School Refusal

Abstract

School refusal is a global psychosocial problem that affects students from preschool to the teen years. School refusal has been identified in all countries with mandatory school policies. When it occurs in young children, it may be identified as separation anxiety. Among older students, school refusal may be mislabeled as truancy. School refusal may lead to academic failure and social and communication difficulties. Older students experiencing school refusal may drop out of school and have an increased chance of suffering economic, social, and emotional problems in adulthood. Therapists have found that the most successful treatment is cognitive behavioral therapy.

Overview

“School refusal,” sometimes known as “school phobia,” is generally defined as a child absolutely refusing to go to school on a regular basis. Some experts broaden the term to include students who repeatedly have emergencies that require them to be picked up at school and those that consistently skip classes or leave after lunch. School refusal may strike a child irrespective of gender, age, family size, or social and economic class. In 2018, it was estimated that school refusal affects 2–5 percent of all American students. When school refusal is combined with truancy, the estimated rate may rise as high as 28 percent. According to the Anxiety and Depression Association of America, school refusal affects one in four students between the ages of thirteen and eighteen. School refusal may be accompanied by symptoms such as headache, abdominal pain, nausea, shakiness, lethargy, dizziness, a racing heart, breathing trouble, sore throat, bedwetting, sleep problems, trouble concentrating, and unexplained weight loss or gain. In young children, it may also involve the crying, screaming, clinginess, and temper tantrums that are common among infants and toddlers experiencing separation anxiety. School refusers may feel a sense of not belonging, which exacerbates their anxiety levels. Some school refusers may be fine in structured situations, such as the classroom, but panic when they are forced to deal with unstructured situations, such as eating lunch in a school cafeteria or attending gym class (Kirby, 2018). Some school refusers may spend time outside of class hiding in a bathroom or library. In the worst cases, a school refuser may become suicidal.

In a student with untreated school refusal, the condition may become more progressive. For instance, a first grader may miss 23 days. As a second grader, that same child may miss 36 days. Students who suffer from school refusal, particularly those who first experience it from the age of fourteen onward, are more likely to experience other social problems, including ongoing mental health issues, teenage pregnancies, higher-than-average withdrawal rates, and social alienation. Those problems may persist into adulthood, leaving individuals more vulnerable to being unemployed, working at low-paying jobs, having marital problems, and experiencing psychological and social disorders.

Some experts identify three types of school refusers: those experiencing anxiousness or separation anxiety, those suffering from anxiety and depression disorders, and those suffering from phobias. Some therapists suggest that school refusal is more common in children whose parents are overly protective or controlling or who are poor communicators, rigid, disengaged, or authoritarian. Others have suggested that school refusal is most likely to strike the youngest child in a family. Some studies suggest that school refusal is most common among children between the ages of five and seven. Others maintain that it is most likely to occur among students on the verge of puberty. Most scholars recognize that school refusal is a widespread problem that may affect both male and female students of any age. The most vulnerable students are generally considered to be those who have other psychological or social disorders or who come from dysfunctional families. Transitions may precipitate school refusal. Thus, the most vulnerable periods are considered to the point at which children go from home or daycare to preschool, from preschool to elementary school, from elementary to middle school, and from middle school to high school. It may also be prompted by a transfer from one school to another.

In 1913, Swiss psychoanalyst Carl Jung was the first to identify school refusal as a problem. By mid-century, British psychiatrist Ian Berg had become the major figure in the study of school refusal. Berg was the first to clearly differentiate school refusal as a condition separate from separation anxiety and truancy. Berg argues that a student experiencing school refusal either outright refuses to go to school or becomes increasingly reluctant to do so over a prolonged period. Once the crisis is over, and the child is assured of not having to go to school, he/she remains at home. The parents are aware that the child has remained in the home. Being told that he/she must go to school results in negative emotional reactions. Otherwise, the child experiences no symptoms of severe antisocial behavior. To be classified as school refusal, there must be no evidence that a parent prevented the child from attending school.

Between the 1930s and 1960s, a number of notable studies, including those conducted by Broadwine (1932), Partridge (1939), Johnson et al. (1941), and Hersov (1960), built on earlier studies linking school refusal to anxiety. A 1974 study in the United Kingdom revealed that one in ten children were out of school on a given day. Berg, in the 1990s, maintained that by the 1980s, school refusal had become an urgent problem and suggested that it was most likely to affect older children, particularly those within two years of reaching the age when they could drop out of school. At an earlier period, British school refusers could be removed from parental custody.

In the 1980s, parents faced fines, and school refusers could be taken to juvenile court. American educators had realized that excuses given by children, such as acute respiratory infections, painful menstrual periods, chronic illnesses, and handicapped status, could not explain prolonged absences of particular students. Scholars had been trying to determine whether certain schools were responsible for high incidences of school refusal. It was estimated that school environments and irresponsible faculty/staff behavior could explain approximately 15 percent of all school refusal cases.

Applications

In 2006, the National Center for Children in Poverty conducted a longitudinal study of children, tracking students enrolled in kindergarten through third grade. They learned that 11 percent of kindergartners, 8 percent of first graders, and 6 percent of third graders missed more than 18 days in the academic year. The study demonstrated that school refusers in kindergarten were likely to be chronically absent as they progressed through school. Consultations with teachers suggested that school refusers were les socioemotionally developed, operated at lower functioning levels, were less likely to be involved in interpersonal relationships, exhibited lower self control, and were likely to exhibit either internalizing or externalizing behaviors. Teacher-identified school-refusal behavior among K-3 students were more common among those eligible for free or reduced-price lunches, those with disabilities, and those who were English learners. (Gresham, Vance, Chenier & Hunter, 2013).

Experts who define school refusal broadly identify several common behavior patterns of school refusers, which include going to school only after long battles and under significant stress, misbehaving as school time approaches, being chronically tardy, periodically being absent for or skipping a particular class, spotty class attendance, and prolonged absences over a lengthy period (Kearney, 2007). A school refuser may dawdle instead of getting dressed for school, resulting in chronic tardiness. Some children may demand that a parent remain with them in the classroom. Older children may refuse to go to school on days when tests or class presentations are scheduled because they cannot endure the anxiety associated with those events. Others may leave school after lunch. Absences might follow a pattern, with a student being absent two days a week or being absent for as much as two weeks at a time. Some school refusers may only refuse to go to school on certain days of the week.

Parents are advised to seek professional help if a child exhibits the following symptoms for at least four months: having trouble attending or staying in school, suddenly but persistently refusing to go to school, essentially having no other social or behavioral problems besides school refusal, and exhibiting school refusal over a stable time period. School refusal occurs only when the child should have been at school but was not and when the parents want the child to be in school (Kearney, 2007). Joanne Garfi (2018) warns that school refusers may persist in behaviors simply because it allows them to avoid situations that make them anxious; so they can stay home, eat whatever they like, watch television, play video games, or visit social media sites; and if it allows them to be spoiled and comforted by grandparents. A child who is being bullied may experience school refusal related to that behavior, but bullying should be dealt with within its proper context. If bullying is the only cause for school refusal, the behavior may disappear if the problem is dealt with.

Issues

One of the major issues in treating school refusal is determining the proper treatment for a particular student. Depending on the age of the child and the severity of the problem, treatment for students with school refusal may involve social workers and/or therapists as well as parents, teachers, counselors, and administrators. Experts in school refusal have identified three stages of school refusal. In the primary stage, symptoms are just beginning to appear. At this stage, prompt action may prevent the problem from developing further. In the secondary stage, parents and teachers may need assistance from trained counselors or therapists to halt further development. In the tertiary stage, school refusal is full blown, and proper treatment is indicated.

Many colleges and universities do not train education or social work students to deal with school refusal. This lack of training may be dealt with through teacher training and staff development programs. Some schools have also initiated programs that involve collaboration between parents, teachers, counselors, and social workers. Such programs tend to focus on identifying links between school refusal and underlying issues such as sexual abuse or physical violence in the home, being homeless, or dealing with family problems such as divorce, hospitalization or military deployment of a parent, a new baby in the family, or drug or alcohol abuse or mental illness in the home.

School refusal may call for additional treatment by psychologists and psychiatrists. Cognitive behavior therapy (CBT) is generally the treatment of choice for school refusal, and it involves such techniques as psycho education, relaxation training, cognitive restructuring, gradual exposure, and social skills training (Melvin et al., 2017). CBT is generally the sole treatment, but some therapists have had success with combining CBT with antidepressant drugs treatments such as imipramine and tricylic. Because of its toxicity and the potential for fatal overdosing, the use of tricylic has become rare. The use of fluoxetine, a serotonin reuptake inhibitor, is seen as a safer option. In one study comparing school refusers to a waitlist, the active group of school refusers improved at a rate of 94 percent as compared to 56 percent for the waitlist.

Typically, CBT involves sessions with the students and parent(s) individually and together. In one case study, a fifteen-year-old girl was involved in thirteen individual sessions and two joint sessions with her mother. Therapists usually consult with teachers during the course of treatment. In the case study, school attendance improved, and the treatment helped the student to develop more self-efficacy and reduced her inclination toward internalizing behavior. Symptoms related to her depression and anxiety disorders decreased (Heyne, Sauter, Ollendick, Widenfelt & Westenberg, 2014).

Traditionally, the first step in CBT involves having school refusers take age-appropriate tests such as the Global Assessment of Functioning Test, the Children’s (7 to 17) Depression Inventory, the Revised Children’s Manifest Anxiety Scale, the Self-Efficacy Questionnaire for School Students, and the School Refusal Program Consumer Satisfaction Questionnaire. Therapists may then begin holding twice-weekly sessions with school refusers. Once the school refuser reaches a desired state, periodic booster sessions are held for two to three months. Heyne et al. (2014) also use Optional Modules designed to meet the needs of specific students. Examples include, “Thinking about the Teenage Years,” “Solving Family Problems,” “Dealing with Social Situations,” and “Dealing with Depression.”

CBT has proved to be more effective in younger children than in teenagers. In a study conducted in the 1950s, treatment resulted in an 89 percent success rate for children between the ages of five and ten and a 36 percent success rate for children eleven to thirteen. In a 1998 study of young children with school refusal, school attendance improved by 95 percent after treatment. In a 2002 study of school refusers between the ages of seven and fourteen, those eleven and under were successfully treated. Among those twelve to thirteen years old, successes and failures were fairly evenly divided. Overall, the success rate for those under fourteen was 66 percent. There was only a 22 percent success rate with school refusers once they reached fourteen. Experts suggest that adolescent school refusers may experience more severe symptoms than younger children because school refusal may only be one issue among many at a time when most young people are undergoing major physical and emotional changes. Adolescents are more likely to experience depression and anxiety disorders at a time when rebelling against parents is considered normal teenage behavior. Adolescents experiencing school refusal may physically and aggressively resist efforts to make them attend school.

In a 2017 study, Glenn Melvin et al. conducted a study of school refusers aged eleven to sixteen and a half, dividing them into three groups. The first group was treated using CBT alone; the second group was treated with CBT and fluoxetine, a drug used to treat depressive disorders; and the third group received CBT and a placebo. All groups demonstrated significant improved school attendance. Clinicians rated each participant individually on anxiety, depression, self-efficacy, and global functioning. Follow-ups conducted at six months and one year revealed stable school attendance (54%) among all groups and a continuing decline of anxiety and depression. The chief difference in the three groups was that the one receiving CBT and fluoxetine expressed greater satisfaction with their treatment. There was, however, no greater success in treating school refusal in that group than in the group that received CBT alone.

Terms & Concepts

Cognitive Behavioral Therapy: A form of talk therapy in which clients meet with therapists for a period of weeks or months to learn to deal with negative thoughts and develop positive ways of dealing with stressful situations.

Externalizing Behavior: Behaviors in which individuals take out their anxieties or frustrations on others through such actions as fighting, shouting, cursing, stealing, or destroying property.

Global Assessment of Functioning: A 100-point continuum ranging from “very much improved” to “very much worse” used by therapists to access mental health and identify a client’s ability to function psychologically, socially, and occupationally.

Internalizing Behavior: Blaming oneself for problems or situations even when one is not at fault. Examples of internalized behavior, which is common among school refusers, include a sense of not belonging, unjustified guilt, withdrawal from social situations, and feelings of being unloved, unwanted, and lonely.

Placebo: An inert medication used in control groups to test whether study participants are reacting to a particular treatment or are reacting to the belief that they are receiving treatment. The placebo effect occurs when the condition of a participant taking a placebo improves.

Self-efficacy Questionnaire for School Students: A 12-item questionnaire used with child and adolescent school refusers to determine how effective they are in dealing with situations that cause them to experience anxiety.

Separation Anxiety: A normal stage of development in which children between the ages of eight and fourteen months become overly anxious when separated from a parent or caregiver. Shy children may experience separation anxiety for a longer period. School refusal was initially considered to be a type of separation anxiety, but most experts now identify them as two distinct conditions. However, some experts believe an infant/toddler who suffers separation anxiety may be more prone than others to experience school refusal as an older child.

Truancy: Involves a student intentionally absenting him/herself from school without a parent’s permission. Unlike the student suffering from school refusal, the truant does not remain at home when not in school, and there are no accompanying emotional and physical symptoms or patterns of social disorders. In clinical terms, truancy is considered a conduct problem, but school refusal is identified as an anxiety disorder.

Waitlist: A type of control group used in research studies in which participants initially receive no treatment while they wait to become involved in a study. The waitlist is used to assess the effectiveness of the treatment being received by the active group.

Bibliography

Elliott, J. G. & Place, M. (2019). Practitioner review: School refusal: Developments in conceptualisation and treatment since 2000. Journal of Child Psychology & Psychiatry, 60(1), 4–15. Retrieved January 1, 2019 from EBSCO Online Database Education Source. http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=133603052&site=ehost-live

Elsherbiny, M. M. (2017). Using a preventive social work program for reducing school refusal. Children and Schools, 39(2), 81–88. Retrieved September 30, 2018, from EBSCO Online Database Education Source. http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=122013013&site=ehost-live

Garfi, J. (2018). Overcoming school refusal: A practical guide for teachers, counsellors, caseworkers, and parents. Brisbane: Australian Academic Press.

Gresham, F. M., Vance, M. J., Chenier, J., & Hunter, K. (2013). Assessment and treatment of deficits in social skills functioning and social anxiety in children engaging in school refusal behaviors. In D. McKay and E. A. Storch (Eds.), Handbook of Assessing Variants and Complications in Anxiety Disorders. (pp. 15–28). New York: Springer.

Heyne, D., Sauter, F., Ollendick, T., Widenfelt, B., & Westenberg, P. (2014). Developmentally sensitive cognitive behavioral therapy for adolescent school refusal: Rationale and case illustration. Clinical Child and Family Psychology Review, 17(2), 191–215. Retrieved September 30, 2018, from EBSCO Online Database Education Source. http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=95877739&site=ehost-live

Kearney, C.A. (2007). Getting your child to say “yes” to school: A guide for parents of youth with school refusal behavior. New York: Oxford University Press.

Kirby, A. (2018). Refusal: Kids who just say no to school. Education Digest, 83(8), 41–43. Retrieved September 30, 2018, from EBSCO Online Database Education Source. http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=128627067&site=ehost-live

Melvin, G., Dudley, A., Gordon, M., Klimkeit, E., Gullone, E., Taffe, J., … Tonge, B. J. (2017). Augmenting cognitive behavior therapy for school refusal with fluoxetine: A randomized controlled trial. Child Psychiatry and Human Development, 48(3), 485–497. Retrieved September 30, 2018, from EBSCO Online Database Education Source. http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=122653701&site=ehost-live

Suggested Reading

Havik, T., Bru, E., & Ertesvåg, S. (2015). School factors associated with school refusal- and truancy-related reasons for school non-attendance. Social Psychology of Education, 18(2), 221–240. Retrieved January 1, 2019 from EBSCO Online Database Education Source. http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=103144886&site=ehost-live

Inglés, C. J., Gonzálvez-Maciá, C., García-Fernández, J. M., Vicent, M., & Martinez-Monteagudo, M. C. (2015). Current status of research on school refusal. European Journal of Education & Psychology, 8(1), 37–52. Retrieved January 1, 2019 from EBSCO Online Database Education Source. http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=109102089&site=ehost-live

Turn around challenging behaviours, absenteeism and school refusal so all students succeed. (2018). Connect: Supporting Student Participation, (230), 30–31. Retrieved January 1, 2019 from EBSCO Online Database Education Source. http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=129286680&site=ehost-live