A study on psychiatric conditions in children with school refusal- A clinic based study

ABSTRACT

Introduction:

School refusal is a broad term that encompasses a child-motivated refusal to attend or remain at school, or a clear and apparent difficulty in doing so. Different factors that may influence the development of school refusal include a genetic predisposition, the home and family environment, the school environment, and social pressures. the present study aimed at examining, the psychiatric diagnostic status of children and adolescents who presented with school refusal.

Materials and Methods:

92 consecutive subjects who attended the Child guidance clinic at Tata Main Hospital Jamshedpur were taken up for this study. The Clinical Diagnosis was based on the classificatory system of the International classification of diseases-10(ICD-10) through interviews.

Results:

findings show that the mean age of the patient was 9.6 years. The prominent psychiatric co-morbidity present was Childhood emotional disorder unspecified, separation anxiety, conversion disorder, over-anxiety disorder, and somatoform disorder.

Conclusion:

Among children who refuse school, emotional reasons and anxiety disorders are most prevalent. This calls for early recognition and appropriate culturally relevant intervention to ensure early return to school.

Introduction

School refusal is a broad term that encompasses a child-motivated refusal to attend or remain at school, or a clear and apparent difficulty in doing so.[1] This refusal often stems from anxiety generated either by the separation from a major attachment figure or from the perceived fearful situations at schools such as bullying or an oral presentation. School refusal can also result from positive reinforcement, or rewards, such as access to television, video games, or simply attention that is received outside of school.[1]

The operational criteria for school refusal are: severe difficulty in attending school often resulting in prolonged absenteeism, severe emotional upset when having to go to school, remaining at home with the awareness of the parents during school hours, and absence of severe antisocial behavior.[2] It is often associated with emotional distress (e.g. separation anxiety, social anxiety, depression); somatic complaints; learning disabilities; maladaptive coping skills; and family history of anxiety disorders and family stressors (e.g. parental divorce, prolonged illness, shifting residence).[3]

School refusal affects approximately 1-2% of school children and occurs in children of both genders aged 5-7 years and 11-14 years, owing perhaps to developmental vulnerabilities (e.g. starting school, transition to middle school).[3]

Numerous factors that may impact the development of school refusal include genetic susceptibility, the home and family environment, the school atmosphere, and social demands, as well as learning theories that highlight the role of social reinforcement and modeling.[4] It is possible that the four functions of school refusal may have distinct patterns of contributing factors; however, this research is only in the early stages.[5]

Various clinic-based diagnostic studies have been reported in the literature on school refusal. Studies indicate that a high proportion of children presenting with school refusal have an anxiety disorder and or depressive disorder.[6] High rates of anxiety disorders with multiple diagnoses and associated family stressors have been reported.[7,8] School-phobic children had more severe school refusal at later age of onset compared to separation-anxious children.[8] Recent research studies on adolescents with school refusal show a high prevalence of mood disorders.[9] In addition, environmental and temperamental considerations appear to contribute substantially to the problem. Short-term follow-up studies have shown how goal-oriented multi-modal interventions are very effective.[10,11,12] A downside of many outcomes studies has been that select diagnostic groups have been taken and important outcome measures such as school attendance and return to school have not been studied.[12]

Education is one of the strongest forecasters of health: the more schooling people have the better their health is likely to be. Although education is highly correlated with income and occupation, evidence suggests that education exerts the strongest influence on health.[13,14] Poor mental health was significantly associated with dropout among students in vocational and higher education.[15] This study brings into light the other factors that accompany complaint school refusal. It highlights the fact that children who drop out of school need not necessarily be due to low intellectual ability and financial constraints but may carry issues deeper than that. Identifying the contribution of early-onset psychiatric illness to school incompletion is necessary to inform effective, targeted prevention and intervention policies at the national level. Although it is often tough to differentiate causes from consequences, youth who drop out of school are at increased risk for exhibiting socioemotional problems and engaging in delinquent and criminal behavior.[16]

There have been no such studies reported in the eastern part of the Indian subcontinent. The present study aimed at examining, the psychiatric diagnostic status of children and adolescents if any who presented with school refusal and how we managed their early return to school.

Materials and Methods

Study setting: the study was carried out in the Child guidance clinic, which is a part of the psychiatry Dept of a tertiary care hospital in eastern India.

Study duration

The study was carried out between December 2016 to December 2019, 3 years.

Study design

Cross-sectional study.

Sample size and sampling

purposive sampling was used and 92 consecutive subjects who met the inclusion criteria were recruited from the Child Guidance Clinic of tertiary care hospital in eastern India.

Data collection

92 consecutive subjects were taken. the Inclusion criteria were school-going subjects of either sex aged below 16 years, presenting with child-motivated refusal (Berg’s criteria) to go to school for a minimum period of seven days. A review of the literature shows a variable definitions of the duration of school refusal ranging from one day to several weeks in a school term.[17,18] A duration of seven days was selected as a compromise between too short or too long a duration of school refusal. Exclusion criteria included the presence of organic disorder, psychosis, truancy, and Mental retardation.

The treating team interviewed all the subjects and parents at baseline and follow-up. With the consent of parents, the intake proforma for each subject was filled with the socio-demographic details, schooling history including educational level (class), and scholastic performance. The Clinical Diagnosis was based on the classificatory system of ICD-10. Assessment for diagnosing learning disorders was done by the researchers whenever it was suspected on clinical grounds.

Data analysis

Descriptive Statistics was used to analyze the various diagnoses present in children & adolescents with School refusal.

Ethical clearance

Ethical approval was obtained from the Institutional Ethical committee.

Results

The results show that 52.2% of the patients were female gender and the majority of the patients were studying in primary classes from nursery to class 5 [Table 1].

Table 1.

The table shows the socio demographic details of distribution of gender of the sample and the educational qualification

Socio demographic variables	Number of patients (n=92)
Gender
Male	44 (47.8%)
female	48 (52.2%)
Education (class)
Primary (nursey-class5)	61 (66.3%)
Secondary (class 5 & above)	31 (33.7%)

The results show that the mean age of the patients was 9.6 years and a standard deviation 3.47 was present. The minimum age of the patient in the present sample was 3.6 and the maximum age was 15 years [Table 2].

Table 2.

Shows the minimum, maximum, mean and standard deviation of age of the patients of the study

Variable	n	Minimum	Maximum	Mean	Std Deviation
Age	92	3.6	15.00	9.66	3.47

This Table shows the number of patients with school refusal with their diagnostic breakup. The maximum number of children suffered from emotional disorders followed by separation anxiety and conversion disorder [Table 3].

Table 3.

Showing the Psychiatric Diagnostic Break up of patients with School refusal

Diagnosis	Total number of patients
Childhood emotional disorder, unspecified	23 (25%)
Seperation anxiety	13 (14.13%)
Conversion disorder	13 (14.13%)
Over- anxious disorder of childhood	10 (10.86%)
Somatoform	7 (7.60%)
Social anxiety	6 (6.52%)
Depression	6 (6.52%)
Child Sexual Abuse	5 (5.43%)
Conduct disorder	5 (5.43%)
Acute stress reaction	2 (2.17%)
Leraning disabilties	2 (2.17%)
Total	92 (100%)

Discussion

To the best of the authors’ knowledge, this is the first reported clinic-based study on the clinical characteristics of school refusal in the eastern part of India. A Prescribed Psychiatric diagnosis does not include school refusal. However, children with school refusal may suffer from significant emotional distress, especially anxiety and depression.[9] Children with school refusal usually present with anxiety symptoms, and adolescents have symptoms associated with anxiety and mood disorders.[19]

Socio-demographics factors

According to the study, approximately 1 to 5 percent of all school-aged children demonstrate school refusal, and the rate is similar between boys and girls.[12] These consistent findings have influenced some researchers to conclude that, gender is not highly predictive of cases of school absenteeism.[20] Similarly, Tekin et al. (2018)[21] found gender did not yield any differences in school refusal behavior. In our study also, the difference between male are female cases are not significantly more towards any specific gender.

Previous research done by Kearney (2006)[22] found that school refusal behavior is at its peak at the age level of 10 and 13 years old, regardless of gender. Similarly, findings were seen in the index study, as the age group was 9.66 ± 3.47. This finding is congruent with previous research which suggests that school refusal behavior is most prevalent during transition years in school[12], and tension runs high in both gender as the students couldn’t make themselves familiar with this new academic situation having to study more, teachers being less play oriented and more task-oriented, loads of homework and sudden increase in school hours. These changes may be overwhelming to some students and could lead to an increase in students’ school-refusing behavior.

Psychiatric diagnosis

The most common comorbid psychiatric disorders include separation anxiety, social phobia, simple phobia, panic disorder, post-traumatic stress disorder, major depressive disorder, dysthymia, and adjustment disorder.[9,10,23] Similar Findings were found in our study where the prominent psychiatric diagnosis that we came across in our sample population was Childhood emotional disorder unspecified, a range of anxiety disorders, which included Over-anxious disorder of childhood and Separation anxiety.

Separation anxiety disorder was present in 14%, which is less than in other studies.[8] There is a likelihood of lesser occurrence of separation anxiety disorder in the Indian culture. This could be because of a more secure and nurturing parent-child relationship.[7] This needs further exploration.

In our study, 25% of children had Childhood emotional disorders, unspecified and stress-related disorders. On further exploration, we found that it was arising out of family conflict and interpersonal/Peer problems. Challenges with family functioning may contribute to school refusal in children; nevertheless, few studies have systematically evaluated and measured these problems.[24]

Dysfunctional family interactions that correlate with school refusal include over-dependency, detachment with little interaction among family members, isolation with little interaction outside the family unit, and a high degree of conflict.[17] Communication problems within families, problems in role performance (especially in single-parent families), and problems with family members rigidity and cohesiveness also have been identified as probable stressors.[25,26]

Somatoform and conversion disorder are a few such diagnoses, which does not have specific diagnostic criteria for the child and adolescent population. Children with hysterical symptoms form a notable proportion of cases in child guidance and psychiatry clinics in India. It could be that, in this culture, having a “medical” illness is one of the more acceptable means of seeking psychiatric help. (Srinath et al., 1993).[27]

Somatoform disorders & Conversion combinedly amounted to 20% of the total cases. the children who came to us presented with pain abdomen, severe headaches, and a few cases with pain in limbs. On detailed exploration, we identified that in most cases poor parental handling was the main factor. In a few cases, the parents were given relatively less attention due to the new addition to the family. In some cases, the gains of staying at home during school hours and doing activities like watching TV and parents not going to their work and giving attention to children was contributing factor.

In literature, Conversion disorders mainly present as fainting spells, with or without co-morbid diagnoses is high in clinical populations in India.[27] Somatic complaints like pain abdomen, headache, and fatigue are common in school refusing children when faced with the prospect of going to school.[28] Parental Overindulgence, over protection as a significant factor along with to significant factors along with other contextual psychosocial factors, was found which have also been mentioned in the western literature.[17] Somatic presentation coupled with parental anxiety about the child having a serious “physical illness” delays presentation to psychiatric services, with medical help being sought after first.[7]

Depressive disorders were found in 4 children in our study which has also been documented in earlier literature on school refusal.[9] Children with depressive disorders mostly were disturbed because of their studies and expectations from themselves and their parents and in one case, there was bereavement in the family. Appropriate treatment of depression using antidepressants and psychosocial interventions may help speedy return to school.[7]

The primary treatment goal for us was the early return to school of the child along with addressing the comorbid psychiatric problems, family dysfunction, and other contributing problems. When parents escort their child to school, somatic complaints, protests, crying, temper tantrums, and negotiation are all likely to occur.[29] In the current study, parents were confronted with a variety of resistive responses, but they managed these and persisted in escorting the child back to school, in accordance with our guidance. Although we do not have rates of school attendance, it is promising that majority of the subjects attended school during the follow-up. A small number of patient still manifest symptoms in varied forms when encountering stress.

The Children & adolescents with a diagnosis of Childhood emotional disorder, unspecified, all the anxiety spectrum disorders, which included Over-anxious disorder of childhood, Separation anxiety, Social anxiety, acute stress reaction & Depression, showed significant improvement and returned to school. but previous studies have shown many separations anxiety and anxiety disorder school refusers continue to have problems as adults and signal the need for follow-up to discuss their difficulties.[3] Behavioral intervention along with family intervention in these cases helped in a significant way in early return to school. Behavior treatments include systematic desensitization (i.e., graded exposure to the school environment), relaxation training, problem-solving, and social skills training. Family Oriented Intervention focused on improving parent-child relationships & other techniques like contingency Contracts, Ignoring Simple Inappropriate Behaviors, Establish Fixed Routines & Definite Consequences for School Refusal. In the subsequent follow-ups the children have been consistent in attending school & in their performance.

Patients with conduct disorder, Somatoform and conversion disorder showed significant improvement but, persist to have symptoms occasionally, these children exhibit poor attendance at school. They had identifiable parental pathology, the environment at home & temperamental issues, and mishandling on the part of teachers and parents. These are the few areas which further research and exploration.

Among the 5 children who had been subjected to Child Sexual Abuse, 2 were successfully rehabilitated back to school, while the other 3 children still have the problem of absenteeism and adjustment issues. In such cases, social management like having school counselors, and forming buddy support groups to handle issues like abuse and bullying will make the school environment more conducive and will prove very useful since this is lacking in most Indian schools.[7]

Limitations

The findings of the study have some limitations. This was only a hospital-based sample there was a lack of a control group and no structured scale was used for diagnostic interviews and to identify the psychosocial factors. However, this is the first study from Eastern India on school refusal.

Conclusion

There is no single cause for school refusal. Children who exhibit school refusal are a heterogeneous group who differ in the level of severity and motivation for their behavior. Among children who refuse school for emotional reasons, anxiety disorders are most prevalent. This emphasis on early identification and appropriate intervention to ensure early return to school.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.