Rebecca, an eight-year-old girl, has always had difficulty attending school. Since she began third grade two months ago, her problems have significantly worsened. She constantly begs to stay home from school, having tantrums that cause delay in dressing and often result in her missing the bus. After arriving at school, Rebecca frequently complains of stomachaches, headaches and a sore throat to her teacher and asks to visit the school nurse with whom she pleads to call her mother. Her mother typically picks her up early twice a week. When Rebecca gets home she spends the remainder of the afternoon watching TV and playing with her toys. When her mother is unable to pick her up early, Rebecca calls her mother's cell phone periodically throughout the afternoon to "check in" and reassure herself that nothing bad has happened. Rebecca's teacher has expressed concern about her missing so much class time which has resulted in incomplete assignments and difficulty learning.
Nicholas is a fourteen-year-old boy who has missed forty-three days of school since beginning the eighth grade four months ago. When home from school, Nicholas spends most of the day online or playing video games. On the days he does attend school he is typically late for his first period which enables him to avoid hanging out with other kids before class. He always goes to the library during lunch. When he does go to class, he sits in the back of the classroom, never raises his hand and has difficulty working on group projects. Nicholas' teachers have noticed that he is always absent on days that tests or book reports are scheduled. His parents have already punished him after his first report card came home since he received D's in Math and Social Studies and failed Gym for cutting. Nicholas' parents have started to wonder if they should change his school placement and have asked the school to arrange home tutoring while this alternative is explored.
Prevalence and defining characteristics
As much as 28% of school aged children in America refuse school at some point during their education.1 School refusal behavior is as common among boys as girls. While any child aged 5-17 may refuse to attend school, most youths who refuse are 10-13 years old. Peaks in school refusal behavior are also seen at times of transition such as 5-6 and 14-15 years as children enter new schools. Although the problem is considerably more prevalent in some urban areas, it is seen equally across socioeconomic levels.
Rebecca and Nicholas are just two examples of how school refusal manifests in youth. The hallmark of this behavior is its heterogeneity. Defined as substantial, child-motivated refusal to attend school and/or difficulties remaining in class for an entire day, the term "school refusal behavior" replaces obsolete terms such as "truancy" or "school phobia," because such labels do not adequately or accurately represent all youths who have difficulty attending school. School refusal behavior is seen as a continuum that includes youths who always miss school as well as those who rarely miss school but attend under duress. Hence, school refusal behavior is identified in youths aged 5-17 years who:
- are entirely absent from school, and/or
- attend school initially but leave during the course of the school day, and/or
- go to school following crying, clinging, tantrums or other intense behavior problems, and/or
- exhibit unusual distress during school days that leads to pleas for future absenteeism.
As evidenced by Rebecca and Nicholas, there are varying degrees of school refusal behavior. Initial school refusal behavior for a brief period may resolve without intervention. Substantial school refusal behavior occurs for a minimum of two weeks. Acute school refusal behavior involves cases lasting two weeks to one year, being a consistent problem for the majority of that time. Chronic school refusal behavior interferes with two or more academic years as this refers to cases lasting more than one calendar year. Youths who are absent from school as a result of chronic physical illness, school withdrawal which is motivated by parents or societal conditions such as homelessness, or running away to avoid abuse should not be included in the above definition of school refusal behavior as these factors are not child-initiated.
While some school refusers exhibit a more heterogeneous presentation, typically these youths can be categorized into two main types of troublesome behavior -- internalizing or externalizing problems. The most prevalent internalizing problems are generalized worrying ("the worry-wart"), social anxiety and isolation, depression, fatigue, and physical complaints (e.g. stomachaches, nausea, tremors and headaches). The most prevalent externalizing problems are tantrums (including crying and screaming), verbal and physical aggression, and oppositional behavior.
The cause and maintenance of school refusal behavior
Rebecca had several physiological symptoms at school and went home to be with her mother and play. Nicholas on the other hand, avoided potentially distressing social and evaluative situations at school which negatively impacted his academic performance. Although many behaviors characterize youths who refuse school, there are a few variables that serve to cause and maintain this problem. School refusal behavior occurs for one or more of the following reasons:
- To avoid school-related objects or situations that cause general distress such as anxiety, depression or physiological symptoms
- To escape uncomfortable peer interactions and/or academic performance situations such as test-taking or oral presentations
- To receive attention from significant others outside of school
- To pursue tangible reinforcement outside of school
The above four reasons for school refusal behavior can be explained by principles of reinforcement. Any one child can refuse school for one or more of these reasons. The first two reasons characterize youths who refuse school to avoid or escape something unpleasant (negative reinforcement). For example, one of the reasons for Rebecca's crying in the morning is her fear of riding the school bus. By tantruming she accomplishes her goal of avoiding the school-related object (the school bus) that causes her distress. Another example of negative reinforcement is when Nicholas escapes aversive peer interactions and exams by school refusing. The third and fourth reasons characterize youths who refuse school to gain rewards (positive reinforcement). Rebecca, as is common with many younger children, tries to avoid school as a means of having her mother provide her with excessive attention and closeness. Thus, Rebecca's behavior in this situation may be associated with separation anxiety. Another instance of positive reinforcement is exemplified by Nicholas, who basically has more fun being at home on the computer and listening to music than being in school. It is important to note that alcohol and drug use can occur among adolescents who school refuse for one or more of the reasons listed above. For example, a teenager who is extremely socially anxious may drink alcohol as a way of enduring distressing social or evaluative situations. Another youngster who avoids school may smoke marijuana during school hours as a means of gaining acceptance by peers or simply because it is more enjoyable than attending school. While all forms of school refusal can be equally debilitating, typically, mental health professionals receive fewer referrals for youths who have internalizing as opposed to externalizing behavior problems. In other words, the youth who exhibits anxiety is less likely to receive treatment than the youth who is disruptive.
School personnel -- teachers, nurses, principals -- are frequently the first professionals to identify the existence of a problem that requires immediate attention and intervention. As such, school personnel play a vital role in alerting parents to the problem and helping facilitate referrals for treatment by mental health specialists. The next step towards effective treatment by mental health professionals is gaining an understanding of the reasons that motivate school refusal. While school refusal per se is not a clinical disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, it can be associated with several psychiatric disorders (e.g. Separation Anxiety Disorder, Social Phobia, Conduct Disorder). Thus, it is vital that youths who are school refusing receive a comprehensive evaluation that includes a structured diagnostic interview and empirically supported assessment measures, such as "The School Refusal Assessment Scale" (SRAS)2, to understand the biopsychosocial factors contributing to their behavior. Once a clear diagnostic picture is established, an individualized treatment plan can be developed to address the positive and negative reinforcers that are associated with the school refusal behavior and comorbid psychiatric disorders.
The traditional treatments for school refusal behavior employed by mental health professionals have unfortunately had limited effectiveness. While certain treatment modalities such as psychodynamic therapies, forced school attendance, family-based techniques, medication and use of systematic desensitization work as the sole treatment modality for some youngsters, not all children who refuse school will improve with the chosen treatment. Thus, clinical scientists have developed a scientifically-based, comprehensive assessment and treatment package for youths with school refusal behavior. Table 1 illustrates this effective, straightforward treatment model which addresses each of the four components of school refusal behavior. Consultation with child psychiatrists may be necessary in certain cases of school refusal behavior that involve highly complicated clinical symptoms and comorbidities. For example, in order to increase the probability of successful therapeutic intervention, the child refusing school who exhibits mainly internalizing problems may benefit from adjunctive pharmacotherapy (e.g., Selective Serotonin Reuptake Inhibitor - SSRI) to help lower his or her anxiety.
TREATMENT COMPONENTS FOR EACH FUNCTION OF
SCHOOL REFUSAL BEHAVIOR 1
Function or Reason
|Escape from negative affect |
(Sadness, the blues, fears, generalized anxiety and worry, separation anxiety, various phobias)
|Escape from aversive social and evaluative situations |
(Social phobia, test anxiety, public speaking fears, shyness, social skills deficits)
|Attention-seeking behavior |
(Tantrums, crying, clinging, separation anxiety)
|Positive tangible reinforcement |
(Lack of structure or respect for house rules and responsibilities, free access to reinforcement, disregard for limits)
Returning to our case examples, careful evaluation revealed that Rebecca's school refusal behavior was initially a function of separation anxiety which was positively reinforced by having her mother's attention and play time during school hours. This lead her therapist to design a treatment program combining somatic management skills, practice in being away from her mom and parent training in contingency management. Following Nicholas' evaluation he was prescribed a treatment to address his social anxiety that motivated his school refusal. Nicholas' behavior was negatively reinforced by avoiding social and evaluative situations. Thus, his treatment plan involved cognitive restructuring, role plays, social skills and problem-solving skills, and gradual reintroduction to school. In addition, a strong working relationship between the therapist and the youth's school officials is an integral component of a successful treatment program for school refusal behavior. As an example, through a structured treatment plan with clear goals and a definitive time frame, a helpful school official might facilitate Nicholas' return to school or Rebecca remaining in her classroom rather than the nurse's office.
When children like Rebecca and Nicholas refuse school, immediate intervention is necessary not only because school attendance is mandated by law, but also to address negative social, psychological and academic consequences to the youth and family. If not identified and treated, school refusal behavior has severe short- and long-term consequences. Some of the short-term consequences of school refusal behavior include significant child stress, deteriorating school performance, social isolation, and family tension and conflict. Some of the longer term consequences include decreased probability of attending college, impaired social functioning impacting personal and professional goals, and increased risk of substance abuse, anxiety and depression in adulthood. Furthermore, the longer the youth refuses to attend school, the greater the risk of these problems developing. Taken together, it is essential that children, parents, mental health professionals, and school officials act collectively to further understand school refusal. It remains a prevalent and potentially grave problem that is under-investigated regarding empirically-based assessment and treatment.
A version of this article by these authors appeared previously in School Nurse News, September 2001.
About the Authors
This article was written by Nicole Setzer, Ph.D., and Amanda Salzhauer, MSW, for the New York University Child Study Center.
1. Kearney, C.A. & Albano, A.M. (2000). Therapist's guide for the prospective treatment of school refusal behavior. San Antonio, TX: The Psychological Corporation.
2. Kearney, C.A. & Silverman, W.K. (1993). Measuring the function of school refusal behavior: The School Refusal Assessment Scale. Journal of Clinical Child Psychology, 22, 85-86.
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