BHIPP Bulletin

Volume 8, Issue 8

February 2023

This month's BHIPP Bulletin is a contribution from

Rick Ostrander, EdD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine,

Founder of Pediatric Medical Psychology Program at Johns Hopkins Children's Center and BHIPP Consultant.

As pediatric primary care providers, you may be the first to hear parents' concerns about their child's school refusal behaviors. This newsletter will provide information about the common reasons behind school refusal and how to address them. By being aware of school refusal concerns, you can assist families in managing this behavior.

Incidence and Psychiatric Considerations:

The U.S. Department of Education (2016) estimates that almost 20% of high school students miss 15 or more days of school in one school year. Understandably, some children miss school because of medical illness. However, many children do not attend school due to behavioral or emotional considerations, with the rates of school refusal approximating 10% (Egger, Costello & Angold, 2003). Early estimates suggest that between 40-88% of severe school attendance problems meet criteria for one or more psychiatric disorders (Egger, Costello & Angold, 2003). Most children who refuse to attend school have their own internal motivations and represent a heterogeneous group of children. Some researchers have separated youth that refuse to attend school into subgroups. These subgroupings are associated with differential psychiatric, family, and school related factors. This has led some researchers to suggest that the term "school refusal" should be reserved for a subset of children that have underlying anxiety and point to strong associations between refusing to attend school and having an anxiety disorder and/or being bullied at school (Heyne et. al., 2019). In contrast, young people that are considered truant are more likely to be diagnosed with externalizing behaviors, such as oppositional or conduct disorders, and are more inclined to have a learning disability (Heyne et. al., 2019; Kearney, 2008). The Great Smoky Mountains Study reported that the three-month prevalence rate of young people with the anxious subtype of school refusal was 2.0% and those with truancy was 6.2% (Egger, Costello & Angold, 2003). These distinctions have been criticized as being overly broad and imprecise (Heyne et. al., 2019); however, this line of research would suggest that children who refuse to attend school are at high risk of having at least one psychiatric diagnosis and should be referred for mental health assessment and treatment (Egger, Costello & Angold, 2003; Heyne et. al., 2019).

What is the Function of School Refusal?

Although a child who is not attending school may be defined by broad tendencies, the more immediate presentation of any child’s school refusal is typically more nuanced and may include a variety of behaviors. They might display extended or frequent absences, chronic or episodic tardiness, behavioral difficulties in the morning, leave school during the day, express extreme distress and temper outbursts, or might act more covertly (Kearney & Silverman, 1996). While many of these children may need treatment for an underlying psychiatric disorder, the specific intervention for school refusal often requires a more detailed understanding of the specific motivation and function of a given young person’s refusal to attend school.

Kearney & Sheldon (2017) have identified four functions of school refusal:     

1. Avoidance: Students may refuse school to avoid feeling anxious or other negative emotions that are associated with being in school.

2. Escape: Students may want to escape from difficult circumstances, such as taking a test or being teased and/or bullied by classmates.

3. Attention: Students may be seeking the attention of parents or other significant people in their lives.

4. External reinforcement: Students may refuse school to participate in more appealing activities at home, such as playing video games or affiliating with other youth that are also not attending school.

These functions are often linked to specific psychiatric disorders. For instance, avoidance of negative thoughts and emotions and escape from unpleasant situations are often associated with general anxiety disorders, whereas attention-seeking behaviors are more likely associated with separation anxiety disorder (Kearney & Albano, 2004). Interventions for students with anxiety should emphasize education about anxiety and school refusal as well as the type of training associated with Cognitive Behavioral Therapy (Kearney & Bensaheb, 2006). Children with oppositional or defiant problems may display school refusal behaviors to gain access to tangible or social rewards (Kearney & Albano, 2004). Interventions for these children should focus on changes in the environment and consequences for behavior at home and at school (Kearney & Bensaheb, 2006). For example, parents could reward their student for attending school and eliminate rewards for staying home and playing games or affiliating with other young people with similar tendencies.

Specific Interventions:



While school refusal may be linked to certain psychiatric conditions and serve certain functions, there are several recommendations that can be effective at improving school attendance and improving positive engagement with school activities (Peacock et. al., 2019). Such interventions include: 

1. Encourage Appropriate Outpatient Treatment: Encourage community-based treatments for any underlying psychiatric disorders that are contributing to school refusal. Depending on the underlying disorder, both psychosocial and/or psychopharmacological approaches are often effective. In addition, school support involving the school psychologist or interventions within the context of an IEP or 504 plan can complement community-based treatment approaches.

2. Ensure a Positive School Environment: Children may avoid school because they are being bullied or ridiculed. Having an effective school-wide positive behavior support system can help prevent issues that may lead to school refusal. Parents can be encouraged to assertively inform the school if they believe there is an issue with bullying or scapegoating.

3. Reinforce School Attendance: Parents should be encouraged to set a clear expectation of school attendance and develop a morning routine that leads to the student going to school. Examples of reinforcement programs include the following:

• Younger aged students may earn stickers or points for behaviors that encourage school attendance at each step in the process. For example, the child may earn stickers for getting dressed in the morning, getting in the car, getting to their classroom, staying in school for an agreed-upon time, etc. However, this approach will only work if the number of points earned are reliably traded for increasing rewards that the child values.
• Middle and High school aged students may respond to the use of contracts. For example, the student and parents agree on activities that can only be accessed if the student attends school. This might include access to the car, video games, electronics, staying up later, a preferred dessert, etc.

4. Ignoring Somatic Complaints: Children with anxiety may display related somatic complaints. While they may really feel queasy or achy, parents and teachers should be encouraged to use the following approaches:

• A child dealing with school refusal should not stay at home just because they complain of illness; likewise, the school should not send students home (or allow them to sit out of class) because of these complaints. Whenever possible, they should attend school unless they are throwing up or have a fever.
• Parents and teachers should not indiscriminately discuss complaints with a child who experiences school refusal. Instead of attending to somatic complaints, parents and teachers should look for positive behaviors they can reinforce. A parent, for example, should be encouraged to pay attention to any behavior that resembles getting to school rather than somatic complaints.

5. Planning for School Return: It is critical to avoid reinforcing school refusal behaviors. If school refusal is due to anxiety, allowing the student to stay home (and escape or avoid the anxiety-provoking situation) will only increase the school refusal behavior. However, if school refusal behavior has been present for some time, a gradual return to school might make sense. Initially, the student may return for only part of the day and at a time when experiencing success is most likely (e.g., during a favorite class). At the same time, if a student is most anxious during math class, this expectation could be added later. The school and parents should be encouraged to incorporate contact with adults and other students that can help the student feel more connected to the school. Preferred peers can be an important source of support. In addition, it may be helpful to have a trusted teacher or administrator meet the student outside the school to escort the student into the building. This can prevent running away from school and a drawn-out goodbye with parents.

6. Keep the Young Person at School and in the Classroom: Students may attempt to leave the classroom or school building. This can be addressed by including more frequent rewards for engagement in schoolwork. Rewards might also include brief breaks from the classroom if requested appropriately and are contingent on staying in class for a specific time period. Monitoring the student at all times (including adult supervision for trips to the restroom) is often required to ensure the young person stays in school. For older students, this might involve having a trusted peer or adult escort the student. It is important not to reinforce escape behaviors. For example, the nurse's office may be seen as less aversive (and more rewarding) than the classroom. Therefore, interventions should focus on keeping the student in the classroom whenever possible.

Recommended Resources:

https://adaa.org/find-help/by-demographics/children/school-refusal

• The Anxiety and Depression Association of America provides possible reasons for school refusal and related recommendations

https://www.healthychildren.org/English/health-issues/conditions/emotional-problems/Pages/School-Avoidance.aspx

• This website is sponsored by the American Academy of Pediatrics. The content includes how to address a variety of child related problems and when to seek help

Kearney, C. A. (2007). Getting your child to say “yes” to school: A guide for parents of youth with school refusal behavior. New York, NY: Oxford University Press. https://amzn.to/3xPrbUx

• This book provides parents with advice on managing school refusal before it becomes entrenched and requires more intensive forms of treatment.



Kearney, C. A. (2008). Helping school refusing children and their parents: A guide for school-based professionals. New York, NY: Oxford University Press. https://amzn.to/3KCU5z2

• This book is written for school personnel; however, it can also be a helpful resource for health care professionals.

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

BHIPP Announcements

Sign up for our upcoming BHIPP Resilience Break!

Register for the BHIPP ECHO Clinic Core Foundations Session on Suicide Prevention!

Join us for our next BHIPP Mental Health Crisis Training

Announcing the next BHIPP Resilience Break!

The American Academy of Pediatrics Request for Applications: Evaluation of Use of NASEM's Resilience and Wellbeing Tools in Pediatric Practices

The American Academy of Pediatrics is recruiting up to 5 pediatric practices to pilot test resilience and wellbeing tools for children and adolescents to increase coping skills and resilience to stressors. The aim of the project is to evaluate the recently developed National Academies of Sciences, Engineering, and Medicine (NASEM) Resilience and Wellbeing Tools for potential use in pediatric practices.

Submission Deadline: March 20th, 2023

For more information about the project visit this link: https://downloads.aap.org/AAP/PDF/Evaluation-of-Use-of-NASEM's-Resilience-and-Wellbeing-Tools-in-Pediatric-Practices-updated.pdf