School Refusal: Information for Primary Care

Michael Cheng, MD, FRCP(C), Psychiatrist Hub Specialist

Matt Manion, RSW, Ottawa Carleton District School Board (OCDSB), Guest Expert Thursday, October 25th, 2018

Special thanks to Olivia MacLeod, Psychiatrist

School Refusal:

Information for Primary Care

Faculty and/or Presenter Disclosure

• Presenter: Michael Cheng, Project ECHO® Ontario CYMH

• Relationships with commercial interests:

◦ Grant funding from uOttawa Brain and Mind Research Institute for the eMentalHealth.ca/ PrimaryCare (for project personnel such as web

development), of which one source was Lundbeck/Otsuka, which markets Citalopram (Celexa).

• Disclosure of commercial support:

◦ None for this session

• Conflict of interest:

◦ None for this session

• Mitigating potential biases:

◦ Recommendations are consistent with published guidelines; current practice

patterns; unrelated to products/services/treatments involved in above disclosure

statements.

Learning Objectives

At the end of this presentation, participants will be able to:

◦ Name two reasons for school refusal.

◦ List three different strategies for school refusal.

◦ List two ways to work with the school to support a student with school refusal.

Case: Jennifer

ID Jennifer, 12-yo female, Gr. 7, living with mother

Chief concern Mother: She won’t go to school! I am going to lose my job!

Patient: I can’t handle school!

Goal Less anxiety (i.e. feeling calmer) about school

History of Presenting Problem

Always shy, with separation anxiety, school anxiety Summer

• Mother in hospital for appendicitis x 2-weeks Sep 2018

• Attended initially, but then began having school refusal Oct 2018

• Sunday morning expresses anxiety

• Monday mornings  crying inconsolably.

• When stays at home, mother does work while she watches videos

Image: Adobe

What are you going to do?

Q1. With this presentation, what is the most likely psychiatric diagnosis?

a) Anxiety disorders.

b) Mood disorders.

c) Attention-deficit hyperactivity disorder (ADHD).

d) Autism spectrum disorder (ASD).

e) No diagnosis.

Q2. What is your management plan?

a) Refer to the school truant officer.

b) Rapid re-entry plan that focuses on quickly getting the student to full-attendance to prevent avoidance from being entrenched.

c) Address anxiety, support school/family to create gradual re-entry plan.

d) Cognitive behaviour therapy (CBT) for anxiety.

e) Ensure mother takes away all electronics until she starts attending school again.

Definition of School Refusal

Behavior with:

• Emotional distress, plus

• Difficulty attending school and/or staying in school for entire day

(King & Berstein, 2001; Kearny and Silverman, 1996)

◦ School attendance by law until age 18 in Ontario

─ Education compulsory up to the age of 16 in every province in Canada, except for Manitoba, Ontario, and New Brunswick, where the compulsory age is 18, or as

soon as a high school diploma has been achieved. Image: Adobe

Is it School Refusal or Truancy?

School Refusal Truancy

Emotional distress about school (e.g. anxiety, depression)

Lack of fear about attending school

Student doesn’t usually try to hide absence, thus parents are aware

Student usually tries to hide absence so that parents are unaware

Absence of significant externalizing behavioural problems

Often oppositional, or antisocial behaviours

Kearney, 2001; King and Bernstein, 2001

Case: F.B.

• Identifying data

◦ 18-yo male

◦ Living with parents

• Goals

◦ To miss school because “life moves pretty fast.”

• Q. Is this a case of…

A. School Refusal B. Truancy

Image: Fair Use, Paramount Pictures

Case: F.B.

• Identifying data

◦ 18-yo male

◦ Living with parents

• Goals

◦ To miss school because “life moves pretty fast.”

• Q. Is this a case of…

A. School Refusal B. Truancy

Image: Fair Use, Paramount Pictures

Why Do Students Refuse to Go to School?

Kearney, 2007 Mediated by:

• Protective factors (e.g. secure relationships with parents)

• Predisposing/precipitating factors (e.g. adverse childhood experiences, stresses, traumas, mental health conditions) 1. To avoid negatives (i.e. distressing,

stressful situations)…

2. To seek positives (i.e. pleasurable, rewarding, meaningful situations…)

✘ Images: Adobe

Assessment, Diagnosis and Differential Diagnosis of

School Refusal in Primary Care

Identify any Medical Conditions including:

Symptom Medical DDx

Diarrhea Irritable bowel

Fatigue Asthma

• Leading cause of absenteeism worldwide

• Youths with asthma miss 1.5 – 3.0 times more school days that youth without

Headache, stomach aches Chronic pain and illness (e.g. cancer, Crohn’s disease, dyspepsia, hemophilia, chronic fatigue syndrome)

Nausea and vomiting Diabetes

Palpitations and respirations Dysmenorrhea

Kearney, 2006

NOT a comprehensive list!

Identify any Psychiatric Conditions such as:

Condition Features Frequency

Anxiety disorders Troubles with anxiety, to the point where it impairs function?

* Separation anxiety Is there anxiety specifically around separation? 22%

* Generalized anxiety Is there anxiety about numerous issues? 10%

* Social anxiety disorder

Is there extreme shyness? Anxiety with social situations?

3.5%

* Specific phobia Is there worries about specific things, e.g.

insects? The dark?

4.2%

* Panic disorder Episodes of sudden anxiety, out of the blue? 1.4%

Kearney & Albano, 2004

Identify any Psychiatric Conditions such as:

Condition Features Frequency

Oppositional defiant disorder

Oppositionality to rules? 8%

Depression Troubles with depressed mood, along with problems with appetite, energy, concentration, sleep?

5%

ADHD Troubles paying attention? Troubles being hyperactive/impulsive?

1.4%

Autism spectrum disorder (ASD)

Troubles interacting with others? Narrow interests?

Sensory issues? Troubles seeing other’s perspectives?

Learning disorders (LD), e.g. Non-verbal LD

Troubles learning any specific subjects or in general?

No DSM Diagnosis 33%

Kearney & Albano, 2004

Identify any Other Issues / Conditions such as:

Condition Features

Technology overuse Does your child/youth use a lot of technology? Does your

child/youth have problems getting off the technology? Do you think this is getting in the way of your child’s life?

• Video gaming Play a lot of video games?

• Social media Use a lot of social media?

• Internet, including

YouTube, pornography addiction

Use the internet a lot? Watch a lot of videos? Watch adult material?

Frances Allen: School Refusal and Severe Social Withdrawal, 2015

https://www.psychologytoday.com/us/blog/dsm5-in-

distress/201505/school-refusal-and-severe-social-withdrawal

Assessment Tool

School Refusal Assessment Scale - Revised (SRAS-R)

• Consider SRAS-R

◦ 24 questions

◦ Possible reasons to school refusal

◦ What is the student trying to avoid?

◦ What is the student trying to seek out?

◦ Validated measure for school refusal symptoms

http://learnpsychiatry.org/w/images/5/5c/School_refusal_assessment_r_p.pdf

Kearney, 2002

Management of School Refusal

in Primary Care

Manage / Refer for Treatable Conditions

Conditions such as…

• Anxiety

• Depression

• Attention deficit hyperactivity disorder (ADHD)

• Learning problems

• E.g. Non-verbal LD

• Autism spectrum disorder (ASD)

Refer to the Truant Officer?

• No, there are no longer truant

officers…

Image: Wikimedia

Liaise with the school

• Consider contacting involved educators (e.g. teachers, guidance counselors, VP, etc.) during visit

• Consider a “Dear school” letter:

 Let them know about issues / conditions

“I am writing to give you an update about your student, who is coping with ISSUE/ CONDITION…

 Dates of known absences include…

 “We are working with this student on the following issues ….” (e.g. medication management, counseling, referrals, stabilization, etc.)

 Suggest possible classroom accommodations:

─ “Accommodations are essential for the student to function in the academic program”.

─ “You might consider…”

• Reduced course load or half days.

• Allowing use of learning strategies room for completing work.

─ Emphasize exposure to school rather than academic progress.

 Date when you envision improvement.

• Examples

• https://cheo.echoontario.ca/knowledge-base/school-refusal-accommodation-letter/

• www.eMentalHealth.ca/PrimaryCare> Choose condition > Click “Workplace/School Letter” tab

• www.SchoolPsychiatry.org

Personal communication, Manion, 2018

Educate Parents about School Refusal / Avoidance

www.seattlechildrens.org/pdf/PE1373.pdf

Keep at School unless Medical Symptoms Present

Child should attend school, unless medical symptoms:

• Fever

• Diarrhea

• Acute flu-like symptoms

• Frequent vomiting

• Bleeding

Kearney, 2006

School Interventions

School Interventions

1) Discussions at school multidisciplinary (“multi-D”) meetings

◦ Meetings with school and school support staff to discuss strategies

◦ Can also refer to in-school supports such as social worker, psychologist, speech pathologist, youth worker

2) Case conference

◦ Meet with key stakeholders involved in the student’s care

3) IPRC / IEP

◦ Your letter will help lead to

1) meeting of the Individual Placement and Review Committee (IPRC), followed by 2) creating an Individualized Education Plan (IEP).

Less Intensive

More Intensive

Principles: Gradual Reintegration via Step-by-Step

• Preferred approach to school refusal is gradual reintegration.

• Start with:

◦ Attending 1 class (or less!)

• If successful, then:

◦ 2 classes, then 3 classes, etc.

◦ Gradually increase until full attendance.

Full

attendance

1 class

Principles

• Connection:

◦ Beginning and end of the day, check in with school (adult) ally.

• Unable to tolerate regular classroom?

◦ Consider alternative settings such as resource room, etc.

• Self-regulation:

◦ Build regular self-regulating activities into the daily routine. (E.g.

“body breaks” for self-regulation, e.g. sensory room; “nooks”; walks)

◦ Examples of self-regulation programs / strategies used include

◦ Zones of Regulation ™

◦ Incredible 5-point Scale

Alternate Programs

• If accommodations / modifications in the regular classroom are

insufficient, the school may consider other options which may include:

• Gr. 1-3

◦ Behavioural Classroom.

◦ EA (educational assistant) Support.

• Intermediate / High School

◦ Resource room access.

◦ Spare period or half days.

◦ In-home tutoring (SAL Program).

◦ Alternative High schools.

◦ Technical High schools.

Care and Treatment Programs

Formerly “Section 23”

• Indications

◦ For students whose mental health needs prevent them from attending a regular school setting.

• Staffed by:

◦ Educators (Teachers, EAs, etc.).

◦ CYCs, with clinical support from social worker, (possibly) psychologist / psychiatrist.

• Features include:

◦ Smaller class size, e.g. 10 students with a teacher / child (rather than 30).

◦ Therapeutic programs such as mindfulness, CBT group for anxiety.

• How to refer?

◦ Referral is through the school

◦ Note: You cannot ask for a specific program; it is up to the appropriate agency to

recommend a specific program.

Management of School Refusal

Management of School Refusal

• CBT strategies such as:

◦ Calming strategies such as breathing training, muscle relaxation

◦ Exposure strategies such as gradual re-exposure to school and triggers

◦ Learning strategies to cope with the specific trigger or issues

◦ Social skills issues? Explicitly teaching the child social skills

◦ Problem-solving and role playing how to respond in a specific situation, e.g. bullying

Kearney and Albano, 2000

Management of School Refusal

• Distress with separations from parents?

◦ Ensure parents can provide:

◦ Emotional support, e.g. empathy, validation, acceptance, soothing (e.g.

hugs).

◦ Consistency, e.g. consistent morning and evening routines.

◦ Eliminate positive reinforcement for school refusal

 No recreational screen time when the child misses school and stays at home.

Kearney and Albano, 2000;

Triple P and other positive parenting programs

Medication Treatment for School Refusal

Significant problems with anxiety / depression despite non-medication interventions?

1st-line:

• SSRIs

◦ Fluoxetine (Prozac) 10-20 mg daily

◦ Fluvoxamine (Luvox) 50-250 mg daily

◦ Sertraline (Zoloft) 85-160 mg daily 2 ^nd line:

• Venlafaxine XR (Effexor XR)

Wehry et al.: Assessment and Treatment of Anxiety Disorders in

Children and Adolescents, Curr Psychiatry Rep, 2015,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480225/

When and Where to Refer in Ontario?

If issues persist despite working with the school, other services include…

• Public services:

◦ (School-based) Mental Health and Addictions Nurse (MHAN) (if not already involved).

 While the student is still attending, the MHAN can meet with the student / family, and help ensure that appropriate resources are in place.

◦ Publicly funded children’s mental health agencies

◦ Hospital based services.

• Private practice services:

◦ Mental health professionals (e.g. psychologist, social worker, registered

psychotherapist, etc.).

Q1. With this presentation, what is the most likely psychiatric diagnosis?

a) Anxiety disorders.

b) Mood disorders.

c) Attention-deficit hyperactivity disorder (ADHD).

d) Autism spectrum disorder (ASD).

e) No diagnosis.

Q1. With this presentation, what is the most likely psychiatric diagnosis?

a) Anxiety disorders.

b) Mood disorders.

c) Attention-deficit hyperactivity disorder (ADHD).

d) Autism spectrum disorder (ASD).

e) No diagnosis.

Correct Answer: A) Anxiety Disorders. The most likely diagnosis is an

anxiety condition, based on the history of longstanding shyness and anxiety symptoms. Further assessment would be required of course, to confirm

anxiety, but based on the information available, it would be reasonable to

wonder about anxiety. Next steps would include understanding stresses, and

other factors contributing to the anxiety.

Q2. What is your management plan?

a) Refer to the school truant officer.

b) Rapid re-entry plan that focuses on quickly getting the student to full-attendance to prevent avoidance from being entrenched.

c) Address anxiety, support school/family to create gradual re-entry plan.

d) Cognitive behaviour therapy (CBT) for anxiety.

e) Ensure mother takes away all electronics until she starts attending school again.

Q2. What is your management plan?

a) Refer to the school truant officer.

b) Rapid re-entry plan that focuses on quickly getting the student to full-attendance to prevent avoidance from being entrenched.

c) Address anxiety, support school/family to create gradual re-entry plan.

d) Cognitive behaviour therapy (CBT) for anxiety.

e) Ensure mother takes away all electronics until she starts attending school again.

Correct Answer: C)

For the management plan -

a) You cannot refer to the school truant officer, because there is none.

b) You do not want a rapid re-entry plan, because that runs the risk of not being successful.

c) You want to address underlying anxiety (e.g. whether it is non-medication interventions such as therapy, etc.) plus work together with the school for a school plan. The school truant officer is really our school social workers 

d) CBT for anxiety is a good intervention to consider, but is part of an overall plan, not the plan per se.

e) Removal of electronics is a good intervention to consider, but part of an overall plan, not the

plan per se.

How you Support Jennifer’s Needs?

• Jennifer is a 12-yo in Gr. 7 who has trouble attending school…

• Mom, “I’m going to lose my job if she can’t go to school!”

You do the following:

• Identify anxiety problems.

• Inform the school through phone call and letter;

• Speak with the school mental health and addictions nurse.

• She starts seeing a clinician for psychotherapy at the local mental health agency, but doesn’t improve;

• You start an SSRI which reduces anxiety to allow her to benefit from psychotherapy.

• By the end of the year, she is looking forward to going to school again…

Image: Adobe

Clinical Pearls

• School refusal is serious; primary care providers can play a key role

• Two reasons

◦ Avoiding negatives, e.g. avoiding bullies

◦ Seeking out positives, e.g. staying home with parent

• Three strategies for school refusal

◦ Identify treatable medical conditions

◦ Liaise with school

◦ If non-medication strategies ineffective, consider medication for treatable issues such as anxiety

• Two ways to work with school

◦ Call school during appointment;

◦ Write letter to school during appointment.

References

• Wehry A et al.: Assessment and Treatment of Anxiety Disorders in Children and Adolescents, Curr Psychiatry Rep, 2015 July; 17(7): 591. Review.

• Kearney C: Dealing with school refusal behavior: A primer for family physicians, J. Family Practice, Aug 2006

• Kearney CA. School absenteeism and school refusal behavior in youth: a contemporary review. Clin Psychol Rev. 2008 Mar;28(3):451-71. Review.

• Sewell J. School refusal. Aust Fam Physician. 2008 Jun;37(6):406-8. Review.

• King NJ, Bernstein GA.. School refusal in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2001

Feb;40(2):197-205. Review.