90 Chapter 8
to leave home or attend school. In other cases, school refusal assumes
a ‘somatic disguise’ without overtly expressed fears. For example, there
may be complaints of headache, stomach-ache, malaise or tachycardia
before leaving for school or once at school. The absence of complaints at
weekends or during school holidays is a helpful clue.
Attempts to force the school refuser to attend school are met with tears,
pleading, tantrums or physical resistance. In contrast to truancy, school
refusers do not make a secret of their non-attendance: the parents know
where their child is, generally because their child is in or near the home.
The onset of school refusal may be abrupt, or may be gradual, with the
individual expressing increasing reluctance to attend school and staying
away for more and more days each week. Precipitating factors can often
be identified, for example, a change of teacher, a move to a new school,
the loss of a friend, or an illness. The onset is more likely to be insidious in
adolescence, with a progressive withdrawal from peer group activities that
were previously enjoyed. Onset or relapse of school refusal is particularly
common after a period off school due to holiday or illness.
School refusal can be a manifestation of a variety of underlying family
dynamics and psychiatric disorders. These underlying problems commonly
result in symptoms other than the school refusal itself, and these additional
symptoms provide useful clues to the nature of the school refusal. For
example, a child who refuses to go to school because of separation anxiety
may also refuse to go to sleep-overs or birthday parties. By contrast, a
child who refuses to go to school because of fear of being bullied may be
happy to go to sleep-overs or parties. An underlying depressive disorder is
suggested when symptoms of misery and hopelessness persist even when
there is no pressure to attend school, for example, at weekends or during
school holidays. In contrast, a timid child who will attend on the few
occasions when his father drives him to school, but not on most days,
when it is his mother’s role, may have some underlying fears compounded
by having learned that his mother will give in.
Associated features
Family factors
As well as the child or adolescent’s unwillingness to attend, there is often
a lack of effective pressure from the parents to get their child to school
and keep him or her there. In some cases this may seem justified by
the marked distress experienced by their child. Often, however, it reflects
some combination of three family processes:
1 Ineffectual home organisation and discipline. This may be apparent in a
general lack of enforced house rules, and is more likely to occur if the
father is absent or ineffectual.
2 Emotional over-involvement. For example, the mother may fail to be firm
because she is anxious not to incur her child’s disapproval; or she may