The presenting problems will vary with the type of school and the age range of its pupils. Conduct problems are likely to be a common cause of concern and referral, particularly with children and younger adolescents and even more so if the school is trying to cope with a socially and culturally deprived population. Bullying is a major problem in some schools/1.5,!6) and while there are a range of direct and indirect approaches to behaviour problems, in some cases an educational and preventive approach should be considered for classroom-based problems, for example as employed in the Help Starts Here project (l7> in which play therapy, counselling for parents, and a consultative approach with teaching staff was combined.
Emotional problems, including anxiety and depression linked to educational anxieties (including the fear of examinations) and school non-attendance or refusal, present in different ways throughout the child and adolescent age range, including at undergraduate level, with quite different types of service required for each type of clientele.(l. ,19) Many different types of approach are taken, and in a large college or university campus there may be an emphasis on one particular type of counselling or therapy, or style of service.
Suicide and attempted suicide, and the possibility of them, are common sources of anxiety about older children and teenagers. Shaffer and Piacentini (20) have discussed the rising suicide rate among some groups of young people and ways of responding to it.
Misuse of drugs and alcohol is another growing problem in schools and colleges, as elsewhere. (21,22) Dorn and Murji(23) have reviewed strategies for drug prevention programmes, and not surprisingly the best chance of dealing with these problems is through educational and prevention programmes, and in these the school psychiatrist, perhaps in liaison with the school's doctor, can play an important part.
The incidence of anorexia nervosa, bulimia nervosa, and other eating disorders peaks among schoolchildren and students in the mid to late teens, particularly although not exclusively among girls, and appears to be increasing.(24) Most studies support the impression of an association with Western culture, with middle- to higher-level socio-economic status, and with particular students and professionals, for example athletes, fashion models, and ballet students. (25) Again, an educational and preventative programme would seem a worthwhile experiment, for example in liaison with the school or college health unit.
Obsessive-compulsive disorder is increasingly being seen in child and adolescent psychiatry (2627) and may present because of its effects on academic work. The psychiatrist can also expect to see anxious and depressed young people who, while not symptomatically obsessive-compulsive, are overconscientious and driven by overt or implied pressure from home or school to 'do well'. It is commonly accompanied by a combined drive to succeed and fear of failure which have become self-perpetuating within the student, so that both individual and family approaches to treatment may be needed, with sensitive liaison with teachers and tutors to help get the balance right between expecting too little or too much.
In these and other presentations the visiting school psychiatrist will often find his or her work needs to combine individual counselling or therapy in privacy with liaison with others, for example key teachers or tutors, psychologists undertaking educational/vocational assessment, or psychological therapies. A varying amount of work with the young person's family will be needed, either at the level of advice and the exchange of information, or as family therapy. In all this work an important skill is to determine how much psychiatric intervention is needed, and how much of another type of experience and skill (e.g. that of a tutor) will be helpful. Agreeing who is in the best position to do which part of the work is an important function of consultative work. (6,12,28>
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