This article is a modified excerpt from the Symposium on School Refusal event held on January 7th in Kuala Lumpur. It’s made for therapists, but it can also be helpful for parents experiencing issues with school refusal. To view the full hour-long source video, watch below or click here.
Amanda would have been 15 years old when I worked with her in the early 90s. But today, she would be in her 40s. Amanda had been absent from school for six months. The principal of the Catholic school I worked for sent me a referral (I worked there for 15 years, seven years as a school counsellor and seven years as an outreach family therapist). Paul Mendey knows me and my work, so he said, 'How can you help this family?' I was swamped at the time and could only offer them one appointment - a home visit of two hours. So, I went to their home and listened to their stories about why Amanda wasn't going to school. I interviewed the family for a good hour, and then I stopped and gave myself some space to think about the last hour of my interview. Then, I interviewed them for another hour. At the end of the interview, I gave myself some space to look at what I would say to the family and what my prescriptive message would be; about my understanding of why Amanda does not go to school.
Amanda’s 16-year-old sister was moving to another Catholic High School (It's not uncommon to go from year 7 to year 10 of HSC (high school certificate) at another Catholic High School). And Amanda had some medical issues; her hips were a bit funny when she was born, so she had multiple surgeries. She also fractured her arm, which meant she had to give up her favourite sports. Her best friend moved on to another school, and Amanda was also very worried about her parents' unhappiness. I'll get back to Amanda's story later.
Definition of School Refusal
In terms of school refusal, the definition is that reluctance or refusal to attend school often leads to prolonged absence. Sometimes it's insidious; you fall off one day and don't go to school, and over time it adds up. The child is usually at home with the parents' blessing; the parents know their child is at home. That's why it's different from truancy. The child may be emotionally upset with the prospect of attending school, which may be reflected in excessive fearfulness, temper tantrums, unhappiness, or possibly unexplained physical symptoms. Social somatic complaints, such as headaches, are a common presentation.
So, I reframe that the child is worried sick. And the idea of being worried sick is that you become physically sick when you get really worried. So remember, you can never discount headaches. Always agree and accept the headaches, and then treat them symptomatically. Give them two panadol and give the school permission to provide them with the panadol. Then you don't get into a power struggle because the child says she's really sick. If I said, "No, you're not sick; you just don't want to go to school." It's pointless. You don't get mileage from that. It's better to acknowledge and treat the symptoms.
Many therapists got it wrong when they said that the child is ODD (Oppositional Defiant Disorder) when the child becomes defiant and oppositional. When a child loses control and tries to regain control, they can be aggressive and defiant. But when you understand school refusal from a context of heightened anxiety, when there's heightened anxiety, it's because they have no control. So it's not uncommon for school refusal to manifest in aggressive or defiant behaviour, resulting in a mistaken diagnosis of ODD.
Generally, anti-social behaviour is absent, so conduct disorder is not the case. Parents try to get their children to school but often give up. It is not uncommon for the child to make a lot of empty promises, such as 'I'll go to school tomorrow', and the parents will lighten up, but come tomorrow, it is a disappointment and another disappointment. You can appreciate the parental feeling of being overwhelmed. It is a common presentation. By the time the parents come to me, they are overwhelmed, exhausted, and have had enough. They are getting tired, and it is not uncommon for them to become very frustrated and angry with the child. As a result, the child may develop guilt, which is unhelpful.
Statistics on School Refusal
School refusal is common across genders and often occurs in children ages five to ten years. However, most of my client base is adolescents between 13 and 16 years old. I don't work with too many children, but I do have twin boys who are seven years old. So, we work with all ages, but the clients I work with often tend to be adolescents that are 14 or 15. The question then is, how does COVID-19 fit into all of this?
The Movement Control Order (MCO) has contributed significantly to the escalation of anxiety, school refusal, and inability to attend school, which can contribute to feeling alienated.
Special Considerations
School refusal is known by different names, such as school phobia, separation anxiety, and generalised anxiety. It is not uncommon for OCD to be a comorbidity. Underneath it all, it is an anxiety-based issue, particularly separation anxiety. Threats of suicide are not uncommon; imagine when you lose control, you'll say anything to have some control. So, the fact that they threaten suicide at that point will contribute to many therapists taking the necessary step to make it workable. Because they're worried that the child might die, they back off. The threats of suicide may be an expression of control as well. So, it's crucial to assess the child, but when they do talk about suicide, then you have to evaluate the risks of suicide. It would be best to take them at face value and not discount them.
Gaming addiction is secondary to family dysfunction, and gaming addiction is often a way of coping with unhappiness. It's a good distraction; you don't have to think about going to school tomorrow. Gaming addiction is a big problem in the 21st century. If you look around, you're out Yum Cha, you'll see that everyone has a phone, and nobody talks anymore. I now prescribe family time in my work with families.
So, there are only two methods of getting a child back to school; early full-time and early part-time.
Early Full-time:
Early full-time is commonly known as a flooding technique that can be a traumatising experience. Do we further traumatise the child if we go for the works using a flooding technique? Because it's terrible to watch. They scream, yell, run away, and damage stuff, so it's a scary experience when you return a child to school early.
But one important thing about school refusal is that they know they belong in school. But they don't know how to get back to school. That's a critical distinction. But half the time, you know they want to go back to school, but they don't know how to anymore; this is when a directive approach will get a better outcome.
Early Part-time:
Like a tortoise, you're going slowly. The child goes to school for one period or two periods. Amanda was like that; she was dry retching in the morning when I was there at their home; she was genuinely sick, and it was scary to look at her from the parent's perspective. She was complaining of headaches too.
The accessibility of a therapist is essential with early part-time increase.
Clinical Implications and Consequences for an Early Return to School
An early return to school interferes with therapy because young people are prevented from solving internal emotional conflicts. So when you go for the fast method, you might miss doing the therapy work that's essential to help them to make sense of their issues.
Clinician's failure to insist on an early rapid return feeds on the neurotic patterns within the family, so we can possibly get contaminated by the family's anxiety.
Many families provoke an escalation of anxiety and panic attacks and are concerned about the possibility of traumatic experiences. Families are also worried that you might give them yet another PTSD diagnosis. So doing due diligence to assess the history of their mental health is a critical component of your assessment, a holistic evaluation that covers all bases.
A part-time approach may help circumvent treatment dropout; however, lower attendance at the start of treatment was significantly related to poorer treatment outcomes. So when you go for the slow part-time method, the chances of failure are higher.
You're looking at a 72 percent positive outcome when you use the fast method. You've done well when doing school refusal treatment, and you get a 50% positive outcome.
Research in Japan, when a child refuses therapy, it's just the school and the child working together to get the child back to school; they get 72 percent positive outcomes without therapists.
I've had success with both the slow and fast methods. But getting a positive outcome from the early full-time method is quicker; you can get a positive result within 48 hours when the child attends one or two days of school, and going to school becomes normal again. I say to the parents, prepare for two weeks of battle. If you can prepare for two weeks and go through the early full-time method, you’re more likely to maintain the momentum and keep your child in school.
School-refusing adolescents have poorer outcomes relative to children who do not refuse to go to school. That's obvious, but you can't brute-force the older kids to go to school; it's harder to carry a 16-year-old to school than a seven-year-old. However, many adolescents might struggle, and you might think they are big, but the construct I play with is that I know they want to go to school. I play with that construct. So, how they resist you tells you they want to go to school. For example, I have a boy; let's call him Mitch. Mitch has a father that is a big man, and he is a big boy. So, you can't physically carry him. But from the house visits (I do house visits for school refusal cases because I want to look at the family dynamics), Mitch responded when the mother used a firm voice, but Mitch resisted more when the mother used a soft voice. That's why the presence of a therapist as a coach in the early stage of initial reintegration into school is critical. And then, when you edge Mitch to the car, he could fall on the floor on purpose, and you can't do a thing, but you continue to walk to the car, though it might take a bit longer. Eventually, we arrived at the school, and the system was all in place. The school counsellor was waiting for Mitch because we made a phone call to say that we were on the way.
When we reached the school, he hyperventilated and had a full-blown panic attack. The school counsellors took over, knew what to do, and within 15 minutes, we must excuse ourselves. Once you take the child to school, the stakeholders like us excuse ourselves and let the school manage it from then on. Leaving the child with the school is a crucial step. If you stay in school, the odds of the child coming home are high, but if you leave the school to manage, the odds of him staying in school are higher.
The second clinical implication is poor academic outcomes, underachieving or failure, dropping out of school, and poor employment prospects. A percentage of school refusals will lead to poor academic outcomes, underachievement, failure, dropping out of school, and poor employment prospects. Unfortunately, many children end up dropping out of school as a result. I worked with a 16-year-old boy who used technology for 16 hours a day. It is unlikely that he will be able to go to school if he does not have a normal sleep pattern. Additionally, prolonged use of technology can lead to problems such as poor eyesight and hunched shoulders. I have had difficulty addressing this issue because the child is not the customer; the parents were. This child ended up dropping out of school.
Many therapists advocate for homeschooling as a solution, but it is important to thoroughly assess if homeschooling or schooling through correspondence is the way to go; because such options open up the child to social and peer relationship issues. I personally do not recommend homeschooling unless all other psychological interventions have been exhausted.
Problematic family functioning is also another vital aspect to consider.
Holistic Assessment
The Presenting Problem
In my assessment, I focus on what brought them to therapy, the duration of the problem, and the family's developmental history. I look at the child, the pregnancy, and how the family decided they should or should not have a child. I also look at any instances of separation anxiety when they went to preschool for the first time, any mental health history in the family system, and any significant events that may have occurred. I also conduct a full family developmental history by looking at the three-generational family network using a multi-generational framework. I look at three family generations in the context of unresolved issues on both sides of the family. I often ask the parents what they would have liked at the child's age, as this can reveal a lot of information about the intergenerational transmission of issues related to school refusal.
The Family of Origin
I look at the family of origin, specifically the parents and how much they have differentiated from their own parents. In terms of differentiation, I focus on Murray Bowen's work on the process of differentiating and how much the parents have become independent adults.
Assess the School System
When assessing a child's school refusal, I also like to assess the school system; this includes interviewing the parents to learn about the school and who they are close with in the school. I also interview the child and the teachers to learn about their relationships with the teachers and determine resources that can help in the child's reintegration. I take a collaborative approach and work with the school counsellors and teachers to support the child when they are at school. Most schools will say yes to the opportunity to collaborate. When I have a meeting, I will have the child present, the parents, and the key people in the school (especially someone in charge) who can rubber stamp my suggestions. I want the school counsellors involved to support the child when he's in school. There's also the peer coordinator who's connected with all the teachers.
Peer Relationship and Academic History
Even when most of the kids are bright, they're also worried about academics because of how long they haven't been in school (at times 6-12 months). To help the child, I look for a positive cohort of kids in the school that can help the child's reintegration process. I also assess the child's peer relationships and academic history; this includes understanding how much of the child's learning has been a problem and if they have developed anxiety-provoking situations around academic pressure.
I will tell you about Jordan's story. He's in year 9. I could get Jordan into the school office, but I couldn't get him into a classroom despite my best efforts. Jordan has two best friends. One day, I asked him if he would allow me to get his best friend to help him get back to class. He said, "No, no, no," but that was just his school worry germs talking. So one day, I asked his mother to access his best friend and get permission from the deputy principal and the best friend's parents to speak to him. We surprised Jordan by bringing his best friend to the school office, and he was initially in shock, but he quickly felt better knowing that it was no longer a secret that he had a school refusal problem. He was relieved and happy. Sometimes, what 'worry germs' tell children are so wrong. The next day, we brought his second best friend, and he started to feel more relaxed. Because his mother works in the school, we were able to do exposure therapy after school with her help. Now, he is in the last year of a university degree in engineering.
Look for Competence in the Child
I like to also look for competence in the child; what they are good at. Let me tell you Zach's story. Zach had learning difficulties and a low average IQ, with five diagnoses, including ADHD, OCD, and generalised anxiety disorder. However, looking at his diagnoses alone didn't get me very far. Instead, I noticed that Zach loved waveboard jumping and had never competed before. But once he started competing, he got three gold medals. So, when I had a case conference at school, I told the teachers and the deputy principal that this kid was a waveboard jumping champion with three gold medals. I explained that if he could do that, he could do anything. As a therapist, it's essential to borrow this 'I can do it' belief from the child.
When I finished my work with Zach, I asked him, "What part of my work was really helpful?" He replied, "David, I believe in me."
Another example is Ian, who had severe ADHD and a low average IQ. He was also very aggressive, throwing chairs and tables in the classroom. I was asked to help him, so I went to his home and did a home visit. Over time, Ian became engaged in therapy, and one of the things I said to Ian at the end of our therapy session was, "We'll get there together." This became my statement for him at the end of every therapy session. I worked with Ian for three school terms, got him tested and met his learning needs. At the end of therapy, Ian's mother was so proud that her son had finished year 10. She asked me to come to the school and say goodbye to him. I went to school, and Ian gave the school principal a clock as a gift, symbolising their time together. Ian also gave a big clock to the special needs educator that helped him immensely to get back to speed with school work. Ian gave me a set of pens, but the most meaningful was a card that he had written, which said, "We got there together."
I work with another severely ADHD boy; let's call him Matt. His competence was in lighting (light bulbs and candles). The teachers hated him. He was an ODD kid, so he was a pain in the neck. But he loves lighting. So, I advocated for him. I asked the teacher, "Can you give him a leadership role?"
"That's a joke, isn't it?" The teacher inferred. "That's a troublesome boy; he can't be in a leadership role."
So I changed my tone. I ask, "Can you give Matt something he can be involved with in the school community?" That way, it's more digestible. They agreed and gave him a duty in the chapel. Every Friday, he puts up the lighting in the chapel, and they can't do without him; they miss him when he takes a day off sick. And not only that, he showed leadership abilities by recruiting other troubled young kids to put up lighting. So, when you focus on competence, there's a lot more light in the tunnel when you work with kids like this because they have enough people telling them what they can't do. And one of the biggest problems they have is poor self-esteem. A pervasive sense of poor self-esteem is worse than depression.
Look for resources
So, I look for grandparents that can help me. Here's Amelia's story, Amelia didn't go to school for a while due to severe separation anxiety. To cut a long story short, we did the flooding technique (early full-time). The father tried the flooding technique by himself but failed miserably because he didn't have a system in place. The mother was an assistant principal, and the father was a businessman in charge of disability services. They were desperate to get their daughter back to school. They loved her too. But she had severe separation anxiety.
What was interesting about Amelia was that she had a sense of persistence that I liked about her. The theme of awkwardness and embarrassment about going back to school. And she was most commonly afflicted by anxiety-provoking situations, which happened often.
To handle her separation anxiety, we used the flooding technique with Amelia. I was at Amelia's home during the flooding technique, and we did the usual stuff; we took her blankets off as she lay in bed, but she resisted getting up. However, we managed to get her up, and she never resisted us in a way that stopped progress. She could have decided to sit on the floor, and it would be almost impossible to carry her to the car. Thankfully she didn't, and we were able to inch her along and get her to the car. I was very directive and got the school bags, shoes, and uniform ready in the car. So, she knew everything was already in the car waiting for her. She knew we weren't mucking around and would be carrying her to school (if everything else failed).
In the car, she threatened to kill herself and said she would ring the police; her father tried to pacify her. So, in a relaxed manner, I told her that she could call the police when they arrived at school. When we arrived at the school, the system was in place, and the room was in place for her to have privacy. We went after the school bell had gone, so we had to be very strategic in how we intervened and made sure that we covered as many bases as possible in terms of anxiety-provoking situations.
We handed Amelia over to the school representative, and we excused ourselves. I could see that Amelia's father had a tear in his eye. Within less than half an hour, Amelia got herself together. After school, she told her parents how nice school was for her for the last 6 hours. I asked Amelia's father about the tears, and the father talked about his experience of feeling so inadequate and helpless when Amelia was born; she was so full of problems.
Resources
As for resources, I asked Amelia's grandfather to be involved because I needed more than one person, especially since the father could not always be available. I want to normalise the family as soon as possible, so I mobilise whatever resources I have. So I asked Amelia's father if his father (Amelia's grandfather) to help. So I asked Amelia's grandfather to help, and he came, but the mother didn't think it would work. However, it did work because Amelia immediately went to school with her grandfather.
The Prescriptive Message To Amanda's Family
When it comes to Amanda, I want you to appreciate how to normalise stress and look at school refusal as a stress model. It is much more liberating than looking at it from a psychopathology model and generalised anxiety.
So I saw the family for two and a half hours and gave a message to Amanda's parents:
As discussed, we responded to the school's concern that Amanda has not been attending school. Thank you for your honesty and openness in discussing some difficult issues. I'd like to share my opinion with the family:
Given all the stresses Amanda has gone through in the past few years, it is no wonder she is not attending school. Any stress can cause difficulties, but Amanda was bullied in year seven, lost a close friend, and lost her sister as a mate and protector when she changed schools. She has also experienced significant medical challenges, including ongoing vomiting, arm surgery to a hip, and uncertainties that she may need further surgery. She has also lost her favourite sport.
I am puzzled as to why Deborah (Amanda's mother) told her kids that the father had an affair many years ago. I want Amanda and Judy to know that this is adult business and that Mom and Dad need to sort it out themselves. Given that the paediatrician has diagnosed Amanda with a weak stomach, I believe that any further referral to a specialist regarding the vomiting would not be helpful.
Amanda is extremely sensitive and in tune with her mother's needs, and I wonder how much Amanda's refusal to go to school is a way of looking after her mother. I am unsure of where Amanda got the idea of correspondent school from, as she mentioned thinking about going to one. However, I believe it's too early (at this stage) to decide on correspondent schooling. Instead, I would like Amanda to start entertaining the idea of what it would be like to go back to school again and for her to record her inner thoughts and worries in a journal.
Amanda will not go to school this week, which is a paradox. However, she should start school slowly and gradually the following week. As for you, Deborah, you have been hard at work looking after Amanda, and it's taking a toll on you. It's time for you to rest and for George to take a more active role in taking Amanda to school. It would also be helpful if Judy could again be a friend to Amanda.
From the short message above, one can see that there have been multiple strategic interventions to deal with the family dynamic and to look at the power and structure of the family. When I delivered the message above, the outcome was that she went to school for the first time for one period, not more, not less. It took me three or four school terms to get her back to school.
I asked Amanda, "Amanda, can I talk to you by yourself?" She said, "No, I'm uncomfortable talking to you alone." I asked, "How about a phone call?" You give the child a lot of power to say no to you. She replied, "Yes, you can talk to me on the phone." So, I did individual therapy with her over the phone. After every session, I put together a therapeutic card and sent it to her about what we discussed. That's how I got Amanda back to school.
Be innovative in how you work with school refusals.
Recently, I picked up a boy with severe separation anxiety who doesn't wants to go to school. I recruited the mother as a core therapist and asked her to do therapy work with the child through the homework that I gave. The homework contains my thoughts and how I made sense of the situation. I asked the mother to ask her child, 'Correct me, which part is wrong, which part is right.' And the boy would reply to his mother. Then, I asked the mother to do some therapeutic work by drawing the dream bubble. The dream bubble says, 'This is you, and this boy you see here on this piece of paper is John. John is like you, has parents like you, and has the same problems as you; tell me, what are John's worries? Draw a picture about John's worries.'
So, I recruited the mother to be a core therapist, but not all mothers are suitable, so you have to do some research. If they are suitable, they become a rich resource for therapeutic work.
Common Themes That Emerge in School Refusal
Common themes in school refusal include embarrassment and awkwardness, structural issues, power and control, and avoidance. These students are experts at avoiding schoolwork, which can cause secondary problems of poor self-esteem. Every time a parent mentions homework, the situation escalates.
Worried Sick:
I construe that children don't want to go to school because they're 'worried sick'.
I have a model of a brain in my office. I point to it and ask, "How are worry germs running your life?"
I externalise 'not going to school' as 'worry germs running their life'. Externalising the problem can be a powerful tool so that children do not view themselves negatively. You give children some control by asking them,
"How can you beat worry germs?"
"How can I help you to conquer worry germs?"
Common themes among parents:
Common themes among parents include feeling overwhelmed, frustrated, angry, and desperate. It's essential to avoid making a child feel guilty and to help parents not get into too many power struggles. To avoid escalation, parents can make a statement, then walk off, and do that repeatedly instead of getting into arguments.
I also look for who the worriers are in the family. It's not uncommon that the mother is the worrier. The mother caught the worry germs from her own mother, and her sisters are all worriers too. So I look at how worry gets transmitted along generations.
Parents can feel a sense of hopelessness too. Sometimes if you try to do more as a therapist, parents can become overprotective. So it's important to assess both parents' psychopathology, especially when one is more troublesome.
I had a case where a mother disassociated in school because of the stress; I didn't quickly give her the individual attention she needed. I suggested individual therapy to her, and we were in the process, but I was not quick enough to support her mental anguish that came about as she tried to get her child back to school.
Interactional patterns in the family (how the family interacts with one another) are also essential to consider. I like to do house visits and look at the reenactment of family dynamics in front of my eyes to understand the family dynamics better.
Family Dynamics
In a dysfunctional family dynamic, role boundaries and hierarchy can become blurred, and the child can become the boss in the family. However, a 15-year-old can't be in charge of a family.
A parentified child can be triangulated in the marital relationship, and their problems with not going to school can stem from their worries about their parents' unhappiness. To deal with this, I make it explicit, and I ask the child,
"How much are you worried about your parents?"
"How long have you been worried about your mom and dad?"
Then I asked the child, "Would you allow me to support your mom and dad so that you can focus on yourself?"
It's also common for peripheral or absent fathers to be involved in the family dynamics, as most of the time, the child's problems stem from an absent father. Because of the absent father, the mother-child relationship can become too close to the extent that it's suffocating for the child, and it can be a relief when therapists intervene and when the child goes to school for the first time.
It's crucial not to lose sight of how the normal sibling may suffer. It's important to ask questions to the normal sibling, such as,
"What is life like for you?"
"Are you missing out because mom has to give so much attention to your brother/sister?"
Murray Bowen's work on differentiation is an important model to consider when assessing school refusal within a family system. If you have a teenager who's 15 and treated like a ten-year-old, they haven't really differentiated; the child is developmentally arrested and overprotected.
How I Use Language and Words
Language and words are powerful tools that can amplify the issues in a family system. For example, when dealing with school refusal, it's essential to recognise that the problem is often contagious, just as depression can be highly contagious, as described in Michael Yapko’'s book.
Sensitivity to unhappiness in the family system is common, and the identified child is often very sensitive to it.
I also use the concept of "hiccups" to prepare for potential setbacks and to apologise for any mistakes.
I also explore the role boundaries and responsibilities within the family and how they may have blurred over time. For example, if a child becomes a "mother to her own mother" or a "therapist to her own mother", I would explore the boundaries and responsibilities.
A House of Many Islands. An absent father is an island. In situations where there is an absent father, working on aligning the father's relationship back to the system is essential, especially because the mother is too tired. This can include explaining to the father why his involvement is vital,
"Your wife is too tired; I need you to help me (the therapist). I need your wife to have a break."
When it comes to Amanda, I would also explore how much of her staying at home is a way of looking after her mother.
Therapist Toolkits
As a therapist, my toolkit includes therapist presence, confidence, and accessibility as predictors of success.
The self of a therapist is how one uses oneself in therapy. I tend to use my own experiences and struggles, such as my own struggles with ADHD, to connect with and understand my clients who also have ADHD. Minuchin talks about the idea of multiple selves, and as a therapist, it's essential to be authentic and genuine to build trust with clients.
I also embrace a coaching role in my therapy and make myself available to parents in the morning during the week of reintegration into school, as that is a high-risk time for children with ADHD. Parents know they can call me if issues arise when bringing the child back to school. Otherwise, I'll be at the child's home to help the child to get back into school. But not every child needs me to be at their home to help them. In Amelia's case, I went to her home for two days, and she successfully reintegrated into school. Her father was strong enough to take her back to school.
My goal is strategically aligning and calming the system (the mother system, the father system), especially when co-parenting issues occur – how to help them to agree to disagree but be on the same page when getting the child back to school. I will always ask the question to the parents, "I want a positive outcome for you, but are you both on my side?"
Be a good storyteller. Storytelling connects children to the experiences of other young people who have improved.
Trust the therapeutic process. I also emphasise the importance of trusting the therapeutic process, even if the progress is not immediately visible.
Prepare parents for battle. In therapy, it's important to prepare clients for the hard work ahead and constantly evaluate and use solution-focused scaling questions (scale of 1-10) to measure progress. If progress is not immediately visible, it's important to remember that sometimes progress can happen later, and it is important to trust the therapeutic process.
Focus on action-oriented activities. When trying to get a child back to school, don't have too much dialogue; usually, the kid will talk you and the parents out of it.
Have a school meeting or case conference. I usually organise a case conference within a week of the first therapy session and would like the child to return to school the following week. And I always involve the child in deciding how they would like to return to school.
It's important to define the role of stakeholders, such as who will take on the role of the "bad cop" or "good cop." As a therapist, I sometimes have to take on the role of the "bad cop", and it's important to be aware of the other parents' roles in this process; if I', the bad cop, who's the good cop?
To further understand this concept, I recommend two books: "The School Wobblies" by Chris Wever, which provides a detailed understanding of school refusal and its psychology, and "How to Bust the Worry Warts", because psychoeducation must be a part of the whole intervention."
What Can a School Climate Research Tell Me?
Research on school climate tells me that there are a few challenges that families and schools face when it comes to getting a child back to school. Nathan Ackerman, a prominent pioneer in family therapy, identified that there are no established procedures for problem-solving and information sharing within the home and school. The lack of communication procedures can create difficulties in effective communication, particularly when there are cultural, racial, and economic differences between school personnel and families.
I often find that there are issues between parents and the school, and they tend to blame each other, which creates a lack of trust. I take on a mediator's role in these situations and always focus on the child. My goal is to find ways to get the child back to school rather than placing blame on the parents or the school.
When there are significant problems between the parents and the school, I will have the first meeting without the child. However, in most cases, I always have the child present in the meeting as they should be aware of the discussions and the plan that will be implemented. Unfortunately, many school management plans don't involve children in decision-making.
I also find that parents are often not viewed as partners or core decision-makers by the school. There is an inherent concern that parents will take over the process, but in my experience, this has not been the case. When I take on the role of a mediator, I only have a tiny percentage of cases where the parents blame the school, and the school blames the parents.
Having a clear policy and a team approach makes our shared project successful. Leadership is crucial, and I tend to take on the caseworker role by putting together a management plan after discussing it with key personnel, such as stakeholders and school counsellors.
Roles and responsibilities are clearly defined, and communication is vital. The best way to communicate effectively is through email, using the "reply all" function to keep everyone informed. I am also very accessible and strive to create a proactive, individualised and inclusive plan that gives a voice to the child and adolescent. For example, when working with an eight-year-old boy with ADHD who was getting into fights and getting suspended, I asked him why he was unhappy. He explained that he felt punished and that other kids who bullied him were not getting punished. I brought this to the principal's attention, and the boy could express his feelings directly to her. The principal then explained what had happened. Giving a voice to the child and valuing their input is essential because they can be competent and honest in their communication.
Often overlooked, advocacy and respectful intervention are essential aspects of therapy. Many therapies do not take on the advocacy role, but when working with clients who struggle with school refusal and ADHD, it is crucial. Children with ADHD are more likely to be bullied, as research shows. In Australia, a survey of 1000 parents revealed that schools often fail to provide appropriate support for children with ADHD. This is a sad predicament, and what these families are asking for is not individualised support but accommodation. For example, providing a table where the child can stand and work, or allowing them to walk while they work, can make a significant difference in managing their behaviour. Giving the child a sense of agency and control over their environment can be beneficial.
Regarding school climate, it is essential to consider how connected the school is to the family and community. A positive connection between the school and the family predicts positive student outcomes. When the school and parents communicate effectively, it leads to better results for the student's health and well-being.
For more resources, the Australian Journal of Guidance and Counseling is dedicated to working with schools. It is a well-established journal that dates back to 2015 that focuses on a collaborative, person-centred approach to working with students.
Developing an Individualised Management Plan
The first step is to identify universal principles, such as themes of awkwardness, embarrassment and traumatic complaints. All teachers must be aware of these issues. For example, as the school year coordinator, I may send out a message to all teachers asking them not to bring attention to a particular student when they arrive late to class.
When developing the management plan, it is essential to consider recent events that exacerbate school refusal. For example, if a student has experienced bullying or has lost a loved one, these issues should be addressed in the plan. It is important to obtain permission from the parents before sharing any sensitive information. Still, if there is value in sharing certain information, such as maternal mental health, I will ask for permission.
Establish clarity on family structure, roles, expectations, and boundaries, and exclude learning difficulties. Exploring these issues can help to reduce school refusal, which is often a complex issue. It is essential to mobilise resources and access a school counsellor or therapist to assist the student.
More Therapist Tools
I enjoy telling stories, and many of the students I work with have allowed me to use their stories to share with you today.
One of the techniques I use is reframing school refusal as a stubborn and tricky problem instead of viewing it as a child being stubborn or difficult.
I also use metaphors, humour, and rituals to address this issue.
An externalisation technique from narrative therapy, such as the use of 'worry germs', can be potent in addressing school refusal.
I also use methods to amplify change, such as celebrating successes. For example, Amelia did really well, so I surprised her by bringing her a certificate and a cake to celebrate her progress in attending school. She took the cake home, and she was beaming.
Relapse prevention work is also an important aspect of my approach. I monitor for signs that a student or family may be at risk of relapse and take steps to prevent it. In Australia, I also work with homeschool liaison officers and youth police liaison officers who specialise in addressing legal issues related to school refusal. These professionals are brought into the therapy room for psychoeducation and to provide specialised support for the student and family.
What Can You Learn From My Failures
Failure is an opportunity for growth. What you can learn from my failures is the importance of normalising and embracing failure. It is important to re-evaluate and assess the therapeutic process to identify where things may have gone wrong. This may include reenacting certain situations, reviewing family dynamics, and conducting additional home visits.
Expanding the systems involved in the child's life and intervening structurally can also be beneficial.
Plant Seeds of Hope
It is also important to continue to plant seeds of hope for the child, as children struggling with school refusal, as well as those with ADHD, are entitled to happiness.
This article is a modified excerpt from the Symposium on School Refusal event held on January 7th in Kuala Lumpur. To view the full hour-long video, click here.
If you need help with school refusal, please contact us at hello.andolfi@gmail.com.
David Hong is a practising family & couples therapist in Australia with over 30 years of clinical experience; he works with children and adolescents with serious emotional, behavioural, and mental health issues along with their families. David has a special interest in working with ADHD and family systems, and also school refusal and school systems.
David launched the inaugural Graduate Certificate of Family Therapy programme in 2015. Since then, he has been supervising his students to support their ongoing clinical development.
Always a student, since 2005, David has been undergoing advanced training and supervision under the guidance of Professor Andolfi, a master family therapist and trained child psychiatrist. He has attended the Intensive Experiential Clinical Practicum and “The use of self of the therapist” at the prestigious Accademia di Psicoterapia Familiare in Rome, Italy. In 2016, David was invited to attend the Supa-meta Practicum in Todi, Umbria, Italy, with 18 family therapists from around the world. And since January 2020, he has been part of the European Family Therapist supervision group conducted by Professor Andolfi.
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