School refusal is a serious emotional disorder in children.It occurs in 1-5% of children and prevalent equally in boys and girls. It is usually seen in the beginning of the school term especially when the child first starts school:

• During preschool

• Starting Year 1 of primary school

• Starting Form 1 of secondary school.

It must be differentiated from truancy although it is not mutually exclusive

The main differences between school refusal and truancy are summarized in the following table:-

CLINICAL FEATURES

Onset

• It often occurs after school holidays or an episode illness which caused the child to miss school. Factors which trigger it may be  stressful events at school e.g. being punished by their teacher, home e.g parental illness or with peers e.g being bullied by schoolmates

• Presenting  symptoms include:

  • Fearfulness, feeling panicky, crying  episodes

  • Temper  tantrums, threats  of  harming themselves, aggressive behaviour

  • Physical symptoms

    • Sweating, palpitations

    • Stomach upset, vomiting

    • Headache

      Symptoms are usually worse in the morning around the time the child has to go to school and improves if the child is allowed to stay home. The longer the child stays out of school, the more difficult it will be to return as the child develops feelings of inferiority.

SEQUELAE

Short-term

• Poor academic performance due to frequently missing classes

• Family difficulties e.g parental arguments because of child’s behaviour

• The child may avoid his or her friends

Long-term

• Doing poorly in studies

• Having problems getting jobs when older

• Increased risk for psychiatric illness

Assessment

• Complete medical history and physical examination

• Clinical interview with child and parents

• History of onset and development of symptoms

• Associated stressors

• School history

• Family psychiatric history

• Mental status examination including evaluation for psychiatric problems and substance abuse

Treatment

• Consultation with school authorities

• Behavior strategies

• Family intervention

• Pharmacotherapy

• Effective factors

  • Parental involvement

  • Exposure to school

Behaviour Strategies

• Systematic desensitization

• Graded  exposure  to  the  school  environment

• Relaxation training

• Social skills training.

• Cognitive behavior therapy

  • Help gradually increase their exposure to school e.g start by driving past their school and gradually enter the school gate and eventually their classroom.

  • Children should be encouraged to confront  their  fears e.g feeling scared when entering school grounds

  • Teaching children to modify their negative thoughts e.g “Everyone will laugh at me when I go to school”

Parent Interventions

• Parents are very important in helping their children attend school again especially in terms of:

  • Behaviour management strategies

  • Escorting the child to school

  • Providing positive reinforcement for school attendance e.g praise

  • Decreasing the child’s enjoyment for staying home (e.g., the child has to do school-work during school hours instead of watching television)

  • Cognitive training to help reduce their own anxiety

Teacher Interventions

• Parent’s need to discuss with the child’s teachers’ regarding the best way to help the child

• School staff to prepare for the child’s return

• Use of positive reinforcement e.g praise

• Academic, social, and emotional accommodations e.g. are given allowance to start school gradually, be allowed to sit in the library first if they are not confident about going to the classroom.

With support from parents, teachers as well as health care providers, most children will be able to gain the confidence needed to start attending school