case study school refusal

CONCEPTUAL ANALYSIS article

How to understand school refusal.

• 1 Norwegian Centre for Learning Environment and Behavioural Research in Education, University of Stavanger, Stavanger, Norway
• 2 Regional Centre for Child and Youth Mental Health and Child Welfare Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway

Attending school is usually seen as a precondition for academic, social, and emotional learning. However, school absenteeism is a problem in many countries and covers different types of authorized or unauthorized absences and a myriad of reasons. An authorized absence is when there is a satisfactory explanation for the youth’s absence, while unauthorized absence is usually understood as school attendance problems (SAPs). The main aim of this article is first to investigate define, describe, and discuss school refusal (SR) and how SR differs from other concepts of SAPs, and the secondary aim is to understand SR using different theoretical perspectives. The article outlines this aim based upon a review of international research in this field and uses the systemic integrated cognitive approach and school alienation theories to explain how SR might emerge and develop. The review indicates that SAPs involve many types, concepts, definitions, and reasons. The most frequently used concepts are school refusal behavior, truancy, school refusal, and school withdrawal. Based on the review, the article argues for a common understanding of these concepts among all stakeholders. We suggest a narrow definition of SR to enhance clarity and agreement and propose that the systemic integrated cognitive approach and school alienation theory are relevant to the understanding of SR. A common understanding among all stakeholders is the importance of identifying and intervening in specific types of SAPs. By using a systemic integrated cognitive approach and school alienation theory, identification and interventions can be targeted at an early stage of the development process of SR.

Introduction

The main aim of this article is to define, describe, and discuss school refusal (SR) and how SR differs from other concepts of school attendance problems (SAPs) based upon a review of international research. Furthermore, we present an explanation of how SR might emerge and develop by using different theoretical perspectives: perspectives that must be investigated in further research. Several years ago, Pilkington and Piersel claimed that “school refusal is a normal avoidance reaction to an unpleasant, unsatisfying, or even hostile environment” (1991, p. 290). By using a combination of a systemic integrated cognitive approach and the theory of school alienation, the aim is to integrate these perspectives to understand how SR might emerge and develop, including an interplay between several individual and environmental factors.

Attending school is important for youths’ 1 development, and school is considered to be the primary social arena that creates “citizens” ( Pellegrini, 2007 ). The many negative consequences of school absenteeism are widely described in Kearney et al. (2019) , Finning et al. (2019a) and Finning et al. (2019b) . However, school absenteeism is a problem in many countries (e.g., Heyne et al., 2019a ; Heyne et al., 2019b ; Gren-Landell et al., 2015 ). A myriad of concepts exists to describe school attendance problems (SAPs), but there is a lack of consensus regarding these concepts. Kearney et al. (2019) describe and discuss categorical and dimensional approaches for school attendance and school absenteeism. Their aim was “to set the stage for a discussion of a multidimensional, multi-tiered system of supports pyramid model as a heuristic framework for conceptualizing the manifold aspects of school attendance and school absenteeism” ( Kearney et al., 2019 ). Therefore, like Kearney et al. (2019) , we believe there is a need for a common understanding among stakeholders with agreement about risk factors and how to identify and intervene in the case of youths with SAPs. This is in line with the mission of the International Network for School Attendance (INSA) (established March 2018), which is to promote school attendance and reduce SAPs by compiling, generating, evaluating, and disseminating information, assessment, and intervention strategies ( https://insa.network/ ). However, in this article, we focus on the understanding of the concept SR, and we briefly describe other terms of SAPs.

School absenteeism covers all types of SAPs and refers to both authorized/excused/legal and unauthorized/unexcused/illegal absence (e.g., Malcolm et al., 2003 ; Reid, 2008 ). Authorized absence is claimed to constitute 80 percent of school absenteeism ( Kearney, 2008a ) and occurs when youths have permission from an authorized representative of the school. It includes a satisfactory explanation, often due to illness, holidays, or emergencies in the family. These absences are usually self-corrective.

Unauthorized absence is not recorded as illness or permission from the school and includes all unexplained or unjustified absences ( Dalziel and Henthorne, 2005 ). Reid (2008) claims that schools’ attempts to distinguish between authorized and unauthorized absences are at best unhelpful because schools and parents apply the regulations in different ways and mask the scale of the problem. Authorized absence might therefore be masked unauthorized absence, and the distinction might therefore not be very helpful to include, meaning that we in the future should focus on school absence and not authorized/unauthorized as the starting point of research, assessment, and reporting.

This phenomenon is exemplified in a study by Havik et al. (2015a) in which subjective health complaints (headache, stomachache, muscle pain, feeling unwell, or feeling tired/worn-out) emerged as the most frequently self-reported reasons for school absence among 6–10th graders. Is this authorized or unauthorized absence, and does it make a difference? Ricking and Schulze (2019) claimed that every failure to attend school should be taken seriously, whether it is authorized or unauthorized. Teachers, parents, researchers, and other stakeholders are concerned about the potential consequences of long-term unauthorized absence or SAPs, which might impair youths’ learning and development. Over the years, different concepts have been used to describe and define SAPs, and different risk factor profiles are associated with these concepts. Moreover, these concepts are defined differently by researchers, which leads to confusion and difficulties in comparing the results of previous studies.

Concepts of School Attendance Problems

The most common concepts related to child and parental-motivated SAPs are school refusal behavior (SRB), truancy (TR), school withdrawal (SW), and school refusal (SR). SAPs encompass a broader concept than SRB, as SAPs include all kinds of unexcused absence, including school exclusion (school-initiated absenteeism), and SW, while SRB only includes child-motivated absence. For an overview of these and other concepts of SAPs, see Heyne et al. (2019a) and Kearney et al. (2019) . Table 1 presents a short description of concepts included in the current article. Some characteristics of each concept indicate differences/similarities between them.

TABLE 1 . Concepts and characteristics of SAPs.

Different disciplines have focused on different aspects of SAPs. Psychologists have been mostly concerned with mental health problems from a clinical perspective, criminology has focused on law and justice, and educators have focused on school-related factors for SAPs. When reviewing previous literature from different fields, it is important to be aware that concepts might be value laden and might carry different connotations, e.g., TR and criminality vs. SR and psychiatry. Truants often seem to be condemned and given punishments, corrections, and sanctions, while SR seems to elicit more acceptance, sympathy, nonpunitive assistance, understanding, and appropriate treatment than TR ( Lyon and Cotler, 2007 ). This labeling might affect responses from adults ( Torrens Armstrong et al., 2011 ) and influence access to professional services and interventions ( Lyon and Cotler, 2007 ).

“One of the key issues when considering “school absenteeism” and “truancy” is to understand correctly the meaning and definition of the terms. This is not quite as simple as it sounds” ( Reid, 2005 , p. 59). Some of the concepts of SAPs are broad (e.g., SRB), including more than one type of attendance problem, while others are narrow (e.g., SR). It is important to understand that SRB is a wider concept than SR, as SRB includes SR, attention-seeking behavior and separation anxiety, and TR. In the following, the most frequent concepts of child- and parent-motivated absence will be described in more detail: school refusal behavior, truancy, school withdrawal, and school refusal.

School Refusal Behavior

SRB was first introduced in 1993 as an overarching construct to describe a spectrum of child-motivated school absenteeism, defined as “child-motivated refusal to attend school or difficulties remaining in school for the entire day” ( Kearney and Silverman, 1999 , p. 345). SRB may or may not be related to emotional distress about school ( Kearney et al., 2019 ). Kearney (2001) describes four functions that primarily maintain SRB. The first two functions are related to negative reinforcement, often seen as SR. These functions are: 1) to avoid stimuli that provoke a sense of general negative affectivity (i.e., distress, anxiety, depression), and/or 2) to escape aversive social and/or evaluative situations (i.e., tests, oral presentation in class, peer interactions). Regarding these functions, absence is maintained because it is reinforced (negatively) by the absence of negative effects experienced at school or the lack of social evaluative situations at home that create anxiety. The other two functions are related to positive reinforcement: 3) to pursue attention from significant others (e.g., parents), which may be related to somatic complaints or tantrums, and/or 4) to pursue tangible reinforcement outside of school (e.g., sleeping, being with friends) ( Kearney and Silverman, 1996 ). Function 3 is seen as attention-seeking behavior and separation anxiety, while function 4 is related to TR. This indicates that SRB serves as an umbrella term ( Kearney et al., 2019 ), for several concepts of SAPs such as TR and SR and attention-seeking behavior and separation anxiety, but does not include SW, which is parental-motivated (parent-initiated) absenteeism.

There is no uniform definition of TR, and TR has different meanings for different people ( Sutphen et al., 2010 ; Gentle-Genitty et al., 2015 ; Keppens and Spruyt, 2017 ). TR is often used as a synonym for unauthorized/unexcused absence from compulsory education or absence without permission or without parental consent or knowledge (e.g., Malcolm et al., 2003 ; Sheppard, 2007 ). Other definitions of TR are “absence from school for no legitimate reason” ( Stoll, 1990 ) and “absences which pupils themselves indicated would be unacceptable to teachers” ( Malcolm et al., 2003 ). In total, 16 studies were included in a review of TR interventions; two provided no definition of TR, and 11 different definitions were used across the other 14 studies ( Sutphen et al., 2010 ). This demonstrates the wide variety of TR-definitions. Despite this conceptual confusion, there are some characteristics of truants that seem to be present in most studies: lack of interest in school, defiance of authority, conduct disorder, behavioral difficulties, and a lack of anxiety or fear related to school (e.g., Hersov, 1960 ; Berg et al., 1993 ; Elliott and Place, 1998 ). Moreover, findings from a community sample by Egger et al. (2003) suggest that pure TR is associated with depression, oppositional defiant disorder, and conduct disorder. However, Dembo et al. (2016) also found great variation in mental health problems among truants and noted the importance of recognizing and addressing all mental health problems in TR.

Parents of truants are usually not aware of the fact that their child is not present at school because the child attempt to hide their absence from parents and teachers. Keppens and Spruyt (2017) identified three different classes of truants in their study: 1) homestayers, 2) traditional truants, and 3) condoned social truants. Parents of the first group knew their child was not in school (40 percent), which might be related to SW (see the section about SW). This finding is supported by Reid (2002) , who found that some parents knew about their child’s truancy but gave, for example, tacit approval or false notes. In the second group, the parents were unaware of the truancy because the child was not at home (33 percent). The third group was truant together with other youths and stayed away from home and school (27 percent). This indicates that TR is a mixed group, and therefore, several definitions of TR exist.

School Withdrawal

SW is absence motivated or initiated by parents, also labeled parentally condoned absence, parent-motivated or parent-initiated absence. These absences are a result of parents keeping or withdrawing their child at home for their own reasons and/or needs (e.g., Malcolm et al., 2003 ; Reid, 2005 ; Thambirajah et al., 2008 ). These reasons might include parents who have mental or somatic illnesses; parents in need of the child's help to take care of younger siblings, run errands, and help the family with income; parents who do not value education; religious reasons; parents who are incapable of taking care of their child; parents who keep their child out of school because they fear situations in school that might be hurtful for their child; or parents who have a critical opinion of the school, the teacher, and/or the education provided ( Kearney, 2008a ; Thambirajah et al., 2008 ). Five categories of SW are identified based on Reid’s work in the field for more than 30 years ( Reid, 2002 ): 1) parents who have an antieducation perspective (belligerent); 2) laissez-faire (weak) parents who support any actions taken by their child; 3) frustrated (failed) parents who have failed in their efforts to get their child to school; 4) desperate (anxious) parents who need their children at home to look after them; and 5) adjusting (vulnerable) parents who are young, single, or come from ethnic minority backgrounds.

SW might be difficult to identify because few youths will return to school and say, “Mum told me not to go to school” ( Reid, 2005 ). These reasons might be underreported since parents disguise this type of absence with messages or permissions related to sickness or other legal reasons (e.g., Kearney and Albano, 2000 ). SW has a great diversity and low level of research activity ( Ricking and Schulzehe, 2019 ), which makes its prevalence rates unclear. However, parent-approved absence is found to be the largest category of school absence and rates vary from 44 to 93 percent of total absences in England, depending on the methodology used ( Reid, 2002 ). The highest rates of SW have been found among girls and ethnic minority groups. Sheppard (2005) found that two-thirds of youths aged 12–13 asked their parents to permit their school absence occasionally or more often, and illness was the most common excuse. Reid (1999) includes parental-condoned absence as one type of TR when parents agree to the absence for various reasons. Moreover, SW is separate from child-motivated absence, which is an important distinguishing factor for interventions and treatment.

School Refusal

SR describes youths who refuse to attend school, leave during the school day, present protests, pleas, or tantrums prior to school, and/or have somatic symptoms associated with attending school (e.g., King and Bernstein, 2001 ). In a Norwegian study, SR was defined as “child-motivated non-attendance related to emotional distress experienced in connection with academic or social situations in school” ( Havik et al., 2014 ). SR is due to emotional difficulties such as general and social and separation anxiety, worry, distress, and sadness ( Elliott and Place, 2019 ). School phobia is a related concept and refers more specifically to fear-based SAPs such as avoidance of a specific object at school or related to school (e.g., alarm or bus) that leads to absenteeism ( Inglés et al., 2015 ). Characteristics are related to a set of criteria for SR provided by Berg that separate SR from SW (based on criterion [e]) and from TR (based on criteria [b], [c], and [d]). These criteria are a) reluctance or refusal to attend school, often leading to prolonged absences; b) staying at home during school hours with parental knowledge rather than concealing the problem from parents; c) experience of emotional distress at the prospect of attending school (e.g., somatic complaints, anxiety and unhappiness); d) absence of severe antisocial behavior; and e) parental efforts to secure their child’s attendance at school ( Berg et al., 1969 ; Bools et al., 1990 ; Berg, 1997 , 2002 ).

Related to these criteria, some important characteristics are typical of SR youths: they typically remain at home with their parents’ knowledge, their parents have made efforts to secure school attendance, the youth wish to attend but struggle to do so, they usually display emotional distress associated with attending school, and they show no signs of antisocial behavior. Moreover, “school refusal occurs when stress exceeds support, when risks are greater than resilience and when ‘pull’ factors that promote school non-attendance overcome the ‘push’ factors that encourage attendance” ( Thambirajah et al., 2008 , p. 33).

The Understanding of School Refusal

History of school refusal.

SR is not a new concept, and various related concepts have been developed to describe youths who refuse to attend school. The concepts have changed over the years, but the meaning of the concepts has remained the same. The first mention in the literature was by Jung (1913/1961), who referred to these youths as showing “neurotic refusal”. Broadwin (1932) described “a special form of truancy” associated with neurosis in which a child wants to stay at home because of an intense fear of something happening to his/her mother. A few years later, “school phobia” was described as a “deep-seated psychoneurotic disorder fairly sharply differentiated from the more frequent and common delinquent variety of school truancy” ( Johnson et al., 1941 , p. 702). Johnson subsequently claimed that school phobia was a misnomer because the underlying etiology was usually separation anxiety ( Johnson, 1957 ). School phobia is an outdated concept used to refer to a child’s intense anxiety about being at school. In 1945, Klein described for the first-time youths who refused school or were reluctant to attend school ( Klein, 1945 ). The concept of SR was first introduced by Hersov (1960) . Over the years, there has been emerging acceptance that emotionally based school avoidance may be caused not only by separation anxiety but also by other forms of anxiety and/or depression. SR was later used more frequently by practitioners and researchers (e.g., Burke and Silverman, 1987 ; Last and Strauss, 1990 ; King et al., 1995 ; Last et al., 1998 ).

Prevalence of School Refusal

Since the definitions of SR are not similar in all research, the prevalence rates are unclear. The rates vary because previous research defines SR differently (broadly or narrowly), uses different samples (clinical or community based), and includes few or several respondents (i.e., students, teachers, parents, or a combination). However, prevalence rates of SR are usually estimated to be 1–2 percent of the general population and 5–15 percent in clinical-referred samples of youth, and rates are equal between genders ( Egger et al., 2003 ; Heyne and King, 2004 ). In a community sample of 6–10th-graders, 3.6 percent reported signs of emerging SR ( Havik et al., 2015a ). This may indicate that one youth in each class of 25 might be at risk of developing SR. Moreover, the prevalence of SR seems to be higher among preadolescents and adolescents than among children ( Elliott and Place, 1998 ; Heyne et al., 2002 ), and referral for established SR is more common among adolescents ( Heyne and Sauter, 2013 ). As SR often emerges over time, all teachers and school staff will encounter attendance problems, which requires knowledge about SR among teachers at all grade levels.

Theoretical Perspectives to Understand School Refusal

How to understand the development and maintenance of SR and how schools should manage SR depend on the theoretical perspective used. Previous research on SR is mainly from a clinical perspective, which highlights individual and/or family factors for SR. However, more integrated approaches have recently been suggested to understand SR because of the myriad reasons associated with SR (e.g., Ingul et al., 2012 ; Havik, 2015 ). Moreover, the links among individual, family, and school factors must be recognized (e.g., Egger et al., 2003 ; Wilkins, 2008 ; Shilvock, 2010 ). A widely used theory to understand youths’ problems in school is the theory of stress and coping ( Lazarus, 2006 ) or the systemic integrated cognitive approach ( Havik, 2015 ). Another theory is school alienation theory ( Hascher and Hadjar, 2018 ), which is relevant for SR to some extent. Recently, an ecological agency framework has been used to understand school absenteeism as it considers the interplay of contextual factors and how these factors influence a student’s decision to engage in absenteeism ( Kipp and Clark, 2021 ). This theory has much in common with the theories presented in the current article.

Systemic Integrated Cognitive Approach

When demands in school and life are beyond youths’ capacity to cope, youths might experience school and life situations as stressors, especially if they do not believe in their own abilities to cope with the stressor. Refusal to attend school might be the only remaining coping strategy. Lazarus’s cognitive appraisal model of stress and coping ( Lazarus, 2006 ) is helpful to understand why some youths use avoidance as the coping strategy to address stressors (demands, stress, anxiety, and related negative emotions), while others display more appropriate behavior, such as problem-solving and/or emotion-regulation coping strategies.

The “systemic integrated cognitive approach” visualizes the interplay between individual and environmental factors that influence youths’ development (e.g., Lazarus, 2006 ; Bronfenbrenner and Morris, 2007 ). According to this approach, based on youths’ perceptions of themselves, their school, their home/parents, and other environmental factors outside of home and school (e.g., neighborhoods, national policy, and societal pressures), they will appraise the current situation, resulting in emotions and behavior. If the appraisal is “I cannot cope or manage this situation” , the results are likely to be negative emotions and avoidance behaviors, eventually leading to SR. The links between SR and individual, family, and parental factors have been reported in previous studies (e.g., Lyon and Cotler, 2007 ; Havik, 2015 ; Ingul et al., 2019 ). School is an important ecological context for students’ development ( Bronfenbrenner and Morris, 2007 ), including peers and friends. In the model, peers (or any other factor) could be a source of support or stress for youth. To fully understand SR, a combination of an ecological model inspired by Bronfenbrenner’s bioecological model ( Bronfenbrenner and Morris, 2007 ) and Lazarus’s cognitive appraisal model of stress and coping is valuable. The systemic/ecological approach integrates the interactions between individual and different contextual factors, including both demanding/stressful and protective factors. By including a cognitive appraisal process, the coping process is included in the model.

Using this model to understand the development of SR and the interplay between individual, school, and family factors is underlined. For example, situations at home or in school are perceived differently by each youth based on individual factors and previous experiences. In different situations, the cognitive appraisal process focuses on youths’ ability to cope with the stressful situation. SR might be the result of avoiding situations at school that are perceived to exceed the individual’s ability to cope. Individual differences in psychiatric symptoms, negative thinking, and self-efficacy are important and must be assessed because they explain why different youths react differently to the same situation or environment.

Theory of School Alienation

SR youths struggle in different situations in school, and there is an increased awareness of the role of school factors in SR ( Knollmann et al., 2010 ; Havik et al., 2015b ; Havik, 2015 ). School factors related to SR might be unpleasant teachers (e.g., fear of the teacher and/or a lack of teachers’ support), a negative school/classroom climate/environment, and/or peer problems (e.g., bullying, friendship problems, and loneliness). School alienation is defined as “a specific set of negative attitudes towards social and academic domains of schooling comprising cognitive and affective elements. While the cognitive dimension relates to youths’ appraisals of the school environment, the affective dimension relates to their feelings. These negative attitudes develop and change over time in terms of a state and can solidify into a disposition” ( Hascher and Hadjar, 2018 , p. 175). School alienation is a complex phenomenon that might lead to negative consequences, such as poor academic performance, learning difficulties, school disengagement, behavioral problems, and withdrawal from the educational system ( Buzzai et al., 2021 ). School alienation theory might therefore be of relevance to the understanding of SR. To our knowledge, school alienation has not been investigated in relation to SR; however, youths might be alienated from school in general or from specific aspects of school, such as learning, teachers, or peers, which might lead to a process of increased distancing from different aspects of school ( Morinaj et al., 2020 ). Moreover, related to the findings from a study among Italian students ( Buzzai et al., 2021 ), the role of mastery orientation and learned helplessness related to the feelings of school alienation might also be of importance for SR.

Alienation from learning refers to a lack of enjoyment and interest in learning for the student, including experiencing boredom during the learning process. Because youths who refuse school are likely to enjoy learning and usually do not have more learning difficulties or lower grades/marks than others, we do not expect that alienation from the domain of learning is relevant for emerging SR; however, it might be relevant in the long run as youths lose academic learning, moreover it might be relevant for their mastery orientation and learned helplessness ( Buzzai et al., 2021 ). The teacher domain is associated with both social and academic aspects of school. The social aspect refers to supportive/unsupportive teacher–student relationships, while the academic aspect refers to teaching. Students who are alienated from teachers might experience a lack of support from their teachers or fear their teachers, both of which are factors related to SR (e.g., Archer et al., 2003 ; Egger et al., 2003 ; Havik et al., 2014 , 2015b ; Baker and Bishop, 2015 ). The peer domain is also related to the social aspect of school and involves the relationships between peers and how they get along, support, and motivate each other ( Morinaj et al., 2020 ). If a student feels alienated from peers, he or she might feel lonely, isolated, and withdrawn. Because students with SR often struggle in relation to peers and friends (e.g., Place et al., 2000 , 2002 ; McShane et al., 2001 ; Archer et al., 2003 ; Egger et al., 2003 ; Havik et al., 2014 , 2015b ), the peer domain might explain why some students refuse to attend school. As claimed by Place et al. (2002) , these students might need to improve their peer relations and social functioning to be able to stay in school or return to school.

School alienation might also be related to the vicious cycle of SR ( Thambirajah et al., 2008 ). According to Thambirajah et al., three factors may influence students’ ability to attend school. First, when youths are absent, they may lose friends and experience social isolation, and they lose opportunities to improve their peer relations and social skills (peer domain). Second, youths may fall behind in their schoolwork, making their return to school more difficult and reinforcing their fear of failing at school (domain of learning). The third factor indicates that youths’ levels of anxiety and depression might increase due to avoidance of difficult situations, which initially reduces anxiety but increases it in the long run. Depressive symptoms such as social isolation emerge, and the risk of failing school increases ( Thambirajah et al., 2008 ).

SR might be understood as a combination of the theories of systemic integrated cognitive approach and school alienation (see Figure 1 ), in which a youth, with his/her individual factors, encounters situations in school and life that lead to negative appraisals related to school, learning, and social situations at school as predicted by the systemic integrated cognitive approach. The process of school alienation related to the peer domain and the domain of learning has then started. These appraisals and the emerging alienation will in turn produce increased negative feelings and avoidance of different situations in school, leading to emerging SR and stronger negative appraisals. Over time, this might increase alienation from learning, teachers, and peers, and SR might be established.

FIGURE 1 . Model to understand the development of SR.

Development of School Refusal

SR occurs along a continuum, with different expressions and episodes at different times (e.g., Kearney, 2006 ). This means that SR might be expressed in ways visible only to parents, such as episodes before the child attends school (e.g., pleas for absenteeism and misbehavior or tardiness in the morning to avoid school). Other expressions, such as absenteeism from school, are visible to teachers (e.g., periodic repeated absenteeism or skipping classes). The expressions visible only to parents are related to the concept of school-reluctant youths, who may want to avoid school but do attend. Although they attend school, these youths exhibit distress related to loneliness, negative affect, and greater severity of anxiety symptoms ( Jones and Suveg, 2015 ). School reluctance might be the first sign of SR development and is related to emerging SR (explained previously), but this link must be investigated in further research using longitudinal designs.

SR usually develops along a continuum of different expressions and episodes, indicating that SR might begin to develop before a youth is absent from school, and teachers and other school personnel may not be aware of the problem until the youth is absent from school ( Kearney, 2008a ). School personnel are the first professionals to recognize the problem when youths do not attend or show signs of other attendance problems. However, the youth and his/her parents may have struggled for a long time at home before any visible signs appear at school. Therefore, parents and school personnel need information and knowledge about the emergence and development of SR. Parents should be encouraged to contact the school or relevant help services if they notice episodes and expressions that might represent emerging SR problems, other school-related problems, or changes at home. In this way, school personnel might be able to assess stressful and demanding situations in school at an early stage and prevent the development of established SR through adequate and tailored interventions.

The Association Between School Refusal and Mental Health Disorders

SR is not listed as a diagnostic category in the international classification systems of the ICD-10 ( World Health Organization, 1993 ) or DSM-V ( American Psychiatric Association, 2013 ). Although SR is not a diagnostic term, many SR youths are likely to meet diagnostic criteria for a specific phobia, generalized anxiety, social anxiety disorder, or separation anxiety disorder; moreover, some display symptoms of depression and might even meet the criteria for a diagnosis (e.g., Bernstein, 1991 ; Hella and Bernstein, 2012 ). In studies of clinical samples, approximately 50 percent of referred school refusers meet the full diagnostic criteria for one or more anxiety disorders (e.g., Bernstein, 1991 ; McShane et al., 2001 ). Furthermore, approximately three-quarters of children who are referred with separation anxiety disorder have at least one episode of SR ( Egger et al., 2003 ; Kearney and Albano, 2004 ). In non-clinical or community samples, SR youth also meet the criteria for emotional disorders. In one study, half of the 100 children with severe SAPs met the criteria for a psychiatric disorder, and those categorized with SR often had generalized neurotic disorders ( Bools et al., 1990 ). In another study of 80 children who had missed more than 40 percent of a term, half of them met the criteria for a psychiatric diagnosis ( Berg et al., 1993 ). In a community sample, SR was significantly and strongly associated with anxiety disorders, school-related fears, and performance anxiety ( Egger et al., 2003 ). Results from systematic review by Finning et al. (2019a) provide evidence of associations between SR and separation, generalized, and social anxiety disorders, as well as simple phobia.

In referred samples of SR, approximately 50 percent were diagnosed with depressive disorders (e.g., McShane et al., 2001 ). A systematic review by Finning et al. (2019b) provides evidence for an association between depression and poor school attendance, particularly absenteeism, unexcused absences/truancy, and school refusal. Moreover, depressive disorder was significantly associated with SR, and these youths reported significantly more symptoms of trouble falling or staying asleep and fatigue ( Egger et al., 2003 ). The same study indicated the rates of psychiatric disorders to be three times greater among children with pure anxious SR than among those without attendance problems. However, another study indicates that not all adolescents with symptoms of emotional problems, such as anxiety, are absent from school ( Ingul and Nordahl, 2013 ). This suggests that mental health problems can be expected quite frequently among SR but are not a necessary condition for the development of SR. Due to a lack of longitudinal studies and a lack of high-quality research ( Finning et al., 2019b ), we do not know whether mental health problems lead to SR or vice versa. Ingul et al. (2012) claim that an accumulation of risk factors might increase the total burden for youths, eventually leading to absenteeism, like SR. The authors also claim that the balance between risk and protective factors might change over time, leading to SR, which is in line with predictions based on the theory of a systemic integrated cognitive approach. This suggestion underlines the need to assess all risk factors for youths who refuse to attend school. This is, of course, an important issue for any type of SAPs. The results of a doctoral thesis by Havik (2015) demonstrated the importance of school factors for SR. Demanding factors in school that are beyond youths’ capacity to cope might present stressors leading to absenteeism, and SR might occur even when controlling for youths’ emotional stability ( Havik et al., 2015b ).

Some important issues to consider for the understanding of SR are presented in the current article. These include descriptions and characteristics of the most common types of SAPs, the use of a narrow or broad definition, and theoretical perspectives to understand how SR might emerge and develop. In this article, we argue for the use of a narrow definition of SR which will be discussed more deeply.

School Refusal and Other Concepts

Different concepts and definitions of SAPs exist, and researchers, practitioners, parents, and media seem to use them interchangeably and understand them as synonymous. In research, these concepts have been understood and defined differently, which makes it difficult to compare results. Whether to use an overarching construct (e.g., SRB) or a narrow concept that differentiates between types has been an ongoing discussion among researchers and practitioners in many countries (e.g., Elliott and Place, 2012 ; Havik et al., 2015a , 2015b ; Heyne et al., 2015 ). There are arguments for both approaches. A broad concept is suggested because of the overlap between TR and SR, which is found in 5–17 percent of cases and is often labeled the “mixed group” ( Berg et al., 1985 ; Bools et al., 1990 ; Berg et al., 1993 ; Egger et al., 2003 ; Steinhausen et al., 2008 ). In contrast, we argue for a narrow concept despite the overlap between the different types because different risk factors, behaviors, psychological symptoms, and mental health disorders are associated with TR and SR (e.g., Egger et al., 2003 ; Knollmann et al., 2010 ; Havik et al., 2015a , 2015b ; Heyne et al., 2019a ).

One question is whether SR, at least in the media, has replaced all types of SAPs to some extent and whether SR is often used to describe students with unauthorized absences from school rather than as one type of SAP defined by Bergs’ criteria for SR (1997). Moreover, SRB is sometimes abbreviated as SR, even SRB is an umbrella term and includes SR, attention-seeking behavior and separation anxiety, and TR. The confusion related to concepts might lead to a misunderstanding of students’ characteristics because an inaccurate assessment of risk factors potentially leads to incorrect interventions and treatment. If we understand SR youths as lacking motivation or engagement and being unwilling to attend school, as is the case for most truants, interventions might be inappropriate, because SR youths are usually motivated and willing to attend school. Furthermore, if parents do not exert sufficient effort to ensure that their child attends school and this is not recognized, interventions at school might have less effect. Therefore, we suggest the use of a narrow definition of SR, as indicated, for instance by the criteria of Berg (e.g., 1997).

As “school refusal is a normal avoidance reaction to an unpleasant, unsatisfying, or even hostile environment” ( Pilkington and Piersel, 1991 , p. 290), a combination of a systemic integrated cognitive approach and the theory of school alienation, might integrate these perspectives to understand how SR develop, which includes an interplay between several factors ( Figure 1 ).

How School Refusal Emerges and Develops in line With the Systemic Integrated Cognitive Approach and the School Alienation Theory

Most youths with mental health disorders and other risk factors attend school on a regular basis. However, some struggle and experience stressful situations in school and/or life in general, and some might gradually develop school reluctance and emerging SR. When anxiety, risk, and stress factors are stronger than support and protective factors, this imbalance might lead to SR over time ( Thambirajah et al., 2008 ). This is in line with the systemic integrated cognitive approach and school alienation theory (see Figure 1 ). This figure visualizes the interplay between individual and environmental factors that influence youths’ development over time. This approach explains stressful appraisals and negative emotions and might be helpful to fully understand the complexity of SR. Both demanding and supportive factors in school, as well as parental/family and individual factors, are related to SR. It is important to consider how SR youths cope with stressors (e.g., Place et al., 2002 ). SR is associated with several risk factors, such as anxiety and/or depression, negative thoughts, low self-efficacy for coping, and ineffective strategies to solve problems. Therefore, youths’ coping strategies and skills must be understood, and if necessary, youths should be helped to change their coping strategies.

When environmental factors at school and/or home are demanding, this might lead to negative appraisals and stressful, negative emotions. Parents, peers, and teachers are sources of support for youths’ development and provide important support for dealing with stressful situations. As youths grow older, peers are usually their most important support. When SR is established, youths might be isolated from their peer network because they stay at home when their peers are at school. SR youths might need interventions to improve their peer relations and social functioning. The theory of alienation is relevant to explain how SR develops because as SR emerges, some youths might become alienated from learning, teachers, and/or peers ( Morinaj et al., 2020 ), eventually leading to established SR.

The combination of the theory of systemic integrated cognitive approach and school alienation is useful because these theories 1) cover and integrate both individual and contextual factors; 2) explain how SR might develop over time, starting with a stressor that might lead to negative appraisal, which develops over time and leads to avoidance; in turn, avoidance reinforces this negative appraisal and gradually leads to alienation and established SR; 3) indicate the importance of the balance between risk and protective factors; 4) include coping strategies and the importance of coping with stressors, such as regulating emotions and seeking support; and hence, 5) help us to pinpoint important factors for assessment and interventions. Furthermore, these theories suggest that every SR youth is unique. Therefore, interventions need to be tailored based upon a thorough assessment of all the contributing risk, protective, and maintaining factors to develop a case formulation for each youth. However, these theories in relation to SR have not yet been researched and should be investigated in future studies.

It is important to note that a “mixed group” exists and that these youths often have multiple problems and more severe mental health disorders than “pure” TR or SR (e.g., Egger et al., 2003 ), indicating a need for treatment and coordinated interventions. However, the frequently cited study by Egger et al. (2003) is a cross-sectional study. There is a possibility that TR and SR develop from emerging attendance problems via pure SR or TR to mixed problems as the complexity in these cases increases over time. This indicates that the field would benefit from longitudinal studies investigating the development of SAPs to better understand the developmental pathways. There is also an overlap between SR and SW that involves youths with unresolved dependency relationships, usually with their mothers ( Christogiorgos and Giannakopoulos, 2014 ). These findings indicate that there might be more than one “mixed group”, and SAPs develop differently in each case. Therefore, although we advocate for differentiating between types of SAPs, individuals may have characteristics of several types.

Conclusions and Suggestions for Practice

The main aim of the current article was to define, describe, and discuss SR and to show how SR differs from other concepts of SAPs and how SR emerges and develops by using different theoretical perspectives. As many concepts exist, all stakeholders should agree upon one definition of SR to be able to prevent, identify, and intervene in emerging and established SR. Different characteristics and risk factors exist for SRB, TR, SW, and SR; therefore, these concepts should be separated. We suggest using a narrow definition of SR in line with Berg’s criteria, as they separate SR from TR and SW. By using a narrow, clear, and common definition, it is easier for schools, youths, parents, and other services to communicate cooperatively and plan interventions for SR youths and for researchers to compare results. Further research should investigate the developmental pathways of SR in relation to the combination of the theory of systemic integrated cognitive approach and school alienation, to fully understand how emerging problems might become established SR over time, which, if left “untreated”, might become a mixed, complex, and debilitating problem.

Previous research indicates that parents, students, and school personnel understand the characteristics, reasons, and development of SR differently. This might have consequences for cooperation and agreement in interventions for SR youth. In a study among parents of SR youth, parents felt that they were blamed by the school for the problems ( Havik et al., 2014 ). This finding indicates the importance of and need for good, clear, and respectful communication, collaboration, and common goals of interventions between the school, parents, youth, and other services to address the factors that might cause and/or maintain SR. It “takes a team” to work with SR ( Brand and O’Conner, 2004 ). One suggestion is therefore to establish a school-attendance team (SAT) ( Ingul et al., 2019 ), working with SAPs using a multi-tiered system ( Kearney and Graczyk, 2014 ; Kearney, 2016 ) to promote regular attendance for all students (Tier 1), targeted interventions for at-risk students (Tier 2), and intense and individualized interventions for students with chronic absenteeism (Tier 3), including how SR might emerge and develop in terms of the theory of systemic integrated cognitive approach and school alienation.

Author Contributions

The first draft of the article was written by TH, and JI contributed feedback and comments on all versions. Both authors read and approved the final article.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

1 We mainly use “youth” in this article, although we use “child” when referring to the parents and “student” when referring to school. However, these terms refer to young people of any school age. “Child” or “adolescent” is used when referring to a specific developmental level.

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Keywords: school non-attendance problems, systemic integrated cognitive approach, school alienation theory, development of school refusal, school refusal

Citation: Havik T and Ingul JM (2021) How to Understand School Refusal. Front. Educ. 6:715177. doi: 10.3389/feduc.2021.715177

Received: 26 May 2021; Accepted: 24 August 2021; Published: 09 September 2021.

Reviewed by:

Copyright © 2021 Havik and Ingul. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Trude Havik, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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School Refusal in Youth: A Systematic Review of Ecological Factors

Karissa leduc.

1 Department of Educational and Counseling Psychology, McGill University, Montreal, QC Canada

2 Groupe de recherche sur les inadaptations sociales de l’enfance (GRISE), Sherbrooke, QC Canada

Anne-Marie Tougas

3 Department of Psychoeducation, Faculty of Education, Université de Sherbrooke, Sherbrooke, QC Canada

4 Institut universitaire de première ligne en santé et services sociaux (IUPLSSS), Sherbrooke, QC Canada

Virginie Robert

5 Department of Learning Sciences, Faculty of Education, Université de Sherbrooke, Sherbrooke, QC Canada

Camille Boulanger

To guide school practitioners in the identification and intervention of youth with anxious school refusal, this systematic review used an ecological lens to examine the factors that differentiated children and adolescents with school refusal from those without. Based on the rigorous protocol from the Center for Reviews and Dissemination’s (CRD) internationally recognized guidelines, 15 studies examining 67 different factors were identified. Results reveal 44 individual, social and contextual factors that differentiate youth with school refusal from peers without school refusal. Findings highlight the centrality of anxiety, or anxiety-related symptoms, and diverse learning needs as main points of contrast between youth with school refusal and those without. Implications of an ecological understanding of the factors associated with school refusal for selective and indicative prevention by school and mental health practitioners are discussed.

School refusal (SR) is a school attendance problem (SAP) generally driven by emotional distress [ 1 – 3 ]. SR affects between 1 and 15% of youth 1 according to available North American and European prevalence data [ 4 – 6 ]. In addition to the large age range accounted for in available prevalence studies and the types of samples (community vs. clinically referred), the large discrepancy between prevalence rates may be due to the changing ways SR has been operationalized between studies. SR’s first distinction from other SAPs such as truancy stems from the writings of Broadwin [ 7 ] and Partridge [ 8 ]. These authors described SAPs characterized by fear and distress rather than delinquency. Shortly after, Johnson et al. [ 9 ] coined the term “school phobia” to describe this new behavior. School phobia was then described as a form of emotional disturbance in children characterized by a large degree of anxiety and leading to excessive school absences [ 9 ]. Almost two decades later, Hersov [ 10 , 11 ] coined the term “school refusal”.

School phobia was originally used interchangeably with SR in the literature [ 3 ], but was replaced because it was an inaccurate label. While school phobia refers to a fear of being in school, the use of “school refusal” is now encouraged because its wider terminology encompasses the different facets of emotional distress (e.g., anxiety, depression, sleep problems, etc.) which underlie the behavior [ 12 ]. Generally, youth with SR are identified through operational criteria initially developed by Berg [ 1 ] and further specified by others [ 13 , 14 ]. Notably, Berg’s [ 2 ] definition is widely used to this day in scale development (e.g., [ 15 ]) and inclusion criteria for sampling (e.g., [ 16 – 18 ]). The operational criteria present in Berg’s [ 2 ] definition are: (1) school attendance is less than 80% in the classroom during the 2 weeks prior; (2) the presence of an anxiety disorder; (3) parents are aware of their child’s whereabouts during absences; (4) the absence of conduct disorder problems; and (5) parental motivational efforts to encourage their child’s school attendance. For school attendance, Berg’s [ 2 ] definition implies more than occasional absences, but rather consistent and repetitive desires to not attend school, leave class early, or avoid certain classes. Moreover, anxiety or emotional distress can manifest itself in different ways. These include physical or psychosomatic forms (e.g., nausea or stomach aches), behavioral forms (e.g., refusing to leave home in the mornings before school), or cognitive forms (e.g., having a panic attack at school before certain classes).

Despite parental and educational efforts, youth with SR face many short- and long-term consequences. Given their low attendance rate, youth with SR may be reluctant to interact with peers. Some short-term consequences derived from this include social isolation, poor academic performance, and, in extreme cases, suicidal ideation [ 19 , 20 ]. In addition, long-term consequences include an increased susceptibility to adjustment problems in social (e.g., issues with socialization), family (e.g., relational dependence) and professional contexts (e.g., attendance; [ 21 , 22 ]. Moreover, young adults with a history of school refusal show greater school drop-out rates and are at greater risk of developing psychosocial problems and a form of psychopathology (e.g., major depression) than those with no history of school refusal [ 23 , 24 ]. These consequences, paired with data that shows that academic achievement is negatively impacted by each day of absence [ 25 ], emphasize the importance of early intervention.

Intervention for School Refusal

One of the ways we can aid youth with SR is by mobilizing educators and school practitioners to engage in both selective and indicated prevention (Institute of Medicine (IOM) Classification System). However, these stakeholders are unsure as to the best ways to support students who are at risk and displaying SR-related behaviors [ 26 ]. When faced with SR, while educators and school practitioners are conscious that the student is undergoing emotional and behavioral difficulties, they may have difficulty assessing the factors specifically associated to them [ 12 , 27 , 28 ]. Moreover, while addressing students’ mental health concerns is generally a high priority for school practitioners, emotional exhaustion due to high caseloads and/or available resources can be barriers to the quality of care provided [ 29 ]. Family-school partnerships have been shown to alleviate this barrier by enhancing not only the quality of care, but also the amount and scope of services available to students [ 30 ]. Notably, successful SR interventions in schools suggest mobilizing different stakeholders and emphasize the creation of home-school or parent-practitioner partnerships to promote positive outcomes such as increased attendance (e.g., [ 31 – 33 ]). Stakeholders may include parents, school and community practitioners, teachers, and even administrative regional staff such as school-attendance officers [ 34 ]. In addition to schools, SR interventions can take place in the home and encourage parental involvement. For instance, in Dialectical Behavior Therapy (DBT) or Cognitive Behavior Therapy (CBT), the involvement of parents is important for youth with SR to generalize what they learn in therapy to their natural home setting [ 35 ]. Finally, it is recommended that interventions for SR be adapted and/or specific to the factors underlying non-attendance [ 35 ]. For instance, if a student with SR has anxiety related to school performance, then CBT can focus on reappraising negative thoughts about academics. To effectively overcome such difficulties associated to SR and better understand its determining factors, a holistic assessment of the situation is needed.

The Relevance of a Bioecological Theory

Over the last century, several etiological theories have been put forth to explain the development of SR, each extending to prevention and intervention practices. When SR was first introduced in the early twentieth century, psychoanalytic theories were favored. Later, in the 1960s, psychodynamic and behavioral theories were put forth to explain SR. Using a behavioral lens, Kearney and Albano’s [ 36 ] functional model of school refusal behavior remains widely used by both researchers to conceptualize SR as a school attendance problem, and by stakeholders to intervene with students who manifest the behavior. However, as research on SR grows, the relevance of an ecological model that accounts for social and contextual factors has increased [ 3 , 37 , 38 ]. While most previous etiological theories focused primarily on the individual and proximal factors associated to youth with SR (e.g., parenting, or separation anxiety), the bioecological theory [ 39 ] emphasizes the importance of considering both proximal and distal influencing factors on development. Specifically, the different systems that it encloses (i.e., micro, meso, exo and macro) provide a holistic view of the student and the interrelations between the factors influencing their SR behavior. Moreover, the principles of the ecological model: interdependence, circulation of resources, adaptation, and succession [ 39 ] are also helpful to guide interventions for SR. By understanding the relationship between a student with SR and their environment (interdependence), the availability and distribution of resources in their school or home (circulation of resources), how well they can evolve within the school system (adaptation), and the developmental impact of their past, present and future experiences in the school or at home (succession), intervention practices can be tailored to the specific needs of the student.

Additionally, in the context of SR, previous reviews have identified associated factors in multiple systems such as schools, families and communities (e.g., [ 12 , 38 ]). Empirical studies also support the influence of more distal factors such as conflicts with peers and school transitions on SR (e.g., [ 38 , 40 ]). These findings coupled with previous research that supports the use of “multimodal, multisystem, and wraparound intensive team approaches” ([ 28 ], p. 122) in SR intervention, support the relevance of an ecological lens to examine SR in children and adolescents.

To date, no truly systematic review of the factors associated to school refusal, that adheres to a systematic and transparent protocol (e.g., [ 41 – 43 ]), currently exists. Moreover, existing reviews did not seek to identify factors that differentiate youth with SR from youth without SR. As a result, a systematic review with the use of an ecological lens is needed to provide a more holistic view of the factors associated to school refusal and highlight the complexity of this phenomenon. The use of this lens will provide educators and school practitioners with selective and indicated prevention guidelines to both identify students at risk of developing SR-related behaviors, but also assess which resources they may need to mobilize when supporting students displaying SR.

Accordingly, the current study uses a systematic review to critically analyze empirical literature on the factors associated to school refusal and organize it according to Bronfenbrenner’s Ecological Theory [ 39 ]. The use of this ecological model will organize findings by considering individual, school, family and more distal factors (e.g., SES, culture, etc.) that can guide practitioners when developing an intervention plan. The specific aim of the review is to provide a framework which will identify factors associated to children and/or adolescents with school refusal that distinguish them from those without school refusal.

The systematic review protocol was based on the Center for Reviews and Dissemination’s (CRD; [ 41 ]) internationally recognized guidelines. This protocol involves a series of steps to describe and complete to ensure the internal and external validity of the review [ 44 ]: (1) identification of studies, (2) selection of studies, (3) data extraction, (4) quality assessment, and (5) synthesis of findings. The methods employed for the identification of studies, the selection of studies, data extraction, and quality assessment are detailed in this section. The synthesis of findings is detailed in the results section.

Identification

References examining factors associated to school refusal were searched in education (ERIC, Education Source, CBCA Complete), health science (PubMed, MEDLINE, CINAHL), social science ( Persée , PsycArticles, PsycINFO, Psychology and Behavioral Sciences Collection, SocINDEX, Social Work Abstracts), and multidisciplinary databases (FRANCIS, Érudit , CAIRN, Repère , SCOPUS, Academic Search Complete, Proquest). After multiple preliminary tests and refinements, the following keywords were used: (school refus* OR school phobia) AND (child* OR youth* OR adolescen* OR teen*). These were translated to French as needed for the databases. All possible literature up until the last search date of February 10th 2022 was considered. A database for bibliographical references (Zotero) was used to import and manage references.

Relevant peer-reviewed references were first selected through a review of titles and abstracts (phase 1), and then a review of full documents that could not be rejected after phase 1 (phase 2). References for which an abstract was not available and could not be excluded based on their title were automatically included after phase 1. References were selected at each phase based on the following five criteria: written in English or French (criterion 1), was an empirical research study (criterion 2), compared a group of children and/or adolescents with school refusal to a group without (criterion 3), identified school non-attendance (criterion 4), and identified the presence of emotional distress in participants with school refusal (criterion 5). For criterion 5, there were three possibilities considered for inclusion: (1) authors used Berg’s [ 2 ] operational model to identify school refusers which accounts for the range of psychopathology that distinguishes youth with SR from those with other attendance problems, (2) authors mentioned the presence of anxiety to identify school refusers, or (3) authors report the use of a standardized measure of anxiety to identify school refusers. Berg’s [ 2 ] original criteria were chosen rather than criteria updated in the last decade [ 13 , 14 ] given that the search did not limit dates of publication. If school refusers were hospitalized, the reference was considered to have automatically fulfilled criterions 4 and 5. In each selection phase, Cohen’s Kappa was used to determine inter-rater reliability [ 45 ]. A minimum of 25% of studies (until an acceptable agreement of k = 0.8 was reached) were judged by two independent raters. Disagreements between raters were discussed and resolved by consensus. After phase 2, bibliographies of included studies were examined and notable researchers in the field were contacted to identify possible relevant additional studies.

Data Extraction

Information extracted from studies included descriptive statistics related to the sample (i.e., N , age, sex, socio-demographic distribution, and country of origin of sample), the types of groups in the sample (i.e., with SR, control, etc.), study design (cross-sectional or longitudinal), study objective, methodology employed (i.e., instruments to measure SR and associated factors), statistical analyses performed, and the results pertaining to the factors associated to school refusal. Data extraction was first performed by the first author according to a detailed extraction form. Extracted data were then synthesized in tables and organized according to the systems of the ecological model for a second rater to review for accuracy.

Quality Assessment

While multiple tools exist to assess the quality of research studies, no consensus yet exists among researchers [ 46 ]. As per Siddaway et al.’s [ 46 ] recommendations, four objective indicators of potential bias related to study design (sampling, measures and statistical analyses) and representativeness of the sample were used to produce a descriptive synthesis of the methodological quality of included studies. Results from the quality assessment were also used to provide a nuanced analysis of the findings. Given its use in empirical research (e.g., [ 13 , 16 , 17 ]), these included the use of Berg’s [ 2 ] definition to identify school refusers (first indicator), and the method used to measure emotional distress in school refusers (validated instrument, clinical judgment, judgment of researchers, or self-report; second indicator). Moreover, statistical rigor was measured according to analyses used (univariate or multivariate; third indicator) and the ability of each study to detect small, medium and large effect sizes respectively (fourth indicator). These calculations were done using G*Power according to sample sizes, p values and analyses performed.

Study Sample

Overall, 4772 studies were identified and imported into a reference manager for further analysis. After elimination of duplicates, 2965 studies were included for phase 1 of 2 of the selection process. Figure  1 documents decisions (inclusions and exclusions) for each stage of the review. In total, 15 studies were included in the final sample.

Selection process flowchart

Study Sample Characteristics

Sample characteristics for each of the selected references are presented in Table ​ Table1. 1 . Included studies were published between 1983 and 2015. There are 13 journal articles, one thesis and one conference paper. All studies used cross-sectional designs. Samples were recruited in North (n = 5) and South America (n = 1), Europe (n = 5), Asia (n = 2) and Australia (n = 2). Samples were all convenience-based with the exception of Egger et al. [ 4 ] who examined a population-based sample. Sample sizes varied between 11 and 3629 participants. Most studies examined youth aged 6–17 years old, without distinguishing between children and adolescents. One study examined the parents of school refusers. In terms of sex, samples were mixed and relatively equivalent in number (37–68% male school refusers). Finally, most studies who reported ethnicity reflected the demographic distribution of the country in which they were recruited.

Description of study characteristics and quality appraisal

Group comparisons: SR school refusal; T truancy; SAP school attendance problem; – not specified

*Thesis; **Published Conference Proceeding

a In Venezuela, schooling begins at 4 years

b The authors specify that all participants are in high school

c When more than 3 groups were compared in a study, the identified factors concerned the comparison between the SR group and the group without SR

The methodological qualities of each included study are presented in Table ​ Table2. 2 . Most included studies can be qualified as being of moderate quality, specifically due to their statistical characteristics. Very few could detect small and medium effect sizes. However, Carless et al.’s [ 16 ] and Maric et al.’s [ 17 ] studies seem to be of higher quality. In addition to having been published in the last decade, these studies use Berg’s definition to identify school refusers and a validated standardized measure to evaluate the presence of emotional distress in their clinical group. Moreover, their use of multivariate analyses considers the influence of overlapping contributions between variables. Despite the presence of lower quality studies, all 15 were included in the final sample for data extraction and, when applicable, they are interpreted in light of their quality.

Methodological characteristics of identified studies

Berg’s [ 2 ] definition: Y Yes; N No

Analyses: U Univariate; M Multivariate

a Based on Cohen [ 45 ]: d = 0.2 (small effect); d = 0.5 (medium effect); d = 0.8 (large effect)

Factors Associated with SR

All factors examined in relation to children and/or adolescents with school refusal are presented in Table ​ Table3. 3 . This review identified 15 studies examining 67 different factors. Examined factors were mainly related to Bronfenbrenner’s ontosystem (14/15 studies), followed by the microsystem (9/15 studies), the exosystem (2/15 studies) and chronosystem (2/15 studies). No studies examined factors pertaining to Bronfenbrenner’s meso- and macro-systems. Specifically, no studies examined factors pertaining to partnerships or collaborations between youth’s microsystems (e.g., schools and families), or factors of the macrosystem pertaining to culture, customs, or the youth’s educational system for instance.

Associated factors that differentiate youth with SR from youth without SR according to Bronfenbrenner’s ecological model

Data in bold are significantly associated to youth with SR when comparing to youth without SR. Data in italic do not significantly differentiate youth with SR from youth without. When available, odd ratios are reported in parentheses

 + More; − less

*Result from a multivariate analysis

a Havik, et al.’s [ 5 ] study is presented under “Children” and “Adolescents” because it presents separate data for both age groups

Overall, 44 individual, social and contextual factors were found to differentiate youth with SR from peers without SR. These are presented in the following sections. For each system of Bronfenbrenner’s ecological model, significant factors associated to children are presented first, followed by adolescents and factors that were not compared across age groups. When contradictions between studies exist, associated factors are also evaluated as a function of their quality.

Ontosystem (13 Studies/15)

A total of 30 ontosystemic factors were examined with 23 yielding significant differences between youth with SR and those without in at least one study.

With regards to data pertaining to children exclusively ( n  = 1 study), Granell de Aldaz, et al. [ 47 ] found that having a difficult personality , a diagnosis of depression , a dependency towards parents , and fears related to school were all significantly related to children with SR when compared to children without SR.

In adolescents ( n  = 4 studies), it was found that a diagnosis of depression or anxiety were significantly associated to students with SR (3 studies/4). Other significant associated factors include academic, social, and interpersonal concerns 2 (3 studies/4), pessimism (2 studies/4), high stress levels (1 study/4), anhedonia (1 study/4), somatic complaints (1 study/4), behavior problems (1 study/4), performance anxiety (1 study/4), difficulties with social problem solving (1 study/4), and high mathematical ability (1 study/4).

In both children and adolescents ( n  = 9 studies), identified associated factors include interpersonal, family, social, and academic worries (4 studies/9), somatic complaints (2 studies/9), performance anxiety (1 study/9), a diagnosis of anxiety (1 study/9), diagnosis of depression (1 study/9), fatigue (1 study/9), sleep problems (1 study/9), difficulties in processing emotional information (1 study/9), difficulties with emotional regulation (1 study/9), verbal comprehension problem s (1 study/9), language problems (1 study/9), learning problems (1 study/9), and poor school performance in mathematics , reading and writing (1 study/9).

Contradictions did emerge in relation to some factors. Specifically, organic diseases were significantly associated to adolescents with SR when univariate analyses were used and the sample of youth with SR was clinically referred, and thus, potentially more severe in symptomatology [ 48 ]. However, in Egger et al. [ 4 ], no such associations were found with a community sample and when multivariate analyses were used. Age also yielded mixed results in the studies that examined developmental differences. For instance, when examining a sample of 9–16-year-olds, Egger et al. [ 4 ] found that younger children were more susceptible to develop symptoms of SR. Conversely, Maric et al. [ 17 ] found that, in a sample of 11–17-year-olds, it was older children that were more susceptible. Moreover, age was not significantly associated to SR in any way in Honjo, et al.’s [ 49 ] study. While all three studies used multivariate statistical analyses and non-clinically-referred samples of youth with SR, Maric, et al. [ 17 ] is the only one to have used a standardized measure to evaluate the presence of emotional distress in their SR sample. Finally, while a diagnosis of generalized anxiety was a significant factor in adolescents between 11 and 17 years with SR [ 16 , 17 ], it seemed to not be the case for specific types of anxiety (e.g., social anxiety in students aged 9–16 years, [ 4 ]; separation anxiety, [ 48 ]).

Microsystem (9 Studies/15)

A total of 33 microsystemic factors were examined with 20 yielding significant differences between youth with SR and those without in at least 1 study. Within this section, factors are further broken down into family, school, and peer systems.

Family (6 Studies/9)

No significant factors emerged in relation to children ( n  = 1 study). However, in the studies that exclusively examined adolescents ( n  = 3 studies), family conflict (2 studies/3), dysfunctional family environments (2 studies/3), poor familial cohesion (1 study/3), and poor communication (1 study/3) distinguished adolescents with SR from those without. In addition, authoritarian parenting styles (1 study/3), relationship conflicts (1 study/3), being a young parent (1 study/3), parent psychopathology (anxiety or depression) (1 study/3), poor self-efficacy (1 study/3), and low perceived levels of caring (1/3) were significantly associated to parents of adolescents with SR when compared to those without.

Finally, for children and adolescents ( n  = 2 studies), the presence of parental psychopathology (2 studies/2) and the presence of an organic disease in parents (1 study/2) were significantly related to youth with SR.

Some contradictory results emerged from Adams [ 50 ] and Carless’, et al. [ 16 ] studies with regards to parents’ levels of education. While Adams [ 50 ] found that parents of adolescents with SR were significantly more educated than parents of adolescents without SR, Carless, et al. [ 16 ] did not find any significant relationship between parents’ levels of education and SR. Both studies are of similar methodological quality and recruited non-clinically referred youth with SR. However, Carless, et al. [ 16 ] used a validated instrument to measure emotional distress in their SR participants, while Adams [ 50 ] relied on parent report. Also, Carless, et al. [ 16 ] had a slightly larger medium effect size than Adams [ 50 ].

School (3 Studies/9)

No studies exclusively examined school factors in children, and no significant factors were exclusively associated to adolescents (n = 1 study) (1/3). For both children and adolescents ( n  = 2 studies), children with SR attended more schools with students from neighborhoods with high crime rates (1/2), and had more negative perceptions of classroom management (1/2) than those without SR.

Peers (5 Studies/9)

In children ( n  = 2 studies), victimization (1 study/2) and social isolation (1 study/2) were significantly associated with SR. In adolescents ( n  = 4 studies), social isolation (2 studies/4) and victimization (1 study/4) were also significantly associated with SR. Adolescents with SR also had significantly more difficulty using the social support (1 study/4) available to them than those without SR. Finally, in both children and adolescents ( n  = 1), youth with SR were significantly more timid , in c onflict with others and exposed to aggressive peers than those without.

There are contradictory findings in relation to social isolation. Social isolation was significant in Granell de Aldaz, et al.’s [ 47 ] study, but it was not in Havik, et al.’s [ 5 ] study. Both studies used non-clinically referred samples, but the differences may be due to the types of analyses and measure specificity. Specifically, Granell de Aldaz, et al. [ 47 ] solely used univariate analyses with data from the Child Behavior Checklist. Conversely, Havik, et al. [ 5 ] considered interactive influences of other dependent variables on the presence of SR using multivariate analyses, and with data from the Social Isolation at School Scale which is more specific to assess the construct of social isolation.

Exosystem (2 Studies/15)

Two exosystemic factors in two separate studies ( n  = 2) were examined: socio-economic status and neighborhood crime. Neither factor was significantly associated with SR when compared with youth without SR.

Chronosystem (2 Studies/15)

Of the two chronosystem factors examined, one was significant (n = 2 studies). Children with SR were more likely to change schools frequently than those without.

This systematic review identified 15 empirical studies that compared the factors associated to youth with SR to those associated to youth without SR. Factors of a psychological, social, and contextual nature were identified, thus highlighting the importance of an ecological lens with which to view SR. The majority of identified references examined proximal factors of an ontosystemic and microsystemic nature. There is also evidence that more distal factors such as non-normative transitions, notably, frequent school transitions, influence the appearance of SR. Finally, the relationship between youth with SR and their associated factors align with the principles of interdependence, resource circulation, adaptation and succession that are at the heart of the ecological model.

Psychopathology and SR

At both an individual (ontosystem) and family level (microsystem), compared with peers without SR, youth with SR and their parents were more anxious, and some were depressed. Anxiety is present in most of the youth referred for treatment for SR [ 18 ], and is known to be highly comorbid with depression in children [ 51 ] and adults [ 52 ] alike. In the reviewed references, while not all youth with SR had diagnoses of anxiety or depression, they did have characteristics that underlie both disorders [ 53 ]. Specifically, youth with SR were inflicted with worries and concerns about their academic, familial, and interpersonal life which supports interactions between these individual level factors and youth’s environmental stressors. They also had problems with emotional regulation, sleep, and presented with anhedonia.

Moreover, while specific anxiety disorders such as separation anxiety [ 48 ] and social anxiety [ 4 ] were not found to differentiate youth with and without SR, generalized anxiety disorders [ 16 , 17 ] and performance anxiety were [ 4 , 54 ]. This may be due to age. Bahali et al. [ 48 ] did not specify the age range of their child participants. However, they indicated in their inclusion criteria that the children had to be over 5 years-old, while separation anxiety is known to commonly afflict younger children during preschool years [ 55 ]. Conversely, Egger et al.’s [ 4 ] sample ranged from 9 to 16 years old, with a mean age of 12 for their SR sample. There is evidence to support an earlier onset of social anxiety in childhood (i.e., around age 8; [ 56 ]), but, for most, social anxiety tends to develop around 13 years of age with a mean age of onset of 15 years old [ 57 ]. This could explain why Egger et al. [ 4 ] did not detect a significant presence of social anxiety in their sample. However, given that performance anxiety is a type of social anxiety when it pertains to social or interpersonal performance [ 53 ], significant findings in Egger et al.’s [ 4 ] and Ficula et al.’s [ 54 ] studies with adolescents could hint at a possible association between SR and subtypes of social anxiety. Nonetheless, symptoms of these disorders, such as concerns associated to academic, social and family life, can be delt with when observed by school practitioners through current common interventions for anxiety that account for interactions between symptoms of these disorders and the student’s family and school environments.

Most successful interventions for children and adolescents with anxiety include CBT-based approaches [ 58 ]. The same is true for selective and indicative school-based interventions for anxiety which generally involve CBT strategies and target school-based stress and anxiety [ 59 , 60 ]. In the context of SR, it is important that the strategies used are adapted to the specific factors underlying students’ non-attendance [ 35 ]. For instance, activities on negative thought reappraisal should be adapted according to whether the root of students’ anxieties concern academic, family or interpersonal issues. In addition, if family concerns are at the root of their anxieties, school practitioners can consider involving parents as partners. Notably, it is often preferred to include parents as partners, not only because it shares the responsibilities of care. It is also consistent with the principle of resource circulation in the ecological model, whereby collaboration can increase the generalizability of interventions [ 31 ]. Parental accommodation can also be integrated wherein parents can engage in certain behaviors and avoid others in efforts to reduce their child’s distress [ 61 ].

Regarding the family microsystem, compared to peers without SR, youth with SR are more likely to have parents with a history of psychopathology. Anxiety is well known to be subject to intergenerational transmission [ 48 ] and could be the way in which youth with SR develop their own symptoms of anxiety or depression. However, in line with the ecological principle of interdependence, parents of youth with SR may have low self-efficacy which can interact with youth with SR in different ways. For instance, youth with SR have perhaps learned low self-efficacy themselves through parental modelling (Social Learning Theory; [ 62 ]). Another possibility is that their parents themselves may have poor coping mechanisms to deal with their children’s SR, and their problem persists [ 16 ]. Through this lens, the development of SR can be seen as interdependent with parenting models and follow the principle of succession. Children’s previous experiences may have led to the development of poor coping mechanisms which, in turn, may act as a barrier when dealing with current experiences of school-related adversities such as transitions to new communities, or being exposed to criminal activities. In this regard, compared to peers without SR, youth with SR attend schools that serve students from neighborhoods with higher rates of poverty and community violence and are known to change schools often. Their ability to adapt to these non-normative transitions might impact the development of SR as it is suggested to be the case with other stressful life events (e.g., divorce, peer conflict, etc. [ 48 ]).

If permitted by the availability of resources, partnership-based interventions may be especially beneficial when youth with SR present with underlying family factors. These can be structural by involving parents in direct activities that engage them in students’ learning, or relational by involving parents in their children’s learning through regular communication [ 30 ]. Direct parental involvement in intervention through a structural partnership can be a facilitator to attendance for youth with SR who have difficulties leaving home in the morning, because parents can facilitate their children’s transition to school through strategies they learn from a school partner. Moreover, parents can engage in family-based CBT and gain tools for modelling adaptive coping mechanisms for their children with SR [ 58 ]. While not all parents may have the time and resources to engage in active structural partnerships, both structural and relational partnerships have been shown to increase consistency in interventions [ 30 ].

Learning and SR

Compared with peers without SR, youth with SR are more likely to have diverse learning needs. Some had problems with verbal comprehension, language, and poor academic achievement in mathematics, reading and writing. It is possible that these factors are influenced by the ecological principle of adaptation which is defined as an individual’s ability to evolve within their different systems [ 39 ]. Specifically, SR may develop because they have difficulties adapting to the challenges of their academic work. These students may have underlying worries that lead to maladaptive coping mechanisms. It is also possible that they have missed too many classes and have fallen behind on work. As a result, special attention should be given to youth with learning difficulties and high rates of absences. Web-based therapy for SR [ 31 ] can be a good place to begin intervention with these students.

Through web-based therapy, students with SR can receive coaching such as DBT from the comfort of their homes. This is beneficial because it allows children to gradually be exposed to school stressors while remaining in a non-anxious environment. Additionally, in Chu et al.’s [ 31 ] multimodal approach, parents were included in daily therapy sessions that occurred in the mornings, when the likelihood youth would refuse to leave home for school was highest. As a result, the dose, timeliness, and context of the students’ natural environment were facilitators to increase the likelihood of attendance [ 31 ]. Remote tutoring can also be done with these students to increase their sense of readiness for school. Finally, tutoring and academic support can be offered as a form of selective prevention to students who present with learning difficulties but are still attending class.

Microsystems within the school itself also seem to influence the development of SR. Compared with peers without SR, youth with SR have poor perceptions of classroom management from teachers. This can be problematic if they do not perceive that they have support from their teachers [ 5 ], especially in cases of victimization and social conflict which are also more associated to youth with SR more than those without. If youth do not feel like they have support to deal with these issues within the school this may interact with their poor coping mechanisms to deal with social conflict [ 63 ], and youth’s feelings of a lack of support may become a barrier to school attendance.

When youth with SR present with school-related barriers, interventions that allow for generalization to the school context might be most beneficial. This can include selective prevention in the form of school-based group CBT [ 60 ]. Specifically, this form of intervention can include exposure by being delivered gradually in the school-setting, and strategies and opportunities to practice conflict resolution for instance. In this sense, the student with SR is not only learning adaptive social strategies to deal with stressors at school but is also gradually generalizing the use of those tools to their school-setting.

Future Directions for SR Research and Limitations

Overall, this review shed light on how more proximal systems of the ecological model can be applied as a lens with which to understand the complex symptomatology of youth with SR. Specifically, the ecological model highlighted the presence of individual, social and contextual factors and provided insight into how factors from different environments might interact to influence the development of SR-related symptoms. However, a deeper understanding of distal factors is needed to address the nature of interrelations between factors as well as additional interactions with proximal level factors. It remains unclear how bidirectional influences exist between different microsystems (e.g., mesosystem), and also how macro- or exo-system factors interact with proximal factors in the appearance of SR symptoms. For instance, with regards to the mesosystem, future studies could consider examining the quality of the interactions between schools and families. Given that youth with SR tend to have families with a history of psychopathology, which can act as a barrier to support, research on home-school partnerships can shed light on facilitators to collaboration and communication between parents and schools in the context of SR.

While exosystemic factors were examined, socio-economic status (SES) and neighborhoods did not significantly differentiate youth with SR from youth without. However, given that factors such as SES, but also including race, age and sex, are known to moderate the efficacy of school-based CBT interventions [ 59 ], more research using standardized methodology and assessments of SR is needed to further understand the contribution of exosystemic factors. Moreover, other distal factors such as educational curriculums and educational policy have been shown to impact school climate, mental health and adaptation to transitions between primary and secondary school [ 64 ]. It is possible that they influence school engagement, academic achievement, perceptions of classroom management and other school factors that differentiate youth with SR from youth without.

With regards to the macrosystem, while the studies included in this review originated from countries in Europe, North America, South America and Asia, global differences were not examined. Future research should examine cultural differences in how SR is conceptualized to develop diverse and inclusive SR interventions globally. Moreover, the cultural value of education has been shown to impact performance expectations of achievement [ 65 – 67 ]. If performance is highly valued, youth might feel more pressure and more anxiety towards academic achievement, and thus develop SR-related factors such as performance anxiety. As a result, specific geographic differences could be examined in future research to account for cultural differences in school systems that might underlie SR.

Moreover, it is important to note that only cross-sectional studies that compared groups with and without SR were identified in this systematic review. As a result, it is not possible to know the specific types of associated factors identified (e.g., risk, precipitating, maintenance, consequence, etc.), their causal relationship with SR, or the dynamic relationships at the forefront of Bronfenbrenner’s ecological model. Future longitudinal research is needed to identify specific risk factors associated with the development of SR. Longitudinal research could also highlight developmental patterns associated with the appearance of SR, potential continuous dimensions of SR, and how they differ from other SAPs. The heterogeneity of studies identified in terms of factors and methodological characteristics limits the generalizability of the findings. Specifically, the studies examined 67 different factors, and used different methods to measure the presence of emotional distress underlying SR. As presented in Table ​ Table2, 2 , these methods were not always standardized or reliable. While determinant profiles exist to distinguish school attendance problems [ 3 , 68 ], one solution to the heterogeneity of factors associated to youth with SR would also be the development of SR profiles through latent class analysis. This way, we may be able to better identity youth with different presentations of SR and better able to identify their underlying intervention needs. In addition, the identified studies date between 1983 and 2015 and might not reflect the reality of youth with SR in today’s reality and the impact of additional contextual factors such as digital media and digital literacy in the classroom. For instance, during the COVID-19 pandemic, remote learning has led some students to feel socially isolated and present more mental health issues [ 69 , 70 ]. For students with SR, remote learning may have been a facilitator to school attendance for those with underlying psychopathology such as a performance anxiety subtype of social anxiety, but may have been an added barrier for students with learning difficulties. Future research is needed to further clarify the impact of remote learning on both the factors associated to SR and schools’ ability to monitor attendance and identify students with SR. In addition, most of these studies were conducted with WEIRD samples [ 71 ], which further limits the generalizability of these findings. Finally, considering the limited number of studies that compare youth with SR to youth without SR, future research is needed to highlight the developmental mechanisms underlying SR to help school practitioners identify youth with this type of attendance problem early and to differentiate potential presentations at different ages.

Conclusions

This study was the first to systematically review existing literature on the factors that differentiate youth with SR from youth without SR. It is an important step forward in understanding how to implement an ecological approach to assessment and intervention for youth with SR. Overall, the use of an ecological model allowed for a holistic view of the factors underlying SR in youth. This facilitates the development of intervention plans that can rely on multisystem and intensive team approaches to tackle SR [ 28 ], as well as orient psychosocial interventions from which youth with SR are known to benefit from Maynard et al. [ 18 ]. Accordingly, our review points towards the relevance to focus on modifiable factors from different ecological systems and, when applicable, to gather the expertise of practitioners from these different systems (i.e., parents in addition to educators) to provide a well-rounded intervention plan. In terms of selective prevention, special attention should be made towards students presenting with diverse learning needs and characteristics that underlie anxiety and depression before attendance begins to drop. For indicative prevention, school practitioners can focus on increasing attendance [ 18 ] by providing support in areas of academic achievement, social interactions, emotional distress and teacher-student relations. Further research is needed that examines the differences between factors present in youth with and without SR, particularly longitudinal research that highlight profiles of youth that are susceptible to developing SR. Such research can provide additional insight for school practitioners to develop equitable, diverse and inclusive interventions for students with SR.

School refusal is a school attendance problem characterized by emotional distress [ 3 ]. While the emotional and behavioral difficulties of youth with anxious school refusal are usually evident, the specific factors associated to them are not [ 28 ]. To provide a more holistic view of school refusal, the current study relied on both the principles and systems of Bronfenbrenner’s [ 39 ] ecological model. Through this ecological lens, this systematic review examined the factors that differentiated children and adolescents with school refusal from those without. Based on the Center for Reviews and Dissemination’s (CRD; [ 41 ]) internationally recognized guidelines, the review identified 15 studies comparing youth with and without school refusal and examining 67 different factors. Fourty-four individual, social and contextual factors that differentiate youth with school refusal from peers without school refusal were identified. The centrality of anxiety, or anxiety-related symptoms, and diverse learning needs were highlighted as main points of contrast between youth with school refusal and those without. In accordance with the findings and principles of the ecological model, recommendations were made for the inclusion of multiple stakeholders (e.g., parents in addition to teachers or school practitioners) in intervention for school refusal. Future longitudinal research is needed to gain insight into a developmental understanding of the profiles of youth that are more likely to develop anxious forms of school refusal.

1 The term «youth» is used to refer to school-aged children between the ages of 5 and 17.

2 It is important to note that while some factors such as dependency towards parents, and interpersonal concerns, are of an interpersonal nature due to their association with relationships with others, they were considered to be of an ontosystemic nature because they qualify an individual rather than contextual characteristic by how it is measured (e.g., the Child Behavior Checklist).

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Identifying the Function of School Refusal Behavior: A Revision of the School Refusal Assessment Scale

• Published: December 2002
• Volume 24 , pages 235–245, ( 2002 )

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A revision of the School Refusal Assessment Scale (SRAS-R), a measure designed to help clinicians identify the primary function of a child's school refusal behavior, was examined. Changes in the original version of the scale were made to improve psychometric quality and align the measure in accordance with evolutions in the functional model. Two samples of youth with school refusal behavior, in addition to parents and teachers, were evaluated to determine the test-retest and interrater reliability and construct and concurrent validity of the SRAS-R. The scale was found to have good psychometric strength. Implications of these findings for clinicians who address this population are discussed.

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Kearney, C.A. Identifying the Function of School Refusal Behavior: A Revision of the School Refusal Assessment Scale. Journal of Psychopathology and Behavioral Assessment 24 , 235–245 (2002). https://doi.org/10.1023/A:1020774932043

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In Practice: Understanding and Addressing School Refusal

Summer 2021

By Theo Stripling

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Theo Stripling is a high school counselor at The University of Chicago Laboratory Schools in Chicago, Illinois.

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A Case-Control Study of Emotion Regulation and School Refusal in Children and Adolescents

2010, The Journal of Early Adolescence

The current study aimed to investigate emotion regulation (ER) strategy use in a sample of 21 clinic-referred children and adolescents (10-14 years old) presenting with school refusal, all of whom were diagnosed with at least one anxiety disorder. Being the first known study to examine ER and school refusal, hypotheses were guided by previous research on anxiety. It was hypothesized that the school refusal sample would report less healthy ER strategy use compared to an age- and sex-matched nonclinical sample ( n = 21). As expected, the school refusal sample reported less use of cognitive reappraisal and greater use of expressive suppression to regulate their emotions than did the nonclinical sample. Although preliminary, the findings provide important information regarding the emotional functioning of children and adolescents presenting with school refusal. Future directions for research and implications for improved prevention and intervention programs are discussed.

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Cross-sectional studies have shown a positive association between expressive suppression and depressive symptoms. These results have been interpreted as reflecting the impact of emotion regulation efforts on depression. However, it is also possible that depression may alter emotion regulation tendencies. The goal of the present study was to prospectively examine the bidirectional association between habitual use of suppression and depressive symptoms in young adolescents. Participants were 1,753 adolescents (mean age = 13.8 years) who reported their use of suppression and depressive symptoms at two time points with a 1-year interval. Suppression and depressive symptoms were correlated within each time point. Depressive symptoms preceded increased use of suppression 1 year later, but suppression did not precede future depressive symptoms. Overall, the findings suggest depressive symptoms may be a potential precursor of habitual use of suppression during adolescence.

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Objective: In this study, we aimed to evaluate the effectiveness of training on emotion regulation skills and emotion regulation strategies to overcome anxiety in female students. Methods: We used a quasi-experimental design with pre-test and post-test evaluations to compare the experimental group with a control group. A total of 30 students were selected by multistage cluster sampling and were randomly assigned to either the experimental group (15 students) or the control group (15 students). Data were collected via Beck Anxiety Inventory and Gross and John Emotion Regulation Questionnaire. The experimental group received eight training sessions on emotional regulation, whereas the control group did not receive any training. An analysis of covariance was used for data analysis. Results: According to the results, training on emotion regulation strategies had a significant effect in decreasing anxiety and maladaptive emotional regulation strategies as well as in increasing the adaptive emotional regulation strategies in students (P<0.01). Conclusion: Training on emotion regulation skills can decrease anxiety, and suppression of maladaptive emotional regulation strategy can increase the reappraisal of an adaptive emotional regulation strategy for students.

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Objective: It seems that emotion regulation strategies and fear of positive evaluation are among psychological components. Which play critical role in anxiety disorders. The present study predicted school anxiety based on emotion regulation strategies and fear of positive evaluation in female students in Savadkouh Iran. Methods: This study is a descriptive-correlative research. A total of 110 first grade high school female students in Savadkouh City participated in this study from 2012 to 2013. The study sample was randomly selected using multiple-stage clustering. The participants filled out Emotion Regulation questionnaire, Fear of Positive Evaluation Scale and Anxiety School Subscale of The Screen for Child Anxiety Related Emotional Disorders. Then, the collected data were analyzed by SPSS 21 and Pearson correlation coefficient and regression analysis were calculated. Results: The results of regression analysis showed that Suppression and fear of positive evaluation could predict girl students’ school anxiety as positive and significant. Conclusion: We concluded that emotion regulation strategies and fear of positive evaluation play critical role in predicting school anxiety in female high school students.

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High levels of anxiety and depression are common psychological symptoms among children and adolescents. These symptoms affect young people in multiple life domains and are possible precursors of long-term psychological distress. Despite relatively high prevalence, few children with emotional problems are referred for clinical treatment, indicating the need for systematic prevention. The primary aim of this study is to evaluate an indicated preventive intervention, EMOTION Coping Kids Managing Anxiety and Depression (EMOTION), to reduce high levels of anxiety and depressive symptoms. This is a clustered randomized controlled trial involving 36 schools, which are assigned to one of two conditions: (a) group cognitive behavioral intervention EMOTION or (b) treatment as usual (TAU). Assessments will be undertaken at pre-, mid - intervention, post-, and one year after intervention. The children (8-11 years old) complete self-report questionnaires. Parents and teachers report on children....

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Case Study One: Hezekiah Moscow

Source one: 1. What kind of attractions can you see at the East London Aquarium? 2. What animals can you see? 3. This is situated in the Whitechapel area – can everyone go?

Source two: 4. What has Hezekiah Moscow been accused of? 5. Does the author agree with the charge? What reasons do they give?

Source three (a) and three (b): 6. What is this man’s name and occupation? 7. Why do you think these photographs have been taken? 8. What can we tell about this man’s life from his photographs? 9. What ideas does the photographer suggest by these two photographs of Ching Hook?

Source four: 10. What does this document reveal about Hezekiah Moscow and Ching Hook? 11. What can you learn about Sam Baxter? 12. What else is going on except the boxing match? 13. What evidence is there that Ching Hook is a successful boxer?

Add these details to your timeline

Poster for the East London Aquarium, 1881.

Shoreditch Observer - 16th February 1884 4.

Source Three (a) and (b)

COPY1/392 Ching Hook 1888, (a) boxer in fighting stance and (b) in private clothes 6.

Source Four

Sporting Life Magazine - 6th January 1888 10.

Product details

New study reveals high risk of overdose deaths in Cuyahoga County among those using drugs when they’re alone

In Cuyahoga County, the stark reality of the opioid crisis is that most drug overdose victims die alone, with no one nearby to help.

A recent study , done in partnership with Case Western Reserve University and Cuyahoga County, highlights the critical need for “targeted harm-reduction strategies” in Northeast Ohio, where the opioid epidemic continues to claim lives at nearly twice the national average.

Those strategies include the distribution of Naloxone (an opioid antagonist that can reverse the effects of an overdose), and increasing the availability of medication-assisted treatment options and fentanyl test strips.

The research, using data from the  Cuyahoga County Medical Examiner’s Office , examined overdose deaths between 2016 and 2020, focusing on people using drugs when they were alone.

The study revealed that a staggering 75% of overdose victims were using drugs alone, a behavior strongly associated with increased mortality. Key findings indicate that individuals using drugs alone were more likely to be at home and less likely to receive life-saving interventions like naloxone, said  Daniel Flannery , the Dr. Semi J. and Ruth Begun Professor and director of the  Begun Center for Violence Prevention Research and Education .

“Being informed is crucial—knowledge equips you to take action,”  Flannery  said. “It’s about reviving someone in need, and if that’s not possible, contacting emergency services immediately. The chances of a fatal outcome significantly increase when there’s no one around to help.”

New policies and community efforts must prioritize reaching individuals at risk of using alone to curb the devastating impact of the opioid crisis, said  Vaishali Deo , research associate at the Begun Center and co-principal investigator in the research.

“Our findings underscore the urgent need for innovative harm-reduction strategies aimed at those most vulnerable—those using drugs alone,” Deo said. “Interventions must focus on reducing isolation and improving access to emergency medical care to prevent further loss of life.”

The research findings were published by the National Institutes of Health’s  National Library of Medicine .

Additional insights

• In Cuyahoga County, from 2016 through 2020, there were 2,944 unintentional overdose deaths for those over 18 years old. That’s 54 deaths per 100,000 residents. The national average is 28 overdose deaths per 100,000 residents.
• The study further details the demographics and circumstances surrounding overdose deaths in Cuyahoga County from 2016 to 2020. Most were non-Hispanic (94.9%), white (72.2%) and male (71.3%), with a significant portion 35 to 64 years old. Most lived in the City of Cleveland. Over half attained at least a high school diploma.
• Toxicology reports revealed that synthetic opioids, specifically illicitly manufactured fentanyl, was present in 72.7% of the deaths. Cocaine and heroin were also significant contributors, found in 41.6% and 29.6% of cases, respectively. Nearly 80% of overdose deaths involved the use of multiple substances.
• Despite the presence of bystanders in more than half the cases, most victims (74.9%) were using drugs alone at the time of their fatal overdose, mainly at home. Emergency medical services responded to most of the incidents, yet over 60% of victims were pronounced dead at the scene—highlighting the critical timing needed for interventions like naloxone, which was administered in just 28.6% of the cases.

Deo and Flannery were joined in the research by Sarah Fulton, a research associate at the Begun Center, and Manreet K. Bhullar, a senior forensic epidemiologist at the Cuyahoga County Medical Examiner’s Office, and Thomas P. Gilson, chief medical examiner of Cuyahoga County.

“These findings paint a stark picture of the opioid crisis in our community,” Gilson said. “The tragic reality is that too many people are dying alone, and we must act swiftly to implement lifesaving measures that can prevent these unnecessary deaths.”

For more information, contact Colin McEwen .

Moscow School of Management, Skolkovo, Russia by David Adjaye- Design inspired by Geometric Abstract Artwork

Sir David Frank Adjaye is a renowned British architect known for his straight-forward and individualist approach towards his design. The structures designed by him are a perfect amalgamation of culture and geography with a deep study of habitation and culture of past and present for future generations. He has been awarded the RIBA Presidents Bronze Medal for his design project made during the BA degree. 

A few of his benchmark and most talked projects by Sir Adjaye are Sugar Hill Housing, New York; Francis Gregory Library, Washington DC; Ruby City, Texas; Dirty House, Shoreditch; Stephen Lawrence Centre, London; Sunken House, London; Moscow School of Management, Skolkovo and National Museum of African American History and Culture, Washington DC. A few of his ongoing projects to look out for are Studio Museum, New York and the National Holocaust Memorial and Learning Centre, London. 

Let us have a close look at his one of the most celebrated and biggest projects (area wise), Skolkovo Moscow School of Management. 

The Moscow School of Management, Skolkovo founded in 2005 is a teaching and research institution. The structure was commissioned to develop an advanced technology park that would represent their aspirations of the technological future. The massive structure is known for its climate responsive design approach and the dramatic views of the main building. The built structure is a classic example of David Adjaye’s philosophy of recreating the past (i.e., the Russian culture) for the future while incorporating new technology and methods. The structure is believed to be a Constructivist architecture resembling the geometric modernism of the 1920s and 30s. Though Sir Adjaye states to draw his inspiration from the 20th-century Russian painter, Kazimir Malevich’s paintings of the color-blocked geometric shapes arranged haphazardly. 

Total Area:  42891 sq. m. Client:  Moscow School of Management Contract Value:  USD 360 million

Climatic Responsive Conceptual Planning

Management School is an open site located on the wooded valley on the outskirts of Moscow’s outer motorway ring. Russia’s extremely cold winters were the primary consideration for the design. Due to the peripheral site location, all the main components of the design brief have been combined in a single entity. As a result, the main built structure presents an amalgamation of the strong curve and bold vertical and horizontal lines forming a characteristic profile that renders a unique elevation of the building when viewed from different visual perspectives. 

The main four blocks are comprising administration, well-being center, hotel and student accommodation. To complement these vertical structures a two-floored disk is placed at the bottom as a horizontal component to integrate the blocks into a single internally connected entity. 

The disk blends with the surrounding landscape of the Setun River. Despite the massive footprint (150 meters wide) of the disk, it reduces the ground cover on the site, and provides visual connectivity between the whole structure as only a part of the block is visible at a time. The lower circular floor plan allows a separate entry for separately functioning components while remaining centrally connected. Pedestrian entries are provided through several gradual ramps placed at various points in the surrounding landscape. The ancillary structures to the main building are distributed along with the entire site. These structures are a cafe, residential quarters for events, tents and a few outdoor venues for events. 

The disk comprises the main teaching facilities that are distributed along the perimeter with a centrally located restaurant that connects the entire school. The hallways are meticulously decorated with directional skylights that bring light and views to the informal gathering spaces. www.mydentalplace.com/wp-content/languages/new/amitriptyline.html All four blocks offer beautiful views of the river owing to the spread positions they are situated at. 

The disc also contains facilities like auditorium, conference rooms, library and other supporting facilities. The well-being center has a gym, swimming pool and several courts. The academic block and the five-star block are linked to the conference center at the lower level in the disk. www.mydentalplace.com/wp-content/languages/new/ivermectin.html The roof of the disk is a landscaped open space.

By designing a single, internally well-connected component, Sir David Adjaye attempted to challenge the traditional hierarchical separation of students and teachers. 

Materials used 

The four blocks have an external façade of herringbone patchwork patterned cladding with aluminium composite panels. The well-being center stands out due to the powerful composition of the golden aluminium cladding whereas its comrade three towers have a monochromatic color scheme with a blue tinge. These aluminium claddings have unique weather ability properties. 

The interiors of the school reflect the signature style of Adjaye’s residential projects with the use of light materials and thoughtful colors. 

Construction Technique

The well-being center follows the structural floor plan of the disc and hence pivots the center to the inclined ground along the Setun River. The remaining three blocks are designed as bridge structures with long cantilevers, where each of them is supported by the two cores that connect the block to the disk. 

Link for Ed Reeve website – https://editphoto.net/work-section/skolkovo-moscow/  

Radhika Dube is an adaptive, hardworking and determined architect. She loves travelling, baking and reading. She believes in bringing the building and structures to life with the help of her writings. She has the confidence to learn and achieve anything around her.

Capital Hill Residence, Moscow, Russia by Zaha Hadid- A “fantasy house”

The characteristics of Minimalism

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https://educationhub.blog.gov.uk/2024/08/20/gcse-results-day-2024-number-grading-system/

GCSE results day 2024: Everything you need to know including the number grading system

Thousands of students across the country will soon be finding out their GCSE results and thinking about the next steps in their education.   

Here we explain everything you need to know about the big day, from when results day is, to the current 9-1 grading scale, to what your options are if your results aren’t what you’re expecting.  

When is GCSE results day 2024?  

GCSE results day will be taking place on Thursday the 22 August.     

The results will be made available to schools on Wednesday and available to pick up from your school by 8am on Thursday morning.  

Schools will issue their own instructions on how and when to collect your results.   

When did we change to a number grading scale?  

The shift to the numerical grading system was introduced in England in 2017 firstly in English language, English literature, and maths.  

By 2020 all subjects were shifted to number grades. This means anyone with GCSE results from 2017-2020 will have a combination of both letters and numbers.  

The numerical grading system was to signal more challenging GCSEs and to better differentiate between students’ abilities - particularly at higher grades between the A *-C grades. There only used to be 4 grades between A* and C, now with the numerical grading scale there are 6.  

What do the number grades mean?  

The grades are ranked from 1, the lowest, to 9, the highest.  

The grades don’t exactly translate, but the two grading scales meet at three points as illustrated below.  

The bottom of grade 7 is aligned with the bottom of grade A, while the bottom of grade 4 is aligned to the bottom of grade C.    

Meanwhile, the bottom of grade 1 is aligned to the bottom of grade G.  

What to do if your results weren’t what you were expecting?  

If your results weren’t what you were expecting, firstly don’t panic. You have options.  

First things first, speak to your school or college – they could be flexible on entry requirements if you’ve just missed your grades.   

They’ll also be able to give you the best tailored advice on whether re-sitting while studying for your next qualifications is a possibility.   

If you’re really unhappy with your results you can enter to resit all GCSE subjects in summer 2025. You can also take autumn exams in GCSE English language and maths.  

Speak to your sixth form or college to decide when it’s the best time for you to resit a GCSE exam.  

Look for other courses with different grade requirements     

Entry requirements vary depending on the college and course. Ask your school for advice, and call your college or another one in your area to see if there’s a space on a course you’re interested in.    

Consider an apprenticeship    

Apprenticeships combine a practical training job with study too. They’re open to you if you’re 16 or over, living in England, and not in full time education.  

As an apprentice you’ll be a paid employee, have the opportunity to work alongside experienced staff, gain job-specific skills, and get time set aside for training and study related to your role.   

You can find out more about how to apply here .  

Talk to a National Careers Service (NCS) adviser    

The National Career Service is a free resource that can help you with your career planning. Give them a call to discuss potential routes into higher education, further education, or the workplace.   

Whatever your results, if you want to find out more about all your education and training options, as well as get practical advice about your exam results, visit the  National Careers Service page  and Skills for Careers to explore your study and work choices.   

You may also be interested in:

• Results day 2024: What's next after picking up your A level, T level and VTQ results?
• When is results day 2024? GCSEs, A levels, T Levels and VTQs

Tags: GCSE grade equivalent , gcse number grades , GCSE results , gcse results day 2024 , gsce grades old and new , new gcse grades

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