Evidence-Based Reviews

Solutions to school refusal for parents and kids

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Is there a link between school violence and absenteeism?

Violence on school campuses across the country naturally makes many parents skittish about possible copycat incidents. In fact, some parents acquiesce to their children’s pleas to remain home on school shooting anniversaries—particularly the Columbine tragedy of April 20, 1999.

Student and parental fears likely are exacerbated by new episodes of violence, such as three school shootings in 2006:

  • On September 27, a 53-year-old man entered a high school in Bailey, Colorado, and shot one girl before killing himself.
  • On September 29, a high school student near Madison, Wisconsin, killed his principal after being disciplined for carrying tobacco.
  • On October 2, a heavily armed man barricaded himself in a one-room Amish schoolhouse in Paradise, Pennsylvania. He bound and shot 11 girls before killing himself, and five of the girls died.

Compared with highly publicized school violence, however, personal victimization is a much stronger factor in absenteeism.32 Specifically, school violence is related to school absenteeism especially for youths who have been previously victimized. The literature shows:

  • Students who have been bullied are 2.1 times more likely than other students to feel unsafe at school.
  • 20% of elementary school children report they would skip school to avoid being bullied.33
  • High school students’ fear of attending classes because of violence is directly associated with victimization by teachers or other students.
  • Missing school because of feeling unsafe is a strong risk factor for asthma and, potentially, being sent home early from school.34

Assessment scale. One method for quickly assessing the role of these 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 (see Related resources). Item means are calculated across the measures to help determine the primary reason for a child’s school refusal.

In addition to using the assessment scale, you may ask interview questions regarding the form and function of school refusal behavior (Tables 4,5). 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 such as 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

Questions related to forms of school refusal behavior

What are the child’s specific forms of absenteeism, and how do these forms change daily?What specific school-related stimuli are provoking the child’s concern about going to school?
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)?Is the child’s refusal to attend school legitimate or understandable in some way (eg, school-based threat, bullying, inadequate school climate)?
What comorbid conditions occur with a child’s school refusal behavior (Table 3), including substance abuse?What family disruption or conflict has occurred as a result of a child’s school refusal behavior?
What is the child’s degree of anxiety or misbehavior upon entering school, and what specific misbehaviors are present in the morning before school (Table 2)?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.)

Table 5

Questions related to functions of school refusal behavior

Have recent or traumatic home or school events influenced a child’s school refusal behavior?Is the child willing to attend school if a parent accompanies him or her?
Are symptoms of school refusal behavior evident on weekends and holidays?What specific tangible rewards does the child pursue outside of school that cause him or her to miss school?
Are there any nonschool situations where anxiety or attention-seeking behavior occurs?Is the child willing to attend school if incentives are provided for attendance?
What specific social and/or evaluative situations at school are avoided?

Treating youths who refuse school

Treatment success will be better assured if you work closely with school personnel and parents to gather and share information, coordinate a plan for returning a child to school, and address familial issues and the child’s comorbid medical problems that impact attendance.

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