School absenteeism and school refusal behavior in youth: A contemporary review

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Abstract

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

Introduction

Absenteeism from school is a serious mental and physical health concern for many children and adolescents. Absenteeism or placement in alternative educational settings, usually for absenteeism, is a key risk factor for suicide attempt, perilous sexual behavior, teenage pregnancy, violence, unintentional injury, driving under the influence of alcohol, and alcohol, marijuana, tobacco, and other substance use (Almeida et al., 2006, Chou et al., 2006, Denny et al., 2003, Grunbaum et al., 2004, Guttmacher et al., 2002, Hallfors et al., 2002, Henry and Huizinga, 2007). Chronic absenteeism is often associated as well with school dropout, an event that leads to immediate disconnection from school-based health and mental health programs, economic deprivation, and marital, social, and psychiatric problems in adulthood (Kogan et al., 2005, Tramontina et al., 2001, US Census Bureau, 2005).

Absenteeism from school may also result from physical and psychiatric problems. As discussed later, absenteeism is intricately linked to myriad medical conditions, especially asthma. In fact, some have suggested that absenteeism rates may be a useful barometer of disease outbreaks (Besculides, Heffernan, Mostashari, & Weiss, 2005). Psychiatric conditions related to extensive school absences primarily include anxiety, depressive, and disruptive behavior disorders. As such, school absenteeism remains an important public health issue for mental health professionals, physicians, and educators.

The purpose of this article is to provide a concise review of contemporary research on school absenteeism and related concepts in youth. Reviews of literature prior to 2001 are available (Heyne et al., 2001, Kearney, 2001, King and Bernstein, 2001), so the emphasis in this paper will be on the extensive research literature published after 2000. Following a brief description of key concepts, data and theory regarding prevalence, physical conditions, psychiatric conditions, classification, contextual risk factors, assessment, intervention, and outcome are presented.

Section snippets

Key concepts

Absenteeism refers to excusable or inexcusable absences from elementary or secondary (middle/high) school. Researchers generally focus on youths aged 5–17 years with excessive (1) excusable absences related to medical illness or injury or (2) inexcusable absences related to environmental, social, psychiatric, or other conditions. Inexcusable absences may be caused by school withdrawal, where parents deliberately keep a child home from school for economic purposes, to conceal maltreatment, to

Prevalence

According to the National Center for Education Statistics for 2005, 19% of fourth-graders and 20% of eighth-graders missed at least 3 days of school in the past month. More specifically, 7% of fourth-graders and 7% of eighth-graders missed at least 5 days of school in the past month. School absenteeism is largely unrelated to gender but more common among diverse students, especially American Indians, as well as students with disabilities, students eligible for free or reduced-price lunch, and

Physical conditions

Researchers have linked school absenteeism to myriad medical problems (see Table 2). References are provided for the reader in the table for more detailed information. Not included on this list is a full presentation of infectious diseases such as malaria or parasitic conditions such guinea worm disease or urinary schistosomiasis frequently linked to absenteeism in developing countries. Also not included on this list is a full presentation of surgical and medical procedures (and recovery from

Psychiatric conditions

Youths who refuse to attend school commonly have psychiatric conditions that help precipitate their absenteeism or result from extended absences. Two recent studies have provided the most comprehensive view yet of psychiatric comorbidity among youths with problematic absenteeism. These studies are superior to prior studies in two main ways. First, large samples of youths with absentee problems were assessed. Second, structured diagnostic interviews with excellent psychometric properties were

Classification and proximal variables

Because problematic absenteeism is not a formal psychiatric diagnosis, debate continues to occur as to how the behavior should be defined and classified. The traditional notion of dividing youths with school refusal behavior into those with anxiety-based school refusal and truancy remains a popular but flawed one for several reasons. First, enormous diagnostic heterogeneity comprises both groups. Among youths with anxiety-based school refusal in the Egger et al. study, for example,

Contextual risk factors

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

Cross-cultural variables

Research regarding school absenteeism and school refusal behavior has come historically and primarily from samples in the United States, United Kingdom, Canada, and Australia. In recent years, however, research attention on these topics has burgeoned in other European countries as well as nations such as South Africa, Japan, Saudi Arabia, and India (Al-Dawood, 2002, Ananthakrishnan and Nalini, 2002, Liang et al., 2002, Nishida et al., 2004). Remarkably, many findings from these studies mirror

Assessment

The assessment of school absenteeism per se traditionally involves measuring days or periods of time a child is out of school. Other pertinent variables include child resistance going to school and having to be taken to school by a parent (Egger et al., 2003). Researchers often rely on parent and child report as well as school attendance records to monitor absenteeism. When absenteeism is associated with psychiatric conditions or school refusal behavior, however, assessment becomes broader.

Intervention

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

Outcome

As mentioned earlier, youths with chronic school absenteeism and school refusal behavior are at risk for delinquency and school dropout in adolescence and various economic, psychiatric, social, and marital problems in adulthood. In fact, school refusal has been identified as a key variable for the persistence of separation anxiety disorder into adulthood (Silove et al., 2002). Youths who receive intervention for these problems may be at less long-term risk, however.

McShane and colleagues

Final comments

School absenteeism and school refusal behavior continue to represent critical public health problems for educators and health and mental health professionals. A key problem with the research literature in this area, however, is a general disconnection between sets of professionals who use varying terminology, publish in different journals, and investigate only specific subsets of youths with problematic absenteeism. Greater coordination and synthesis of research information is necessary to

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