Applied Evidence

Dealing with school refusal behavior: A primer for family physicians

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If no medical condition is found, explore the reasons a particular child refuses school. A common model of conceptualizing school refusal behavior involves reinforcers1-2:

  • To avoid school-based stimuli that provoke a sense of negative affectivity, or combined anxiety and depression; examples of key stimuli include teachers, peers, bus, cafeteria, classroom, and transitions between classes
  • To escape aversive social or evaluative situations such as conversing or otherwise interacting with others or performing before others as in class presentations
  • To pursue attention from significant others, such as wanting to stay home or go to work with parents
  • To pursue tangible reinforcers outside of school, such as sleeping late, watching television, playing with friends, or engaging in delinquent behavior or substance use.

The first 2 functions are maintained by negative reinforcement, or a desire to leave anxiety-provoking stimuli. The latter 2 functions are maintained by positive reinforcement, or a desire to pursue rewards outside of school. Youths may also refuse school for a combination of these reasons.17 In Nathan’s case, he was initially anxious about school in general (function 1) but, after his parents allowed him to stay home for a few days, was refusing school as well to enjoy fun activities (eg, video games) at home (function 4).

One method for quickly assessing the role of these 4 functions is the School Refusal Assessment Scale–Revised.18,19 This scale poses 24 questions, the answers to which measure the relative strength of each of the 4 functions. Versions are available for children and parents, who complete their respective scales separately (TABLES 4-5). Item means are calculated across the measures to help determine the primary reason for a child’s school refusal.

In addition to using the School Refusal Assessment Scale–Revised, you may ask interview questions regarding the form and function of school refusal behavior (TABLE 6). Take care to assess attendance history and patterns, comorbid conditions, instances of legitimate absenteeism, family disruption, and a child’s social and academic status. Specific questions about function can help narrow the reason for school refusal.

Assess specific school-related stimuli that provoke absenteeism (eg, social and evaluative situations), whether a child could attend school with a parent (evidence of attention-seeking), and what tangible rewards a child receives for absenteeism throughout the school day. Information about the form and function of school refusal behavior may also be evident during in-office observations of the family. Data from the School Refusal Assessment Scale-Revised, interviews, and observations can then be used to recommend particular treatment options.

TABLE 4
Child version of the School Refusal Assessment Scale–Revised

  1. How often do you have bad feelings about going to school because you are afraid of something related to school (for example, tests, school bus, teacher, fire alarm)? (1)
  2. How often do you stay away from school because it is hard to speak with the other kids at school? (2)
  3. How often do you feel you would rather be with your parents than go to school? (3)
  4. When you are not in school during the week (Monday to Friday), how often do you leave the house and do something fun? (4)
  5. How often do you stay away from school because you will feel sad or depressed if you go? (1)
  6. How often do you stay away from school because you feel embarrassed in front of other people at school? (2)
  7. How often do you think about your parents or family when in school? (3)
  8. When you are not in school during the week (Monday to Friday), how often do you talk to or see other people (other than your family)? (4)
  9. How often do you feel worse at school (for example, scared, nervous, or sad) compared to how you feel at home with friends? (1)
  10. How often do you stay away from school because you do not have many friends there? (2)
  11. How much would you rather be with your family than go to school? (3)
  12. When you are not in school during the week (Monday to Friday), how much do you enjoy doing different things (for example, being with friends, going places)? (4)
  13. How often do you have bad feelings about school (for example, scared, nervous, or sad) when you think about school on Saturday and Sunday? (1)
  14. How often do you stay away from certain places in school (eg, hallways, places where certain groups of people are) where you would have to talk to someone? (2)
  15. How much would you rather be taught by your parents at home than by your teacher at school? (3)
  16. How often do you refuse to go to school because you want to have fun outside of school? (4)
  17. If you had less bad feelings (for example, scared, nervous, sad) about school, would it be easier for you to go to school? (1)
  18. If it were easier for you to make new friends, would it be easier for you to go to school? (2)
  19. Would it be easier for you to go to school if your parents went with you? (3)
  20. Would it be easier for you to go to school if you could do more things you like to do after school hours (for example, being with friends)? (4)
  21. How much more do you have bad feelings about school (for example, scared, nervous, or sad) compared to other kids your age? (1)
  22. How often do you stay away from people at school compared to other kids your age? (2)
  23. Would you like to be home with your parents more than other kids your age would? (3)
  24. Would you rather be doing fun things outside of school more than most kids your age? (4)
NOTE: (1)=avoidance of school-related stimuli that provoke a sense of negative affectivity, (2)=escape aversive social and/or evaluative situations, (3) pursuit of attention from significant others, (4) pursuit of tangible reinforcers outside of school.
NOTE: Items are scored on a 0-6 scale where 0=never, 1=seldom, 2=sometimes, 3=half the time, 4=usually, 5=almost always, and 6=always.

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