School Phobia and School Refusal
School Phobia and School Refusal
The term school phobia reflects the terminological and conceptual confusion that has plagued the problem of excessive school absenteeism since it was first introduced as a phobia by Adelaide M. Johnson and her colleagues (1941). Most investigators currently working in the area, therefore, have come to view school phobia as a subset of school refusal behavior. As a consequence, the more comprehensive term, school refusal behavior (SRB), has come to be preferred over school phobia (Hansen et al. 1998). Even the term SRB has its difficulties, however, as it may be taken to imply a conscious decision on the part of the child to refuse to go to school—a perspective that clearly is not appropriate to all cases (Wicks-Nelson and Israel 1997). Truancy usually is characteristic of children who are absent from school on an intermittent basis, usually without parental knowledge. Children with SRB are absent for extended durations, such as consecutive days, weeks, or months, and usually with parental knowledge. Truancy also is usually associated with other externalizing child behavior problems (e.g., conduct problems) as well as poor academic performance.
There is no one picture of the school-refusing child. Some children who display SRB fail to attend school fully and completely. Other children may initially attend school in the morning but call their parents to be picked up early, frequently because they have somatic complaints (e.g., nausea, headaches). Another group of children who display SRB may attend school and even manage to stay there all day. However, it is a chore each morning to get these children to school because of the severe problem behaviors (e.g., temper tantrums, crying, pleading) exhibited. Another group of children with SRB similarly attend school, but they experience high levels of distress while in school, leading to regular pleas to remain home in the future. These are not distinctive patterns of SRB, however; it is not uncommon for children to display more than one such pattern at a given time. Nor is it uncommon for children to move in and out of varying patterns over time.
The heterogeneity of SRB also is manifested in the diagnostic picture. Research has documented the clinical features of children who display SRB by evaluating these children with structured diagnostic interviews and deriving Diagnostic and Statistical Manual (DSM) diagnoses. For example, Cynthia G. Last and Cyd C. Strauss (1990) investigated DSM-III-R anxiety disorder diagnoses in sixty-three school-refusing youth (ages seven to seventeen years). The most common primary diagnosis was separation anxiety disorder (n=24), followed by social phobia (n=16), and simple phobia (n=14). Children with SRB also frequently display multiple (comorbid) diagnoses (Kearney, Eisen, and Silverman 1995). The main implication of these findings is that a number of the clinical features that characterize SRB are the same as those that characterize diagnoses that accompany a given SRB case (e.g., excessive avoidance if criteria for phobic disorder are met).
Even more heterogeneity may exist among children who meet criteria for a particular DSM diagnostic category. For example, although school might be considered a circumscribed and specific stimulus for children with SRB who meet primary diagnosis for specific phobia, school phobia actually covers several different types of specific stimuli, such as hallway, classroom, gymnasium, pool, fire alarm, or school bus (Kearney, Eisen, and Silverman 1995). Identifying the specific phobic object or event thus also becomes important to consider when assessing SRB in children with a primary diagnosis of specific phobia.
Heterogeneity among children with SRB also is apparent in terms of the presence (yes/no) and types of somatic symptoms or complaints that children may report. Although somatic symptoms or complaints are frequently the main reason why parents feel they need to keep their children at home rather than force attendance, not all children report somatic symptoms. In a sample of adolescent school refusers (n=44) who were comorbid with anxiety and depression, many (32%) but not all participants reported somatic complaints (Bernstein et al. 1997). The specific somatic complaints varied across the youth and included autonomic (e.g., headaches, sweatiness, dizziness) and gastrointestinal (e.g., stomachaches) symptoms. These findings highlight the importance of inquiring about somatic complaints (presence/absence and type) among children with SRB.
Christopher A. Kearney and Wendy Silverman (1993) suggested that SRB may be maintained by at least one of the following functions or motivating conditions: (1) avoidance of objects or situations provoking specific fearfulness or generalized anxiety; (2) escape from aversive social or evaluative situations; (3) attention-getting behavior (analogous to traditional externalizing symptoms of separation anxiety, such as tantrums); and (4) positive tangible reinforcement (analogous to truant behavior, or preferring to stay home and play or avoiding school for reasons other than fear or anxiety). The first two refer to school refusal behavior maintained by negative reinforcement; the latter two refer to school refusal behavior maintained by positive reinforcement.
Distal factors also may spur SRB. Such factors include homelessness, maltreatment, school victimization, teenage pregnancy, divorce, and child self-care (Kearney 2000). Kearney, for example, indicated that homelessness in youth has been linked to educational problems such as school dropout, severe absenteeism, expulsion, higher risk of school failure, and poor achievement in reading and arithmetic.
Age and Gender
Research evidence suggests that the most common age of onset for SRB is generally in early adolescence, though this may simply reflect age at the time of referral. Last and Strauss (1990), for example, reported that onset of school refusal was, on average, about one to two years prior to referral. In terms of gender, SRB occurs fairly evenly across boys and girls (Kearney 1995).
Culture/Ethnicity and Race
According to the U.S. National Center of Education Statistics, 5.5 percent of students are absent from school on a typical school day. However, only a small number of studies have examined cultural/ethnic or race variations in SRB. Elena Granell de Aldaz and her colleagues (1984) examined the prevalence of school refusal and school-related fears in 1,034 Venezuelan children (ages three to fourteen years). Results indicated that children were generally afraid of test failure (35%), poor grades (33.4%), visiting the principal (29.7%), tests (18.4%), going to the blackboard (13.5%), talking to agroup or class (13.4%), being called on unexpectedly in class (12.5%), becoming ill at school (11.2%), and waiting to be picked up at school (11.0%). In a subsequent study Granell de Aldaz and her colleagues (1987) further classified fifty-seven Venezuelan school-refusing children (ages three to fourteen years) based on presenting problems (i.e., adaptation problems [49.1%], phobia [42.1%], and emotional problems [8.8%]). Among these children, common but different fears emerged, including fear of the teacher (43.9%), other children (21.1%), and separation from parents (21.1%). Angelica Hibbet and Ken Fogelman (1990) found that 19.4 percent of sixteen-year-old adolescents in Great Britain displayed regular unexcused absences.
Although there is evidence that school dropout rates are substantially higher among Hispanic (29.4%) than African-American (13.0%) or white students (7.3%) (see www.nces.ed.gov for recent updates), some studies have shown that absence from school is higher among African-American students and those students with lower family income (Berg et al. 1993). It is not clear however whether minorities and socioeconomic status were well represented in these studies.
Specific family factors have been linked with SRB. These include birth order, family size, marital problems and status, and parental psychopathology (Kearney 2000). In terms of birth order, several studies indicate that children with SRB tend to be the youngest in two-child families (Kearney 2000). For example, Ian Berg, Alan Butler, and Ralph McGuire (1972) found that 55 percent of their sample of 100 youth with SRB were either only or youngest children, and the average number of children in these families was 2.93. In terms of marital problems, Duane Ollendick (1979) reported that from a sample of 177 fourth-grade students, boys from single-parent families were absent from school significantly more than boys from two-parent families. In terms of parent psychopathology, Last and her colleagues (1987) found in their clinical school phobia sample that 57.1 percent of the mothers met DSM-III criteria for an anxiety disorder and 14.3 percent met criteria for an affective disorder. Kearney and Silverman (1995) provided a summary of the research literature relating to the family environments of children with SRB and concluded that five environments were most common: (1) enmeshed, (2) conflictive, (3) detached, (4) isolated, and (5) healthy. Kearney and Silverman (1995) also provided additional empirical support for these family environments based on the responses of sixty-four parents to the Family Environment Scale whose children (ages seven to sixteen years) displayed SRB.
Generally, all psychosocial treatment approaches stress the importance of getting the child back to school, and thus in parents taking an active approach in returning the child to school (Wicks-Nelson and Israel 1997). Controlled clinical trials provide empirical evidence for the efficacy of this approach. Nigel Blagg and William Yule (1984), in a study comparing behavioral treatment condition, in-patient condition, and home schooling-psychotherapy condition with sixty-six youths (ages eleven to sixteen years) with SRB, found that more youth in the behavioral treatment condition returned to school (93.3%) compared with youth in the in-patient (37.5%) and home schooling-psychotherapy groups (10%). Blagg and Yule concluded that behavior therapy produced rapid and successful outcomes for most of the cases. More recently, Neville King and his colleagues (1998) randomly assigned thirty-four children (mean age=11.0 years) with SRB to two groups: cognitive-behavioral treatment and a wait-list control condition. Results indicated that youth in the cognitive-behavioral treatment group improved significantly more with respect to school attendance, fear, anxiety, depression, general internalizing behavior, and global clinician ratings.
Two studies have compared exposure-based cognitive-behavioral treatment to an attention-placebo control condition. Specifically, Cynthia G. Last, Cheri Hansen, and Nathalie Franco (1998) assigned fifty-six youths (age six to seventeen years) with school phobia to one of two groups: cognitive-behavioral treatment and an education support condition that did not involve therapist prescription for child exposure to school stimuli. Although children in the cognitive-behavioral treatment showed significant improvement, including increased school attendance, children in the education support condition showed similar improvement. A similar pattern of findings was found by Silverman and her colleagues (1999) in a treatment study for child phobic disorders (n=104; age six to sixteen years), including SRB. In this study education support also was used and contained no therapist prescription for child exposure to phobic stimuli. The two experimental conditions were a behavioral condition (i.e., contingency management) and a cognitive condition (i.e., self-control). Although some exceptions were found, overall, on most of the main outcome measures, similar patterns of improvements were found across conditions, including the education-support condition. Taking the findings of Last and her colleagues and Silverman and her colleagues together, the implications are that further psychosocial intervention research is needed for use with children with SRB that moves beyond wait-list control design, and that focuses particularly on investigating mediators or mechanisms of change.
In addition to cognitive behavioral interventions, family-based psychosocial intervention approaches are widely used by practitioners, including structural, strategic, experiential, and behavioral (Kearney 2000). Unfortunately, we are not aware of randomized controlled trials that have investigated the efficacy of treating SRB using family-based psychosocial therapy.
Using Kearney and Silverman's (1993) functional motivational approach to SRB, described earlier, in which SRB is conceptualized as maintained by positive and/or negative reinforcement, Kearney and Silverman (1999) used single case study design methodology in which children and their parents were assigned to either prescriptive treatment, based on the functional motivational condition as measured by the School Refusal Assessment Scale (Kearney and Silverman 1993) or nonprescriptive treatment, not based on the functional motivational approach youth. For youth who refused school for the functional motivational condition relating to attention-getting behavior, for example, parent training in contingency management was used to establish clear parent commands, regular evening and morning routines, and consequences for compliance and noncompliance. In contrast, youth who were assigned a nonprescriptive treatment (i.e., received a treatment based on their lowest-rated functional condition), these children showed worsened percentage of time out of school and daily ratings of anxiety and depression. Prescriptive treatment immediately following the nonprescriptive treatment was found to be effective, however. In summary, there is a need for further psychosocial intervention research for children who display SRB. Of particular importance will be examining the role of family factors in terms of both development/maintenance of SRB as well as SRB's treatment.
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