Mental Health Archive 2014
Margaret L. Stivers, Ph.D.
Margaret is a clinical and social psychologist trained at the University of Kansas and the University of Miami. She has taught psychology at four major universities and directed mental health, residential, and nonpublic school programs for children and adolescents. Her experience includes 30 years of consultation and collaboration with educational programs throughout the country, including schools in urban and rural areas and on Indian reservation.
Click a topic below to expand the full question and answer.
School Refusal Behavior in First Grade
I am a first grade teacher and every couple years I have a student who refuses to come to come to the classroom, then refuses to let the parent leave. Sometimes the child has been coming to school without any problems and this behavior suddenly appears “out of the blue.” What could cause this?
School refusal in a young child is usually caused by anxiety. Generally it is due to separation anxiety (fear of being separated from parents) or a school-related anxiety (fear of school). In separation anxiety, the child feels excessively frightened or terrified whenever a parent is not present. In school-related anxiety, the child experiences major fears about being at school, such as fears about being bullied or teased or fears of being unable able to meet expectations. The first step in addressing the problem is to determine what is frightening or stressing the student.
To determine what is frightening the child, you need to gather as much information as possible from the child and family. A staff member with whom the child seems comfortable is likely to obtain the best information from the child. Otherwise a school counselor, school psychologist, or a child therapist can establish rapport and help the child express fears through a series of play interviews. Information from parents can help determine whether the child shows fear of separation from parents in other settings besides school, such as when parents leave him home with a sitter. Does the child have trouble sleeping alone or complain of nightmares about separation, such dreams about being lost or having a parent leave and fail to return? If not, the anxiety may be based on a particular experience associated with school.
Separation anxiety is often associated with a family history of anxiety. The association may be based on a genetic predisposition. It may also be based on parental anxiety being “transmitted” to the child through modeling or other subtle cues that the parent finds particular situations uncomfortable or unsafe. It may be useful to find out about any major negative experiences the parents associate with their own school years.
Even when there is no family history of anxiety, early experiences, such as a long separation from a parent or the loss of attachment figure, can contribute to the development of separation anxiety. Ask the parents about particular times the child potentially experienced separation or loss. For instance, if the family moved recently, ask whether the child lost regular contact with a grandparent or other significant person who regularly cared for the child. If it is an immigrant family, ask when the family moved to U.S. and whether everyone made the move together or some family members came on ahead and waited for others to join.
Although it seems puzzling when separation anxiety problems appear “out of the blue” after a child has attended school smoothly, this does occur. The median age for school refusal is 7.5 years, an age at which most children have been attending school regularly for quite a while. Given a genetic predisposition toward anxiety and/or some history that sensitizes the child to separation, a relatively minor trigger, not easily identified by others, can tip the balance. Sometimes it is a serious illness in the family and the child becomes concerned about losing a family member. The trigger can even be the mother’s pregnancy. Observing pregnancy-related events, such as changes in the mother’s appearance, seeing fatigue or morning sickness, or hearing about how the mother will go to the hospital to have the baby all could conceivably give rise to concerns. The child may feel that the mother’s physical state is precarious and unpredictable and become fearful when she out of sight and the child can’t monitor her.
When a young child’s school refusal is not due to separation anxiety, it is likely to be associated with particular fears about going to school. These fears are often about social situations or about meeting classroom expectations.
A fear of social situations with peers at school most likely reflects some real experience of being teased or bullied or seeing other students bullied or teased. For a sensitive child, being laughed at, called names, or excluded from recess games may be sufficient to cause anxiety about attending school. It is important to find out about this and remedy the situation. A child who feels frightened and unsafe in the school environment may not feel safe talking about it due to fear of retaliation if the feared students are then confronted by adults. The child may also hesitate due to embarrassment or fears that others see the situation as “no big deal” and something that the child should be expected to handle. It may take time and sensitivity to bring the child to feel safe enough to divulge.
Fears about being unable to meet expectations may be related to a child’s anxieties about getting in trouble due to inappropriate behaviors or about a perceived inability to do academic work. If the child is having trouble meeting behavioral expectations, you, as the teacher, are very aware of this and working on a plan to improve the situation. If the child is struggling with academic work, the problem may be more subtle (e.g., taking longer than seatmates to complete written assignments, struggling to remember what was read). The teacher may have the perspective to see that such differences are fairly normal and likely to resolve with time. A sensitive or perfectionistic child may be acutely aware of academic performance differences whether or not the teacher deems it as a problem. This can lead to high anxiety about academic work and fear of attending school.
Other Potential Problems
Other potential problems could result in school refusal, but are very unusual causes during first grade. However, if none of the problems above appear to apply, these should be considered:
Social anxiety is the fear of humiliation or extreme embarrassment whenever one’s behavior may be observed, and therefore evaluated, by others. Children with social anxiety are very self-conscious and severely inhibited about social and/or academic performance when unfamiliar people are present to observe.
Generalized anxiety is characterized by an excessive tendency to worry. The anxiety is ever-present, but the focus constantly shifts. The child’s anxiety may focus on nearly anything available to worry about (floods, erupting volcanoes or other natural disasters seen on the news, whether or not a parent will be there to pick the child up after school, whether the bus will break down during a field trip, or whether a school shooting will occur).
When school refusal is due to health-related anxiety, the child refuses to attend school due to feeling sick in the morning and fear of being sick at school. These fears may reflect generalized anxiety in which child has developed many somatic anxiety symptoms such as head-aches or stomach aches. Another possibility is that the child may have been sick and recovered, but fears getting sick again while at school.
Children struggling with depression experience excessive sadness or irritability, feel down on themselves, and have a negative outlook on life. These children may lack the necessary energy and motivation to get up in the morning or get through the school day.
In short, the cause of school refusal must be determined individually for each child.
Thank you for writing and good luck with your class.
Depression, Anxiety, and Other Health Impaired
My colleagues and I have been discussing whether or not a student with mild depression could be made eligible under OHI vs. ED.
From time to time, questions come up among school psychologists about whether students whose progress in school is impeded by symptoms of depression or anxiety can be found to qualify for special education services under the handicapping condition Other Health Impaired (OHI) rather than under Emotional Disturbance (ED). Although you ask about depression symptoms, I will address both types of symptoms because similar questions and concerns come up. Although students with depression and anxiety probably are occasionally served under OHI, I have strong reservations about it.
According to state and federal law, adverse educational impact due to “a general pervasive mood of unhappiness or depression” is specified as a criterion that qualifies for services under the designation ED. Likewise, adverse educational impact due to anxiety symptoms, or “fears associated with personal or school problems,” is specifically listed as a qualification for services under ED. Because symptoms of depression and anxiety are explicitly listed among the qualifying criteria for ED, this category appears to be most consistent with the legislative intent and legal guidelines.
Arguments can be made for inclusion of depression and anxiety under OHI, but the justifications are more complex and less convincing. Neither disorder is listed as an example under the official description of OHI, although that list is not inclusive of all disorders that may qualify. To qualify under OHI, a student must have “limited strength, vitality, or alertness” that interferes with educational progress. The examples provided include chronic health conditions such as cancer or tuberculosis as well as infectious diseases. One psychiatric diagnosis, attention deficit/hyperactivity disorder (ADHD), is included among the examples. ADHD is likely included because, although it is generally considered a behavioral and psychiatric disorder, it is not generally considered an “emotional” disorder. A student with ADHD whose executive functioning deficits are associated with a discrepancy between learning and achievement may be found to qualify under SLD.
Some argue for including depression and anxiety under OHI by pointing out that here is a biological component to both mood disorders and anxiety disorders. They may site evidence that genetic factors contribute to an individual’s vulnerability to mood and anxiety disorders. They may cite evidence that these disorders can be associated with differences in the structure, functioning, and/or levels of various neurotransmitters in parts of the brain or note that medications targeting key brain chemicals can be effective in reducing many of the symptoms.
However, ALL of the handicapping conditions that confer potential eligibility for special education have a biological basis. Differences in hearing, vision, and orthopedic mobility have a physiological and/or neurological basis. Traumatic Brain Injury (TBI) involves injury to the central nervous system. Many individual differences that result in a need for differential instruction and modifications in curriculum materials and/or learning environment are associated with variations in brain development. Specific learning disabilities, speech/language impairments, and problems with motor coordination or sensory-motor integration are classified as “neurodevelopmental” disorders under the DSM-5. The argument of a biological component to depression and anxiety could be extended to conclude that all students who qualify for special education should be served under the OHI designation.
The questions about including depression and anxiety under OHI may reflect many school psychologists’ extreme reluctance to qualify students under ED, particularly students who do not engage in defiant or disruptive behaviors. This reluctance is understandable, but some of the underlying fears may be exaggerated.
I have sometimes heard school psychologists express concern that if depressed or anxious students are served under the ED qualification they are at risk of being placed with students who might victimize them or engage in disruptive behaviors that may further increase anxiety or negative mood. It is important to keep in mind that a student’s qualifying category does not determine his or her educational placement. Once a student is found qualified for special education, the IEP team (including the student, if old enough to participate) looks at the individual student’s needs (stressing the “I” in “IEP”) and determines the most appropriate ways to promote access to curriculum, including instructional strategies to promote participation, modifications or changes in the educational environment, and additional supports.
I have often heard school psychologists argue that the stigma of receiving services as a student with ED may jeopardize the student’s future opportunities. Although this is widely believed, as far as I can determine, it should never occur. Legally, a district cannot share any information about a student’s special education category unless that information is released to a higher education or vocational training program for the purpose of assisting them in providing continued educational support for that student. I have also heard that students labeled ED are excluded from enlistment in the military. My understanding is that neither having received special education nor having been served under ED or any other specific category disqualifies a student from military service. However, the various branches of the military have requirements in a range of areas, including: height and weight, vision, hearing, physical coordination and mobility, intellectual ability, and health status (including a need for regular medication). The requirements may eliminate some former special education students, but not because they received special education or the category under which they qualified for services.
It feels important to add one final thought about stigma: there is an important national movement to eliminate the stigma of mental health problems so that people can more easily acknowledge their difficulties and seek treatment. I have heard school psychologists say they don’t want to qualify a student under ED because it’s “such a serious category,” “such a terrible diagnosis,” or even “because it’s such a stigma.” While these statements reflect strong commitment to the best interests of their students, these school psychologists may also inadvertently be helping perpetuate the stigma. To the extent that there is any truth in the above statements, it may be partly due to the fact that we keep saying and believing these statements. Improvement may begin when we cease to referring to ED as a qualifying category that carries a horrible stigma and should be avoided at all costs.
I hope this discussion is helpful or, at least, thought-provoking.