Since the 1930s, the problem of failure to attend school has been attributed to fear, anxiety, lack of interest and/or defiance of adult authority. Until now, studies of such behavior have failed to take into account the possible role that DSM-IV psychiatric disorders might play in school refusal.
Helen L. Egger, M.D., E. Jane Costello, Ph.D., and Adrian Angold, M.R.C.Psych. of the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center, recently evaluated the association of mental disorders with school refusal in a community sample of children and adolescents by using a descriptive rather than etiological definition of school refusal. Their findings indicate that truancy and anxious school refusal are distinct but not mutually exclusive and may be significantly related to psychopathology and adverse experiences at home and in school.
The study authors obtained a representative sample of 4,500 children aged 9, 11 and 13 through the Student Information Management System of the public school systems of 11 counties in western North Carolina. This sample is part of the Great Smoky Mountains Study (GSMS), an ongoing, longitudinal study of the development of psychiatric disorders in young residents of North Carolina.
Egger and colleagues used the Child and Adolescent Psychiatric Assessment (CAPA) to evaluate psychiatric status in the three months prior to the assessment interview. The results indicated a wide range of DSM-IV diagnoses and were based on reporting from both parent and child, except in the case of attention-deficit/hyperactivity disorder (ADHD), which was based on parental information only.
The authors defined anxious school refusers, truants and mixed school refusers using items from two sections of the CAPA - i.e., the "school/work performance and behavior" section - which addressed truant behaviors, and the "worry/anxiety over school attendance and separation anxiety" section, which concentrated on anxious school-refusing behaviors. Children who failed to reach or left school due to anxiety or those who resisted attending school because of vigorous anxiety forcing a parent to bring them to school at least once during the primary period (i.e., the three-month period prior to the screening interview) were known as anxious school refusers.
To arrive at this definition, the researchers used four variables: school nonattendance (of at least a half-day's duration) due to worry/anxiety; staying home mornings from school because of anxiety; failing to reach school or leaving school, and going home and/or having to be taken to school because of worry and anxiety about attending school.
Truants, who in most cases were older children Egger told The Brown University Child and Adolescent Behavior Letter (CABL), were defined as those who failed to reach or left school without the permission of school authorities, without an excuse -e.g., illness - and for reasons not associated with anxiety about separation or school at least once in the primary period. Again, four variables were considered: skipping at least one half day at school for reasons other than separation or school anxiety; staying home mornings; having to be taken to school to ensure arrival for reasons other than anxiety or emotional disturbance, and failing to reach or leaving school before dismissal.
Mixed school refusers included children who had exhibited anxious school refusal behavior as well as truancy during the three-month primary period. Pure anxious school refusers and pure truants were those who displayed anxious school refusal only and those who endorsed truant behavior only, respectively. Nonschool refusers were children who did not resist or refuse to attend school for any reason.
The study considered a number of DSM-IV psychiatric disorders including separation anxiety disorder (SAD); generalized anxiety disorder (GAD); simple phobia; social phobia; panic disorder; depression; conduct disorder (CD); oppositional defiant disorder (ODD); ADHD, and substance abuse. Additionally, the authors considered association between school refusal and peer relationships as well as school and home experiences. A 26-item vulnerability scale that includes family environment problems, family relationship problems and parental psychopathology, was used to reflect ongoing difficulties in the child's life and family that are known to be connected to psychiatric disorders.
Psychiatric disorders prevalent
The study authors report that the three-month prevalence of overall anxious school refusal was 2 percent (n = 165) and of truancy was 6.2 percent (n = 517). Also, anxious school refusers were 6.8 times more likely than children without anxious school refusal to be truant (p <0 .0001). One quarter of anxious school refusers and 8.1 percent of truants were mixed school refusers (0.5% prevalence; n = 35). One quarter of the pure anxious school refusers and pure truents exhibited at least one psychiatric disorder, compared with 6.8 percent of children without school refusal. Close to 90 percent of the mixed school refusers were found to have a psychiatric disorder.
When the authors accounted for the effects of comorbidity rather than examining for only a single psychiatric diagnosis, different patterns of association between school refusal and psychopathology were revealed. Depression and SAD were found to be significantly associated with pure anxious school refusal.
According to this report, clinical studies have found that simple and social phobias are associated with anxious school refusal. The authors in this study examined why the phobias dropped out of the pure anxious school refusal multivariate model. Egger's study found that social phobia was highly predictive of simple phobia (p 0.0001) and depression (p = 0.03). When the researchers removed social phobia from the multivariable model, the association between anxious school refusal and simple phobia was significant (p = 0.004). When both simple phobia and depression were removed from the model, social phobia was significantly associated with pure anxious school refusal (p = 0.004).
Other associated characteristics
In addition to simple and social phobias, Egger and colleagues examined the prevalence of other associated characteristics and school refusal. Separation fears and worries, sleep patterns and somatic complaints were found to play a role in school refusal. The study reports that anxious school refusers had significantly higher rates of separation fears and worries than children without the problem; however, anxious school-refusing behavior was not strictly synonymous with separation fear and worries.
Different patterns of sleep difficulties were associated with the three types of school refusers, i.e., pure anxious school refusers, pure truants and mixed school refusers. These sleep patterns are additional characteristics associated with the problem of school refusal. Nightmares and night terrors were most prominent in the mixed school refusers, depression-associated sleep symptoms were associated with the pure truants and depression and separation- associated sleep difficulties were related to the pure anxious school refusers. The study revealed somatic complaints in 25 percent of the pure anxious school refusers, 42 percent of the mixed school refusers and very few of the pure truants.
Peer relationship problems factored most significantly in pure anxious school refusers. This group tended to be shyer, the targets of bullying and teasing and experienced social withdrawal and increased conflict in peer relationships more often than nonschool refusers. The mixed school refusers were also likely to be teased or bullied and had difficulty making friends while truants were 2.4 times as likely as non-truants to have conflicted relationships with peers but were not shown as victims of bullying and teasing.
Psychosocial vulnerabilities
In addition to the above-mentioned factors, a number of psychosocial vulnerabilities significantly impacted school refusal behavior. Some of the most predominant vulnerabilities associated with pure anxious school refusal included living in a single-parent home, attending a dangerous school and having a biological or nonbiological parent who had been treated for a mental health problem. Pure truants were found to be more likely the product of an impoverished home, to be living in a single-parent household, to have an adoptive parent, to have been born to teenage parents and to have lax parental supervision than non-school refusers.
Of note is the fact that three quarters of the mixed school refusers (children exhibiting both anxious school refusal and truant behavior) had a biological parent who had undergone treatment for mental health problems. Also, half of this group lived in poverty and 41.3 percent had moved multiple times. They were also more likely to have a parent without a high school diploma or an unemployed parent. Mixed school refusers were nearly 10 times more likely than non-school refusers to attend a dangerous school, and were more likely to have lax parental supervision.
The most significant limitation of this study, according to Egger, was the unavailability of school records. This factor did not allow for the researchers to conduct an all-inclusive evaluation.
"It's important to do a comprehensive developmental and achievement assessment to see if there are learning difficulties," she said. Psychiatric factors as well as family, school, cognitive and academic assessments would help to produce a more complete picture, Egger added.
Although one-quarter of the children in the study were found to have anxious school refusal, Egger emphasizes that three-quarters did not.
"School refusal can't be fully attributed to emotional health," she told CABL. "Societal, parental and family issues are also involved."
Egger speculates that a child's behavior might be based on environmental factors. "It's important that we look at a child's peer relationship and the school and home environment so we can intervene and make a difference in those external factors," she said.
According to Egger, the results of this study highlight the important role that day care providers and teachers play since they occupy the "front lines" in being able to identify early signs of problems. She points out that school refusal peaks at the ages of five to six and then again between the ages of ten and 11, both times of academic transition. Egger cites, too, an increased demand in today's society on youngsters, even those as young as preschool age, as a possible precipitating factor in school refusal.
Egger reiterates that in spite of the low incidence of school refusal found in this study, the problem is nevertheless important and requires careful attention. "Even when a problem is at a low level, it should be taken seriously," she concluded.
References
Egger HL Costello EJ, Angold A: School refusal and psychiatric disorders: a community study. J. Am. Acad. Child Adolesc. Psychiatry 2003; 42(7):, 797- 807. |
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