Refus scolaire anxieux : efficacité d’un programme de TCC en hospitalisation de jour

Contexte

Le refus scolaire anxieux (RSA) est une pathologie sévère appartenant au spectre des troubles anxieux et un motif fréquent de consultations en milieu hospitalier. L’effet des TCC dont les bénéfices sont pourtant mis en avant dans le traitement des troubles anxieux, n’est pas étudié dans le RSA.

Méthode

Étudier l’efficacité d’un programme multidisciplinaire de TCC dans un groupe de 28 adolescents bénéficiant d’une hospitalisation de jour. Vingt-sept patients sur 28 ont réintégré le milieu scolaire, après un délai moyen de 18,9 (SD = 5) semaines de prise en charge. L’effet du programme est estimé au travers de mesures effectuées avant/après hospitalisation : délai de réintégration scolaire, fonctionnement global, sévérité et évolution clinique (échelles C-GAS et CGI), et symptomatologie anxieuse (échelles FSSC-R, STAIC, RC-MAS, MASC et ECAP).

Résultats

Les scores aux échelles d’anxiété ont diminué significativement (p < 0,01) et le fonctionnement global s’est amélioré (p < 0,001).

Conclusion

Le programme TCC apparaît comme un traitement efficace du RSA. Des études mieux contrôlées, effectuées en aveugle sur des effectifs plus importants devront confirmer ces résultats en s’intéressant également au maintien des bénéfices à long terme.

Background

Anxious school refusal (ASR) is a common disorder belonging to the anxiety disorder spectrum. It is defined as “the behavior of children and adolescents who, for irrational reasons, refuse to go to school and resist with very sharp anxiety or panic when forced to”. This diagnostic is not classified as an independent one in the international systems of classification (DSM 5 or ICD 10) (Inglès et al., 2015). Nevertheless, ASR may be linked to diverse mental health disorders such as separation anxiety disorder, generalized anxiety disorder, other children's anxious disorders, or furthermore depression (Kearney and Albano, 2004). The essential features commonly present in school refusal are outlined in criteria developed by Berg et al. (1969): when faced with the prospect of going to school with reasonable parental pressure to attend, the child displays severe emotional disturbance or complains of physical illness thought to have an emotional basis; the child is usually at home with his parents or another family member; the absence of severe anti-social behavior/conduct disorder; A specific ambulatory therapeutic cognitive and behavioral (CBT) program was established within the children and adolescent psychiatric unit number 2 in the University Hospital of Montpellier, France. It implemented cognitive and behavioral therapy techniques to gradually reintegrate the child back into the school environment.

Method

Our team comprises of nurses, social workers, psychologists, a teacher and a child psychiatrist. The program consists of a part-time day hospitalization where adolescents come for a duration of 3 hours: they receive normal school education for 2 hours with a teacher (1 teacher for a group of 5 adolescents) and 1 hour of individual or group CBT. The rest of the time, they stay at home to do homework. CBT is a manualized program with anxiety psychoeducation, stress managing, cognitive restructuration, problem solving techniques, progressive exposure, assertiveness exercises and self-esteem work. When patients are ready, caregivers accompany them to school for gradual exposure. We included adolescents between 11 and 16 years’ old who have completely dropped out from school and sought help because they wanted to return. Inclusion criteria were: anxiety disorder as an initial diagnosis, no current DSM 5 conduct disorder, the ability to stay alone at home and the ability to work alone at home. Parents had also to undergo a CBT program for guidance, psychoeducation and stress management, individually or as part of a group exchange with other families. We evaluated the effectiveness of this program in a cohort of 28 patients treated between September 2014 and July 2017. Alongside school reintegration period assessment, the overall functioning of patients was quantified using C-GAS, the clinical improvement with CGI scales, and anxious symptoms through the FSSC-R, STAIC, RC-MAS, MASC and ECAP scales. The scores were obtained at the beginning and end of hospitalization.

Results

Twenty-seven patients have returned to school partially after 16.6 (SD: 5) weeks of treatment on average. One adolescent did not succeed in returning to school because of further bullying and a severe performance anxiety disorder. She required more time to feel better through the support of home schooling. For all the adolescents, overall functioning assessment with C-GAS scale showed a significant improvement from 50.7 (SD: 14,9) at the beginning of hospitalization to 80.7 (SD: 7.0) at discharge with a significant improvement (P < .001) at the Wilcoxon test. Significant improvement in anxiety level was also found in all anxiety scales when comparing the beginning and the end of institutional cognitive and behavioral therapy: ECAP fear (< .001), ECAP avoidance (.005); RCMAS (< .001); MASC (< .001); STAIC (.008); FSSC R (< .001).

Conclusion

The CBT program for school refusal performed in a day hospital setting is efficient and allows partial attendance in school within the year for the majority of patients. Further studies and monitoring of patients are needed to better characterize the effectiveness of this support.