1. Coping with Life by Coping with School?
School refusal, school phobia and truancy
Andy Miller
3rd March 2008

2. Learning outcomes
After this lecture and its associated reading you will be able to
Describe the major theoretical formulations that have attempted to account for chronic non-school attendance
Explain the link between major theoretical formulations and the intervention approaches that derive from them
Identify those aspects of case presentations that have significant implications for assessment and intervention with school refusers
Justify the selection of components of effective intervention plans for school refusers

3. The ‘clinical presentation’ of school phobia
Historically, Broadwin (1932) was the first to describe a form of non-attendance at school that seemed to be typified by a consistent and long standing absence from school, in which the young person stayed at home, seeming extremely fearful of going to school even though any reasons given usually seemed incomprehensible or disproportionate to parents and teachers.

4. The ‘clinical presentation’ of school phobia (2)
‘The problem often starts with vague complaints of school or reluctance to attend progressing to total refusal to go to school or to remain in school in the face of persuasion, entreaty, recrimination, and punishment by parents and pressures from teachers, family doctors and education welfare officers. The behaviour may be accompanied by overt signs of anxiety or even panic when the time comes to go to school and most children cannot even leave home to set out for school. Many who do, return home half way there and some children, once at school rush home in a state of anxiety. Many children insist they want to go to school and are prepared to do so but cannot manage it when the time comes’ (Hersov 1977)

5. The ‘clinical presentation’ of school phobia (3)
‘Anxiety symptoms often manifest themselves in a variety of somatic forms including headache, stomach pains, nausea, dizziness, fevers and so on. Sometimes the child protests with tears or temper tantrums leading to destructive or aggressive behaviour. Some children become lethargic and depressed and a few threaten suicide. Usually, once the pressure to attend school has been removed, the symptoms accompanying the school avoidance dissipate’ (Blagg 1987)

6. Distinguishing between school phobia, truancy and other non-attendance (Blagg 1987)
Criteria for defining school phobia (from Berg, Nichols and Pritchard, 1969)
severe difficulty in attending school often resulting in prolonged absence
severe emotional upset, which may involve such symptoms as excessive fearfulness, temper tantrums, misery, or complaints of feeling ill without obvious organic cause when faced with the prospect of going to school
pupil remains at home with the knowledge of parents during school hours
absence of significant antisocial disorders such a juvenile delinquency, disruptiveness, and sexual activity

7. Distinguishing between school phobia, truancy and other non-attendance (Blagg 1987)
Defining truancy (from Blagg and Yule 1984)
absent from school without good reason on at least five occasions in one term
pupil shows no evidence of a marked emotional upset accompanying the non-attendance at school
pupil is absent without the parents’ permission or approval, the majority of time off being spent away from home. Parents sometimes aware of the non-attendance but unable to exert any influence over their child

8. Distinguishing between school phobia, truancy and other non-attendance (Blagg 1987)
defining other poor attenders (from Blagg and Yule 1984)
absent from school without good reason on at least five occasions in one term
pupil shows no evidence of a marked emotional upset accompanying the non-attendance at school.
remaining at home with knowledge and permission of parents (possibly kept at home deliberately to help with an ill or ‘needy’ parent).

9. Epidemiological aspects of school refusal (Berg 1996)
Boys and girls are equally affected
There is no relationship to social class
There is no relationship with intellectual or academic ability
The youngest child in a family of several children is more likely to be affected
Parents of school refusers are often older than would otherwise be expected

10. Epidemiological aspects of school refusal (Berg 1996) (contd)
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
The onset tends to be gradual, but it may occur suddenly after time away from school because of illness or holidays or some upsetting event, or just come on without any obvious reason
There may be no associated social impairment but often there often is, including staying home excessively and avoiding contact with other children.

11. Incidence rates
Elliott (1999) cites studies that yield varying incidence rates depending on the stringency with which school refusal is defined and concludes that a proportion of 1-2% of the school aged population is now the widely accepted figure for school refusal defined in this way (eg Hersov, Blagg etc).

12. Early theoretical formulations
From a psychodynamic orientation:
Separation anxiety
Omnipotence
From a behavioural psychology orientation:
School-focused anxiety
Social anxiety

13. Separation anxiety
seen as a product of an unresolved mother/child dependency relationship in which an excessively strong mother-child attachment resulted in a reluctance on the part of a child to leave the home (Johnson et al. 1941)
Also thought to be founded on an inadequate fulfilment of the mother’s emotional needs within an intimate adult relationship. As a result of an interplay of hostility and dependency, and the ‘subconscious mechanisms of displacement and projection’, a level of anxiety about separation developed in the child to an acute degree (Estes et al. 1956)

14. Omnipotence
An alternative psychoanalytic approach, suggested by Berry et al (1993) focused on the child’s feelings of omnipotence. In this theory the child develops a grandiose attitude of himself or herself which, when challenged in school by realities that confront the child’s limitations, leads to avoidance of school and staying at home, where parents further reinforce his or her distorted, omnipotent self-image.

15. School-focused anxiety
deriving from a behavioural viewpoint, and more specifically from within classical conditioning, is school-focused anxiety, in which some particular features of school environments such the size of buildings, the strictness of some teachers, the difficulty of some lessons and tasks, and the potential embarrassment associated with using the toilet or changing for physical education activities, become the source of fear and anxiety.

16. social anxiety
a more specific form of school-based anxiety centring on interactions with others and incorporating fears of being rejected, isolated or bullied, and an inability to make friends.

17. Intervention approaches associated with early formulations - psychodynamic
Blagg (1987) reviewed early treatment studies based on a traditional psychodynamic approach, beginning with a study published by Jung in 1911 and ranging through a number that reported the use of psychoanalysis either with children alone or mother and child together, with some courses of treatment lasting for up to three years.
Also in this review, Blagg referred to a series of interventions, the first being published in 1948, in which children and young people were treated by means of admission to an hospital, usually psychiatric, as an in-patient.

18. Intervention approaches associated with early formulations - psychodynamic (2)
More recent thinking within child and adolescent psychiatry has emphasised the need for a rapid return to school wherever possible (Goodman & Scott 2002) with the possibility of individual psychotherapy to explore more persistent anxieties being offered once the child is back in school (Black & Cotterell, 1993).
By 1993, Black & Cotterell were reporting that, in the British context, in-patient treatment of school refusal was most uncommon.

19. Intervention approaches associated with early formulations - behavioural
systematic desensitisation approaches were located within a classical conditioning framework and attempted to help the young person overcome the anxiety by reciprocal inhibition (Wolpe 1958), by teaching any behaviours antagonistic to the anxiety, such as controlled breathing or imagining pleasant activities. Such treatments either took place entirely in imagination or in vivo, where some or all of the treatment would be carried out in the presence of the anxiety producing stimuli, perhaps in the early morning before school departure or, if it were possible to arrange, at school itself.

20. Intervention approaches associated with early formulations - behavioural (2)
Flooding or implosion is a procedure for confronting the maximally feared situation, usually in imagination, directly rather than after graded exposure as in most desensitisation approaches. Blagg (1987) cautioned that real life confrontation of maximal fears - flooding – was a highly demanding and stressful treatment, not least as a result of the ‘extinction spike’, a temporary accentuation of the fear, as an early phase of classical extinction. For this reason and others, Blagg suggested that, if used at all, flooding was likely to be used as one part of a more complex, composite approach.

21. Intervention approaches associated with early formulations - behavioural (3)
From an operant conditioning stance, approaches have attempted to alter reinforcement contingencies either by attempting to maximise the reinforcement for being in school by building this into the school side of the intervention and, or minimising as far as possible the incentives for remaining at home during the school day. Again, as with flooding, where operant approaches have been used in later applications, they have tended to be as part of multi-element interventions.

22. A CBT approach to school refusal (Heyne & Rollins 2002)
describing the cognitive therapy model
detecting cognitions (e.g. ‘I know the teacher doesn’t like me because she raises her voice’)
determining which cognitions to address
disputing maladaptive cognitions
discovering adaptive cognitions or coping statements
doing between-session practice tasks
discussing the outcome of the tasks

23. How effective are various interventions?
King and Bernstein (2001) have pointed out that neither play therapy, psychodynamic psychotherapy nor family therapy as treatments for school refusal, have been subjected to rigorous evaluation in randomised controlled clinical trials
from the various psychosocial treatments employed with school refusal, only CBT has been subject to rigorous evaluation using randomised controlled trials
Heyne et al (2005) summarise the outcomes of this research. Although the pragmatics and practicalities of conducting such research presents considerable obstacles, these authors conclude that the evaluation research to date provides encouraging support for the efficacy of CBT with school refusers

24. Is school refusal a unitary concept?
Do all cases of school refusal or school phobia share a number of basic common characteristics, making it in essence a unitary concept?
Or, are the broad distinctions adopted by Blagg (1987) – school phobia, truancy, and other instances of poor attending – justifiable as three distinct and disparate phenomena?
Or, are there more valid distinctions that are either more complex and, or, considerably less precise?

25. Is school refusal a unitary concept (contd)?
Kearney (2003) argues that different sets of professionals are often ‘not on the same page’ when
addressing students or clients,
examining research samples, or
classifying absentees
because of the considerable disparity that exists in terms of fundamental concepts such as
definition,
assessment, and
treatment

26. Is school refusal a unitary concept (contd)?
Elliot and Place (2004) argue that it is now widely accepted that school refusal is not a unitary syndrome, even when the term is used only to denote ‘emotionally-based’ absenteeism, but rather is multi-causal and refers to a highly heterogeneous population.
However, practitioners still find it helpful to operate on the basis of there being a group of school refusers characterised by a very high degree of emotionality. (The term ‘school phobia’ is no longer considered appropriate in many quarters). Locally-generated nomenclature varies, e.g.
‘emotionally-based school refusal’ (West Sussex)
‘anxiety-based school refusal’ (North Somerset)
‘anxiety related school attendance difficulties’(Notts)

27. The case for a functional analysis
Kearney and Silverman (1990) argued for an approach that examined the functions served by a pupil not attending school rather than a system based on categorisation through symptoms
They suggested four main sets of reasons for non-attendance, which incorporate a number of earlier formulations, some in novel rearrangements:

28. Keareny & Silverman’s functional analysis
To avoid the experience of severe anxiety or fearfulness related to attending school. One or more specific features of the school day may be feared or causing anxiety; for example, the toilets, the corridors, sitting examinations, or specific lessons (often physical education lessons)
To avoid social situations that are feared, or which cause anxiety. This includes problems with peers, perhaps due to bullying or name calling; social isolation at school, and problems with individual teachers (e.g. being criticised or humiliated by a teacher in front of classmates)

29. Keareny & Silverman’s functional analysis
To seek attention or to reduce the feeling of separation anxiety. Kearney and Silverman (1990) combine these different concepts, arguing that functionally they are equivalent; the young person receives positive reinforcement for their non-attendance in the shape of special attention at home. They quote King et al (1994) - ‘the more fear and avoidance behaviour the child displays the more attention he or she receives’
To enjoy rewarding experiences that non-attendance at school may bring. For example, this could be watching television or playing computer games at home, or associating with friends. Depending on the company kept, this could lead to involvement in anti-social acts, and/or criminal activities. This category therefore includes those children and young people usually referred to as truants.

30. Validity of functional analysis approach
Kearney (2007) has consolidated the usefulness of this four function model as a way of organising, assessing and treating this population by carrying out hierarchical regression analysis and structural equation modelling.
Data on 222 young pupils aged between 5 and 17 years and displaying school refusal was provided by the young people and their parents
Found that ‘behaviour function’ was a better determinant of degree of school absenteeism than ‘behaviour form’ (i.e. types and extent of ‘symptoms’.)

31. Long-term outcomes for school refusers
Evidence is inconsistent (McShane et al 2004) depending on a range of factors such as:
whether treatment interventions have been offered and taken up,
and their type,
but also on characteristics of the young people involved such as the presence of comorbid mental health difficulties or academic difficulties

32. Long term outcomes (contd)
Kearney et al (1995) aver that, if untreated, school refusal can result in long-term problems such as marital and occupational difficulties, anxiety, depression, alcoholism and antisocial behaviour.
In contrast, and in the shorter term, McShane et al (2004) found that, from a sample of 118 young people treated at a specialist adolescent unit in the Australian context, 70% showed an improvement after 6 months and 76% at 3 years

33. Case Study - Part 4 The outcome
After attending five after-school art club sessions, James told his parents that he was willing to attend school full-time after the impending summer holiday.
This he did and in the subsequent year his attendance returned to the same high level of the year prior to the period of intense absenteeism. After completing this year of renewed high attendance he had made up for the missed lessons, and obtained gradings ‘at the nationally expected standard for 14-year olds’ in seven different subjects, including English, maths and science, and ‘below average’ gradings in only three subjects.

34. Coping with life by coping with school?
‘Coping with adverse life events or pressures is a major requirement for maintaining reasonable functioning and has been recognised, together with the presence of protective factors, as the mechanism for reducing the risk of future mental health problems…. Coping successfully with one situation strengthens an individual’s ability to cope in the future. A failure to cope with a complex setting such as school can therefore have potentially serious long-term consequences as various outcome studies have shown’.
(Place et al 2002).

35. References
Blagg, N. (1987) School Phobia and its Treatment. London. Croom Helm.
Chitiyo, M.& Wheeler, J.J. (2006) School Phobia: Understanding a complex behavioural response. Journal of Research in Special Educational Needs, 6, 2,
Elliot, J.G. (1999) Practitioner review: School refusal: issues of conceptualisation, assessment and treatment. Journal of Child Psychology and Psychiatry,
Elliot, J.G. & Place, M. (2004) Children in Difficulty: A Guide to Understanding and Helping (2nd edition). London. Routledge (Chapter 3).
Frederickson, N. Miller, A. & Cline, T. (2008) Educational Psychology (Topics in Advanced Psychology). (Chapter 12) London. Hodder Arnold. (available 28/3/08)
Heyne, D., King, N. & Olendeck, T.H. (2005) School refusal. In Graham, P. (Ed.) Cognitive Behaviour Therapy for Children and Families (2nd edition). Cambridge. Cambridge University Press.
Kearney, C.A. (2003) Bridging the gap among professionals who address youths with school absenteeism: overview and suggestions for consensus. Professional Psychology: Research and Practice, 34, 1,