Overcoming School Refusal. Joanne Garfi

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