East Asian Arch Psychiatry 2011;21:164-169

ORIGINAL ARTICLE

Dr Kayhan Bahali, MD, Department of Child and Adolescent Psychiatry, Bakirkoy Research and Training Hospital for Psychiatric and Neurological Disorders, Istanbul, Turkey.
Dr Aysegul Yolga Tahiroglu, MD, Department of Child and Adolescent Psychiatry, School of Medicine, Çukurova University, Adana, Turkey.
Dr Ayse Avci, MD, Department of Child and Adolescent Psychiatry, School of Medicine, Çukurova University, Adana, Turkey.
Dr Gulsah Seydaoglu, MD, Department of Biostatistics, School of Medicine, Çukurova University, Adana, Turkey.

Address for correspondence: Dr Kayhan Bahali, Department of Child and Adolescent Psychiatry, Bakirkoy Research and Training Hospital for Psychiatric and Neurological Disorders, Istanbul 34147, Turkey.
Tel: (90-212) 5715730; Fax: (90-212) 5719595; Email: mkbahali@yahoo.com

Submitted: 2 February 2011; Accepted: 5 August 2011

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Introduction

Studies dealing with school refusal (SR), which is a short- and long-term stressful condition for both parents and school personnel, have been reported in the literature since the last century. Today SR is defined as a child’s inability to continue school for reasons, such as anxiety and depression.¹ The prevalence of SR has been reported to be approximately 1% in school-age children and 5% in child psychiatry samples,^2,3 whilst its prevalence is similar in boys and girls.^4,5 School refusal can occur at any time throughout a child’s academic life and at all socio-economic levels.^3,6-9 164

It is considered a symptom rather than a clinical diagnosis, and can manifest itself as a feature of many psychiatric disorders, but anxiety disorders predominate.¹⁰ Separation anxiety disorder (SAD), generalised anxiety disorder (GAD), social phobia (SP), specific phobia, and adjustment disorders with anxiety are the most frequent diagnoses associated with SR.⁵ Among those affected, most have various triggering factors that are likely to originate from the children themselves, their parents, and the school.^11,12

There is reliable evidence to suggest familial transmission of anxiety disorders.^13,14 Anxiety disorders also occur more often in the parents and relatives of children with anxiety disorders. Family studies have shown specific familial aggregations for panic disorder,^15,16 GAD,¹⁷ obsessive-compulsive disorder,^18-20 SP, and other phobic disorders.^21-23 Studies conducted on parents of children with SR and SAD have revealed similar results to those of other anxiety disorders.^24,25

Depending on prevailing genetic and environmental factors, parents with psychopathologies run the risk of their children developing psychiatric disorders. Thus, defining parental psychiatric disorders is of great importance in the diagnosis and treatment of children and adolescents who exhibit SR. The purpose of this study was to assess the levels of psychological symptoms in the parents of children with SR and determine familial risk factors associated with its development.

Methods

Participants

This case-control study involved 55 pairs of parents who had children with SR admitted to the Department of Child and Adolescent Psychiatry, School of Medicine, Çukurova University of Turkey. School refusal was defined as a child’s inability to continue school due to the emotional problems. All parents were informed about the study procedures and only those who volunteered were enrolled in the study. The control group included 56 volunteer sets of parents of children without SR from a primary school. The mean ± standard deviation (SD) age of the mothers in the SR and control groups was 36 ± 6 and 37 ± 5 years, respectively. The corresponding figures for the fathers were 41 ± 6 and 41 ± 5 years. Other socio-demographic characteristics of the parents are shown in Table 1.

Inclusion criteria of the study group were: having a child aged > 5 years with an absence from school for at least 1 month. Parents having children with serious organic disease, psychosis, autism, or mental retardation were excluded from the study.

Instruments

Symptom Checklist–90 Revised

The Symptom Checklist–90 revised (SCL-90-R) is a 90-item self-reported symptom inventory designed to evaluate a broad range of psychological problems and symptoms of psychopathology.²⁶ The SCL-90-R provides a 5-point (score 0-4) Likert-type measure. The inventory contains 9 primary symptom dimensions (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) and 3 global indices (the Global Severity Index [GSI], the Positive Symptom Total [PST] index, and the Positive Symptom Distress Index [PSDI]). The GSI was used as a measure of overall psychopathology. In the present study, the Turkish version of the SCL-90-R was used,²⁷ and its Cronbach’s α was 0.97.

Beck Depression Inventory

The Beck Depression Inventory (BDI) is a 21-item self- reported inventory designed to assess the level of depressive symptomatology.²⁸ It uses a 4-point Likert-type measure. Each item is scored between 0 and 3 so the total score can range from 0 to 63. The Turkish version of the BDI was used in this study.²⁹ A total score of 17 was accepted as the cut-off point. Its Cronbach’s α was 0.80.

State-Trait Anxiety Inventory

The State-Trait Anxiety Inventory (STAI) is a 40-item

Table 1. Socio-demographic details of parents.

self-reported instrument designed to measure the level of both the state and trait anxiety.³⁰ It has 2 different scales with each having 20 items (state anxiety [STAI-I] and trait anxiety [STAI-II]). Participants indicated their agreement with each item on a 4-point Likert-type measure ranging from 1 to 4. The total score possible from both scales ranged from 20 to 80. High scores indicated an increased level of anxiety and vice versa. The Turkish version of the STAI was used in this study,³¹ and its Cronbach’s α was 0.91 for state anxiety and 0.87 for trait anxiety.

Socio-demographic Data Form

The socio-demographic data form was prepared to enquire into the socio-demographic characteristics of the children and their parents, as well as the potential familial risk factors for the development of SR.

Procedure

Detailed interviews were conducted with the parents and the children of the SR group. Informed consent was obtained from the parents. All of the clinical interviews were carried out by 2 researchers. Self-reported inventories were applied to the parents of the children who met the inclusion criteria for the study. Treatment of the children (as deemed necessary) was initiated after psychiatric assessment.

Permission to recruit a control group (with no SR) was obtained from the Directorate of National Education of the Province and the Governor of the City of Adana. A researcher went to the recommended school to verify absence of SR. The parents of these children were invited to the school by the counselling service and informed about the study procedure, and were the volunteers from whom controls were recruited. The same self-reported inventories were also applied to the control group, and after being filled up they were collected via the counselling service. The entire study was approved by the Clinical Ethics Committee of the School of Medicine of Çukurova University.

Statistical Analysis

Data were analysed using the Statistical Package for the Social Sciences, Windows version 12.0 (SPSS Inc., Chicago [IL], US). Differences in categorical variables between groups were analysed with the Chi-square test; odds ratios and 95% confidence intervals (CIs) were calculated. For continuous variables, normality of distributions were evaluated using the Shapiro-Wilk test. Differences between evaluated with a non-parametric test. Comparisons between groups were analysed using the Mann-Whitney U test. The results were expressed as mean ± SDs, numbers, and percentages. A p value of < 0.05 was considered statistically significant.

Comparison of Inventory Scores

The respective mean (± SD) BDI score of mothers was 12 (± 10) and 5 (± 4) in the SR and control groups, while the corresponding figures of fathers were 11 (± 8) and 5 (± 4). The difference between respective mean scores in the parents of the 2 groups was statistically highly significant (p < 0.0001). Fifteen (27%) of the SR group mothers and 1 (2%) of the control group mothers scored > 17 (i.e. the cut-off point of the BDI). None of the fathers in the control group scored in excess of the cut-off point, whereas 8 (15%) of SR group fathers did so. The corresponding differences between parents in these 2 groups were very significant (p < 0.0001 for mothers, p = 0.003 for fathers). The parents in the SR group had higher state and trait anxiety levels compared with those in the control group. The mean (± SD) STAI-I scores of the mothers were 44 (± 13) in the SR group, and 29 (± 8) in the controls, whereas the corresponding scores for the fathers were 38 (± 10) and 29 (± 5). A statistically significant difference existed between the mean STAI-I scores of the parents in these 2 groups (p < 0.0001 for each). The mean (± SD) STAI-II scores of the mothers were 45 (± 11) in the SR group, and 35 (± 6) in the controls, while in the fathers they were 42 (± 8) in the SR group and 34 (± 6) in the controls (p < 0.0001 for each). The results of the mean BDI and STAI-I and II scores of the parents of children in both groups are shown in Table 2.

Compared with the control parents, those in the SR group had higher scores in the GSI, PST index, PSDI, and the subscales of the SCL-90-R. The mean (± SD) GSI scores of the mothers were 0.7 (± 0.6) and 0.3 (± 0.2) in the SR and the control groups, respectively; corresponding figures in the fathers were 0.6 (± 0.5) and 0.2 (± 0.2). The mean (± SD) depression scores of the mothers were 0.8 (± 0.7) in the SR group, and 0.3 (± 0.2) in the controls, while in the fathers they were 0.6 (± 0.4) and 0.2 (± 0.2), respectively.

Table 2. Comparison between school refusal (SR) group and control group using Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI).^*

* Data are shown as mean ± standard deviation; p values were all < 0.0001.

Results

Child Psychopathology

The most common diagnosis was SAD, which was present in 75% of the cases, followed by obsessive-compulsive disorder (9%), depression (7%), disruptive behaviour disorder (7%), and SP (in 2% of the cases).

Table 3. Familial risk factors in the development of school refusal (SR).

Also, the respective mean (± SD) anxiety scores of mothers were 0.7 (± 0.7) and 0.2 (± 0.2) in the SR and control groups, while in the fathers they were 0.6 (± 0.5) and 0.2 (± 0.2). The differences between corresponding mean GSI, PST index, PSDI, and the subscales of the SCL-90-R scores of the parents in the 2 groups were all significant (p < 0.02).

Familial Risk Factors in the Development of School Refusal

Among the risk factors for SR, physical punishment of the children by parents, a history of an organic disease in a parent or child, and a history of psychiatric disorder in a parent or other relative were found to be significant (p < 0.02). However, gender, relationship, a history of separation from the mother, and the presence of spousal physical abuse were not found to be significant (p > 0.05). Children who were physically punished by their parents had a 9-fold

(95% CI, 3-26) risk of developing SR compared with non- punished children. The likelihood of developing SR in the children with a history of organic disease was 6-fold (95% CI, 2-15) higher than in those without. While the presence of a history of organic disease in mothers led to 9-fold (95% CI, 1-78) increase in the risk of developing SR in children, for a corresponding history in fathers the risk increased to 9-fold (95% CI, 2-43). The respective risk of developing SR in children having mothers, fathers, or relatives with psychiatric disorder was 2- (95% CI, 2-3), 8- (95% CI, 1-68), and 13-fold (95% CI, 3-60) higher than those without such family history (Table 3).

Discussion

School refusal has been discussed in the literature since the last century, most studies having been conducted in the last decade. Nonetheless, there are relatively few studies on the family epidemiological characteristics, follow-up, and treatment of SR. The current study determined the family characteristics of children with SR, risk factors, and psychological symptoms in their parents. Parents in the SR group had lower levels of education compared with the controls. In addition, there were significantly less working mothers in the SR group than those in the controls. In another study regarding children with SAD in Turkey,³² SR was reported more frequently in children of non-working than working mothers, and that the duration of absenteeism was longer in the children of the former. The fundamental feature of separation anxiety is that it occurs in cases of separation from parents and other people on whom the child is dependent. Children who were separated from their mothers compulsorily and repeatedly because of their mothers’ work learnt not to react severely and to cope with that separation all day long. As the children of non-working mothers often experience long-lasting separation when they first start school, their reaction to the separation can be more severe. Thus, it could be expected that SR may occur more frequently in these children.

According to the results of a comparative study investigating psychiatric disorders in the parents of children with SR, anxiety and depressive disorders were more common in the parents of such children.²⁴ In another Turkish study regarding children with SR and their parents, there was a higher frequency of psychopathology in the parents of such children than in those of the controls.²⁵ In the current study, the presence of psychiatric disorders in parents or the distribution of psychiatric diagnoses were not analysed. Nevertheless, comparison of both groups revealed that parents of SR children had higher scores on the GSI, PST index, PSDI, and the subscales of the SCL- 90-R. According to the BDI, STAI-I and -II, parents in the SR group had higher anxiety and depression scores than those of the controls. The comparison between the number of parents who scored > 17 in the BDI revealed that parents in the SR group were more depressed. It is well known that anxiety disorders have a genetic basis.^13,14,33

Additionally, according to the social learning theory, it is no surprise to find high levels of psychological symptoms in the parents of the children with SR. The social learning theory suggests that humans learn certain behaviours by imitating their parents from early childhood. Similarly, it has been determined that children can learn reaction anxiety by imitating their parents.³⁴ Accordingly, it is believed that both genetic and environmental factors frequently play a role in the development of SR in children having parents with psychological symptoms.

Apparently, various triggering factors including accidents or diseases contribute to the development of SR in children. Situations in which one of the family members contracts a disease or dies, the parents constantly argue or get divorced, a new sibling joins the family, or the child becomes separated from family members may also trigger the development of SR.^11,12 Similarly, in our study, physical punishment by parents, a history of an organic disease in a parent or child, and a history of psychiatric disorder in a parent or relative were all risk factors for SR. From a cognitive aspect, children with SR-related anxiety could have imagined fears and exaggerated situations that could arouse anxiety. Such cognitive distortions in parents or children with a prior or current disease history may facilitate the development of SR in children.

Consequently, depending on genetic and environmental factors, it is thought that parents with psychiatric disorders run the risk of children developing psychiatric disorders. Moreover, apparently psychiatric disorders in parents negatively affect the treatment of children and adolescents. It is therefore important to treat psychiatric disorders of parents having children with psychiatric disorders, so as to increase the parental participation in their children’s therapy. Today, controversies surrounding SR persist. Since there is no agreement among researchers, high-quality scientific studies are needed to determine the aetiology, epidemiology, subtypes, diagnostic criteria, clinical course, and treatment of SR.

As all cases with SR who presented to our clinic were children, no structured interviews of the parents were performed. Another limitation is that our controls were not selected at random and so might have been biased. On the other hand, we secured a larger sample size than previous studies, evaluated the parents together with children, and included age- and gender-matched control group which could all be regarded strengths. Future studies are needed on the familial characteristics of children with SR.

Acknowledgements

No financial support was received for the study. The authors would like to thank Mrs Mehtap Uzel, the local education authority, and the Governor of the City of Adana for their contributions to the collection of the questionnaires.

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