11-year-old girl who has attended the same primary school for 6 years. She has a good group of friends, gets on well with teachers and is doing well academically. Six months prior to referral Jacqui injures her foot resulting in surgery and approximately three months off school.
During her recuperation, Jacqui is forced to stop her beloved dancing and limit outings with friends as walking becomes a challenge. In an effort to support Jacqui, her mother (Bianca) takes time off work. For the first time since beginning school Jacqui spends most days with Bianca while her siblings are at school. Bianca reports that Jacqui remained in touch with friends via social media and telephone calls but had very little face-to-face contact during her time away from school.
As Jacqui’s injury improved Bianca began leaving Jacqui with family and friends so she could return to work. This coincided with Jacqui reporting tummy upsets, headaches and nausea immediately after dinner on days when her mother was due to go to work the following morning. Jacqui would beg her mother not to go to work. To her mother’s credit she never gave in to Jacqui’s pleas but did admit to feeling very guilty and sad at having to leave her.
Just as Jacqui began to settle into staying with grandparents or family friends, her physiotherapist announced that a return to school would be achievable within a week or two. Almost immediately Jacqui’s symptoms worsened ten-fold. Her parents reported uncontrolled bouts of anger, tears, tummy upsets, headaches, broken sleep and variable appetite.
The night before her scheduled return to school Jacqui complains of aches and pains, sore tummy, difficulty breathing and sleeping. By the time Jacqui is woken the following morning she is red-eyed and crying uncontrollably, begging and pleading with her parents to give her ONE more day at home. She assures them that the following day will be different and that she just needs the day to adjust. But guess what? The next day was no better, nor the day after that, nor the week after that. When I met Jacqui she had been absent from school for a total of two school terms.
The three major factors of school refusal — FEAR + ANXIETY + AVOIDANCE — are well illustrated in this case example. Jacqui develops a fear of returning to school following an injury. But why did the fear develop? Let’s think carefully about what happened when Jacqui injured herself: she lost face-to-face contact with friends, stopped dancing, missed school work, developed bad habits (i.e., not needing to follow a morning routine), and got loads of attention from mum while she was recovering. Returning to school became a challenge because Jacqui had lost self-confidence and experienced lots of secondary gains that made being at home comfortable and nonchallenging. She did not believe she could return to school because she had missed so much schoolwork, lost contact with her peers and was afraid she could not fit in as she had before her accident.
Once fear sets in anxiety quickly follows and grows exponentially as anxiety is fed by fear. In fact, anxiety is, at its very root, a fear of fear (in other words, Jacqui became afraid of being afraid). Once fear and anxiety are present, avoidance is highly likely to develop, as no-one (irrespective of age or gender) will willingly place themselves in a situation that provokes fear and anxiety.
Once in place, school refusal is driven by one or more of the following reasons:
• Avoiding situations that evoke negative emotions. ‘If I don’t go to school I don’t need to explain my absence or feel stupid because I’ve missed so much work’.
• Escape from negative social and/or evaluative situations. For example, bullying or receiving exam results.
• Attention seeking. ‘When I don’t go to school mum stays home with me or I go to grandma’s house and everyone wants to know what’s wrong with me’.
• Rewards. ‘Once I’m home I don’t have to do schoolwork, I can watch TV, eat whatever I like and keep in touch with friends using social media’.
Determining what ‘drives’ school refusal is an integral part of beginning to understand the child, and developing a program that is specifically geared to their particular situation. The child who refuses to go to school because they love being at home with mum needs a very different return to school program than the child who refuses to go to school because they are mercilessly bullied.
How common is school refusal?
Although research has struggled to provide a consistent school refusal figure, due to differing opinions on what constitutes school refusal behaviours and when school absences cross the line from acceptable to unacceptable, there seems to be a consensus that school refusal occurs in 1% to 5 % of all children.4
It peaks from the ages of 5 to 7 and then again from the ages of 11 to 14. These ages correspond directly to transition periods. That is, the years when children go from kinder (where they only spend a few hours per week) to primary school (where they are present for full days, 5 days per week) and then again when the child goes from primary school to secondary school where academic demands become greater and social relationships become more complex. Transition periods occur throughout our lives and have varying degrees of impact on our emotional well being.
Our first transition period is often moving from mother’s care to kinder or day care. For the sensitive anxious child this transition can trigger lots of anxiety and manifest as clinginess, poor sleep (often resulting in co sleeping), altered eating patterns, tantrums and refusing activities that require separation from mother. This anxiety is referred to as separation anxiety and is a normal part of development.
Separation anxiety is first noted in infancy when the child reacts negatively to the mother leaving the room or the child being handed to someone else to hold. This need to be with the mother is a normal part of our survival instinct as the baby fears abandonment. Crying and screaming is their attempt, at an instinctual level, to ensure connection with the person who feeds and nurtures them. We see this in the animal kingdom, as well, when offspring cry out for their mother to make her aware that they have been left unattended.
In the nonanxious child this fear of being separated from the mother declines as they become familiar with their environment and begin to trust their new caregivers. Most of us know at least one child who has called their kinder teacher or child carer ‘mum’. A sure sign that the child trusts that person to care for them. The anxious child, however, tends to take longer to settle into their new environment and remains untrusting of their carers. It is not unusual for parents of school refusers to report problems with their child settling into kinder or day care. The re-emergence of their anxiety at the start of school coincides with a new environment, new carers, longer hours, more academic and social demands and, most importantly, longer periods of separation from mother. As a rule we would expect the anxiety to settle within a week or two as the environment becomes familiar and would expect that, by age 7, this fear of being separated from their primary care giver would have ended. Separation anxiety beyond the age of 7 is not considered a normal part of development and is viewed as the beginning of a diagnosable anxiety disorder.
Other transition periods in our lives include moving from primary school to secondary school, secondary school to university or work, leaving the family home to live alone or with a partner, and retirement to name a few. For the clinically anxious person, each of these transition periods equates to a period of instability and stress that extends beyond what would normally be accepted as a ‘settling-in period’.
School refusal occurs across all socioeconomic groups. This means that whether the child is from an affluent family in a private school or a less privileged family in a public school, school refusal can and does develop. It is also equally prevalent amongst boys and girls.
In summary then:
• School refusal can occur in any family and any school. In a medium-sized school of 500 students you would expect between 5 and 25 students to experience some level of school refusal.
• School refusers have often had difficulties settling into kinder and/or day care.
• School refusal does not end when school ends as clinical levels of anxiety will resurface whenever transition periods occur.