drives’ school refusal is an integral part of beginning to understand the child, and developing a program that is specifically geared to their particular situation. The child who refuses to go to school because they love being at home with mum needs a very different return to school program than the child who refuses to go to school because they are mercilessly bullied.
How common is school refusal?
Although research has struggled to provide a consistent school refusal figure, due to differing opinions on what constitutes school refusal behaviours and when school absences cross the line from acceptable to unacceptable, there seems to be a consensus that school refusal occurs in 1% to 5 % of all children.4
It peaks from the ages of 5 to 7 and then again from the ages of 11 to 14. These ages correspond directly to transition periods. That is, the years when children go from kinder (where they only spend a few hours per week) to primary school (where they are present for full days, 5 days per week) and then again when the child goes from primary school to secondary school where academic demands become greater and social relationships become more complex. Transition periods occur throughout our lives and have varying degrees of impact on our emotional well being.
Our first transition period is often moving from mother’s care to kinder or day care. For the sensitive anxious child this transition can trigger lots of anxiety and manifest as clinginess, poor sleep (often resulting in co sleeping), altered eating patterns, tantrums and refusing activities that require separation from mother. This anxiety is referred to as separation anxiety and is a normal part of development.
Separation anxiety is first noted in infancy when the child reacts negatively to the mother leaving the room or the child being handed to someone else to hold. This need to be with the mother is a normal part of our survival instinct as the baby fears abandonment. Crying and screaming is their attempt, at an instinctual level, to ensure connection with the person who feeds and nurtures them. We see this in the animal kingdom, as well, when offspring cry out for their mother to make her aware that they have been left unattended.
In the nonanxious child this fear of being separated from the mother declines as they become familiar with their environment and begin to trust their new caregivers. Most of us know at least one child who has called their kinder teacher or child carer ‘mum’. A sure sign that the child trusts that person to care for them. The anxious child, however, tends to take longer to settle into their new environment and remains untrusting of their carers. It is not unusual for parents of school refusers to report problems with their child settling into kinder or day care. The re-emergence of their anxiety at the start of school coincides with a new environment, new carers, longer hours, more academic and social demands and, most importantly, longer periods of separation from mother. As a rule we would expect the anxiety to settle within a week or two as the environment becomes familiar and would expect that, by age 7, this fear of being separated from their primary care giver would have ended. Separation anxiety beyond the age of 7 is not considered a normal part of development and is viewed as the beginning of a diagnosable anxiety disorder.
Other transition periods in our lives include moving from primary school to secondary school, secondary school to university or work, leaving the family home to live alone or with a partner, and retirement to name a few. For the clinically anxious person, each of these transition periods equates to a period of instability and stress that extends beyond what would normally be accepted as a ‘settling-in period’.
School refusal occurs across all socioeconomic groups. This means that whether the child is from an affluent family in a private school or a less privileged family in a public school, school refusal can and does develop. It is also equally prevalent amongst boys and girls.
In summary then:
• School refusal can occur in any family and any school. In a medium-sized school of 500 students you would expect between 5 and 25 students to experience some level of school refusal.
• School refusers have often had difficulties settling into kinder and/or day care.
• School refusal does not end when school ends as clinical levels of anxiety will resurface whenever transition periods occur.
• School refusal is just as common in girls as it is in boys.
Given the frequency of school refusal and the far reaching implications that it holds for the individual, family and school community, it is essential that time and funds are made available for training and treatment of this difficult and complex issue which we are often ill equipped to manage.
Types of school refusers
School refusers can be grouped into three types: anxious/separation anxiety; anxious/depressed, and phobic school refusers.
Anxious/separation anxiety
This group is mainly characterised by younger children transitioning from kinder to school. We would expect anxiety to diminish as the child becomes accustomed to their environment and should be absent by age 7 when developmental separation anxiety will have been outgrown.
Case example
Sienna is a 5½-year-old prep student who is referred by the family general practitioner (GP) for treatment of separation anxiety that has been present since beginning kindergarten but has become significantly worse since beginning school. Sienna’s mother (Annette) explains that she is a stay-at-home mum with a 2-year-old child, who has only worked intermittently since Sienna’s birth. When not in her mother’s care Sienna has been in her maternal grandmother’s care whom she loves very much. Sienna is reported as having had separation anxiety when she first started kinder but this subsided within the first term. Since beginning primary school, Sienna is reported as having difficulty falling asleep and staying asleep, changes in eating patterns, highly anxious, prone to aggressive outbursts and intolerant of her younger sibling. Annette reports tears and tantrums from the minute she is dropped off at her classroom. Annette admits that there have been several mornings where Sienna has become so distressed that she has allowed her to remain at home. Sienna is typical of many first-year students who struggle with the individuation required to successfully commence school. She has managed kinder but only after repeated exposures and is now struggling with full days at school where she cannot be with her mother, grandmother or sibling. A program tailored to her specific needs with emphasis on developing independence and understanding, rewarding progress and encouraging exposure should produce quick and long lasting changes. We would expect that by the end of the second term, Sienna will have adjusted to her environment and developed enough independence to accept her mother’s absence. If, however, Sienna was still exhibiting extreme levels of anxiety by the end of her first year and into her second year of school we would begin to question the reason for this and perhaps refer her to a paediatrician for a second opinion.
Anxious/depressed group
This group is mainly characterised by older students who may have had a history of separation anxiety in early childhood and experienced varying degrees of success in attending school.
Where a previous history has not been present the school refusal may have been triggered by a life event (for example, bullying, school change, parental split). Unlike the anxious school refuser this group (in addition to anxiety symptoms) exhibit depressive symptoms that could include:
• lethargy (lack of energy, motivation and overpowering drowsiness or sleep)
• anhedonia (an inability to experience pleasure from things that had previously been joyful; e.g., playing football)
• diminished ability to think clearly or concentrate,
• depressed mood or irritability often described as a feeling of sadness or emptiness
• suicidal ideation or plan
• significant weight loss or weight gain
• feelings of worthlessness
• excessive, unwarranted guilt.
This group will often cause parents and teachers enormous concern as their demeanour is flat and negative leading to fears for their well being. It can be very difficult to engage parents to re-motivate this group as they fear that even the slightest push to get their child back to school could lead to self-harm.
Case example
Riley is a 13-year-old boy who attends a local secondary school and is referred for school refusal by his GP. Riley is the eldest of two children and the son of a nurse and mechanic, who both work long hours. Family dynamics are assessed as loving and supportive. Riley informs me at our first session that he was bullied in primary school intermittently for his weight but also for his bowel condition which meant that he could occasionally smell. Although his condition is significantly better and smell is no longer an issue he is still very sensitive to body odour and showers a minimum of two times per day. He admits to exaggerating symptoms when he was younger to get out of school but denies that he is doing so now. His mother reports that Riley has not attended school for six weeks and has stopped attending cricket training, withdrawn from friends and spends most of his time in his room playing computer games. When encouraged to participate in family celebrations Riley becomes aggressive and rude until he is given permission to not be involved. Riley’s parents report that Riley occasionally expresses a desire to be dead, which frightens them and dissuades them from pushing the school attendance issue. Riley claims that his refusal to attend school comes from his immense lethargy and fear that he’ll fall asleep in class and be bullied by other students. Secretly I am informed by Riley’s year level coordinator that Riley was rejected by a girl in his year level, which may have been the catalyst for the school refusal.
As we can see, Riley’s case study is significantly more complex than Sienna’s, and includes symptoms that clearly suggest the presence of depression. Re-establishing healthy daily routines, encouraging reconnection with friends and assessing the need for medication would be among our first priorities. It would be fair to assume that Riley will take longer to be re-integrated but this is still completely achievable.
There is often an overrepresentation of students diagnosed with autism spectrum disorder (ASD) in this group, as is also the case for high achieving/perfectionistic students. Both groups will be discussed in detail in Chapters 7 and 8.
Phobic school refusers
As the name suggests, this group has often had a long history of school refusal with varying degrees of success in re-engagement, and is characterised by older students. This group rarely makes an attempt to get to school and parents rarely try to motivate them on a consistent basis. Parents will often report bouts of yelling and screaming but rarely is there a systematic and consistent approach. This group can be quite complacent knowing that the family has been worn down and will only lash out when forced to make change.
Families of this group are often burnt out and can present as unmotivated, sceptical or resistant. These families require as much (if not more) support than their child as they too need to learn to overcome their anxiety and remain strong in the face of adversity.
Case example
Some years ago I met the parents of a 14-year-old boy (Charles), who had been referred to me by child protection services, for assistance in getting their son back to school. The parents informed me that they worked long hours and had three sons all of whom had, at some point in their education, refused to attend school. They described their many attempts to get their eldest son back to school and spoke of the frustration, anger and heartache they felt when, after much intervention by professionals, school and parents, they were only able to get him back to school for the fourth term of Year 10. At the time of referral they informed me that their eldest son was in his early twenties and unemployed. He had lost contact with most of his friends and tended to stay in his room playing computer games and watching TV. Not surprisingly there was some question of whether this son suffered with depression.
To add to their despair, their middle son also disengaged from school. The parents admitted to making only a half-hearted attempt at getting him back to school given the turmoil the family had experienced with their eldest son. As with his older brother, this son was also unemployed and very much confined to the family home. Their middle son was in his late teens at the time of referral.
It was of no surprise to me that their youngest son, Charles, had followed his elder brothers’ footsteps given that he had watched his parents take the path of least resistance particularly with his middle brother. When I met with Charles, he presented as a respectful and quiet young man who was genuinely distressed when we discussed a possible return to school. Charles admitted to disliking school and feeling out of place when he attended. He understandably preferred to be at home with his two older brothers, who would occasionally include him in one of their computer games.
Charles had scarcely attended school since the start of secondary school with periods of nonattendance reported in primary school. His parents admitted to leaving for work without even attempting to get him out of bed as they were fed up with the arguments, which were ultimately fruitless.
There is no doubt that Charles’s anxiety about going to school was very real but we must remember that Charles had not really been expected to attend school for some time. By the time I met Charles and his parents, the fear of going to school had become so great that avoidance was the only solution. Or to use an old adage: ‘Charles had come off the horse and had never really been expected to get back on’. Hence he had forgotten how to ‘ride’.
It was only with the involvement of his school, extensive education of his parents about anxiety/fear/avoidance and clear expectations of Charles that we were able to slowly get him back to limited school hours.
Sadly, Charles and his family moved away before we were able to complete his return to school. I often wonder what happened to Charles and his brothers and use their story in presentations as an example of what happens when issues are not addressed in their infancy and parents become despondent. In this case, what started as a problem with one child became a scourge for an entire family. As with all phobias, the longer we take to begin the exposure process the more difficult it becomes to challenge and successfully eradicate the phobia.
