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Practitioner Review: School Refusal: Issues of Conceptualisation, Assessment, and Treatment
Abstract
Developments in the assessment and treatment of school refusal have often been hampered by a failure to recognise its essentially heterogeneous nature. This paper provides a review of major conceptual complexities that have helped to undermine developments in clinical practice. In particular, it considers the distinction between school refusal and truancy, and school phobia and separation anxiety. Common approaches to the assessment and treatment of school refusal are outlined. Although behavioural and cognitive behavioural approaches are now widely accepted as central to treatment, it is increasingly recognised that individually tailored programmes, utilising a range of approaches, are most likely to prove successful. An approach focusing upon the functions, rather than the symptoms, of school refusal is advocated as having most promise for assessment and the subsequent formulation of individual prescriptive treatment.
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“The TR youth's preference for more appealing activities outside of school (Elliott, 1999;Havik et al., 2015a;Kearney, 2008c) may well stem from the lack of interest in schoolwork, which is likely associated with the educational difficulties frequently associated with TR.”
From Differentiation between school attendance problems: why and how? (2019) · cites this paper as Elliott, 1999
In the citing paper
“Defiance of school authority has been associated with TR (Elliott, 1999)”
From Differentiation between school attendance problems: why and how? (2019) · cites this paper as Elliott, 1999
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Esch, P., Bocquet, V., Pull, C. B., Couffignal, S., Lehnert, T., Graas, M., Fond‐Harmant, L., & Ansseau, M. (2014) · BMC Psychiatry · doi:10.1186/s12888-014-0237-4 · Cited by 426
Differentiation between school attendance problems: why and how?
Heyne, D., Gren-Landell, M., Melvin, G., & Gentle-Genitty, C. (2019) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2018.03.006 · Cited by 339
“Truants have been referred to as youth kept at home because of their benefit to parents (Berry & Lizardi, 1985; Elliott, 1999), even though this phenomenon had already been referred to as school withdrawal.”
BackgroundFamily therapy and systemic interventions for child‐focused problems: the current evidence base
Carr, A. (2018) · Journal of Family Therapy · doi:10.1111/1467-6427.12226 · Cited by 312
“Systematic reviews have concluded that behavioural family therapy leads to recovery for more than two-thirds of cases, and this improvement rate is significantly higher than that found for individual therapy (Elliott, 1999; Heyne et al. 2013; Kearney and Sheldon, 2017; King and Bernstein, 2001; King et al., 2000; Pina…”
ResultThe role of anxiety symptoms in school performance in a community sample of children and adolescents
Mazzone, L., Ducci, F., Scoto, M. C., Passaniti, E., D'Arrigo, V. G., & Vitiello, B. (2007) · BMC Public Health · doi:10.1186/1471-2458-7-347 · Cited by 245
School factors associated with school refusal- and truancy-related reasons for school non-attendance
Havik, T., Bru, E., & Ertesvåg, S. K. (2015) · Social Psychology of Education · doi:10.1007/s11218-015-9293-y · Cited by 319
“2013), whereas truancy is believed to be related to anti-school sentiments and antisocial characteristics such as finding school boring and seeking more rewarding activities outside school (Reid 2012; Fremont 2003; Kearney 2008b; Kearney and Silverman 1993; Elliott 1999).”
BackgroundThe effectiveness of family therapy and systemic interventions for child‐focused problems
Carr, A. (2008) · Journal of Family Therapy · doi:10.1111/j.1467-6427.2008.00451.x · Cited by 251
“Systematic reviews have concluded that behavioural family therapy leads to recovery for more than two-thirds of cases, and this improvement rate is significantly higher than that found for individual therapy (Elliott, 1999; Heyne and King, 2004; King and Bernstein, 2001; King et al., 2000b).”
ResultCharacteristics of adolescents with school refusal
Mcshane, G., Walter, G., & Rey, J. M. (2001) · Australian & New Zealand Journal of Psychiatry · doi:10.1046/j.1440-1614.2001.00955.x · Cited by 199
“Today, school refusal is viewed as a symptom associated mainly with anxiety disorders in children and with anxiety and depressive disorders in adolescents [2].”
BackgroundThe evidence base for family therapy and systemic interventions for child‐focused problems
Carr, A. (2014) · Journal of Family Therapy · doi:10.1111/1467-6427.12032 · Cited by 215
“…have concluded that behavioural family therapy leads to recovery for more than two-thirds of patients and this improvement rate is significantly higher than that found for individual therapy (Elliott, 1999; Heyne and Sauter 2013; King and Bernstein, 2001; King et al., 2000; Pina et al., 2009).”
ResultPractitioner Review: School refusal: developments in conceptualisation and treatment since 2000
Elliott, J. G., & Place, M. (2019) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12848 · Cited by 162
“Many treatment approaches incorporate a focus upon contextual factors in both the home and in school that may increase or alleviate anxiety (see Elliott, 1999, p. 1007–1008, for an outline of important issues that school personnel should consider tackling school refusal).”
BackgroundInfluentialSelf-citationIntegrating positive psychology into schools: Implications for practice
Terjesen, M. D., Jacofsky, M. D., Froh, J. J., & Digiuseppe, R. A. (2003) · Psychology in the Schools · doi:10.1002/pits.10148 · Cited by 180
Assessing Reasons for School Non-attendance
Havik, T., Bru, E., & Ertesvåg, S. K. (2015) · Scandinavian Journal of Educational Research · doi:10.1080/00313831.2014.904424 · Cited by 145
“…refusal can affect students at any age, but in times of transition (e.g., from primary to secondary school) school non-attendance is more likely (Berg, 1997; Elliott, 1999; Fremont, 2003; King, Heyne, Tonge, Gullone, & Ollendick, 2001; Knollmann, Knoll, Reissner, Metzelaars, & Hebebrand, 2010).”
BackgroundTreatment for School Refusal Among Children and Adolescents
Maynard, B. R., Heyne, D., Brendel, K. E., Bulanda, J. J., Thompson, A., & Pigott, T. D. (2018) · Research on Social Work Practice · doi:10.1177/1049731515598619 · Cited by 135
“Prior narrative reviews have described positive effects of cognitive and/or behavioral treatments for school refusal (Elliott, 1999; King & Bern-stein, 2001; King, Tonge, Heyne, & Ollendick, 2000), but the current review represents a rigorous extension of existing work.”
Current status of research on school refusal
Inglés, C. J., Gonzálvez-Maciá, C., García-Fernández, J. M., Vicent, M., & Martínez-Monteagudo, M. C. (2015) · European Journal of Education and Psychology · doi:10.1016/j.ejeps.2015.10.005 · Cited by 123
DSM-IV–Defined Anxiety Disorder Symptoms in South African Children
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Parental perspectives of the role of school factors in school refusal
Havik, T., Bru, E., & Ertesvåg, S. K. (2013) · Emotional and Behavioural Difficulties · doi:10.1080/13632752.2013.816199 · Cited by 166
“Others distinguish between SR and truancy because of the different characteristics of these phenomena (e.g. Berg 1997; Elliott 1999; Fremont 2003; Hersov 1990; McShane, Walter, and Rey 2001; Place, Taylor, and Davis 2000; Shilvock 2010; Smith 2011).”
BackgroundSchool non-attendance: definitions, meanings, responses, interventions
Pellegrini, D. W. (2007) · Educational Psychology in Practice · doi:10.1080/02667360601154691 · Cited by 103
“Conversely, gradual exposure is built over time to allow a smooth process of desensitisation, but it is important to control positive reinforcement in the home environment, to make it less attractive to the child, while making school attendance more attractive (Elliott, 1999).”
BackgroundInfluentialThe correlates and consequences of early appearing social anxiety in young children
Weeks, M., Coplan, R. J., & Kingsbury, A. (2009) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2009.06.006 · Cited by 97
Responding to Chronic Non-attendance: A review of intervention approaches
Lauchlan, F. (2003) · Educational Psychology in Practice · doi:10.1080/02667360303236 · Cited by 86
“A number of controlled investigations that used medication found that those pupils (labelled ‘school refusers’) who received drugs were no better off at the end of intervention than a ‘placebo’ group of ‘school refusers’ (Elliott, 1999).”
BackgroundWilkins, J. (2008) · The High School journal/The High school journal · doi:10.1353/hsj.2008.0005 · Cited by 88
“…and labeling of different categories of students with behavior most commonly referred to as “school refusal” (Bernstein & Garfinkel, 1986; Elliott, 1999; Granell de Aldaz, et al., 1994; Kearney, Eisen, & Silverman, 1995; Last, et al., 1987; Ollendick & Francis, 1988; Paige, 1996;…”
BackgroundThe Effect of Pupil Absenteeism on Literacy and Numeracy in the Primary School
Carroll, H. C. M. (2010) · School Psychology International · doi:10.1177/0143034310361674 · Cited by 79
“It is confusing because, as revealed to varying extents in valuable reviews by Berg (1992), Elliott (1999), Kearney (2003), King and Bernstein (2001), Lauchlan (2003) and Lyon and Cotler (2007), for both truancy and school phobia/refusal there is limited agreement about terminology, identification,…”
BackgroundBirioukov, A. (2016) · Educational Review · doi:10.1080/00131911.2015.1090400 · Cited by 69
“Many of these variables can accumulate, where a pupil perceives the school as a hostile environment, thereby choosing to avoid the institution (Elliott 1999; Evans 2000).”
BackgroundEffective intervention for school refusal behaviour
Nuttall, C., & Woods, K. A. (2013) · Educational Psychology in Practice · doi:10.1080/02667363.2013.846848 · Cited by 97
“These symptoms may be present in a morning before it is time to leave for school, but may disappear if a child is permitted to stay at home (Elliott, 1999; Kearney, 2002).”
BackgroundIndicated Truancy Interventions: Effects on School Attendance among Chronic Truant Students
Maynard, B. R., McCrea, K. T., Pigott, T., & Kelly, M. S. (2012) · Campbell Systematic Reviews · doi:10.4073/csr.2012.10 · Cited by 65
Comorbidity in attention deficit–hyperactivity disorder
Ishii, T., Takahashi, O., Kawamura, Y., & Ohta, T. (2003) · Psychiatry and Clinical Neurosciences · doi:10.1046/j.1440-1819.2003.01148.x · Cited by 62
Maynard, B. R., Brendel, K. E., Bulanda, J. J., Heyne, D. A., Thompson, A. M., & Pigott, T. (2015) · Campbell Systematic Reviews · doi:10.4073/csr.2015.12 · Cited by 72
“…describe positive effects of cognitive and/or behavioral interventions for school refusal, many also point to mixed results and the overall lack of evidence for any one treatment modality (Elliot, 1999; King & Bernstein, 2001; King et al., 2000), which is consistent with the results of this review.”
ResultFunctional outcome of adolescents with ‘school refusal’
Mcshane, G., Walter, G., & Rey, J. M. (2004) · Clinical Child Psychology and Psychiatry · doi:10.1177/1359104504039172 · Cited by 61
“K E Y WO R D S anxiety disorders, depressive disorders, outcome, school refusal ‘ S C H O O L R E F U S A L’ IS a problem affecting approximately 1–2% of school-aged children and 5% of clinic-referred children and adolescents (Elliott, 1999; King, Ollendick, & Tongue, 1995).”
BackgroundKeppens, G., Spruyt, B., & Dockx, J. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.02623 · Cited by 72
Youth mental ill health and secondary school completion in Australia: time to act
Bowman, S., McKinstry, C., & McGorry, P. D. (2016) · Early Intervention in Psychiatry · doi:10.1111/eip.12357 · Cited by 63
Outcome of children with school refusal
Prabhuswamy, M., Srinath, S., Girimaji, S. C., & Seshadri, S. P. (2007) · The Indian Journal of Pediatrics · doi:10.1007/s12098-007-0063-5 · Cited by 54
Psychopathologie de l'adolescent
Braconnier, A. (2012) · Elsevier eBooks · doi:10.1016/b978-2-294-71157-2.00020-0 · Cited by 49
Gren‐Landell, M., Allvin, C. E., Bradley, M. R., Andersson, M., & Andersson, G. (2015) · Educational Psychology in Practice · doi:10.1080/02667363.2015.1086726 · Cited by 52
“Somatic complaints such as headache and abdominal pain as well as chronic illness are also commonly reported in children with school absenteeism (Elliott, 1999; Breuner, Smith, & Womack, 2004; Thornton, Darmody, & McCoy, 2013).”
BackgroundSeparation Anxiety Disorder, Panic Disorder, and School Refusal
Suveg, C. M., Aschenbrand, S. G., & Kendall, P. C. (2005) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2005.05.005 · Cited by 57
Out of school: a phenomenological exploration of extended non-attendance
Baker, M., & Bishop, F. L. (2015) · Educational Psychology in Practice · doi:10.1080/02667363.2015.1065473 · Cited by 46
“Estimates in the UK literature suggest that 1 to 2% of the school-age population is affected, with higher prevalence among secondary school pupils (Elliot, 1999; *Corresponding author.”
BackgroundHeyne, D. A., & King, N. J. (2004) · Wiley eBooks · doi:10.1002/9780470753385.ch11 · Cited by 46
Multi-Systemic Intervention for School Refusal Behavior: Integrating Approaches across Disciplines
Lyon, A. R., & Cotler, S. (2009) · Advances in School Mental Health Promotion · doi:10.1080/1754730x.2009.9715695 · Cited by 50
Doobay, A. F. (2008) · Psychology in the Schools · doi:10.1002/pits.20299 · Cited by 38
The coping mechanisms of children with school refusal
Place, M., Hulsmeier, J., Davis, S., & Taylor, E. (2002) · Journal of Research in Special Educational Needs · doi:10.1111/j.1471-3802.2002.00167.x · Cited by 35
Extended school non-attenders’ views: developing best practice
Gregory, I. R., & Purcell, A. (2014) · Educational Psychology in Practice · doi:10.1080/02667363.2013.869489 · Cited by 34
“Labels of, for example, “school refuser”, “school phobic” have been identified as obstacles in gaining a shared understanding of this behaviour (Elliott, 1999).”
BackgroundHolzer, L., & Halfon, O. (2006) · Archives de Pédiatrie · doi:10.1016/j.arcped.2006.05.010 · Cited by 31
Development of School Attendance Difficulties: An Exploratory Study
Sheppard, A. (2005) · Pastoral Care in Education · doi:10.1111/j.1468-0122.2005.00338.x · Cited by 35
“As attendance problems have multiple causes (Hallam, 1996; Corville-Smith, Ryan, Adams and Dalcandro, 1998; Elliot, 1999), any correlation between truancy and crime is not straightforward.”
BackgroundNair, M. K. C., Russell, P. S. S., Subramaniam, V. S., Nazeema, S., Chembagam, N., Russell, S., Shankar, S. R., Jakati, P. K., & Charles, H. S. (2013) · The Indian Journal of Pediatrics · doi:10.1007/s12098-013-1208-3 · Cited by 28
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Schulabsentismus: Entwicklungen und fortbestehende Herausforderungen
Lenzen, C., Brunner, R. M., & Resch, F. (2016) · Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie · doi:10.1024/1422-4917/a000405 · Cited by 25
Tyrrell, M. (2005) · The Journal of School Nursing · doi:10.1177/10598405050210030401 · Cited by 25
“dynamic, cognitive, or pharmacological approaches individually or in combination (Elliott, 1999).”
BackgroundInfluentialCharacteristics and outcomes of school refusal in Hiroshima, Japan: proposals for network therapy.
Nishida, A., Sugiyama, S., Aoki, S., & Kuroda, S. (2004) · PubMed · doi:10.18926/amo/32103 · Cited by 25
Emotionally Based School Avoidance (EBSA): Students’ Views of What Works in a Specialist Setting
Halligan, C., & Cryer, S. (2022) · Continuity in Education · doi:10.5334/cie.38 · Cited by 24
Emotionally based school non-attendance: two successful returns to school following lockdown
Corcoran, S., Bond, C., & Knox, L. H. (2022) · Educational Psychology in Practice · doi:10.1080/02667363.2022.2033958 · Cited by 23
Assessment of Risk Factors for Truancy of Children in Grades K-12 Using Survival Analysis.
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“Separation anxiety symptoms (SAS) have received the most attention by clinicians and educators among different anxiety symptoms related to school refusal (Elliott, 1999; Heyne et al., 2001) because SAS has been considered the most important reason for school refusal.”
BackgroundTo go or not to go: School refusal and its clinical correlates
Prabhuswamy, M. (2018) · Journal of Paediatrics and Child Health · doi:10.1111/jpc.14198 · Cited by 19
Behind the SCREEN: identifying school refusal themes and sub-themes
Gallé-Tessonneau, M., & Heyne, D. (2020) · Emotional and Behavioral Difficulties · doi:10.1080/13632752.2020.1733309 · Cited by 14
“Early identification of SR is essential, because a positive prognosis depends on early clinical care (Elliott 1999; Fremont 2003; McAnanly 1986; Okuyama, Okada, Kuribayashi, and Kaneko 1999).”
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Jans, T., & Warnke, A. (2004) · Monatsschrift Kinderheilkunde · doi:10.1007/s00112-004-1049-2 · Cited by 16
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Serious Game Design to Support Children Struggling with School Refusal
Høiseth, M., Alsos, O. A., Holme, S., Ek, S., & Gabrielsen, C. T. (2021) · International Journal of Serious Games · doi:10.17083/ijsg.v8i2.416 · Cited by 11
Pupil absenteeism and the educational psychologist
Carroll, H. C. M. (2014) · Educational Studies · doi:10.1080/03055698.2014.955731 · Cited by 18
“Post-1957 other writers, e.g. Hersov (1960), Elliott (1999) and Thambirajah, Grandison, and De-Hayes (2008), have preferred the term school refusal to school phobia or separation anxiety whilst others, e.g. Berg (1980), have used the terms school phobia and school refusal interchangeably.”
BackgroundShilvock, G. G. (2010) · University of Birmingham Institutional Research Archive (University of Birmingham) · Cited by 10
Chian, J., Holliman, A., Pinto, C., & Waldeck, D. (2024) · Educational and Child Psychology · doi:10.53841/bpsecp.2024.41.1.55 · Cited by 10
Approaches to improving school attendance: Insights from australian principals.
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“Student perceptions of an irrelevant curriculum have also been found to contribute to absenteeism (Corville-Smith, Ryan, Adams, & Dalicandro, 1998; Elliott, 1999).”
BackgroundSharpe, J., Bunting, B. P., & Heary, C. (2023) · School Mental Health · doi:10.1007/s12310-023-09610-0 · Cited by 12
“…knowledge, that is generally related to poor motivation or a negative attitude towards school and is more commonly associated with mental health symptoms relating to behavioural difficulties such as inattention and conduct disorders (Elliott, 1999; Heyne et al., 2019; Knollmann et al., 2010).”
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Treatment of school refusal in an adolescent with comorbid anxiety and chronic medical illness
Rohrig, S. N., & Puliafico, A. C. (2018) · Evidence-Based Practice in Child and Adolescent Mental Health · doi:10.1080/23794925.2018.1447855 · Cited by 7
“, exams, teachers) are more prevalent in adolescents (Elliott, 1999; McShane, Walter, & Rey, 2001).”
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“…researchers have differentiated school refusal from truancy in terms of two other features: children who exhibit school refusal behavior remain at home with their parents’ knowledge, and they do not exhibit characteristics of conduct disorder (Elliot, 1999; Heyne, King, Tonge, & Cooper, 2001).”
BackgroundAnxiety-reducing strategies in the classroom
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“Development and maintenance of a problem like school refusal typically involve heterogeneous risk factors and processes [1,15,18].”
BackgroundAn unusual cause of school refusal
Meenai, Z. M., Sarkar, N., & Biswas, R. (2011) · BMJ Case Reports · doi:10.1136/bcr.10.2011.4902 · Cited by 2
Can improving the “academic buoyancy” of secondary school students improve their school attendance?
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“Each reflects dominant disciplinary paradigms and embeds assumptions that shape how children’s absences are interpreted and acted upon in educational, psychological, and policy contexts (Elliott 1999; Thambirajah, Grandison, and De-Hayes 2008).”
A scoping review of the research on school absences and return to school
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“…personal traits, temperament, mental health, and past experiences, have all been documented to relate to adolescents’ inclination toward school-related behaviors (Elliott 1999; Hassen and Beyene 2020; Havik et al. 2015b; Li et al. 2012a; Meng et al. 2012; Moonie et al. 2008; Parent et al. 2009).”
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Secondary school attendance : the role of the form tutor : an autobiographical inquiry
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Functional outcomes in school refusal
Bonavitacola, L. (2015) · doi:10.7282/t3nk3h06
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Skolevegring: foreldre til skolevegrere og deres opplevelser med skolen
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Robbed of Academic Freedom – Imposition of a Coercive Attendance Policy on Students
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Listening to the stories of parents whose children have experienced school non-attendance
Burrows, H. M. (2020) · White Rose eTheses Online (University of Leeds, The University of Sheffield, University of York)
Metadata
- Authors
- Elliott, J. G.
- Affiliations
- University of Sunderland (GB)
- Corresponding author
- Elliott, Julian G.
- Venue
- Journal of Child Psychology and Psychiatry
- Publisher
- Wiley
- Published
- 1999-10
- Volume
- 40
- Issue
- 7
- Pages
- 1001-1012
- ISSN
- 0021-9630 (ISSN-L)
- 1469-7610
- OpenAlex
- W2144495956
- Cited by
- 128
- References
- 0
- Citations by year
- 2026: 6 · 2025: 3 · 2024: 5 · 2023: 7 · 2022: 3 · 2021: 2 · 2020: 6 · 2019: 4 · 2018: 7 · 2017: 2 · 2016: 2 · 2015: 11 · 2014: 9 · 2013: 9 · 2012: 5
- FWCI
- 12.01
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Child Psychology and Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Education › Youth Substance Use and School Attendance
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › School Health and Nursing Education
- Keywords
- school refusal, truancy, school anxiety, separation anxiety, conceptualization, assessment, treatment, cognitive behavioral therapy, behavioral approach, personalized treatment
- MeSH terms
- Adolescent, Anxiety Disorders, Behavior Therapy, Child, Female, Humans, Male, Phobic Disorders, Student Dropouts, Cognitive Behavioral Therapy
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