Modifiable Parent Factors Associated with Child and Adolescent School Refusal: A Systematic Review

Cognitive Behavioral Interventions for School Attendance Problems: A Systematic Review and Meta-analysis

This pre-registered (#CRD42024509947) systematic review synthesized evidence on cognitive behavioral interventions (CBTs) for youths with school attendance problems (SAPs). The PsycINFO, PubMed, ERIC, and Scopus databases were searched through 1985-2024 for randomized controlled trials (RCTs), non-RCTs, and open trials (OTs) evaluating SAP-focused CBT. Data were synthesized narratively and through meta-analysis. Four RCTs and eleven OTs met eligibility criteria, including 932 youths. Meta-analyses revealed small to large uncontrolled pre- to post-intervention effects for school attendance (g = 1.02), anxiety (g = - 0.57), depression (g = - 0.66), and behavioral problems (g = - 0.40), which were maintained at follow-up. When compared to a control, CBT had a medium effect on school attendance (g = 0.44) but non-significant effects on anxiety (g = - 0.09) and depression (g = - 0.14). While the results hold promise for SAP-focused CBTs, evidence was limited by study heterogeneity, bias risks, methodological limitations, and inconsistent outcome measures, highlighting the needed for further RCTs.

Roll call: Why the child and adolescent mental health sector must be present for severe school refusal

School refusal can be a complex and intractable transdiagnostic syndrome that derails psychosocial development and jeopardises the successful transition to adulthood. Amid a global youth mental health crisis and in the aftermath of the COVID-19 pandemic, school refusal rates appear to have surged, prompting calls for urgent action. With a focus on severe forms of school refusal, we present an agenda for how the child and adolescent mental health sector can support the education sector in answering this call. We first identify three core challenges that must be tackled: (1) the need for clearer distinctions between mild and severe forms of school refusal to support classification, research, and intervention planning; (2) the treatment gap, which leaves many young people without timely or appropriate care; and (3) the absence of an evidence base to guide interventions for treatment non-responders. Then, for each challenge, we identify potential solutions, namely: (1) developing clinical staging frameworks to enhance conceptual clarity and support targeted research; (2) exploring outreach models of care to improve treatment access and engagement; and (3) devising robust methodologies for evaluating intensive Tier-4 interventions to strengthen the evidence base for treatment non-responders. Just as a roll call ensures that every individual is accounted for, this paper calls on the child and adolescent mental health sector to be fully present in addressing severe school refusal. By strengthening collaboration between clinical practice, education systems, and researchers, the field can move towards more effective, integrated, and scalable solutions that better meet the needs of these students and their families.

Intervention for School Anxiety and Absenteeism in Children (ISAAC): Mixed-Method Feasibility Study of a Coach-Assisted, Parent-Focused Online Program

The aftermath of the Covid-19 pandemic has seen an increase in persistent school absenteeism and Emotionally-Based School Avoidance (EBSA). However, suitable evidence-based psychological interventions are often unavailable. We aimed to assess the feasibility and acceptability of a new parent-focused online program, Intervention for School Anxiety and Absenteeism in Children (ISAAC), which has been co-designed with parents and practitioners. This exploratory mixed-method study recruited participants from three schools in southern England, enrolling N = 9 parents for whom a child, aged 5-11 years, was experiencing signs of EBSA. The intervention consisted of three web-based psychoeducational modules respectively addressing parental stress, accommodating parenting behaviors, and communication with school staff. Module completion was assisted by weekly calls with a non-specialist "coach." Feasibility was measured using indicators of retention, module participation, overall program completion and coaching fidelity. Acceptability was assessed using semi-structured interviews, module ratings and written qualitative feedback. We also explored baseline-post change in parent-reported measures of children's school avoidance, absences, anxiety, parental stress, accommodating parenting behaviors, and quality of parent-school communication. Overall, the intervention was feasible to deliver to parents with six (67%) participants completing the full intervention. Participants found the intervention acceptable across thematic domains of affective attitude, burden, coherence, self-efficacy and perceived effectiveness. Participants particularly appreciated the coach's support. We observed small to moderate reductions in school avoidance behaviours (d with Hedges correction = 0.36), child anxiety (d with Hedges correction = 0.33) and accommodating behaviours (d with Hedges correction = 0.44) at the post timepoint compared to baseline. In conclusion, ISAAC shows early promise with the potential to deliver scalable online support for families affected by emerging EBSA. Future research should move toward establishing effectiveness in a randomized controlled trial.

School refusal: Considerations for the primary care NP

ABSTRACT

School refusal refers to child- or adolescent-motivated refusal to attend school or remain in school for the duration of the school day. Importantly, the child or adolescent does not conceal their absence from school from their caregivers. Root causes for school refusal include anxiety, mood disorders, untreated learning disorders, and social difficulties. Long-term outcomes of school refusal include further social withdrawal, ongoing mental health issues, and unemployment. This article reviews the differences between school refusal and other types of chronic absenteeism, and it describes behaviors that may manifest in a child or adolescent who avoids attending school. The primary care provider's role in evaluation and treatment of this population is discussed.

Adapting a coach-assisted web-based intervention for parents of adolescents who refuse school: qualitative study with users of the Partners in Parenting Plus programme

BACKGROUND

School refusal is a heterogenous problem which typically emerges in adolescence and co-occurs with internalising disorders. A substantial proportion of adolescents do not respond to existing treatment modalities; thus, novel, effective intervention options are needed. Partners in Parenting Plus (PiP+) is a coach-assisted, web-based intervention designed to empower parents to respond to adolescent internalising disorders.

AIMS

To conduct a process evaluation of PiP+ and identify programme adaptations required to meet the needs of parents of adolescents who refuse school.

METHOD

Semi-structured interviews were conducted with 14 Australian mothers who had: (a) received the PiP+ programme (not tailored for school refusal) during a prior research trial; and (b) reported that their adolescent was refusing school during their participation in PiP+. Inductive thematic analysis was used to analyse interview transcripts.

RESULTS

Participants were 41-53 years old (M = 47.8) and parenting adolescent children aged 14-17 years (M = 14.9). Three themes illustrated how PiP+ features met or could better meet the needs of parents of adolescents who were refusing school: (a) feeling heard, supported and respected; (b) relevance to me and my context; and (c) seeing positive changes. Participants had favourable views of PiP+, especially coached components. Participants requested programme enhancements to better meet the needs of parents of neurodiverse adolescents and discussed the impact of cumulative help-seeking 'failures' on self-efficacy and locus of control.

CONCLUSIONS

PiP+ was highly acceptable to the majority of parents navigating the issue of school refusal. This has implications for the enhancement of coach-assisted parenting interventions and the context-specific adaptation of PiP+ for school refusal.

Chinese clients' experiences throughout family therapy for school-refusing adolescents: A multiperspectival interpretative phenomenological analysis

OBJECTIVE

This study aimed to explore Chinese clients' experiences with family dynamic change throughout family therapy for school refusal and the interventions adolescents and their parents identified as useful during family therapy.

METHODS

A multiperspective interpretative phenomenology analysis (IPA) was adopted. Thirty-two participants from 11 Chinese families with school-refusing adolescents were recruited after completing family therapy at the hospitals. Semistructured interviews were conducted with the families, and the transcripts were analyzed.

RESULTS

Four main superordinate themes emerged: reshaping healthy family boundaries, building a harmonious family atmosphere, learning to cooperate and fight against stress, and achieving individual growth.

CONCLUSION

Our analysis suggested that changes in school-refusing adolescents through family therapy consisted of multilevel factors. These factors influence the reversal of adolescents' school refusal. Some targeted interventions for Chinese adolescents who refuse school are discussed and suggested.

Psychological characteristics and emotional difficulties underlying school refusal in adolescents using functional near-infrared spectroscopy

BACKGROUND

This study aims to explore the psychological characteristics, related emotional problems and potential NIR brain function mechanism of adolescents who refuse to attend school.

METHODS

The study included 38 adolescents (12-18 years old) who were not attending school and 35 healthy controls (12-18 years old) who are attending school regularly. Participants completed (1) general demographics, (2) Eysenck Personality Questionnaire (EPQ), (3) Zung Self-Rating Depression Scale (SDS), (4) Zung Self-Rating Anxiety Scale (SAS), and (5) Symptom Checklist-90 (SCL-90). In addition to the clinical tests, participants completed functional near-infrared spectroscopy (fNIRS). Mental health, personality, and emotional state were evaluated in both groups to explore the differences and to understand the underlying mechanisms of school refusal during adolescence.

RESULTS

Adolescents who did not attend school had higher neuroticism scores on the Eysenck Personality Questionnaire than healthy controls (p(FDR) < 0.001), introversion and concealment scores were lower than those of healthy controls (p(FDR) < 0.001), there was no significant difference in psychoticism scores between groups. SDS, SAS, SCL-90 scores and factor scores were higher than those of healthy control group (p(FDR) < 0.001), NIR functional brain imaging was different from healthy control group in the 12 and 27 channels (p(FDR) = 0.030, p(FDR) = 0.018), and no difference was found in the remaining channels (p(FDR) > 0.05). There were statistically significant differences in age and gender between the adolescents who refused school and the control group (p(FDR) < 0.001).

CONCLUSION

School refusal adolescents are relatively introverted and sensitive and need more attention in daily life. Although the adolescents' emotional problems did not reach the diagnostic criteria of depressive disorder and anxiety disorder, their scores were still higher than those of the control group, suggesting that we should pay more attention to their emotional problems in order to better help them return to school. Using fNIRS, it was found that abnormalities in frontal lobe regions in adolescents with school refusal behaviors, which would contribute to early diagnosis and timely intervention of school refusal behaviors.

Children and Adolescents with Severe Tyrannical Behaviour: Profile of Youth and Their Parents

This study focused on a subtype of child-to-parent violence, severe tyrannical behaviour (STB). The aim was to examine the clinical characteristics of children and adolescents who physically and/or verbally abuse their parents and the sociodemographic characteristics and generalities of those families. Clinical and sociodemographic data from 73 children and adolescents with STB and their parents have been collected from a randomized control trial. Results showed a specific profile of youth with tyrannical behaviour (aggressive behaviour only in-home settings, only-child, previously mental health care), as well as differential characteristics of these families (late parenthood, high socio-economic status and conjugal family). Children with tyrannical behaviour frequently had psychiatric conditions, such as attention deficit hyperactivity disorder, separation anxiety, sleeping disorders and severe irritability was frequently described. These clinical patterns of combined neurodevelopmental, externalized and internalized symptoms suggest that the combination of individual characteristics, parenting style and parent-child relationship play essential roles in children's STB development.

Practitioner Review: Signposts for Enhancing Cognitive-Behavioral Therapy for School Refusal in Adolescence

Factors associated with adolescent development influence the occurrence and presentation of school refusal (SR). Cognitive-behavioral therapy (CBT) manuals for the treatment of SR account for these developmental issues to varying degrees. Some multimodal treatments aim to address the complexity of adolescent SR by incorporating interventions alongside CBT, such as medication, inpatient treatment, and educational support in a special setting. However, CBT manuals and multimodal treatments appear to fail to help approximately one-third to two-thirds of adolescents, with respect to achieving regular school attendance. This paper provides an overview of suggestions in the literature for improving treatment for SR, with a focus on adolescent SR. Seven signposts emerge from the literature, namely, increased number or frequency of sessions, greater attention to social anxiety disorder and social functioning, greater attention to depression, greater attention to emotion regulation, careful consideration of the role of parents, greater attention to parent-adolescent communication and problem-solving, and the use of alternative educational settings. Professionals may find these signposts helpful when planning and delivering treatment for SR in adolescents. Research is needed to determine the benefit of including one or more of these adaptations alongside an existing SR treatment.

Developmental Issues Associated with Adolescent School Refusal and Cognitive-Behavioral Therapy Manuals

It is important to consider developmental issues when addressing school refusal (SR) in adolescence. Referral rates appear to be higher among adolescents relative to children, and treatment appears to be less effective among adolescents. This paper provides an in-depth review of developmental issues associated with adolescent SR and treatment via cognitive-behavioral therapy (CBT). It begins by considering the reasons for the higher referral and poorer treatment outcomes, including the higher level of absenteeism in adolescence, higher rates of concurrent social anxiety disorder and depressive disorder, and the developmental challenges inherent to adolescence. Such challenges include increased academic and social demands in the secondary-school environment, and increasing autonomy which may contribute to family conflict. These developmental issues may potentiate and exacerbate an adolescent's difficulty attending school, make it difficult for families to cope, and complicate practitioners' efforts to provide effective treatment for SR. Further, the review describes CBT manuals for SR and the extent to which they are developmentally sensitive. There are five CBT manuals, which vary in their sensitivity to developmental issues. Various multimodal treatments employ interventions in addition to CBT, such as medication or inpatient treatment, to address the complexity of SR in adolescence. Nevertheless, nonresponse to treatment for adolescent SR ranges from one-third to two-thirds of youths. Attention thus needs to be given to ways of improving treatment outcomes.