School Refusal in Children and Adolescents

WANDA P. FREMONT, M.D., State University of New York Upstate Medical University, Syracuse, New York

Am Fam Physician. 2003 Oct 15;68(8):1555-1561.

 Patient Information Handout

School refusal is a problem that is stressful for children, families, and school personnel. Failing to attend school has significant short- and long-term effects on children's social, emotional, and educational development. School refusal often is associated with comorbid psychiatric disorders such as anxiety and depression. It is important to identify problems early and provide appropriate interventions to prevent further difficulties. Assessment and management of school refusal require a collaborative approach that includes the family physician, school staff, parents, and a mental health professional. Because children often present with physical symptoms, evaluation by a physician is important to rule out any underlying medical problems. Treatments include educational-support therapy, cognitive behavior therapy, parent-teacher interventions, and pharmacotherapy. Family physicians may provide psychoeducational support for the child and parents, monitor medications, and help with referral to more intensive psychotherapy.

School refusal is a serious emotional problem that is associated with significant short- and long-term sequelae. Fear of going to school was first termed school phobia in 1941.1 An alternative term, school refusal, was used in Great Britain to define similar problems in children who did not attend school because of emotional distress.2 Children with school refusal differ in important ways from children who are truant (Table 1), although the behaviors are not mutually exclusive.

TABLE 1

Criteria for Differential Diagnosis of School Refusal and Truancy

School refusal

• Severe emotional distress about attending school; may include anxiety, temper tantrums, depression, or somatic symptoms.
• Parents are aware of absence; child often tries to persuade parents to allow him or her to stay home.
• Absence of significant antisocial behaviors such as juvenile delinquency.
• During school hours, child usually stays home because it is considered a safe and secure environment.
• Child expresses willingness to do schoolwork and complies with completing work at home.

Vs

Truancy

• Lack of excessive anxiety or fear about attending school.
• Child often attempts to conceal absence from parents.

Frequent antisocial behavior, including delinquent and disruptive acts (e.g., lying, stealing), often in the company of antisocial peers.

• During school hours, child frequently does not stay home.
• Lack of interest in schoolwork and unwillingness to conform to academic and behavior expectations.
  

Epidemiology

Approximately 1 to 5 percent of all school-aged children have school refusal.3 The rate is similar between boys and girls.4,5 Although school refusal occurs at all ages, it is more common in children five, six, 10, and 11 years of age.6 No socioeconomic differences have been noted.7

Clinical Features

The onset of school refusal symptoms usually is gradual. Symptoms may begin after a holiday or illness. Some children have trouble going back to school after weekends or vacations. Stressful events at home or school, or with peers may cause school refusal. Some children leave home in the morning and develop difficulties as they get closer to school, then are unable to proceed. Other children refuse to make any effort to go to school.

Presenting symptoms include fearfulness, panic symptoms, crying episodes, temper tantrums, threats of self-harm, and somatic symptoms8 that present in the morning and improve if the child is allowed to stay home (Table 2). The longer the child stays out of school, the more difficult it is to return.9

TABLE 2

Somatic Symptoms in Children with School Refusal

Autonomic         Gastrointestinal   Muscular

Dizziness             Abdominal pain      Back pain

Diaphoresis        Nausea                    Joint pain

Headaches         Vomiting

Shakiness/trembling  Diarrhea

Palpitations

Chest pains

Short-term sequelae include poor academic performance, family difficulties, and problems with peer relationships.10 Long-term consequences may include academic underachievement, employment difficulties, and increased risk for psychiatric illness (Table 3).11,12

TABLE 3

Long-Term Sequelae in Children with School Refusal

OUTCOME  & PREVALENCE

Interrupted compulsory school  18%

Did not complete high school 45%

Adult psychiatric outpatient care 43%

Adult psychiatric inpatient care 6%

Criminal offense  6%

Still living with parents after 20-year follow-up 14%

Married at 20-year follow-up 41%

Number of children at 20-year follow-up:

None  59%

One or more  41%

School refusal behaviour: Are children and adolescents with autism spectrum disorder at a higher risk?

Ellen Kathrine Munkhaugen, Elen Gjevik, Are Hugo Pripp, Eili Sponheim, Trond H. Diseth, (2017),

Research in Autism Spectrum Disorders, volumes 41–42,

Pages 31-38, ISSN 1750-9467,

Highlights

• •
• School refusal behavior (SRB) is pervasive in students with ASD, aged 9–16 years.
• •
• SRB is equally common in primary and secondary students with ASD.
• •
• Expressions of SRB differ between primary and secondary school students with ASD.
• •
• Illness of other family members is associated to SRB in students with ASD.

Abstract

School refusal behaviour in students with autism spectrum disorder (ASD) is poorly studied despite being considered a serious problem. This study assessed the frequency, duration, and expression of school refusal behaviour in students with ASD, aged 9–16 years, without intellectual disability. Further, the associations between school refusal behaviour and sociodemographic factors were explored. Teachers and parents assessed this behaviour over 20 days in a cross-sectional study of 216 students, including 78 students with ASD and 138 typically developing (TD) students. School refusal behaviour was significantly higher in students with ASD as compared to TD students. Significant associations were found between school refusal behaviour and illness of other family members. The study concludes that school refusal behaviour is pervasive in students with ASD.

Introduction

School refusal behaviour is defined as child-motivated refusal to attend school and/or difficulties remaining in class for an entire day, that manifests in students aged 5–17 years (Kearney & Silverman, 1999; Kearney, 2008). This definition refers to an overarching term that covers behaviour associated with (1) students who want to go to school but stay home out of fear or anxiety, often described as school phobia or school refusal, and (2) students who skip school because of defiant behaviour or lack of interest in school, also referred to as truancy (Kearney & Albano, 2004; Kearney, 2008). The duration of school refusal needs to be considered when assessing the severity of the behaviour. Kearney and Silverman (1996) proposed differentiation between varying durations, where ‘self-corrective’ indicates that the behaviour occurs occasionally in a period of less than 2 weeks, ‘acute’ indicates that the period of such behaviour lasts from 2 to 52 weeks, and ‘chronic’ indicates this behaviour occurs in a period lasting for 53 weeks or more. However, the severity of the problem may be independent of the duration, and its mode of expression needs to be considered as well. School refusal behaviour can have several expressions, including verbal or physical refusal (such as pleading, clinging, crying, or noncompliance), verbal and physical aggression, distress, tardiness, and partial or complete absenteeism. The condition may be understood to occur along a continuum, with different expressions and episodes which might change on a daily basis (Kearney, 2006) (Fig. 1).

Kearney and others defend the use of this broad and more inclusive concept to meet the causal heterogeneity of the condition (Ingles, Gonzalvez-Macia, Garcia-Fernandez, Vicent, & Martinez-Monteagudo, 2015; Kearney & Silverman, 1996). This definition of school refusal behaviour has been more influential in recent years; however, some researchers prefer to differentiate between school refusal and truancy (Heyne, King, Tonge, & Cooper, 2001).

The prevalence of school refusal behaviour is indicated to be 5–28% in the general child and adolescent population (Havik, Bru, & Ertesvag, 2015; Kearney & Bensaheb, 2006; Kearney, 2008). Most studies have reported a prevalence rate of school refusal about 5% (Egger, Costello, & Angold, 2003; Havik et al., 2015; Ingles et al., 2015; King & Bernstein, 2001). School refusal behaviour is more difficult to quantify because most studies and school statistics mainly report full time absenteeism and do not include refusal behaviour (Kearney, 2008). School refusal behaviour occurs in all ages; however, its onset is often reported in early adolescence. Further, it is found to be equally common in girls and boys (Heyne et al., 2001, Ingles et al., 2015, Kearney, 2008).

A number of socio demographic factors are reported to be associated with school refusal behaviour in the general child and adolescent population (Heyne et al., 2001, Kearney, 2008). Physical or psychiatric disease in other family members, parental unemployment, low educational level of mothers, and disorganized and unsafe home environments with poor adult support and attendance are among the factors reported (Bahali, Tahiroglu, Avci, & Seydaoglu, 2011; Fernando & Perera, 2012; Ingul, Klockner, Silverman, & Nordahl, 2012; Kearney, 2008).

School refusal behaviour represents a stressful situation for the child, the family, and the teachers, and it is a serious public welfare problem. Several researchers point out the importance of early identification of this behaviour to prevent both short and long-term consequences. In the short term, failure to attend school may influence both academic and social achievement and attitudes towards school. The long-term consequences may negatively influence the students’ academic, psychological, and social development, and it may ultimately be a risk factor for dropping out of school. The consequences in adulthood may include failure to enter the labour market, low social status, and marital and psychiatric problems, and it may lead to an increased need for social security benefits (Fremont, 2003, Havik et al., 2015, Kearney, 2008, Reid, 2005; Thambirajah, Grandison, & De-Hayes, 2008). Several studies have reported high rates of emotional and behavioural problems as well as somatic complaints in students with school refusal behaviour (Egger et al., 2003; Ingul et al., 2012; Kearney & Albano, 2004; McShane, Walter, & Rey, 2001). Further, language disorders and learning disabilities have been found to be associated with it (Havik et al., 2015, McShane et al., 2001; Naylor, Staskowski, Kenney, & King, 1994). Few studies explore such behaviour in students with ASD. The only study conducted on this topic reported school refusal behaviour in 27.3% of students with ASD with and without intellectual disability, mainly attending special classes or schools (Kurita, 1991).

ASD is a lifelong set of pervasive neurodevelopmental disorders with onset in childhood. Children with ASD are a heterogeneous group; sharing the core symptoms of persistent deficits in social communication; social interaction; and restrictive and repetitive patterns of behaviour, activities, or interests (American Psychiatric Association, 2013; Lai, Lombardo, & Baron-Cohen, 2014). The etiological factors of ASD are mostly unknown, but it might best be understood as a complex interaction between environmental factors and genetics (Lai et al., 2014). Estimates of the prevalence of ASD vary; however, most research indicates a prevalence rate of about 1%. Further, boys are considered to be 2–3 times more likely to be affected than girls are (Lai et al., 2014). ASD affects children of all levels of cognitive functioning, but approximately 50% have normal intellectual ability (Lai et al., 2014).