School refusal is often a symptom of an underlying anxiety disorder. The child may get anxious on separating from their primary caregiver and this manifests itself in different ways depending on the age of the child as much as anything. There are 2 peak age groups who develop school refusal, 5-7 year olds and 11-14 year olds. 25% of school children refuse to attend school at some point in their school career but it becomes a routine problem in about 2% and the longer it goes on, the harder it is to reverse. It is not the same as truancy. It is not a mental illness in itself but many children who feel unable to attend school over a long period do have an underlying mental health issue. Unfortunately funding for CAMHS is being eroded and it is difficult to find good, and timely, help for school refusers. The websites I have listed in December 2010 Paediatric Pearls for GPs may help give parents pointers for why it is happening and how to set about managing it.
Children who present with school refusal often present with somatic symptoms (anorexia, nausea, abdominal pain, feeling faint etc) Normally these children are described by their families or by teachers as polite, inhibited and anxious. Most come from families where relationship are preserved and close however at times to the point of suffocation.
The condition substantially differs from truancy where truants do not show anxiety about being at school, and do not go home during the normal school hours but prefers hanging out with friends or alone and engaging often in delinquent activities (abusing substances, vandalism etc). Commonly the come from unstable families and relationships with their families are characterised by conflict and distance (Bowlby 1973)
Frick 1964 observed how children who refuse to attend school are normally not fearful about attending school but about leaving home, and often fear of a strict teacher or of the bullies are mere rationalisation of unconscious fear of separation.
Bowlby 1973 differentiated four patterns that might underpin school refusal:
Pattern A: mother or more rarely father, is sufferer from chronic anxiety regarding attachment figures and retains the child at home to be a companion
Pattern B: the child fears that something dreadful may happen to his family while at school and so remains at home to prevent it happening
Pattern C: the child fears that something dreadful may happen to him when is away from home
Pattern D: mother or more rarely father fear that something dreadful may happen to their child and so keeps him at home
These patterns are not incompatible and can mix and they are generally unconscious, therefore family fail to recognise them at first.
In my experience it is always paramount to work with the family/child as a system and try to enable them to recognise and challenge the deep and unconscious fears of separation.
However it is important to keep in mind that bullying (more recently cyber-bullying) can cause severe anxieties and therefore induce a behaviour of avoidance (school refusal). In those cases it is essential to liaise with school and occasionally with police in order to achieve a successful outcome
Dr Giovanni Giaroli
Consultant Child and Adolescent Psychiatrist, Honorary Lecturer of pharmacotherapy
Thanks for this information Giovanni. I don’t think I had thought about the possibility of the “fear of bullies” being a “mere rationalisation of unconscious fear of separation”. That’s useful information to be able to tell parents.
I have also had a couple of websites on this topic recommended by one of the Hackney CAMHS clinical nurse specialists: the Royal College of Psychiatrists’ focus factsheet on school refusal is at http://www.rcpsych.ac.uk/pdf/Sheet9.pdf and would be useful for families to print off and give to the school for example. The other site she recommended is aimed more at young people and looks good though admittedly I couldn’t find anything specifically on school refusal on it. It is at http://www.youngminds.org.uk/. Young Minds is a charity committed to supporting the emotional well being of young people.