INTRODUCTION
Persistent non-attendance at school has been the subject of considerable concern amongst educationalists for well over a century. In recent years many local education authorities have started to carry out annual attendance surveys and there have been a number of large-scale national surveys. Estimates of the extent of the problem have varied. For instance, a one-day Department of Education and Science national survey in Britain carried out in January 1974 revealed that approximately 10 per cent of all pupils twelve years or older are absent from school with 2 per cent absent without legitimate reasons. Amongst children aged fifteen years on 31 August 1974 absenteeism reached 14 per cent and unjustified absenteeism 5 per cent. However the National Association of Chief Education Welfare Officers (NACEWO, 1975), reporting on their own survey of 27,000 pupils from sixteen local education authorities, note that 24 per cent of secondary pupils are absent with an estimated 3.5â7 per cent absent without a good reason.
However, survey data can be misleading for reasons well explained by Williams (1974) and Macmillan (1977). In most cases, percentage attendance figures do not indicate whether a large number of children are absent a small amount of the time, or a few children are absent most of the time. Furthermore most percentage figures for individuals reveal nothing about the pattern of attendances so that two individuals with the same percentage figure could have very different sorts of problems, with the one child having regular weekly absences of one day and the other child showing one large continuous period of absence. Commonly, attendance figures refer to an average for a school and this obscures any variation in attendance that might occur with differences in sex, age and ability. It is well known that attendance rates rise in the final two years of schooling particularly amongst low achieving children (Galloway, 1980, 1985).
The reasons for persistent absence from school have been well explored in Galloway (1985). The majority of absences are due to physical illness or some other legitimate cause. However, some children are unlawfully withheld or else actively or passively encouraged to remain at home. A few are absent because of economic reasons like inadequate clothing. Nevertheless it is two other groups of persistent non-attenders that have attracted particular interest in the literature: school phobies and truants. Furthermore, it is school phobia (commonly referred to as school refusal) that has been the subject of most research.
The special clinical significance of school phobia has been highlighted by Miller, Barrett and Hampe (1974). These authors point out that school phobia is more prevalent than any other childhood phobia. Whilst the problem accounts for less than 1 per cent of the school population, the ratio of papers on the topic to that of other phobias is at least 25:1. Graziano, DeGiovanni and Garcia (1979) suggest that the higher referral rate of school phobia may be due to the high cultural value and legal requirements placed on school attendance. Fears of the dark and birds, etc. are socially and legally more acceptable than avoidance of school. Certainly school phobia generates massive anxiety in both parents and teachers. From a developmental point of view, the condition is interesting in that it can be a precursor to major psychiatric problems in adulthood (Berg, Marks, McGuire and Lipsedge, 1974; Tyrer and Tyrer, 1974).
In spite of the plethora of research articles on both school phobia and truancy, our knowledge and understanding of these syndromes has been hampered by: (a) inconsistent and vague use of terminology; (b) a failure on the part of some researchers to define their groups adequately; (c) a tendency to make statements about the conditions based on small-scale studies that suffer from sample bias; and (d) a general lack of controlled statistical studies.
The majority of school phobics have been selected from middle-class families and truants are generally reported as coming from the lower socio-economic groups. Thus it might be argued that school phobia and truancy are clinical artifacts being merely correlates of the social class differences which tend to exist between treatment samples. Indeed some educational psychologists and sociologists have doubted the relevance of distinguishing between different types of non-attenders (Reynolds and Murgatroyd, 1977; Kavanagh and Carroll, 1977).
This chapter will examine the available research in the area with a view to clarifying important issues. The clinical presentation of school phobia will be described and the condition delineated from truancy. Attempts to classify school phobia will be reviewed and the implications for treatment considered. Finally, the aetiology of the syndrome will be discussed.
HISTORICAL BACKGROUND
Early investigations of persistent non-attendance talked only in terms of truancy. Somewhat curiously, Kline (1897) likened truancy to a migratory instinct similar to that found in birds and animals. This simple view failed to explain the condition. Early pioneer studies by Healy (1915) and Burt (1925) produced evidence that firmly linked truancy with delinquency. Poor parental control, mental dullness, temperamental instabilities and broken homes were cited as important factors contributing to truancy.
Broadwin (1932) was the first to describe a form of truancy that was later most commonly referred to as school phobia or school refusal.
The child is absent from school for periods varying from several months to a year. The absence is consistent. At all times the parents know where the child is. It is near the mother or near the home. The reason for the truancy is incomprehensible to the parents and the school. The child may say that it is afraid to go school, afraid of the teacher or say that it does not know why it will not go to school.
This classic description has become a standard quote in the many subsequent papers on the condition (Frick, 1964; Hersov, 1977). Partridge (1939) in a review of truancy noted a group of children that he labelled âpsychoneuroticâ. They appeared to differ from other truants in that they were obedient, reasonably well-adjusted and liked school. He regarded them as victims of âan emotional bond between parent and child, the basis of which lies in undue attachment and overprotectionâ. Johnson, Falstein, Szurek and Svendsen (1941) further delineated this special form of truancy and coined the term âschool phobiaâ emphasising the role the school played in the condition.
When the teacher as a more consistent disciplinarian frustrates the child, she roused his rage. Being less dependent on the teacher, who is a diluted form of the mother, the childâs rage, inhibited toward the mother, can now find expression through displacement and the teacher in her milieu becomes the phobic object. To avoid the teacher and school is now the defence against being placed in the situation in which the overwhelming anxiety is roused.
Johnson et al. (1941) felt that the basis of the problem was separation anxiety with the mother exploiting the situation.
Following Johnsonâs example a number of other American workers adopted the term âschool phobiaâ (Goldberg, 1953; Suttenfield, 1954; Talbot, 1957; Coolidge, Hahn and Peck, 1957). However, these authors did not regard the condition as a specific entity but rather a loose description of any school attendance problem based on emotional disturbance with phobic, hysterical and obsessional tendencies often overlapping. Eisenberg (1958) and Rodriguez, Rodriguez and Eisenberg (1959) regard school phobia as a variant of separation anxiety but recognise that the symptoms may also be indicative of schizophrenia or other disorders.
In Britain the term school phobia has been favoured by Davidson (1960â61), Chazan (1962), Berg, Nichols and Pritchard (1969) and Blagg (1977); but regarded as too specific by Hersov (1960â61a), Kahn and Nursten (1962), and Smith (1970), who have preferred to use âschool refusalâ. Eysenck and Rachman (1965) feel the term school phobia should be retained where the child is truly phobic about something in school, but distinguished from âseparation anxiety in a school situationâ. Somewhat confusedly Bakwin (1965) has used the term school phobia to refer to cases of general non-attendance at school including those refusing without anxiety whilst Cooper (1966a) uses school refusal as an umbrella term to include school phobics and typical truants.
THE CLINICAL PRESENTATION OF SCHOOL PHOBIA
The clinical presentation of school phobia has been particularly well described by Hersov (1977);
The problem often starts with vague complains of school or reluctance to attend progressing to total refusal to go to school or to remain in school in the face of persuasion, entreaty, recrimination and punishment by parents and pressures from teachers, family doctors and education welfare officers. The behaviour may be accompanied by overt signs of anxiety or even panic when the time comes to go to school and most children cannot even leave home to set out for school. Many who do, return home half way there and some children, once at school rush home in a state of anxiety. Many children insist they want to go to school and are prepared to do so but cannot manage it when the time comes.
Anxiety symptoms often manifest themselves in a variety of somatic forms including headache, stomach pains, nausea, dizziness, fevers and so on. Sometimes the child protests with tears or temper tantrums leading to destructive or aggressive behaviour. Some children become lethargic and depressed and a few threaten suicide. Usually, once the pressure to attend school has been removed, the symptoms accompanying the school avoidance dissipate.
Although these descriptions paint a fairly vivid picture of the nature of school phobia, the majority of authors fail to state explicit behavioural criteria for diagnosing the condition. Berg et al. (1969) are unusual in this respect in providing a very clear definition. Among the cases that he and his co-workers selected for treatment, their studies focused on those who show good evidence of:
1.Severe difficulties in attending school, often amounting to prolonged absence.
2.Severe emotional upset â shown by such symptoms as excessive fearfulness, undue tempers, misery or complaints of feeling ill without obvious organic cause on being faced with the prospect of going to school.
3.Staying at home with the knowledge of the parents when they should be at school at some stage of the course of the disorder.
4.Absence of significant anti-social disorders such as stealing, lying, wandering, destructiveness and sexual misbehaviour.
Children suffering from psychosis, gross physical illness, bronchial asthma, truancy and neurotic disturbances other than school phobia, are excluded from their investigations. A number of other workers have adopted Berg et al.âs (1969) formulation, including Baker and Wills (1979) and Blagg and Yule (1984).
DISTINGUISHING SCHOOL PHOBICS FROM TRUANTS â THE RESEARCH STUDIES
The case for building typologies of persistent absentees rests largely on information coming from descriptive studies of school phobics, truants and persistent absentees, together with comparative studies of truants, phobics and control groups. Whilst there is quite a lot of agreement between these studies, the data need to be interpreted cautiously because of the methodological weaknesses inherent in many of the investigations.
A large number of the workers dealing with school phobies are based in specialist clinics (Goldberg, 1953; Waldfogel, Coolidge and Hahn, 1957; Davidson, 1960â61 and Chazan, 1962) or hospitals (Hersov, 1960â61a, b; Berg et al. 1969; Nichols and Berg, 1970; Smith, 1970). Inevitably, child-guidance clinics and hospitals receive rather skewed referral samples. There is the additional problem that many authors do not state whether they are reporting on a treatment series or selected cases. Finally, the majority of authors do not state explicit behavioural criteria for diagnosing school phobia in the first place. One of the problems in this area is highlighted by a remark in Smith (1970). He says that some of his 63 hospital cases were only minimally anxious in their refusal to attend school. This raises the question of just how anxious the child should be before being included in the school phobic group and the associated problem of how one should assess levels of anxiety. It is well known that fear-ratings based on physiological measures, subjective self reports and observed behaviour do not necessarily correlate (Lang, 1970). Researchers are obliged to opt for one or more of these measures. However investigators frequently fail to state which of the measures they are using.
Descriptive studies of truants suffer from similar limitations. The majority of these enquiries have been based on samples involving hospital referrals or children who have appeared before the court for non-school attendance (Tyerman, 1958). Two studies are worthy of particular mention. Tennent (1971) compared 65 truants on remand for non-attendance at school with a stratified random sample of 166 property offenders also on remand. A major study by Tyerman (1958) looked at 137 truants who had been prosecuted for regular non-attendance between 1941 and 1952. Children who had been withheld from school were excluded from this study. Tentative conclusions about this group were tested by a more detailed investigation of a further 40 truants who were compared with 40 non-truant child-guidance cases. At the very beginning of his article Tyerman (1958) states that âTruants are children who absent themselves from school without lawful cause and without permission of the parents.â However, later in the study he points out that 5 of his 40 representative truants were absent despite parentsâ knowledge; two of these being school phobics as defined by Broadwin (1932)...
