School Refusal and Psychiatric Disorders:
A Community Study
HELEN LINK EGGER, M.D., E. JANE COSTELLO, PH.D., AND ADRIAN ANGOLD, M.R.C.PSYCH.
ABSTRACT
Objective: To examine the association between anxious school refusal and truancy and psychiatric disorders in a community sample of children and adolescents using a descriptive rather than etiological definition of school refusal. Method:
Data from eight annual waves of structured psychiatric interviews with 9- to 16-year-olds and their parents from the Great
Smoky Mountains Study were analyzed. Results: Pure anxious school refusal was associated with depression (odds
ratio [OR] = 13, 95% confidence interval [CI] 3.4, 42) and separation anxiety disorder (OR = 8.7, 95% CI 4.1, 19). Pure
truancy was associated with oppositional defiant disorder (OR = 2.2, 95% CI 1.2, 4.2), conduct disorder (OR = 7.4, 95%
CI 3.9, 14), and depression (OR = 2.6, 95% CI 1.2, 56). Of mixed school refusers (children with both anxious school
refusal and truancy), 88.2% had a psychiatric disorder. They had increased rates of both emotional and behavior disorders. Specific fears, sleep difficulties, somatic complaints, difficulties in peer relationships, and adverse psychosocial
variables had different associations with the three types of school refusal. Conclusions: Anxious school refusal and truancy are distinct but not mutually exclusive and are significantly associated with psychopathology, as well as adverse
experiences at home and school. Implications of these findings for assessment, identification, and intervention for school
refusal are discussed. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(7):797–807. Key Words: anxious school refusal,
truancy, epidemiology, psychopathology.
Accepted January 21, 2003.
From the Center for Developmental Epidemiology in the Department of Psychiatry
and Behavioral Sciences at Duke University Medical Center, Durham, NC.
This project was supported by NIMH grants MH-02016 and MH-48085.
Dr. Egger receives support from an NIMH Career Development Award (5K23MH-02016) and a NARSAD Young Investigator Award. The authors acknowledge the assistance of Jane Duncan in the preparation of this paper.
Reprint requests to Dr. Egger, Developmental Epidemiology Program, DUMC
Box 3454, Durham, NC 27710; e-mail: hegger@psych.mc.duke.edu.
0890-8567/03/4207–07972003 by the American Academy of Child and
Adolescent Psychiatry.
DOI: 10.1097/01.CHI.0000046865.56865.79
et al. (1941) coining the term “school phobia,” defined
as an anxious fear of school caused by the child’s and
mother’s separation anxieties (Johnson et al., 1941). Most
definitions of anxious school refusal/school phobia used
in recent studies exclude children with antisocial features,
including truancy, or those who meet criteria for conduct
disorder (CD), reflecting the assumption that anxious
school refusal and truancy are mutually exclusive (Berg,
1992; Berg et al., 1969; Kearney and Silverman, 1995).
Hersov (Hersov, 1960a,b) conducted one of the first
studies to use descriptive, rather than etiologically derived
definitions of “school refusers” and “truants.” He concluded that truancy was an indication of CD, while school
refusal was a manifestation of an emotional disorder, with
anxiety more prominent than depressive symptoms, findings that have been broadly replicated in subsequent studies (King and Bernstein, 2001).
Hersov’s conclusion that refusal to attend school was
not a discrete clinical entity but rather an aspect of behavior in either an emotional disorder or a behavioral disorder is reflected in the DSM, where anxious school refusal
and truancy are symptoms, rather than distinct diagnoses
(American Psychiatric Association, 1994). A “persistent
reluctance or refusal to go to school…because of fear of
separation” is a symptom of SAD. “Often truant from
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797
Clinicians and researchers have commonly divided children who fail to go to school into two groups: those who
stay home from school because of fear or anxiety, and
those who skip school because of a lack of interest in
school and/or defiance of adult authority (King and
Bernstein, 2001). The behavior of the first group has variously been called “school refusal,” “anxious school refusal,”
“school phobia,” or a variant of separation anxiety disorder (SAD), while the behavior of the second group has
been called “truancy.” The terms used to describe nontruant school refusal reflect early conceptualizations of
the etiology of the behavior (for a review see Kearney and
Silverman, 1996). A variant of truancy arising from fear
rather than delinquency was identified in the 1930s and
1940s (Broadwin, 1932; Partridge, 1939), with Johnson
EGGER ET AL.
school” is a symptom of CD if it began before the age of
13. Fear of school can be an aspect of a specific phobia,
if the avoidance of school is caused by excessive or unreasonable fear of a specific stimulus.
Recent clinical studies point to three types of anxious
school refusers (King and Bernstein, 2001): those with
separation anxiety (Bernstein and Garfinkel, 1986; Kearney
and Silverman, 1996; Last et al., 1987), those with simple or social phobia (Last et al., 1987), and those who are
anxious and/or depressed (Agras, 1959; Bernstein, 1991;
Bernstein and Garfinkel, 1986; Gittelman-Klein and
Klein, 1973; Kolvin et al., 1984; Tisher, 1983).
There are few studies of school attendance problems and
psychopathology in nonclinical settings. In a study by Bools
et al. (1990), half of 100 children with severe school attendance problems met criteria for an ICD-9 psychiatric disorder, with the truants more likely to have CD and the
anxious school refusers more likely to have anxiety disorders. Berg et al. (1993) assessed 80 children who had
missed more than 40% of a term. Half met criteria for a
DSM-III-R psychiatric diagnosis. Both studies identified
a significant subset of children with both anxious school
refusal and truancy (9% in Bools et al.; 5% in Berg et al.),
challenging the idea that anxious school refusal and truancy are exclusive of each other. In Bools et al., 11% of
the mixed refusers had CD alone, 22% had an emotional
disorder alone, and 33% had mixed conduct and emotional problems.
Kearney and colleagues have argued that descriptive
definitions of school refusal, free of assumptions about
etiology or associated psychopathology, are critical to
understanding the associations between children’s refusal
to attend school and psychiatric disorders (Kearney and
Silverman, 1996). Community studies are needed to understand these associations prior to referral to mental health
providers. The primary purpose of this report is to examine the association between school refusal and DSM-IV
psychiatric disorders using definitions of school refusal
that do not presuppose the etiology (e.g., separation fears
or phobias), the relationship with psychopathology (e.g.,
by excluding those with CD), or the relationship between
types of school refusal in a population-based sample of
children. A secondary aim was to examine the association
between school refusal and specific fears, sleep difficulties,
and somatic complaints because these symptoms have
been linked to school refusal. The associations between
difficulties in peer relationships and adverse experiences
at home and school and school refusal were examined
primarily to explore whether these risk factors might be
contributing to a child’s fear/resistance to attending school
or leaving home.
798
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METHOD
Sample
The Great Smoky Mountains Study (GSMS) is an ongoing, longitudinal study of the development of psychiatric disorders in youths
living in North Carolina. Full details of the study design can be found
elsewhere (Costello et al., 1996).
Briefly, a representative sample of 4,500 children aged 9, 11, and 13
years, recruited through the Student Information Management System
of the public school systems of 11 counties in western North Carolina,
was selected using a household equal probability design. A screening
questionnaire, consisting mainly of questions about behavioral problems, was administered to a parent (usually the mother), by telephone
or in person. All children scoring above a predetermined cut point, plus
a 1-in-10 random sample of the rest, were recruited for detailed interviews. The response rate at the first wave was 80% (N = 1,422).
The composition of the GSMS sample is as follows: 44.4% female,
55.6% male; 69.9% white, 22.4% Native American, 6% African
American, 0.2% Asian, 0.5% Hispanic, and 1.1% other; education
attainment of primary parent: without high school diploma, 18.9%;
high school diploma, 57.2%; some college, 25.3%; degree from 4year college or more, 14.5%; 34.3% had a family income below the
federal poverty level.
In this report, we analyzed data from eight yearly waves of the
GSMS. In all, the sample included 6,676 annual observations on the
1,422 children aged 9 through 16. There were 517 observations for
the 9-year-olds, 500 for the 10-year-olds, 996 for the 11-year-olds,
753 for the 12-year-olds, 942 for the 13-year-olds, 883 for the 14year-olds, 1,228 for the 15-year-olds, and 856 for the 16-year-olds.
The age variability reflects the fact that partial cohorts were funded
at certain points in the study.
Measures
The child and primary caretaker were separately interviewed about
the child’s psychiatric status using the Child and Adolescent Psychiatric
Assessment (CAPA) (Angold et al., 1995), which generated a wide
range of DSM-IV diagnoses. The reference period was the 3 months
prior to the interview (Angold et al., 1996). Diagnoses and symptom
scales were generated by computer algorithms. All diagnoses, except
for attention-deficit/hyperactivity disorder (ADHD) (which was based
on parent report alone), were based on combined information from
both the parent and child.
The test-retest reliability (Angold and Costello, 1995; Costello
et al., 1998) and construct validity of the CAPA have been wellsupported (Angold and Costello, 2000).
Variables
As with psychiatric diagnoses, school refusal status was based on
combined information from both the parent and the child. The school
refusal groups were defined using items from two sections of the
CAPA. The “school/work performance and behavior” section addressed
truant behaviors and the “worry/anxiety over school attendance and
separation anxiety” section focused on anxious school-refusing behaviors. General absenteeism was not obtained for the children, but rather
school resistance and nonattendance was based on the combination
of relevant variables in these two sections. In both sections of the
CAPA, a specific requirement of a half-day of absence was required
SCHOOL REFUSAL COMMUNITY STUDY
to meet criteria for the school nonattendance items. The school refusal
variables were defined in the following way:
Anxious school refusers were defined as those children who failed to
reach or left school because of anxiety or children who resisted attending school because of anxiety so vigorously that they had to be taken
to school by their parent at least once during the primary period. Four
variables were included: school nonattendance (of at least a half-day’s
duration) due to worry/anxiety; staying home mornings from school
because of anxiety; failing to reach school or leaving school and going
home; and/or having to be taken to school because of worry and anxiety about attending school. Truants were defined as children who
failed to reach or left school without the permission of school authorities, without an excuse (such as illness), and for reasons not associated with anxiety about separation or school at least once in the primary
period. Four variables were included: skipping at least one-half day
at school for reasons other than separation or school anxiety; staying
home mornings; having to be taken to school to ensure arrival for reasons other than anxiety or emotional disturbance; and failing to reach
school or leaving school before dismissal.
Mixed school refusers were children who had been both anxious
school refusers and truants during the 3-month primary period. Pure
anxious school refusers endorsed only anxious school-refusing behavior and pure truants endorsed only truant behavior in the primary
period. Non–school refusers were children who did not resist or refuse
to attend school for either reason during the primary period.
Unfortunately, we did not have access to information from the school
administration or teachers about the children’s absences, school behavior, or school functioning. We also did not have information on mental retardation or learning disabilities.
The DSM-IV psychiatric disorders (American Psychiatric Association,
1994) considered in this report included SAD, generalized anxiety disorder, simple phobia, social phobia, panic disorder, depression (major
depression, depression-not otherwise specified, or dysthymia), CD, oppositional defiant disorder, ADHD, and substance abuse. We also examined the association between school refusal and specific fears and anxieties,
sleep difficulties, and somatic complaints because these symptoms have
been noted in the literature to be associated with school refusal.
The associations between school refusal and peer relationships, as
well as a broad portrait of psychosocial vulnerabilities, were also examined, to examine the hypothesis that adverse peer, school, and home
experiences might contribute to the development of a child’s fears and
resistance to attending school and/or leaving his/her parent. We used
a 26-item vulnerability scale created to reflect ongoing difficulties in
the child’s life and family that has been shown to be associated with
psychiatric disorders (Costello et al., 2002). It included items that pre-
vious studies have identified as risk factors for school refusal. The scale
included family environment problems, family relationship problems,
and parental psychopathology. The 26 items are listed in Table 5.
Data Analysis
The principal statistical procedure used was logistic regression. To
obtain properly adjusted estimates of the population parameters, we
used the generalized estimating equations implemented in SAS PROC
GENMOD. We used robust variance estimates (i.e., sandwich-type
estimates), together with sampling weights, to adjust the standard
errors of the parameter estimates to account for the two-phase sampling design and generate unbiased population parameter estimates
and produce appropriate odds ratios (ORs) and 95% confidence intervals (CIs) (Diggle et al., 1994; Pickles et al., 1995). We also introduced a random effect to account for correlations between the scores
of each individual across waves. The use of multiwave data with the
appropriate sample weights thus capitalized on the multiple observation points over time, while controlling for the effect on variance estimates of repeated measures.
We used both univariable and multivariable models to examine the
association between school refusal and psychiatric disorders. The univariable models examined whether the different types of school refusal
predicted the presence of a specific psychiatric disorder. In the multivariable models, we controlled for the effects of comorbidity by including the other major Axis I disorders as predictor variables, enabling us
to determine the amount of the variance that was accounted for by a
particular disorder. In all of the models, we controlled for the effects of
age and gender, as well as for the other types of school refusal. Percentages
reported were all weighted population estimates. Where cell sizes are
given, they represent unweighted numbers of individuals in the sample.
RESULTS
Prevalence
The 3-month prevalence of overall anxious school refusal was 2.0% (n = 165) and of truancy was 6.2% (n =
517). Anxious school refusers were 6.8 times more likely
than children without anxious school refusal to be truant (OR = 6.8, 95% CI 3.1, 15; p < .0001). A quarter of
anxious school refusers and 8.1% of truants were mixed
school refusers (0.5% prevalence; n = 35). Table 1 describes
TABLE 1
Characteristics of Three Types of School Refusal
Pure ASR
Pure truancy
Mixed school
refusal
Prevalence
Gender (F/M)
Mean Age
1.6% (130)
5.8% (482)
0.5% (35)
52.1%/47.9%
34.9%/65.1% a
48.1%/51.9%
12.3 b
14.7 c
13.0
Mean Age of
Onset
Frequency (HalfDays Missed)
10.9
13.1
ASR: 10.9
Truancy d:
Girls: 14.8
Boys: 10.6
4.2
6.6
Total: 34
Due to anxiety: 16
Due to truancy: 18
Note: Weighted percentages (unweighted n). ASR = anxious school refusal; OR = odds ratio.
OR = 1.9 (1.3, 2.9), p = .002.
b
More common in younger children, OR for age in years = 0.8 (0.7, 1.0), p = .009.
c
More common in older children, OR for age in years = 1.6 (1.4, 1.7), p < .0001.
d
OR = 2.8 (1.5, 4.4), p = .0008.
a
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EGGER ET AL.
the prevalence, gender, and age characteristics and frequency of the three subtypes of school refusal.
Psychopathology
Table 2 presents data on the prevalence of psychiatric
disorders in children with school refusal and the results
of models testing whether school refusal predicted the
presence of specific psychiatric disorders. The models
labeled “sole diagnosis (uncorrected)” did not control for
the effects of comorbid psychiatric disorders on the relationship between school refusal and the specific disorder.
The models labeled “multiple diagnoses (corrected),” controlled for the effect of comorbid psychiatric disorders
on the relationship between a specific diagnosis (e.g.,
SAD) and the subtypes of school.
A quarter of children with pure anxious school refusal
and with pure truancy had at least one psychiatric disorder, compared with 6.8% of children without school
refusal. Nearly 90% of the children with mixed school
refusal had a psychiatric disorder. We also found that
accounting for the effects of comorbidity revealed different patterns of association between school refusal and
psychopathology than were seen if only a single psychiatric diagnosis was examined. For example, all of the psychiatric disorders except panic disorder, ADHD, and
substance abuse were found to be associated with pure
anxious school refusal in an uncorrected model. Yet when
we controlled for the effects of comorbid disorders, only
depression and SAD remained significantly associated
with pure anxious school refusal.
Because simple and social phobia have been found to
be associated with anxious school refusal in clinical studies, we examined why they both dropped out of the pure
anxious school refusal multivariable model. Social phobia was highly predictive of simple phobia (OR = 75, 95%
CI 10, 547; p ≤ .0001) and depression (OR = 6.3, 95%
CI 1.2, 32; p = .03). When social phobia was removed
from the multivariable model, the association between
anxious school refusal and simple phobia was again significant (OR = 5.2, 95% CI 1.7, 16; p = .004). When simple phobia and depression were removed from the model,
social phobia was significantly associated with pure anxious school refusal (OR = 4.0, 95% CI 1.6, 11; p = .004).
The difference between the uncorrected and corrected
models was not as stark for pure truants. In the multivariable model, CD, depression, and oppositional defiant disorder were associated with pure truancy. Only
substance abuse dropped out. All of the disorders were
800
associated with mixed school refusal in the uncorrected
models, while in the corrected model SAD, CD, ADHD,
panic disorder, and substance abuse were significantly
associated with mixed school refusers.
There were no significant age or gender effects on the
association between the three types of school refusal and
psychopathology.
Associated Characteristics
Symptoms Associated With School Refusal. Table 3 examines the association between three groups of symptoms
(fears and worries, sleep difficulties, and somatic complaints) and school refusal. While pure anxious school
refusers had significantly higher rates of separation fears
and worries than children without anxious school refusal,
the rates ranged from 5% to about 18%, suggesting that
anxious school-refusing behavior was not synonymous
with separation fears and worries. The only separation
symptom significantly associated with the mixed school
refusal was “fear of what will happen at home while at
school,” which was found in 40% of these children. The
other prominent fear for both the pure anxious school
refusers and mixed school refusers was fear specific to the
school situation. Again, these fears must be considered
in light of the data in Table 4 on these same children’s
experiences with bullying and their difficulties in peer
relationships. None of the fears and worries was significantly associated with pure truancy.
Differing patterns of sleep difficulties were associated
with the three types of school refusal, with nightmares
and night terrors prominent in the mixed school refusers,
depression-associated sleep symptoms associated with the
pure truants, and depression and separation-associated
sleep difficulties associated with the pure anxious school
refusers. Somatic complaints were found in a quarter of
pure anxious school refusers, 42% of the mixed school
refusers, and very few of the pure truants. No significant
age or gender effects were found for the associations
detailed in Table 3.
Peer Relationships. Table 4 shows the associations of
school refusal with difficulty in peer relationships. The
pure anxious school refusers appeared to have the most
difficulty in peer relationships. They were significantly
shyer, experienced being bullied or teased, and had difficulty in their peer relationships both because of withdrawal and increased conflict more often than nonschool
refusers. The mixed school refusers were not more likely
to be shy, but there was a trend suggesting that they were
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24.5%
(37)
10.8%
(30)
2.2%
(8)
2.1%
(5)
3.2%
(11)
0.3%
(2)
13.9%
(22)
1.3%
(3)
5.6%
(16)
5.0%
(13)
0
25.4%
(134)
0.3%
(3)
0.6%
(6)
0.2%
(2)
0.2%
(2)
0.2%
(3)
7.5%
(31)
0.5%
(5)
9.7%
(67)
14.8%
(79)
4.9%
(36)
Pure
Truants
11.6%
(2)
15.5%
(8)
13.1%
(1)
17.9%
(8)
43.4%
(12)
13.1%
(5)
0
88.2%
(21)
14.4%
(4)
3.4%
(3)
0
Mixed
School
Refusers
6.8%
(490)
0.8%
(70)
0.8%
(57)
0.2%
(9)
0.5%
(22)
0.2%
(18)
1.6%
(118)
0.9%
(99)
2.3%
(254)
1.6%
(180)
0.8%
(44)
NonSchool
Refusers
8.7 (4.1, 19)
p < .0001
0.2 (0.0, 1.4)
p = .1
1.9 (0.2, 19)
p = .5
1.4 (0.2, 9.7)
p = .8
0.4 (0.0, 5.6)
p = .5
13 (3.4, 42)
p = .0001
0.8 (0.2, 3.1)
p = .8
1.1 (0.5, 2.6)
p = .8
1.9 (0.9, 4.2)
p = .1
Not applicable
Multiple
Diagnoses
(Corrected)
No cases
3.0 (1.8, 5.2)
p < .0001
11.0 (4.9, 24)
p < .0001
2.9 (1.0, 8.0)
p = .05
11.0 (3.3, 39)
p = .0001
6.6 (2.6, 17)
p = .0001
2.0 (0.2, 17)
p = .5
10 (4.1, 26)
p < .0001
0.9 (0.2, 4.3)
p = 0.8
2.3 (1.2, 4.4)
p = .009
2.6 (1.2, 5.6)
p = .01
Sole
Diagnosis
(Uncorrected)
Pure Anxious School Refusal
3.6 (2.4, 5.4)
p < .0001
1.0 (0.2, 4.1)
p = 1.0
0.7 (0.2, 2.0)
p = .5
0.6 (0.1, 3.8)
p = .6
0.3 (0.1, 1.4)
p = .1
0.7 (0.1, 3.7)
p = .7
3.9 (1.9, 8.0)
p = .0002
0.8 (0.3, 2.5)
p = .7
3.8 (2.2, 6.5)
p < .0001
8.4 (4.4, 16)
p < .0001
3.1 (1.3, 7.1)
p = .0009
Sole
Diagnosis
(Uncorrected)
1.0 (0.2, 5.1)
p = .9
0.2 (0.0, 1.1)
p = .06
1.7 (0.1, 21)
p = .7
0.2 (0.0, 8.4)
p = .4
0.2 (0.0, 4.2)
p = .3
2.6 (1.2, 5.6)
p = .01
0.5 (0.1, 2.0)
p = .3
2.2 (1.2, 4.2)
p = .01
7.4 (3.9, 14)
p < .0001
1.7 (0.6, 4.9)
p = .3
Not applicable
Multiple
Diagnoses
(Corrected)
Pure Truancy
Multiple
Diagnoses
(Corrected)
38 (11, 135)
5.7 (1.1, 31)
p < .0001
p = .04
8.5 (3.1, 23) 0.8 (0.2, 2.7)
p < .0001
p = .7
16 (2.2, 104) 13 (1.2, 132)
p = .004
p = .03
8.8 (1.6, 47) 2.9 (0.2, 34)
p = .01
p = .4
32 (9.5, 110) 17 (4.2, 66)
p < .0001
p < .0001
25 (5.3, 119) 4.9 (1.4, 18)
p < .0001
p = .02
No cases
49 (21, 116) Not applicable
p < .0001
19 (3.3, 110) 19 (5.3, 72)
p = .001
p = .002
4.4 (1.0, 19) 1.3 (0.2, 11)
p = .04
p = .8
No cases
Sole
Diagnosis
(Uncorrected)
Mixed School Refusal
OR (CI) and p Values From Univariable (Uncorrected) and Multivariable (Corrected) Models
Note: Bold values have p ≤ .05. OR = odds ratio; CI = confidence interval; SAD = separation anxiety disorder; GAD = generalized anxiety disorder; ADHD = attention-deficit/
hyperactivity disorder; ODD = oppositional defiant disorder; CD = conduct disorder.
Substance abuse
CD
ODD
ADHD
Depression
Panic
Social phobia
Simple phobia
GAD
SAD
Any diagnosis
Pure
Anxious
School
Refusers
Weighted Percentage (Unweighted n) With Disorder
TABLE 2
School Refusal and Psychiatric Disorders
SCHOOL REFUSAL COMMUNITY STUDY
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EGGER ET AL.
TABLE 3
Symptoms Associated With School Refusal
Pure Anxious
School Refusers
Fears and worries
Worries about leaving home
for school
Fear of what will happen
at home while at school
Worry about harm befalling
parent
Worry about calamitous
separation from parent
Fear specific to school
Performance anxiety
Social anxiety
Sleep difficulties
Night terrors
Nightmares
Trouble falling or staying asleep
Fatigue
Reluctant to sleep alone
Rises to check on family during
the night
Somatic complaints with separation
or school attendance
Headaches and stomach aches
Mixed
School Refusers
Pure Truants
Weighted %
(n)
OR (CI)
p Value
Weighted %
(n)
OR (CI)
p Value
5.1%
(14)
16.7%
(27)
17.7%
(40)
5.5%
(9)
35.5%
0.2%
(2)
0.5%
(5)
4.3%
(28)
0.6%
(6)
0.7%
0.8%
(8)
1.8%
(10)
2.4 (0.5, 12)
p = .3
0.5 (0.2, 1.2)
p = .1
1.3 (0.6, 3.1)
p = .5
1.1 (0.4, 3.1)
p = .8
0.4 (0.2, 1.0)
p = .05
0.6 (0.2, 1.5)
p = .3
0.6 (0.2, 1.9)
p = .4
0.5% 1.3 (0.1, 19)
(1)
p = .8
40%
39 (6.5, 237)
(9)
p < .0001
6.1% 1.1 (0.3, 3.6)
(5)
p = .9
1.4% 0.8 (0.1, 6.8)
(1)
p = .8
54%
51 (14, 186)
p < .0001
1.4% 0.9 (0.1, 7.6)
(1)
p = .9
14.2% 4.6 (0.7, 31)
(2)
p = .1
0.3%
(16)
1.7%
(112)
4.8%
(377)
1.4%
(90)
2.4%
6.7%
(14)
8.5%
(17)
15 (5.1, 47)
p < .0001
9.5 (4.5, 20)
p < .0001
3.0 (1.5, 6.0)
p = .001
2.9 (0.9, 9.7)
p = .8
20 (10, 39)
p < .0001
4.5 (1.6, 12)
p = .004
2.1 (0.7, 6.1)
p = .2
18.1%
(23)
13.5%
(27)
31.5%
(45)
12.1%
(19)
8.1%
(13)
25.9%
(35)
2.0 (0.7, 6.1)
p = .2
1.6 (0.7, 3.9)
p = .3
2.6 (1.5, 4.5)
p = .001
4.7 (1.9, 12)
p = .001
9.4 (2.9, 31)
p = .0002
6.4 (2.7, 15)
p < .0001
13.5%
(68)
2.4%
(18)
19.4%
(104)
10.4%
(44)
0.2%
(2)
3.7%
(21)
1.1 (0.6, 1.8)
p = .8
0.6 (0.2, 1.8)
p = .4
1.6 (1.0, 2.3)
p = .03
3.1 (1.7, 5.8)
p = .0004
1.0 (0.2, 5.6)
p = 1.0
1.4 (0.5, 4.3)
p = .3
31.6% 4.0 (1.6, 9.9)
(11)
p = .003
34.4% 7.4 (1.9, 28)
(10)
p = .004
33.3% 2.4 (0.5, 10)
(12)
p = .3
15.3% 4.0 (1.5, 11)
(8)
p = .007
10.2% 15 (2.0, 118)
(1)
p = .009
10.7% 2.9 (0.3, 7.6)
(2)
p = .3
9.7%
(716)
5.5%
(392)
13.7%
(888)
3.2%
(188)
0.7%
(45)
4.0%
(275)
0.7%
(7)
0.8 (0.3, 1.9)
p = .6
42.0% 52 (14, 194)
(9)
p < .0001
1.4%
(99)
26.5%
(41)
22 (10, 45)
p < .0001
Weighted %
(n)
OR (CI)
p Value
Non–School
Refusers
Weighted %
(n)
1.5%
(103)
3.6%
(190)
Note: n = unweighted n; bold values have p ≤ .05. OR = odds ratio; CI = confidence interval.
TABLE 4
Peer Relationships and School Refusal
Pure Anxious School Refusers
Pure Truants
Mixed School Refusers
Non–School
Refusers
Weighted %
(n)
OR (CI)
p Value
Weighted %
(n)
OR (CI)
p Value
Weighted %
(n)
OR (CI)
p Value
Weighted %
(n)
Shy with peers
28.2%
10.3%
Difficulty making friends
because of withdrawal
Difficulty making friends
because of aggression
Conflictual peer relationships
18.9%
0.7 (0.4, 1.3)
p = .3
2.8 (0.7, 11)
p = .1
4.3 (0.8, 23)
p = .09
11 (2.8, 41)
p = .0006
2.6 (0.7, 10)
p = .2
11.8%
28.9%
1.0 (0.6, 1.7)
p = .9
1.4 (0.7, 2.6)
p = .3
1.8 (0.9, 3.6)
p = .1
1.3 (0.6, 2.7)
p = .5
2.4 (1.3, 4.1)
p = .003
6.7%
Bullied/teased
2.5 (1.3, 4.6)
p = .005
2.6 (1.3, 4.9)
p = .004
3.2 (1.5, 6.8)
p = .003
4.5 (2.1, 9.7)
p < .0001
3.0 (1.3, 6.7)
p = .007
17.5%
27.0%
8.5%
5.6%
3.9%
16.2%
31.2%
17.8%
34.1%
22.1%
9.6%
4.8%
3.3%
8.7%
Note: n = unweighted n; bold values have p ≤ .05. OR = odds ratio; CI = confidence interval.
802
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SCHOOL REFUSAL COMMUNITY STUDY
more likely to be teased or bullied. They also had difficulty making friends. The only significant association for
the pure truants was that they were 2.4 times as likely to
have conflictual relationships with their peers compared
with nontruants. No significant age or gender effects were
found for the associations detailed in Table 4.
Stressors and Psychosocial Vulnerabilities. Table 5 shows
the weighted percentage of children with school refusal
who had experienced each of the 26 psychosocial vul-
nerabilities. In boldface type with ORs and p values are
those vulnerabilities found to predict the three types of
school refusal in multivariable models that controlled for
the contribution of all of the vulnerabilities. The vulnerabilities associated with pure anxious school refusal
were living in a single-parent home, attending a dangerous school, and having a biological or nonbiological parent who had been treated for a mental health problem.
Pure truants were significantly more likely to live in an
TABLE 5
School Refusal and Psychosocial Vulnerabilities
Pure Anxious School Refusers
Poverty
Pure Truants
Mixed School Refusers
52.4% (16)
Trend 3.7 (0.8, 18); p = .1
1.0% (2)
37.1%
(47)
31.3% (179)
Observed impoverished home
1.6%
(5)
Four or more siblings
Time in foster care
Moved > 4 times in last 5 years
2.5%
4.9%
9.0%
(6)
(5)
(15)
3.4% (28)
5.9 (1.7, 20); p = .005
4.8% (40)
3.2% (15)
7.0% (50)
Child seen as sickly
Single-parent household
Lives with a step-parent
One parent an adoptive parent
Parent(s) teenagers at child’s birth
2.1%
(7)
44.0%
(47)
2.5 (1.4, 4.7); p = .004
15.9%
(15)
2.2%
(3)
6.6%
(10)
Parent(s) without HS diploma
21.2%
(39)
Parent(s) unemployed
15.1%
(17)
Lives in dangerous neighborhood
Attends dangerous school
Lax parental supervision
Harsh disciplinary style
Overprotective parenting style
Child a scapegoat
Violent/frequent arguments
between parents
Biological parent treated for
MH problem
Nonbiological parent treated for
MH problem
Current maternal depression
Biological parent treated for
substance abuse
Nonbiological parent treated for
substance abuse
Biological parent history of
criminal conviction(s)
Nonbiological parent history of
criminal conviction(s)
2.8%
(7)
6.0%
(7)
5.4 (1.5, 20); p = .01
12.4%
(18)
1.1%
0
2.6%
1.9%
(4)
(8)
(7)
40.8%
(51)
Trend 1.7 (0.9, 3.1); p = .08
10.4%
(10)
2.7 (1.1, 6.9); p = .04
13.5%
(22)
0.4%
(5)
45.9% (212)
2.8 (1.9, 4.0); p < .0001
16.2% (73)
8.4%
(8)
3.4 (1.0, 12); p = .05
15.3% (79)
2.3 (1.2, 4.5); p = .01
17.6% (124)
0.5% (1)
3.3% (3)
41.3% (9)
6.1 (1.5, 25); p = .01
0
41.7% (18)
Non–School
Refusers
19.1% (1604)
1.6%
(152)
3.4%
1.9%
7.8%
(304)
(150)
(517)
0.8% (54)
21.8% (1530)
12.2%
4.7%
(2)
(2)
13.2%
3.6%
(881)
(177)
0.3%
(5)
8.4%
(572)
8.1% (11)
0.2 (0.1, 0.7); p = .02
12.0% (59)
41.7% (11)
4.6 (1.2, 17); p = .02
0.9%
(8)
1.9% (2)
1.9% (12)
14.6% (4)
9.9 (2.6, 38); p = .0008
31.5% (167)
28.6% (16)
6.4 (3.9, 11.0); p < .0001 Trend 4.0 (0.9, 17); p = .06
3.5% (17)
12.4% (2)
1.6%
(7)
2.8% (2)
5.3% (29)
2.9% (4)
2.5% (18)
23.8% (18)
7.7 (1.7, 36); p = .009
27.7% (146)
75.7% (19)
6.2 (1.8, 22.0); p = .004
6.7% (28)
4.2% (3)
18.2% (1439)
9.0%
(739)
0.9%
0.8%
(77)
(70)
6.7%
(599)
2.0%
0.8%
2.2%
1.7%
(132)
(76)
(180)
(119)
25.5% (1515)
3.6%
(273)
11.9%
(63)
13.6%
(5)
5.5%
(459)
24.3% (11)
6.9%
(634)
2.0%
(189)
10.5%
(20)
8.4%
(59)
5.4%
(6)
1.5%
(7)
30.0%
(46)
10.5%
(10)
18.7% (122)
2.5%
(18)
1.9%
(2)
57.2% (14)
4.7%
(3)
20.1% (1593)
4.4%
(401)
Note: Values are weighted percentages (unweighted n); bold values also present odds ratios (confidence interval) and p values where p ≤ .10. HS = high
school; MH = mental health.
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803
EGGER ET AL.
The prevalence, age, and gender characteristics of anxious school refusal and truancy were consistent with previous studies (Granell de Aldaz et al., 1984; King and
Bernstein, 2001; Stickney and Miltenberger, 1998). Use
of “agnostic” definitions of school refusal based on descriptions of the behavior rather than assumptions about etiology or associated psychopathology led to three main
findings: (1) All three types of school refusal were significantly associated with psychiatric disorders. (2) We
identified a subgroup of school refusers noted in two
smaller community studies (Berg et al., 1993; Bools et al.,
1990): mixed school refusers with both anxious school
refusal and truancy. A startling 88% of mixed school
refusers had at least one DSM-IV disorder and 75% had
a biological parent who had been treated for mental illness, clearly suggesting that any level of mixed school
refusal should be seen as a red flag alerting providers to
a high risk of childhood psychopathology. (3) By separating school-refusing behavior from psychopathology,
we found an overlap between emotional and behavioral
disorders in all three types of school refusal.
Like the community studies of Bools et al. (1990) and
Berg et al. (1993), we found that school refusal was strongly
associated with, but not synonymous with, psychiatric
disorders. In our study three quarters of the children with
pure anxious school refusal and pure truancy did not meet
criteria for any psychiatric disorders. The rates of psychopathology found by Bools et al. and Berg et al. were
higher than ours (50% in both studies), most likely because
their study populations had severe manifestations of school
refusal (e.g., children remanded to court for nonatten-
dance or who had missed more than 40% of a term),
while the children in our study had fairly mild school
refusal (Berg et al., 1993; Bools et al., 1990). Nonetheless,
we also did find a strong association between even these
“mild” presentations of school refusal and psychiatric disorders. The rate of psychiatric disorders was three times
greater for children with pure anxious school refusal or
pure truancy than children without attendance problems.
Our pure anxious school refusers were most similar to
the anxious school refusers/school phobics identified in
clinical studies. Like Kearney and Silverman (1996), we
found that a wide range of psychopathology was associated with anxious school refusal, yet much of the apparent heterogeneity was due to the comorbidity of psychiatric
disorders (Angold et al., 1999), not a primary relationship with anxious school refusal. When we accounted for
the effects of comorbidity, children with pure anxious
school refusal were specifically at increased risk for SAD
and depression, with the relative risk of depression greater
than for SAD, despite the fact that anxious school refusal
is a symptom of SAD. The apparent association with simple and social phobias was actually mediated by the association between pure anxious school refusal and depression,
not an independent relationship with anxious school
refusal. These data also demonstrate that the association
between depression and anxious school refusal was specific to school refusal, not simply the comorbidity between
anxiety disorders and depression, a distinction that has
been argued in the literature (Last and Strauss, 1990).
These data also do not support the subtyping of anxious
school refusers by types of anxiety disorder as proposed
in the clinical literature (King and Bernstein, 2001).
Similarly, the association between truancy and depression was not due to comorbidity between CD and
depression, but was rather an independent relationship.
Retrospective studies have shown links between childhood truancy and depression (Robins and Robertson,
1996). Further research into the longitudinal course of
depressed versus nondepressed truants might provide
insights into the interaction between antisocial behaviors, behavioral disorders, and depression.
Truancy, a symptom of CD, was, as expected, strongly
associated with CD. Yet the presence of CD did not distinguish truants from either pure anxious school refusers
or mixed refusers. Links between anxious school refusal
and noncompliance, tantrums, and aggression have been
previously noted (Bernstein and Garfinkel, 1986; Cooper,
1966, 1986; Hersov, 1960b; Kearney and Silverman, 1996;
804
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impoverished home (as observed by the interviewer), to
live in a single-parent household, to have at least one
adoptive parent, to have been born to teenage parents,
and to have lax parental supervision. The most striking
finding for the mixed school refusers was that three quarters had a biological parent who had been treated for mental health problems. Half lived in poverty; 41.3% had
moved multiple times. The mixed school refusers were
also more likely to have a parent without a high school
diploma or an unemployed parent. Like the pure anxious school refusers, they were nearly 10 times more likely
than non–school refusers to attend a dangerous school.
Like the pure truants, they were more likely to have lax
parental supervision.
DISCUSSION
SCHOOL REFUSAL COMMUNITY STUDY
McShane et al., 2001; Smith, 1970), but few studies have
found that behavioral disorders were associated with anxious school refusal. Most clinical studies of anxious school
refusal have either used a definition of anxious school
refusal that excluded children with CD or have used CD
or truancy as study exclusion criteria. An exception is
Bernstein and Garfinkel’s (1986) study in which 23%
(n = 6) of very severe anxious school refusers met criteria for CD. The nonsignificant trend linking pure anxious school refusal with CD and the strong association
between mixed school refusal and CD suggest that refusal
to go to school, whatever the underlying relationship with
anxiety or fears, may have “antisocial,” oppositional aspects.
These data highlight the importance of not using CD or
behavioral symptoms as exclusion criteria for anxious
school refusal. Assessments of anxious school refusers
need to include behavioral symptoms and disorders so
that treatments/interventions can target the full range of
psychopathology.
The mixed refusers were more severely affected than
pure anxious school refusers and pure truants across
multiple domains: the frequency of both types of schoolrefusing behavior was greater; their rate of overall psychopathology and the range of disorders was also greater;
they had more nightmares and night terrors; and they
experienced significantly higher rates of stressors. Their
high rate of CD distinguished them from the pure anxious school refusers, while the associations with SAD
and panic disorder, as well as with fears and worries, distinguished them from the pure truants.
In a review of childhood anxiety disorders, Pine and
Grun (1999) distinguished between “unconditioned fear”
anxiety symptoms (i.e., panic, SAD, separation fears) and
“conditioned fear” symptoms (i.e., specific or social phobia, social or performance anxiety), suggesting that separate, although related, neural pathways may underlie
these two types of fear. The mixed school refusers had
increased rates of panic and SAD symptoms (conditioned
fear symptoms) but did not have increased rates of phobias or performance or social anxiety, while the pure anxious school refusers had a mixture of unconditioned and
conditioned fear symptoms. The truants, on the other
hand, did not have increased rates of anxiety disorders
or either type of fears. We also found that having a biological parent treated for a mental health problem was
significantly associated with both anxious school refusal
and mixed school refusal but not truancy. These data suggest that there may be differences in the biological roots
of the anxiety component of anxious school refusal and/or
differences in how biological susceptibility interacts with
social, psychological, or other biological risk factors to
produce the subtypes of anxious school refusal.
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805
Symptoms Associated With School Refusal
Hersov (1960a) found that disturbed sleep was one of
the presenting symptoms of anxious school refusal, and
Schmitt (1971) noted that anxious school refusers often
presented to the pediatrician with insomnia or fatigue.
We did find that separation-type (i.e., refusal to sleep
alone) and depression-type (i.e., insomnia, fatigue) sleep
disturbances were associated with anxious school refusal
and depression-type sleep symptoms with truancy.
Nightmares and night terrors were strongly associated
with mixed school refusal, while there was a trend toward
an association with pure anxious school refusal. We also
found support for the association between anxious school
refusal and somatic complaints (Bernstein et al., 1997).
A triad of school refusal, sleep difficulties, and somatic
complaints might alert pediatricians or family physicians
to the presence of associated psychiatric disorders.
Beyond Separation Fears
Pilkington and Piersel (1991) have argued that the separation anxiety theory (and, we would add, a phobic theory) of anxious school refusal has failed to take into
account the external variables that may be causing anxious school refusal. While our data support the association between separation fears and pure anxious school
refusal, the prevalence of separation fears remained remarkably low considering the hypothesis that the school refusal
arises from separation anxiety.
Fear of school was the most common fear of pure anxious school refusers (35.5%) and mixed school refusers
(54%). Children’s fears of school might arise from external adverse experiences, rather than purely from internal
conflicts. Their resistance to going to school or leaving
home may not be excessive or unreasonable (i.e., phobic),
but rather an “appropriate” response to real events. Recent
research has supported the idea that school environment
and peer effects contribute to behavior problems and school
absences (Berg, 1992; Maughan, 2001). While we did not
have information about the specific content of the children’s school fears, we did have hints about the possible
sources of their fear of school: pure anxious school refusers
and mixed school refusers felt they attended a dangerous
school more often than children without anxious school
EGGER ET AL.
refusal. A third were bullied and/or teased by peers. They
had difficulty making and keeping friends. Conversely, the
pure truants, who were not afraid of school, did not have
difficulty making friends (although their relationships were
more conflictual), were not bullied or teased, and were not
more likely to feel their school was dangerous.
Our data also supported previous findings that problematic family and social environments are associated
with school refusal (Berg et al., 1993; Bernstein and
Borchardt, 1996; Bernstein et al., 1990, 1999; Bools et al.,
1990; Place et al., 2000). In particular, the mixed school
refusers experienced multiple family stressors: half lived
in poverty, 40% had an unemployed parent, 40% had
moved more than four times in last 5 years, a third had
inadequate parental supervision, a quarter witnessed violent and frequent arguments between parents, and as
noted previously, three quarters had a parent who had
been treated for a mental illness. Their worries about what
might happen at home while they were at school, like
their school fears, may have arisen from real experiences,
and thus be “conditioned,” not “unconditioned” fears.
with school attendance problems for psychiatric disorders. Even mild anxious school refusal and/or truancy
warrants screening for psychopathology. There is good
clinical evidence that anxious school refusal, particularly
when coupled with an affective disorder, can be effectively treated with CBT or other behavioral interventions
(Blagg and Yule, 1998; King et al., 1998; Last et al., 1998),
although it is worth noting that the majority of children
in these treatment trials met criteria for at least one anxiety disorder. The role of pharmacotherapy to treat anxious school refusal remains equivocal, although support
for the use of selective serotonin reuptake inhibitors with
anxiety disorders and depression in children points to
their potential efficacy with anxious school refusers and
truants (King and Bernstein, 2001). School-based interventions to decrease bullying in schools, improve school
safety, as well as to teach social skills training to children
who have difficulty making and maintaining peer relationships might also reduce a child’s risk. Future research
should also examine treatment approaches for children
with mixed school refusal.
Limitations
A significant limitation of this study was the lack of
specific data on the frequency, context, and function of
the school-refusing behavior. Our characterization of the
three groups of school refusers would have been strengthened by data from school administrators and teachers and
the court system on school attendance, school and/or
legal responses to absences, and classroom behavior. In
the future, use of an assessment such as the School Refusal
Assessment Scale (Kearney and Silverman, 1990, 1993)
in a population-based study would help us to understand
better not only the specific content of school-refusing
behavior but also the functions these behaviors serve for
the child and his/her family. Data on cognitive functioning with a specific focus on mental retardation, academic achievement, and learning disabilities would also
have enabled us to examine how academic functioning
and ability shapes children’s aversion to school. Another
limitation was that the sample was selected from school
rolls, so our population might exclude children whose
anxious school refusal or truancy was so severe that they
dropped out of school. Thus our findings might underestimate the association with psychopathology.
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