Sara, 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, Sara 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 Sara 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, Sara calls her mother's cell phone periodically throughout the afternoon to "check in" and reassure herself that nothing bad has happened. Sara's teacher has expressed concern about her missing so much class time, which has resulted in incomplete assignments and difficulty learning.
Craig 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, Craig 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. Craig's teachers have noticed that he is always absent on days that tests or book reports are scheduled. His moms & dads 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. Craig's moms & dads 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 kids in America refuse school at some point during their education.1 School refusal behavior is as common among boys as girls. While any youngster 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 kids enter new schools. Although the problem is considerably more prevalent in some urban areas, it is seen equally across socioeconomic levels.
Sara and Craig are just two examples of how school refusal manifests in youth. The hallmark of this behavior is its heterogeneity. Defined as substantial, youngster-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:
1. go to school following crying, clinging, tantrums or other intense behavior problems
2. exhibit unusual distress during school days that leads to pleas for future absenteeism
3. attend school initially but leave during the course of the school day
4. are entirely absent from school
As evidenced by Sara and Craig, 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 moms & dads 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 youngster-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—Sara had several physiological symptoms at school and went home to be with her mother and play. Craig 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:
1. To receive attention from significant others outside of school
2. To pursue tangible reinforcement outside of school
3. To escape uncomfortable peer interactions and/or academic performance situations such as test-taking or oral presentations
4. To avoid school-related objects or situations that cause general distress such as anxiety, depression or physiological symptoms
The above four reasons for school refusal behavior can be explained by principles of reinforcement. Any one youngster 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 Sara'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 Craig escapes aversive peer interactions and exams by school refusing. The third and fourth reasons characterize youths who refuse school to gain rewards (positive reinforcement). Sara, as is common with many younger kids, tries to avoid school as a means of having her mother provide her with excessive attention and closeness. Thus, Sara's behavior in this situation may be associated with separation anxiety.
Another instance of positive reinforcement is exemplified by Craig, 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.
Treatment—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 moms & dads 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), 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 kids 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.
Consultation with youngster 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 youngster 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.
Returning to our case examples, careful evaluation revealed that Sara'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 Craig’s evaluation he was prescribed a treatment to address his social anxiety that motivated his school refusal. Craig's 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 Craig’s return to school or Sara remaining in her classroom rather than the nurse's office.
TREATMENT COMPONENTS FOR EACH FUNCTION OF SCHOOL REFUSAL BEHAVIOR:Escape from negative affect—(Sadness, the blues, fears, generalized anxiety and worry, separation anxiety, various phobias):
· Somatic management skills such as breathing retraining or progressive muscle relaxation training
· Gradual reintroduction (exposure) to school
· Self-reinforcement and building self efficacy
Escape from aversive social and evaluative situations—(Social phobia, test anxiety, public speaking fears, shyness, social skills deficits):
· Cognitive restructuring of negative self-talk
· Role play practice
· Graded exposure tasks involving real-life situations
· Social skills training and problem-solving skills training
· Building coping templates
Attention-seeking behavior—(Tantrums, crying, clinging, separation anxiety):
· Parent training in contingency management
· Changing parent commands
· Establishing routines
· Use of rewards and punishers for school attendance and school refusal
· Forced attendance, if necessary and under special circumstances
Positive tangible reinforcement—(Lack of structure or respect for house rules and responsibilities, free access to reinforcement, disregard for limits):
· Contracting with moms & dads to increase incentive for school attendance
· Curtail social and other activities as a result of nonattendance
· Provide the family with alternative problem-solving strategies to reduce conflict
· Communication skills and peer refusal skills are also sometimes added to this process
When kids like Sara and Craig 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 youngster 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 kids, moms & dads, 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.
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