School refusal

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School refusal is a child-motivated refusal to attend school or difficulty remaining in class for the full day. [1] Child-motivated absenteeism occurs autonomously, by the volition of the child. This behavior is differentiated from non-child-motivated absences in which parents withdraw children from school or keep them home for circumstances such as homelessness. [2] [3] School refusal is characterized by avoidance and/or emotional distress at the time of attending school. [4]

Contents

Rates of absenteeism due to school refusal behavior manifest in a variety of ways and are defined, tracked, and reported differently among schools and school districts. [5] [4] Academic literature estimates that school refusal occurs in 1–2% of the general population and in 5–15% of youth who are referred to clinics. [6] [5] [7]

Classification

School refusal behavior is characterized by an emotional and behavioral component. The emotional component consists of severe emotional distress at the time attending school. The behavioral component manifests as school attendance difficulties. [4] School refusal is not classified as a disorder by the Diagnostic and Statistical Manual of Mental Disorders [DSM-5].

Emotional

Emotional distress typically does not occur until the morning before the child is to attend school, and is often accompanied by physical symptoms, the degree of distress exhibited varying among children. There is also an instant return to a stable mood after the child decides not to attend school or is removed from school. [4]

Behavioral

School attendance difficulties include a broad range of different behaviors. The spectrum of refusal spans from occasional reluctance to complete refusal. [4] Students may miss the entire day, a partial day, skip class, or arrive late. [2]

Assessment

Because school refusal behavior is a multifaceted issue, there is not a single valid measure or assessment method for diagnosis. [7] Assessment first involves measuring and evaluating the number of days the child is absent, late, or leaving school early. Parent reports and self-reports from the child regarding emotional distress and resistance towards attendance are taken into account. [5] The assessment aims to (1) confirm that the behavior represents school refusal as opposed to truancy or legitimate absence, (2) evaluate the extent and severity of absenteeism, (3) the type(s) and severity of emotional distress, (4) obtain information regarding the child, family, school, and community factors that may be contributing to the behavior, and (5) use the information obtained to develop a working hypothesis that is used for planning appropriate interventions. [4] Tools used to obtain information about school refusal behavior include clinical behavioral interviews, diagnostic interviews, self-report measures of internalizing symptoms, self-monitoring, parent- and teacher-completed measures of internalizing and externalizing problems, review of attendance record, and systematic functional analysis. [5] [7]

Signs and symptoms

School refusal behavior is a heterogeneous behavior characterized by a variety of internalizing and externalizing symptoms. Internalizing symptoms include anxiety (general, social, and separation anxiety), social withdrawal, fatigue, fear, and/or depression. [2] Children may also have complaints of somatic symptoms such as headaches, stomachaches, or a sore throat. Children may also exhibit externalizing symptoms such as nausea, vomiting, sweating, diarrhea, or difficulties breathing as a result of their anxiety. [4] Other externalizing symptoms include defiance, aggression, tantrums, clinging to a parent, refusing to move, and/or running away. [2] If the child stays home from school, these symptoms might go away but come back the next morning before school. [8]

Researchers are motivated to assess and treat this behavior because of its prevalence and potential negative consequences. [9] Short-term negative consequences of school refusal for the child include distress, social alienation, and declining grades. Familial conflict and legal trouble may also result. [2] Excessive absenteeism is commonly associated with various negative health and social problems. [3]

Problematic school absenteeism is also associated with illicit drug use (including tobacco), suicide attempts, poor nutrition, risky sexual behavior, teenage pregnancy, violence, injury, driving under the influence of alcohol, and binge drinking. [2] [5]

Causes

School refusal behavior includes absenteeism due to a broad range of potential causes. School refusal can be classified by the primary factor that motivates the child's absence. School refusal behavior has no single cause. Rather it has a broad range of contributing factors that include the individual, family, school, and community. The School Refusal Assessment Scale identifies four functional causes: (1) avoiding school‐based stimuli that provoke negative effects, (2) escaping aversive social and/or evaluative situations, (3) pursuing attention from significant others, and/or (4) pursuing tangible rewards outside of school. Categories one and two refer to school refusal motivated by negative reinforcement. Categories three and four represent refusal for positive reinforcement. [10] [4]

The onset of school refusal can be sudden or gradual. In cases of sudden onset, refusal often begins after a period of legitimate absence. The problem may start following vacations, school holidays, or brief illness. It can also occur after a stressful event, such as moving to a new house, or the death of a pet or relative. [8] Gradual onset emerges over time as a few sporadically missed days become a pattern of non-attendance. [4]

There are a broad range of risk factors, which may interact and change over time. Within the literature the risk factors are typically condensed into four categories: individual, family, school, and community. [11]

Risk Factors for School Refusal Behavior [12] [11]
Individual FactorsFamily FactorsSchool FactorsCommunity Factors
  • behavioral inhibition
  • fear of failure
  • low self-efficacy
  • physical illness
  • learning difficulties
  • separation and divorce
  • parent mental health issues
  • overprotective parenting style
  • dysfunctional interactions
  • loss or bereavement
  • high levels of family stress
  • bullying
  • physical education
  • transitioning into secondary school
  • school day structure
  • tests or exams
  • peer or staff relationship difficulties
  • emergency drills
  • pressure to achieve academically
  • inconsistent professional advice
  • poor support services

There are a variety of primary and comorbid disorders associated with school avoidance behavior. Common diagnoses include separation anxiety disorder (22.4%), generalized anxiety disorder (10.5%), oppositional defiant disorder (8.4%), depression (4.9%), specific phobia (4.2%), social anxiety disorder (3.5%), and conduct disorder (2.8%). [10] It is also associated with autism. [13] Negative reinforcement school refusal behavior is associated with anxiety-related disorders, such as generalized anxiety disorder. Attention-seeking school refusal behavior is associated with separation-anxiety disorder. School refusal classified by the pursuit of tangible reinforcement is associated with conduct disorder and oppositional defiant disorder. [10]

Bullying

At times a child may refuse to go to school because they are being bullied. The possibility of bullying, including cyber bullying, should always be evaluated as part of assessing school refusers. Some children will willingly report being bullied; however, others may be ashamed of their inability to stand up to bullying and wish to conceal the fact that they are bullied within their schools -- by other students, or in some cases by teachers -- or harassed via texting, e-mail, or social media used to intimidate the child.

Treatment

The primary goal of treatment for school refusal behavior is for the child to regularly and voluntarily attend school with less emotional distress. [6] Some scholars also emphasize the importance of helping the child manage social, emotional, and behavioral problems that are the result of prolonged school nonattendance. [4] Treatment of school refusal depends on the primary cause of the behavior and the particular individual, family, and school factors affecting the child. [6] [2] Analysis of the child's behavior often involves the perspective of the parent/family, school, and child. [4] [12] When school refusal is motivated by anxiety, treatment relies mostly on child therapy during which children learn to control their anxiety with relaxation training, enhancement of social competence, cognitive therapy, and exposure. [6] For children who refuse school in pursuit of attention from parents, parent training is often the focus of treatment. Parents are taught to set routines for their children and punish and reward them appropriately. For children refusing school in pursuit of rewards outside of school, treatment often takes a family-based approach, using family-based contingency contracting and communication skills training. [14] [2] In some instances, children may also engage in peer refusal skills training. [14]

Epidemiology

There are no accurate figures regarding the prevalence of school refusal behavior because of the wide variation in how the behavior is defined, tracked, and reported across schools, school districts, and countries. [4] The most widely accepted prevalence rate is 1–2% of school-aged children. In clinic-referred youth samples the prevalence rate is 5–15%. [4] [5] [6] There are no known relationships between school refusal behavior and gender, income level, or race. [2] Whilst refusal behavior can occur at any time, it occurs more frequently during major changes in a child’s life, such as entering kindergarten (ages 5–6), changing from elementary to middle school (ages 10–11), or changing from middle to high school (age 14). [15] [4] [12] [16]

History

There has been little consensus on the best method for organizing and classifying children demonstrating school refusal behavior. School refusal was initially termed psychoneurotic truancy and characterized as a school phobia. [17] [18] The terms fear‐based school phobia, anxiety‐based school refusal, and delinquent‐based truancy were commonly described as school refusal behavior. [2] In early studies, children were diagnosed with a school phobia when they exhibited (1) persistent difficulties attending school, (2) severe emotional upset at the prospect of going to school, (3) parental knowledge of the absence, and (4) no antisocial characteristics. [19] These criteria were later declared inadequate in capturing the full range of school refusal behavior. [18] While the term school phobia is still commonly employed, this anxiety-based classification is not appropriate for all cases of school refusal. [18] School refusal is now considered an umbrella term for non-truant problematic absenteeism, regardless of the root cause. [2]

See also

Notes

Related Research Articles

<span class="mw-page-title-main">Anxiety disorder</span> Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

<span class="mw-page-title-main">Conduct disorder</span> Developmental disorder

Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior that includes theft, lies, physical violence that may lead to destruction, and reckless breaking of rules, in which the basic rights of others or major age-appropriate norms are violated. These behaviors are often referred to as "antisocial behaviors", and is often seen as the precursor to antisocial personality disorder; however, the latter, by definition, cannot be diagnosed until the individual is 18 years old. Conduct disorder may result from parental rejection and neglect and can be treated with family therapy, as well as behavioral modifications and pharmacotherapy. Conduct disorder is estimated to affect 51.1 million people globally as of 2013.

Selective mutism (SM) is an anxiety disorder in which a person who is otherwise capable of speech becomes unable to speak when exposed to specific situations, specific places, or to specific people, one or multiple of which serve as triggers. This is caused by the freeze response. Selective mutism usually co-exists with social anxiety disorder. People with selective mutism stay silent even when the consequences of their silence include shame, social ostracism, or punishment.

Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organization (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is used in assessing mental health and developmental disorders in children up to age five.

Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness." This behavior is usually targeted toward peers, parents, teachers, and other authority figures, including law enforcement officials. Unlike conduct disorder (CD), those with ODD do not generally show patterns of aggression towards random people, violence against animals, destruction of property, theft, or deceit. One-half of children with ODD also fulfill the diagnostic criteria for ADHD.

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Social inhibition is the conscious or subconscious avoidance of a situation or social interaction. With a high level of social inhibition, situations are avoided because of the possibility of others disapproving of their feelings or actions. Related processes that deal with social inhibition are social evaluation concerns, anxiety in social interaction, social avoidance, and withdrawal. Also related are components such as cognitive patterns, anxious apprehension during social interactions, and internalizing problems. It also describes those who suppress anger, restrict social behavior, withdraw in the face of novelty, and have a long latency to interact with strangers.

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<span class="mw-page-title-main">Social anxiety disorder</span> Anxiety disorder associated with social situations

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Victimization refers to a person being made into a victim by someone else and can take on psychological as well as physical forms, both of which are damaging to victims. Forms of victimization include bullying or peer victimization, physical abuse, sexual abuse, verbal abuse, robbery, and assault. Some of these forms of victimization are commonly associated with certain populations, but they can happen to others as well. For example, bullying or peer victimization is most commonly studied in children and adolescents but also takes place between adults. Although anyone may be victimized, particular groups may be more susceptible to certain types of victimization and as a result to the symptoms and consequences that follow. Individuals respond to victimization in a wide variety of ways, so noticeable symptoms of victimization will vary from person to person. These symptoms may take on several different forms, be associated with specific forms of victimization, and be moderated by individual characteristics of the victim and/or experiences after victimization.

Peer victimization is harassment or bullying that occurs among members of the same peer group. It is often used to describe the experience among children or young people of being a target of the aggressive and abusive behavior of other children, who are not siblings and not necessarily age-mates.

Separation anxiety disorder (SAD) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment. Separation anxiety is a natural part of the developmental process. It is most common in infants and little children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. Unlike SAD, normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem.

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Race-based traumatic stress is the traumatic response to stress following a racial encounter. Robert T. Carter's (2007) theory of race-based traumatic stress implies that there are individuals of color who experience racial discrimination as traumatic, and often generate responses similar to post-traumatic stress. Race-based traumatic stress combines theories of stress, trauma and race-based discrimination to describe a particular response to negative racial encounters.

Anne Marie Albano is a clinical psychologist known for her clinical work and research on psychosocial treatments for anxiety and mood disorders, and the impact of these disorders on the developing youth. She is the CUCARD professor of medical psychology in psychiatry at Columbia University, the founding director of the Columbia University Clinic for Anxiety and Related Disorders (CUCARD), and the clinical site director at CUCARD of the New York Presbyterian Hospital's Youth Anxiety Center.

Racial-ethnic socialization describes the developmental processes by which children acquire the behaviors, perceptions, values, and attitudes of an ethnic group, and come to see themselves and others as members of the group.

References

  1. ↑ Kearney, Christopher A. (1996). "The Evolution and Reconciliation of Taxonomic Strategies for School Refusal Behavior". Clinical Psychology: Science and Practice. 3 (4): 339–354. doi:10.1111/j.1468-2850.1996.tb00087.x. ISSN   0969-5893.
  2. 1 2 3 4 5 6 7 8 9 10 11 Kearney, Christopher A.; Turner, Dio; Gauger, Marisa (2010), "School Refusal Behavior", The Corsini Encyclopedia of Psychology, American Cancer Society, pp. 1–2, doi:10.1002/9780470479216.corpsy0827, ISBN   9780470479216
  3. 1 2 Dube, S. R.; Orpinas, P. (2009-04-01). "Understanding Excessive School Absenteeism as School Refusal Behavior". Children & Schools. 31 (2): 87–95. doi:10.1093/cs/31.2.87. ISSN   1532-8759.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 S., Thambirajah, M. (2008). Understanding school refusal : a handbook for professionals in education, health and social care. Grandison, Karen J., De-Hayes, Louise. London: Jessica Kingsley Publishers. ISBN   9781846427473. OCLC   646763769.{{cite book}}: CS1 maint: multiple names: authors list (link)
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  8. 1 2 Fremont, Wanda P. (2003). "Information from your family doctor: What to do when your child refuses to go to school". American Family Physician. 68 (8): 1563–4. PMID   14596444 . Retrieved 2012-10-26.
  9. ↑ Kearney, Christopher A.; Diliberto, Rachele (2013-10-10), Hofmann, Stefan G (ed.), "School Refusal Behavior", The Wiley Handbook of Cognitive Behavioral Therapy, John Wiley & Sons, Ltd, pp. 875–892, doi:10.1002/9781118528563.wbcbt37, ISBN   9781118528563
  10. 1 2 3 Kearney, Christopher A.; Albano, Anne Marie (January 2004). "The Functional Profiles of School Refusal Behavior". Behavior Modification. 28 (1): 147–161. doi:10.1177/0145445503259263. ISSN   0145-4455. PMID   14710711. S2CID   34542111.
  11. 1 2 Maynard, Brandy R.; Heyne, David; Brendel, Kristen Esposito; Bulanda, Jeffery J.; Thompson, Aaron M.; Pigott, Terri D. (2015-08-10). "Treatment for School Refusal Among Children and Adolescents". Research on Social Work Practice. 28 (1): 56–67. doi:10.1177/1049731515598619. ISSN   1049-7315. S2CID   35321528.
  12. 1 2 3 "Educational Psychology Service | West Sussex Services for Schools". schools.westsussex.gov.uk. Retrieved 2019-02-16.
  13. ↑ Munkhaugen, Ellen Kathrine; Gjevik, Elen; Pripp, Are Hugo; Sponheim, Eili; Diseth, Trond H. (2017-09-01). "School refusal behaviour: Are children and adolescents with autism spectrum disorder at a higher risk?". Research in Autism Spectrum Disorders. 41–42: 31–38. doi:10.1016/j.rasd.2017.07.001. hdl: 10852/68503 . ISSN   1750-9467.
  14. 1 2 Kearney, Christopher A.; Bensaheb, Arva (January 2006). "School Absenteeism and School Refusal Behavior: A Review and Suggestions for School-Based Health Professionals". Journal of School Health. 76 (1): 3–7. doi:10.1111/j.1746-1561.2006.00060.x. ISSN   0022-4391. PMID   16457678. S2CID   27815950.
  15. ↑ Wimmer, M. "School refusal: Information for educators" (PDF). National Association of School Psychologists. Archived from the original (PDF) on 2014-02-11. Retrieved 2012-10-26.
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  17. ↑ Partridge, J. M. (1939). "Truancy". Journal of Mental Science. 85 (354): 45–81. doi:10.1192/bjp.85.354.45. ISSN   0368-315X.
  18. 1 2 3 Lyon, Aaron R.; Cotler, Sheldon (2007). "Toward reduced bias and increased utility in the assessment of school refusal behavior: The case for diverse samples and evaluations of context". Psychology in the Schools. 44 (6): 551–565. doi:10.1002/pits.20247. ISSN   0033-3085.
  19. ↑ Berg, Ian; Nichols, Keith; Pritchard, Colin (October 1969). "School Phobia?its Classification and Relationship to Dependency". Journal of Child Psychology and Psychiatry. 10 (2): 123–141. doi:10.1111/j.1469-7610.1969.tb02074.x. ISSN   0021-9630. PMID   5368365.

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