School Anxiety Tips
School refusal is an umbrella term used to describe when a young person does not want to attend school or finds it difficult to remain in class for a full day (Lyon & Colter, 2007). It affects between 1% to 5% of school aged children, the prevalence is much the same across genders (Richardson, 2016). Animosity develops between the young person, the school and parents, which in turn often leads to pressure from parents, teachers, and the community for the therapist to get the young person back to school (Christogiogos & Giannakopoulos, 2014). School refusal is complex and no one approach is most effective.
Kearney (2007) suggests problems such as truancy, school phobia, and anxiety as being grounds for school refusal. Owing to the complex and multifactorial nature of school refusal, it is often difficult for researchers to agree on the term as it comprises of a broad range of issues. The author disagrees with the term school refusal as it implies that the young person is refusing to go to school, and this is simply not always the case. Polyvagal theory will state that we are guided by our instinctual processes, Porges (2018) coined the term neuroception to explain how the autonomic nervous system is constantly scanning looking for cues of safety and danger, the brain creates meaning to these situations, then categorises these experiences, thus creating a response to danger and safety, in turn shaping how the person lives their daily life. The young person will either experience dorsal vagal responses of shutting down or disassociation or perhaps sympathetic responses of arousal of fight or flight.
Contributing factors to school refusal encompass the individual person, and how they internalise or externalise their problems. Family issues, parental mental health problems, parental substance abuse, domestic violence, parental unemployment, poverty, little or no engagement between parents and school, inconsistent parental discipline styles, marital problems and parental over protectiveness. School and community also contribute, academic pressures from teachers or peers, interpersonal conflicts with other students or teachers, lack of understanding by the school of the young person’s problems and bullying (Richardson, 2016).
School refusal can lead to long term and short term problems, educational problems, family problems, peer isolation, separation and attachment issues, school dropout, low self-esteem and other mental health problems (Kearney, 2007). School refusal and truancy are often categorised together, however there are differences between them. Truancy is potentially correlated to antisocial behaviour and conduct disorders (Ek & Eriksson, 2013), truancy related issues are related to peer pressure, boredom, lack of ambition etc. with truancy parents are not aware that their child is not attending school. Elliot & Place (2019) acknowledge that some forms of nonattendance are considered more sympathetically than others, young people can be labelled with conduct and behavioural problems, and perhaps not receive much needed early therapeutic intervention. An empathic understanding of the complexities involved in school refusal will assist in the return of young people to their education (Kearney, 2007).
Hart & O’Reilly (2017) acknowledge that anxiety and depression have a direct impact on the young person’s ability to maintain information, stay present and concentrate, often this can be misread by teachers and caregivers as the young person’s unwillingness to participate. The same can be said for physiological, emotional, cognitive and psychosocial symptoms relating to anxiety and depression. Interestingly, given the high numbers of young people dealing with school refusal and being a well-researched topic, the term itself has not yet made an appearance in the DSM IV or the World Health Organisation classification manuals, the author is curious as to why this may be. However, almost all young people would meet many of the anxiety disorders mentioned in the above manuals (Walter, et al., 2013).
School refusal can occur at any time, it develops in relation to life transitions, starting primary or secondary school, moving, stressful life events, it typically affects children between the ages of five to seven and eleven to fourteen years (NEPS, 2010). Elliot & Place (2019) explore the prevalence of anxiety disorders, separation disorders and PTSD as reasons for school refusal, they also indicate school based factors as another source of anxiety for this vulnerable population. Determining a treatment plan derives from developing a descriptive informative multiagency assessment.
Assessment
The aim of an assessment is to gather information about the young person in order to formulate a case and have effective therapeutic outcomes. Assessments vary greatly depending on the therapeutic background of the practioneer. Assessments are an ongoing process throughout the course of therapy (Fruggle, Dunsmuir, & Curry, 2013). Case formulation is a beneficial tool in psychotherapy, it aims to conceptualise, rationalise and plan (Eells, Lombart, Kendjelic , Turner, & Lucas, 2005). A well thought out formulation describes presenting issues, factors contributing to the problem over the life span of the person, factors in which the problem is maintained, elements that help to reduce the problem, and links theory to formulate an effective therapeutic approach to working with the client (Sim, Gwee, & Bateman, 2005). Effective outcomes begin with carefully planned approaches. An assessment of the young person is based on all areas of their development (Steele & Malchiodi, 2012). The five P’s developed by Eells (2011), presenting, precipitating, predisposing, perpetuating and protective factors, assist the practioneer in developing a treatment plan.
In relation to working with children who present with school refusal, it is essential to have an understanding of childhood developmental psychology, psychoanalytical theory, attachment theory, cognitive theory, behavioural theory, ethological and ecological theory. There are no single assessment tools for diagnosing school refusal, however the School Refusal Assessment Tool developed Kearney & Silverman (1993), (appendix 1) can be used with children as young as five years old, there is also a parent form, the assessment has twenty four questions designed to evaluate school refusal symptoms and the reasons for non-attendance. Given that school refusal can be anxiety based, assessments measuring anxiety can be utilized. Along with attachment questionnaire (Heyne, Vreeke, Maric, Boelens, & van Widenfelt , 2016). The Children’s attachment security scale, a self-reporting psychometric test will assist and support an understanding of the child’s attachment styles (Aspelmeier, Kerns, Gentzler, & Grabill, 2001). Another important aspect of assessment is comparing the young person’s chronological and psychological age (Howe, 2006).
An extensive assessment includes questionnaires on depression, anxiety, child and adolescent self-assessment forms namely, CORE-YP produce weekly practice based evidence on process and outcome measures (Barkham, Mellor Clark, Connell, & Cahill, March 2006). Parents and teachers fill Strengths and Difficulties Questionnaire (Vugteveen, Bildt, Hartman, & Timmerman, 2018), the SDQ evaluates the young person’s prosocial behaviour along with conduct, emotional, hyper-activity or inattention and peer related problems. The use of genograms developed by Bowen (1978) gathers information over three generations, searching for interpersonal relationships, intergenerational trauma, patterns of behaviour, triangulation and family roles (Corey, 2009).Expressive Arts Continuum developed by Lusebrink (2011) provides a theoretical model for continuous assessment. There are three levels, Kinetic/sensory, perceptual/affectual and cognitive/symbolic. Each of these levels relate to different parts of the brain and how the various levels of information is processed. Perry (2002) developed an approach called the Neuro-sequential Model of Therapeutics (NMT), which is a developmental and neurobiological informed way of organising a child’s current functioning and their history. It helps to identify strengths, and indicates which intervention will work best based on assessment. An understanding of the right and left hemispheres of the brain is essential when making informed best practice decisions and to select appropriate media for the client.
Evidence Based Practice v Practiced Based Evidence
Moran (2011) declares there has been a great divide between research and practice, suggesting this may be due to the large over generalised articles compiling quantitative methods and the use of large samples as opposed to therapists preferring to focus on subjective experiences of their clients. Henton (2012), describes research and practice as antagonistic fields, suggesting that therapists described research as being objective, cold, factual and time consuming, and practice being described as subjective, busy, and warm.
Research suggests that there is not one particular intervention that is more effective than any other, however due to time constraints and funding, the shorter length therapies are often employed. Evidence based practice (EBP) seeks to move our profession into the medical field, Prochaska & Norcross (2007) considered the importance of EBP for our profession to be as valued as psychiatry or psychology. Miller (2010) describes how EBP is based on DSM diagnosis and how clients become ‘patients’, which moves us far from seeing each person as an individual. EBP receives a greater amount of funding, it encourages therapists to critically explore theory and apply skills which are scientifically backed up by current research, it creates a framework for newly qualified therapists (Parrish, 2018).
On the other hand Cooper (2007) fears relying on research to inform practice could lead to client’s individual experiences becoming less important. Cooper argues, reading a study about averages will not tell us anything about what may be helpful for the individual, therapists run the risk of using a particular method or intervention that is suggested rather than what suits the individual client. The author recognises both EBP and PBE, therapists learn from studies, research can enhance clinical practice, however clients are individuals, there are so many variables, clinical judgment and the voice of the client to guide the process are also immensely important. The author questions if humans can really be measured in a scientific way, given that each and every moment and person is unique and cannot be replicated, their world based on their perceptions.
Determining the reasons as to why the young person refuses to go to school is important as the therapist can then work on the primary reason as opposed to just getting the YP back to school. Nuttall & Woods (2013) argue finding a specific approach or utilising the gold standard treatments is not always the most effective approach, therapists must be both EB and PB. Reasons such as seeking parental attention, or avoiding anxiety provoking situations occurring in school are named as factors involved in little or no attendance (Egger, Costello, & Angold, 2003). To fully explore an individual’s case, therapists must engage and interact with parents, schools and other agencies. In an article written by Nuttall & Woods (2013), promoting the use of case studies, an exploration of a number of themes arising from school refusal came about, the role of multi professionals and the family ranked high in supporting the YP and moving towards a common goal.
Parental Involvement
Drewes, Bratton, & Schaefer (2011) proclaim parental support plays an important role for the young person. Leblanc & Ritchie (2010) suggests a strong link between the inclusion of parents on having a positive impact on the minor reaching their therapeutic goals. Richardson (2016) states that very few young people are adequately equipped to return to school without support from their family and school, therefore collaborating with parents, caregivers, teachers and other agencies is an essential component to the young person attending school.
Prendiville et al (2017), explains that the child belongs within a system, therefore an important component in the client’s journey is to work closely and in partnership with the family, developing an enhanced nurturing environment where the minor feels safe and supported, this can be done through family or joint sessions, meetings with parents, or at consultation stage. Using a collaborative approach allows caregivers to feel empowered, after all the client is only with the therapist for one hour per week (Leblanc & Ritchie, 2010). Mc Queen & Hobbs (2014) suggest parents feel more empowered and share responsibility in obtaining and maintaining goals for therapy when the therapist maintains a good raport, develops a working alliance and remains inclusive. Issues in relation to power inequalies arise, the inclusion and the voice of both parents and YP is imperetiave to ensure power dynamics do not outweigh the practice of effective therapy (Gillett -Swan & Sargeant, 2018)
The Voice of the Young Person
Listening to the young person, understanding their challenges and experiences is imperative to building a therapeutic relationship and empowering the client. Conversely, this was not always the case in Ireland, we only need to look back on social policy around twenty years ago to grasp the difficulties children had with getting their voice heard. The voice of the young person is now recognised by UNCRC (2010) it contains forty two articles, all of which are relevant when working with minors. Ireland has developed social policies around the safeguarding and protection of the nation’s children, much of these legislation policies came about from inquiries into horrendous cases such as Kilkenny Incest Investigation in 1993 (McGuiness), Kelly Fitzgerald Inquiry in 1995, Monageer Report in 2009 and the Roscommon Childcare Inquiry, which was only very recent in 2010. Out of these inquiries, Ireland continues to develop policies to protect minors.
Tulsa was set up to ensure the safeguarding and welfare of children. Mandatory reporting is now in place. Better Outcomes Brighter Futures (2014) is a national framework with five guiding principles, child’s rights are at the heart of this document, it is based on the UNCRC framework, it is family orientated, advocates for reducing inequalities, promotes social inclusion, is guided by evidence informed and outcome focused approaches, and it holds people and agencies accountable for their actions, which again up until recently was not the case. All of these polices inform how therapists have a unique role in advocating for the voice of the child.
Multiagency Engagement
Hart & O’Reilly (2017) acknowledge the complexities of school refusal and the close link between mental health and the ability to learn. The article considers the importance of sharing information and the voice of the young person at the centre of it. Developing a multi professional approach worked well in Nuttall & Woods (2013) study, as it provided a space whereby professionals could give their opinion, listen to the views of others, share information and agree on a plan. Engaging with multi agencies relies on the permission and consent of parents and the YP (Hart & O’Reilly, 2017). Knowing what and how much information to share can be a complex matter. Hart & O’Reilly’s (2017) journal article explores a number of themes around these challenges namely, fears of the YP being stigmatised by the school, the importance of teachers having some training in mental health matters, ensuring information shared is confidential and on a need to know basis, and provide a collaborative approach whereby parents and YP are involved in the decision making process. Developing a collaborative practice requires skill and time, It is crucial when working collaboratively with other professionals that clear roles are defined, how contact should be made, and develop a common shared understanding of what can be done and who will be doing it.
Equality and Equity in Counselling
The IACP Code of Ethics (2019) provides a framework for best practice in the field of counselling and psychotherapy in Ireland. It has four major principles. Respect, Competence, Responsibility and Integrity. Therapists respect the rights and dignity of their clients. All information is treated with strictest confidentiality. It is critical to always inform and ensure that the client consent to whatever professional action proposed. Up to date knowledge of policies and procedures is important to ensure that client’s best interests are at the heart of it all (Huffman, Shaw, & Loyless, 2012). Equality is a principle that every client is treated fairly and equally, as therapists this is the standards in which we adhere to, nevertheless, there are pitfalls in relation to ensuring this, with reference to accessibility to buildings and therapy spaces, lack of knowledge around culture, issues in regards to communication for clients who may not have English as a first language (BACP, 2018).
Access to counselling is not always a given in Ireland, extremely long waiting lists for CAHMS is a serious issue, there are approximately 2450 children awaiting to be seen by CAHMS (Mental Health Reform, 2020). Families rely on low cost counselling agencies and support from charities to fund private sessions, presently Ireland cannot ensure equal access to services. Economic factors are also at play, as parents who can afford therapy have access to private psychotherapy, therefore equality and equity is a real life issue for many (Rizzo & Killen, 2016).
