School refusal - Psychosocial distress or Psychiatric disorder?

Abstract

Background: School refusal is not a diagnosis by itself but a behavior described when a child frequently refuses to go to school or remain in school. It is often associated with several psychiatric disorders. A prevalence rate of 5-10% is described in most studies. Several psychosocial factors, individual, familial, societal, school and medical are also known to play an important role. The study intends to explore the association of school refusal to either psychiatric disorder or to distress due to psychosocial factors. Aim: To explore the psychosocial factors and psychopathology in children presented with school refusal. Method: A descriptive study conducted on children attending Child and Adolescent Psychiatry OPD at ASHA Hospital with primary complaint of school refusal, from January 2018 to December 2018. Data pertaining to 33 new cases of school going children between 6 years and 18 years, with school refusal as main symptom were collected using a semi structured proforma. Various psychosocial factors which were broadly classified as individual, family, school, societal factors and other medical disorders were analyzed. Psychiatric diagnosis made using ICD 10 criteria was assessed. Data analyzed using SPSS software. Results: About 6.6% of total new child cases in the year of 2018 were with primary complaint of School Refusal. Out of these 33 subjects, 30 (91%) had a psychiatric diagnosis at baseline. Depressive disorder (36.4%) was commonest followed by anxiety disorder (18.2%), conduct disorders (15.1%) and remaining Hyperkinetic disorder, mental retardation and bipolar disorders. Psycho-social factors influenced school refusal contributing to the psychiatric disorder. Conclusion:The study highlights school refusal as a symptom of one or two psychiatric disorder rather than psychosocial distress alone, indicating high psychiatric morbidity. Further it emphasizes that the symptom need to be taken as an emergency and intervened. This would entail child going back to the school early and avoid chronic school refusal with serious consequences of poor academics and social development and risk of psychiatric illness into adulthood.

School Refusal Behavior: A Narrative Review

“…8, 10 Other factors, including an account of abuse, adoption, stepmother, and issues with peers, influence school refusal behavior. 10 However, contrary to other studies, Fukuya et al found that child rearing, such as parent–child dealings and child maltreatment, may not be associated with school refusal among elementary school pupils. 7 Differences in study design and cultural differences in parenting and child-rearing practices may account for this discrepancy in findings.…”

“…7,8 In India, several studies have reported a prevalence rate of up to 7%. 9,10 Research indicates that school refusal peaks around the age of transition between school stages at the start of primary school or after the move to secondary school and is more common in secondary-age pupils. [11][12][13] Some studies have found a significant association between school refusal and socio-demographic aspects like the gender of the children, family type, regular income of families, and parental education.…”

“…For example, in one study, 57.6% ( n = 19) children presenting with school refusal had temperamental issues: anxious traits, adamancy, sensitivity to criticism, and introversion. 10 Carpentieri et al concluded that children with school refusal were characterized by inhibited, self-constricted, and emotionally dysregulated personality styles. These children reported more negative automatic thoughts concerning personal failure, fewer negative automatic thoughts concerning hostility, and fewer positive ones.…”

“…Other factors include chronic medical illnesses (like typhoid fever, history of febrile seizure, disorder, h/o surgery, obesity) preceding the onset of school refusal, which may lower the child's self-esteem. 10 In addition, many students also have to contend with "bias bullying," which results from the victim's perceived membership of a particular, often marginalized, group (e.g., based upon gender, race/ethnicity, sexual orientation, faith/religion, and disability). 24 Identification of such personal factors becomes crucial and also pertinent to ensure holistic care.…”

Prevalence and factors associated with chronic school absenteeism among 207,107 in-school adolescents: Findings from cross-sectional studies in 71 low-middle and high-income countries

“…CSA is associated with a high degree of school dropout, poor psychological wellbeing and physical health, poor academic performance as well as social development [ 14 ]. Additionally, CSA exacerbates the risk of non-participation in the workforce, and subsequent long-term poverty [ 7 , 15 – 17 ]. CSA is influenced by a combination of individual, family, and social factors [ 17 ].…”