Amalia Londono Tobon, MD
Chief Resident PGY-5, Solnit Integrated Training Program at Yale Child Study Center.
Wendy K. Silverman, PhD, ABPP
Professor of Child Psychiatry and Director at Yale Child Study Center Program for Anxiety Disorders.
Drs. Londono Tobon and Silverman have disclosed that they have no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Editor’s note: School refusal is a common problem, affecting up to 5% of schoolchildren. Even so, there are few clear guidelines on how to manage this problem. After seeing their article on the subject, we were able to talk with a child psychiatrist and a clinical child psychologist who focus a significant portion of their work on treating school refusal.
CCPR: Thank you both for joining me today. We all see kids who won’t go to school. How do we help the child, family, and school in this situation?
Dr. Silverman: School refusal has been difficult to conceptualize—people have trouble distinguishing delinquent cutting from more innocently playing hooky. In other words, we didn’t distinguish between children who didn’t want to be in school, versus children who did want to be in school but were unable to go due to psychological emotional problems (eg, anxiety and depression). Further muddying the issue was the term “school phobia,” implying that the problem was something specific to school—we now know that’s not the case. Also, people mistakenly assumed that if the issue wasn’t school phobia, it stemmed from separation anxiety.
CCPR: So how might we better think about the problem?
Dr. Silverman: It’s heterogeneous. Some children stay away from school to reduce their anxiety or depression. School avoidance is maintained by the negative reinforcement—ie, the relief of not being at school. Other children stay home doing things that feel good, like watching TV or gaming—ie, positive reinforcement. It is important to look at both aspects when planning treatment.
Dr. Londono Tobon: In our review, we found that truancy and school refusal behavior due to anxiety, depression, or other psychiatric or psychological problems can also be mixed. Therefore, it is important to look at all problems.
CCPR: For child psychiatrists, are there some specific things to consider in assessment?
Dr. Londono Tobon: School refusal affects over 15% of child psychiatric patients. Silverman and Kearney wrote a questionnaire that helps clinicians identify factors affecting school refusal: learning difficulties, anxiety about speaking to other children in school or trouble making friends, difficulty in the family dynamics or separating from family members, specific days of the week that are more difficult, feelings of embarrassment, and challenging relationships with teachers and other school personnel, among others (Kearney CA & Silverman WK, J Clin Child Psychol 1993;22(1):85–96). Bullying and school shootings have also raised increasing worries for children and families.
CCPR: What is your approach to assessment and treatment?
Dr. Silverman: Dig in. Don’t assume that the child has separation anxiety or a phobia. What is the child avoiding? For some children, it’s related to a social anxiety disorder. For other children, it’s the need to be perfect and worrying about mistakes relating to generalized anxiety disorder. Some have separation anxiety. This is important in cognitive behavioral therapy (CBT), because CBT involves exposure to feared anxiety-provoking stimuli. You do a different exposure with someone avoiding school for social anxiety reasons vs for separation anxiety. Also, the more chronic and severe the case, the more important it is to involve all the stakeholders, because the school setting must be addressed. Teachers can help with treatment.
CCPR: Parents sometimes say, “Let’s just let him stay home so we don’t upset him.”
Dr. Silverman: Look for family accommodation. Parents with anxious children want to reduce their child’s anxiety, so they allow the child to avoid situations that cause the anxiety, but they need other ways of solving the problem. We have data that we are writing up showing that accommodation levels are higher in the parents of children who are both anxious and avoiding school, vs children who are anxious but attending school. This suggests targeting parent accommodation to help children get to school.
CCPR: Do we have data showing that parent guidance to reduce accommodation is effective?
Dr. Silverman: In uncontrolled research by Kennedy in the 1960s, parents were told to get the child to school. This is probably more helpful in acute cases than chronic ones.
Dr. Londono Tobon: It’s important to think developmentally or you could make things worse. Also, sometimes the school fit is not good. I had one patient who ended up going to another school that was a better fit, after which the patient had no problem with school refusal.
CCPR: Can you elaborate on your thoughts about developmental differences?
Dr. Londono Tobon: Forcing adolescents to go may be less effective—you have to get their buy-in. You may need to work with younger children to process their fears, not just put them in school.
Dr. Silverman: The issues are probably more pronounced now because of school shootings creating an added level of realistic anxiety.
CCPR: What about medications? Certainly, SSRIs for a specific anxiety disorder, maybe for depression. Otherwise, do we treat it like PTSD with central alpha-agonists or maybe propranolol?
Dr. Londono Tobon: We did a systematic review of pharmacologic treatment studies for school refusal and anxiety (Londono Tobon A et al, J Child Adolesc Psychopharmacol 2018;28(6):368–378). There’s not a lot of literature, and the bigger trials in anxiety and depression have not looked at children with school refusal. In many of the existing studies, the control arm also had behavioral intervention, so it was difficult to tell if pharmacologic interventions were helpful. Many of the studies had children with comorbid anxiety and depression symptoms. These studies showed that fluoxetine, imipramine, and clomipramine all have pre- and post-benefits in depression, anxiety, and school refusal symptoms, but not always group differences. The bottom line is to target the underlying psychiatric condition with psychotherapy and pharmacotherapy if needed. There are many CBT manuals now for school refusal, and many engage the school and parents.
Dr. Silverman: But even the CBT trials for school refusal are few in number, small in sample size, and have limited follow-up.