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Deborah Howell (Host): Hello. I’m Deborah Howell, the host of Understanding School Refusal, a special podcast series from Rogers Behavioral Health. This is episode two or our four part series where we will look at some common questions around school refusal. I’d like to welcome Dr. Heather Jones, a psychologist at Rogers Behavioral Health where she provides clinical assessments, consultation and supervision of behavioral specialists working in the adolescent center for OCD and anxiety. Such important work. Welcome Dr. Jones.

Heather Jones, PhD (Guest): Thank you.

Host: So, here we go with part two of our series. My first question to you, what are some factors associated with school refusal?

Dr. Jones: Four factors that I’d like to discuss today are social factors, educational factors, mental health factors and then kind of I have another category that – they are fairly interrelated to the first three. So, social factors; I mean we talked a little bit about this in part one but things like bullying, the impact of social media, substance use certainly in our adolescents is socially related. So, it’s pretty obvious I suppose, that when I’m at school and have problems with bullying, it’s going to create an undesirable situation and I’m going to want to avoid that, right and that makes sense thinking back to the days when we were in school and maybe we had a bully or a friend situation that didn’t go exactly how we wanted it to. It was kind of hard to go to school the next day and so those are certainly factors that we are identifying as contributing to school avoidance.

The social media piece is really relevant today in that the contact socially really doesn’t end when you leave school and go home. So, whether it’s bullying or just sort of that social pressure that our children and adolescents feel now is carried with them at home and so there are things happening, said on social media or texts or tweets or posts or whatever about them that certainly could be a prompting event for them to want to avoid those people the next day.

Finally, and I mentioned this a little bit already but substance use. So, if I’m in a situation where I am using substances, it’s going to for both that social factor as well as the biological factor, contribute to me not really feeling like getting up and going to school the next day. So, those would be in that – the social factors.

The educational factors are things like a learning disability. If I struggle to be in school. I just have a hard time being there, I don’t really enjoy it, it’s hard for me, I don’t really understand what I am learning, or I certainly notice that I don’t understand it to the same rate as my peers, it’s going to be hard for me to be there. Same with autism spectrum disorders. Again, that sort of that social piece certainly in adolescence becomes more challenging. Students that have ADHD, hard to sit still, think of thinking back to like blocked scheduling, right? I have a 90 minute class and I have to sit and pay attention and so that presents a challenging environment.

Mental health factors, so certainly anxiety whether it’s generalized anxiety disorder, social anxiety disorder, I am anxious about being in school, worried about how I’m doing in school and depression certainly. So, I have low mood, it’s difficult for me to get going in the morning. I’m sort of ambivalent or I don’t really care about how I’m doing because I just feel sad a lot of the time.

So, and the final factor I guess kind of takes all three of these into consideration. So, it’s either sort of risk factors, think about our students who are really suffering from any one of these at the same time and then we’ll talk about I think in a little bit, some of the factors that maintain these behaviors of not going to school.

Host: Boy, it’s a lot, isn’t it?  So, what maintains or contributes to school refusal behaviors?

Dr. Jones: So, we talk about when we do parent trainings and even talk to our clients and the kids that we work with; we talk about patterns of reinforcement. Really, we are talking about things that happen in our environment that either maintains a behavior or increases the likelihood that that behavior is going to happen again. So, think about the example I gave with bullying. So, if I go into the lunchroom at high school and I’m picked on and bullied; that feels awful and terrible and so the next time I have the opportunity to go to the lunchroom, I avoid the cafeteria and then that behavior of avoidance of not going is reinforced by the lack of that undesirable stimuli.

So, in the same way that I’m escaping from social situations that illicit anxiety; I am avoiding something undesirable and thus, that avoidance is reinforced. I’m more likely to avoid it. It’s kind of – I use the example of the – when you are in your car and you get in your car and you turn on the ignition and then that dinging is going off, right? That dinging is telling you to buckle your seat belt. If you don’t buckle your seat belt, the dinging is going to continue. And so, that’s an example of negative reinforcement. I’m alleviating that irritation or in this case, a painful stimuli by engaging in a behavior or buckling my seatbelt or avoiding the lunchroom.

Similarly, there is also positive reinforcement and things that happen that actually inadvertently usually, encourage my avoidance. So, for example, I have a really hard time going to school, maybe because I don’t really understand school, it’s just not really what I’m good at and I stay home. And at home, I have video games, Netflix, You Tube, and so instead of sitting in a classroom that’s kind of boring and full of complex concepts that are hard for me to understand; I get to stay home and hang out on You Tube all day which is much more rewarding to me. 

Host: Now what should educators and parents be aware of when confronting a child refusing to go to school?

Dr. Jones: The same things that we have talked about already. We want to educate our parents and the school personnel on these patterns of reinforcement. We really do want to talk to them about that. And then we talk with parents about symptom accommodation. So, factors that could contribute to them inadvertently rewarding their child for not going to school.

One factor that we talk about is parental tolerance for their child’s distress and anxiety. So, for example, we had talked earlier about a tantrum and how do I – my kindergarten student or my first grade student is crying, doesn’t want to go to school, heartbreaking. That’s awful. And I don’t want to see my child in such distress so I’m going to be more likely to acquiesce with them staying home or making arrangements that just this one time, they don’t have to go and then unfortunately, it becomes a bit of a slippery slope and the other piece is building awareness around expectations. So, we’re in I don’t know if some people can relate, we are in a bit of a culture of perfectionism or high expectations. I’m thinking about our adolescents who are in high school. Parents – what parents may be doing that could actually contribute to their child having an overwhelming sense of anxiety about school. So, getting into college and what we know is that a little bit of pressure is great and keeps us motivated, too much pressure actually will do the opposite and then it will actually decrease the likelihood that we are going to approach and do things that we need to do. So, just parents being aware of how much pressure they are putting on their child to perform when they may be prone to some anxiety already.

I guess on the other continuum, or something that parents need to be aware of is thinking about their follow through or urgency as it relates to being in school. We can kind of habituate to the chronicity of school refusal, so my child has refused, maybe they’ve sort of had poor attendance over the course of a year and I’ve just sort of accepted it. Because well one, parenting is the hardest job on earth and two because it’s – I have a fulltime job myself or there are other responsibilities that I have, and it’s just sort of good enough and so we just need to be aware that being in school, is really our children’s jobs. It promotes their own sense of self-efficacy and builds grit and resilience to be able to be in the world and so, it’s a really important factor that we just need to be aware and not sort of give up on the urgency of our kids being in schools.

The other factor that we talk about too is alternative and online school options. So, our parents will consider these a good solution for children who tend to avoid going to school or refuse to go to school. While this is an option to have our students educated, it also could feed students who have anxiety or depression, it could actually feed their mental illness and so if I avoid further, it could only build even more anxiety and so if I avoid going to school, I’m allowed to maybe do online school at my house, I will actually have more anxiety just about being out in the world, being out of my house. So, we just again, it’s not a one size fits all. It’s just some things that we definitely need to be aware of.

Something that schools – we talk with schools about is truancy policies. Now I said that there’s a difference between students who are engaging in school refusal versus who are chronically truant. I think we just need to work together as mental health providers, parents and schools to make sure that there is a truancy policy or that they have the ability to reasonably consequate school refusal so there is that consequence. 

That being said, we also want to make sure that schools can work together with us to address the mental health needs of our students as well. So, those are just some of the things that we want to make sure to highlight on and to help everyone be aware of so we can go together with – or go in this together with the most amount of information.

Host: Well, it’s a lot to chew on, but it’s such good information and we thank you so much for joining us today Dr. Jones.

Dr. Jones: You’re welcome. Thank you.

Host: Rogers Behavioral Health is working each day to ensure those with mental health challenges have access to the highest quality of care and most effective treatment available today. To learn more about the many ways Rogers can help children, teens, families and schools; please visit rogersbh.org today. That’s rogersbh.org. I’m Deborah Howell. Thank you so much for tuning in and have a great day.