Running head: SCHOOL REFUSAL School Refusal Behavior: …

1 1 Running head: SCHOOL REFUSAL SCHOOL REFUSAL Behavior: From Terminology to Treatment Joe Viskochil University of Utah Author Note Joe Viskochil, Department of Education Psychology, University of Utah This monograph was supported by a grant from the United States Office of Education. SCHOOL REFUSAL 2 Abstract SCHOOL REFUSAL is broad term that encompasses a child motivated REFUSAL to attend or remain at SCHOOL . Many externalizing and internalizing behaviors are associated with SCHOOL REFUSAL , including tantrums, aggression, noncompliance, anxiety, depression and somatic complaints. The heterogeneity of both the behavioral presentation and terminology of SCHOOL REFUSAL make classification difficult, however there are common comorbidities such as separation anxiety disorder, major depressive disorder, and social or specific phobia. It is proposed that SCHOOL REFUSAL behavior is maintained by four possible functions: escape, avoidance, attention, and tangible rewards.

2 These four functional profiles have received continuous empirical support, and offer prescriptive treatment heuristics. This monograph analyzed prevalence, etiology, assessment and treatment from this perspective. SCHOOL REFUSAL 3 Description and prevalence SCHOOL REFUSAL is a broad term that encompasses a child motivated REFUSAL to attend or remain at SCHOOL , or a clear and apparent difficulty in doing so (Kearney, 2008). This REFUSAL often results from anxiety produced either by the separation from a major attachment figure or from fear of an aversive situation at SCHOOL such as bullying or an oral presentation. SCHOOL REFUSAL can also result from positive reinforcement, or rewards, such as access to television, video games, or simply attention that is received outside of SCHOOL . The main condition of SCHOOL REFUSAL is severe difficulty attending or remaining in SCHOOL , resulting in prolonged absences.

3 From this core symptom there can result both internalizing and externalizing behaviors (Kearney & Albano, 2000). Internalizing behaviors include anxiety, depression, fear, fatigue, and somatic complaints. Externalizing behaviors include tantrums, aggression, clinging, noncompliance, refusing to move and Running away. Some situations can preclude the term SCHOOL REFUSAL , such as a legitimate illness or disorder. Also, if the REFUSAL is parent motivated rather than child motivated, the term SCHOOL withdrawal is more appropriate than SCHOOL REFUSAL . Finally, there are certain societal or familial conditions such as vacations, homelessness, economic reasons, or Running away from an abusive environment that make the term SCHOOL REFUSAL inappropriate (King, Ollendick & Tonge, 1995). SCHOOL REFUSAL can have a negative impact on multiple areas of functioning. In the short term, SCHOOL refusing children are at risk for decreased academic performance, increased stress, alienation from peers, family conflict, and a decrease in supervision (Kearney & Albano, 2000).

4 This decrease in supervision is also a risk factor for illicit activity and legal trouble. The long term outlook of SCHOOL refusing youth includes a heightened risk for economic deprivation, marital problems, substance abuse, criminal behavior and poor psychosocial functioning. SCHOOL REFUSAL 4 Because SCHOOL attendance is a critical component of our social and academic development, these potential risks are compounded by the duration of the SCHOOL REFUSAL (King, Tonge, Heyne, Turner, Pritchard, Young, Rollings, Myerson & Ollendick, 2001). It is normal to want to stay at home, and many children will refuse to go to SCHOOL a few times throughout their lives. The difference between this normal tendency and substantial SCHOOL REFUSAL is that the latter generally involves absences of at least two weeks. SCHOOL REFUSAL is thought of as acute if it occurs between two weeks and one year, and chronic if it spans two consecutive academic years (Kearney, 2007).

5 Acute SCHOOL REFUSAL is common for younger children and children who have recently moved or experienced a large change in their home environment. Chronic SCHOOL REFUSAL is more readily observed in adolescents, but is harder to treat. Because precise criteria for SCHOOL REFUSAL have not been well established, it is difficult to determine accurate prevalence rates. Although 28% of children may refuse SCHOOL at some point, estimates of those who display chronic SCHOOL REFUSAL are around (Granell de Aldaz, Vivas, Gelfand, & Feldman 1984; Heyne, King, Tonge, & Cooper 2001). SCHOOL REFUSAL peaks at ages 5-6 and 14-15, however the mean age falls around 10. Overall, SCHOOL REFUSAL is equally distributed among gender, socioeconomic status (SES), and intelligence (Kearney & Albano 2000). There are, however, some demographic variables that are associated with specific subtypes of SCHOOL REFUSAL .

6 For example, children with a low SES tend to be more anxious or fearful of social elements of SCHOOL (teachers and peers), whereas those from higher SES s are more afraid of evaluative situations such as grades and exams. Further, SCHOOL REFUSAL with or resulting from separation anxiety seems to be comprised of more females, while SCHOOL REFUSAL associated with a specific phobia seems dominantly male (King, Ollendick, & Tonge 1995). SCHOOL REFUSAL 5 Classification and terminology The Diagnostic and Statistical Manual (DSM-IV-TR) does not have a specific code for SCHOOL REFUSAL . However, many children who demonstrate this behavior may meet classification criteria for an anxiety or affective disorder (American Psychiatric Association, 2000). The most common disorders in which SCHOOL REFUSAL is seen include separation anxiety, specific or social phobia, and major depressive disorder (King, Ollendick, & Tonge, 1995).

7 Due to the heterogeneity of SCHOOL REFUSAL , and the wide spectrum of behavioral problems associated with it, it is difficult to classify as a single, specific condition. Finding the most appropriate title of SCHOOL REFUSAL behavior compounds the difficulty of classification. In the literature, terms such as SCHOOL phobia, SCHOOL REFUSAL and truancy are all used to describe a similar condition. In the past, SCHOOL phobia was the favored term, as it captured those who clearly presented anxiety and physiological arousal while refusing SCHOOL . However, this term did not account for those who refused SCHOOL to gain access to positive reinforcement. SCHOOL truancy is a different subtype of SCHOOL REFUSAL as it most often does not result from intense anxiety or fear, and because it does not come into play until later adolescence. Also, in most situations of SCHOOL REFUSAL , the parents are aware that their child is not at SCHOOL , while truancy implies that the whereabouts of the child are unknown.

8 SCHOOL REFUSAL is a broad term that can include the most categories, and that is why it has been the predominant term used in recent literature. This paper will use SCHOOL REFUSAL as an all encompassing term. Functions SCHOOL refusing behavior is thought to be maintained by two functions, negative and positive reinforcement. From these two main functions, four profiles have been proposed (Kearney & Albano, 2004). Each profile represents a different set of behaviors, and knowing SCHOOL REFUSAL 6 which profile the child fits can be useful in determining what course of treatment to take. Although there will be very few times when a child shows behaviors from only one profile, to know the primary reason that SCHOOL REFUSAL is being maintained is very helpful to therapists, parents and teachers for information regarding comorbid conditions and treatment guidelines (Kearney, 2002; Kearney & Albano, 2000; see Table 1).

9 The first profile is the child who refuses SCHOOL to avoid SCHOOL related objects and situations. This profile is most congruent with a child who has a specific phobia, such as a fear of the playground or of fire alarms. In this profile, by staying home the child avoids something that he or she is afraid of. The next profile includes the child who stays home to escape aversive social and evaluative situations, such as presentations, exams, or reading out loud. This profile of SCHOOL REFUSAL may be more difficult to detect, since oral presentations and tests do not always follow a regular schedule. In each of these profiles, the SCHOOL refusing behavior is maintained by negative reinforcement, which means that even though they aren t receiving a tangible reward, they are being excused from a situation or environment they dislike and given the chance to go to one that they prefer. The third profile represents the child who refuses SCHOOL to receive attention from a primary caregiver.

10 This profile includes children with separation anxiety, and by refusing SCHOOL these children are often allowed to remain with their major attachment figure. Finally, the fourth profile describes the individual who receives tangible rewards while refusing SCHOOL . These rewards will vary based on the individual, but they frequently include access to television and video games, treats at home, or even illicit substances. SCHOOL REFUSAL depicted by these profiles is maintained by positive reinforcement, meaning by refusing to go to SCHOOL the children gain access to a preferred person, object or activity. SCHOOL REFUSAL 7 Table 1: Functional profiles of SCHOOL REFUSAL . Adapted from "When Children Refuse SCHOOL : A Cognitive-Behavioral Therapy Approach," by Kearney and Albano, 2000, p. 3-5. Functional Profile Description Associated Conditions Prescriptive Treatment 1: Avoidance To avoid SCHOOL -related objects or situations that cause general distress/negative affectivity Generalized anxiety disorder; specific phobia; panic disorder; emotional disturbance; depression; agoraphobia Psychoeducation; exposure; systematic desensitization; self reinforcement 2: Escape To escape aversive social and/or evaluative situations at SCHOOL Social phobia; depression; social issues or anxiety; shyness Psychoeducation; role play; modeling; cognitive therapy; social skills groups 3: Attention To receive attention from significant others outside of SCHOOL Separation anxiety disorder; oppositional defiant disorder; noncompliance Parent training; contingency management; differential reinforcement 4: Rewards To pursue tangible reinforcement outside of SCHOOL Oppositional defiant disorder.