Children who refuse to go to school
Another school year is upon us, and most children and their parents look forward to it.
But there are children who simply cannot face the prospect of school. These students suffer from a condition known as school refusal.
Child psychiatrists often receive referrals connected with school refusal, but it is important to recognise that while it is a common condition, it is not a diagnosis. It is a reflection of an underlying problem.
Children who suffer from school refusal generally fall into two types: they either refuse point blank to leave the house in the morning, or they set off full of good intentions, only to come running home when the reality of going to school hits them.
In school refusal, children find going to school upsetting. They experience heightened levels of anxiety, and in some cases feel physical discomfort.
Proof that the act of going to school is the root cause is found in the fact that during weekends and holidays there are no symptoms.
Truancy is not a factor. Ironically, children who play truant are not afraid of school; they have other unrelated issues.
School refusal affects children in three age groups: at age five to seven; at age 11 (during transition to higher school); and at age 14 to 16. A British study notes school refusal affects seven out of 1,000 children at age 15, with an equal incidence in boys and girls. Perhaps this worryingly high figure is prevalent in Hong Kong, because of the pressures on students to achieve from an early age.
Education here is undeniably tough and, as a result, is often the target of criticism. After all, the system does not open itself to the children's perspective. They have complained of heavy school bags and having play time taken away when sent to playschools at a very early age.
Furthermore, there is plenty of evidence to suggest that the biggest educational stress for children is pressure from their parents.
While parents themselves often identify the source of pressure as the results-orientated education system, and schools giving too much homework, unrealistic parental expectations of a child's ability and potential can be highlighted as the most common cause of stress among students.
Hong Kong parents, as a rule, find it very difficult to accept anything other than a stellar academic performance from their children, but they should remember that students with school refusal are usually youngsters of normal intelligence.
It is generally found that the youngest child may be at increased risk.
When it comes to solving the problem, the family is usually ineffective in encouraging the child to return to school. Parents can be over-involved and unable to reach a consensus on the best way to cope.
It is also important to consider that there may be some underlying psychiatric problems associated with children with school refusal, including separation anxiety, fear of being bullied, depression and substance abuse.
Schizophrenia should also be considered in some adolescents.
Referral to a doctor should screen for any undiagnosed physical illness, but school refusal usually does not need any treatment with medication, except in children with a psychiatric condition.
Behavioural therapy is the main type of treatment. Try to let the child go back to school as soon as possible.
If the condition is long-standing, a gradual plan of returning to school is required.
Close liaison between teachers, parents and a social worker is important, while family therapy is a useful way to help parents support children with school refusal when they head back to the classroom.
Dr Stephen Ng Wai-man is a Hong Kong-based specialist in psychiatry