Unearthing the drivers of school refusal in any individual young person can be challenging, and each young person may be different from other young people.
My research with school nurses in Western Australia suggests that at least some of these drivers are likely to be occurring outside the school gates.
Anxiety about the state of the world, difficulties with peers, family problems and health issues are common factors that contribute to poor psychosocial health in children and young people.
Over time, these difficulties can lead to school refusal.
Addressing school refusal requires all hands on deck, and should utilise all available expertise both within and external to the school.
This expertise will necessarily be drawn from both the health and education sectors, and this is where school nurses can bring a wealth of knowledge and expertise.
School nurses are typically based on the school premises, although some will provide a part-time or visiting service. Most school nurses are registered nurses and have completed a three-year bachelor’s degree at university.
This is important, because health service provision to children and young people is a specialised area of practice and should call on the skills and expertise of genuine health professionals.
In Australia the title of nurse is protected, and an individual cannot call themselves a nurse unless they have recognised nursing training and credentials in the Australian context.
School nurses are uniquely positioned to recognise early signs of school refusal, assess young people’s psychosocial health, engage with families, and facilitate access to the broader healthcare system.
In this series of articles, we first consider a short case study illustrating the complex health issues that can contribute to emerging school refusal.
Jacob was a 14-year-old boy living with his mother and grandparents. While Jacob got on well with his grandparents, he sometimes felt he didn’t have much time with his mother.
Her employment role was demanding and required significant travel. Her work often took up much of her time and attention even when she was at home.
As a child Jacob coped with these difficulties by eating. Over a period of years, he had become quite overweight and now also experienced sleep apnoea because his chest and abdomen were so heavy.
Although he couldn’t have told you this, it meant that he stopped breathing for short periods on multiple occasions every night.
This had a significant impact on his sleep quality and most mornings he woke up irritable and tired. Not unexpectedly, he was often late for school.
Now that he was a bit older he had started experimenting with alcohol and recreational drugs to manage the challenges in his life. His attendance at school had also started to drop off.
At first it wasn’t that noticeable, maybe one day a month. But increasingly it became more often, and his absences started to interfere with his academic progress.
This is when Jacob first came to the attention of the school’s pastoral care team, and he was identified as a student at educational risk.
On those days he was at school, Jacob often presented to the school nurse because he had pain. His weight made it difficult to be mobile and sometimes his joints ached.
He hated phys-ed and often presented to the school nurse at the start of the class, just to avoid it. He knew the school nurse was onto him about this. Other times he presented to the nurse with abdominal pain.
Often he didn’t eat breakfast in the morning because he was late, and if he didn’t have money to buy lunch he could go all day at school without eating. This made his stomach hurt.
Initially he would ask the nurse for some pain medication, but sometimes he sought permission to go home. The school nurse rarely let him go home, but that was ok because she made him a toastie and some Milo before sending him back to class.
If she wasn’t too busy she would chat with him about his life for a short while. Over time, he told her a lot of things he hadn’t really mentioned to anyone else before.
Other times she would talk to him about how to make healthy food and how to get better sleep. Although he found it hard to put these things into practice, talking to her helped him feel better.
As the case study above illustrates, school nurses are well positioned to identify and assess early signs of difficulties. They typically have well-developed knowledge of the health services available in the local area and can refer presenting concerns in health terms to other health professionals.
Young people, their families and other caregivers can find it difficult to articulate the health problems they’re experiencing, and this in turn can present a significant barrier to accessing the broader health system.
In a subsequent article we will consider a broader range of health issues that may be contributing to school refusal and examine the importance of early intervention in these types of cases.
