A recent study – Practitioner Review: School refusal: developments in conceptualisation and treatment since 2000 by Elliott & Place (2017) summarises existing research into school refusal and this is the abstract provided:
A generation has passed since the literature on the conceptualisation, assessment and treatment of school refusal was reviewed in this journal (Elliott, 1999). In the light of considerable gaps in the literature, identified at that time, and growing international interest, the current paper sought to identify progress subsequently made this century.
We open with discussion of continuing conceptual uncertainty as to whether school refusal should incorporate both truancy and absenteeism marked by anxiety and distress. We then consider progress in treatment, and conclude by examining prognosis and subsequent adult functioning. In selecting intervention studies for review, our primary focus has been upon RCTS, systematic reviews and meta‐analyses.
The literature review indicates that, since the turn of the century, there has been little substantial advance in knowledge that can guide practitioners. Many of the issues raised in the 1999 paper, in particular, conceptual confusion over this heterogeneous condition, a dearth of rigorous RCT designs, limited knowledge of underlying mechanisms and uncertainty as to the long‐term effects of specific forms of intervention, are little clearer than before.
While several sound publications are available to guide intervention for school refusal, there is a continuing need for rigorous studies that can provide evidence to support individualised and tailored responses to an incapacitating problem with many causes and manifestations. While a multisystemic response to intervention approach is considered attractive, the practicalities of operating this across disparate professional borders are likely to present a long‐term challenge.
This illustrates how there is a large amount of research that is still needed to provide a better understanding of the causes of school refusal, and to identify effective approaches that can be implemented to help children and young people.
Here, we list some of the key areas we have identified as significant and potentially helpful:
Society in general has not recognised mainstream school as an inappropriate environment for children. ‘Going to school’ is such an accepted social convention that any difficulties are attributed to something being wrong with the child, rather than the school environment. Most school refusal behaviour has been considered an irrational reaction (Berg & Nursten, 1996; Blagg, 1987) and dismissed as bad behaviour or the consequences of poor or over-indulgent parenting. In recent years however, it has also been argued that other factors should be considered, as it is entirely rational for children to forsake the negative aspects of the school environment and they shouldn’t be stigmatised for avoiding them (Havik et al, 2014; Shilvok, 2010).
- Ongoing research studies should now recognise that within-child explanations are only one aspect of the school refusal and therefore consider other influences in greater depth.
Thambirajah, Grandison & De Hayes discuss statistics for school non-attendance in their book Understanding School Refusal: A Handbook for Professionals in Education, Health & Social Care (2008), and note ‘hidden somewhere in the statistics is a small but significant subgroup of school non-attenders variously called school phobics, school refusers and school avoiders.’ They suggest this signifies a reluctance to acknowledge the issue in official record keeping. It is also noted that ‘this category of school non-attenders has been recognised by educationalist and health professionals for more than seventy-five years, yet they are ignored in official statistics and remain largely invisible’.
- This invisibility and lack of recognition needs to be addressed, especially as it is suspected that the number of children experiencing school attendance difficulties must be increasing at a greater rate due to the rise in mental health difficulties in schools.
A recent report into the well-being of children in the UK noted that ‘different children have different experiences even at the same school, and that for well-being, ‘child-school’ fit is as important as attending a ‘good’ school (Gutman and Feinstein, 2008, cited in ONS, 2014:21). Many children do enjoy their experience at school and this could be attributed to a positive ‘child- school’ fit, meaning they feel comfortable and supported at school. A poor ‘child-school’ fit could equally be a factor in a child’s school refusal and some families do find a change to a different school can be helpful. However, sometimes a change of school is not possible or the child’s anxiety and emotional difficulties have become so powerful it makes little difference to the situation.
- If a child’s welfare was considered to be of paramount importance, school refusal in these circumstances should prompt consideration of what type of education is most suitable and how the education system should resolve a poor ‘child-school’ fit.
As adults, it is normal for us to assume that all children will enjoy going to school and we may find it difficult to accept that some children do not find it easy. Often, we make assumptions that children are ‘ready’ for school and will cope with the academic expectations and the physical, social and emotional environments. In relation to these assumptions, West Sussex Educational Psychology Service state;
We are aware of a great range of individual differences across children with regard to tolerance, confidence, self-belief and resilience, and in the variety of climates we find in schools and in the nature of pupil populations within them.
(West Sussex EPS, 2004:5)
Considering the reality of the variation in children’s abilities to ‘fit in’ at school they also comment; ‘it should be no surprise that some pupils experience considerable difficulty…resulting in reluctance to attend school’.
Ingul and Nordhal (2013), found that each child’s ability to cope with the demands of the school environment, (whether they were predisposed to anxiety or not), were related to the compounding effects of a combination of factors, including levels of negative personality traits, panic symptoms, social isolation, and any family issues. Consequently, they recommended that each case should be individually assessed and treated according to need, rather than assuming all cases of school refusal have the same causes and should be treated with the same response. Kearney and Silverman (1990) developed the School Refusal Assessment Scale to aid identification of the form and function in each case of school refusal in recognition of the need to consider individual influences and circumstances.
- Would a similar School Refusal Assessment Scale developed today have the same forms and functions or would it need to consider new or alternative influences and circumstances?
One element of the school environment that is increasingly considered to be a cause of anxiety and stress, both for staff and pupils is the relentless focus on assessment and achievement with the consequential fear of failure (Claxton, 2008; Harber, 2004; Prever, 2006). Governments now place constant pressure on schools to raise grades, meet targets and tick boxes, and this pressure is then transferred to pupils. ‘The Secret Teacher’ newspaper column featured an article written by a teacher who stated;
Already, the stress that teachers are put under seems to have been passed on to our students. More of them are suffering from anxiety and depression, hiding under the duvet and refusing to attend. Their eyes glaze over: all that hard talking about what was at stake in those management-led supposedly inspirational assemblies on that first day back in September didn’t give our students the self-belief or the determination they needed to succeed. It left them demoralised and defeated.
(The Guardian Online, 2015)
This concern is echoed in various reports and research studies. Claxton examined a selection of these, including UNICEF’s (2007) assessment2, which ‘ranked the UK worst overall out of twenty-one wealthy nations’ (2008:3). Also in 2006, the Mental Health Foundation reported on self-harm as; ‘a hidden epidemic of horrific proportions’ in young people who listed academic pressure as one factor that triggers their self-harming behaviour. Claxton considers academic pressure to be one of the prime causes of apprehension and stress in young people and concludes; ‘UK Government concerns with standards and accountability have led to teenagers being tested virtually to destruction’. It is apparent too, that higher stress levels for teachers can affect children’s experience at school with the resulting negative reactions such as shouting, verbal put-downs and poorly planned lessons, increasing any reluctance to attend. It also seems logical to conclude that such high levels of stress and pressure are going to have an effect on young people’s ability to cope in the school environment, and lead to school refusal or truancy when it all becomes too much for some of them.
According to Murphy and Fonagy (2012); ‘1 in 10 children and young people under the age of 16 had a diagnosable mental disorder ‘. This equates to an average of three children in every classroom and it would be plausible to expect that some of these children become affected by these disorders to such a degree that they refuse to go to school, especially if the problems are exacerbated within the school environment. However, the report exemplifies the lack of acknowledgement of the negative influence of school environments, as it focuses on the school only as a place to build resilience and offer interventions. Department for Education advice on Mental Health and Behaviour discusses the benefits of building resilience in children and states that to facilitate this; ‘School should be a safe and affirming place for children where they can develop a sense of belonging and feel able to trust and talk openly with adults about their problems’ (2014:7). Yet children often become school refusers’ precisely because they do not feel safe, supported or have a sense of belonging within their school and would consequently have difficulty in accessing any school-based intervention.
- Research now needs to consider the most applicable interventions and provisions for children in these circumstances.
AUTISM AND ANXIETY
Parents often report that diagnosed or suspected Special Educational Needs are often the underlying cause of severe anxiety that leads to school refusal. As an example, Autistic Spectrum Disorders (ASD) are often linked to school attendance difficulties, as Preece and Howley observe: ‘given the nature of ASD and social anxiety, it is perhaps not surprising that some individuals are absent from school for extended periods and thus become disengaged from formal education.’ (2018:3). Munkhaugen, et al (2017) confirm this by explaining that cases of school refusal behaviour are significantly higher in children with ASD than in typically-developing students.
The influence of special educational needs that are inadequately supported in school holds current significance as The Driver Youth Trust researched SEN provision reforms in schools since 2010 (when the current SEND Code of Practice was introduced). Their Joining the Dots report (2015) found SEN provision is: fragmented, leading to difficulties in sharing information and knowledge. As a result, many children and young people do not receive the support they deserve […] Ultimately students, parents, schools and sector organisations have been finding it difficult to navigate the new system and this is standing in the way of the reforms’ success.
This also means that when a child is school refusing with a possible link to SEN it is increasingly difficult to arrange appropriate support or provision to be put in place at school. Returning to the link with ASD, the National Autistic Society published a report ‘Autism and Education in England 2017’ which illustrates the difficulties found in organising SEN provision, as they make the following observations based upon responses to their survey:
- More than 50% of autistic children say they are not happy at school
- Fewer than 50% of teachers say they are confident about supporting a child on the autistic spectrum
- 50% of parents waited more than a year for the right support to be put in place at school for their child
- 42% of children are refused an education, health and care assessment by their local council on first request
Some of the comments made in responses include:
- “Autistic pupils are probably the SEN group I need the most guidance with and have received the least guidance on” (a teacher)
- “We are stuck in a system that wants the child to fail before help is offered” (a parent)
The failure referred to in the second comment relates to failure to attend or cope at school, or failure to learn and make progress.
- A number of recent research studies have considered autistic children’s experiences at school. Many parents within support groups struggle with school attendance and are in the process of trying to arrange assessments and/or support for children on the autism spectrum. Further research is needed to consider the link between autism and school refusal, and how children and young people should be best supported when they struggle in school.
PARITY of ESTEEM
Levels of mental health difficulties in school children have been rising, yet access to Child and Adolescent Mental Health Services (CAMHS) is worsening (Cowburn & Blow, 2017; House of Commons, 2017). The Children’s Commissioner for England published The Lightning Review: Access to Child and Adolescent Mental Health Services in May 2016, which found large numbers of children and young people – some with apparently serious conditions – are being turned away from CAMHS upon referral and/or are having to wait long periods of time for treatment. Families are therefore struggling to access assessment, treatment, or support and this creates high levels of stress and distress (family breakdown, financial difficulties, depression). Kahn (2015) noted that three quarters of parents of children with a mental health problem seek help, but only one quarter of children receive any help. In addition, Kahn found that there is an average ten-year delay between children displaying first symptoms and getting help.
- Research is needed to explore why mental health difficulties are so poorly dealt with. It is thought that this could relate to possible attitudinal factors that create the parity of esteem between physical and mental ill-health acceptance and treatment (Lamb, 2013); and the stigma and discrimination experienced by children who have mental health issues, for instance, the Time-to-Change campaign state that: The professionals that young people come into contact with were also reported as a source of stigma and discrimination: 40% said that they had experienced negative reactions from teachers and 47% from doctors and other medical professionals. (2012:6)
- Parity of esteem is especially significant when it is considered in relation to a school’s willingness to authorise or not authorise a child’s absence because the reason given relates to mental ill-health rather than physical ill-health.