Definition, signs and risk factors, assessment, social work with parents and young people
Three sections follow:
1. Background Material that provides the context for the topic
2. A suggested Practice Approach
3. A list of Supporting Material / References
Feedback welcome!
Background Material
Definition
School refusal is when young people get extremely upset at the idea of going to school and often miss some or all of the school day. Young people who refuse to go to school usually spend the day at home with their parents’ knowledge, even though their parents try hard to get them to go. School refusal is a name for an emotional problem (Raising Children Network, 2022). School refusal is not highly prevalent, but it can be highly problematic. Non-referred youth with school refusal experience psychological and psychosocial problems and approximately 50% of youth referred for treatment of school refusal meet diagnostic criteria for an anxiety disorder, depressive disorder, or both. School refusal often persists when untreated and there is a risk for psychosocial problems in adulthood. Early intervention is thus essential, further underscored by the ineffectiveness of state-of-the-art treatment for some school-refusing youth (Ingul et al., 2019).
Both Ingul et al (2019) and Heyne et al., (2019) suggest school refusal has a number of aspects that differentiate it from truancy. School refusal is defined by
a youth’s reluctance or refusal to attend school, often leading to prolonged absence;
the youth is usually at home when not at school, and the parents are usually aware of this;
the youth experiences emotional distress about going to school (e.g., somatic complaints, anxiety, depressed mood);
there is an absence of severe antisocial behavior, although the youth may show resistive behavior when parents try to get them to school; and
parents have tried to secure the youth’s attendance at school.
School refusal is often differentiated from truancy based on criteria b, c, and d.
Signs/risk factors of school refusal
A young person who refuses to go to school might:
cry, throw tantrums, yell or scream
hide or lock themselves in their room
refuse to move
beg or plead not to go
complain of aches, pains and illness before school (somatic complaints), which generally get better if the young person stays at home
show high levels of anxiety
have trouble sleeping
threaten to hurt themselves
School refusal can occur at any age but is more common in young people aged 5-6 years and 10-11 years (Raising Children Network, 2022).
Ingul et al. (2019) analyses the signs of emerging school refusal by examining characteristics related to the young person, the school setting and the family situation as follows:
Characteristics related to the young person
Absence or partial absence, e.g. late arrival, returning home during the day, absence for the whole day and missing particular activities or classes. Absence has the tendency to lead to more absence.
Anxiety and depression Emotional distress seems to be a sign of emerging school refusal as are anxiety disorders (e.g. fear specific to school, worry about harm to parents, and fear of what will happened at home while attending school). Separation anxiety and social anxiety are potential causes of school refusal.
Somatic complaints, i.e. subjective health conditions (e.g. headache, stomach ache, feeling unwell and other types of physical symptoms). Some studies show illness-related absence may precede school refusal in some cases.
Age and transitions In studies, SR emerged more often in childhood than adolescence but appears to be more severe and complex in adolescents. The first two years of secondary school is a peak time for school refusal in adolescents sometimes because of the larger and more complex school environment, and an increase sense of being unsafe because of the unpredictability of the new environment. Other transitions that can result in school refusal include moving to a new area or school, a change of teacher or class, the beginning of a school year, returning to school after a holiday period, an absence due to illness, the departure of a friend, parent separation or divorce and mother starting work.
Problematic emotional regulation Higher levels of negative emotions and a poorer self-concept than their peers can result in school refusal.
Negative thinking, low self-efficacy (belief in one’s abilities) and limited problem solving.
Characteristics related to the school setting
Teachers are frequently the first to identify school attendance problems but, unfortunately, teachers often blame parents’ attitudes while parents and students often blame the school. School-based factors should always be considered in school refusal.
Problematic student-teacher relationship and unpredictability at school e.g. fear of the teacher, conflict with the teacher, fear around less structured aspects of the school (e.g. breaks) and poorly monitored areas (e.g. toilets), transition moments.
Bullying, social isolation and loneliness, e.g. few friends, social isolation outside and at school, shy, lonely.
Educational difficulties, e.g. poor grades, special education needs, learning disabilities, academic difficulties, anxiety about academic performance.
Limited cooperation between school and home Both parents and teachers complain of limited cooperation from the other party; effective communication between schools and families has be shown to positively impact school attendance.
Characteristics related to the family situation
Parental psychopathology, i.e. mental health issues such as anxiety disorders may lead to a less responsive parent to school refusal.
Parental over protection, e.g. over involvement in the mother-child relationship.
Unhealthy family functioning, e.g. lack of understanding, lack of clear family roles, inability to cope with changing demands, ignoring painful situations, low cohesion, low adaptability.
Elliott & Place (2019) suggests the following as potential signs or causes: anxiety disorders in general and separation anxiety specifically, academic pressures, negative peer experiences, bullying, and cyberbullying (especially received in the relative safety of the child’s home).
Assessment
Assessment should seek to ascertain the extent to which a child’s unwillingness to attend school is a response to particular elements of the school context itself, a general fear of potentially stressful social situations, a reluctance to leave the family home, gain additional parental (and other) attention, and a perception that alternative settings are more rewarding than school. The School Refusal Assessment Scale offers a means to assess key functions of school refusal: a) avoidance of negative emotions, often resulting from specific fears, b) escape from social aversion or evaluative situations, c) seeking attention, often stemming from separation anxiety, or d) seeking tangible reinforcements outside of school. In order to provide a detailed and nuanced understanding, the use of the Scale should be complemented by interview and observational data, and parent, teacher and child self-report measures. The measure may be less valuable when considering severe or chronic cases where many contextual influences may operate (Elliott & Place., 2019). [You will find links to this scale in the Supplementary Material / References section at the end of this post.]
Practice Approach
Overall, social workers who are supporting young people and their parents with a school refusal situation should draw on the material above and the two sections below (‘assisting parents…’ and ‘supporting young people…’) to chart a preliminary course that may need to be adjusted along the way. It will involve:
Identifying why the young person is having difficulty attending school. At some stage the School Refusal Assessment Scale may be useful (web links in References section below).
Conduct a psychosocial assessment to uncover any underlying strengths, social contacts, family characteristics, issues that may be troubling the young person
Ensuring the young person knows he or she will be supported as solutions are explored.
Ask the young person what can happen to have her or him attending school and endeavour to implement this. Gather family support for what is suggested.
Ask permission from the young person to approach the school to discuss the situation.
Gather ideas from the school around what can be done. Gather school support for any proposed initiatives.
Work with the young person, school and family to implement agreed-upon strategies. These could include the cognitive behaviour therapies and behavioural approaches, improving social ties with friends, providing academic support, starting the program with partial school days, and/or other suggestions.
Continually evaluate progress and alter the plan as necessary, all-the-while working from the young person’s strengths and positively reinforcing/rewarding improvements.
Assisting parents about school refusal
Raising Children Network (2022) has a number of suggestions that parents can try if they find their young person is refusing to go to school. The Network suggest the young person continues to go to school while solutions are being explored. Approaches include:
Identifying why the young person is having trouble going to school
Talk with the young person about school and why they don’t want to go. ‘If you could change one thing about school, what would it be?’
If the young person finds it hard to talk about the problem, ask him or her to rate each part of the school day.
Explore whether anything has happened that’s making it hard for the young person to leave and go to school (e.g. death in the family, recently moved house, someone at home, a pet unwell).
Finding solutions to school refusal
Use a problem-solving approach to the things that make it hard for them to leave home or go to school.
Tell the young person that you’re going to work together with their school to help them go to school.
Talk with the young person about seeing a counsellor or psychologist if they feel they can’t manage their worries or fears about school.
Working as a team with the school
Explain what’s going on and why your child is refusing to go to school – for example, bullying, learning difficulties, mental health problems and so on.
If relevant, ask the school about their strategies to manage and prevent bullying.
Ask what support the school can offer for a learning difficulty that may be evident.
Try a gradual start back at school for the young person, e.g. shorter school day or favourite subject.
At home, show support in the following ways:
When talking to your young person
Show the young person you understand.
Use clear, calm statements—say ‘when’ rather than ‘if’.
Say positive and encouraging things.
Use direct statements that don’t give the chance to say ‘No!’, e.g. ‘Jo, please get up and into the shower’.
When you’re at home with your child
Stay calm.
Have morning and evening routines.
Praise when young people show appropriate behaviour, like getting ready for school.
Make your home ‘boring’ during school hours.
Do work provided by the school while at home.
Getting to school
Get someone else to drop off the young person.
Praise going to school. Consider a reward.
Focus on any efforts made to go back, be patient, and do not become frustrated in front of the young person.
Supporting young people with school refusal and their parents
Elliott and Place (2019) suggest intervention programs for school refusal appear to be more successful for younger children, irrespective of the approach employed. Several factors may contribute to the greater difficulty encountered in intervening with older children. Adolescent refusers tend to have a greater sense of autonomy than younger children that can help them to refuse adult instructions. They may encounter greater difficulty in re-engaging with more complex, demanding, specialised curricula at a stage when high stakes testing is becoming more pressing.
Elliott and Place (2019) suggest a number of treatment approaches:
Cognitive behaviour therapy is the most popular, drawing upon a combination of psychoeducation, relaxation training, social skills training, gradual exposure, and cognitive restructuring.
Behavioural approaches are primarily exposure-based drawing on techniques such as systematic desensitisation (incorporating relaxation training), flooding, emotive imagery, modelling, shaping, and contingency management.
Pharmacotherapy treatments continue to be contentious with SSRIs the choice of treatment for anxiety disorders.
The Response to Intervention (RTI) framework commences with a detailed assessment of the situation. Decisions about future action are taken and these are implemented. Further actions are dependent on how the young person responds to each action as it is implemented. RTI does not specify which forms of intervention, but strongly suggests they have a sound research base.
Farrell-Whelan (2023) describes an initiative referred to as Open Dialogue that builds on the RTI framework. A student’s family, teacher, support services and school support staff are invited to a meeting to talk together, alongside the student. The group listens and holds off on solutions or plans until all can talk together in an open non-judgemental, non-pathologising way. The group minimises the talk that happens outside of these meeting, with only limited “pre-planning’ or discussion after the meeting. These meetings guide the support and adjustment that are to be in place for any student. The Open Dialogue approach is designed to meet together, build relationships and let those at the centre of the discussion speak for themselves.
Ingul et al., (2019) suggests schools have a system in place to identify early signs of and risk factors for school refusal.
Form a dedicated attendance team of relevant staff, e.g. assistant principal, student welfare staff, and staff responsible for attendance.
Ensure school personnel, parents and youth are aware of the signs of emerging school refusal and the risk for school refusal through flyers, school web pages, information evenings for parents, and in-service for school personnel.
Meet regularly (e.g. every two weeks) to review attendance data and teacher’s concerns.
When school refusal is identified, a team member is appointed as coordinator to facilitate further assessment (e.g. the administration of questionnaires together with face-to- face, telephonic, and written contact with teachers, parents, the young person, and other relevant parties.
This information is brought to the next meeting so the team can decide on an appropriate targeted intervention to prevent school refusal becoming established.
References
(available on request)
Elliott, J.G., & Place, M. (2019). Practitioner review : School refusal : Developments in conceptualisation and treatment since 2000. Journal of child psychology and psychiatry, 60 (1), pp. 4-15. https://doi.org/10.1111/jcpp.12848
Farrell-Whelan, S. (2023). A “rebellious act” to support students in distress. Social Work Focus, 8(1), 25-26.
Heyne, d., Gren-Landell, M., Melvin, G., & Gently-Genitty, C. (2018). Differentiation between school attendance problems: Why and how? Cognitive and Behavioral Practice. (Article in press). https://doi.org/10.1016/j.cbpra.2018.03.006
Ingul, J. M., Havik, T., & Heyne D. (2019). Emerging school refusal: A school-based framework for identifying early signs and risk factors. Cognitive and Behavioural Practice, 26, 46-62. doi:10.1016/j.cbpra.2018.03.005
Raising Children Network. (2022). School refusal: Children and teenagers. https://raisingchildren.net.au/school-age/school-learning/school-refusal/school-refusal
School Refusal Assessment Scale:
Child version
Parent version