Understanding School Refusal (page 2)
Rebecca, an eight-year-old girl, has always had difficulty attending school. Since she began third grade two months ago, her problems have significantly worsened. She constantly begs to stay home from school, having tantrums that cause delay in dressing and often result in her missing the bus. After arriving at school, Rebecca frequently complains of stomachaches, headaches and a sore throat to her teacher and asks to visit the school nurse with whom she pleads to call her mother. Her mother typically picks her up early twice a week. When Rebecca gets home she spends the remainder of the afternoon watching TV and playing with her toys. When her mother is unable to pick her up early, Rebecca calls her mother's cell phone periodically throughout the afternoon to "check in" and reassure herself that nothing bad has happened. Rebecca's teacher has expressed concern about her missing so much class time which has resulted in incomplete assignments and difficulty learning.
Nicholas is a fourteen-year-old boy who has missed forty-three days of school since beginning the eighth grade four months ago. When home from school, Nicholas spends most of the day online or playing video games. On the days he does attend school he is typically late for his first period which enables him to avoid hanging out with other kids before class. He always goes to the library during lunch. When he does go to class, he sits in the back of the classroom, never raises his hand and has difficulty working on group projects. Nicholas' teachers have noticed that he is always absent on days that tests or book reports are scheduled. His parents have already punished him after his first report card came home since he received D's in Math and Social Studies and failed Gym for cutting. Nicholas' parents have started to wonder if they should change his school placement and have asked the school to arrange home tutoring while this alternative is explored.
Prevalence and defining characteristics
As much as 28% of school aged children in America refuse school at some point during their education.1 School refusal behavior is as common among boys as girls. While any child aged 5-17 may refuse to attend school, most youths who refuse are 10-13 years old. Peaks in school refusal behavior are also seen at times of transition such as 5-6 and 14-15 years as children enter new schools. Although the problem is considerably more prevalent in some urban areas, it is seen equally across socioeconomic levels.
Rebecca and Nicholas are just two examples of how school refusal manifests in youth. The hallmark of this behavior is its heterogeneity. Defined as substantial, child-motivated refusal to attend school and/or difficulties remaining in class for an entire day, the term "school refusal behavior" replaces obsolete terms such as "truancy" or "school phobia," because such labels do not adequately or accurately represent all youths who have difficulty attending school. School refusal behavior is seen as a continuum that includes youths who always miss school as well as those who rarely miss school but attend under duress. Hence, school refusal behavior is identified in youths aged 5-17 years who:
- are entirely absent from school, and/or
- attend school initially but leave during the course of the school day, and/or
- go to school following crying, clinging, tantrums or other intense behavior problems, and/or
- exhibit unusual distress during school days that leads to pleas for future absenteeism.
As evidenced by Rebecca and Nicholas, there are varying degrees of school refusal behavior. Initial school refusal behavior for a brief period may resolve without intervention. Substantial school refusal behavior occurs for a minimum of two weeks. Acute school refusal behavior involves cases lasting two weeks to one year, being a consistent problem for the majority of that time. Chronic school refusal behavior interferes with two or more academic years as this refers to cases lasting more than one calendar year. Youths who are absent from school as a result of chronic physical illness, school withdrawal which is motivated by parents or societal conditions such as homelessness, or running away to avoid abuse should not be included in the above definition of school refusal behavior as these factors are not child-initiated.
While some school refusers exhibit a more heterogeneous presentation, typically these youths can be categorized into two main types of troublesome behavior -- internalizing or externalizing problems. The most prevalent internalizing problems are generalized worrying ("the worry-wart"), social anxiety and isolation, depression, fatigue, and physical complaints (e.g. stomachaches, nausea, tremors and headaches). The most prevalent externalizing problems are tantrums (including crying and screaming), verbal and physical aggression, and oppositional behavior.
The cause and maintenance of school refusal behavior
Rebecca had several physiological symptoms at school and went home to be with her mother and play. Nicholas on the other hand, avoided potentially distressing social and evaluative situations at school which negatively impacted his academic performance. Although many behaviors characterize youths who refuse school, there are a few variables that serve to cause and maintain this problem. School refusal behavior occurs for one or more of the following reasons:
- To avoid school-related objects or situations that cause general distress such as anxiety, depression or physiological symptoms
- To escape uncomfortable peer interactions and/or academic performance situations such as test-taking or oral presentations
- To receive attention from significant others outside of school
- To pursue tangible reinforcement outside of school
The above four reasons for school refusal behavior can be explained by principles of reinforcement. Any one child can refuse school for one or more of these reasons. The first two reasons characterize youths who refuse school to avoid or escape something unpleasant (negative reinforcement). For example, one of the reasons for Rebecca's crying in the morning is her fear of riding the school bus. By tantruming she accomplishes her goal of avoiding the school-related object (the school bus) that causes her distress. Another example of negative reinforcement is when Nicholas escapes aversive peer interactions and exams by school refusing. The third and fourth reasons characterize youths who refuse school to gain rewards (positive reinforcement). Rebecca, as is common with many younger children, tries to avoid school as a means of having her mother provide her with excessive attention and closeness. Thus, Rebecca's behavior in this situation may be associated with separation anxiety. Another instance of positive reinforcement is exemplified by Nicholas, who basically has more fun being at home on the computer and listening to music than being in school. It is important to note that alcohol and drug use can occur among adolescents who school refuse for one or more of the reasons listed above. For example, a teenager who is extremely socially anxious may drink alcohol as a way of enduring distressing social or evaluative situations. Another youngster who avoids school may smoke marijuana during school hours as a means of gaining acceptance by peers or simply because it is more enjoyable than attending school. While all forms of school refusal can be equally debilitating, typically, mental health professionals receive fewer referrals for youths who have internalizing as opposed to externalizing behavior problems. In other words, the youth who exhibits anxiety is less likely to receive treatment than the youth who is disruptive.
Reprinted with the permission of the NYU Child Study Center. © NYU Child Study Center.
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