1 – Introduction

1.1 Non-attendance at school – The statistics

During their school career, many children and young people will experience a period of non-attendance (Kahn and Nursten, 1968; Reid, 1985; Lauchlan, 2003; Fortune-Wood, 2007; Thambirajah et al. 2008). For many, this will be an infrequent absence that tends to last for a short period of time, which can be for a multitude of reasons. However, for some, long term non-attendance will be a bigger problem. The broad terms used to describe the behaviour of pupils who fail to attend school are School Non-Attendance (SNA) or School Absenteeism (Thambirajah et al, 2008). These terms cover all types of absences from short-term illness to truancy, whether initiated by the student, the school and/or parent.

The issue of school attendance is currently the focus of intense activity in schools and local education authorities in England (George et al. 2010; Hands et al, The National Audit Office 2005). The Department For Education (DfE) release school attendance figures three times each academic year, specifically, the autumn term release, the combined autumn/spring term release and the full year release. The DfE (2016) reported that there has been a slight increase (0.1%) in the overall absence rate in state funded primary, secondary and special schools between the academic year of 2013/14 and 2014/15. Despite this slight increase, school absence rates in England have remained relatively stable since 2013/14, with a general decline in overall absences rates since 2006/07. However, the reasons for this are not expressed within the literature. The highest rate for school absence is in state funded special schools (9.1%) in 2015/16. Due to the nature of these schools, with their wide variety of complex issues, special schools will be excluded from the rest of this research. Overall absence rates in state funded secondary schools have remained relatively stable (around 5.2%-5.3%) between 2013/14 and 2015/16. An alarming, yet relatively unsurprising, statistic is that pupils in national curriculum year group 11 have the highest overall absence rates at 6.2%. This could be because of the intense pressure students feel at this stage of their schooling as they sit their GCSEs before the next transition of their lives. However, the obvious impact of this is very concerning. There is a significant difference in the absence rate in state funded primary and secondary schools with 1.2% more absences in secondary schools compared to primary. The reasons for this will be explored later in this project. The Department For Education (2016) state that the most common reason for absence is illness, accounting for 57.3% of all absences. However, it was also reported that 1 in 10 students in schools in England were persistent absentees during the academic year of 2015/16. The Department For Education defines persistent absence “as pupils that miss 10% or more of their possible school sessions during an academic year”. The proportion of students classified as persistent absentees in state funded primary, secondary and special schools in 2015/16 was 10.5%, a 0.5% decrease from 2014/15. The persistent absence rate for state funded secondary was 13.1%. On the face of it, this rate is quite low but involves a large number of students. Despite this, persistent absentees account for almost a third (30.9%) of all authorised absence and more than half (53.8%) of all unauthorised absence (DfE, 2016). Although the Department For Education provides in depth statistics about school absence rates, it fails to break these down geographically, ethnically and socio-economically. Therefore, little conclusions can be drawn into the possible reasons for persistent absences so further analysis of the statistics is not possible.

Prolonged and persistent absences, remains a puzzling and complex problem, in which schools must distinguish between authorised absence and unauthorised absence (Thambirajah et al, 2008). For an absence to be authorised, permission from the school has been granted for the student to be absent. This permission may be obtained by receiving an explanation in advance or after the absence. An unauthorised absence is an absence that has not gained permission from the school and includes unjustified absences. Additionally, it is also important to distinguish between a SNA and a child that is home schooled, a traveller or a young person at work. In the UK, it is the parents’ responsibility to ensure a child receives a full-time education from the age of 5. However, the child does not have to attend a school or follow the national curriculum (GOV.UK, 2017). A child can be educated at home, with permission from the school and local education authority (LEA). However, if the LEA are unsatisfied with the quality of education received they can serve a school attendance order, which the parents must adhere to by sending their child to school to be educated (GOV.UK, 2017). As well as home schooling, travelling children also have the right to an education, which due to the nature of these children’s lives can be difficult for them to attend school. In 2008 the Department For Education established the Taskforce on Traveller Education, which produced the action plan Traveller Child in Education Action Framework. The main aim of this was to support schools, children and parents with travelling children. Therefore, home-schooling and travelling children will be excluded from further description and data analysis. This is due to the poor accessibility to the records and research regarding these groups of children.

In addition to authorised and unauthorised absence, Whitney (1994) stated that condoned absence is when there is a failure on the parent’s legal duty to ensure their child attends school. Whitney (1994) stated that there may be several reasons for a ‘condoned’ absence for example; the need for the child to work in the family business, moving around the country, looking after sick relatives or younger children, exploiting their parent’s lack of interest in education. However, Whitney (1994) also stated that condoned absences can be initiated by the school for example as a “cooling off” period after an incident. Sometimes it is in the best interest of the school for the child not to attend, for example when waiting for admissions to alternative schools.

School attendance is extremely important, and a persistent lack of attendance can obviously lead to poor academic performance due to the number of lessons missed (Fremont, 2003). Also, it can disrupt social and extracurricular activities, which may lead to isolation and depression (King and Bernstein, 2001). Persistent school non-attendance can also affect family and peer relationships negatively (Berg and Nursten, 1996). The problems in social adjustment due to the strain on peer relationships could, in the short-term, lead to child and family distress. Sometimes, due to the need of supervision of the child, legal and financial difficulties give rise to family conflict and disruption (Kearney, 2001). In the long term, persistent lack of school attendance can cause psychiatric disturbances, economic deprivation, marital and occupational problems and social maladjustment (Berg and Jackson, 1985; Hibbett and Fogelman, 1990).

1.2 School absence – Truancy Vs School Refusal debate

This research project is focused on the specific SNA known as School Refusal, which can often be referred to as School Phobia, however this term is unhelpful as the root of the behaviour may not have anything to do with school itself (Whitney, 1994). It is important to understand the differences between school refusal and truancy.

What is truancy?

Truancy is a complex term to define (Reid, 1985). This is due to the issue of parental knowledge and consent around the absence. Since the beginning of the 19^th Century the term “truant” and related terms have been used interchangeably to describe SNA. This further complicates the defining of the term. Truancy as a dictionary definition provided by the Oxford English Dictionary online (2017) is “the action of staying away from school without good reason”. This definition offers no clarity in the knowledge of the absence, for example, the knowledge of the parents of the child’s absence is unknown. Thambirajah et al. (2008) attempted to clarify the terms surrounding SNA and states that students who are absent through truancy are absent without the knowledge and/or permission of parents, guardians, the school or any other person in authority. The definition of truancy for the use and purpose of this project is short-term absence from school without good reason and without the knowledge of parents.

In addition to the definition, it is also important to understand the characteristics and reasons for a student to be truant. Lauchlan (2003) stated that truancy is often linked to conduct disorder (i.e. behavioural disorders), as a young person who truants often shows behaviours of defiance, antisocial behaviour, aggression and rule breaking (Thambirajah et al, 2008; Maynard et al, 2015; Egger et al., 2003; Vaughn et al, 2013). Further characteristics of truancy include the attempts to conceal the absence from parents; the lack of excessive fear or anxiety about attending school; the lack of interest in schoolwork and unwillingness to conform to expectations regarding academic achievement or behaviour and the tendency to avoid home during school hours (Thambirajah et al. 2008; Kearney, 2008; Fortune-Wood, 2007; Sewell, 2008; Elliot, 1999). Reasons for truancy include avoiding particular situations or lessons, peer pressure or just missing school because they “feel like it” (Whitney, 1994). Fortune-Wood (2007) stated that truancy should be regarded as a wholly voluntary act on the part of the child.

What is school refusal?

Unlike truancy, school refusal is characterised by young people having difficulty attending school and experience problematic levels of anxiety, fear or depression (Berg, 2002; Sewell, 2008).

Berg at el (1969) noted that students with school refusal behaviour share common characteristics. However, not all students present with the same symptoms at the same time and students may suffer with these symptoms to varying degrees. The behaviour displayed can be categorised into internalising and externalising problems. For example, internalised behaviour can range from generalised worrying, social anxiety, isolation, depression, fatigue, physical complaints e.g. stomach-aches, nausea, tremors and headaches. Externalised behaviour can include tantrums, screaming, crying, verbal and physical aggression and oppositional behaviour (Fritz, 2008).

Fritz (2008) stated that there are varying degrees of school refusal behaviour (SRB). This spectrum of SRB varies from an initial problem where the behaviour usually only lasts for a brief period, which it resolved without intervention, to substantial SRB, which occurs for a minimum of two weeks. Furthermore, acute SRB is where there is a consistent problem for the majority of time during a two week to a one-year period. In contrast it can be a chronic problem, where SRB lasts more than one calendar year or two academic years. It is important to note that children who are persistently absent due to chronic illness or absence motivated by the school or parents are not noted as school refusers. The main driver behind school refusal behaviour is child-initiated, whether controlled by the child or due to a psychiatric problem.

Main differences between school refusal and truancy

In summary, some of the early literature does not distinguish between school refusal and truancy, However, contemporary literature does differentiate these terms and the behaviour associated with them. The main differences are that school refusers are excessively anxious or fearful about school. Therefore, parents are aware of the child’s absence from school, consequently when they are absent from school they remain at home. However, a truant does not exhibit these anxious or fearful tendencies and their absence can be attributed to behavioural reasons such as defiance or disinterest in school. In addition, a truant tries to conceal their absence from parents or guardians by avoiding home during school hours. After extensive reading of the literature around truancy and school refusal, school refusal seems to be the more complex reason for school absence. Therefore, this investigation will focus on school refusal.

2. Literature review

From here on, the main focus of this research will be based around school refusal and the definitions of school refusal defined above. This next section will outline the prevalence, reasons and identification of school refusal behaviour (SRB).

 2.1 Prevalence of school refusal

Statistics and prevalence rates for school refusal are contested in the literature. Some authors state that school refusal behaviour affects as many as 5-28% of school aged children (Kearney, 2001; Kearney and Albano 2004; Kearney and Bates 2005) whilst others state that school refusal occurs in about 1-2% of young people (Elliott, 1999; Kearney, 2008; Maynard et al, 2015). The statistics vary due to the definition used. For example, the higher prevalence rates could be explained if the definition of school refusal is expanded to include those who have trouble staying in school as well as those who refuse to go altogether. However, when the narrower definition is used, namely one that just incorporates those who refuse to go to school, the statistics are slimmed down to 1-2% of young people (Lyon, 2009). Furthermore, statistics presented in the literature do not take into account adolescents as a separate group. In addition, school refusal behaviour can be a term that combines both school refusal and truancy, it is therefore difficult to understand the real extent of school refusal due to the lack of differentiation amongst researchers (Havik et al, 2015). One criticism of these statistics around school refusal, is that they are estimates, and some authors suggest that official figures do not take school refusal into consideration (Thambirajah et al, 2008). This could be because of the lack of awareness of the extent and impact of school refusal, the difficulties in distinguishing school refusal from other groups of SNA amongst others (Thambirajah et al, 2008). A further criticism of the statistics regarding school refusal is that the understanding of the concept of school refusal, which makes the recordings of such behaviour difficult (Nuttall and Woods, 2013). The definition of school refusal behaviour that will be used in this research project is child-initiated absence from school. Also, the project will include those with severe distress at the prospect of attending school for unclear reasons or reasons which are part of an emotional/psychological disorder.

Despite the difficulties in the statistics, the onset of school refusal is a lot more definitive within the literature. Pellegrini (2007) stated that school refusal behaviours are likely to peak around 5-6 years and 11-13 years, in the UK these follow key transitions into school and the movement from primary to secondary school. This is supported by Packer (2010) who stated that 10.3 years is the average age of onset for school refusal. This suggests that school refusal tends to be more common among young adolescents entering a new school building for the first time (Kearney and Bates, 2005). School refusal does not tie itself to a particular group, the literature suggests that gender, race and income are equally represented groups when it comes to school refusal behaviour (Kearney and Bates, 2005; Sewell, 2008). This is supported by Berg (1997) who stated that both genders are equally affected by school refusal. There is no relationship between school refusal and social class or intellect or academic ability. This suggests that school refusal is an issue that can affect any child or adolescent. A deeper review of the literature is needed in order to understand the causes of school refusal. A criticism of this is that it is unclear on how these conclusions have been drawn. The literature read does not give indications of the empirical studies looking into SRB and ethnographic characteristics.

2.2 Reasons for school refusal

The research draws upon several reasons for school refusal. Many young people may meet criteria for multiple internalising and externalising behaviour problems. King and Bernstein (2001) stated that anxiety or depression may be significant factors in several cases of school refusal. According to Kearney and Albano (2004) the most common diagnoses for young people with school refusal are; Separation anxiety disorder (22.4%), Generalised Anxiety Disorder (10.5%), Oppositional Defiant Disorder (8.4%), Depression (4.9%), Specific Phobia (4.2%), Social Anxiety Disorder (3.5%) and Conduct Disorder (2.8%). Due to the nature of diagnoses, a lot of studies around these causes of school refusal come from psychiatric units or places where children are getting professional support. Consequently, there is a lack of community studies around the causes of school refusal behaviour. This could account for the fact that over half of school refusers have a medical diagnosis. A summary of some of these psychological reasons behind school refusal is outlined below. It is important to note, however, that a child can be a SR without a medical diagnosis. The other reasons for SRB are also discussed in this section.

Separation Anxiety Disorder (SAD)

Separation Anxiety Disorder is a diagnosis given to individuals who have an unusually strong fear or anxiety to separating from people they feel a strong attachment to (American Psychiatric Association DSM-5, 2013). Thambirajah et al (2008) stated that separation anxiety is “normal” around the ages of one to three years old, where a child becomes anxious when separated from the primary care giver. The anxiety declines when the child starts nursery and by the time they are in full-time school the child is used to being away from the care giver for a significant period of the day (Thambirajah et al, 2008; Csoti, 2003; Morris and March, 2004). However, the sudden onset or developmentally inappropriate and excessive anxiety at the point of, or lead up to, separation from the home or primary caregiver is known as separation anxiety disorder.  Thambirajah et al (2008) stated that the most common onset of separation anxiety disorder is middle childhood (between 7-12 years old). School refusal is a common feature associated with SAD (Morris and March, 2004). However, it is clear that not all children with SAD present SRB and not all children with SRB present with SAD. There are many other causes of SRB. Last and Strauss (1990) found that 24 of 63 school refusing youths (ages 7-17) were primarily diagnosed with SAD. Suggesting it can be a significant contributor to SRB but not always the primary reason.

Generalised Anxiety Disorder (GAD)

Morris and March (2004) stated that worry is the defining feature of Generalised Anxiety Disorder (GAD). In a person with GAD, worry tends to be more intense, prolonged and uncontrollable than someone without GAD. Thambirajah et al (2008) stated that this type of anxiety does not derive from separation from parents, school, social situations or any other event but is “free floating” and present most of the time. Therefore, the severity of GAD can have marked impairments in social, educational and recreational realms. The worry is not merely worrying about the immediate future e.g. an up and coming test at school, but can include worry about personal future, health, performance and also that of others. Weems et al (2000) found that school was in the top five things that children with GAD worried about. Morris and March (2004) stated that it is not uncommon for children with GAD to avoid completing activities or events due to the fear that they may fall shy of perfection. This could be a reason why children with GAD could refuse to attend school. However, like SAD not all young people with GAD will refuse to go to school.

Specific Phobia

Specific phobias are the fears of a specific stimuli. Fears are part of the normal day-to-day course of development for children (Gullone, 2000; Ollendick et al, 1997). These fears are normally short-lived and often do not cause distress beyond the normal reactions (King et al 1998). However, children suffering from specific phobias are characterised by the clear and persistent excessive or unreasonable fear. In the event of specific phobia and school refusal, the stimuli is school (or is school related). Children with specific phobias often know that the fear is excessive or unreasonable however cannot control the immediate anxiety response or panic attack. Therefore, they avoid the situation as much as possible by refusing to go to school.

Social Anxiety Disorder

Thambirajah et al (2008) reported that social anxiety was common in around 50% of the sample of 12-17-year olds in a community study. Like all the previous disorders, it is normal to experience some social anxiety that is normally short lived and transient. However, in some young people it can be severe and disabling. The characteristics of social anxiety disorder include the fear of being scrutinised, evaluated or being at the centre of attention in a negative light. Young people with social anxiety disorders may refuse to attend school as Beidel et al (1999) found 13 of the top 17 social situations that could provoke social phobias originate in school. These for example included: reading aloud in front of the class, speaking to adults, writing on the blackboard, taking tests, answering a question in class, asking teacher for help and eating in the school canteen.  This therefore could suggest why some adolescents with social anxiety disorders refuse to attend school.

Non-psychological causes of SRB

In addition to these psychological factors, there are a range of other external circumstances that could lead to school refusal such as; bullying, coping ability, classroom routines, difficulties in peer/teacher relationships, low academic concept and exam pressure. After reviewing the literature, bullying seems to be the reason most contested. Some researchers have found that bullying has a profound effect on school attendance whilst others have reported that bullying has little impact on school attendance. Knox (1990) reported that children who refuse to go to school (both school phobic and truant) give bullying as their main reason for not going. However, this is disputed by O’Keeffe and Stoll (1994) who found that out of the 38,000 adolescents from 150 schools surveyed, only 2% reported bullying to be the underlying factor behind their unauthorised absence. A criticism of this study was that the respondents had to fill out questionnaires. This raises questions of reliability of this study due to the problems of this particular data collection method. Also, the main aim of the study was to broadly look into truancy and persistent school absenteeism rather than just school refusal. It is therefore impossible to pick out data just related to school refusal. This was also supported by Smith and Ford (1995) who stated that bullying was not cited by any pupil in their research study as a cause of blanket truancy with only 1% stating that bullying was a reason for post-registration truancy. It appears that bullying can be a contributing factor in school refusal cases but less prominent in truancy. For example, McShane et al (2001) found that 14% of the 191 students surveyed quoted bullying as part of the reason why they have refused to go school.

Another possible cause of school refusal is the pressure that surrounds academic achievement and exam success. Since the No Child Left Behind Act of 2001, there has been an increased focus on the importance of standardised testing. These tests can affect school funding, thus creating pressure, real or perceived, onto students to perform well so that schools can maintain, or receive higher, funding (Segool et al, 2013). This pressure can lead to school refusal behaviour from students who do not see themselves as academic. They do not want to “fail” as this could bring on negative feelings, which they wish to avoid.

Havik et al (2015) found that an important direct factor that can lead to school refusal behaviour, is poor relationships with peers at school. They also found that students in secondary schools indirectly attributed their school refusal behaviour to the lack of ability to manage classrooms by teachers. For example, students surveyed stated that teachers failed to prevent bullying and social exclusion. The students also reported poor support from teachers. The results in this study could be considered reliable as a large number of participants were used, 5465 students from 45 schools across seven districts in Norway. However, the research design of a self-report questionnaire raises questions about the reliability of these results (Havik et al, 2015).

Summary of reasons behind school refusal

Thambirajah et al (2008) stated that factors that contribute to school refusal can be separated into child factors, family factors and school factors. These are summarised by Thambirajah in the table below:

Thambirajah et al (2008, P36)

A criticism of the causes of school refusal is put forward by Havik et al (2015) who stated that research into the causes of school refusal behaviour is normally centred around a clinical or family approach with samples often being taken from child mental health clinics. This limits the information obtained about the role of the school in school refusal behaviour. Havik et al (2015) also stated that research lacks the use of control groups. The perspective of the family and individual child is also lacking. In addition to this, Evans (2000) stated that children and young people who present with school refusal behaviour may meet the criteria for multiple internalising and externalising behaviours.  These difficulties arise in trying to determine the cause and effect of school refusal behaviours and disorders. What is clear is that the reluctance to attend school, no matter what the cause, can lead to social, emotional, and educational problems (Fremont, 2003).

2.3 Intervention strategies for school refusal

There are a range of intervention strategies explored within the literature that help school non-attenders to re-enter the classroom. Strategies used for students with a medical diagnosis are primarily based around psychosocial interventions such as Cognitive-Behavioural Therapy (CBT) or emotion regulation. These methods are used on an individual and group basis, which can also involve the parents as part of the strategy. However, there are also school based intervention strategies that are used for school refusal with students both with and without a diagnosis of an underlying issue. A range of intervention strategies will be evaluated in this next section.

Berg (1997) stated that the treatment of choice is early return to school. To achieve this a coordinated action plan from the family, school, community workers and medical professionals is needed. He stated that there needs to be a speedy investigation to rule out any physical cause for the symptoms associated with SRB. If no physical cause is found, then a referral to mental health services should be promptly followed.

Behavioural approaches

Eilliot (1999) stated that there are a number of behavioural programmes that can be used to help treat SRB. Many of which are primarily based on exposure to the school environment and draw upon several techniques such as systematic desensitisation (removing the fear and replacing it with relaxation responses to the stimuli), modelling, contingency management (reinforcement of positive behaviours), emotive imagery (imagining the stimuli that brings negative emotions, whilst relaxing and being comforted and protected) and flooding (forcing return to school).

The ethical appropriateness of one behavioural technique, in particular flooding which encourages the “forced” return to school, has been at the centre of much controversy amongst researchers and practitioners (Eilliot, 1999). However, there are some supporters of this forced return. They stated that it is most appropriate for cases where onset of school refusal behaviour is rapid with no prior history of similar problems (Kennedy, 1965). However, this technique can prove highly stressful for all parties involved (Elliot, 1999).

In contrast, there are other techniques that employ graduated exposure rather than forced or rapid return, these are desensitisation approaches. These approaches are more suited to cases where high levels of anxiety are present and include the child returning to school for activities that cause minimal anxiety. Systematic desensitisation, emotive imagery, contingency management and modelling, are all techniques based around classical conditioning. The aim is to progressively reduce the child’s anxiety around the stimulus, the school, thus increasing the child’s attendance to school (Lazarus et al, 1965; Lazarus and Abramovitz, 1962). Gradual return to school is considered to be less stressful and unsettling for all parties involved. This method works well for cases where the child suffers from severe anxiety. It is said to be more effective with adolescents with chronic school refusal (Kractochwill and Morris, 1991).

There is debate amongst researchers as to which behavioural technique works better, forced return or gradual return. There is strong evidence to suggest that forced return to school is more successful. Kearney and Beasley (1994) found that forced return was 100% successful at increasing school attenders. Whether forced return was successful or not, this method raises serious ethical questions, both from the parents and child’s point of view. It is therefore questionable whether this technique should be ever used.

Psychosocial interventions

Most psychosocial approaches to the treatment of school refusal behaviour focus on play therapy, psychotherapy, family therapy, counselling and Cognitive Behavioural Therapy (CBT) (Lingenfelter and Hartung, 2015; Heyne et al, 2001).

The most extensive research on treatments for SRB focuses on CBT where a wide range of case studies and randomised controlled clinical trials have supported positive outcomes of this intervention strategy (Heyne et al, 2004; Kearney and Bates, 2005; King and Bernstien, 2001; King et al. 2000). Compared to other intervention strategies CBT takes less time and is less costly (Heyne et al, 2001).

CBT is a combination of behavioural techniques and psychological interventions that work on changing the child’s perceptions and anxiety-provoking thoughts. The main aim of CBT is to change the negative perceptions into more positive thoughts. It has been proposed that when working with school-refusing children there are four essential components of CBT; relaxation training, cognitive therapy, exposure to the feared stimuli and the enhancement of social competence (Pellegrini, 2007; Heyne et al., 2004). There have been many studies on the use of CBT as an intervention strategy with SR children, King et al. (2000) stated that there is some evidence of its success. However, more empirical studies are needed to fully evaluate the effectiveness of the strategy.

CBT is not 100% effective in treating school refusal behaviour, due to the complex nature of conditions that could lead to SRB. However, it is highly effective in a large percentage of cases. King et al (1998) found that 88.23% of the 34 children in the treatment group showed a significant improvement in school attendance by returning to normal school attendance (defined as attending school 90% of the time). The comparative control group only achieved a 29.41% attendance rate. This study raises ethical questions regarding the use of control groups in intervention studies. This is because children in the control group do not receive the same help, thus being disadvantaged.

Heyne et al (2011) found significant and maintained improvements in school attendance. They also found a reduced number of examples of self-reported school-related fear and anxiety when using the modular programme of CBT known as the “@school programme”. This treatment programme involved 20 adolescents (and their parents) who took part in ten to fourteen 1hour to 1.5hour sessions. Topics in the programme included; putting problems in perspective, setting goals, managing stress, thinking about teenage years, dealing with depression and solving family problems. Although there were significant improvements in school attendance, this study does not come without it’s criticisms. One such criticism is that it is an uncontrolled study with a small ethnically homogenous sample. Thus, the results found in the study cannot be applied to the general population. Also, the long-term effectiveness of this treatment is unreliable due to the short time, 2 months, used for following up. In order to improve the reliability and applicability of this study longer follow up periods are needed. It was suggested by the authors that a group intervention strategy may be needed for socially anxious school refusers.

Long-term successes with CBT were also questioned by Tolin et al (2009) who found that 3 out of the 4 cases showed demonstrable and meaningful improvement in school attendance and students were able to re-enter the public-school system. However, none of the students sustained 100% attendance over a long period of time with all eventually opting for alternative educational provisions. They also found that the risk of future school refusal behaviour increases after school holidays, even in successful treatment cases. Tolin et al (2009) completed a study using the “School Refusal Programme” with 4 adolescent boys and their parents. This treatment programme incorporates 15 sessions of CBT 5 days a week for 3 weeks. It is derived from existing school refusal programmes as well as other child anxiety interventions. A criticism of these studies is that intensive treatment such as this is unsustainable in practice.  A more realistic time scale suggested by researchers is 6-8 sessions of CBT over 3-4 weeks with follow up sessions (Heyne et al, 2001).

School based interventions

Despite the clinical approaches to the treatment of school refusal behaviours, it is important to recognise the importance of school based interventions as well. Especially in the treatment of non-school attendance for children that do not have a diagnosis thus not qualifying for clinical help. There is much research that provides a variety of techniques that schools, and frontline professionals could use to help encourage school refusers back into the classroom. Techniques, that could be used include social care support, mentors, reward systems, part-time timetables, nurture groups and partial returns. Thambirajah et al (2008) stated that successful treatment of the anxiety that is associated with SR will ensure successful and sustained return to school.

The first step of school based intervention suggested by many researchers is to conduct an assessment on the causes of the school refusal behaviour (Sewell, 2008). Whether this be anxiety around the school or other anxieties that is inhibiting the child from attending school. Thambirajah et al. (2008) stated that there should be four steps to combat school refusal behaviours; one early identification. The earlier the problem of low attendance is spotted, the easier it will be to prevent, combat and address the issue. The second is prompt assessment. Identifying the factors that led to such behaviours is paramount to be able to address them and ensure a successful return to school. Thirdly, it is early intervention. Rather than waiting on a medical diagnosis or clinical help it is often the view that early intervention at school will reduce the problems in the future. Finally, there should be a graded return to school. A Return to School Plan (RSP) should be constructed that is realistic, individualised and agreed by all parties involved.

Kearney and Bates (2005) provided a comprehensive list of common school-based techniques. These include an increased monitoring of daily attendance, assignment of a “buddy” or special assistant who helps a child attend classes on time and to complete work. It is important to give frequent recognition and reward of school attendance. They also suggest that increased participation of the child in work-study placements as well as extracurricular or other social activities could also help to increase school attendance.

Reid (1985) suggested that schools and teachers need to adopt child-centred approaches to school refusal behaviour. The school should work sympathetically to remove the barriers and anxieties that cause the child to refuse school. It is suggested that changes to the curriculum, pastoral care, teacher attitude and individual programmes are essential in order to encourage return to school.

If students have received clinical treatment, Lingenfelter and Hartung (2015) suggested that there should be a transition period. During this time the school should provide the opportunities needed in order for the child to practice skills learnt during clinical treatment so that there is a successful re-entering to school. The following list of school-based techniques have been suggested by the Anxiety and Depression Association of America (2014)

Other school based interventions include curriculum and timetable adjustments. It is suggested by Thambirajah et al (2008) that the demands and teachers of specific curriculum subjects could be a cause of SRB. It is therefore suggested that providing the child with a reduced timetable, where, on a temporary basis, the child is exempted from lessons and/or demands of teachers that lead to heightened anxiety levels. It is also suggested that reducing the amount of time the child is expected to stay in school for can reduce the anxiety levels. It would allow the child to feel as though they can be in the school environment on a part time basis (Nuttall and Woods, 2013).

Factors that contribute to successful treatment

There are several factors that contribute to the successful treatment and intervention of SRB so that students can return to school. Thambirajah et al (2008) stated that early identification and intervention are the keys to successful return to school. He also stated that a gradual return to school is more effective than full exposure. Kearney and Bates (2005) suggested that for sustained return to school and to reduce the risk of relapse then there needs to be follow up intervention sessions that could involve meetings with the student, family and school practitioners. This allows the child to regularly express feelings and ensures the school and family can continue to support and monitor the situation. What is important to note here is that what works for one child might not work with another. Also, what is successful in one school might not be successful in another. It is therefore important that a child-centred approach with a multitude of intervention strategies is used (Nuttall and Woods, 2013).

Summary of interventions

Maynard et al (2015) completed a systematic literature review. They found that there are very few studies that provide rigorous evidence for the success of intervention strategies for SRB. However, there are several intervention strategies that range from professional medical interventions such as behavioural or psychosocial interventions or school based interventions such as mentoring, reduced timetable and safe places. In many cases a combination of intervention strategies will be needed to be successful.

2.4 Main aims and research questions

From an initial review of the literature there are clear and defined areas of research conducted in this area. For example, much research has been done on the reasons and causes of school refusal and school refusal behaviour. In addition, there are also a range of intervention and treatment strategies explored within the literature. A lot of the research has a family or clinical approach where samples for many studies have been taken from child mental health clinics. Yet, there are few studies that take on the perspectives of SENCOs especially from nonclinical settings (Havik et al, 2015; Egger et al, 2003). Therefore, it would be an interesting and innovative approach within this research area to consider school refusal behaviour from the perspective of mainstream secondary school Special Educational Need Coordinator (SENCOs). Therefore, the research questions are:

1. How do mainstream secondary school SENCOs rate their own knowledge around School Refusal Behaviour?
2. What strategies have schools tried to encourage the pupil to attend school?
3. What has been the impact of those strategies and what would SENCOs recommend to other frontline professionals?

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