Pediatric Primary Care Case Studies (14 page)

Kearney and colleagues define school refusal behavior as “child motivated refusal to attend school and/or difficulties remaining in classes for an entire day” (Kearney & Albano, 2004, p. 147). This term thus encompasses all students who refuse to go to school, truants, those with anxiety-related disorders, and other unidentified reasons for school refusal, and does not focus on etiology but instead on behaviors. School refusal behavior occurs in all age groups, in boys and girls equally, and is reported to occur in from 1–5% of students (Fremont, 2003) to as many as 28% of students at some point in their school career (Kearney, 2006). Peak ages appear to be 5–7 and 10–14 years of age (Kearney; King & Bernstein, 2001; Marcontel-Shattuck & Gregory, 2006; Plante, 2007; Sewell, 2008). Transitions and changes from one school to another (Kearney; King & Bernstein) or from an extended time at home and a return to school (e.g., vacations, brief illness) (Marcontel-Shattuck & Gregory), as well as stressful experiences at home (e.g., death of a grandparent or pet) or at school (e.g., a bullying episode or exams), can all be triggers for school refusal behavior (Marcontel-Shattuck & Gregory).

Clinical Presentations

School refusal is complex, with various patterns of physical complaints/ somatization, behaviors, and emotions displayed by children with school refusal behaviors. If a physical complaint is associated with school refusal, complaints may include headaches, abdominal pains, nausea and vomiting, fatigue, and dizziness (Egger et al., 2003; Kearney & Bensaheb, 2006). Both internalizing and externalizing behavior problems are seen in school refusal, such as anxiety, fear, depression, physical complaints, noncompliance, aggression, and temper tantrums. School refusal behavior is not a
Diagnostic and Statistical Manual of Mental Disorders
, 4th edition, text revision (DSM-IV-TR) diagnosis, but is seen as a behavioral symptom in children with a number of DSM-IV-TR diagnoses (Egger et al.). In one study, the most common
diagnoses associated with students with school refusal behaviors were separation anxiety disorder (22.4%), generalized anxiety disorder (10.5%), oppositional defiant disorder (8.4%), depression (4.9%), specific phobia (4.2%), social anxiety disorder (3.5%), and conduct disorder (2.8%) (Kearney & Albano, 2004).

Children who are truants do not typically tell their parents that they are missing school. These children often do not report physical complaints but often display more externalizing behaviors such as delinquency, lying, and stealing in addition to not attending school (Fremont, 2003). In contrast, parents of children with anxiety-related school refusal behavior typically know about the absences, and parents are usually concerned about the child’s absences. The child either may completely refuse to attend school or may attend but leave early. These children often report physical complaints and display behaviors related to problems such as fears, anxiety, separation anxiety, social phobia, post-traumatic stress disorder, panic disorders, and depression (Fremont). These behaviors may include crying, panic, temper tantrums, threats of self-harm, and, as noted in Katie’s case, somatization complaints such as stomachaches or headaches (Fremont). Children with anxious school refusal behaviors may have a fear of school that is based in reality (not phobic), such as a fear of being bullied or teased (Egger et al., 2003), an unrecognized learning problem (King & Bernstein, 2001), or a recent life-changing event such as a death in the family or relocation. For many of these children, they feel safer staying at home (Fremont).

Family Dynamics

Dysfunctional family interactions may be noted in children with school refusal behaviors (Fremont, 2003; Marcontel-Shattuck & Gregory, 2006). Family and social stressors such as poverty, unemployment, frequent moves, family conflicts, and a parent with a mental health problem are often found in children with school refusal behaviors (Egger et al., 2003; King & Bernstein, 2001). A study of family functioning in children with school refusal found that single-parent families were overrepresented in this group and that single mothers reported more family problems, particularly role performance and communication (Bernstein & Borchardt, 1996). In a study of 46 adolescents with school refusal behavior and anxiety and major depressive disorders, both parents and children reported low family cohesion or engagement and low adaptability/high rigidity (Bernstein, Warren, Massie, & Thuras, 1999). Parents of children with anxiety-related school refusal have been found to have an increased prevalence of similar symptoms. For example, parents of children with phobic school refusal were found to have an increased prevalence of social phobia, and parents of children with separation anxiety and school refusal have an increased prevalence of panic disorder (Martin, Cabrol, Bouvard, Lepine, & Mouren-Simeoni, 1999).

Consequences

The consequences of school refusal behaviors are both immediate and long term. Immediate consequences are problems with academic achievement, peer relationships, and family functioning. Long-term consequences include ongoing underachievement, employment problems, social difficulties, and an increased risk of psychiatric problems (Fremont, 2003; King & Bernstein, 2001; Sewell, 2008). More negative outcomes are associated with long episodes of school refusal occurring when the student is an adolescent, when the student is depressed, and/or when the student has a lower IQ (Elliot, 1999; Sewell).

You ask Katie and her mother to provide further details about school and the history of absences from school. Katie is in the seventh grade in middle school. Prior to the last 3 weeks, Katie often missed a day or two a month from school for some type of problem that seemed legitimate to mom. During the first week when Katie’s school absences began 3 weeks ago, she was home ill on Monday due to the stomachaches. She returned to school on Tuesday and midway through the morning she called her mother saying that her stomach hurt again. Ms. Murphy picked Katie up from school at 11:15 a.m. Katie went back to school on Wednesday but was reluctant about going and voiced her concerns that she didn’t want to have to leave school with a stomachache again. She was able to attend a full day on Wednesday, but didn’t go to school on Thursday until 10 a.m., and was home on Friday due to stomachaches again. The second week Katie was absent from school on Monday, Thursday, and Friday. Katie’s complaints were the same each day—stomachache and intermittent nausea, no vomiting, diarrhea, or fevers. The third week of absences included full days of being absent from school on Monday, Tuesday, Wednesday, and Friday. In order to recognize patterns of school absence and summarize her school absence, you document it in a calendar format.

This week, the school attendance secretary contacted Ms. Murphy because the school was concerned about Katie’s recent attendance. Ms. Murphy states that she is also concerned about all the days of school that Katie is missing but does not know what she should do. Ms. Murphy is at home with Katie during these days of school absence and enjoys spending the extra time with her. Ms. Murphy acknowledges Katie’s stomachaches and encourages Katie to go to school but she also knows that Katie will most likely report to the school office stating that she doesn’t feel well and they will call and ask Ms. Murphy to pick her up. Katie reports that her stomachaches improve during the day. When asked what she does when she stays home, Katie says she watches TV, plays on the computer, and helps her mother with cooking and chores around the house.

Next, you explain to Katie and Ms. Murphy that you often talk with children alone at this age and following approval from both Ms. Murphy and Katie, Ms. Murphy goes to the waiting room while you interview Katie in private.

An approach for interviewing adolescents is to follow the acronym HEADSS(W), and ask questions about home, education, activities, drug use, sexual behaviors, suicide/depression, and weight (Cohen, Mackenzie, & Yates, 1991; Roye, 1995). Asking questions in this order allows the interviewer to begin with presumably less stressful topics
and move to more sensitive areas. You start with general questions about how Katie feels about home and school. Katie denies any problems at home. She gets along well with her parents and brother, although she reports that she sometimes doesn’t want to be around her family. Katie states that she has several friends in school and two best friends that she has known since kindergarten. During the last 3 weeks, her best friends have only called her twice to see why she was not in school. On both occasions Katie told her friends that she just had a stomachache and did not mention anything else. When you ask more about her two best friends, Katie starts to have tears in her eyes and states that she is hurt that they have only contacted her twice in the last 3 weeks. “It’s like they don’t care that I’m not in school,” she says. Katie states she does not participate in any extracurricular activities other than a church youth group. Katie denies any alcohol or other substance use; she reports that she has never tried alcohol or drugs and is not interested in experimenting. She also denies that she is sexually active and reports that no one has ever touched her in a way that has made her uncomfortable.

Making the Diagnosis

Katie’s history and negative physical examination are consistent with school refusal behavior, probably initially related to anxiety and now being reinforced by the response to her staying at home. Having ruled out any physical etiology for Katie’s stomachaches, you determine that Katie’s pattern of school absences appear to be anxiety-related school refusal behavior. This diagnosis needs to be explained to the family, with support provided in helping them understand the connection between mind and body.

You explain to Ms. Murphy and Katie that there does not appear to be a physical cause for Katie’s stomachaches, but people’s emotions, such as anxiety, can result in physical symptoms, such as stomachaches. In addition, the rewards of staying at home and spending time with her mother are now reinforcing Katie’s stomachaches.

Management

What information do you need about the management of school refusal in order to help Katie successfully return to school?

The first step in developing a management plan for a student with school refusal behavior is to perform a complete assessment of multiple areas including:

•   History of factors that may contribute to, trigger, or maintain school refusal behavior

•   Physical exam to rule out health problems and reassure child and family

•   School information related to achievement, attendance, behavior, and social interactions

•   Behavior screening tools completed by parents and teachers (Sewell, 2008)

In this case, you have carried out a physical exam and obtained background information and a description of the school absence behaviors, but will need more on school performance, social interactions, and psychosocial adjustment in order to develop a comprehensive management plan.

The goal of the management plan for a child with anxiety-related school refusal is to return to school, without unauthorized absences, “happy, healthy, and ready to learn.” This requires a multidisciplinary team approach that will likely include the primary care provider, teachers, school personnel such as the school nurse and the counselor, and the child’s family. The primary care provider rules out organic causes for the physical symptoms and provides information to the team about the link between stress and physiological symptoms; school personnel work with the family on making up missed class work and developing a plan for the child to return to school; and mental health providers may be needed to provide support to manage the school refusal behavior and to help the child and family cope with anxiety and related concerns. The plan needs to be well coordinated, agreed on by all members including the child, and supportive of the family.

The primary care provider needs the parent’s permission to contact the school and to obtain information about school performance. Information to obtain includes course grades; standardized test scores; school attendance history; frequency and reasons for visiting the school nurse; any disciplinary actions; Individualized Education Programs (IEPs) or 504 plans, if there are any; and other pertinent records. An IEP or 504 plan would identify any accommodations needed in the school to help the student succeed (U.S. Department of Education, n.d.). The primary care provider may want the principal, teacher, or other school professional to interpret some of these documents. Some of the questions to be answered through school records include whether the student is performing at grade level or as expected and whether any specific learning disorders have been identified.

Both the student’s parents and teachers may be asked to complete instruments that assess behavior and emotional concerns in general and school refusal behavior specifically. Behavioral questionnaires are helpful in assessing a child’s emotional adjustment and overall behavior (Achenbach & Ruffle, 2000; Glascoe, 2000; Perrin & Stancin, 2002). These instruments often are available in several versions that allow the child, a parent, and/or a teacher to complete similar versions of the instrument and for responses to be compared. As noted earlier, an example of a screening instrument that may be appropriate for use in primary care is the Pediatric Symptom Checklist (PSC) (Jellinek et al., 1988), which has both parent and child versions available. However, when diagnosis is the goal, behavioral assessment instruments, such as the Child Behavior Checklist (CBCL) (Achenbach & Ruffle, 2000) and more specific
instruments such as the Children’s Depression Inventory (Kovacs, 2003), may be used. For students with school refusal behavior, the use of an assessment instrument (such as the School Refusal Assessment Scale) that specifically evaluates school refusal behavior and clarifies the motivation for the behavior would be particularly valuable.