School Refusal

Introduction

School attendance is the foundation of a student’s ability to receive education and the benefits that such education provides. However, this most basic ability of attending school consistently proves elusive for many students. There are myriad proximal and distal factors that contribute to school absenteeism, which include physical health, mental disorders, and family, school, and community variables. For practitioners, when a patient presents with problematic absenteeism, it can be difficult to formulate a case conceptualization and a treatment plan, particularly because this problem exists as a behavior rather than a diagnosis. Despite the varied complexities involved, treatment for patients who struggle to attend school can be successful in enabling them to resume sustained school attendance. For the sake of brevity, we will use the term children to include both children and adolescents unless otherwise noted.

It is important to begin with defining the many terms commonly used to describe missing school, which are not necessarily interchangeable. Broadly, absenteeism refers to any excusable or inexcusable absence from school, planned or unplanned. As absenteeism by nature is not always considered a concern, and in certain cases may be normative, there are further terms to delineate problematic and nonproblematic absenteeism. To combat disparities in terminology, the proposed standard definition of problematic school absenteeism in the literature includes (1) missing at least 25% of total school time for at least 2 weeks, (2) severe difficulty attending classes for at least 2 weeks with significant interference in the child or family’s daily routine, and/or (3) absences for at least 10 days of school during any 15-week period while school is in session (with absence defined as 25% or more of the school day missed). Truancy is a legal definition, which varies state to state but is generally considered an amount of 20% or more school days missed within a 6-week period. Although not mutually exclusive with school refusal, in the literature, truancy is generally separated by a lack of anxiety or fear base. School refusal , also previously referred to as school phobia, generally refers to school absenteeism related to anxiety-based reasons. Furthermore, school refusal behavior , which can be associated with school refusal or truancy, broadly refers to behaviors such as missing full days of school, tardiness, reluctance to go to school in the morning, or difficulty remaining in classes. Although definitions vary from country to country, school refusal is an issue that has been identified and studied across the globe and is a focus of the Global Program of Child Mental Health.

There are disparities in the literature regarding the prevalence of school refusal, likely in part due to differences in definitions of truancy, school refusal, and absenteeism. Additionally, it can be hard to quantify, as not all school refusal behaviors result in missed days of school. From the results of various studies on school refusal and analyses of the national educational data, school refusal prevalence rates can be estimated as somewhere between 1% and 28%. Although some studies suggest insignificant differences in prevalence between gender, race, and income level, others suggest that rates may be higher in lower-income rural or urban areas. School refusal behaviors most commonly begin in children aged 10–13 years; however, some studies suggest that rates are higher among older children.

It is important to stress that school refusal is not a disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5 ). For the anxiety-based school refusal that we focus on in this chapter, missing school is, in essence, a symptom of the underlying anxiety disorder(s). School refusal is heterogeneous in nature and has a multitude of family and environmental factors to consider in its treatment, for those with and without underlying psychiatric disorders. There are various risk factors that have been linked to school refusal, and when conceptualizing a school refusal case, it is important to consider all the child-, family-, parent-, peer-, school-, and community-based factors.

It is suggested that school refusal be conceptualized based on the functionality of the school refusal behaviors, which fall into one of the four major categories. These categories are divided into students who refuse school to (1) avoid school-related stimuli that provoke a general sense of negative affectivity (i.e., anxiety and depression); (2) escape school-related aversive social and/or evaluative situations; (3) gain attention from significant others (e.g., parents); and/or (4) pursue tangible reinforcement outside of school (e.g., shopping, playing with friends, or drug use). School refusal to avoid negative affectivity or to gain attention tends to be found more in younger children, whereas school refusal to avoid aversive social/evaluative situations or to pursue tangible reinforcement tends to be found more in older children. One study suggests that the majority of children fall into the two categories that include pursuit of positive reinforcement (i.e., attention or tangible reinforcement).

There are many reasons why a child may not attend school, with medical reasons cited as one contributor to missed school days. Absenteeism has been linked to students who experience high levels of pain, have unmet dental needs, experience chronic headaches, and/or are overweight/obese. Absenteeism has also been linked to students with frequent somatic complaints and sleep difficulties, particularly insomnias, parasomnias, and daytime sleepiness. Interestingly, one sample showed no significant differences in chronic health problems for students with high rates of absenteeism but did show differences in perceived health by the students.

Children with increased behavioral problems and greater severity of psychiatric symptoms tend to have higher rates of absenteeism. Some studies suggest that although students with both internalizing and externalizing problems exhibit school absenteeism, the relationship between absenteeism and internalizing problems was not linked, whereas the relationship between absenteeism and externalizing problems was. Interestingly, although school refusal has been linked to anxiety disorders, students with higher rates of absenteeism tend to report lower levels of fear, which could suggest that, although anxiety disorders may be a risk factor, there are other variables indicated to result in a student refusing school.

Higher rates of school absenteeism have been noted among children from single-parent families, low-income families, and families with low parental education. Children from families with less emphasis on personal development and recreational activities outside of the home also show greater rates of absenteeism. Additional familial risk factors for school refusal include physical punishment by parent, parental or child physical illness, and parental mental illness. Studies have also looked at the link between school refusal and parental self-efficacy (PSE), a parent’s appraisal of their competence to parent a child refusing school. PSE was linked to parental anxiety and depression, as well as higher levels of family dysfunction. PSE was found to be lower in parents of students refusing school, which could in part explain why it has been suggested that parents may have difficulty forcing their child to attend school, particularly when the child is expressing fear.

As noted previously, students may refuse to attend school to avoid aversive social and/or evaluative situations. Being bullied has been linked to higher rates of absenteeism, and for students who refuse school, poor peer relationships in general are linked to future nonattendance. Students may even stay home from school when they do not feel safe either at school or on their way to/from school.

Absenteeism has been linked to school environment particularly for older children, which can include variables such as sharing of resources, order and discipline, parental involvement, student interpersonal relationships, and student-teacher relationships. Teachers’ classroom management has been specifically linked to school refusal as a predictive risk factor or a reductive risk factor, especially in relation to a teacher’s ability to influence relationships among peers. For example, children who missed school with comorbid medical diagnoses associated with high levels of pain were less likely to miss school when they perceived their teachers as highly supportive of competence and autonomy.

Because of the heterogeneity of school refusal, the risks associated are also varied; however, the consequence of school refusal, which is arguably most notable, is school dropout. As of 2015, 88% of adults have at least a high-school diploma, with lower rates of graduation among Hispanics and foreign-born adults. Although not all dropouts are related to school refusal, absences from school even as early as the elementary years are a significant predictor of eventual school dropout. Additionally, absenteeism is also linked to increased levels of anxiety and depression, increases in conduct problems, suicide attempts, risky sexual behavior, teen pregnancy, and substance use. School refusal has also been linked to continued social, economic, and occupational problems into adulthood, which can include continued psychiatric care as an adult and continuing to live at home with parents.

Diagnostic Assessment

School refusal is a cluster of behaviors that are related to mental disorders that often interact in complex manners with the youths’ environment. Consequently, assessment of youth exhibiting school refusal must be multifaceted and comprehensive. Specifically, this assessment should examine diagnostic, dimensional, and functional characteristics of the child and of the school refusal behavior.

With regard to diagnostic evaluation, it is important to consider a broad range of disorders and the absence of a diagnosable mental disorder. Kearney and Albano found that among the children refusing school, 22.4% met criteria for separation anxiety disorder, 10.5% for generalized anxiety disorder, 8.4% for oppositional defiant disorder, and 4.9% for depression. Interestingly, approximately one-third of the children (32.9%) did not meet criteria for any mental disorder.

In addition to mental disorders, school-refusing children often report a range of somatic complaints. The rates of problematic somatic complaints among children refusing school range from 36.5% to 79.4%. Somatic complaints are myriad and wide-ranging and have been found to include headache, stomachache, nausea or vomiting, fatigue, sweating, light-headedness, abdominal pain, heart palpitations, diarrhea, shortness of breath, and menstruation symptoms. Clearly, these symptoms overlap considerably with the symptoms of anxiety disorders, mood disorders, and somatic symptom disorders. However, these symptoms can obviously also be indicative of an underlying general medical condition, which themselves are often related to the onset of school refusal. For this reason, it is important that medical rule-outs be performed by qualified medical professionals.

Commonly used assessment measures used to assist in the evaluation of children exhibiting school refusal include the Screen Child Anxiety Related Disorders, Anxiety Disorders Inventory Schedule, School Refusal Assessment Scale–Revised (SRAS-R), Self-Efficacy questionnaire for School Situations, Child Behavior Checklist, Multidimensional Anxiety Scale for Children, and the Child Depression Inventory.

It is recommended that in addition to the use of a clinical interview and psychometrically sound measures listed earlier, it is also important to include a behavior avoidance task (BAT) during the assessment. The BAT should include measuring the avoidance of interoceptive cues (e.g., dyspnea, light-headedness, tachycardia) and external stimuli (e.g., perceived social evaluation, separation from parents, phobic item). In addition to allowing the clinician to directly observe both the intensity and the topography of the avoidant behavior in response to various cues and thus obtain convergent or discriminatory diagnostic information, the BAT is believed to be particularly sensitive to treatment outcome and may be used to assess progress during and after treatment.

Dimensional Assessment

However, the particularly complex interactions observed between the child, his/her family, and school while treating school refusal behavior speak to the importance of a dimensional assessment of the phenomenological experience of the affected child to properly design an effective treatment. For example, the polythetic nature of the DSM-5 produces 715 unique combinations of symptoms possible within a single panic attack.

To that end, it is recommended that each child’s constellation of avoided and/or feared situations be examined in depth. These feared and/or avoided situations that form this constellation are not randomly distributed and serve as “branches on a tree,” while the core fear serves as the “tree trunk,” from which the avoidance of specific stimuli emerges. For example, a teen with social anxiety disorder who completes the sentence “I’m afraid that people will think of me as …” with “weird” will have a different constellation of avoidance and fear than a teen who completes that sentence with “stupid.”

Specifically, the teen whose core fear centers around being seen as “weird” will be more likely to avoid unstructured social situations such as lunch or time between classes when there is no clear social rubric to follow and in which he/she will be more likely to say or do something that might be interpreted as socially inappropriate or weird. However, this same teen may feel much lower levels of anxiety while giving a well-rehearsed class presentation or answering a question from a teacher because these situations provide less of an opportunity to be judged as “weird.” However, a teen who fears being seen as “stupid” may exhibit the opposite pattern of fear and avoidance and primarily attempt to avoid a situation during which his/her intellectual abilities may be scrutinized.

In addition, assessment of the manner of a child’s anxiety acquisition directly informs the treatment design. For example, some children will display a marked aversion to cognitions associated with feared catastrophic outcomes that are exceptionally unlikely to be experienced at school, such as severe illness resulting in death, natural disasters, and school shootings, which are often acquired through information transfer. These children are clearly experiencing overvalued ideation and struggling to contextualize the probability of risk and are likely to exhibit a marked intolerance of uncertainty. The low-frequency and high-intensity nature of the feared outcome means that habituation following exposure to a school setting will be slow because the children will not likely attribute the absence of feared events to the absence of danger, but rather to luck, in a manner similar to someone who survived a game of Russian roulette.

On the contrary, some children have experienced events at school, which have produced a learning history that has resulted in a conditioned fear response to school, which has in turn become a conditioned stimulus. Such events can include bullying, sexual assault, and even panic attacks while at school. These individuals will likely experience consistently high levels of anxious arousal when presented with school-related stimuli (including entering the school building) while not engaging in safety behaviors. Thankfully, these individuals will likely experience a more rapid habituation while remaining in the presence of the school-related stimuli. However, the level of anxiety and the topography of the observed avoidant behavior can appear indistinguishable, regardless of the process of fear acquisition. Nonetheless, it is critical to understand the nature of this acquisition, as it will determine the extent to which the treatment design will need to incorporate extinction learning in the school itself versus training in metacognitive skills related to intrusive and overvalued ideation.

In addition, it is helpful to assess the child’s level of distress tolerance. For some children, avoidance can be reflexive and can occur very early within the escalation in anxious arousal. In fact, these children’s avoidance can be so effective that the child may not experience even moderate levels of anxiety unless avoidance is unavailable as a coping response. These children tend to exhibit lower levels of self-efficacy and more reliance on proximity to caregivers as a method of emotional regulation. These children often escalate their behavior quickly upon parental insistence of the child entering into an anxiety-provoking situation, which is often negatively reinforced by rapid parental acquiescence. Distress tolerance can be assessed in a variety of ways, but we favor direct observation of a parent-involved behavioral avoidance task (BAT), which also allows us to examine the interaction between the child and the parent as the child is asked to confront an anxiety-inducing stimuli. When such a pattern of poor distress tolerance and parental negative reinforcement of anxiety-based behavior are encountered, parent management training (PMT) will often be the focus of the treatment design.

Finally, it is critical for the clinician to assess ecologic and contextual variables related to the school refusal behavior. These variables include parental psychopathology, family system, and school resources. For example, some children have a history of learning disorders (e.g., executive functioning disorder, processing speed disorder) but have not exhibited school refusal behavior (or other problematic avoidant coping behaviors) until attempting to reintegrate back into school following a prolonged absence due to illness, injury, bereavement, etc. Learning disabilities in these children were manageable in earlier grades without accommodations because of a lighter workload or lower demands for higher-order cognitive skills. These children often experience marked distress when they can no longer complete the work at a level commensurate with internal or external expectation and struggle to accommodate this new information about themselves and thus begin to avoid school entirely as a means of coping. For these children, treatment will often have an early focus on academic remediation, attaining appropriate school accommodations regarding missed work, and assistance in planning and organizing an effective approach to completing missed work while also completing current assignments.

On the other hand, many assessments of a youth exhibiting school refusal behavior will reveal very problematic family systems. For example, a child with a prior diagnosis of an anxiety disorder who begins to exhibit high levels of hostility toward a custodial parent following his/her parents’ divorce and who is himself/herself currently struggling with tolerating distress may prompt that parent to avoid conflict with the child through an increase in permissive parenting, which ultimately results in parental complicity in the child’s anxious avoidance of school. In situations such as these, the parent(s) will be referred for individual treatment, parent training focused on authoritative parenting strategies will likely need to occur concurrently with the child’s treatment, and family therapy itself may be recommended.

Unfortunately, many children present with an insidious onset of school refusal behavior that began early as intermittent refusal and gradually increased over the course of several academic years until complete refusal to attend school is observed. These children often present with a complex interaction of mental disorders, family system pathology, learning challenges, and problematic interactions between the family and school. These children, we find, will benefit from aggressive and comprehensive treatment that consists of four major treatment components.