School Refusal Behavior Associated with Separation Anxiety Disorder - Coursework Example

Introduction School refusal is a normal behaviour shown by the child when the first time he/she moves out of his own house and parental care. This phobia is developed due to internal forces and emotional disturbances in the child. As the child grows up, this age associated anxiety reduces at around 5 years of age in normal development of the child. This is a healthy attachment in a protective environment for a normal child and develops sense of security. Moving into adulthood is important transformation in the span of human life. As the child grows up, the reluctant attitude of the child to go to school might have negative educational and social impact. When the pupil is remaining absent for a long period of time, his educational growth is hampered, this might reflect in his/her results. The child might have to face grade retention which inhibits developmental opportunities. The child loses self confidence and might become victim of poor self esteem. Improper communication among young children and parents due to school refusal issue delivers negative impact on children. Parents feel guilty about unmanageable and uncooperative behaviour of their children. School refusers in the long term might face clashes in their relationships which give rise to disharmony in the family, alienation from peers, financial and legal issues, lack of good employment etc. (Kearney, 2006). If this refusal behavior continues or develops at the later stage, it gives rise to mental health illness and associated negative outcomes. There are many reasons for the children not to go to school. This absenteeism might be due to some illness experienced by the student because of which he has long gap period. After that long gap, the child is hesitant to go to school. If the school is changed he might feel isolated for sometime, therefore he would try to avoid going to school. The school refusal behaviour also might come from the fear of victimization by the school bully (Wilmshurst, 2008, p.211). When school refusers are excessively attached to their major attachment figures (e.g., parents, grandparents, older siblings), (Karlovec, Yazdi, Rier, Marksteiner, & Aichhorn, 2008) they develop extreme anxiety when they are away from them. This reflects into their behaviour when they are separated from their caregivers. This severe and prolonged anxiety causing excessive mental distress is referred as ‘Separation anxiety disorder’. Separation anxiety disorder (SAD) is listed in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as one of the most natural anxiety disorder (Bernstein, 2008). Almost 75% of SAD patients are school refusers (Wilmshurst, 2008, p.211). The onset of School refusal behavior associated with separation anxiety disorder is around the age of 10 years and most prevalent in females (Bernstein, 2008). SAD can be exhibited before the age of 18 years and can last for at least four weeks. Unhealthy attachment and unsecured feeling leads to abnormal behaviour of SAD children. For such individuals normal time being separation situations turn into anxiety inducing situations. This vulnerable age group is always under stress due to persistent and excessive worry and might develop somatic complaints. They are not ready to go to school and are not able to participate in any social activity including sports. As a result they develop limited social skills (Reynolds, 2007, pg. 1835). SAD sufferers feel that they have to face danger when their care providers are not present with them. They face consequences of unrealistic worry. They are enable to cope normal separation situation. Nonthreatening generalized environment also sensitizes person in anxiety disorder causing less self control in their actions. They scared to sleep alone with constant fear in their mind and feeling of loneliness (Reynolds & Fletcher-Janzen, 2007, pg. 1835). For the target population, the developmental milestones are not achieved at the level required for the same age group. This population lags behind in terms of becoming biologically and psychologically independent and mature. SAD patients might lack essential parenthood skills in the future, lack of proper educational skills and degree make them unemployable. It has been reported that around 22.4% population showed SAD as primary psychiatric disorders among youths with school refusal behavior (Kearney, 2006). It has been reported that early and traumatic separation from the primary caregiver comprising of lengthy stay away from the parents during infancy or early childhood, sudden hospitalization due to health issues, and premature deprivation of parental care due to their sudden death or divorce might be the causes of SAD in long term. This behavioural disorder might be hereditary which could pass on from parents to their offsprings. The changes in the level of hormones like ACTH due to excessive stress could also lead to SAD cases (Bernstein, 2008). The SAD individuals suffer from depression, anxiety, panic, and fear. They might feel helpless and isolated. The psychological treatments like behavioral therapy and cognitive-behavioral therapy work better in addition to antidepressant drug therapy for this behavioral disorder (Wilmshurst, 2008, p.211). The strategies should be aimed to improve behavioral outcomes, enhance life satisfaction, and greater level of competence in activities of daily living. Early intervention is necessary to reduce negative outcome in the future. It should start immediately once SAD symptoms are recognised to prepare them physically and mentally strong. Teacher, school psychologist, Mental health clinic, family service agencies should give helping hand to SAD sufferers to resolve educational, psychological, and familial problems by early intervention. The counselor should able to cherish desirable personal characteristics, problem solving skills and social skills in SAD young people. Psychosocial team that consists of a social worker and a mental health professional can help them in reducing distress resulting from psychosocial issues. The team should assist them by taking care of their emotional needs by finding positive events in such situation and at the same time mentally prepared them for all possible outcomes. Behavioral interventions include rigid guidelines and rules for compulsory minimum school attendance for school refusers with SAD children. The behavioral theoretical approach aims to increase desirable behavior by increasing the interest of the child daily to come to school by implementing positive reinforcement procedures like rewards. An educator would able to cultivate interest of the student to enter the school daily and learn by motivating them. The teacher could create supportive as well as relaxed environment for school refuser’s comfortable entry to school. Conventional behaviour therapy includes systematic desensitization in individualized and group education programs like Coping Cat Program, Coping Koala, Coping Bear to treat SAD children to reduce anxiety. The efficacious Coping Cat Program is divided into two main parts. The first part focuses on enhancing coping ability of young people to deal effectively in anxiety induced situations by inducing fear stimuli in the environment to feel negative behaviour. The second part is the application of first part in imaginary and in vivo situations, where rewards are given for the positive step taken to cope the induced situation (Reynolds & Fletcher-Janzen, 2007). Relaxation technique is generally used before the start of cognitive therapy to reduce any anxiety of the following procedure, and it builds up positive outlook in patient for the therapy (Bernstein, 2008). Short duration treatment with definite positive outcome in 100% school attendance is benefit of cognitive therapy. Family therapy is based on educating the parents of the SAD sufferers to increase patience with their children, to take care of their emotional needs, and to increase positive interaction with them to prepare them to go to school. The pharmacotherapy is given as an adjunctive and second line treatment therapy to treat school refusal behavior associated with severe anxiety and depression disorder. Anxiolytics and tricyclic antidepressant such as imipramine might be useful in some school refusers associated with SAD (Kearney, 2006). It has been reported that medical depressive condition with comorbidity is successfully treated in 76% SAD patients with fluvoxamine. Due to increased suicidal tendencies caused by the use of antidepressants and SSRI agents, their use is not always recommended by US Food and Drug administration. It is necessary to use them only to treat associated medical symptom. (Sadock & Kaplan, 2007, p.1283). Health care practitioners should recognise the necessity for prolong treatment even after remission of separation anxiety disorder since such individuals are prone to distinct psychiatric disorders (Karlovec et al., 2008). Conclusion Though school refusal is a normal behaviour shown by the child at an infancy age, it becomes problematic when it is accompanied with severe and prolonged anxiety causing excessive mental distress. An early and traumatic separation from primary care givers leads to School refusal behavior associated with separation anxiety disorder. Early intervention is necessary to reduce negative outcome in the future. It should start immediately once SAD symptoms are recognised to prepare them physically and mentally strong. The psychological treatments like behavioral therapy and cognitive-behavioral therapy work better in addition to antidepressant drug therapy for this behavioral disorder. Coordinated efforts of Teacher, school psychologist, social worker and school therapist could able to achieve individualized or group education program’s objective. This aids the individual to become physically and intellectually mature to take right decisions and positive outlook in anxiety induced situations. Health care practitioners should recognise the necessity for prolong treatment even after remission of separation anxiety disorder since such individuals are prone to distinct psychiatric disorders. References Bernstein, B. E. (Dec 3, 2008). Anxiety Disorder: Separation Anxiety and School Refusal. Article no: 916737 emedicine.medscape.com/article/916737-overview Karlovec, K., Yazdi, K., Rier, U., Marksteiner, J., & Aichhorn, W. (2008). Separation Anxiety Disorder and School Refusal in Childhood: Potential Risk Factors for Developing Distinct Psychiatric Disorders? Prim Care Companion J Clin Psychiatry, 10(1), 72–73. Kearney, C. A. (2006). Dealing with school refusal behavior: A primer for family physicians. The Journal of Family Practice, 55(8), 685-692. Reynolds, C.R. & Fletcher-Janzen, E. (2007). Encyclopedia of Special Education: P-Z John Wiley and Sons. Sadock, B. J., Kaplan, H. I., & Sadock, V. A. (2007). Kaplan & Sadocks synopsis of psychiatry: behavioral sciences/clinical psychiatry. Lippincott Williams & Wilkins. Wilmshurst, L. (2008). Abnormal Child Psychology: A Developmental Perspective. CRC Press. Read More