92 Chapter 8
3 Physical illnessis by far the commonest reason for non-attendance at
school, except during the last year or so of compulsory education, when
truancy rates are often high. It is not always easy to distinguish between
physical illness and school refusal in a ‘somatic disguise’. Being better at
weekends is not an infallible guide: physical illnesses may be aggravated
by school-related stresses, and most children are capable of exaggerating
genuine symptoms when it suits them.
Underlying psychiatric conditions in the child
School refusal can be the presenting complaint for children with a vari-
ety of underlying disorders, withseparation anxietybeing the commonest
diagnosis, particularly among younger children. In many cases, school
refusal results from the combination of: a child who does not want
to separate and parents who do not insist very forcefully on school
attendance, either because they are poor at imposing limits in general
or because they share their child’s anxieties about separation.
In a minority of cases, school refusal arises not from anxiety about
leaving home but from aspecific phobiarelated to school or to the journey
to and from school. There may be a specific travel phobia, a fear of
bullies, of one particular teacher, or of one particular subject. Complaints
about school may be a smokescreen for separation anxiety, but they
should not be dismissed without investigation.
Depressionis particularly important as a cause of school refusal in adoles-
cents, though different studies have generated very different prevalence
estimates.
Psychosisis a rare cause of adolescent school refusal.Treatment
A behavioural ‘back to school’ approach is particularly likely to be success-
ful when refusal to attend school began recently and relatively suddenly. A
rapid return to full-time school is often possible once parents are persuaded
that consistent firmness is in their child’s best interests. With motivated
parents and supportive teachers, this approach can be very effective. When
the anxiety level in the school refuser or parents is particularly high, or
when the child or adolescent has been out of school for a long time, a
gradual desensitisation approach may be more appropriate, for example,
initially visiting the school out of hours and then spending progressively
longer periods at school every day.
Parents are usually already well aware of the academic and social disad-
vantages of their child being out of school – it is not generally necessary to
rub this in and risk making the parents feel more like failures than they do
already. It is more productive to empower parents to set firm boundaries
and exert control over their child, while reducing over-involvement.