Applied Evidence

Dealing with school refusal behavior: A primer for family physicians

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TABLE 5
Parent version of the School Refusal Assessment Scale–Revised

  1. How often does your child have bad feelings about going to school because he/she is afraid of something related to school (for example, tests, school bus, teacher, fire alarm)? (1)
  2. How often does your child stay away from school because it is hard for him/her to speak with the other kids at school? (2)
  3. How often does your child feel he/she would rather be with you or your spouse than go to school? (3)
  4. When your child is not in school during the week (Monday to Friday), how often does he/she leave the house and do something fun? (4)
  5. How often does your child stay away from school because he/she will feel sad or depressed if he/she goes? (1)
  6. How often does your child stay away from school because he/she feels embarrassed in front of other people at school? (2)
  7. How often does your child think about you or your spouse or family when in school? (3)
  8. When your child is not in school during the week (Monday to Friday), how often does he/she talk to or see other people (other than his/her family)? (4)
  9. How often does your child feel worse at school (for example, scared, nervous, or sad) compared to how he/she feels at home with friends? (1)
  10. How often does your child stay away from school because he/she does not have many friends there? (2)
  11. How much would your child rather be with his/her family than go to school? (3)
  12. When your child is not in school during the week (Monday to Friday), how much does he/she enjoy doing different things (for example, being with friends, going places)? (4)
  13. How often does your child have bad feelings about school (for example, scared, nervous, or sad) when he/she thinks about school on Saturday and Sunday? (1)
  14. How often does your child stay away from certain places in school (eg, hallways, places where certain groups of people are) where he/she would have to talk to someone? (2)
  15. How much would your child rather be taught by you or your spouse at home than by his/her teacher at school? (3)
  16. How often does your child refuse to go to school because he/she wants to have fun outside of school? (4)
  17. If your child had less bad feelings (for example, scared, nervous, sad) about school, would it be easier for him/her to go to school? (1)
  18. If it were easier for your child to make new friends, would it be easier for him/her to go to school? (2)
  19. Would it be easier for your child to go to school if you or your spouse went with him/her? (3)
  20. Would it be easier for your child to go to school if he/she could do more things he/she likes to do after school hours (for example, being with friends)? (4)
  21. How much more does your child have bad feelings about school (for example, scared, nervous, or sad) compared to other kids his/her age? (1)
  22. How often does your child stay away from people at school compared to other kids his/her age? (2)
  23. Would your child like to be home with you or your spouse more than other kids his/her age would? (3)
  24. Would your child rather be doing fun things outside of school more than most kids his/her 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.

TABLE 6
Sample questions and targets of assessment regarding the forms of school refusal behavior

QUESTIONS RELATED TO THE FORM OF SCHOOL REFUSAL BEHAVIOR
What are the child’s specific forms of absenteeism, and how do these forms change daily?
Is a child’s school refusal behavior relatively acute or chronic in nature (in related fashion, how did the child’s school refusal behavior develop over time)?
What comorbid conditions occur with a child’s school refusal behavior (see TABLE 3), including substance abuse?
What is the child’s degree of anxiety or misbehavior upon entering school, and what specific misbehaviors are present in the morning before school (see TABLES 2 AND 4)?
What specific school-related stimuli are provoking the child’s concern about going to school?
Is the child’s refusal to attend school legitimate or understandable in some way (eg, school-based threat, bullying, inadequate school climate)?
What family disruption or conflict has occurred as a result of a child’s school refusal behavior?
What is the child’s academic and social status (this should include a review of academic records, formal evaluation reports, attendance records, and individualized education plans or 504 plans as applicable)?
QUESTIONS RELATED TO THE FUNCTION OF SCHOOL REFUSAL BEHAVIOR
Have recent or traumatic home or school events occurred to influence a child’s school refusal behavior?
Are symptoms of school refusal behavior evident on weekends and holidays?
Are there any non-school situations where anxiety or attention-seeking behavior occurs?
What specific social and/or evaluative situations at school are avoided?
Is the child willing to attend school if a parent accompanied him or her?
What specific tangible rewards does the child pursue outside of school that causes him or her to miss school?
Is the child willing to attend school if incentives were provided for attendance?

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