Why we need to rethink our approach to school refusal.

It probably comes as no surprise that our students are often in a state of school refusal when they are admitted into our hospital. Some have been out of school for up to a year, and even before the non-attendance due to medical needs, there would be a significant history of school anxiety. Often, a link with their pastoral teacher and a gentle integration into our school works, but sometimes the refusal runs so deep that all attempts to educate are futile and each interaction is met with a more active refusal.  

The difficulty with bringing a young person in a state of refusal to education came up in a meeting recently. Our teachers sought solutions, and mirroring the young person’s refusal itself, the discussion became circular. The problem was presented, a reward-centred solution discussed, frustration at it not working expressed, and then we went back to the problem of refusal again.

Because that’s the issue with refusal – it can become a stalemate with the young person refusing to relinquish control and the teacher desperately trying to find some way of controlling the situation in order to help the child. 

Which all results in a deadlock.

I spoke to a student of mine about this as she was considered to be in a complete state of refusal when she was admitted. I asked her what worked for her, and she shared with me her incredible insight. To her, it boiled down to being respected that she knew what she needed in order to learn. She said that a reward/punishment approach would not have worked because that would have made her feel manipulated. She believes that had the wrong approach been taken from the start, she would never have made the progress she did. She needed to feel understood.

From my end, I know when I started working with her, delivering education was a gentle negotiation, and it was always important that this student felt she was in control. I would never begin a lesson without asking her permission to be in the room. I would remind her that she could end the session whenever she wanted to, but I would be returning for the following lesson at our scheduled time – signalling that the rejection was not personal. We talked further about this, and she brought up the medical condition: Pervasive Refusal Syndrome* coined by Bryan Lask, and used until one day a patient told him that this term was unfair and created negative associations. He then changed the term to Pervasive Withdrawal Syndrome. My student said she was never refusing, she was withdrawing to keep herself safe.

I saw this played out on the ward the next day when one of our most prolific “refusers” would not come over to school again that morning, until another student went over to her and said that she would take her to school and keep her company. It worked. She got up immediately and followed her friend, walking alongside in the safety of the student who had reached out to her.

I believe it begins with language.

School-based withdrawal is very individual and there is no one way to make a young person feel they are able to engage with school but it is worth sharing and discussing how to understand and support. Sometimes, the teacher needs to step back and sometimes, the teacher needs to be very present. The perceived power should always stay with the withdrawn student and the teacher should take gentle, slow, consistent steps. The most powerful act from a withdrawn student is them trusting you enough to take the first step towards you, even if it takes them a significant length of time to do so.

I told my student that I will be delivering training sessions on school withdrawal next academic year and asked whether I could record some of our conversations as part of the training series. She agreed but, even then, I ended our discussion with, ‘you know, you can always say no – that’s completely ok.’

I see myself as invited into the withdrawn student’s space, even if I’m the teacher in charge of that lesson.

Samreen Shah

*Pervasive refusal syndrome is a severe, pervasive and life-threatening disorder. Most commonly seen in girls between the ages of 8 and 15, although also affecting boys and younger age groups, it is characterised by a profound and pervasive refusal to eat, drink, talk, walk and engage in any form of self-care. A determined resistance to treatment is a striking component of the condition. The causes are unclear, but likely to be complex, multiple and associated with a sense of hopelessness. (Pervasive refusal syndrome

Published online by Cambridge University Press:  02 January 2018)