School Avoidance and Refusal
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1) A Mental Health Emergency: Chronic school refusal and avoidance is underestimated as a serious problem, with severe consequences on the child and their family in the present and the future. It should be considered an emergency requiring an immediate mental health and psychiatric evaluation.
2) Biologically Based Mental Health Causes: The causes discussed here will those common mental health problems that have a biological basis, where medication treatment may not only be helpful but essential as part of a comprehensive treatment plan implemented by a multidisciplinary team to get the child back to school as soon as possible.
3) Delay in evaluation and treatment: Though this is considered an emergency there is much delay in evaluation by mental health professionals because often primarily dramatic physical symptom presentations have been evaluated and treated with little success in the child returning to school and/ or the school refusal is episodic with gradually more and more resistance in going to and staying in school going on for months, even years before there is what is perceived as significant avoidance and refusal.
4) Disguised Problems: There are legitimate medical reasons for missing school , as there are environmental factors like a child staying home to care for a parent or to protect siblings. There are also children who are simply truant because they are acting out on non biologically based mental health problems such as Conduct or Oppositional Defiant Disorder, or Antisocial Personality problems. However often in these cases on closer evaluation there may in part be biologically based disorders that are not being diagnosed and treated.
5) Most Common Disorders: Many times these disorders are gradual and or episodic, that is they come and go, and present or are preceded by physical symptoms and disorders that disguise their significance as being the cause of the school avoidance. The best example of this is Panic Disorder presenting with primarily gastrointestinal symptoms like nausea, vomiting, diarrhea, stomach and belly aches, which can be both gradual and episodic. However any Anxiety or Mood Disorder or their physical equivalents like headaches, can result in school avoidance, and less likely psychotic disorders like Schizophrenia, Tourette’s Disorder, and ADHD especially when mild and complicated by other disorders, especially Learning Disorders. School bullying in a vulnerable child especially in what I call the “Atypical Child” is also a cause of school avoidance.
6) Most Crucial Rule Out: Panic attacks may occur in the course of an Atypical Mood Disorder or Bipolar Disorder, and may be its first presentations. It is crucial to tell these apart because the medication used for uncomplicated Panic Disorder the SSRI/NRI ‘s may make the Mood Disorders worse and harder to treat, leading to Mania, Psychosis, and dangerous behaviors to self and others.
7) Panic Disorder with Agoraphobia: Panic Disorder is when you have unexpected panic attacks over and over again, followed by at least by one month of serious worry of about having another attack, or worry about its consequences. If one is avoiding places, or having too much distress in places, because of fears of the attacks or needs a companion, one also has Agoraphobia.
8) What is a Panic Attack? A panic attack is a very real and scary thing and is not just your imagination. It is an attack of intense fear, or emotional, mental or physical discomfort, reaching a peak in 10 minutes, in which four or more of the following 13 symptoms are present [A] palpitations, pounding heart, or a fast heart rate, [B] sweating, [C]trembling and shaking, [D] sensations of shortness of breath or smothering, [E] feelings of choking, [F] chest pain or discomfort, [G]nausea or abdominal distress, [H] feeling dizzy, unsteady, lightheaded, or faint, [I] feelings of unreality, like you’re in a dream or being detached from oneself,[J]fear of losing control or going crazy, [K] fear of dying, [L] numbness or tingling sensations,[M] chills or hot flashes.
9) School Avoidance and Panic: Physical symptoms, like stomach and intestinal problems in part or in total represent the panic attack, and what is avoided, that is the agoraphobia is the school. In one take a careful history the other symptoms are usually present and confirm the diagnosis. The typical pattern is that the symptoms reach their peak as one anticipates or actually has to face with the feared situation. So when would expect as Sunday night before school the symptoms may begin and peak in the morning before school, and then subside once in school and as the week goes on, each day gets easier to face, and the symptoms get less severe. The cycle repeats itself week after week, resulting in more and more school avoidance and refusal as the symptoms get worse.
10) Biological Basis of Panic Disorder? One theory if that there is an unpredictable, episodic, over reaction of the brain chemistry that has to do with the biologically necessary flight fight response that has a genetic basis. It has been estimated that first degree relative of individuals with panic disorder are up to 8 to 20 times more likely to develop panic disorder. The fight-flight response exits to prepare us to fight or flight when faced with actual or perceived danger with potential to threaten our physical and mental survival , a literal matter of life or death. When this occurs the body reacts with symptoms similar to a panic attack, with a faster heart rate, sweating, faster breathing, a heighten sense of vigilance, and anxiety, doom and dread to get ready to run or fight. One is motivated by a fear of death and to do whatever it takes to survive. On one level the child is fighting for their life to avoid the panic attack showing itself in the dramatic efforts used to stay at home and avoid school.
11) Brain Chemistry of Panic: The brain chemicals in part believed to be involved with this response have to do with the balance of serotonin, norepinephine, and dopamine, which also form the theoretical basis of how the medication that are antipanic work. The unpredictable, episodic, over reaction based on a biologically based and driven brain chemical imbalance, is similar to what is seen in seizure disorders. Panic attacks like seizure episodes or attacks fuel other attacks, making the new attacks more intense and frequent and sometimes harder to treat. Thus the importance of eliminating the attacks to prevent future attacks, and like with seizures to avoid complications, with the hope once attack free, the medication can be tapered with no further occurrence of attacks. The earlier one does this in the course of the disorder and at the earliest age better is the long term outcome.
12) Panic Disorder is the forgotten cause of some of the worse explosive rage seen in a previously quiet, subdued, generally compliant gentle, unaggressive, person with a previously stable mood, [the stable mood rules out a Bipolar type of mood disorder], is seen in a child, teen, or adult with previously unsuspected Panic Disorder with Agoraphobia, when challenged with the phobic or feared situation, where conforming with everyday routine mandated by authorities is necessary. Examples are the child and teen forced to go to school, or the adult forced on a business trip or even in a leisure situation to be force to face the feared situation.
13) A Matter Life and Death: Panic attacks are so intense and frightening that they cause severe anticipatory anxiety about panic attacks in the feared situation condition the person not only to avoid the situation but not even to think about the feared situation, where they may be alone, or without the phobic partner, and help will not be available, and they fear they may lose control, or actually die. This is caused by triggering of the fight- flight response, where it feels like it is a matter of life or death; it is a matter of survival, run, collapse, or fight for one’s life. Thus in the mind of the Panic Disorder victim it is justified the irritability, anger, and rage for the goal of self preservation.
14) Education, Support and Care: The panic person knows there is something very wrong and is very much in distress, but is afraid, very afraid, sometimes more afraid of medication then than the panic itself. With much support and education and careful medication management once they see the medication is helpful they are grateful for the help and want to return back to school and be in a sense again like everyone else. This not the case for the mood disordered person which is described below, which is helpful again in making the right diagnosis.
15) Medication Treatment of Panic: . The major problem with Panic is not the treatment which is usually straight forward, but that it is not thought of as common cause of school avoidance and refusal. In uncomplicated Panic that isn’t too severe the treatment of choice is one of the anti panic medications of the SSRI/NRI class with Prozac being recommended for people under 18 years of age. The only serious concerns with this class of medications is that if there is a history in the individual or the family of severe mood swings, with anger and rage attacks, or severe thinking problems like racing or disorganized thinking or behavior, all of which may get worse, so another class of medications may be needed and started first. This and all side effects are less likely to happen if the medication is started very low and increased very slowly , with frequent communication with the prescriber so it can be adjusted or stopped. Initially and temporarily a medication from the benzodiazepine class Klonopin may be prescribed to get some faster control over the panic and is also helpful to manage any activating side effects. The usual side effect of medication like Prozac tend to be mild and easily controlled by adjusting the dose. These may include mild tiredness and the medication can be moved to bedtime, or mild activation like caffeine, and the dose is lowered or the Klonopin can be used, side effects such as nausea and stomach upset if they occur are controlled by lowering the dose or adding a temporary antidote like phenergan or meclazine.
16) School Avoidance Based on Atypical or Bipolar Mood Disorder: There may or may not be Panic Attacks present but the essential feature both in the individual and in the family history is usually mood disturbance and drug and alcohol problems. There are rapidly shifting nasty mean, irritable moods, with or without periods of sadness, and explosive anger and rage attacks. This mood disturbance is accompanied by very poor sleep, which may be the initial and main complaint, usually difficulty falling asleep with a decreased need for sleep, this is usually accompanied by a very active mind and body that won’t allow the individual to fall asleep. Other symptoms are distractibility that is episodic and driven by mood, the person paying attention to what interests them, pleases them, and when they are in the right mood. They are very self centered like to be in control , being the boss, in charge, always right, oppositional, defiant, with an inflated sense of self worth. They like getting involved in many activities especially those that may be risky and thrilling and often don’t take the time to think about the consequences of their behavior.
17) Progression of Symptoms to School Avoidance: As these symptoms come together they find school boring, not interesting, where peers and teachers just don’t understand their special needs and talents, their high energy level makes it difficult for them to be in classroom experience, they become more and more irritable, angry, sometimes feeling not only misunderstood, but persecuted by people at school, they stay up later and later, getting harder and harder to get up, low energy in the morning, higher energy in the late afternoon and evening, having a tendency to develop physical symptoms to which they over respond to like being tired, headaches, colds, flu, GI disturbances giving them added reason to start missing school, their sleep pattern may get reversed, missing more and more school, getting more and more behind, and they decide what is the use of going, sometimes requesting home bound education, or the parent of this difficult child succumbs to the child’s wishes and home schools the child, weeks turning into months, sometimes into years. What I just described is a typical scenario for any school refusal but make more specific for the mood disordered child.
18) Resistance to Treatment: Unlike the panic person who feels great distress, and after education and support, are very willing and grateful for medication help, the mood person often feels there is very little if anything wrong. They deny and project their problems on others and the school, and want people to just understand them and their needs, and consider doing things their way, when they are ready . This together with the fact that their parents and loved ones have been intimidated and are fearful of them, any treatment including medication treatment is very difficult to start. Often this is only done after much reluctance, and sometimes only after there is coercion from school, other authorities like the judicial system if they been adjudicated truant and delinquent. All of this is based on the core mood disturbance and its other symptoms and may be very responsive to medication management.
19) Comprehensive Treatment for Atypical/Bipolar Mood: These mood disturbed children and their family require comprehensive treatment usually for a long period of time that includes medication, support , education, in home and in school services, individual, and family counseling and therapy.
20) Medications: Biochemical Diagnosis-General Medication Management: The underlying brain chemistry problem is based on imbalances of certain brain chemicals such as dopamine where there may too much, in some parts of the brain, and not enough in other parts. This would explain why stimulants used for mood problems thought to be ADHD, which very specifically only increase the dopamine , may initially be non therapeutically and falsely helpful because[A.]it delays the proper treatment and[B.] leads to worsening of all the symptoms in the long run. Serotonin again may imbalanced rather than depleted like in Unipolar depression, and again if medications like Lexapro, Effexor, Paxil are used, which only increase serotonin, rather than help the imbalance, like stimulants they help in a non therapeutic way, and can make matters extremely bad, leading to psychosis, violent behaviors to self and others, including homicide and suicide, and should be avoided. The chemical imbalances leads to mood instability, and excitability which is the core problem and medications that stabilize the mood and dampen this excitability are needed and are the medications of choice. There are 3 classes of medications that can stabilize the mood [A.] neuroleptic medications like Risperdal and Thorazine, [B.] mood stabilizing anticonvulsants like Depakote, Tegretol, and Lamictal, [C.] Lithium Carbonate a naturally occurring mineral in a class by itself.
21) Medications of Choice: Atypical neuroleptics are often used first because of their ease of use, quick action, safety profile, no need for lab or blood work, and their good side effect profile. These include Risperdal, Zyprexa, Seroquel, Geodon and Abilify. If these are not helpful, Depakote may be substituted or added. Lamictal is useful if there are strong depressive components being the only anticonvulsant mood stabilizer with true stand alone antidepressant properties, and having the advantage it will not fuel aggression, psychosis, mania and mood swings like other antidepressants. Some people are very Lithium responsive helping moods, depression, racing thoughts, high energy over self evaluation, distractibility and impulsivity, and in these people it often works with no side effects except thirst. Others develop too many side effects with little or no good effects and it cannot be used, though it may be worth challenging the person again. Lithium is the only medication has been shown to actually prevent suicide attempts and successful suicides, and when it works without side effects it can not only literally save lives but can successfully treat for decades what I call lithium deficient mood disorders.
22) Unipolar Major Depression-School Avoidance: The progression of symptoms can be similar to that occurs in Bipolar types of mood disorder, but absent the mood swings, and manic or high energy features. However it can occur much more slowly and more subtle in its presentation, with many more vague yet significant physical complaints. In many of these presentation there is some physical illness that precedes the progression , or there are exacerbations of some illness the child has such as asthma. Besides the two week period of depression, irritability, or one week if a child, there may be decreased interest , pleasure “ I don’t care.” “Everything is boring” “Nothing is fun anymore”, the other symptoms at least 5 must be present,
a) depressed or irritable mood
b) sleep disturbance especially waking up in the middle of the night unable to get to sleep
c) not enjoying things like previously, less drive , ambition and motivation
d) negative and down on self, others, and about past, present and future, worthless, guilty
e) decreased or increase of physical energy, restless, tired, fatigued
f) poor concentration, distractible, trouble with memory and learning
g) eating more, eating less, headaches, GI problems, frequently sick, aches and pains
h) mind or thinking too slow, too fast,
i) hopeless, helpless, feeling unlucky, why me? Suicidal, feeling better off dead
23) GAD- A Great Pretender: GAD presenting first as Over Anxious Disorder of Childhood, at a very young age, is A Great Pretender, disguising itself as a physical problem like headaches, gastrointestinal distress, or sleep difficulties. It may present with school difficulties with poor concentration to the primary care practitioner, and be misdiagnosed and mistreated as ADHD. Persistent physical complaints at any age caused by GAD are treated symptomatically, and don’t get better because the cause is not addressed. The worry and anxiety is often ignored or seen as normal.
24) Normal Worry vs. Generalized Anxiety Disorder [GAD]: Anxiety in GAD is a. difficult to control, b. interferes significantly with functioning, c. more persistent, distressing, involving more things and often without a cause. It is d. present more days than not and lasts at least 6 months.
25) Making the Diagnosis of GAD: The combination of the worry described above and three of the following symptoms when present, in children only one is needed, to make the diagnosis of GAD, a. problems concentrating and mind goes blank, b. restless, keyed up, on edge, c. irritability, d. easily fatigued, e. muscle tension, f. sleep disturbance.
26) GAD, Dysthymia and Unipolar Major Depression: There is a very common progression of an anxiety disorder especially Generalized Anxiety Disorder, that is considered normal of insignificant that gradually progressing into as second diagnosis, Dysthymia , or Depressive Disorder NOS, a low grade depression that often goes unrecognized, which in itself may progress to Unipolar Major Depression, that may first present as school avoidance and refusal. These three diagnoses often share the same brain chemistry that over years gradually worsens leading to three different disorders that may also share the same medication management.
27) Medication in Anxiety and Unipolar Mood Disorders: If the symptoms are not too severe and there are no , not even mild Bipolar of Psychotic features or complicating problems, the medication approaches are similar to that of uncomplicated Panic Disorder, that is SSRI/NRI medication.
28) Schizophrenia and Related Disorders: Schizophrenia is very rare in childhood and early teens by its nature there is lack of insight, denial, projection of symptoms, and has at its beginnings a slow , quiet , insidious progression. In a more mild case and in a high functioning child, teen or adult this diagnoses can be missed for years. It is a psychotic disorder that primarily effects thinking content and processing. The early symptoms can be easily missed and confused with other disorders. When it is full blown the diagnosis is hard to miss and the dramatic symptoms and presentation are familiar to most.
29) Psychosis Defined: Psychotic symptoms mean you may be losing touch with reality, confusing what is real and what is fantasy or pretend, like not sure if you dreams are real or not, and things that normally happening in a dream happen in real life or you are not sure, like your thoughts start sounding like voice, or you hear and see things that shouldn’t be there, your thinking get illogical, and your connections between you thoughts, or your thoughts and your feeling get too loose and off the track, other senses get too real and powerful like smell, touch and taste.
30) Schizophrenia Defined: The thinking problems listed below must be present for a least a month and there must be impairment of function for at least six months to qualify for the diagnosis. The younger person is with these symptoms the harder it is to make the diagnosis and it is often deferred for this reason and because of the poor prognosis it usually carries. However the early symptoms need to watched by qualified professionals and if causing impairment and distress, one should not hesitate to treat with the appropriate medications.
31) Associated and Prodromal Symptoms: Prodromal symptoms means early symptoms or signs or those that might indicate the disorder, before the disorder reaches the severity and duration to make the clinical diagnosis. The 4 A’s of Bleuler a pioneer in diagnosis are autism, ambivalence, associations and affect and were used to diagnosis this disorder. Bleuler noted that people with Schizophrenia were autistic meaning very self centered and too much within themselves. They had highly ambivalent , that is love hate relationships with many people , sometimes alternating with this autistic quality, giving them a dual or split presentation. Schizophrenia means “split mind”. The split mind persona is further amplified by the associations or loose or split thinking that is presented , with the flattened affective or emotional responses that can also be very inappropriate. The original 4 A’s should be added to or replaced by the 4 A’s of the negative symptoms which also may be prodromal and diagnostic and are discussed below.
32) Thinking Problems and School Avoidance: Though Schizophrenia is rare, thinking problems associated with it are more common. Though usually only thought of as only occurring in overtly psychotic people they may be present as part of another disorder or as symptoms or symptoms clusters in atypical disorders or disorders that are severe and lead to decline and deterioration. Any of these can have devastating effects and lead to school avoidance.
a) These could include negative symptoms that may be the first to occur and most impairing. These must be differentiated from depression because the medications used for depression can make Schizophrenia worse very quickly.
i) affective flattening – there is little to no emotional response or expression
ii) alogia - hard to think with little to no speech , brief emotionally empty replies
iii) avolition – hard to start and persist in goal directed activities
iv) anhedonia - an almost total loss of interest and pleasure
b) positive symptoms such as hallucination i.e. hearing and seeing things that aren’t there and paranoia , believing people are out to get you, and delusions- a false belief in external reality not shared by society, like you are God or the devil
c) thought process problems like
i) thought blocking- thinking gets stuck, loosing one train of thought
ii) loose thinking – the connections between thought become illogical with very subtle or loose connections sometimes only known to the person, like occur when dreaming
iii) illogical and disorganize thinking- it doesn’t make sense, words and thoughts are in the wrong order, and don’t follow logically
iv) thinking that may be too concrete or too abstract – a word or a few words are use in an idiosyncratic way to mean much more i.e. concrete, or many words are used to express something simple that could be said in more succinctly , like would occur in dreaming or in poetry
33) Medication for Schizophrenia-Psychosis-Thinking Problems: The typical and atypical neuroleptics are the class of medications of choice because of their anti psychotic properties. The atypicals have a helpful effect on the negative symptoms that are often confused for laziness , boredom, and I don’t care attitude, or some sort of depression with they getting either no treatment for years or the use of antidepressants that can fuel the underlying psychosis and make it worse. These people are as children, teens or adults are seen as being slightly off in their relatedness, and generally of track, but these signs are not seen as symptoms of a thinking problem the is biologically based and potentially very medication responsive especially if treated at an early age and early in the course of the disorder.
34) The “Atypical Child”-Depression-Anxiety-Bullying: What follow is my theoretical construct based on my experiences. There have always children, teens and adults referred for services that that don’t fit diagnostically into any category easily including the NOS [ not otherwise specified] section of a class of disorders such as anxiety, mood, pervasive developmental , or psychosis. Parents or loved ones will say “there is something just not right about this child” being called in the vernacular “atypical”. These people often have symptoms and problems from multiple classes that are episodic, unstable and unpredictable in their presentation, intensity, duration and the amount of impairment they may cause at any one time or age.
35) Victimization-Depression –Aggression of “Atypical” person:These people as children and teens because of who they are and how they react are particularly sensitive to bullying at school and as adults at work. The are in a sense natural victims and picked on and yet don’t have the emotional and cognitive resources to deal with bullies at home, school, play or at work. They are often excellent students, workers and seen by those in charge as model people. They tend to have quiet non disruptive distress and impairment at work or school may be late in coming. They are prone to excessive anxiety, depression to the point of thinking of suicide or aggressive retaliation towards their persecutors and often first present as school avoidant and refusal.
36) Symptoms that may be present in this “Atypical” diagnosis: Not all need to be present:
a) Shifting alertness, attention and concentration not related to mood or anxiety almost narcoleptic like at times, unlike ADHD the focus problems are intermittent not continuous.
b) Oversensitivity to emotional or environmental triggers leading to excessive anxiety and depression , impairment and distress grows slowly.
c) Trouble calming down more related to anxiety than mood , with no extreme rage attacks.
d) Qualitative and quantitative difficulties in relatedness that are not continuous but related to anxiety and Unipolar mood changes, with the person going in and out of relatively normal relatedness, and not qualifying for Autistic or Schizophreniform Spectrum Disorders.
e) Gestural and non verbal communication that varies in appropriateness, e.g. inconsistent eye contact and emotional responses. Blunted emotional responses may difficult for others to read, and be misread as calmness, when in fact there may be much emotional distress that has to be deduced from thought , dream , play content, and other representations of thoughts and feelings, like preferred or written poetry, music and art work.
f) Mild thinking disturbances in process like mild looseness, and blocking, odd speech patterns, not in content like hallucinations, or overt paranoia.
g) There may be feelings of unreality, depersonalization, and mild persecution. If there are anything that might appear like a psychotic symptoms reality testing is intact, and don’t qualify for schizoid, schizotypal, or borderline personality disorder. Other near break downs in reality testing may only show in sleep like hypnopompic, or hypnogogic, hallucinations or related to dreams or nightmares. There may be overly emotional dream content with a breakdown of the functions of dreams and nightmares to awaken the person. Similar issues may be seen in fantasy, play and representations such as writings like poems, stories, music, art or in choice or preferences in these or in movies and TV shows.
h) Can be overly or under emotional, too tuned in , or too tuned out, cold and distant to overly empathic and sensitive.
Other symptoms and features to consider in considering this as a distinct diagnostic entity include the following:
1) [ ]Uneven development as infant-child, loosing & gaining functions unpredictably like speech and language
2) [ ]Transitions cause panic anxiety or rage attacks, physical symptoms like hives, irritable bowel, headaches
3) [ ] Unusual sensitivities to touch, taste, positioning, sound, lights.
4) [ ] Poor eye contact, and poor non verbal communication using gestures, body language
5) [ ] Not getting social rules, and cues from other, not getting the point of jokes or riddles or social moves
6) [ ] Socially stiff, and awkward, verbally and non verbally, marches to his or her own drummer
7) [ ] Unusual or peculiar relatedness, but not overtly strange or bizarre, slightly off emotionally
8) [ ] Something just “not right” about how they relate, respond, react to people, even those they know well
9) [ ] Get stuck in doing something, and has to finish it, and if not panic, gets angry, or too upset
10) [ ] Unusually high and over developed abilities in some areas of usually in the area of the thinking and doing mind, with unusually low function if not actual deficits in other area especially those related to the experiencing relationship feeling mode of the mind.
37) Possible Biochemical Diagnosis and Medications for the “Atypical Child”. Biochemically the symptoms cluster around severe anxiety, and Unipolar depression, to a point thinking may get derailed and blocked, with in and out appropriateness of relatedness, with no evidence of bipolar, and reality testing remains intact. This can be classified as a non psychotic mild thought and qualitative relationship disorder very prone to pan anxiety and Unipolar depression that can progress to an agitated psychotic depression, really fitting into no class and thus “Atypical Child/Person” diagnosis. They seems to respond preferentially and best treated with atypical neuroleptic, in small doses, with SSRI’s may not make worse, and but more helpful, if use second after the atypical . SSRI’s may be added carefully in very small doses watching for worsening of symptoms. There may be varying responses with Welbutrin, Straterra and SSNRI’s, which if used may again have to be used with cautious watchfulness and starting at very small doses because of their potential activation. Traditional sedative- hypnotics, drugs like alcohol and marijuana don’t calm or make mellow, but agitate are dysphoric and may lead to serious dishinhibition with aggression toward self and others.
38) Summary of School Refusal: School refusal is a mental health emergency that requires a comprehensive treatment plan implemented by a multidisciplinary team to get the child back to school as soon as possible. Medication for biologically based disorders that are causative is necessary and essential. These disorders are too often missed and diagnosed late in the course of school refusal.