School Avoidance From the Point of View of Child and Adolescent Psychiatry: Symptomatology, Development, Course, and Treatment

Up to 60% of students at secondary schools in Germany report having avoided attending school for several hours or even a whole day over the course of their schooling so far (1). However, school avoidance gains importance in terms of child and adolescent psychiatry only when it occurs to a notably greater degree and is accompanied by psychiatric symptoms. This article aims to review the findings on the psychopathologically relevant features of children and adolescents who avoid school. In view of the available recent review articles (2–6, e1) and the scarcity of available data in Germany, the emphasis lies on the more recent, mostly English language, literature and the results of two of the authors’ own recent studies (7, 8).

Symptoms, classification, and prevalence
The term “school avoidance” (e2) is used in this article to describe absences from school that are associated with psychiatric symptoms. The literature further differentiates between truancy (deliberately not attending school) without anxiety symptoms and anxiety related school refusal (Figure 1 gif ppt). The latter is further subcategorized into school related anxieties (test anxiety, social phobias) and separation anxiety (fear of being separated from a parent or loved carer) (Figure 1) (9). A close association is assumed between conduct disorders and truancy on the one hand, and on the other hand between school refusal and anxiety disorder and other emotional disorders (2). There are indications that school avoiders may have symptoms covering the entire range of child and adolescent psychiatric disorders (8) and that substantial overlaps exist between school refusers and truants (Figure 1). A study that is representative for the US (10) found a greater extent of conduct disorders than of emotional disorders in truants than in school refusers (and vice versa), but the highest rate of psychiatric disorders was seen in children with a mixture of truancy and school refusal. The frequency of psychiatric diagnoses differs depending on the type of sample under consideration (clinical sample: up to 90%, representative samples: up to 24.5 %) (2).

It is difficult to estimate the prevalence of school avoiding behavior because different definitions and data collection methods are in use (1, 2). Most authors assume a proportion of 5% to 10% of regular school avoiders in Germany, whose school absences reach “a substantial extent” (3, 11, 12). School avoidance is notably more common in adolescents than in children. Individual studies have shown that boys are affected more often than girls, at a ratio of 2:1 (2, 3). The highest rates of school avoidance are seen in secondary general schools (Hauptschulen) and schools catering for special needs (Sonderschulen) (11), but no school type is exempt from the phenomenon. The current National Report on Education shows that the number of school leavers without a final graduation certificate in Germany (in 2006: about 76 000; i.e. about 8% of every year) is still high compared with the rest of Europe (13); a higher proportion of these youngsters may be assumed to avoid school. Although proportionally more students from (im)migrant families leave school without graduating (13), no clear indications exist that school avoidance prior to school drop out is more common in these students (1). In interpreting studies with positive findings in this regard (e3, e4), possible confounding by socioeconomic status should be considered (6, e5, e6).

Course
Most studies have shown an increase in school refusal between the 5th and 6th as well as the 10th and 11th year of life. By contrast, truancy typically occurs for the first time at the age of about 11 and increases between the 13th and 17th years of life (2, 10, 11). Whereas anxiety related school refusal dominates during childhood, the range of disorders widens substantially with the onset of adolescence (5). Truancy is prognostically associated with an increased risk for social problems, such as:

• School failure (odds ratio [OR]=4.6)
• Unemployment (OR=2.4)
• Drug misuse (OR=2.2)
• Delinquency (OR=4.0) (e7).

Anxiety related school refusal is primarily associated with the continued existence or development of psychiatric disorders (OR=3.1) (14).

Prognostically favorable factors include:

• Acute onset of symptoms
• Younger age at symptom onset
• Less time spent absent from school
• Early diagnosis and treatment
• Lower psychiatric morbidity
• Lesser extent of avoidance (15).

Conversely, the risk of symptoms becoming chronic increases when help is not given rapidly and the so-called protective factors are lacking (Box 1 gif ppt).

The unfavorable effects of school avoidance on children’s or adolescents’ further development are obvious: School attendance and subsequent employment are important to ensure not only their future financial security but also their participation in social life and activities, and to establish social contacts. School and employment further provide a useful and beneficial structure for people’s daily lives. In spite of these obvious connections, studies of youth unemployment have only rarely investigated the topic of school avoidance in the subjects’ histories (16). In the context of the collaboration project “SUPPORT 25”, unemployed people younger than 25 in whom psychiatric disorders are suspected are offered psychiatric diagnosis and advice at short notice (7). 97.6% of those examined (n=165, 96 female; mean age=21) had at least a psychiatric Axis I disorder according to ICD-10. School avoiders—individuals who during their school years remained absent from lessons for at least a month (30% of the participants)—significantly more often left school without graduating and also sought psychiatric help before their 18th year of life more often. The trend was also for school avoiders to seek psychiatric care more often once they had reached legal age and they more often displayed conduct disorders as per a retrospective lifetime diagnosis. Further, school avoiders responded more pessimistically to the question on the likelihood of finding a job and starting gainful employment within the coming 2 years.

Development
School refusal should not be reduced to medical or psychological aspects but is always embedded in complex social conditions. The available findings give credence to the assumption that factors such as parenting style, relative poverty, living in socially disadvantaged areas, attitudes to schooling, and the school system itself all have an influence (2, 6, 10, 17). Psychological models of the development of school avoidance emphasize interactions between family related, school related, and individual variables. For truancy, parallels have been shown with etiological models of conduct disorder (e8), for school refusal the parallels were with models of the development of anxiety disorders (9). At the same time, there are many common factors (Figure 2 gif ppt), which will be explained on the basis of relevant studies and the authors’ own findings from a sample of 89 patients (42 female; mean age=14.4). These patients attended a child and adolescent psychiatric outpatient clinic specializing in school avoidance/refusal (8). Accordingly, school avoidance should be interpreted as a reaction to being overchallenged in the school, peer, and family contexts, which develops on a background of individual vulnerabilities.

School context and peer context
Of all patients in the authors’ own sample, 11.2% attended a school for children with special needs (Sonderschule), 34.8% secondary general school (Hauptschule), and 23.6% comprehensive school (Gesamtschule). 51.6% had repeated a class at least once. 61.8% had switched to lower-grade schools (with the exception of one case, where the student moved to a higher-grade school). These data, which significantly differ from those of representative non-clinical samples (8), confirm other findings according to which school avoiders typically have a school career that is characterized by failures (1, 15, 17). Further, the peer-relationships of school avoiders are often characterized by conflict (6, 10, 17). Truants often have contact to deviant youth groups (18), whereas school refusers often have problems with social integration. In the authors’ own sample, 22.5% of patients describe themselves as victims of bullying; 33.7% were categorized as altogether poorly socially integrated. These data are roughly consistent with those of international studies (6, 19). Some studies have pointed out that, further to experiences of violence or social exclusion, another factor contributing to school avoidance may also be the subjective experience of the school atmosphere as bad (6, 17, e9). Factors that may play a part in this context include:

• School size and class size
• The relationships between teachers, principals, and students
• Cooperation between school and parents
• Teachers’ monitoring of students’ absence (6, 17, e3).

Family context
The proportion of children who were affected by their parents’ separation in the authors’ own sample was significantly higher (60.5%) than in representative samples (about 19%) (e10). The frequency of severe physical (29.2%) and mental (14.6%) parental illness (e11) in our sample also underlines the importance of family stresses. In comparable studies with populations of school avoiding patients from specialized child and adolescent psychiatric outpatient clinics, family stresses figured even more prominently (8, 19). Further familial risk factors include:

• Low socioeconomic status of the parents
• Unemployment
• Frequent relocations
• Low parental control
• Social isolation of the family
• Complex/convoluted or emotionally distant family relationships
• Frequent family conflicts (5, 10, 11, 17, 19, e12).

In truanting children, the dominating stress factors are associated with low socioeconomic status, whereas school refusers tend to have a higher proportion of mentally ill parents (3, 10). Generally, school avoiders seem to be exposed to more stressful life events (20) than others.

Individual features
39.1% of the authors’ own patients had a lower than average IQ (<85), a significant difference to the proportion that might be expected on the basis of the reference norm (13.6%). Although other studies have hinted at an association merely between truancy and low intelligence (17), many school avoiders have reported problems with school performance before they started avoiding school (19). This indicates potential cognitive overchallenges owing to misplacement in the wrong type of school (17); in individual cases, above average intelligence should be considered (e13, e14). The authors’ sample also yielded indications from psychological testing that attention deficit disorders may contribute to the lack of success at school especially in truants; other studies have found that specific developmental disorders of scholastic skills contribute to the development of school avoidance (21).

Pre-existing relevant child and adolescent psychiatric disorders may be assumed to contribute substantially to the individual factors even before a child starts to avoid school (Figure 2). In their histories, 20.2% of patients in the authors’ sample had internalizing symptoms and 23.6% had externalizing symptoms before starting to avoid school (8). Recent studies have shown that physical disorders such as asthma (6, e15) or obesity (e16–e18) are associated with absenteeism.

Diagnosis and treatment
The most important treatment objective in school avoidance is the resumption of school attendance. Doctor’s sickness certificates for any psychosomatic complaints (Figure 1) are contraindicated because they increase school avoidance (by legitimizing the absence) and thus contribute to making it a chronic problem.

Pediatricians and primary care physicians should be familiar with the relevant symptoms (Box 2 gif ppt). The main diagnostic clue is the occurrence of symptoms in the morning or even on the preceding evening and their absence at weekends or during holidays. In individual cases, parents changed their doctors often in order to be able to obtain repeated sick notes. It also should be borne in mind that conducting invasive, time-consuming, and costly physical diagnostic tests without including psychological factors in the diagnostic considerations bears the risk of chronification of the problem.

In child and adolescent psychiatry, the diagnosis includes—in addition to an extensive exploration of the child and its parents/carers—a psychological test for possible intellectual underchallenge or overchallenge and specific developmental disorders of scholastic skills. Questionnaire methods and structured clinical interviews are used to assess the key symptoms (21, e19) and to capture comorbid disorders. Kearney (22, e20, e21) distinguished between 4 functions of school avoidance:

• Attention seeking behavior/separation anxiety
• Avoidance of negative affect
• Positive reinforcement outside school
• Avoidance of exams and socially stressful situations.

These points should be captured in a questionnaire (e21, e22) and used as supporting information in treatment selection.

Therapy includes child centered, school centered, and family centered methods to reduce anxiety related avoidance behavior (23, e23, e24). Several studies have shown the efficacy of cognitive behavioral therapies—also in combination with antidepressant drug treatment (imipramine) (3, 6, e25). To date, however, only few randomized, controlled evaluation studies (evidence level Ib) have been conducted; superiority to other treatments and increased efficacy if the parents are included has not been consistently shown (3, e26–e28). For the treatment of truancy which is associated with dissocial behaviour, controlled evaluation studies are lacking to date (6). In view of the often overlapping internalizing and externalizing symptoms, Kearney et al. (e29) recommend integrated treatment of all school avoiders, which should be oriented to the functional profile of the school avoiding behavior.

Especially in chronic cases, outpatient treatment is often not sufficient. In 20.2% of patients in the authors’ own sample, inpatient treatment or a combination of in and outpatient treatment was recommended (8). A recent evaluation study has shown good effects 9 months after inpatient treatment had been concluded (e30). Follow-up studies over a longer time period, however, have shown that at least one third of school avoiding patients display mental problems later in life (3, 6, 14, 24, e31–e33). Exclusively psychiatric therapy is thus usually insufficient (6). For the individual case, a support system should be established that should include school, child and youth services, and pediatricians and primary care physicians. In recent years, a multitude of such model projects has been implemented (e34). In 2006, the German federal government initiated the program “Schulverweigerung – Die 2. Chance [School Avoidance—A Second Chance]” (25), in whose context coordination posts were set up in more than 150 sites. Case managers in those sites establish contact with school avoiders; the primary objective is reintegration into school. If this is unrealistic then those affected are given the option of graduating outside the regular school system. These projects have not been systematically evaluated to date.

Conclusions and outlook
The large number of adolescents who leave school without graduating underlines the need for political action. The symptoms of school avoidance have to be taken very seriously in this context. The school system is confronted with the challenge to identify such students rapidly and initiate measures for their reintegration. In order to execute this important function properly, schools need support. The authors think it would be ideal for affected children and adolescents and their parents to be able to present to a team as early as possible—with the team consisting of an independent teacher, a social worker, and a child and adolescent psychiatrist. A task force of this kind could develop a concept for reintegrating the patient into school while considering the interdisciplinary diagnosis, and it could supervise its implementation. Bearing in mind the high financial follow-on costs of school avoidance, the expense of such measures seems more than justified. This hypothesis should be tested and proved by means of relevant evaluations.

Physicians should be familiar with the physical symptoms and psychiatric disorders that are associated with anxiety related school avoidance (Figure 1, Box 2). If initial diagnostic testing for physical disorders does not yield any pathological findings or if the findings are unclear, then—rather than (or in parallel to) further time consuming and costly physical investigations (risk of the problem becoming chronic)—an initial exploration of psychiatric disorders should be undertaken (leading questions: see Figure 1 and Box 2) and early referral to a child and adolescent psychiatrist should be instigated. Doctors’ sickness certificates and prescription of “Mutter und Kind Kuren” (a medical service that is covered by the statutory health insurers and offers 3 weeks of residential care to mothers [and their children if these cannot be looked after at home]) increase the symptoms and are contraindicated. Child and adolescent psychiatrists are tasked with offering and establishing special consultations with short waiting times for school avoiders. The effectiveness of mobile consultations at schools and in institutions catering for young people should also be studied. Research is needed into the role of child and adolescent psychiatric disorders, psychosocial and school related risk factors in the development of school avoidance and its effects in the medium and long term.

Conflict of interest statement
The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.

The authors are in receipt of financial funding from “Med in.NRW— Innovative Gesundheitswirtschaft” (the state government of North Rhine-Westphalia’s largest competition for innovation in health management).

The scientific studies into school avoidance were supported by Zonta Essen (Zonta International is a global organization of executives and professionals working together to advance the status of women worldwide through service and advocacy) and the Bundes-Betriebskrankenkasse (BKK, one of Germany's health insurers). JobCenter Essen finances one psychiatrist and one psychologist in the context of the model project SUPPORT25. The RWE Youth Foundation supports research into mental disorders as a cause of unemployment in young people.

Manuscript received on 14 April 2009, revised version accepted on 19 August 2009.

Translated from the original German by Dr Birte Twisselmann.


Corresponding author
Dr. phil. Dipl.-Psych. Martin Knollmann
Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters
LVR-Klinikum Essen, Universität Duisburg-Essen
Virchowstr. 174
45147 Essen, Germany
martin.knollmann@lvr.de

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