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Clinical Psychology Review 28 (2008) 451 – 471

School absenteeism and school refusal behavior in youth:

A contemporary review
Christopher A. Kearney ⁎
Department of Psychology, University of Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas, NV 89154-5030, United States
Received 6 April 2007; received in revised form 13 July 2007; accepted 26 July 2007

Abstract

Absenteeism from school is a serious public health issue for mental health professionals, physicians, and educators. The
prevalence of unexcused absences from school exceeds that of major childhood behavior disorders and is a key risk factor for
violence, injury, substance use, psychiatric disorders, and economic deprivation. This article involves a contemporary research
review on absenteeism prevalence, comorbid physical and psychiatric conditions, classification, contextual risk factors, cross-
cultural variables, assessment, intervention, and outcome. Contextual risk factors include homelessness and poverty, teenage
pregnancy, school violence and victimization, school climate and connectedness, parental involvement, and family variables,
among others. A description of intervention includes medical, clinical, and systemic interventions. Medical professionals,
community- and school-based mental health professionals, and educators are encouraged to fully understand the parameters of
school absenteeism to develop better, consensual policies regarding definition, classification, assessment, and intervention of
youths with problematic school absenteeism.
© 2007 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
2. Key concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
3. Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
4. Physical conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
5. Psychiatric conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
6. Classification and proximal variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
7. Contextual risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
7.1. Homelessness and poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
7.2. Teenage pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
7.3. School violence and victimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
7.4. School climate and connectedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
7.5. Parental involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
7.6. Family and community variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460

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doi:10.1016/j.cpr.2007.07.012
452 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471

8. Cross-cultural variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461

9. Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
10. Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
10.1. Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
10.2. Clinical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
10.3. Systemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
11. Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
12. Final comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465

1. Introduction

Absenteeism from school is a serious mental and physical health concern for many children and adolescents.
Absenteeism or placement in alternative educational settings, usually for absenteeism, is a key risk factor for suicide
attempt, perilous sexual behavior, teenage pregnancy, violence, unintentional injury, driving under the influence of
alcohol, and alcohol, marijuana, tobacco, and other substance use (Almeida, Aquino, & de Barros, 2006; Chou, Ho,
Chen, & Chen, 2006; Denny, Clark, & Watson, 2003; Grunbaum et al., 2004; Guttmacher, Weitzman, Kapadia, &
Weinberg, 2002; Hallfors et al., 2002; Henry & Huizinga, 2007). Chronic absenteeism is often associated as well with
school dropout, an event that leads to immediate disconnection from school-based health and mental health programs,
economic deprivation, and marital, social, and psychiatric problems in adulthood (Kogan, Luo, Murry, & Brody, 2005;
Tramontina et al., 2001; US Census Bureau, 2005).
Absenteeism from school may also result from physical and psychiatric problems. As discussed later, absenteeism is
intricately linked to myriad medical conditions, especially asthma. In fact, some have suggested that absenteeism rates
may be a useful barometer of disease outbreaks (Besculides, Heffernan, Mostashari, & Weiss, 2005). Psychiatric
conditions related to extensive school absences primarily include anxiety, depressive, and disruptive behavior
disorders. As such, school absenteeism remains an important public health issue for mental health professionals,
physicians, and educators.
The purpose of this article is to provide a concise review of contemporary research on school absenteeism and related
concepts in youth. Reviews of literature prior to 2001 are available (Heyne, King, Tonge, & Cooper, 2001; Kearney,
2001; King & Bernstein, 2001), so the emphasis in this paper will be on the extensive research literature published after
2000. Following a brief description of key concepts, data and theory regarding prevalence, physical conditions,
psychiatric conditions, classification, contextual risk factors, assessment, intervention, and outcome are presented.

2. Key concepts

Absenteeism refers to excusable or inexcusable absences from elementary or secondary (middle/high) school.
Researchers generally focus on youths aged 5–17 years with excessive (1) excusable absences related to medical
illness or injury or (2) inexcusable absences related to environmental, social, psychiatric, or other conditions.
Inexcusable absences may be caused by school withdrawal, where parents deliberately keep a child home from school
for economic purposes, to conceal maltreatment, to prevent abduction from an estranged spouse, to protect a child from
perceived school-based threat, to assist a parent with psychopathology, or for other reasons (Kearney, 2004).
Inexcusable absences may also be caused by school refusal behavior, or child-motivated refusal to attend school
and/or problems remaining in classes for an entire day. Researchers generally focus on school refusal behavior and not
school withdrawal. School refusal behavior is a heterogeneous, dimensional construct consisting of extended absences
from school, periodic absences from school or missed classes, chronic tardiness, and intense dread about school that
precipitates pleas for future nonattendance (see Fig. 1). Episodes of school refusal behavior may include any of these
forms and may change on a daily basis. School refusal behavior is an umbrella term that subsumes constructs such as
truancy, school refusal, and school phobia (Kearney, 2003).
Truancy generally refers to unexcused, illegal, surreptitious absences, non-anxiety-based absenteeism, absenteeism
linked to lack of parental knowledge about the behavior, absenteeism linked to delinquency or academic problems, or
absenteeism linked to social conditions such as homelessness or poverty (Fremont, 2003). School refusal generally
 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471 453

Fig. 1. Continuum of school refusal behavior in youth.

refers to anxiety-based absenteeism, often from separation, generalized, or social anxiety. School phobia generally
refers to fear-based absenteeism, but youths are rarely phobic of school and so this term has been deemphasized in
recent research literature (Hanna, Fischer, & Fluent, 2006; Suveg, Aschenbrand, & Kendall, 2005). A key problem in
the literature is that truancy, school refusal, and school phobia are used interchangeably or defined inconsistently
(Lauchlan, 2003; McCune & Hynes, 2005). This article will thus focus on overarching concepts of school absenteeism
and school refusal behavior.

3. Prevalence

According to the National Center for Education Statistics for 2005, 19% of fourth-graders and 20% of eighth-graders
missed at least 3 days of school in the past month. More specifically, 7% of fourth-graders and 7% of eighth-graders
missed at least 5 days of school in the past month. School absenteeism is largely unrelated to gender but more common
among diverse students, especially American Indians, as well as students with disabilities, students eligible for free or
reduced-price lunch, and students in schools whose populace is largely eligible for free or reduced-price lunch (see
Table 1). Absenteeism rates have remained stable since 1994 (National Center for Education Statistics, 2006a).

Table 1
Percentage of 4th-grade and 8th-grade students missing 3 or more days of school in the past month in 2005
Grade4/Grade8
Total 19/20
Male 18/20
Female 20/21
White 18/19
African–American 21/24
Hispanic 21/23
Asian/Pacific Islander 13/12
American Indian 25/29
English language learner—yes 21/23
English language learner—no 19/20
Disability—yes 24/29
Disability—no 19/20
Language other than English spoken in the home—yes 20/21
Language other than English spoken in the home—no 18/20
Student eligible for free/reduced-price lunch—yes 23/25
Student eligible for free/reduced-price lunch—no 17/18
School in central city 20/22
School in urban fringe/large town 18/20
School in rural/small town 20/19
School with 10% or less students eligible for free/reduced-price lunch 16/17
School with 11–25% students eligible for free/reduced-price lunch 18/18
School with 26–50% students eligible for free/reduced-price lunch 19/21
School with 51–75% students eligible for free/reduced-price lunch 21/23
School with more than 75% students eligible for free/reduced-price lunch 22/25
Source: National Center for Education Statistics (2006a).
454 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471

Absenteeism in high school students is more difficult to quantify because many adolescents leave school
permanently. According to the National Center for Education Statistics, the 2004 status school dropout rate for 16–
24-year olds is 10.3%. Status dropout rate refers to percentage of those out of school and who have not earned a high
school credential. Status dropout rates are slightly higher for males (11.6%) than females (9.0%) and for Hispanics
(23.8%) than African–Americans (11.8%) or European–Americans (6.8%). Status dropout rates are also higher
among youths in lowest-income families (17.7%), employed youths (53.0%), and youths with 11 or 12 years of
education (40.3%) (National Center for Education Statistics, 2006a). These figures suggest that many youths leave
school to financially support themselves or their families. In addition, many youths are classified as dropouts when
in fact they were never enrolled in school.
Recent attempts have been made, however, to pinpoint absenteeism at the high school level. A comprehensive
attempt to do so was by Guare and Cooper, who surveyed 230 youths in 4 high schools and 1 middle school in the
United States. The authors found many students to sometimes (29.1%) or often (9.1%) deliberately and completely
miss school. In addition, 54.6% of students sometimes skipped classes and 13.1% often did so. Rates of absenteeism
from school were generally equal across gender but more prevalent among European–Americans (48.4%), non-
English-speaking families (65.0%), students with fair to poor academic achievement (52.4%), and 12th-graders
(55.0%) (Guare & Cooper, 2003). Rates of absenteeism range widely, however, across school districts. The daily
absenteeism rate for New York City public high schools, for example, has been reported as 15–30% (Weitzman,
Guttmacher, Weinberg, & Kapadia, 2003).
As mentioned, absenteeism may occur for many reasons, including illness or injury. According to the Centers for
Disease Control and Prevention for 2004, 10.9% of youths aged 5–17 years missed 6–10 days of school in the past year
due to illness or injury. In addition, 5.1% missed 11 or more days and 1.0% did not attend school due to illness or injury.
Those missing 11 or more days tended to be male (5.3%) than female (4.9%) and aged 12–17 years (6.7%) than aged
5–11 years (3.8%). Missing 11 or more days of school due to illness or injury was also more common among single-
parent (mother) families (8.0%), parents with less than a high school diploma (7.2%), families of income less than
$20,000 (8.7%), families living in smaller communities (6.0%), and families in the Northeast (6.2%) (Centers for
Disease Control and Prevention, 2006).
Absenteeism due to school refusal behavior is much more difficult to quantify because the behavior includes
complete and partial absences, tardiness, and anxiety-based difficulties attending school. Partial absences such as
skipped classes are counted as full-day absences in some school districts but not others. Indeed, a key problem in this
area is that school districts often inconsistently define, track, and report instances of absenteeism.
Tardiness is a common problem reported by 32% of principals and teachers but no consensual definition or
classification of the behavior exists (National Center for Education Statistics, 1999–2000). Several researchers have
pegged the prevalence of anxiety-based difficulties attending school at 1–5%, but this remains controversial (Suveg
et al., 2005). A recent comprehensive community study of youths with anxiety-based school refusal and truancy
revealed a total prevalence rate of 8.2% (Egger, Costello, & Angold, 2003).
School absenteeism and school refusal behavior are common problems whose prevalence rates rival those of major
childhood behavior disorders such as depression, substance abuse/dependence, depression, and conduct, oppositional
defiant, and attention deficit hyperactivity disorder (median prevalence estimates all b 5%) (Costello, Egger, & Angold,
2005). Unfortunately, comprehensive and empirically-based research attention to these vital issues has only recently
burgeoned. Some of this research has included common physical and psychiatric conditions associated with school
absenteeism and school refusal behavior. These conditions are described next.

4. Physical conditions

Researchers have linked school absenteeism to myriad medical problems (see Table 2). References are provided for
the reader in the table for more detailed information. Not included on this list is a full presentation of infectious diseases
such as malaria or parasitic conditions such guinea worm disease or urinary schistosomiasis frequently linked to
absenteeism in developing countries. Also not included on this list is a full presentation of surgical and medical
procedures (and recovery from the procedures), such as adenotonsillectomy or upper gastrointestinal endoscopy,
commonly linked to school absenteeism.
A leading cause of absenteeism worldwide is asthma and related respiratory illnesses (Borrego, Cesar, Leiria-Pinto, &
Rosada-Pinto, 2005; Tinkelman & Schwartz, 2004). Within the United States, the Centers for Disease Control and
 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471 455

Table 2
Medical problems commonly linked to school absenteeism in recent literature
Allergic rhinitis (Blaiss, 2004; Galant & Wilkinson, 2001)
Cancer (Lahteenmaki, Huostila, Hinkka, & Salmi, 2002; Vance & Eiser, 2002)
Chronic fatigue syndrome (Patel, Smith, Chalder, & Wessely, 2003; Sankey, Hill, Brown, Quinn, & Fletcher, 2006; Smith, Martin-Herz, Womack, &
Marsigan, 2003)
Chronic illness and pain (Chalkiadis, 2001; Liang et al., 2002)
Epilepsy (Taras & Potts-Datema, 2005a)
Headache (Bandell-Hoekstra et al., 2001; Breuner, Smith, & Womack, 2004)
Head lice (Goldsmith, 2003)
Hemophilia (Shapiro et al., 2001)
HIV/AIDS (Grassly et al., 2003; Mialky, Vagnoni, & Rutstein, 2000)
Influenza (Neuzil, Hohlbein, & Zhu, 2002)
Injury—minor (bruise, sprain, laceration, fracture, head injury, puncture wound, bite, abrasion, nasal injury, eye injury, burn/scald, foreign body,
haemarthrosis) (Barnes et al., 2001)
Irritable bowel syndrome/inflammatory bowel disease/Crohn's disease/dyspepsia (Condino, Fidanza, & Hoffenberg, 2005; Hulisz, 2004)
Menstrual complaints/dysmenorrheal (Chen, Lin, Heitkemper, & Wu, 2006; Houston, Abraham, Huang, & D'Angelo, 2006)
Obesity (Taras & Potts-Datema, 2005b)
Orodental disease (Albert, McManus, & Mitchell, 2005)
Orthopedic injury (Conroy et al., 2006; Sesko, Choe, Vitale, Ugwonali, & Hyman, 2005)
Rheumatic fever (Terreri, Ferraz, Goldenberg, Len, & Hilario, 2001)
Sickle cell anemia (Ogunfowora, Olanrewaju, & Akenzua, 2005)
Sleep disorder and daytime sleepiness (Drake et al., 2003)
Type I diabetes (Glaab, Brown, & Daneman, 2005; Moussa et al., 2005)

Prevention estimate that 8.3% of children aged 0–17 years have asthma and 14.7 million days of school were missed due
to asthma in 2002 (Centers for Disease Control and Prevention, 2004). The prevalence of asthma in American children
has increased sharply over the past 25 years. Youths with asthma miss 1.5–3.0 times more school days than youths
without asthma and approximately 60% of students with asthma miss school at some point in the academic year due to
problematic respiratory symptoms (Bonilla et al., 2005; Dey & Bloom, 2005; Moonie, Sterling, Figgs, & Castro, 2006;
Silverstein et al., 2001). Absences from physical education classes are also common among youths with asthma (Austin,
Selvaraj, Godden, & Russell, 2005).
School absenteeism due to asthma appears to be exacerbated by several factors. Youths with asthma are more likely
to miss school if they are younger, poorer, less adherent to medical regimens, and living in an environment with
considerable dust, vermin, or dampness and mold. In addition, greater absenteeism from asthma is related to critical
fathers, mothers with asthma, poorer quality of life, diagnosis from a physician, higher ozone, smoking, and exposure
to tobacco smoke. Ethnicity is an inconsistent predictor of absenteeism due to problematic respiratory symptoms
(Austin et al., 2005; Freeman, Schneider, & McGarvey, 2003; Gilliland et al., 2003; Okelo et al., 2004; Taras & Potts-
Datema, 2005c).
Problematic respiratory symptoms that lead to absenteeism can also result from environmental deficiencies such as
indoor nitrogen dioxide and chemical pollutants, low outdoor air ventilation, and changes in thermal conditions
(Mendell & Heath, 2005). School nonattendance has also been associated with classroom carbon dioxide
concentrations and poor air quality from sulfur dioxide, ozone, and particulate matter. Researchers have thus issued
recommendations for limiting children's exposure to pollutants by improving school filtration systems, building parks
and schools away from high traffic exhaust, reducing outdoor exercise during poor air quality days, and increasing
children's intake of antioxidants (Kunzli et al., 2003; Park et al., 2002; Rondeau, Berhane, & Thomas, 2005; Shendell
et al., 2004).
School absenteeism is also commonly associated with risky health behaviors. In particular, absenteeism has been
linked to adolescent illicit drug use (including alcohol and tobacco), binge drinking, driving under the influence of
alcohol, perilous sexual behavior and HIV risk, suicide attempt, and poor nutrition (Alberg, Diette, & Ford, 2003;
Almeida et al., 2006; Aloise-Young, Cruickshank, & Chavez, 2002; Chou et al., 2006; Denny et al., 2003; Grunbaum
et al., 2004; Guttmacher et al., 2002; Hallfors et al., 2002; Henry & Huizinga, 2007; Kleinman et al., 2002; Weitzman
et al., 2003). Causation remains largely unclear, however, so knowing whether absenteeism predisposes these risky
behaviors or vice versa is in need of further study. Conversely, however, one study indicated that increased risk of
456 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471

absenteeism actually promoted influenza vaccine acceptance among parents (Nettleman, White, Lavoie, & Chafin,
2001).
School absenteeism and school refusal behavior are also commonly associated with somatic complaints among
children. Somatic complaints are especially frequent in youths with anxiety-based absenteeism, affecting 26.5% in one
recent comprehensive community study (Egger et al., 2003) but much more so (79.4%) among a clinical sample in
another study (Honjo, Nishide et al., 2001; Honjo, Sasaki et al., 2001). Somatic complaints among youths with
problematic absenteeism typically include headache, stomachache, nausea or vomiting, fatigue, sweating,
lightheadedness, abdominal or back or other pain, heart palpitations, diarrhea, shortness of breath, and menstruation
symptoms.
Youths with somatic complaints in conjunction with school refusal behavior may be suffering from a true physical
malady, such as those described above. However, many youths with school refusal behavior embellish actual low-grade
physical symptoms that may partially result from stress. Embellishment of these symptoms may occur to derive
attention from significant others or to induce parental acquiescence to stay home from school. In addition, many youths
with school refusal behavior falsely claim to have somatic complaints. Physicians have been encouraged to conduct a
full medical examination to exclude organic problems or treat true medical conditions affecting a child with school
refusal behavior (Kearney, 2006a).

5. Psychiatric conditions

Youths who refuse to attend school commonly have psychiatric conditions that help precipitate their absenteeism or
result from extended absences. Two recent studies have provided the most comprehensive view yet of psychiatric
comorbidity among youths with problematic absenteeism. These studies are superior to prior studies in two main ways.
First, large samples of youths with absentee problems were assessed. Second, structured diagnostic interviews with
excellent psychometric properties were used. One study represented a community sample and one represented a
clinical sample.
In the community study, Egger et al. (2003) utilized the Child and Adolescent Psychiatric Assessment to diagnose
165 youths with anxiety-based school refusal and 517 youths with truancy or otherwise unexcused absences. The most
common diagnoses for youths with anxiety-based school refusal included depression (13.9%), separation anxiety
disorder (10.8%), oppositional defiant disorder (5.6%), and conduct disorder (5.0%). In all, 24.5% of this group
received a diagnosis. The most common diagnoses for youths with truancy included conduct disorder (14.8%),
oppositional defiant disorder (9.7%), depression (7.5%), and substance abuse (4.9%). In all, 25.4% of this group
received a diagnosis (Egger et al., 2003).
The authors also found that youths with anxiety-based school refusal had significantly more fears and worries, sleep
difficulties, and somatic complaints (headaches and stomachaches) compared to youths with truancy. However, the two
groups did not differ with respect to social anxiety, worry about calamitous separation from parents, or nightmares.
Youths with anxiety-based school refusal generally had more peer relationship problems than youths with truancy and
were more likely to have parents treated for mental health problems. Youths with truancy were more likely to
experience lax supervision. No differences were found between the two groups, however, with respect to poverty,
family size, living with a stepparent, parents without a high school diploma or unemployed, living in a dangerous
neighborhood, parenting style or conflict, maternal depression, or parents with history of criminal conviction (Egger
et al., 2003).
Kearney and Albano (2004) examined a large clinical sample (n = 143) of youths with school refusal behavior.
Youths aged 5–17 years were referred to a specialized outpatient therapy clinic for problematic absenteeism, and the
mean absentee rate was 37.2%. The Anxiety Disorders Interview Schedule for Children (child and parent versions) was
used to assign diagnoses. The most common primary diagnoses included separation anxiety disorder (22.4%),
generalized anxiety disorder (10.5%), oppositional defiant disorder (8.4%), and depression (4.9%). Nearly one-third
(32.9%) met criteria for no diagnosis (Kearney & Albano, 2004).
A third recent diagnostic study involved case review for 93 inpatient and 58 outpatient youths aged 10–17 years
with school attendance difficulties. Primary diagnoses among the inpatient/outpatient groups included mood (30%/
15%), anxiety (28%/14.5%), and disruptive behavior (18.5%/11.5%) disorder. The most common specific disorders
among the two groups were major depression (31.8%), dysthymia (25.2%), oppositional defiant disorder (23.8%), and
separation anxiety disorder (22.5%). Although only 4.6% of the total sample had a learning disorder, 31% reported that
 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471 457

academic difficulties were associated with onset of school attendance difficulties. In addition, 37% of the sample had a
physical illness as well as 18% of mothers and 14% of fathers. One-fifth reported that physical illness was associated
with onset of school attendance difficulties. Maternal (53%) and paternal (34%) psychiatric disorder was present in
many cases as well (McShane, Walter, & Rey, 2001).
These and other studies indicate remarkable consistency with respect to type of diagnosis most commonly seen in
youths with problematic absenteeism, which essentially involves depression, anxiety, and disruptive behavior disorder
(Silove, Manicavasagar, & Drobny, 2002; Tramontina et al., 2001). The diagnostic studies are consistent as well with
studies linking problematic school absenteeism to aggression and affiliation with aggressive peer groups (Farmer et al.,
2003; Lounsbury, Steel, Loveland, & Gibson, 2004). However, the diagnostic studies also convey that many youths
with school refusal behavior demonstrate no psychiatric condition. Many youths display problematic absenteeism as
their sole behavior problem without comorbidity. This finding may partially reflect the fact that problematic
absenteeism represents a symptom of two psychiatric disorders in childhood (separation anxiety disorder, conduct
disorder) and not a psychiatric disorder per se.

6. Classification and proximal variables

Because problematic absenteeism is not a formal psychiatric diagnosis, debate continues to occur as to how the
behavior should be defined and classified. The traditional notion of dividing youths with school refusal behavior into
those with anxiety-based school refusal and truancy remains a popular but flawed one for several reasons. First,
enormous diagnostic heterogeneity comprises both groups. Among youths with anxiety-based school refusal in the
Egger et al. study, for example, externalizing behavior problems such as oppositional defiant and conduct disorder were
highly prevalent. Second, substantial overlap in symptoms marks these groups. Youths with anxiety-based absenteeism
are also commonly noncompliant about attending school, for example, and many youths with longstanding truancy
display nervousness at the prospect of returning to school. Third, the descriptors of school refusal and truancy are not
clearly linked to effective or useful assessment and intervention strategies for this population (Kearney, 2003).
An alternative method of classifying youths with school refusal behavior based on diagnosis or behavior form is to
examine reasons why youths have difficulties attending school. These reasons may be divided into specific proximal
variables and broader contextual risk factors. Proximal variables include those having a direct and immediate effect on
behavior, such as reinforcements. Kearney and colleagues designed a taxonomic system of school refusal behavior
based on function or reasons why youths refuse school. These functions are linked to specific reinforcements youths
often receive for school refusal behavior (Kearney, Lemos, & Silverman, 2006).
The first function or reinforcement is avoidance of school-related stimuli that provoke negative affectivity, or
general anxiety and depression. This function applies typically to younger children with difficulty identifying the cause
of their distress at school but who refuse to attend because of discomfort there. In some cases, the child's discomfort
can be linked to difficulty with transitions between classes or time periods, entry into a school building or classroom, or
riding a school bus. This function is commonly associated with generalized anxiety disorder, somatic complaints,
tardiness, and constant pleas for nonattendance (Kearney & Albano, 2004; Kearney, Chapman, & Cook, 2005;
Kearney et al., 2006).
The second function or reinforcement is escape from aversive social and/or evaluative situations at school. This
function applies typically to older children and adolescents with difficulty interacting with peers or others at school or
difficulty with evaluative situations such as examinations, oral presentations, recitals, athletic performances, and eating
in the cafeteria. In many cases, youths have problems assimilating into middle or high school or feel ostracized from
peer or racial groups. This function is commonly associated with generalized and social anxiety disorder as well as
shyness and withdrawn behavior (Kearney & Albano, 2004; Kearney et al., 2006).
The third function or reinforcement is pursuit of attention from significant others. This function typically applies to
younger children who refuse school to remain home with parents or others. In this case, school itself is not aversive but
the child prefers to be home or at a parent's workplace. Common misbehaviors include tantrums, running away from
school, and noncompliance. This function is commonly associated with separation anxiety disorder and oppositional
defiant disorder, though excessive worry about separation is not always present (Kearney & Albano, 2004; Kearney,
Chapman, & Cook, 2005; Kearney et al., 2006).
The fourth function or reinforcement is pursuit of tangible reinforcers outside the school setting. This function
typically applies to older children and adolescents who refuse school to pursue more alluring activities outside of
458 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471

school such as watching television, playing videogames, spending time with friends, or engaging in day parties or
substance use. This function may be most analogous to the traditional concept of truancy. Common problems linked to
this function include family conflict as well as delinquent, rule-breaking behavior. This function is commonly
associated with oppositional defiant and conduct disorder (Kearney & Albano, 2004; Kearney et al., 2006).
Recent data support the utility of a functional model for school refusal behavior. Among a clinical sample of 222
youths with school refusal behavior, Kearney utilized structural equation modeling to find function of school refusal
behavior to be a better predictor of school absenteeism rate than traditional behavioral measures of fear, anxiety, and
depression (Kearney, 2007a). In addition, confirmatory factor analysis of a measure associated with the functional
model, the School Refusal Assessment Scale-Revised (child and parent versions), affirmed the presence of these four
distinct functions of school refusal behavior (Kearney, 2006b). This measure is discussed at more length later in the
assessment section.

7. Contextual risk factors

Contextual risk factors refer to those having an indirect or less immediate effect on school refusal behavior. Recent
work has more closely and empirically linked school absenteeism and school refusal behavior to several environmental
contextual risk factors summarized here.

7.1. Homelessness and poverty

Homelessness is a significant barrier to school attendance for children because many school districts require certain
documentation as prerequisites to enrollment. Examples include immunization or academic records, birth certificates,
permanent home address, and proof of guardianship. Frequent relocation, financial costs, inaccessibility to
transportation, inadequate clothing and school supplies, and school concerns about liability also represent substantial
barriers to school enrollment for homeless families (US Department of Education, 2002). According to the U.S.
Department of Education, 87% of homeless school-age youths are enrolled in school but only 77% of these youths
attend school regularly. In addition, less than 16% of homeless preschoolers are enrolled in preschool programs. In
some American cities, over half of homeless children miss more than two weeks of school per year (US Department of
Education, 2004). Related problems include loss of education, higher grade retention, and inappropriate placement in
special education classes (Nunez, 2000; Rafferty, Shinn, & Weitzman, 2004).
A related but broader variable is poverty, which is also closely linked to school absenteeism. As noted earlier,
American youths from families of lower income levels are much more likely to miss school than their peers. The link
between poverty and school absenteeism has been well demonstrated in other countries as well (Population Council,
2006). For example, Zhang examined absentee rates in several United Kingdom schools and found significant
correlations with child poverty level at primary (.70–.86) and secondary (.50–.56) schools. Although the reasons for
this link are complex, family need for financial support from youths and poor parental involvement in the educational
process, a topic discussed in more detail in a subsequent section, are likely contributors (Zhang, 2003).

7.2. Teenage pregnancy

Teenage pregnancy is also commonly associated with school nonattendance and dropout. Pregnancy and its
complications often predispose youths to permanently leave school. In addition, sudden, frequent absenteeism may be
a signal of pregnancy and accompanying symptoms to educators and others. Teenage mothers complete 1.9–2.2
fewer years of schooling than women who do not give birth prior to age 30. Odds of completing high school or college
are greatly reduced as well, as only 60–80% of early childbearers complete high school (Hofferth, Reid, & Mott,
2001).
In a recent Brazilian study, pregnancy and having a child was the primary reason for females leaving school. Over
twice as many females left school after pregnancy (36.7%) than before or during pregnancy (16.7%). A similar trend
was evident for males (18.1% versus 40.4%) (Almeida et al., 2006). On the other hand, school absenteeism and
dropout from teenage pregnancy decreases significantly with provision of family support, school-based prenatal
services, and availability of alternative educational programs during postpregnancy (Barnet, Arroyo, Devoe, &
Duggan, 2004).
 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471 459

7.3. School violence and victimization

According to the National Center for Education Statistics for 2004–2005, 583,000 violent crimes were committed
against students aged 12–18 years. Of these crimes, 107,000 involved rape, sexual assault, robbery, and aggravated
assault. Many male (10%) and female (6%) students in grades 9–12 were reportedly threatened or injured with a
weapon on school property. This was especially so for Hispanic (10%) than European–American (7%) students. In
addition, the percentage of public schools reporting at least one violent incident increased from 71% in 1999–2000 to
81% in 2003–2004. In 2005, 24% of students aged 12–18 years reported gangs at their schools; this was more common
among urban (36%) than suburban (21%) or rural (16%) schools. In addition, 28% of students aged 12–18 years were
reportedly bullied at school in the past six months. Most said bullying occurred 1–2 times in six months, but 25% were
bullied 1–2 times per month, 11% were bullied 1–2 times per week, and 8% were reportedly bullied almost daily
(National Center for Education Statistics, 2006b).
School shootings, related violence, and victimization of youth via bullying in American schools have led
researchers to explore whether these phenomena are related to school absenteeism. The National Center for Education
Statistics indicates that 6% of students avoided a school activity in the previous six months due to fear of attack or harm
(National Center for Education Statistics, 2006b). Victims of bullies display higher rates of absenteeism than their peers
(Dake, Price, & Telljohann, 2003). Students who have been bullied are 2.1 times more likely than other students to feel
unsafe at school and 20% of elementary school students would reportedly skip school to avoid being bullied (Glew,
Fan, Katon, Rivara, & Kernic, 2005). Among high school students, fear of attending classes because of violence is
directly related to previous victimization by teachers or peers (Astor, Benbenishty, Zeira, & Vonokur, 2002). Missing
school because of feeling unsafe is also a risk factor for asthma and potentially early dismissal from school (Swahn &
Bossarte, 2006). Bullying and school refusal behaviors have been noted across cultures (Kawabata, 2001).

7.4. School climate and connectedness

School climate is also a key contextual factor for school absenteeism. School climate refers to student feelings of
connectedness to their school and degree of support a student feels regarding academic, social, and other needs. School
climate and connectedness may also include positive classroom management, participation in extracurricular activities,
and tolerant disciplinary procedures. The extent to which students feel safe, accepted, valued, and respected at school is
a key aspect of school connectedness as well (Brookmeyer, Fanti, & Henrich, 2006; McNeely, Nonnemaker, & Blum,
2002; Shochet, Dadds, Ham, & Montague, 2006).
School climate is moderately but significantly correlated with school attendance (.40) and inversely to school
dropout (− .36). Class and school size, which are inversely related to school climate, are inversely related as well to
school attendance (− .23/− .21) and positively related to school dropout (.24/.41) (Brookmeyer et al., 2006). All values
are statistically significant. Others have found school climate to be inversely related to victimization by others
(students, teachers, staff), the latter of which is positively related to student fear of attending school due to school
violence (Astor et al., 2002). Students in smaller schools with more challenging courses, less grade retention, and more
positive relationships with teachers are also less likely to drop out of school (Jimerson, Anderson, & Whipple, 2002;
Lee & Burkham, 2003).
Boredom in school and inadequate school climate are a key reason why many youths miss school and eventually drop
out (see Table 3) (Guare & Cooper, 2003; National Center for Education Statistics, 2006a). Boredom is a common
reason as well why many youths prematurely leave after-school programs (Weisman & Gottfredson, 2001). Poor school
climate may be linked to harsh and inflexible disciplinary practices, rigid regulations regarding school reintegration,
school curricula not well tailored to a child's individual needs or interests, poor teaching and student–teacher
relationships, inattention to diversity issues, and inadequate attendance management practices (Conroy, Conroy, &
Newman, 2006; Reid, 2005). In a recent comprehensive survey of youths who dropped out of school, 47% said a major
factor in their decision to leave school was that classes were uninteresting (Bridgeland, Dilulio, & Morison, 2006).

7.5. Parental involvement

Parental involvement in a child's educational progress is also commonly linked to academic achievement and
attendance. No consensual definition exists for parental involvement, though the National Education Association
460 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471

Table 3
Percentage of high school sophomores who left school prematurely by reason
Reason for leaving school Percentage
Missed too many school days 43.5
Thought it would be easier to get GED 40.5
Getting poor grades/failing school 38.0
Did not like school 36.6
Could not keep up with schoolwork 32.1
Became pregnant (females only) 27.8
Got a job 27.8
Thought could not complete course requirements 25.6
Could not get along with teachers 25.0
Could not work at same time 21.7
Had to support family 20.0
Did not feel belonged there 19.9
Could not get along with other students 18.7
Was suspended from school 16.9
Had to care for a member of family 15.5
Became father/mother of a baby 14.4
Had changed schools and did not like new one 11.2
Thought would fail competency test 10.5
Did not feel safe 10.0
Was expelled from school 9.9
Got married/planned to get married 6.8
Source: National Center for Education Statistics (2006a).

focuses on behaviors such as reading to a child, attending parent–teacher conferences, checking homework, limiting
television on school nights, being active in the development and progress of a child's school, and, presumably,
monitoring a child's school attendance.
The latter would ostensibly involve frequent parent–school official contact, but Guare and Cooper found that school
officials failed to inform parents of a child's unexcused absence in 57.9% of cases. Over half (51.0%) of students who
cut class reported having never been caught for doing so, and 26.5% had been caught only once. In addition, 74.4% of
students caught for skipping school were not punished by the school for doing so (Guare & Cooper, 2003). In another
comprehensive survey of school dropouts, 59% of parents or guardians were involved in their child's education and
only 21% were very involved. Most parents of school dropouts who did become involved did so only for disciplinary
reasons (Bridgeland et al., 2006).
School officials commonly lament that many parents are uninvolved in their child's education and school
attendance. Several researchers have ascribed this partially to cultural factors such as parent–school official language
barriers and other cultural differences, lower family acculturation, parental opposition to a child's distance from the
family via pursuit of higher education, relaxed attitudes about developmental milestones or self-reliance skills, school-
based racism and discrimination, and parental mistrust of school officials (Franklin & Soto, 2002). Past episodes of
parent–school official conflict, extensive teacher absenteeism, low teacher expectations, and poor interactions between
parents and school officials also reportedly cause many parents to be less involved in their child's academic progress
and attendance (Brand & O'Connor, 2004; Martinez, DeGarmo, & Eddy, 2004; Teasley, 2004). Students who drop out
of school are also more likely than graduating peers to have parents and siblings who dropped out of school (Orfield,
2004).

7.6. Family and community variables

Parental involvement is a key aspect of a child attendance but broader family variables serve as important contextual
risk factors as well. Previous work in this area reveals that families of youths with school refusal behavior are often
marked by poor cohesion and considerable conflict, enmeshment, isolation, and detachment. Recent evidence affirms
these findings (Chapman, 2007; Lagana, 2004). In the study of inpatient and outpatient youths with school attendance
difficulties presented earlier, many reported conflict at home (43%) and family separation (21%) (McShane et al.,
 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471 461

2001). Increased school absenteeism and dropout risk has also been recently linked to parents with alcoholism (Casas-
Gil & Navarro-Guzman, 2002). Conversely, decreased substance use in African–American dropouts has been
associated with positive family relationships and religiosity (Kogan et al., 2005).
Other contextual risk factors have been linked to absenteeism, though greater empirical data to support these links
are needed. These factors include divorce, child self-care, problematic neighborhoods, and maltreatment. McShane and
colleagues reported that only 54% of youths with school attendance difficulties lived with an intact, two-parent family
and that 39% lived with a single parent. Youths living in disorganized, unsafe, or unsupportive neighborhoods that
include poor adult supervision of attendance and high rates of child self-care are at substantial risk for absenteeism as
well (Chapman, 2003; Crowder & South, 2003; Henry, 2007; Reid, 2005).
Maltreated youths are more likely than nonmaltreated peers to miss school. This may be due to parents who attempt
to conceal maltreatment, child hospital stays or recovery time from maltreatment, and psychiatric sequelae of abuse.
Conversely, however, some maltreated children attend school assiduously or linger after school to avoid going home
(Kearney, 2001). In addition, many jurisdictions consider chronic absenteeism from school to be a form of educational
neglect under which parents may be prosecuted. Youths placed in foster care may also be at greater risk for school
absenteeism (Taussig, 2002).

8. Cross-cultural variables

Research regarding school absenteeism and school refusal behavior has come historically and primarily from
samples in the United States, United Kingdom, Canada, and Australia. In recent years, however, research attention on
these topics has burgeoned in other European countries as well as nations such as South Africa, Japan, Saudi Arabia,
and India (Al-Dalwood, 2002; Ananthakrishnan & Nalini, 2002; Liang, Flisher, & Chalton, 2002; Nishida, Sugiyama,
Aoki, & Kuroda, 2004). Remarkably, many findings from these studies mirror those of historical studies. First, great
heterogeneity is seen with respect to symptomatology. Second, comorbid psychiatric diagnoses evident in children with
school attendance difficulties largely include anxiety, depressive, and disruptive behavior disorders. Third, poverty and
chronic illness are quite clearly associated with absenteeism. Finally, emphasis is made on specialized intervention
conducted in close conjunction with family members, school officials, and other relevant agencies (Holzer & Halfon,
2006; Lehmkuhl & Lehmkuhl, 2004).
Some authors have discussed variables related to school absenteeism that are idiosyncratic to culture. Much of this
comes from an escalating Japanese literature on school refusal behavior. Kameguchi, for example, noted that Japanese
schools often overemphasize uniformity and intense pressure to perform well on curriculum-based examinations.
Children whose academic or interpersonal needs are ignored by teachers in this rigid system have been prone to
absenteeism. In addition, the traditional three-generation household in Japan has deteriorated in recent years, leading to
higher divorce rates, urbanization, and work hours among mothers. These forces are thought to contribute to the sudden
increase in school refusal behavior among Japanese youth (Kameguchi, 2004). In general, however, cross-cultural
aspects of school absenteeism and school refusal behavior remain in need of greater exploration and explication.

9. Assessment

The assessment of school absenteeism per se traditionally involves measuring days or periods of time a child is out
of school. Other pertinent variables include child resistance going to school and having to be taken to school by a parent
(Egger et al., 2003). Researchers often rely on parent and child report as well as school attendance records to monitor
absenteeism. When absenteeism is associated with psychiatric conditions or school refusal behavior, however,
assessment becomes broader.
Traditional methods of assessing school refusal behavior include structured diagnostic interviews, child self-report
measures of internalizing problems (fear, anxiety, depression, worry, self-efficacy, problematic cognitions), and parent
and teacher reports of internalizing and externalizing problems (rule-breaking, aggression, noncompliance, running
away from home/school) (Hanna, Fischer, & Fluent, 2006; King, Heyne, Tonge, Gullone, & Ollendick, 2001). In
addition, parents and children may be encouraged to complete daily logbooks that assess attendance, difficulties
preparing for and entering school, level of emotional distress, and defiance and other misbehaviors as well as parent
and teacher reactions. A full medical examination and reviews of psychiatric, academic, legal, and other pertinent
records are commonly recommended for this population as well (Heyne, King, Tonge, & Cooper, 2002; Kearney,
462 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471

2003). Specific questions that family physicians may submit to parents of youths with school refusal behavior, with
other recommendations for assessment, have been presented in recent literature (Kearney, 2006a).
The development of measures specific to youths with school refusal behavior has advanced recently. Of particular
note is the School Refusal Assessment Scale-Revised, a 24-item measure with parent and child versions designed to
assess the relative strength of four functions of school refusal behavior mentioned earlier (avoidance of school-related
stimuli that provoke negative affectivity, escape from aversive social and/or evaluative situations, pursuit of attention
from significant others, pursuit of tangible reinforcers outside of school). The scale in original and revised form has
demonstrated good reliability, validity, and utility. A recent confirmatory factor analysis affirmed the four-factor
structure of the scale (Brandibas, Jeunier, Clanet, & Fouraste, 2004; Brandibas, Jeunier, Gaspard, & Fouraste, 2001;
Higa, Daleiden, & Chorpita, 2002; Kearney, 2002a,b). The scale has been used successfully to assign prescriptive
intervention, or intervention tailored to the individual characteristics of a child with school refusal behavior (see
Intervention section).
The School Avoidance Scale and School Refusal Personality Scale have also been recently designed to assess youth
dislike of school and desire to leave school. The latter scale purportedly measures obsessive–compulsive, passive–
unsocial, and socially introverted behavior in this population. Scores on both scales have been linked to depression, a
particularly common phenomenon among youths with anxiety-based absenteeism (Honjo et al., 2003). Although these
measures represent great strides in assessing youths with problematic absenteeism, more specific and consensual
protocols for evaluating this population to increase comparability across studies are needed (Kearney, 2003).

10. Intervention

Intervention for youths with school attendance difficulties includes a wide gamut from medical to clinical to
systemic interventions. Recent developments regarding each set of interventions are discussed next.

10.1. Medical

The primary medical intervention for youths with problematic absenteeism has focused on those with anxiety-based
problems such as generalized, social, or separation anxiety disorder. Pharmacotherapy for this population has mainly
included tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, buspirone, beta-
blockers such as propranolol, and antiepileptics such as gabapentin (Bernstein et al. 2000; Durkin, 2002; Fourneret,
Desombre, De Villard, & Revol, 2001; Heyne, King, Tonge, & Cooper, 2001; Masi, Mucci, & Millepiedi, 2001).
Imipramine (3 mg/kg/d), fluoxetine (10–20 mg/d), fluvoxamine (50–250 mg/d), sertraline (85–160 mg/d), and
paroxetine (10–50 mg/d) have been found useful for some youths with anxiety and depression and possibly comorbid
school refusal behavior (Kearney, 2006c).
A recent follow-up study of school refusal youths treated with imipramine revealed that prognosis was better for youths
with higher baseline rates of attendance and poorer for youths with comorbid separation anxiety and avoidant disorder
(Layne, Bernstein, Egan, & Kushner, 2003). In general, however, youths with anxiety-based absenteeism respond
ambiguously to medication, in part because of the fluid and amorphous nature of anxiety and depressive symptoms in this
population (Tyrrell, 2005). Intense side effects of SSRIs, including suicidal behavior, must be monitored closely as well.
Finally, studies regarding medications to treat non-anxiety-based school refusal behavior are virtually nonexistent.
Other somatic procedures have been used for youths with school attendance difficulties, including procedures to
address the myriad physical conditions associated with absenteeism. With respect to the most common physical
condition associated with absenteeism, several school-based and pediatric primary care asthma management programs
have been developed. These programs are designed to increase parent and child education about the disease, physical
conditioning, child monitoring of daily symptoms, peak flow meter use, contact with a physician, corticosteroid use,
and appropriate school official responses to asthma attacks (Clark et al., 2004; Halterman et al., 2004; Rance & Trent,
2005; Tinkelman & Schwartz, 2004; Welsh, Kemp, & Roberts, 2005). A recent wide-ranging review of these programs
revealed significant decreases in school absenteeism and number of days of restricted activity (Guevara, Wolf, Grum, &
Clark, 2003). Other somatic procedures that have helped reduce absenteeism include comprehensive handwashing and
use of hand sanitizers and mass FluMist immunization in schools (Guinan, McGuckin, & Ali, 2002; Meadows & Le
Saux, 2004; Wiggs-Stayner et al., 2006). Addressing true medical conditions related to school refusal behavior is
obviously imperative as well (Stein, Duffner, Werry, & Trauner, 2001).
 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471 463

10.2. Clinical

Clinical intervention for problematic school absenteeism has primarily focused on reducing symptoms associated
with school refusal behavior, especially anxiety and depression. Toward this end, cognitive–behavioral strategies have
been most popular and empirically supported. These strategies are designed to help youths effectively manage physical
symptoms of stress and anxiety, modify irrational thoughts related to school attendance, and gradually reintegrate into a
particular school setting (Heyne et al., 2001). Techniques most central to this approach include relaxation training,
cognitive restructuring, and exposure-based practices. These techniques have been empirically supported across
various case studies as well as open, randomized, and nonrandomized clinical trials. Recent research has provided
additional confirmation (Barnes, Bauza, & Treiber, 2003; Heyne et al., 2002; King, Tonge, Heyne, & Ollendick, 2000).
Hypnosis has also been found effective for reducing stress and increasing attendance in adolescents with school refusal,
but this approach is not widely used for this population (Aviv, 2006).
A key drawback to most cognitive–behavioral intervention approaches in this area is that researchers generally
focus on youths with anxiety-based absenteeism (Heyne et al., 2002; Layne et al., 2003). Youths who refuse school for
other reasons or who have externalizing behavior problems are often excluded. Kearney and colleagues thus designed
prescriptive intervention strategies for youths who refuse to attend school for the four functions mentioned earlier (see
Table 4). These functions cover all youths who refuse to attend school, and effective, specific intervention packages can
be prescribed based on assessment data that include School Refusal Assessment Scale-Revised scores, interviews,
direct observations, and other information (Kearney, 2002b; Kearney, Pursell, & Alvarez, 2001; Kearney & Silverman,
1999; Moffitt, Chorpita, & Fernandez, 2003). These intervention packages are available in manualized and self-
directed format (Kearney, 2007b; Kearney & Albano, 2007a,b).
As research into the clinical intervention of youths with school refusal behavior progresses, greater attention will
likely be needed to family and other contextual variables that impinge on this population. Several researchers have
called for more extensive interventions that include cognitive–behavioral strategies as well as family therapy, social
skills training to better develop peer relationships, and frequent consultation with physicians and school officials
(Gosschalk, 2004; Kearney & Bates, 2005; Lauchlan, 2003; Moffitt et al., 2003; Place, Hulsmeier, Davis, & Taylor,
2000). In addition, researchers have called for more systemic interventions in conjunction with medical and clinical

Table 4
Prescriptive interventions based on function of school refusal behavior
1. Refusing school to avoid school-based stimuli that provoke negative affectivity (child-based)
Psychoeducation regarding anxiety and its components
Somatic management techniques such as relaxation training and deep diaphragmatic breathing
Gradual re-exposure to school setting using anxiety and avoidance hierarchy
Self-reinforcement of gains
2. Refusing school to escape aversive social and/or evaluative situations (child-based)
Psychoeducation regarding anxiety and its components
Somatic management techniques such as relaxation training and deep diaphragmatic breathing
Cognitive restructuring to modify irrational thoughts
Practicing coping skills in real-life social and evaluative situations
Gradual re-exposure to school setting using anxiety and avoidance hierarchy
Self-reinforcement of gains
3. Refusing school to pursue attention from significant others (parent-based)
Modify parent commands toward brevity and clarity
Establish a set morning routine prior to school as well as daytime routines as necessary
Establish rewards for attendance and punishments for nonattendance
Forced school attendance in specific cases
4. Refusing school to pursue tangible rewards outside of school (family-based)
Contingency contracting that involves increasing incentives for attendance and disincentives for nonattendance
Establish times and places for family members to negotiate problem solutions
Communication skills training
Escorting a youth to school and classes as necessary
Increasing monitoring of attendance
Peer refusal skills training (to refuse offers from others to miss school)
464 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471

approaches to effectively treat youths with severe or chronic school attendance difficulties. These systemic approaches
are described next.

10.3. Systemic

Systemic intervention for school absenteeism refers to school- or community-wide approaches to reduce
absenteeism in youth. The National Dropout Prevention Center lists systemic strategies found useful for reducing
absenteeism and dropout. These strategies generally involve (1) school–community partnerships to improve the safety
and infrastructure of schools, (2) early intervention programs to boost family engagement, early academic enrichment,
and reading and writing skills, (3) alternative educational and after-school programs to help students receive their
diploma, and (4) professional development programs to better prepare teachers to work with at-risk youth as well as
individualized and flexible instruction to better meet the academic needs of a given child.
Systemic strategies to reduce absenteeism may also involve ideas more specific to individual cases. An important
model in this regard is coordination of school-based and other services for impoverished children. In this model,
schools provide early intervention and after-school programs to meet a child's educational needs, but these programs
are linked directly to human service agencies (Bowen & Richman, 2002). Kearney and Bates, for example,
recommended that school-based social workers help families coordinate educational and other services. This can be
done by arranging a weekly meeting with parents, teachers, medical personnel, mental health professionals, juvenile
detention officers, and representatives from housing, employment, and legal services agencies as necessary. This would
preclude asking families to arrange multiple trips during the week to procure services and help develop an overarching
plan for monitoring a child's school attendance and achievement (Kearney & Bates, 2005).
Other specific systemic strategies for reducing absenteeism and dropout are listed in Table 5 (with accompanying
references from recent literature). Key aspects of many of these programs are to eliminate barriers to attendance, such
as school-related violence and language differences, as well as to increase monitoring of attendance and provide swift
consequences and return to school following unexcused absence. Providing alternative educational opportunities and
individualized instruction, increasing parental involvement and incentives for attendance, assigning adult and peer
mentors to youths at-risk for prematurely leaving school, and employing flexible school-based responses to chronic
attendance problems are particularly effective strategies (Kearney & Hugelshofer, 2000; Reid, 2003b; Scott & Friedli,
2002).

11. Outcome

As mentioned earlier, youths with chronic school absenteeism and school refusal behavior are at risk for
delinquency and school dropout in adolescence and various economic, psychiatric, social, and marital problems in
adulthood. In fact, school refusal has been identified as a key variable for the persistence of separation anxiety disorder
into adulthood (Silove et al., 2002). Youths who receive intervention for these problems may be at less long-term risk,
however.
McShane and colleagues followed 117 adolescents with school attendance difficulties 6 months and three years
following inpatient or outpatient intervention. At 6-month follow-up, adolescents had either resumed schooling (47%),
enrolled in home schooling or vocational college with some employment (23%), were unemployed (19%), enrolled in
home schooling (10%), or were fully employed (1%). At 3-year follow-up, adolescents were enrolled in home

Table 5
Systemic strategies relevant for reducing absenteeism
Reducing violence, bullying, and parent/child-school official conflict (Astor, Meyer, Benbenishty, Marachi, & Rosemond, 2005; Woody, 2001)
Increasing parent–teacher collaboration, particularly in cases of ethnic differences (Broussard, 2003)
Increasing positive school climate and easing transitions between schools (Reid, 2003a)
Customizing curriculum and instruction to student needs with advocates/mentors (Lever et al., 2004; Reid, 2007)
Early education, family, and health services (Reynolds, Temple, Robertson, & Mann, 2001)
Court referral and community services (Fantuzzo, Grim, & Hazan, 2005; Garrison, 2006; McCluskey, Bynum, & Patchin, 2004; Schoenfelt &
Huddleston, 2006)
Police pick-up of absentee students with immediate school return and consequences (White, Fyfe, Campbell, & Goldkamp, 2001)
 C.A. Kearney / Clinical Psychology Review 28 (2008) 451–471 465

schooling or vocational college with some employment (36%), remained in school (22%), were fully employed (18%),
were unemployed and not in education (16%), or were in home schooling (8%) (McShane, Walter, & Rey, 2004).
Poorer outcome at 6 months was associated with comorbid diagnoses such as major depression, dysthymia, and
oppositional defiant disorder. Poorer outcome at 3 years was associated with social phobia, academic difficulties, and
withdrawn behavior. Although outcome was satisfactory for 70–76% of adolescents, these results mirror earlier
findings that about one-third of youth treated for school attendance difficulties continue to have serious adjustment
problems later in life (Kearney, 2001). Other researchers have also found, over a 10-year follow-up period, that 30% of
youths with school refusal continued to meet criteria for a psychiatric disorder (McCune & Hynes, 2005).
Predictors of school dropout in recent studies reveal several individual factors to be particularly salient, especially
psychiatric comorbidity, adolescent employment, and low socioeconomic status. However, researchers have begun to
gravitate toward developmental models of problematic absenteeism, contending that multiple predictors compound
over time to produce premature departure from school. These multiple predictors include socioeconomic, behavioral,
family, and attitudinal variables (Alexander, Entwisle, & Kabbani, 2001; Attwood & Croll, 2006; Jimerson, Egeland,
Sroufe, & Carlson, 2000; Warren & Lee, 2003).
In one possible scenario, for example, a child may be initially predisposed toward absenteeism via placement in
family and educational systems that do not closely monitor or value school achievement and attendance. During middle
school, adverse events such as bullying or teacher–student conflict could exacerbate achievement and attendance
difficulties or may intertwine with undiagnosed child psychopathology such as anxiety, depression, or learning disorder.
Problematic absences or dropout may escalate in high school years as these increasingly severe problems lead to school
failure or may intersect with new alternatives to school attendance, such as outside employment. More extensive
longitudinal research is necessary, however, to specifically identify pathways leading to chronic nonattendance and
eventual dropout.

12. Final comments

School absenteeism and school refusal behavior continue to represent critical public health problems for educators
and health and mental health professionals. A key problem with the research literature in this area, however, is a general
disconnection between sets of professionals who use varying terminology, publish in different journals, and investigate
only specific subsets of youths with problematic absenteeism. Greater coordination and synthesis of research
information is necessary to fully understand and address this complex population. Cross-disciplinary investigations,
conferences, and grant proposals, for example, might be helpful in leading to improved consensus regarding definition,
classification, assessment, and intervention. Pertinent disciplines include psychology, medicine, education, social
work, criminal justice, law, and sociology. In addition, mental health professionals within schools should educate
teachers and others about symptoms and assessment and intervention methods for school refusal behavior.

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