Motivation and emotion/Book/2015/Anxiety and school refusal

Overview
Would you rather be anywhere but sitting in a classroom tomorrow? When it comes to school and social events do you feel nervous? Scared? Fearful? This chapter aims to look at the role anxiety plays in school refusal, and different techniques to improve a reduction in this behaviour. The onset of school refusal is usually seen in primary aged children and adolescents. Operant Conditioning and Hull's theory, with the aid of parental perspectives allow us to explore this phenomenon further. Pharmacological approaches combined with Cognitive Behaviour Therapy are the most common and most effective treatments.

What is Anxiety?


Anxiety is "an aversive emotional and motivational state which occurs in threatening circumstances"(Eysenck et al. 2007). It can cause feelings of nervousness, dread and fear of awaited events. This is commonly paired with nervous behaviours that can manifest in many different ways. Anxiety has been linked to high competency functioning of the goal- directed attentional system. This is thought to "increase the extent to which processing is influenced by the stimulus driven attentional system" (Eysenck et al. 2007). "It is argued that distortions and biases in the processing of social/evaluative information lead to heightened anxiety in social situations and, in turn, help to maintain social phobia" (Rapee & Heimberg, 1997). Anxiety is seen in most cases of school refusal.

Cases of anxiety can have a negative impact on the functioning of a family unit. Parents supporting children with anxiety can be impacted in a number of ways including spending less time with other offspring and also struggling to manage their own employment obligations. For example consistently getting to work late, because of their endeavours to get an anxious child to school, which in turn places their behaviour under scrutiny. A dominant parent in an effort to break school refusal cycle may strike unreasonable or illogical bargains with an anxious child which in turn further alienates the entire family unit. Fathers of school refusers were more likely to report feelings of depression, phobic anxiety and present symptoms of somatization (psychological distress) in comparison to mothers. (Bernstein & Borchardt, 1996).

The impacts for schools can include an inability to accommodate the non-normative behaviour of anxious children. This could be due to teachers managing a number of students with different needs or even simply contending with large class numbers. This situation can vary occasionally, resulting in poor choices within the school community for managing children with behavioural issues (the recent use of a cage in an ACT school for containing a child is an example of a poor choice that can be made by a school authority when under extreme pressure). "Understanding the educational needs of students with chronic illness is essential if we are to provide equitable educational opportunities for them. Chronic illness can impact on every aspect of a student's development, affecting academic performance, self-esteem, social relationships, and ultimately the ability to access the same educational outcomes as healthy peers" (Shiu, 2001).

Anxiety manifests and can be seen in a range of anti-social and negative behaviours. This does not allow an individual to function at what is deemed to be a socially acceptable level in a range of social settings. When looking at school refusal on occasion, anxious people will engage in practices of procrastination in order to avoid going to school. Procrastination may be evident in a range of ways including not going to bed, not getting up in the morning despite sufficient sleep and bargaining with parents to stay away from school in exchange for subsequent school attendance and efforts.

fig 1. Some typical symptoms of anxiety

What is School Refusal?
School Refusal is a phenomenon that involves extreme emotional distress, usually seen in a child or adolescent when thinking about having to attend school. It is best treated earlier rather than later and is commonly thought to be linked with separation anxiety and depression (Eggar, Costello, Angold, 2003). School refusal is prevalent in about 1-2% of young people, and is estimated that among clinically referred youth it is considerably higher (Maynard et al. 2015). School refusal is detrimental to a child or adolescent's educational future as missing prolonged amounts of school can lead to delayed learning and development. Unlike Truancy which is associated with oppositional defiant disorder and conduct disorder, school refusal is thought to impact on other emotions which can result in social fears, trouble sleeping and strains on both peer and parental relationships (Eggar, Costello, Angold, 2003). The onset of school refusal is thought to occur during childhood or adolescence, and before adulthood (American Psychiatric Association, 2000). It is considered a "symptom" rather than a diagnosis in the DSM-IV, and is commonly linked to anxiety and mood disorders (American Psychiatric Association, 2000). "School refusal is viewed as symptomatic of separation anxiety disorder" (Kearney & Silverman, 1993). Due to high anxiety levels, difficulty sleeping can occur which, in turn impacts on the refusal to attend school. Some children are thought to avoid school due to difficulties learning or boredom and "Inactivity and boredom may promote sleepiness and high exertion may diminish sleepiness" (Lichstein et al. 1997), making it hard to break the cycle of sleep difficulties and anxiety.



Causes: School refusal is thought to have several different causes, but many stem from anxiety or conflict that has resulted at school. To date, some known causes include:
 * Anxiety that has manifested from social situations
 * Being separated from family; especially parents or guardians
 * Conflict issues with peers or teachers
 * Trauma that a child or adolescent has experienced
 * The rewards and goals perceived by staying home (able to watch T.V, access to internet, the use of video games).

Effect of Anxiety on School Refusal
There are many different factors that can impact on unexcused school avoidance. School refusal behaviour can refer to many school attendance problems (Havik, Bru & Ertesvag, 2014). Anxiety has a significant impact on School Refusal. Separation anxiety has been linked to school refusal in young children. Social Anxiety, as discussed above can emerge from many different scenarios and situations. Adverse experiences at either home and school can contribute to the avoidance of school (Egger, Costello, and Angold, 2003). School refusal is a psycho-social problem characterised by a student’s difficulty attending school and, in many cases, substantial absence from school. (Maynard et al. 2015). Although anxiety and school refusal are quite prevalent in today's' society, child guidance clinics and the like had only occasionally treated children that presented with this behaviour. School refusal literature was not easily accessible until 1941.

Test your knowledge
{School refusal is thought to be a symptom of anxiety?} + True - False

{Post-traumatic Stress Syndrome is the most common form of anxiety associated with school refusal?} - True + False

{Panic and fear are common symptoms of anxiety?} +True -False

Theories
Several theories can be considered when looking at the role anxiety plays on school refusal.

Operant Conditioning

Operant conditioning, popularised by psychologists such as Thorndike, Skinner and Mowrer, focuses on anxiety reduction with the use of coping strategies, with avoidance and escape being central concepts. Avoidance of stimuli that causes anxiety is thought to remove unfavourable emotions. Because this leads to the removal of negative thoughts and feelings, the act of avoidance reinforces the behavior; in this case decreasing the amount of days a person may go to school. When a child refuses (avoids) going to school, it can be seen as a reward and reinforces the escape of social settings. Theoretical based approaches such as desensitisation and including coaxing, encouragement and relaxation were used to minimise anxiety in a school setting (Lazarus, Davison & Polefka, 1965). Reward and punishment plays a major role in reducing school refusal, and with the aid of cognitive restructuring, shaping, and differential reinforcement to other anxious behaviours, moderate improvement was seen in school attendance on a daily basis (Kearney & Silverman, 1990).

The two-factor theory when looking at school refusal is:
 * Anxiety about school (including avoidance of stimuli)
 * Escaping from school and socially designed situations (Havik, Bru & Ertesvag, 2014).

Case Study: "When he was referred for therapy Paul, age 9, had been absent from school for 3 weeks. The summer vacation had ended 6 weeks previously, and on entering the fourth grade, Paul avoided the classroom situation. He was often found hiding in the cloakroom, and subsequently began spending less time at school each day. Thereafter, neither threats, bribes, nor punishments could induce him to re-enter school. The very acts of inducing relaxation, employing "emotive imagery," and giving reassurance may provide positive reinforcement for dependent behaviour." (Lazarus, Davison & Polefka, 1965)

Hull's Theory/ Parental Perspectives

Clark Hull's Theory relies on the notion that Biological motives are connected to the nervous system. These motives include basic needs known as primary reinforcers such as hunger and thirst. However, pleasure and the avoidance of pain are also related. The concepts connected to the Hullian Approach are derived from biology. When looking at school refusal and Hull's theory, it can be noted that particular stimuli can lead to a particular response. Hull's theory included a specific formula involving reinforced trials, deprivation and drive, the size of the goal, delayed reactions, and intensity of the stimulus to allow a reaction or behavior. This type of theory also fits in with cognitive motives and behavior therapy.

Parental perspectives give an interesting insight into the way anxiety and school refusal can be described. "The majority of the parents described noisy, disorganized classrooms as a challenge in their children’s views. They described how such classrooms contributed to a perception of unpredictability and made the child feel unsafe and insecure. In addition, in a noisy classroom, it may be difficult for a vulnerable student to be noticed by teachers" (Havik, Bru & Ertesvag, 2014). Although Some parents have been advised to force their children to attend school and disregard their anxiety and emotions, "forced school attendance may work well for children who refuse school simply for attention, but such exposure may not work well for children with considerable distress about school" (Kearny & Silverman, 1999). The most motivating factors of school refusal can be seen as "Specific fearfulness, general over-anxiousness, escape from averse social situations, attention getting/ separation anxious behaviour, and tangible reinforcement" (Kearney & Silverman, 1990). It is also noted that single-parent (especially single mothers) report a higher amount of school refusing children and adolescents than those whose father's are present (Bernstein & Borchardt, 1996).

Treatments
Cognitive Behaviour Therapy is found to be most effective when treating anxiety and school refusal, as well as the use of pharmacological approaches.

Cognitive Behaviour Therapy (when looking at anxiety) aims to educate and identify negative thoughts and beliefs, and change the way a person thinks or feels about a situation that would have previously caused anxiety. Exposure therapy can also be a part of CBT, alongside relaxation training, and in some cases hypnosis. In an experiment conducted by Cartwright-Hatton et al., (2004), Cognitive Behaviour Therapy was seen to have the most effective results in relation to anxiety and school refusal "when employing conservative criteria, the remission rate in the CBT groups (56.5%) was higher than that in the control groups (34.8%). The use of pharmacological treatments for anxiety are common practice in today's society. Antidepressants for the treatment of anxiety are now considered first line intervention. It is important to note that although other treatments are readily available, the highest response rate is seen when CBT is administered and "Approximately two-thirds of anxiety-disordered young people receiving CBT for school refusal are free of their primary anxiety disorder following treatment" (Heyne et al., 2011). This is fantastic news for those who are not only struggling with the avoidance of school but are feeling strong emotions of anxiety and fear. For the best results a combination of CBT and pharmacotherapy is used to overcome anxiety and school refusal.

Take Home Strategies
Some helpful Tips to take home for children and adolescents displaying school refusal behaviour!


 * Set Clear and enforceable attendance policies
 * Keep note of all absences rather than excusing behaviour
 * Maintain communication with both school personnel and child (eg check in on academic progress)
 * Set clear expectations and follow through on either incentive/ punishment.

It is important to provide open communication while combining the use of cognitive behaviour treatment for the most effective results in reduction of school refusal.

Conclusion
School refusal has been proven a genuine symptom of an anxiety disorder, and is closely related to separation anxiety. Research shows that Cognitive Behaviour Therapy combined with pharmacological approaches offer the best prospects of successfully treating cases of anxiety involving school refusal. While the best treatment pathways are well known, it is also important that clinicians and caregivers ensure their interaction with school avoiders is always appropriate and complimentary to therapies. In this context avoidance of a negative stimuli becomes a reward which reinforces behaviour. This in turn can negate the quality and value of successful treatment.