Some scholars have outlined it as refusal to enter school or/and inability to maintain a full day at school with the knowledge of parents and school authorities, and staying at home during non-school hours. By definition SR includes: not attending school at all; leaving school in the middle of the school day; exhibiting behavioral manifestations of school avoidance, such as: persistent states of anxiety, tantrums when waking up in the morning, begging parents not to let him/her go to school, and experiencing somatization symptoms (headaches, abdominal pain, breathing difficulties, etc.). There are seven levels according to their severity.
(1) Threatening or begging not to go to school;
(2) Repeated avoidance of school in the morning;
(3) Repeatedly “cheating” in the morning and needing to be accompanied to school;
(4) Occasional non-attendance or absence from school;
(5) Repeatedly alternating between not attending school, missing school, or attending school;
(6) Complete absence from school for a period of time during a semester;
(7) Complete and prolonged absence from school. As the duration of non-attendance due to SR increases, it can eventually lead to drop out of school (drop out).
SR is characterized by parental knowledge, staying home during school hours and not attending school, feeling great pressure to attend school, and ineffective parental efforts to force the child to attend school, but the behavior is understandable and not antisocial. Truancy, on the other hand, is not going to school and hiding the fact that it is not going to school from parents. Truancy is clearly deceptive, with parents not fully aware of the problem, and is often accompanied by antisocial behaviors such as lying, stealing, and vandalism. Truancy is also not a psychiatric disorder under the DSM-IV classification, but it is associated with a diagnosis of conduct disorder.
Some scholars have suggested classifying SR into three subtypes: social phobia, specific phobia (school), and separation anxiety disorder according to DSM-IV diagnostic criteria. Separation anxiety disorder is a state in which the patient exhibits excessive anxiety incompatible with the developmental stage of the child when separated or about to be separated from the object of attachment (parent or primary caregiver). Social phobia is characterized by excessive fear and avoidance of social situations that may cause embarrassment, such as avoiding school because of excessive fear of performing badly at school (e.g., being teased by peers or criticized by teachers).
If the target of excessive fear is related to certain school settings (e.g., toilets, playgrounds, or classrooms), it is considered a specific phobia, and some scholars also refer to it as school phobia. In addition to the above three subtypes, a subset of patients with SR exhibit symptoms of major depression and meet the diagnostic criteria for major depressive disorder (MDD) or dysphoria (DD), which is considered another subtype of SR. It is worth noting that clinical findings often do not allow a single subtype to determine SR, and sometimes two or more subtypes may co-exist in the same patient, e.g., some patients with SR may have co-morbidities of depression and anxiety disorders.
Epidemiology and impact SR is a psychological disorder that seriously interferes with the learning and development of school-aged children and adolescents. The prevalence of SR is almost identical in boys and girls, with peak incidence at 6-7 and 10-12 years of age, and its prevalence is independent of the economic and social status of the patient.
Short-term effects of SR: disruption of mood and schooling, disruption of family or relationships with classmates or friends. Almost all children and adolescents with SR have one or more psychiatric or psychological disorders that meet DSM-IV or ICD-10 diagnostic criteria, which directly affect the individual and family, leading to decreased academic performance, social dysfunction, and disturbed family relationships.
Long-term effects of SR: It leads to educational and employment problems in youth and adulthood, and is also a high risk factor for developing mental illness later in life. Some scholars believe that SR is a precursor to severe anxiety in children and adolescents, and that anxiety in childhood is a precursor symptom to depression, suicide, agoraphobia and panic attacks in adults. Effective treatment of SR can help improve the future physical and mental health of patients, and a 7-year follow-up study found that effective treatment reduced the incidence of subsequent psychiatric and psychological disorders such as substance abuse and depression.
Studies have also found that approximately 31%-69% of SR have a co-morbid affective disorder (having two or more psychiatric or psychological disorders at the same time is called a co-morbidity or co-morbid disorder Comorbidity), with patients who have both co-morbid depression and anxiety disorders having poorer treatment outcomes than those with co-morbid anxiety disorders and are even more likely to go on to develop psychiatric or psychological disorders in adulthood.
Modes of functional impairment
SR, like other psychiatric and psychological disorders, can lead to impairment of the patient’s overall functioning (personal, social, and family functioning, etc.) The functional impairment of SR is often not singular but multifaceted, and an analysis of the mode of impairment can provide a basis for diagnosis and treatment. Some scholars have described four ways of functional impairment in SR as follows.
1. Avoidance of specific situations that cause them to fear and worry, such as facing teachers, fire, playgrounds, and schools, etc. These patients are diagnosed with specific phobias.
2. Avoidance of some social situations at school, such as contact with classmates with impulsive behavior, explaining to classmates or teachers the reasons for not attending school, and taking exams. These patients were diagnosed with social phobia.
3. Behaviors that attempt to seek solutions. Such as crying, “playing” or not wanting to move, exaggerated headache or abdominal pain asking to stay with parents, and not wanting to go to school. These patients are diagnosed with separation anxiety disorder.
4. Seeking positive stimuli, these patients believe that they do not go to school because there are things outside of school that make them happier, such as watching TV, watching video games, gambling, game addiction, internet addiction, and shopping sprees. It is easy to confuse this with truancy at this point and should be identified. Surveys have found that about 27% of people with SR admit that having better opportunities to engage in things of interest outside of school is the number one reason for SR, with emotional reasons coming in second at only 13%.
Treatment advances: Effective treatment of SR in childhood may provide an opportunity to prevent and manage the onset of serious mental and psychiatric disorders. Current international approaches to treating SR in children include both psychotherapy, and psychotherapy + medication.
Psychotherapy: Some commonly used time-consuming treatments such as psychodrama therapy, psychodynamic therapy, and systemic family therapy are under investigation, and their efficacy is currently unclear. Cognitive behavioral therapy (CBT) is a new psychotherapeutic approach, proposed by Beck et al. in the late 1970s and early 1980s, and has become a major psychological intervention for many psychiatric and psychological disorders such as anxiety and depression due to its scientific design and flexible treatment modalities, which have been proven effective by extensive clinical practice in the last decade.
Some experts who study school refusal recommend different treatment strategies in CBT for SR depending on its different modes of functional impairment and different types. If SR is related to a school setting that causes the patient to fear and worry, using relaxation training, grade-by-grade exposure, or imaginal desensitization with the patient can help with returning to school.
When patients with SR avoid social situations at school, behavioral rehearsal exposure and cognitive restructuring can be used with the goal of improving the patient’s social skills, reducing social anxiety, and/or changing distorted cognitions to help the patient attend school. When patients with SR cause concern and worry from others (e.g., parents), the use of family-based CBT can help the patient and parents establish treatment goals, manage the patient’s behavior through the parents, and encourage the patient to attend school.
For those SR patients who seek positive stimuli outside of school, family-based CBT can also be used to limit inappropriate behaviors through tutoring, while providing assertiveness training so that the patient learns to deal with conflict and stress at school, with the goal of returning to school.
Several randomized controlled studies have shown that CBT is effective in treating SR in children. one study found (n=34) that CBT was effective, using a variety of assessments including return to school, anxiety and depression self-assessments, which confirmed significantly better outcomes than the control group. Another study (n=61) found that all treatments were effective, with approximately 60% of SR patients returning to school after 20 weeks of treatment, with no significant difference in efficacy between treatment groups.
Combination therapy: No current studies have identified medications that can be used exclusively to treat SR, but studies have shown that combining CBT and pharmacotherapy may improve return rates and reduce relapse in SR patients.
In 2000 Bernstein found that the tricyclic antidepressant-promethazine increased the efficacy of CBT for SR. This led the authors to suggest that combination medications may improve the efficacy of CBT for SR, especially for those with co-morbid depression and SR in late adolescence. The reason for the former may be related to the fact that the medication can treat co-morbidities in SR patients. For the latter difference, the authors suggest that it may be related to endocrine-induced psychological changes during adolescence. Although Bernstein’s study showed that promethazine improved the efficiency of CBT for SR, however, tricyclic antidepressants have potential toxic side effects that limit their clinical use.
Fluoxetine, a 5-hydroxytryptamine reuptake receptor inhibitor (SSRIs), is currently the only antidepressant/anxiety drug officially approved by the FDA for use in children and adolescents, and can effectively treat anxiety and depression, as well as co-occurring disorders. Studies have shown fluoxetine to be effective in treating a variety of anxiety disorders related to SR in children and adolescents aged 6-17 years. An international multicenter study, the Childhood and Adolescent Depression Treatment Group, showed that fluoxetine + CBT was superior to fluoxetine alone or CBT alone for the treatment of depression in children and adolescents.
A total of 439 outpatients aged 12-17 years with depression were randomized to fluoxetine (10mg-40mg/day) alone, fluoxetine (10mg-40mg/day) + CBT, CBT alone, and placebo, and fluoxetine + CBT was found to be significantly better than fluoxetine alone and CBT alone, and fluoxetine alone was better than CBT alone. CBT alone, and all treatment groups had better outcomes than the placebo treatment group.
The efficacy rates as judged by the Comprehensive Clinical Impression Inventory (CGI) scores were 71% for fluoxetine + CBT, 61% for fluoxetine alone, 43% for CBT alone, and 35% for placebo. This study suggests that fluoxetine has the potential to increase the efficacy of CBT for depression associated with SR. Therefore, it is theoretically believed that the combination of fluoxetine and CBT is effective in treating SR, but further confirmation is needed in future clinical studies.
Summary: SR is a common psychological disorder that causes difficulties in school and school avoidance behaviors due to mood disorders, especially anxiety and depression, which severely interferes with the learning and growth of school-age children and adolescents and affects patients’ personal, social, and family functioning in different ways across the board, and it is also a high-risk factor for patients to develop psychiatric disorders later in life. Effective treatment of SR in school-aged children and adolescents may provide an opportunity to prevent and manage the onset of serious psychiatric and psychological disorders. There is evidence that CBT is effective in treating SR [10],and CBT + fluoxetine may increase the efficacy of CBT for SR, but further clinical confirmation in a large sample is needed.