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Somatic symptoms in school refusal: a qualitative study among children, adolescents, and their parents during the COVID-19 pandemic

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Abstract

School refusal (SR) is commonly associated with somatic symptoms that are temporally related to school attendance. Abdominal pain, headache, vomiting, and musculoskeletal pain are frequently encountered and are usually not caused by a physical disease. School refusers, parents and health care workers are often puzzled by these impairing symptoms. In this qualitative study, we assessed somatic symptoms in a population encompassing both school refusers and their parents. We aimed at better understanding experiences and strategies in the management of these debilitating symptoms, while also investigating the journey of these symptoms and their behavioral consequences on the said population. We conducted qualitative interviews both within an Integrated Youth Health Care Unit in Paris and through a French parent-led support group improving care for school refusers. We interviewed 19 young persons with SR (aged 6–21 years old) and 20 parents. Using the Grounded Theory, three themes were identified: (1) somatic symptoms’ journey in four phases (emergence, coping, crisis, and disappearance in the context of school dropout); (2) their deconstruction, indicating the patients’ emotional state; and (3) their management through self-care practices as well as increased emotional and body awareness. Some parents, who could portray similar symptoms at a younger age, mentioned familial pattern of heightened emotional and sensorial sensitivity as a possible cause. Findings suggested that somatic symptoms in SR offer an insight into the patients’ emotional state. We recommend that psychotherapies targeting somatic symptoms could be further assessed in SR, along with educational content aimed at increasing emotional literacy in schools and health care settings.

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Abbreviations

ADHD:

Attention-Deficit/Hyperactivity Disorder

ASD:

Autism Spectrum Disorder

APS:

Association Phobie Scolaire

EAET:

Emotional Awareness and Expression Therapy

GT:

Grounded Theory

SAP:

School Attendance Problem

SE:

Somatic Experiencing

SR:

School Refusal

References

  1. Kearney CA, Graczyk PA (2020) A Multidimensional, Multi-tiered System of Supports Model to Promote School Attendance and Address School Absenteeism. Clin Child Fam Psychol Rev. https://doi.org/10.1007/s10567-020-00317-1

    Article  PubMed  Google Scholar 

  2. Heyne D, Gren-Landell M, Melvin G, Gentle-Genitty C (2018) Differentiation Between School Attendance Problems: Why and How? Cogn Behav Pract 26:8–34

    Article  Google Scholar 

  3. John A, Friedmann Y, DelPozo-Banos M, Frizzati A, Ford T, Thapar A (2022) Association of school absence and exclusion with recorded neurodevelopmental disorders, mental disorders, or self-harm: a nationwide, retrospective, electronic cohort study of children and young people in Wales. UK Lancet Psychiatry 9:23–34

    Article  PubMed  Google Scholar 

  4. Roué A, Harf A, Benoit L, Sibeoni J, Moro MR (2021) Multifamily Therapy for Adolescents With School Refusal: Perspectives of the Adolescents and Their Parents. Front Psychiatry 12:624841

    Article  PubMed  PubMed Central  Google Scholar 

  5. Havik T, Ingul JM (2021) How to Understand School Refusal. Front Educ. https://doi.org/10.3389/feduc.2021.715177

    Article  Google Scholar 

  6. Prabhuswamy M (2018) To go or not to go: School refusal and its clinical correlates. J Paediat Child Health. https://doi.org/10.1111/jpc.14198

    Article  Google Scholar 

  7. Schmitt BD (1986) School refusal. Pediatr Rev 8:99–105

    Article  CAS  PubMed  Google Scholar 

  8. Johnson AM, Falstein EI, Svendsen M (1941) SCHOOL PHOBIA. Am J Orthopsychiatry. https://doi.org/10.1111/j.1939-0025.1941.tb05860.x

    Article  Google Scholar 

  9. Bernstein GA, Massie ED, Thuras PD, Perwien AR, Borchardt CM, Crosby RD (1997) Somatic Symptoms in Anxious-Depressed School Refusers. J Am Acad Child Adolesc Psychiatry 36:661–668

    Article  CAS  PubMed  Google Scholar 

  10. Li A, Guessoum SB, Ibrahim N, Lefèvre H, Moro MR, Benoit L (2021) A systematic review of somatic symptoms in school refusal. Psychosom Med. https://doi.org/10.1097/PSY.0000000000000956

    Article  PubMed  PubMed Central  Google Scholar 

  11. Egger HL, Costello EJ, Angold A (2003) School refusal and psychiatric disorders: a community study. J Am Acad Child Adolesc Psychiatry 42:797–807

    Article  PubMed  Google Scholar 

  12. Honjo S, Nishide T, Niwa S, Sasaki Y, Kaneko H, Inoko K et al (2001) School refusal and depression with school inattendance in children and adolescents: comparative assessment between the Children’s Depression Inventory and somatic complaints. Psychiatry Clin Neurosci 55:629–634

    Article  CAS  PubMed  Google Scholar 

  13. King NJ, Ollendick TH, Tonge BJ, Heyne D, Pritchard M, Rollings S et al (1996) Behavioural management of school refusal. Scand J Behav Ther 25:3–15

    Article  Google Scholar 

  14. Heyne D, Sauter FM, Ollendick TH, Van Widenfelt BM, Westenberg PM (2014) Developmentally sensitive cognitive behavioral therapy for adolescent school refusal: rationale and case illustration. Clin Child Fam Psychol Rev 17:191–215

    PubMed  Google Scholar 

  15. Last CG, Hansen C, Franco N (1998) Cognitive-Behavioral Treatment of School Phobia. J Am Acad Child Adolesc Psychiatry 37:404–411

    Article  CAS  PubMed  Google Scholar 

  16. Chu BC, Rizvi SL, Zendegui EA, Bonavitacola L (2015) Dialectical Behavior Therapy for School Refusal: Treatment Development and Incorporation of Web-Based Coaching. Cogn Behav Pract 22:317–330

    Article  Google Scholar 

  17. Brand C, O’Conner L (2004) School refusal: It takes a team. Child Sch 26:54

    Article  Google Scholar 

  18. Kearney CA, Silverman WK (1999) Functionally based prescriptive and nonprescriptive treatment for children and adolescents with school refusal behavior. Behav Ther 30:673–695

    Article  Google Scholar 

  19. Guessoum SB, Lachal J, Radjack R, Carretier E, Minassian S, Benoit L et al (2020) Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. Psychiatry Res 291:113264

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 19:349–357

    Article  PubMed  Google Scholar 

  21. Patton MQ (2002) Qualitative Research & Evaluation Methods. SAGE

  22. Benoit L, Cottin P, Moro MR (2018) What is a “Maison des Adolescents”? A history of integrated youth health care services in France. Early Interv Psychiatry 12:1000–1005

    Article  PubMed  Google Scholar 

  23. Hetrick SE, Bailey AP, Smith KE, Malla A, Mathias S, Singh SP et al (2017) Integrated (one-stop shop) youth health care: best available evidence and future directions. Med J Aust 207:S5–S18

    Article  PubMed  Google Scholar 

  24. Charmaz K (2006) Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. SAGE

  25. Charmaz K (1991) Good Days, Bad Days: The Self in Chronic Illness and Time. Rutgers University Press

  26. Boussand E, Phan O, Benoit L (2021) Refus scolaire anxieux et addiction aux jeux vidéo chez les adolescents : une revue narrative de la littérature. Neuropsychiatrie de l’Enfance et de l’Adolescence. https://doi.org/10.1016/j.neurenf.2021.04.013

    Article  Google Scholar 

  27. Benoit L, Barreteau S, Moro MR (2015) « Phobie scolaire chez l’adolescent migrant », la construction identitaire dans une approche transculturelle. Neuropsychiatr Enfance Adolesc 63:84–90

    Article  Google Scholar 

  28. Rosenthal L, Moro MR, Benoit L (2019) Migrant Parents of Adolescents With School Refusal: A Qualitative Study of Parental Distress and Cultural Barriers in Access to Care. Front Psychiatry 10:942

    Article  PubMed  Google Scholar 

  29. Martin R, Benoit JP, Moro MR, Benoit L (2020) A Qualitative Study of Misconceptions Among School Personnel About Absenteeism of Children From Immigrant Families. Front Psychiatry 11:202

    Article  PubMed  PubMed Central  Google Scholar 

  30. Miller A (1979) The drama of the gifted child and the psycho-analyst’s narcissistic disturbance. Int J Psychoanal 60:47–58

    CAS  PubMed  Google Scholar 

  31. Miller A (2006) The Body Never Lies: The Lingering Effects of Hurtful Parenting. W. W. Norton & Company

  32. Steiner C (1997) Achieving Emotional Literacy. Bloomsbury

  33. Benoit L. Du refus scolaire au suivi psychiatrique. Trajectoires d’adolescents déscolarisés. 2018. Available: https://www.semanticscholar.org/paper/ed63f0dc48e29f9b547938b07759cec262244b84

  34. Ludot-Grégoire M, Harf A, Ibrahim N, Merlo M, Hassler C, Rietsch J et al (2022) Bodily expression of psychological distress in adolescents: a qualitative study. Child Adolesc Psychiatry Ment Health 16:40

    Article  PubMed  PubMed Central  Google Scholar 

  35. Lumley MA, Krohner S, Marshall LM, Kitts TC, Schubiner H, Yarns BC (2021) Emotional awareness and other emotional processes: implications for the assessment and treatment of chronic pain. Pain Manag 11:325–332

    Article  PubMed  PubMed Central  Google Scholar 

  36. Lane RD, Subic-Wrana C, Greenberg L, Yovel I (2020) The role of enhanced emotional awareness in promoting change across psychotherapy modalities. J Psychother Integr. https://doi.org/10.1037/int0000244

    Article  Google Scholar 

  37. Lumley MA, Schubiner H (2019) Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review. Curr Rheumatol Rep 21:30

    Article  PubMed  PubMed Central  Google Scholar 

  38. Payne P, Levine PA, Crane-Godreau MA (2015) Somatic experiencing: using interoception and proprioception as core elements of trauma therapy. Front Psychol 6:93

    PubMed  PubMed Central  Google Scholar 

  39. Kolacz J, Porges SW (2018) Chronic Diffuse Pain and Functional Gastrointestinal Disorders After Traumatic Stress: Pathophysiology Through a Polyvagal Perspective. Front Med 5:145

    Article  Google Scholar 

  40. Levine PA (2010) In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. North Atlantic Books

  41. Kuhfuß M, Maldei T, Hetmanek A, Baumann N (2021) Somatic experiencing - effectiveness and key factors of a body-oriented trauma therapy: a scoping literature review. Eur J Psychotraumatol 12:1929023

    Article  PubMed  PubMed Central  Google Scholar 

  42. Newman PA, Guta A, Black T (2021) Ethical Considerations for Qualitative Research Methods During the COVID-19 Pandemic and Other Emergency Situations: Navigating the Virtual Field. Int J Qual Methods 20:16094069211047824

    Article  Google Scholar 

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Acknowledgements

We gratefully acknowledge the tremendous help received from the Association Phobie Scolaire (APS) which made it possible to recruit participants for our research. Our warm thanks go to all participants for their time and effort. This research has been supported by QUALab, the Qualitative & Mixed Methods Lab, a collaboration between the Yale Child Study Center (New Haven, CT), and CESP, the Centre de recherche en Epidémiologie et Santé des Populations (Paris, France).

Funding

Dr. Benoit received the financial support of Inserm through a career development award. The authors thank the Thellie crowdfunding platform, the Jasmin Roy Foundation, and private donors.

Author information

Authors and Affiliations

  1. Maison de Solenn, Maison des Adolescents, AP-HP, Cochin Hospital, 97 Boulevard de Port-Royal, 75014, Paris, France

    Anne Li, Agathe Beauquesne, Marie Rose Moro & Laelia Benoit

  2. PCPP, Paris Cité University, 92100, Boulogne-Billancourt, France

    Anne Li & Marie Rose Moro

  3. CESP, UVSQ Inserm U1018, Paris-Saclay University, Villejuif, France

    Anne Li, Marie Rose Moro, Bruno Falissard & Laelia Benoit

  4. French Clinical Research Group in Adolescent Medicine and Health, Paris, France

    Anne Li, Agathe Beauquesne & Laelia Benoit

  5. Department of Pediatric Emergency, AP-HP, Necker-Enfants Malades Hospital, Paris, France

    David Dawei Yang

  6. Sorbonne University, 75006, Paris, France

    Agathe Beauquesne

  7. Child Study Center, Yale School of Medicine, New Haven, CT, USA

    Laelia Benoit

Authors
  1. Anne Li
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  2. David Dawei Yang
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  3. Agathe Beauquesne
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  4. Marie Rose Moro
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  5. Bruno Falissard
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  6. Laelia Benoit
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Contributions

AL: data collection, data analysis. LB: study design, data collection, data analysis. DY, AB, MM, BF: data analysis. All authors approved the final version.

Corresponding author

Correspondence to Anne Li.

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Competing interests

The authors declare no competing interests.

Ethical approval

The study was approved by the Ethics Evaluation Committee of the National Institute of Health and Medical Research (IRB00003888). The Ethics Evaluation Committee requested the consent to be orally recorded to minimize risk of confidentiality breach. All subjects gave informed consent for the research and its publication in accordance with the Declaration of Helsinki and French law.

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Li, A., Yang, D.D., Beauquesne, A. et al. Somatic symptoms in school refusal: a qualitative study among children, adolescents, and their parents during the COVID-19 pandemic. Eur Child Adolesc Psychiatry (2023). https://doi.org/10.1007/s00787-023-02313-6

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