What the research says

[accordion id=”1″ first=”1″ title=”Definitions of school refusal” tag=”h2″]

Kearney (2007) remarks that “school refusal is an umbrella term that covers many hypothesized sub types of youths with problematic absenteeism, including truancy, school phobia, and anxiety.”

In an attempt to address some of the definition inconsistencies, Thambirajah et al (2008) list the range of terminology that had in the past been used to describe non-attendance.

• Truancy is absence from school without the permission or knowledge of parents, guardians or teachers. Students often use the terms ‘wagging’ and ‘skiving’.
• Parentally condoned absence is where the parent keeps their child at home for  their own reasons or needs. This might be for emotional reasons, social support, caring, running errands or possibly because the parents lack the control over whether their child attends or not and therefore choose not to effectively challenge the child.
• School Phobia is now considered an outdated psychological term that is used to describe an irrational and specific fear of a school situation. This term is considered misleading, as it implies that the child has a phobia of a stimulus that is always situated in school. As with many school refusers, school itself is rarely the object of fear and the refusal is the result of other sources of stress or anxiety. It is generally accepted that school refusal can result from a considerable range of factors.
• Separation anxiety is an unrealistic fear of separation from the child’s primary attachment figure. It is argued that the child does not fear being in school, but rather fears leaving home and the attachment figure. This may be one of the most significant reasons for younger children refusing to go to school.
• School refusal refers to a situation where children fail or find it difficult to attend school. This may be associated with severe emotional distress, particularly anxiety. The anxiety or distress being the key factor in the definition of school refusal.

Berg, Nichols and Pritchard (1969) were the first researchers to attempt to provide criteria to help distinguish school refusal from truancy. Berg’s criteria are now over 40 years old but nonetheless, they remain highly referenced in much of the subsequent research. To enable the opportunity for Berg et al to establish a more rigorous and explicit criteria to determine school refusal traits the authors were careful to select their subjects.

The authors were keen to exclude subjects with any extraneous variables other than those that Berg et al considered as school refusal traits. These excluded variables included parentally authorised absences, child psychosis, chronic or acute physical illness, truancy, and neurotic disturbances. Berg et al considered that an absentee would be a school refuser if they met the following criteria:

• Severe difficulty in attending school often amounting in prolonged absence.
• Severe emotional upset shown by symptoms such as excessive fearfulness; undue tempers, misery or complaints of feeling ill without obvious organic cause, on being faced with the prospect of going to school.
• Staying at home with the knowledge of parents, when the child should be at school.
• Absence of significant antisocial disorders such as stealing, lying, wandering, destructiveness and sexual misbehaviour.

Berg’s work seeks to offer criteria that will allow professionals to distinguish school refusers from truants. Berg considers that truants are more likely to exhibit a lack of interest in school and the child is more likely to choose to engage in more appealing activities other than attending school. Berg argues that a school refuser is more likely to suffer excessive anxiety and emotional upset about attending school or even the thought of attending school.

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[accordion id=”2″ title=”How common is school refusal?” tag=”h2″]

There are no formal statistics relating to the extent of the school refusal problem within the UK. The Department for Education publishes attendance figures annually in its Statistical Release. Unfortunately, there is no category for school refusal absences.

Some predictions and estimations of prevalence can be found within school refusal research, but the true extent of the problem for children and young people remains unknown (Lyon and Cotler, 2007).

Predictions of prevalence rates found within school refusal research can vary considerably (Elliot, 1999; Kearney and Bensaheb, 2006).

Sewell (2008) suggests that school refusal may occur in 15% of all children.

Kearney (2001) suggests that the problem affects between 5% and 28% of all school aged children at some stage.

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[accordion id=”3″ title=”Possible signs and symptoms” tag=”h2″]

Kearney and Bensaheb (2006) suggest that the substantial heterogeneity of symptoms in school refusal can result in a complex presentation of both internalising and externalising behaviours.

Internalising behaviours may include:

• general and social anxiety
• worry
• fear
• self-consciousness
• depression and suicidal behaviour
• fatigue and somatic complaints (common somatic complaints include stomach aches, abdominal pain, headaches, nausea, diarrhoea and shortness of breath)

Externalising behaviours can include:

• defiance and non-compliance
• running away from home or school
• verbal and physical aggression
• temper tantrums and clinging
• refusing to get ready or get out of the car

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[accordion id=”4″ title=”What can prompt school refusal?” tag=”h2″]

Amongst the research literature, it is accepted that school refusal is associated with a combination of interrelated factors. It has been suggested that school refusal can be related to both of the following:

• Predisposing factors – these are factors that might be present in the nature of the school, the child’s family or the child themselves, which can vary according to an individual child’s unique set of characteristics and circumstances.
• Precipitating factors – these are factors related to a particular event or change of circumstances, which interact with predisposing vulnerabilities and lead to a child’s school refusal.

Various stressors may trigger school refusal behaviour, including:

• problematic family dynamics
• parents’ marital difficulties
• impending school based changes
• family based transitions (bereavement, divorce)
• illness and traumatic experiences

In many cases, however, cause triggers are far from obvious (Timberlake, 1984).

Possible family and home factors?

Kearney and Silverman (1995) looked at the dynamics within the school refusers family and concluded that the following familial relationship subtypes are often associated with school refusal behaviour:

• The enmeshed family. This involves an over dependent parent and child relationship.
• The conflictive family. Researchers found that hostility and conflict were key characteristics of many families with children exhibiting school refusal behaviour.
• The detached family. A detached family is one where family members are not involved with each other’s activities, or attentive to each other’s thoughts and feelings. The family is no more than a collection of individuals.
• The isolated family. The isolated family is characterised by little interaction outside of the family grouping. These families are reluctant to engage in outside interventions.
• The healthy family. A significant number of families showed adaptive and healthy functioning, but also include a child with individualised behavioural difficulties.

Additionally, Bernstein and Borchardt (1996) assessed one hundred and thirty four families from a school refusal outpatient clinic. They found that single parent families were overrepresented amongst the sample. It was found that often there was an inappropriate level of control within the family enjoyed by the child. Inappropriate child leadership roles were established in family communication often leading to role reversals where the child holds more power within the family dynamics than the parent.

Archer (2003) listed the following factors associated with the home or family that may spark school refusal:

• Problems within the child such as low self-esteem, anxiety issues or low social skills.
• Psychological problems in the parent affecting the child (such as depression and/or anxieties that a parent might communicate inappropriately to the child).
• Family breakdown, separation and divorce.
• Traumatic events at home such as bereavement.
• Violence and abuse in the home.
• Separation anxiety experienced by the child or by the parent.
• Situations where the child was required to look after younger siblings.
• Inadequate parenting, lack of organisation or control over the child.
• Poverty, where the family cannot afford uniforms or meals for school.

Possible school based factors?

Pellegrini (2007) argues that the ‘school refusal’ label is problematic in as much as it suggests a ‘within child’ explanation of the refusal behaviour. For the past two decades researchers have indicated the need for more research into the specific role of school related factors in school refusal, and found that school related factors are often underrepresented in accounts of the causes of school refusal (Pilkington & Piersel, 1991).

Lauchlan (2003) suggests that it is Kearney’s functional analysis of non attendance that has finally led to acceptance that school based factors may sometimes be responsible for the child’s difficulties and reluctance to attend. Kearney cites his first function of school refusal as ‘the avoidance of specific fearfulness or general over anxiousness related to the school setting.’ This could cover a multitude of school based factors such as the setting itself, the social anxiety resulting from crowded areas, the hustle and bustle of school life or the issue of bullying which is a common thread through absence literature.

Common sense dictates that if a child is anxious about going to school then there must be a trigger for that anxiety and that trigger may well stem from a school based factor. The previously mentioned Archer research questioned teachers and other professionals working with school refusers about their perceptions of the specific school factors involved in school refusal. The following were identified as possible contributors:

• The size and layout of the school.
• The structure of the school day.
• Conflicts with teachers.
• Transition periods from Primary to secondary school.
• Fear of specific subjects.
• Academic pressures and struggling with work.
• Bullying or perceived bullying.
• Friendship issues.
• Inappropriate provision or ‘the wrong child in the wrong school’.

It would seem from Archer’s study (2003) that, “many of those interviewed felt that factors at school could trigger a period of school refusal or phobia but that factors at home were more likely to be the root cause of the problem”. Where a child was refusing to come to school because of something that had ostensibly arisen at school.

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[accordion id=”5″ title=”The functions (benefits) of school refusal?” tag=”h2″]

Elliot (1999) suggests that there should be a decreased emphasis on the symptoms of school refusal and a greater focus upon the functions served by school refusal.

As opposed to conceptualising school refusal as a constellation of symptoms (Berg et al, 1969), a behavioural perspective has been advocated by a lead researcher and writer in the field, Christopher Kearney. In his extensive work within the area of school refusal, Kearney chose to focus specifically on child motivated school refusal behaviour. Kearney developed a model of school refusal behaviour that comprises of an assessment of negative and positive reinforcing behaviours through four functional profiles that describe why a child is refusing school.

Kearney was interested in discovering what the functional benefits were for school refusers, in essence, what was to be gained from school refusal for these children.

Kearney and Silverman (1990) concluded from their research findings that four motivating factors or functions surrounding school refusal behaviour can be identified:

• Avoidance of specific fearfulness or general over anxiousness related to the school setting or something within in the school setting. This is considered as negative reinforcement.
• Avoiding aversive (uncomfortable) social situations, for example, concerning problems based upon difficult or negative relationships with others in school. Considered as negative reinforcement.
• Attention getting or separation anxious behaviour, which may be related to somatic complaints (often vague symptoms of illness) or tantrums. Positive reinforcement through gaining the desired attention from parent.
• Rewarding experiences provided outside of school, for example, the child gains opportunities to engage in preferred activities. This group are usually called truants. Positive reinforcement through getting to do what they want when they should be at school, such as TV, video games, sleeping in. These children prefer not to be at school.

More recent studies build upon the functional model, for example, Kearney and Albano (2004), provide continued support for the functional model of school refusal classification. However, the authors acknowledge that children might display mixed functional conditions, thus the complexities involved in understanding a child’s school refusal behaviour are increased. For example, a child may initially avoid school due to a specifically aversive situation (category 1 in Kearney’s original list of functions), but then later refuse school due to the rewards gained from staying at home (category 4).

They also suggest that missing school purely for the tangible benefits of category 4 is most likely to be truancy or a conduct or oppositional defiance disorder and less likely related to anxiety or emotional distress.

Sometimes, choosing not to go?

Kearney and Albano found that 41% of students were missing school for positive tangible rewards whilst 24% missed school to avoid or escape negative situations.

Dube and Opinas (2009) suggest that the majority of children’s attendance problems are positively reinforced. Of their sample, 60% missed school to gain parental attention or receive tangible rewards. The sample was made up of students with poor attendance and no medical justification.

On Dube’s research, Fallis and Opotow (2003) comment that “this finding is not surprising given that previous studies have found that students often think school is boring, classes are unengaging and staff members are unapproachable, making absences more likely to occur.”

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[accordion id=”6″ title=”Potential consequences of school refusal” tag=”h2″]

Kearney (2001) discussed how, if left unaddressed, school refusal behaviour could lead to significant short and long term consequences.

Short term problems during the periods of avoidance may include:

• child and family conflict and distress
• academic problems (child gets behind at school work)
• legal issues (as a result of prosecution for non-attendance)
• financial difficulties (lost employment to provide childcare while child not at school)

Long term, Kearney (2001) suggests that an inconsistent and often emotionally disruptive childhood experience of the educational system can give rise to a host of possible social inequalities for the refuser. These can include:

• future economic deprivation
• occupational problems (lack of career choice or inability to maintain work routines)
• mental health issues
• heightened risk of future social maladjustment

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[accordion id=”7″ title=”Links with other emotional issues” tag=”h2″]

Comorbidity of school refusal behaviour with other mental health issues

Kearney and Bates (2005), suggest that; “in many cases, school refusal is comorbid with other mental disorders, especially separation and generalized anxiety disorders. From a clinical perspective, Kearney and Albano (2004) consider that the most common clinical diagnoses for school refusal behaviour are:

• separation anxiety disorder (22.4%)
• general anxiety disorder (10.5%)
• oppositional defiance disorder (8.4%)
• specific phobia (4.2%)
• social anxiety disorder (3.5%)
• conduct disorder (2.8%)

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[accordion id=”8″ last=”1″ title=”Practitioner understanding of school refusal” tag=”h2″]

The findings from Archer et al’s (2003) study are perhaps the most revealing piece of research within this specific area of school refusal research. Their research was a large scale study that investigated widespread professional understanding of school refusal. The aims of the research were to:

• explore different perceptions of school refusal and school phobia amongst education professionals
• describe the range of profiles that represent pupils identified as school refusers or phobics (discussed above)
• describe the approaches and action taken by local education authorities (LEAs) and schools to support school refusing pupils and their families; identify training and staff development needs and identify preventative measures and good practice in this area

The study adopted a mixed method approach across three strands:

• A survey of local education authorities.
• A survey of schools.
• Case studies in a sample of schools.

Over half of the LEAs who responded to the survey indicated that they did not distinguish school refusers and/or school phobics as a separate group from other non attenders. Additionally, no clear definitions among practitioners in schools distinguished between the terms school phobia and school refusal.

Many schools noted that they did not have a formally documented definition of school refusal or school phobia but would use phrases such as ‘persistently refusing to attend school’, ‘pupils who can’t face school’ and ‘acute anxiety about attending school’ (Archer,2003).

Overall, the questionnaire and interview data provided firm evidence that there was little common understanding amongst practitioners about school refusal and school phobia, and more specifically, very few schools had any written guidance on the topic.

As frontline practitioners, education professionals might be expected to have a secure understanding of school refusal however, as Archer suggests, this does not appear to be the case.

Research findings also indicated that few practitioners had any training on identifying or treating school refusal. In short, Archer found that professionals responsible for working with refusers were often ill equipped to do so.

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