A study to evaluate the effectiveness of self-instructional module (SIM) on knowledge of teachers regarding school refusal behaviour among
School going children, in selected government high schools
At Bangalore.
M.Sc., Nursing Dissertation Protocol Submitted to
Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore – 560 041
By,
Mr. Girish D.S.
(M.Sc., Nursing I Year)
Under the Guidance of
Prof. M.V. YASHODAMMA
HOD, DEPT. OF PSYCHIATRIC NURSING
Smt. Nagarathnamma College of Nursing,
Soldevanahalli, Bangalore -560090
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1 / NAME OF THE CANDIDATEAND ADDRESS / MR: GIRISH D.S.
Smt. NAGARATHNAMMA COLLEGE OF NURSING,
SOLDEVANAHALLI,
HESARAGHATTA MAIN ROAD,
BANGALORE 560090
2 / NAME OF THE INSTITUTION / Smt. NAGARATHNAMMA COLLEGE OF NURSING,
SOLDEVANAHALLI,
HESARAGHATTA MAIN ROAD,
BANGALORE 560090
3 / COURSE OF THE STUDY / I YEAR M.SC NURSING
PSYCHIATRIC NURSING
4 / DATE OF ADMISSION TO THE COURSE / 16-06-2010
5 / TITLE OF THE TOPIC / EFFECTIVENESS OF SELF-INSTRUCTIONAL MODULE (SIM) ON KNOWLEDGE OF TEACHERS REGARDING SCHOOL REFUSAL BEHAVIOUR AMONG SCHOOL GOING CHILDREN, IN SELECTED GOVERNMENT HIGH SCHOOLS AT BANGALORE.
6 / BRIEF RESUME OF THE INTENDED WORK:
6.1 / NEED FOR THE STUDY
Many terms have been applied to school refusal behaviour, including problematic absenteeism, truancy, psychoneurotic truancy, and school phobia and separation anxiety. Each term describes a subset of youths with school refusal behaviour. The behaviour applies to 5 t0 17 year children who are completely absent from school. The peak age of onset of school refusal behaviour is 10 to 13 years, though many youths entering a school building for the first time appear especially vulnerable. School refusal behaviour is equally common among boys and girls1.
The varying degrees of School Refusal Behavior:
· Initial School Refusal Behavior – for a brief period (less than two weeks) may resolve
without intervention
· Substantial School Refusal Behavior – occurs a minimum of two weeks
· Acute School Refusal Behavior – two weeks to one year, being a consistent problem for
a majority of the time
· Chronic School Refusal Behavior – interferes with two or more academic years2.
School refusal behaviour can lead to serious short-term problems such as distress academic decline, alienation from peers, family conflict and financial and legal consequences. Common long-term problems include school dropout, delinquent behaviours, economic deprivation, social isolation, marital problems and difficulty in maintaining employment. Approximately 52% of adolescents with school refusal behaviour meet criteria for anxiety, depressive, conduct-personality or other psychiatric disorder later in life3.
School refusal behaviour may be initial school refusal behaviour for a brief period may resolve without intervention. Substantial school refusal behaviour occurs for a minimum of two weeks. Acute school refusal behaviour involves cases lasting two weeks to one year, being a consistent problem for the majority of that time. Chronic school refusal behaviour interferes
With two or more academic years as this refers to cases lasting more than one calendar year. While some school refusers exhibit a more heterogeneous presentation, typically these youths
Can be categorized into two main types of troublesome behaviour ….. Internalizing or externalizing problems. The most internalizing behaviour problems are generalized worrying, social anxiety and isolation, depression, fatigue and physical complaints (examples stomach aches, nausea, tremors and headaches). The post prevalent externalizing problems are tantrums (including crying and screaming), verbal and physical aggression and oppositional behaviour4.
School refusal is a problem that is stressful for children, families, and school personnel. Failing to attend school has significant short- and long-term effects on children's social, emotional, and educational development. School refusal often is associated with co morbid psychiatric disorders such as anxiety and depression. It is important to identify problems early and provide appropriate interventions to prevent further difficulties. Assessment and management of school refusal require a collaborative approach that includes the family physician, school staff, parents, and a mental health professional. Because children often present with physical symptoms, evaluation by a physician is important to rule out any underlying medical problems5.
Although a variety of efficacious interventions are available to reduce or eliminate school refusal behaviors, it is quite possible that in reality, school personnel are not properly responding to students displaying these behaviors. In a survey of elementary and secondary school principals from North Dakota schools, Stickney and Miltenberger (1998) attempted to assess schools’ responses to school refusal, as well as gather information regarding the characteristics and prevalence of this behavior. Study found that about 90% of the school refusers were confronted and 89% had parents notified about the behavior. The behavior was addressed in a meeting between the teacher or school administration and the child’s parents in only 58% of the cases. Most frequently, children met with school counselors in 64% of the cases of school refusal. Stickney and Miltenberger found that schools made referrals to outside agencies in only 60% of the cases. Referrals sources included social workers (22%), juvenile courts (18%), mental health professionals (19%), physicians (7%), and psychiatrists (4%). Based on this research, it appears that school officials need to be educated on the importance of intervening with school refusal behavior. Education regarding the availability of community
Mental health resources to aid children exhibiting this behavior may also be beneficial6.
The percentage of youths who refuse to attend school is difficult to pinpoint, though 5-28% are likely to display school refusal behaviour at some point in their lives. According to the nation center for education statistics (2006), skipping time from school accounted for 26.1% of days missed from school accounted for 26.1% of days missed from school among 12th graders. These numbers were 15.6% 10th graders and 9.0% for 8th graders. In addition, tardiness to school may affect 4.4- 9.5% of youths and intense distress during school attendance may affect 1.7-5.4% of youths7.
When asked about school refusal behaviour in the year 1998, 63 out of 300 psychologists in youth and family practices responded with information regarding age of client, the length of treatment, the reason for school refusal behaviour and the method and success of treatment. It was found that 11.2% of clients with school refusal behaviour were between the age of 5 and 6, 31% between 7 and 9, 21% between 10 and 12, 20% between 13 and 15 and 15% were between the ages of 16 and 178.
Stickney and Miltenberger polled 288 schools in regards rate of school refusal across grades K-12. Between all thirteen grade levels, a prevalence rate of 1.7% was reported. The highest reported incidence of school refusal behaviour case between ninth and twelfth grade, which was 4.5% of sample population. Next was grades 7 through 12 which was 3.9%, 7 through 8 2.3%, 5 through 6 1.3%. it was also found that 49% of school refusers reported somatic complaints that were accompanied by any medical condition while 30 % reported somatic complaints that did have an accompanying medical condition. In regards to the reason refusing, 13% reported depression or other affective difficulties; another 13% reported difficulties with separating from their care giver and 27% avoided school to pursue more enjoyable activities9.
The school serves as the agent for transmitting the values of the society to each succeeding generation of children and as the setting for many relationships with peers, as a socializing agent second only to the family; the school exerts a profound influence on the social development of children. Although school should provide a safe environment for
fostering education and self-esteem, it may also be a violent and stressful environment. It is estimated that corporal punishment is administered approximately 1 to 2 million times a year in the united states (AAP2000). Corporal punishment by teachers can result in both physical and intense psychologic stress to students. Studies show that when corporal punishment in school is abolished, attendance, scholastic performance and moral improve10.
To facilitate the transition from home to school, teachers should have personality characteristics that allow them to deal with the needs of young children. Teachers, like parents are concerned about psychologic and emotional welfare of children. Teacher’s primary responsibility is stimulating and guiding children’s intellectual development. The differential systems of reward and punishment administered by teachers affect the emotional adjustment and self concept of children as well as how they respond to school in general10.
From the above mentioned statistics, researches, and examples and its outcomes, it was felt that there is a need to conduct a study which could increase the knowledge of teachers, as school personnels are frequently the first professional to identify the existence of a problem that requires immediate attention and intervention. School personnel play a vital role in alerting parents to the problem and helping facilitate referrals for treatment mental health specialists.
6.2 / REVIEW OF LITERATURE
A study was conducted on outcome of children with school refusal. Study assessed 33 subjects (8-16yrs) presenting with school refusal. The Missouri Assessment of Genetics Interview for Children (MAGIC) to ascertain psychiatric diagnoses, Parent Interview Schedule (PIS), and the Children's Global Assessment Scale (CGAS). The study resulted in Twenty-nine subjects (87.9%) had a psychiatric diagnosis at baseline. Depressive disorder (63.6%) was commonest followed by specific phobias (30.3%). Psycho-social factors influenced school refusal in a majority (87.9%). Twenty of the thirty subjects (66.6%) who could be followed-up had returned to school. The study came to conclude that: Psychiatric morbidity is high in a clinic population of youngsters with school refusal. It is associated with temperamental, family, and other environmental adversities11.
A study was conducted on feelings of school avoidance, depression and character tendencies among general high school children. The study assessed 425 first year and second year high school students with questionnaire method on children’s depression inventory (CDI) and school refusal personality scale. The study resulted that mean CDI score and standard deviation was 19.44 +/- 7.49, and that for 'feelings of school avoidance' was 20.18 +/- 5.61. The two subordinate factors of the School Avoidance Scale were intimately associated with both 'feelings of interpersonal maladaptation' and 'core depression' of the CDI, and negatively correlated with the 'obsessive-compulsive' factor of the School Refusal Personality Scale12.
A study was conducted on forms and function of school refusal behaviour in youth; an empirical analysis of absenteeism severity. The study included 222 youths aged 5 to 17yrs (134males, 88females) with school refusal behavior and their parents. Participants were assessed at a specialized university-based clinic for youths with school refusal behavior. Study results in: Hierarchical regression analysis and structural equation modeling revealed that function was a better determinant of degree of school absenteeism than behavior form. The study came to conclusion that Assessing the function of school refusal behavior is likely a key factor in the evaluation of that population and may be linked to informed decisions about choice of treatment13.
A study was conducted on socio medical study of factors related to the occurrence of children’s refusal to attend school and Evaluation of school refusal inducing factors. The study assessed 1030 students (518 male and 512 female junior college students) were classified into three groups (school-refusal group, school-refusal emotion group and non-refusal group). The results are as follows: 1) Of 1030 students, 76 (7%) were included in school-refusal group, 132 (13%) in school-refusal emotion group and 822 (80%) in non-refusal group. 2) In the school-refusal group, students with three or more school refusal-inducing factors accounted for 70% of the total14.
A retrospective study of 27 consecutive child-patients seen at the Child Psychiatric Clinic from 1996-2001 for school refusal showed that there were more boys than girls with the condition. Students of all school grades were represented. More of them complained of somatic symptoms than of psychological symptoms. 16 out of the 27 patients attended school
Successfully after treatment. Of the 11 who failed to attend school, 9 were aged 10 and above and 3 of these 9 patients later exhibited psychotic symptoms. Of the 16 who returned to school, 8 of them did so within 8 weeks of treatment15.
A study was conducted on characteristics of school refuters toward the development of high risk profile. The sample consisted of 57 school refusers and 57 nonrefusers. As compared with nonrefusers, the refusers had changed schools more often, somatic complaints, and were perceived by their parents and teachers as more difficult to manage. Stepwise multiple regression analyses revealed that school refusal status could be predicted by both situational and personality variables including the child's fear level, dependency, depression, frequency of school changes, and other variables. Refusal onset frequently coincided with situational stress (e.g., the beginning of the school year, a new school or teacher, or trouble with a teacher or peers). In the future, these risk factors can be used to identify and treat potential school refusers16.
A study was conducted on characteristics of those who refuse to attend school. An analysis based on teacher’s report. They investigated the characteristics of children who refused to attend elementary and junior high schools in Fukuoka City, The main results were as follows: Prevalence of school refusers in elementary schools (0.13%) was much higher in Fukuoka City , but almost similar in junior high schools (0.47%). These results suggest that school refusers, who may have a borderline personality organization, are likely to prevail17.
A study was conducted on characteristics of adolescents with school refusal. A study assessed 192 adolescents for school refusal between1994-98 at the Rivendell Unit, Sydney, Australia were identified. Study resulted in School refusers had a high prevalence not only of anxiety, but also of mood and disruptive behaviour disorders. The study concludes that School refusal in adolescence can be a symptom of a variety of disorders, particularly anxiety and mood disorder. Treatment programs need to be geared to the range of diagnoses which occur in this patient group and to the various circumstances associated with the onset of the problem18.
A study was examined the predictors associated with the severity of school refusal in a sample of children who were diagnosed with an anxiety disorder and displayed school refusal behavior. This investigation included 76 children ranging in age from 6 to 17 years that had been diagnosed with an anxiety disorder. Subjects in this study had participated in a treatment investigation at the Anxiety Treatment Center of Nova Southeastern University. Data collection occurred via parent and child interview, review of school records regarding absenteeism, and completion of questionnaires including the Fear Survey Schedule for Children-Revised, Modified State-Trait Inventory for Children, Children’s Depression Inventory, and the Family Environment Scale19.