Le recours à l’équipe mobile : la réponse de choix dans le refus scolaire ?

Abstract

Le refus scolaire est une problématique courante qui est susceptible de concerner tous les élèves et qui peut avoir des conséquences délétères sur la santé mentale à moyen et long terme (King et al., 2000). En Suisse, environ 5 % des élèves ne se rendent pas en cours régulièrement, dont la moitié pour des raisons psychiatriques (Holzer et al., 2006). Le retard à l’identification des cas par l’école, la banalisation et la tolérance de l’absentéisme scolaire par les parents ou les professionnels contribuent à retarder l’instauration de soins appropriés pour le refus scolaire. Comme le pronostic s’aggrave avec la durée de l’absentéisme scolaire, et comme le temps nécessaire pour obtenir une fréquentation scolaire normale (supérieure à 90 % des périodes scolaires) est grossièrement équivalente à la durée de l’absentéisme lui-même, nous considérons que le refus scolaire est une urgence qui nécessite une identification et un traitement précoces. Alors que la conceptualisation cognitivo-comportementale des différents types de refus scolaire a progressé, les programmes de traitement manualisés qui en découlent n’ont pas fait la preuve de leur supériorité par rapport aux soins usuels (Elliott et al., 2017). Le processus de soin est complexe et souvent paralysé dans l’immobilisme généré par le refus scolaire. Les équipes mobiles pour enfants et adolescents sont pertinentes dans cette problématique et peuvent améliorer l’ensemble du processus de soins en (1) faciliter l’identification des cas à travers une étroite collaboration avec les écoles, les pédiatres et les généralistes, (2) évaluer le comportement de refus scolaire selon les catégories de Kearney et Albano (2007) qui permettent d’orienter les options de traitement, (3) initiation rapide du traitement incluant l’accompagnement scolaire, (4) offrir un soutien et une guidance parentale, (5) instaurer une coordination interdisciplinaire avec les écoles, les services sociaux, les services pédopsychiatriques et les parents. Une stratégie par étapes a été développée dans le secteur lausannois, commençant par la consultation ambulatoire, suivie par une intervention rapide de l’équipe mobile et complétée par l’hospitalisation de jour ou à temps complet si nécessaire, et par des interventions des services sociaux qui peuvent avoir des effets de levier.

School refusal is a common concern for all pupils and may have deleterious consequences for long-term mental health (King et al., 2000). In Switzerland, almost 5% of pupils do not attend school on a regular basis, half of them for psychiatric reasons (Holzer et al., 2006). Delayed identifications of cases by schools, normalization and tolerance of school absenteeism by parents or professionals contribute to delay appropriate care for school refusal. As prognosis worsens with the duration of school absenteeism, and as the duration time necessary for obtaining normal school attendance (i.e. ≥ 90%) is roughly equal to the duration of school absenteeism itself, school refusal can be considered as an emergency and needs early identification and intervention. Despite progress in cognitive and behavioral conceptualization, the manualized treatment programs inspired by such advances have not been found to be superior to normal treatment (Elliott et al., 2017). The treatment process is characterized by complexity and inertia generated by school refusal. Child and adolescent mobile teams are relevant for that purpose and may facilitate the whole process by (1) facilitating identification of cases in close collaboration with schools, pediatricians and GP, (2) assessing school refusal behavior according to Kearney and Albano categories (2007) orienting treatment options, (3) prompt initiation of treatment including school accompaniment, (4) parental guidance and support (5) interdisciplinary coordination with school, social services, psychiatric services and parents. A step-by-step strategy has been developed in the Lausanne Catchment Area, starting with outpatient consultations and followed by rapid intervention of the mobile team, and completed with day care or inpatient hospitalization measures if needed, social services or legal interventions, which may have potential leverage effects. Founded in 2005, the mobile team works on an assertive community treatment basis and is available 5 days a week from 8 a.m. to 6 p.m. It may provide intensive care with 2 interventions per day (Bonsack et al., 2008). The mobile team is composed of 3 child and adolescent psychiatrists, 1 psychologist, 4 nurses and 1 social worker. Referrals come from child and adolescent mental health professionals and social workers, rarely from school officials. Patients referred to the mobile team are at high risk for mental illnesses and escaping from usual care (outpatient treatment or day care treatment). The mobile team also serves the psychiatric needs of children and adolescent placed in foster homes. During 2017, 20 out of 63 referrals were school refusal patients. Eight of them returned to mainstream school, 9 of them were oriented to a specialized school and 3 of them to hospitalization. The mean duration time between referral to the mobile team and full time school attendance was 87 days. Three months are usually necessary to ensure full time school attendance with the mobile team intervention, whereas hospitalization offers a shortened time for returning to school, as normal school attendance is usually a discharge condition. The high occupation level of the hospitalization unit prevents school refusal patients from benefiting from inpatient care in the majority of situations. School remains a major concern for children and adolescent referred to the mobile team and they are often ask for help in returning to school rather than in caring for psychological disturbances. However, attending school remains a great challenge for school refusal patients and the support of the mobile team is crucial. The adaptability and responsiveness of mobile teams may offer the best way for early identification and intervention for school refusal patients in collaboration with schools and health professionals. Even if efforts are still needed in order to improve collaboration with schools and to tailor more efficient cognitive and behavioral interventions, mobile teams appear to be a promising solution for the challenges of school refusal.