Understanding School Refusal (page 2)

By — NYU Child Study Center
Updated on Apr 22, 2014

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:

  1. To avoid school-related objects or situations that cause general distress such as anxiety, depression or physiological symptoms
  2. To escape uncomfortable peer interactions and/or academic performance situations such as test-taking or oral presentations
  3. To receive attention from significant others outside of school
  4. 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.


School personnel -- teachers, nurses, principals -- are frequently the first professionals to identify the existence of a problem that requires immediate attention and intervention. As such, school personnel play a vital role in alerting parents to the problem and helping facilitate referrals for treatment by mental health specialists. The next step towards effective treatment by mental health professionals is gaining an understanding of the reasons that motivate school refusal. While school refusal per se is not a clinical disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, it can be associated with several psychiatric disorders (e.g. Separation Anxiety Disorder, Social Phobia, Conduct Disorder). Thus, it is vital that youths who are school refusing receive a comprehensive evaluation that includes a structured diagnostic interview and empirically supported assessment measures, such as "The School Refusal Assessment Scale" (SRAS)2, to understand the biopsychosocial factors contributing to their behavior. Once a clear diagnostic picture is established, an individualized treatment plan can be developed to address the positive and negative reinforcers that are associated with the school refusal behavior and comorbid psychiatric disorders.

The traditional treatments for school refusal behavior employed by mental health professionals have unfortunately had limited effectiveness. While certain treatment modalities such as psychodynamic therapies, forced school attendance, family-based techniques, medication and use of systematic desensitization work as the sole treatment modality for some youngsters, not all children who refuse school will improve with the chosen treatment. Thus, clinical scientists have developed a scientifically-based, comprehensive assessment and treatment package for youths with school refusal behavior. Table 1 illustrates this effective, straightforward treatment model which addresses each of the four components of school refusal behavior. Consultation with child psychiatrists may be necessary in certain cases of school refusal behavior that involve highly complicated clinical symptoms and comorbidities. For example, in order to increase the probability of successful therapeutic intervention, the child refusing school who exhibits mainly internalizing problems may benefit from adjunctive pharmacotherapy (e.g., Selective Serotonin Reuptake Inhibitor - SSRI) to help lower his or her anxiety.

Function or Reason Treatment Components
Escape from negative affect (Sadness, the blues, fears, generalized anxiety and worry, separation anxiety, various phobias)
  • Somatic management skills such as breathing retraining or progressive muscle relaxation training
  • Gradual reintroduction (exposure) to school
  • Self-reinforcement and building self efficacy
Escape from aversive social and evaluative situations (Social phobia, test anxiety, public speaking fears, shyness, social skills deficits)
  • Cognitive restructuring of negative self-talk
  • Role play practice
  • Graded exposure tasks involving real-life situations
  • Social skills training and problem-solving skills training
  • Building coping templates
Attention-seeking behavior (Tantrums, crying, clinging, separation anxiety)
  • Parent training in contingency management
  • Changing parent commands
  • Establishing routines
  • Use of rewards and punishers for school attendance and school refusal
  • Forced attendance, if necessary and under special circumstances
Positive tangible reinforcement (Lack of structure or respect for house rules and responsibilities, free access to reinforcement, disregard for limits)
  • Contracting with parents to increase incentive for school attendance
  • Curtail social and other activities as a result of nonattendance
  • Provide the family with alternative problem-solving strategies to reduce conflict
  • Communication skills and peer refusal skills are also sometimes added to this process

Table 1

Returning to our case examples, careful evaluation revealed that Rebecca's school refusal behavior was initially a function of separation anxiety which was positively reinforced by having her mother's attention and play time during school hours. This lead her therapist to design a treatment program combining somatic management skills, practice in being away from her mom and parent training in contingency management. Following Nicholas' evaluation he was prescribed a treatment to address his social anxiety that motivated his school refusal. Nicholas' behavior was negatively reinforced by avoiding social and evaluative situations. Thus, his treatment plan involved cognitive restructuring, role plays, social skills and problem-solving skills, and gradual reintroduction to school. In addition, a strong working relationship between the therapist and the youth's school officials is an integral component of a successful treatment program for school refusal behavior. As an example, through a structured treatment plan with clear goals and a definitive time frame, a helpful school official might facilitate Nicholas' return to school or Rebecca remaining in her classroom rather than the nurse's office.

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