Coping with Life by Coping with School?

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Coping with Life by Coping with School?

• School refusal, school phobia and truancy
• Andy Miller
• 3rd March 2008

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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

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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.

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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)

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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)

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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

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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

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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).

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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

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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.

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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).

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Early theoretical formulations

• From a psychodynamic orientation
• Separation anxiety
• Omnipotence
• From a behavioural psychology orientation
• School-focused anxiety
• Social anxiety

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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 mothers 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)

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Omnipotence

• An alternative psychoanalytic approach,
  suggested by Berry et al (1993) focused on the
  childs 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 childs
  limitations, leads to avoidance of school and
  staying at home, where parents further reinforce
  his or her distorted, omnipotent self-image.

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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.

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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.

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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.

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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.

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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.

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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.

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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
  doesnt 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

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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

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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?

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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

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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)

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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

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Keareny Silvermans 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)

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Keareny Silvermans 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.

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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.)

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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

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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

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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.

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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 individuals 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).

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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, 87-91.
• Elliot, J.G. (1999) Practitioner review School
  refusal issues of conceptualisation, assessment
  and treatment. Journal of Child Psychology and
  Psychiatry, 1001-12
• 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, 57-65.