School Refusal 93Once school refusal has become chronic, there are a variety of additional
obstacles that need to be overcome. For example, it is harder to get back to
school if you are way behind with schoolwork, if your former friends have
made new friends, and if you cannot find a good explanation for why you
have been away from school for so long. At the same time, extra parental
attention while at home all day may be very rewarding. If the individual
is to return to school, the obstacles need to be overcome, for example, by
providing coaching on how to explain their absence to classmates. Overall,
the balance of rewards and disincentives needs to be altered to favour
school attendance rather than non-attendance.
Liaison with the school is essential. Teachers need to be as well prepared
as possible to support the return to school. They may need to be backed
up by social workers and psychologists working with the school. Providing
home tuition during the period when the pupil is out of school is often
inappropriate since it reduces the pressure on all concerned to achieve a
more definitive solution and legitimises the individual spending all day at
home. If return to school is delayed, attending a tutorial unit with other
people of their own age is a more satisfactory interim solution. Though
families often maintain that a change in school would solve the problem,
this is rarely the case. Instead, the slow process of arranging a school
transfer delays the implementation of a more appropriate solution. Even
when school factors (such as bullying) are important, the school should
generally be given a reasonable chance to overcome the problems rather
than opting at once for a school transfer.
The evidence does not generally favour the use of medication for school
refusal that is due to separation anxiety disorder. One possible indication
for medication is the use of tricyclics for adolescents whose school refusal
is associated with panic attacks. The value of medication is also uncertain
when school refusal is due to depression. As discussed in Chapter 10,
tricyclic antidepressants are ineffective in the treatment of childhood or
teenage depression. While fluoxetine – a selective serotonin reuptake
inhibitor (SSRI) – may be helpful for severe depression, a psychological
treatment is generally preferable for mild or moderate depression.
In-patient treatment is sometimes appropriate when problems are so
severe or entrenched that there is no response to other forms of treatment,
and when the family environment actively maintains the disorder and
blocks effective treatment.
Prognosis
Even though many reported studies include a disproportionate number
of severe cases, the success rate for return to school is generally 70% or
better. This success rate is higher when the individual is younger, when
the symptoms are less severe and when intervention occurs soon after
the onset. It is therefore very important to try to get the child or adoles-
cent back to school as soon as possible. Even when return to school is