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School Refusal

School Refusal. 吳佑佑 醫師 宇寧身心診所 www.yuning.tw 台北市大安區復興南路二段 6 號 3 樓. 吳佑佑. 現職：宇寧身心診所負責人 長庚紀念醫院精神部兒童心智科兼任主治醫師 學歷：私立中國醫藥學院醫學系學士（ 1987.06 ） 美國南康州州立大學特殊教育研究所碩士 2003.01 經歷：長庚紀念醫院精神科住院醫師（ 1987.07—1990.06 ） 國立台灣大學附設醫院兒童心理衛生中心研究員 （ 1990.07--1992.06 ） 長庚兒童醫院兒童心智科主任

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School Refusal

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  1. School Refusal 吳佑佑 醫師 宇寧身心診所 www.yuning.tw 台北市大安區復興南路二段6號3樓

  2. 吳佑佑 現職：宇寧身心診所負責人 長庚紀念醫院精神部兒童心智科兼任主治醫師 學歷：私立中國醫藥學院醫學系學士（1987.06） 美國南康州州立大學特殊教育研究所碩士 2003.01 經歷：長庚紀念醫院精神科住院醫師（1987.07—1990.06） 國立台灣大學附設醫院兒童心理衛生中心研究員 （1990.07--1992.06） 長庚兒童醫院兒童心智科主任 ( 1995.06--2002.07, 2008.07—2011.08) 耶魯大學兒童研究中心研究員 (2001.09—2002.08)

  3. 不去上學症候群（拒學症） • School Refusal is classified as a childhood emotional disorder, describing children who refuse to go to or stay in school with significant short and long term sequelae. • 拒學被歸為兒童情緒障礙 描述拒絕到學校或留在學校已造成明顯短期或長期的後遺症 (Royal College of Psychiatrists 2003) • 懼學症（school phobia）- 1941 • 拒學症（school refusal） • 避學症（school avoidance）

  4. 定義 • 困難上學且缺課一段時間 • 情緒困擾如逼上學則出現身體症狀 • 家長知道學童留在家沒上學 • 沒有明顯反社會行為 • 逃避學校中特定畏懼或焦慮的對象 • 逃避不舒服的社交狀況 • 分離焦慮行為 • 校外活動吸引力大過於學校

  5. School Refusal and Truancy

  6. 拒學的發生率 • 高峰期 • 剛上小學的新生 • 進入青春期的國小五、六年級、國中生 • 佔學齡人口的 1~2 ％ • 男女比例相當 • 青少年比兒童多 • 年齡愈大，障礙通常愈嚴重，預後也較不好 • 低年級：典型的害怕症狀 • 青少年：身體症狀及明顯拒絕上學的態度 資料來源：台大醫院兒童心理衛生研究中心

  7. A child may exhibit each behavior on this spectrum at different times

  8. Common symptoms that could signal school refusal behavior

  9. Somatic Symptoms in School Refusal

  10. 拒學的可能原因 • 個人因素 • 個性特質， • 挫折忍受力低 • 精神病理學 • 家庭因素 • 調和家庭衝突 • 害怕離家 • 社會文化所許可的：如家人同意他在家照顧弟妹、賺錢或逃避考試。 • 學校因素 • 學校中有危險，個案害怕他的身體受到傷害。 • 老師 • 上學途中或校內發生的事 • 功課、考試

  11. Other mental illness, ASD

  12. 拒學的協助要點 • 盡快回到學校 • 增加學校的吸引力 • 家人間的溝通 • 尋求專業協助

  13. Practice recommendations • Assess forms of a child’s school refusal behavior as well as reinforcers that maintain the problem. • Assessed for severe anxiety and depression. • Treat medical conditions associated with school refusal behavior, work with school-based personnel to gradually reintroduce a child to school and address comorbid educational, psychological, and familial problems. Dealing with school refusal behavior J. Of Family Practice August 2006 · Vol. 55, No. 8

  14. Goals: schooling ASAP • Attend school on consistent basis • Parents establish and maintain appropriate boundaries, setting firm, consistent limits • Eliminate anxiety prior to leaving home and after arriving at school • Eliminate somatic complaints • Resolve the core conflicts contributing to the emergence of the school refusal • Increase frequency of independent behaviors

  15. How to Help • Parents agree that student the must go to school everyday • Apply tough love principles. The student can talk all day about wanting to go to class, but he/she will often not go until they are forced to go. • Parents acknowledge that when they let their child stay home, it will be much more difficult tomorrow to get the student to come to school. • Allow child time to cry in class. Most students will stop after a few minutes. • Speak with child later in the day. Compliment them on doing a great job staying in class. Let them express their fears and embarrassments. Set a plan for how things can go smoother tomorrow. • Have a class buddy (buddies) make a plan with the student on where they will meet in the bus, breakfast room or hallway. • Assist teacher in setting special projects/activities that the student will enjoy.

  16. TREATING YOUTHS WITH SCHOOL REFUSAL BEHAVIOR • Psychopharmacology • Selective serotonin reuptake inhibitors (SSRIs), Benzodiazepine, Neuroleptics, B-blockers, Others • Cognitive management • Child-based to manage anxiety in a school setting • Behavior contract with child • Parent-based manage contingencies for school attendance and nonattendance • Family-based to manage incentives and disincentives for school attendance and nonattendance. • School management • Flexibility • Academic support

  17. 我不是不想上學 • 媽媽，我不要去上學：淺談拒學 • 情緒牢籠：躁鬱症 & 憂鬱症 • 請不要離開我：分離焦慮症 • 擔心到破表：焦慮症 • 害怕在心口難開：選擇性不語症 • 星星兒悲歌：典型自閉症 • 完美的靈魂不允許被污衊：亞斯伯格症 • 無止盡的循環：強迫症 • 是真實還是虛幻：精神分裂症 • 歷劫歸來「憶」難忘：創傷後壓力症候群 • 灰姑娘上學去：以童話故事為媒介 • 「專心」溜走了：注意力不足過動症

  18. Psychiatric Disorders • 分離焦慮症：害怕跟父母分開，五成至八成個案會非常緊張，不願上學或是抱怨身體不適，如頭痛、胃痛、噁心或嘔吐。 • 通常到成人才會出現的精神疾病： • 憂鬱症(個案可能會有心情不佳、變得不愛講話、活動力減少、睡眠或胃口有改變、功課退步等症狀)， • 躁症的個案則是所需要的睡眠減少、較多話、心情可能變可能變得特別高興，但有的則是暴躁。 • 過度焦慮症(個案害怕與人接觸) 、畏懼症、恐慌症社交畏懼症則是個案害怕與人接觸，可能因而會逃避上學。 • 恐慌症的個案會有突發的、陣發性的症狀出現，可能的症狀包括心悸、發抖、覺得呼吸困難、胸部疼痛或不舒服、噁心、腹部不舒服、頭暈、害怕自己快死了，而身體的檢查（包括心電圖）都找不出其他病因。患者可能會不去上學，甚至避免一個人留在家中，因為擔心沒人在旁照顧。 • 精神異常較嚴重，誤以為有人要害他，也可能因而不去上學。 • 強迫症或嚴重的精神異常。 • 其它

  19. Separation Anxiety Disorder • Prevalence of about 2% • Children aged 5 to 8 most commonly report unrealistic worry about harm to parents or attachment figures and school refusal. • Children aged 9 to 12 usually manifest excessive distress at times of separation, whereas adolescents most commonly manifest somatic complaints and school refusal. • Boys and girls manifest similar symptoms of separation anxiety disorder. • 75% of children with separation anxiety disorder manifest school refusal

  20. 兒童青少年期焦慮症的種類 • 恐慌症 (Panic Disorder) • 廣泛性焦慮症 (Generalized Anxiety Disorder) • 特定對象恐懼症 (Specific Phobia) • 社交恐懼症 (Social Phobia) • 強迫症 (Obsessive-Compulsive Disorder)

  21. 認識恐慌症 • 恐慌發作 • 突然極度強烈的害怕或不舒服，有快要死掉的感覺 • 至少出現四種生理症狀，如：心悸、出汗、窒息、顫抖、呼吸短促、肌肉緊繃、胸悶、頭暈、噁心想吐、肚子痛 • 症狀發作來得快，去得也快

  22. Afraid to entering to school • Multiple somatic discomfort • Aggression at home to avoid school • Panic attack

  23. 特定對象恐懼症的診斷 • 對已經出現或預期出現的特定物體或情境產生明顯過度或不合理的害怕反應 • 接觸到該刺激時，幾乎立即引發焦慮。兒童可能以哭鬧、亂發脾氣、身體僵硬發抖或緊緊黏住大人的行為來表現 • 大人能夠理解自己的害怕是過度或不合理的，但兒童不見得 • 會主動避開或痛苦忍耐

  24. 社交恐懼症的診斷 • 對一種或多種社會情境持續產生明顯過度或不合理的害怕反應，尤其怕被別人審視。 • 接觸到該情境，幾乎立刻引發焦慮。 • 大人能夠理解自己的害怕是過度或不合理的，但兒童不見得。 • 會主動避開或痛苦忍耐。 • 干擾日常生活及學習表現。

  25. 強迫症的診斷 • 強迫意念 (Obsession) • 反覆而持續的思考、衝動或影像，造成明顯的焦慮或痛苦。 • 不只是針對現實生活問題的過度憂慮而已。 • 會設法忽視或壓抑。 • 這些意念是由自己心理產生的。 • 強迫行為 (Compulsion) • 重複的行為或心智活動。 • 做出強迫行為以避免或減少痛苦，但兩者不見得有關聯。

  26. 重鬱症(major depressive disorder) • 如果一個人在兩星期內，有下列五種以上的症狀，尤其是第一項及第二項，便符合了重鬱症的標準。 • １　幾乎每天心情都非常惡劣２　幾乎對每件事或活動喪失原有的興趣３　因胃口的改變而造成體重明顯的下降或增加４　幾乎每天失眠或睡得太多５　心智反應變得焦躁或遲緩６　易感到疲累且失去活力７　對許多事情變得沒有信心，甚至有罪惡感８　思考能力減退，且注意力無法集中９　有自殺傾向及企圖

  27. Depression • Irritability is often the primary symptom • Suicidality increases substantially after age 10 • Kids often brighten temporarily when in positive environment or with friends • School performance often drops (amotivation, poor concentration)

  28. 躁症 A.在清楚的一段時期內，異常且持續地具有高昂的、開闊的、或易怒的心情，延續至少一星期 B.心情障礙期間，下列症狀中三項持續存在： (1)膨脹的自尊心或自大狂 (2)睡眠需求減少 (3)比平時多話或不能克制地說個不停 (4)意念飛躍或主觀經驗到思緒在奔馳 (5)注意力分散 (6)增加目的取向之活動或精神運動性激動 (7)過份參與極可能痛苦後果的娛人活動

  29. Autism Spectrum Disorder (ASD) • Autism, Asperger’s • Impairment in Language • Deficits in social functioning • Abnormally restricted activities and interests

  30. Learning disorder (academic skills disorders) 學習障礙 • Reading disorder (閱讀障礙) • Mathematics disorder (數學學習障礙) • Disorder of written expression (書寫障礙) • Developmental coordination disorder (動作協調障礙) • Expressive language disorder (語言表達障礙) • Mixed receptive expressive language disorder (語言接受理解及表達障礙) • Phonological disorder (構音障礙) • Stuttering (口吃) A specific learning achievement, as measured by individually administered standardized tests, is substantially below that expected given the person’s chronological age, measured intelligence, and age appropriate education Interferes with academic achievement or activities of daily living requirement

  31. 建議 • 輔育院除做智力評估外，應對學員做學習 能力的評估，對收容的兒童青少年進一步的提供補救教學，應設立專職特教老師數名的職缺，或請教育部或教育局支援。 目前解決此一議題尚存有困難

  32. Schizophrenia • Delusions Grandeur • Control • Persecution • Reference • Thought disorder • Loose associations • Cognitive slippage • Distorted Perception • Hallucination: Auditory, Visual, Tactile • Loss of motivation • Social withdrawal

  33. 1991-1994, 9 centers, 1256 (57% male, 43% female ) • Elementary: 357, Junior high school: 636, High school:236. Peak age 13-14 years old. • 84% double parents, 15% sibling has the same problem. • 44% history of school refusal. • 50% seek help within 3 months.

  34. Mental Retardation • Etiology: • 30% inborn chromosomal & metabolic abnormalities • Prenatal infection, intoxication • Perinatal trauma • Postnatal infection, hyperbilirubinemia, trauma • Psychosocial deprivation • Mild 輕度 (IQ 50-70): 85%, educable with social and vocational skills, 6th grade level • Moderate 中度 (IQ 35-49): 10%, 2nd grade level, unskilled tasks in sheltered workshop • Severe 重度 (IQ 20-34): 3-4%, basic self care skill • Profound 極重度 (IQ below 20): 1%, constant supervision

  35. 資料來源：教育部訓委會。

  36. 國 中 小 學 生 中 輟 率 及 復 學 率

  37. Thank you for your attention!

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