School Refusal Behavior

Historical Overview

Many terms have been applied to school refusal behavior, including problematic absenteeism, truancy, psychoneurotic truancy, school phobia, and separation anxiety. Each term describes a subset of youths with school refusal behavior. For example, truancy refers to illegal absenteeism in which a child misses school without parental knowledge. Other terms describe youths with anxiety-related conditions such as dread (psychoneurotic truancy), fear (school phobia), and worry about separation (separation anxiety). The term “school refusal” is often used to refer to anxiety-based absenteeism as well. Many of these terms have been poorly defined, however, and are used in various ways by educators, clinicians, and researchers. The umbrella term “school refusal behavior” has been proposed to cover all youths with problematic absenteeism, whether anxiety-related or not, and to provide consensus for educators, clinicians, and researchers.

Characteristics of Youths with School Refusal Behavior

School refusal behavior affects an estimated 5% to 28% of school-age children. According to the National Center for Health Statistics, 0.9% of children did not attend school at all in 2003. Furthermore, 5.4% of youths missed 11 or more days of school, 11.3% missed 6 to 10 days of school, and 28.1% missed 3 to 5 days of school in 2003. The number of absences due specifically to school refusal behavior, however, is unclear.

Peak age of onset of school refusal behavior is 10 to 13 years, though many youths entering a school building for the first time appear especially vulnerable. School refusal behavior is equally common among boys and girls and across sociocultural groups, though school dropout rates tend to be higher among Hispanics than among the general population. School refusal behavior is generally associated with adequate academic achievement up to the onset of absenteeism.

A hallmark of youths with school refusal behavior is symptom heterogeneity. The clinical picture of youths who refuse school is quite varied and includes many internalizing (covert) and externalizing (overt) symptoms. Common internalizing symptoms include general and social anxiety, depression, fatigue, somatic complaints, fear, worry, and self-consciousness. More specifically, common somatic complaints include headaches, stomachaches, abdominal pain, nausea, vomiting, diarrhea, trembling, and heart palpitations. Common externalizing symptoms include noncom-pliance and defiance, refusal to move, running away from school or home, aggression, and acting-out behaviors in school in an attempt to be sent home.

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