ABSTRACT
Even though the majority of studies are bedevilled by methodological flaws, a picture does emerge from Chapters 2, 3 and 4 allowing for some tentative conclusions:
The treatment outcome for younger children (of 10 years and below) is extremely good irrespective of the treatment approach. This applies to behavioural, psychodynamic, community based and in-patient treatment. Studies that have dealt exclusively with younger children (Glaser, 1959; Barker, 1968) and investigations that have broken down outcome in terms of age (Rodriguez, et al., 1959; Warnecke, 1964; Miller, et al., 1972) consistently report that for the 5–10-year-olds there is a treatment success rate of 95 per cent or more. This certainly accords with the clinical experiences of the author and explains why Blagg and Yule’s (1984) study was confined to children 10 years and older. Many younger children were successfully treated during the period of the study but were not included in the treatment sample as they did not pose a significant treatment challenge.
The treatment outcome for older children (in the 11–16 years age range) seems far less predictable and has varied widely from study to study. In general the outcome for this age range is far less favourable. Thus, Rodriguez et al., (1959) report only a 36 per cent success rate with their older children. Hersov (1960–61a,b) managed a 58 per cent success rate with his 50 hospitalised cases. Treatment was not broken down according to age although 42 out of the 50 cases fell into the 10–16 years age range. If the 8 younger cases were eliminated from the analysis, a much poorer outcome seems likely. Berg et al., (1969) achieved only a 11059 per cent favourable outcome with 29 cases aged 10–15 years. Miller et al.’s (1972) comparative study tentatively suggests that for older phobies (most of whom were school phobies) neither systematic desensitisation with contingency management or psychotherapy were any more effective than being placed on a waiting list. In Blagg and Yule’s (1984) comparative treatment study, the 16 hospitalised children produced a 37.5 per cent favourable treatment outcome. However, the group that received home tuition with psychotherapy produced a poorer treatment outcome than any other reported study. Only 10 per cent of the home tutored group returned to school.
Although the prognosis for older school phobic children looks poor a few studies have produced remarkably impressive results with this more difficult age range. All of these studies emphasise a vigorous energetic approach to treatment in which fears and anxieties are exposed and uncompromisingly confronted. In every case enforced school attendance is advocated where necessary. Escort systems are favoured and the explicit or implicit threat of legal intervention is regarded as a legitimate therapeutic lever. The papers describing these more successful approaches are characterised by an optimistic stance and a powerful commitment to ensuring that treatment does work.
Kennedy (1965) reported a 100 per cent success rate with 50 cases using a behavioural approach emphasising a rapid return to school. However, it is important to remember that only 13 of his cases were above 11 years. Furthermore, the cases were not a treatment series but rather a selected sample of less severe (type 1) cases. Indeed, Kennedy argued that such an approach would not be appropriate to more disturbed type 2 cases. Nevertheless, a similar behavioural approach was subsequently applied by Rines (1973) to an older type 2 case with rapid and effective results. In fact, prior to Kennedy’s study, Warnecke (1964) published a paper reporting an 80 per cent success rate with what appeared to be a treatment series of older school phobies. Although the treatment approach was framed in psychoanalytic terms, it did have much in common with Kennedy’s approach. A variety of practical measures were taken at home and school to ensure an immediate and, if necessary forced, return to school.
In a retrospective study of 20 older school phobies, Skynner (1974) also claims highly impressive outcome figures with 88.2 per cent successfully treated on long-term follow-up. Skynner’s 111results were surprising, given the amount of time devoted to treatment. In most cases only one interview was required. Skynner’s (1974) approach is explained as conjoint family therapy with the crucial issue being argued as the need to address faulty family mechanisms. Once again, however, the approach involved enforced school attendance. As noted earlier Skynner (1974) recognises the overlap between his approach and other more explicitly behavioural strategies. Indeed he argues that Kennedy’s (1965) success was probably more an outcome of the implicit focus on faulty family mechanisms rather than the explicit focus on behavioural techniques. Framrose (1978) vividly describes the successful treatment of four older, highly disturbed school phobies. One cannot help being impressed by the powerful sense of conviction and intentionality accompanying this paper. Framrose was clearly totally determined that the adolescent phobies would overcome their difficulties in a highly active, vigorous way. Again, the essential treatment elements are expressed in strategic family therapy terms but at the same time explicit use is made of behavioural techniques and a range of school factors are also addressed. Framrose places a strong emphasis on the establishment of a foolproof system of attendance checks once the child is back in school.
Framrose’s positive approach and thorough detailed case management is paralleled in Blagg’s (1977) description of a rapid behavioural treatment approach. Interestingly, this latter approach applied to a treatment series of 30 cases in Blagg and Yule’s (1984) comparative treatment study produced a more successful long-term treatment outcome with children in the 11–16 years age range than any other reported study. Of the behaviourally treated group, 93.3 per cent returned to school and were still attending regularly at long-term follow-up. Treatment was extremely quick in most cases with the majority of children needing no further help beyond three weeks. A high expectancy of success also permeates Blagg and Yule’s (1984) paper. Many practical measures are taken to ensure the child is being reasonably and fairly treated at home and school. At the same time a rapid and, if necessary enforced, return to school is organised. Great care is taken to block any avoidance responses. Even at the first point of contact with the child and family there is never any question of ‘if’ the child will return to school, but only ‘when’ and ‘how’ it will be accomplished.
Children who have been hospitalised for treatment have 112received from 6–19 months therapy. Undoubtedly, hospitalisation represents the most intensive and costly treatment intervention. At the same time there is no conclusive evidence to suggest that this kind of help is reserved for the most profoundly disturbed cases. It seems more likely that hospitalisation is an outcome of patterns of referral and the restrictions and bias of professionals involved than a carefully considered intervention weighed against alternative community-based approaches. Blagg and Yule’s (1984) comparative study revealed that the hospitalised cases were closely matched to the two community-treated groups on all significant indices even though they were not randomly allocated.
In spite of the cost and intensity of provision, the outcome figures for studies involving hospitalisation are no better for younger or older children than many community based approaches and certainly not as effective as strategic family therapy approaches or comprehensive behavioural packages emphasising a rapid enforced return to school. Under the circumstances, it seems wholly unreasonable and uneconomic to subject school phobies to hospitalisation, particularly where intensive, meaningful community-based approaches have not been vigorously pursued. Barker’s (1968) study is especially open to criticism in this respect.
Home tuition with psychotherapy is commonly used in the United Kingdom as a treatment intervention with school phobia. Apart from Blagg and Yule’s (1984) paper, there appears to be no recorded trial of this approach in the literature. This is rather worrying as the treatment outcome for the home-tutored group in Blagg and Yule’s (1984) study was so appallingly poor that this kind of intervention may inhibit spontaneous remission or, even worse, reinforce the school phobia pattern. Clearly experimental evidence for these statements is limited but nevertheless the clinical experience of the author suggests that school phobies who have been put on home-tuition and given psychotherapy prior to a more direct attack on the problem are much more difficult to treat than those who have been out of school for the same amount of time but have had no previous treatment. It is not uncommon for the home tutor to become over-involved with the child and the family and to unwittingly become a powerful maintaining factor. Very often the kind of people that take up a home-tutor post are unemployed or retired teachers. Naturally, some of them may have a vested interest in maintaining the 113school phobia as their job depends upon it. In view of these considerations there seems to be a good case for avoiding the use of home-tuition with psychotherapy at all costs.
As Chapter 3 shows a wide range of behavioural techniques have been usefully employed with many different cases of school phobia. The behavioural purist’s search for the most effective technique or combination of techniques is perhaps naïve given the nature of school phobia. Above all, the previous chapters have demonstrated that school phobia cannot be regarded as a specific clinical entity. It is a complex syndrome of varying pathology, symptomatology and severity involving a wide number of child, family, school and social factors. Although there are recurring themes, the complex interplay of factors involved in each case will be unique. Thus the trend towards flexible, comprehensive, behavioural management is to be welcomed. The strength of behaviour therapy lies in its problem-solving approach to treatment and rigorous attention to detail.
Even so, there does seem to be a case for building more detailed and comprehensive typologies of school phobia provided this can be linked to the kind and sequence of treatment approaches appropriate to each case. In particular, more attention needs to be paid to the way in which avoidance behaviours, physiological arousal and self-assessed fear-ratings co-vary in different types of problems undergoing different treatment regimes.
It is clear from the treatment reviews that pupils who have been refusing school for only a few days are much easier to treat than long-standing cases of school phobia. There seems to be a strong case for heightening awareness of school phobia amongst professionals, especially teachers, family doctors and social workers so that problems can be caught early or even prevented. As yet there has been very little research on screening techniques to highlight those pupils most at risk. However, it is interesting to note that a by-product of the community-based treatment approach adopted in Blagg and Yule (1984) was a lowering of the referral rate for school phobia during the years following the study. There was good evidence to suggest that the numbers of children showing this problem did not diminish over time but that teachers, family doctors and social workers became much more aware of the problem and more confident in dealing with it. Indeed, during the latter stages of the Blagg and Yule (1984) study, it was quite common for teachers to call on help from the 114psychologist only after they had carried out much of the diagnostic and treatment planning work. Within each of the secondary schools in the study, a group of teachers at senior management level became very efficient at spotting and handling school phobies.
