School refusal is a child-motivated refusal to attend school or difficulty remaining in class for the full day. 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 or circumstances such as homelessness. School refusal is characterized by avoidance and/or emotional distress at the time of attending school.
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. 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.
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. 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.
Behavioral
School attendance difficulties include a broad range of different behaviors. The spectrum of refusal spans from occasional reluctance to complete refusal. Students may miss the entire day, a partial day, skip class, or arrive late.
Assessment
Because school refusal behavior is a multifaceted issue, there is not a single valid measure or assessment method for diagnosis. 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. 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. 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.
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. 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. Other externalizing symptoms include defiance, aggression, tantrums, clinging to a parent, refusing to move, and/or running away. If the child stays home from school, these symptoms might go away but come back the next morning before school.
Researchers are motivated to assess and treat this behavior because of its prevalence and potential negative consequences. 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. Excessive absenteeism is commonly associated with various negative health and social problems.
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.