School Refusal Behavior

School refusal behavior refers to child-motivated refusal to attend school or difficulties remaining in classes for an entire day. The behavior applies to 5- to 17-year-old children who are completely absent from school, who skip classes or certain sections of a school day, who are chronically tardy to school, or who attend school under intense duress that precipitates pleas for future nonattendance. Many youths display a fluctuating course of school refusal behavior that may include full absence one day, partial absence another day, and tardiness or a skipped class still another day.

Acute school refusal behavior may be defined as absenteeism lasting less than 1 calendar year, whereas chronic school refusal behavior may be defined as absenteeism persisting for more than 1 calendar year. In general, school refusal behavior is considered problematic if it lasts at least 2 weeks or significantly interferes with daily functioning. School refusal behavior is distinguished from school withdrawal, which refers to a parent who deliberately keeps a child home from school. In addition, school refusal behavior is not meant to include youths who fail to attend school because of extenuating circumstances such as homelessness or maltreatment.

Historical Overview of School Refusal Behavior

Many terms have been applied to school refusal behavior, including problematic absenteeism, truancy, psychoneurotic truancy, school phobia, and separation anxiety. Each term describes a subset of youths with school refusal behavior. For example, truancy refers to illegal absenteeism in which a child misses school without parental knowledge. Other terms describe youths with anxiety-related conditions such as dread (psychoneurotic truancy), fear (school phobia), and worry about separation (separation anxiety). The term “school refusal” is often used to refer to anxiety-based absenteeism as well. Many of these terms have been poorly defined, however, and are used in various ways by educators, clinicians, and researchers. The umbrella term “school refusal behavior” has been proposed to cover all youths with problematic absenteeism, whether anxiety-related or not, and to provide consensus for educators, clinicians, and researchers.

Characteristics of Youths With School Refusal Behavior

School refusal behavior affects an estimated 5% to 28% of school-age children. According to the National Center for Health Statistics, 0.9% of children did not attend school at all in 2003. Furthermore, 5.4% of youths missed 11 or more days of school, 11.3% missed 6 to 10 days of school, and 28.1% missed 3 to 5 days of school in 2003. The number of absences due specifically to school refusal behavior, however, is unclear.

Peak age of onset of school refusal behavior is 10 to 13 years, though many youths entering a school building for the first time appear especially vulnerable. School refusal behavior is equally common among boys and girls and across sociocultural groups, though school dropout rates tend to be higher among Hispanics than among the general population. School refusal behavior is generally associated with adequate academic achievement up to the onset of absenteeism.

A hallmark of youths with school refusal behavior is symptom heterogeneity. The clinical picture of youths who refuse school is quite varied and includes many internalizing (covert) and externalizing (overt) symptoms. Common internalizing symptoms include general and social anxiety, depression, fatigue, somatic complaints, fear, worry, and self-consciousness. More specifically, common somatic complaints include headaches, stomachaches, abdominal pain, nausea, vomiting, diarrhea, trembling, and heart palpitations. Common externalizing symptoms include noncompliance and defiance, refusal to move, running away from school or home, aggression, and acting-out behaviors in school in an attempt to be sent home.

Most children with school refusal behavior display a complicated diagnostic picture as well. The most common diagnoses associated with school refusal behavior are anxiety-related conditions, such as separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder, and depressive-related conditions such as major depression and dysthymia. However, about one third of this population meets criteria for no mental disorder.

In the short term, school absenteeism causes substantial stress for a child and family members and can lead to social alienation, declining grades, family conflict, and financial and legal troubles. In the long term, chronic absenteeism is a risk factor for juvenile delinquency and school dropout. Longitudinal studies of youths with chronic absenteeism also reveal increased risk for social, occupational, economic, marital, and psychiatric problems in adulthood.

Functional Model of School Refusal Behavior

Many systems have been designed to classify youths with school refusal behavior with respect to various forms of internalizing and externalizing behavior. Examples include general clinical, diagnostic, and empirical/statistical methods of classification. These systems demonstrate only mixed success at categorizing large percentages of youths who refuse school because of the heterogeneity of symptoms for these children. An alternative functional model for classifying youths with school refusal behavior along the major reasons or reinforcers of absenteeism has gleaned substantial empirical support. These functions include avoidance of stimuli that provoke a general sense of negative affectivity (symptoms of anxiety and depression), escape from aversive social or evaluative situations, pursuit of attention from significant others, and pursuit of tangible rewards outside of school.

The first two functional conditions refer to youths who refuse school for negative reinforcement, or to avoid or escape something aversive at school. The latter two functional conditions refer to youths who refuse school for positive reinforcement, or to pursue rewards outside of school. Many youths refuse school as well for a combination of these functions. The functional model may serve as the basis for a comprehensive assessment and treatment process.

Assessment of School Refusal Behavior

Assessing youths with school refusal behavior typically involves structured diagnostic interviews, child self-report measures of internalizing symptoms, parent- and teacher-based measures of internalizing and externalizing behaviors, behavioral observation, and examination of medical, academic, and attendance records. In addition, the assessment process should focus on the function of a child’s school refusal behavior. Medical assessment of somatic complaints and related physical conditions is common as well. Assessment is best conducted as a multidisciplinary process that involves parents, children, peers, school personnel, and health and mental health care professionals.

Treatment of School Refusal Behavior

Treatment of youths with school refusal behavior often involves an emphasis on restoring full-time attendance and addressing anxiety and other mental conditions associated with the behavior. As such, treatment usually includes child-, parent-, and family-focused techniques. Child-based techniques include psychoeducation about the nature of anxiety, somatic control exercises to ease physical symptoms of anxiety (e.g., relaxation training, breathing retraining), cognitive restructuring to challenge and change irrational thoughts, and exposure-based practices to ease a child back into school. This last technique is often done by systematically adding hours, periods, or classes to a child’s school day. The general goal of these child-based techniques is to reduce distress associated with school and increase school attendance on a gradual basis.

Parent-based techniques include restructuring parent commands toward brevity and clarity, ignoring a child’s simple inappropriate behaviors (e.g., morning dawdling), establishing fixed routines in the morning and evening, establishing rewards and punishments for attendance and nonattendance, reducing excessive reassurance-seeking behavior, and engaging in forced school attendance under certain conditions. The general goal of these parent-based techniques is to reduce attention-seeking child behaviors and re-establish parental control via contingency management.

Family-based techniques for school refusal behavior include negotiating and designing written contracts, escorting youth to school and classes, communication skills training for family members, and peer refusal skills training to help youths decline peers’ suggestions to miss school. The goal of these family techniques is to increase incentives for school attendance and decrease incentives for nonattendance while improving family problem-solving skills.

Treatment for school refusal behavior may also involve medication, monitoring of school attendance on a daily basis, increased parental and school supervision, resolution of peer- and teacher-related conflicts, social skills training, behavioral activation, and development and modification of 504 and individualized educational plans. Use of daily attendance journals and increased participation of the child in school-based extracurricular activities is recommended as well. In addition, ongoing consultation with a child’s pediatrician, school guidance counselor, school psychologist, and teachers is often crucial to resolve a particular case of school refusal behavior. Relapse prevention following resumption of full-time attendance is also necessary in many cases.

References:

Kearney, C. A. (2001). School refusal behavior in youth: A functional approach to assessment and treatment. Washington, DC: American Psychological Association.
Kearney, C.A. (2003). Bridging the gap among professionals who address youth with school absenteeism: Overview and suggestions for consensus. Professional Psychology: Research and Practice, 34, 57-65.
Kearney, C.A. (2006). Confirmatory factor analysis of the School Refusal Assessment Scale-Revised: Child and parent versions. Journal of Psychopathology and Behavioral Assessment, 28, 139-144.
Kearney, C. A. (2007). Forms and functions of school refusal behavior in youth: An empirical analysis of absenteeism severity. Journal of Child Psychology and Psychiatry, 48, 53-61.
Kearney, C. A., & Albano, A. M. (2000). When children refuse school: A cognitive-behavioral therapy approach/Therapist’s guide. San Antonio, TX/New York: The Psychological Corporation/Oxford University Press.
Kearney, C. A., & Silverman, W. K. (1999). Functionally-based prescriptive and nonprescriptive treatment for children and adolescents with school refusal behavior. Behavior Therapy, 30, 673-695.