Preventing and Treating School Refusal and Severe Social Withdrawal

I first heard about “hikikomori” on a visit to Japan 25 years ago. It was a new term then, used to describe severe and prolonged school refusal in teenagers, sometimes evolving into complete social withdrawal. The person’s life would become confined to a bedroom, with no friends and minimal contact even with family. In extreme cases, the hikikomori would remain isolated for years or even decades.

The problem has grown worse over time. There may now be more than a million hikikomori in Japan, many of whom are in their 20s, 30s, or 40s. The government wonders what will happen in coming decades as their parent’s age and begin to die. Who will care for this army of hermits completely unable and unwilling to care for themselves?

Hikikomori was originally regarded as a phenomenon peculiar to Japanese culture-perhaps related to its perfectionistic expectations, shyness, easy embarrassment, inhibition, parental indulgence, school bullying, wealth, and increasingly constrained job and marital prospects.

But the shut-in phenomenon has since gone global, increasingly reported also in South Korea, the United States, Oman, Spain, Italy, and France.

A major driver is the spread of Internet gaming which can provide someone with an appealing alternate reality and a 24/7 international network of virtual friends-a more compelling and controlled social world than the rough and tumble rejections that occur in everyday life.

On a recent visit to Sweden, I discovered increasing concern about an identical set of behaviors (locally called “home-sitting”) and an excellent program to prevent and treat it, directed by Ia Sundberg Lax and her colleagues in Magelungen Utveckling.

She writes:

School refusal can be the first step toward a complete and lifelong alienation from society- causing personal and family suffering, health problems, unemployment, and large social welfare expenses. The economic costs can be more than one million dollars per person over a lifespan.

Prevention is easier and cheaper than cure. The goal is to help get the person back to school as soon as possible before the withdrawal becomes a deeply ingrained behavior. You have to learn the psychological factors, social context, and educational issues involved in starting the school refusal and what makes it continue.

Our target group is 10-18 year olds, but the method can also help young adults (18-24 year olds) get back to work and/or education.

We use a team approach based cognitive behavioral therapy (CBT) to provide the person, the parents, and the school with new skills and motivation. The team goes where the problem is, often at home or in school.

The program is divided in three phases: assessment, treatment, and maintenance.

The assessment phase aims to understand the reasons for school refusal by asking questions about the school experience, family problems, and the person’s lifestyle. Many kids spend long hours on internet gaming or in social media, as a way of reducing anxiety and negative thoughts.

The assessment provides valuable information about the social and study skills the child will need to get back to school. Many children tell us that they had no friends, feel anxious about school work and homework, and worry what the classmates might say when they return. They also frequently report physical symptoms such as headache or pain in the stomach.

We meet the parents, the principal, and the teachers to uncover learning and social problems, family and peer stresses, and whether there has been teasing or bullying.

All information becomes part of a behavioral analysis-which behaviors need to increase and which need to decrease to get the kid back to school.

We set achievable goals and define sub-targets to reach them. Strong relationships among therapist, child, parents, and teachers are crucial if the plan is to be followed effectively.

The treatment for school refusal focuses on changing the daytime activity schedule; getting a good night’s sleep; waking up at the right time in the morning; normal use of internet; teaching skills to cope with anxiety and negative thoughts about school; helping parents and teachers to support social interaction and discourage avoidance behaviors; teaching and rehearsing social skills; encouraging peer contact; and dealing with family conflict.

Kids who are still in school, but just missing days intermittently, are usually cooperative with the therapists and highly motivated to participate in the treatment plan that gets them back to full schedule. A few months of treatment, followed by occasional maintenance visits usually works well.

Starting treatment early reduces the risks the child will develop severe school refusal, become completely homebound, and refuse to participate in the treatment.

What to do if the kid doesn’t leave his room and won’t talk to you? The main message is- Don’t give up! Be patient and non-invasively persistent. Sit outside the door and talk. Write letters and slip them under the door. Say you will come back tomorrow and try again. Establish contact by email or Skype.

Be creative in finding ways to get the person to communicate with you and gradually accept you into his world. Mention other people with similar problems who were able to solve them. Instill hope. Most of all don’t give up- just being there on a regular basis is half the battle.

A child who doesn’t attend school ruins the daily life of the family and fills it with conflict and nagging about school. It’s important to end the vicious family cycles and forge better family relationships. Your being there automatically helps change a deteriorating family dynamic.

It is not easy, but is essential, that you help the shut-in wean from excessive and consuming use of the internet. The more real life experiences the person has, the less retreat will there be into the virtual world. And going into the virtual world is often an avoidance behavior to reduce discomfort and anxiety in the real world. So in order to help the person, you set gradual, step-wise, realizable goals that include first leaving the room, then spending time with family, going out of the house, and finally going back to school.

Motivational interviewing increases the person’s awareness of the problems and its consequences. When the person is ready for change techniques as behavioral activation and gradual exposure is used.

The therapist will help the person to rank a list of feared situations, an anxiety hierarchy. You start with the easiest situations and work up the hierarchy- reducing isolation, getting more in the swing of real life, and getting closer to school (or work).

When the school attendance is at an acceptable level (for early school refusers you usually reach this phase after a few months, for chronic it take much longer) the third phase, maintenance, starts. The aim of this phase is to make sure that the results of the treatment will continue. We aim to reach the goal of therapist not being needed. If problems occur, the patient, the parents, and the school all know what to do.

Thanks so much for this comprehensive plan of action. A kid not going to school is a crisis moment for a family and a serious problem for the school. Parents and teachers often feel helpless and perplexed. The kid may quickly spiral down into increased anxiety, avoidance, despair, and gaming.

Quick intervention is crucial. Every day of delay reinforces withdrawal and reduces motivation. Isolation is self reinforcing. Prevention is much cheaper and more effective than cure. Successful intervention is much more difficult once the shut-in pattern has been established.

But hope should not be lost, even for the most isolated shut-in. Just as withdrawal creates a vicious cycle of isolation, gradual reentry creates a benign cycle of increasing social comfort. Persistence, patience, courage and skill do pay off. Shut-ins who could never return to regular life on their own are able to gradually wean from their virtual world and rejoin the real world.

Disclosures:

Dr Frances is a Professor Emeritus at Duke University and was the chairman of the DSM-IV task force.