School Refusal: Clinical Features, Diagnosis and Treatment

Abstract

Children regularly and voluntarily go to school in order to fulfill the expectations of society from them to continue their education or schooling. School continuation has been made compulsory by laws. Nonetheless, contrary to popular belief, for some children it is distressing to go to school. These children have difficulty continuing school and/or refuse to go to school. Today school refusal is defined as a child's inability to continue school for reasons, such as anxiety and depression. The prevalence of school refusal has been reported to be approximately 1% in school-age children and 5% in child psychiatry samples. The prevalence of school refusal is similar among boys and girls. School refusal can occur at any time throughout the child's academic life and at all socio-economic levels. School refusal is considered a symptom rather than a clinical diagnosis and can manifest itself as a sign of many psychiatric disorders, with anxiety disorders predominant. Separation anxiety disorder, generalized anxiety disorder, social phobia, specific phobia, and adjustment disorder with anxiety symptoms are the most common disorders co-occurring with school refusal. While separation anxiety disorder is associated with school refusal in younger children, other anxiety disorders, especially phobias, are associated with school refusal in adolescents. Children who have parents with psychiatric disorders have a higher incidence of school refusal, and psychiatric disorders are more frequently seen in adult relatives of children with school refusal, which supports a significant role of genetic and environmental factors in th etiology of school refusal. School refusal is a emergency state for child mental health. As it leads to detrimental effects in the short term and the long term, it should be regarded as a serious problem. The long-lasting follow-up studies of school refusing children have revealed that these children have a higher incidence of psychiatric disorders or that they are more likely to require psychological assistance. It is for these reasons that the treatment of school refusal is increasingly gaining impor-tance. The major aim of the treatment is to help the child return to school at the shortest time possible. The treatment should be carried out in cooperation with the child's parents and the school personnel. A widely accepted approach to the treatment of school refusal is one that is concerned with the application of a multi-faceted treatment. Psychosocial and psychopharmacological approaches constitute the crucial parts of the therapeutic process. Today, cognitive behaviour therapy and medication are the most frequently employed approaches in the treatment of school refusal.

Keywords

• School Refusal, Child, Diagnosis, Psychopathology, Treatment

Okul Reddi: Klinik Özellikler, Tanı ve Tedavi

Öz

Toplumun eğitim ve okula devam etme gibi beklentilerini karşılamak için çocuklar düzenli ve gönüllü olarak okula gitmektedir. Okula devam etme yasalar ile de zorunlu hale getirilmiştir. Bununla birlikte, bazı çocuklar için okula gitmek beklenenin ötesinde sıkıntı verici bir durumdur. Bu çocuklar okula devam etmede güçlük çekmekte ve/veya okula gitmeyi reddetmektedir. Günümüzde okul reddi, çocukların anksiyete ve depresyon gibi duygusal sorunlar nedeni ile okula devam edememesi olarak tanımlanmaktadır. Okul reddinin yaygınlığı tüm okul çağındaki çocuklar için yaklaşık % 1 ve kliniğe başvuran tüm çocuklar için % 5 olarak bildirilmektedir. Okul reddi erkek ve kız çocuklarda eşit oranda görülmektedir. Okul hayatının herhangi bir döneminde ortaya çıkabilmektedir. Okul reddinin tüm sosyoekonomik düzeylerde görülebildiği bildirilmektedir. Okul reddi klinik bir tanı olmayıp bir belirti olarak değerlendirilmektedir. Anksiyete bozuklukları başta olmak üzere birçok ruhsal bozukluğun belirtisi olabilmektedir. Ayrılma anksiyetesi bozukluğu, yaygın anksiyete bozukluğu, sosyal fobi, özgül fobi ve anksiyete ile giden uyum bozukluğu okul reddi ile birlikte en sık görülen tanılardır. Tanılarda yaşa bağlı eğilimler görülmektedir. Ayrılma anksiyetesi bozukluğu genelde yaşça daha küçük çocuklardaki okul reddi ile ilişkilendirilirken, diğer anksiyete bozuklukları özellikle de fobiler ergenlerdeki okul reddi ile ilişkilendirilmektedir. Ruhsal bozukluğu olan ebeveynlerin çocuklarında okul reddi sık görülmektedir. Bu, genetik ve çevresel faktörlerin okul reddi gelişimindeki rolünü desteklemektedir. Okul reddi bir çocuk ruh sağlığı acilidir. Kısa ve uzun dönemde olumsuz sonuçlar doğurduğu için ciddi bir sorun olarak değerlendirilmektedir. Okul reddi olan çocukların uzun süreli izlem çalışmalarında, genel toplum ya da kontrol gruplarına göre daha yüksek oranda ruhsal bozuklukların bulunduğu ya da ruhsal yardıma gereksinim duyma olasılıklarının daha yüksek olduğu gösterilmiştir. Bu nedenlerden dolayı okul reddinin tedavisi çok önem kazanmaktadır. Tedavide temel amaç çocuğun en kısa süre içerisinde okula dönmesini sağlamaktır. Tedavi ebeveyn ve okul personeli ile işbirliği içinde yürütülmelidir. Tedavide genel kabul gören yöntem çok eksenli bir tedavi yaklaşımı uygulamaktır. Psikososyal ve psikofarmakolojik yaklaşımlar tedavinin önemli ayaklarını oluşturur. Günümüzde bilişsel davranışçı terapi ve ilaç sağaltımı tedavide en sık kullanılan yaklaşımlar olarak öne çıkmaktadır.

Anahtar Kelimeler

• Okul Reddi, Çocuk, Psikopatoloji, Tanı, Tedavi

Kaynakça

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