Educational Psychology Research and Practice Volume 5, Issue 2, 2019 The Use of Cognitive Behavioural Therapy for School Refusal Behaviour in Educational Psychology Practice Harriet Lee Trainee Educational Psychologist, University of East London Understanding around school refusal behaviour has significantly changed over time, from be- liefs that it stemmed from a phobia, to more recent views that the behaviour serves a function for the child or young person. These changes run in parallel to a dominant medicalised and within-child view of school refusal, which has subsequently impacted on the interventions used by professionals. This article looks at the evidence base around the most commonly used intervention, Cognitive Behavioural Therapy (CBT) (Maynard et al., 2018), to determine whether its extensive use is validated. The use of this intervention in educational psychology practice is explored, with consideration for the merits of finding a “gold standard” intervention in comparison to adopting a more individualised approach. To support a more individualised and systemic approach, Nuttall and Woods’ (2013) “Ecological Model of Successful Reinte- gration” is explored in relation to educational psychology practice. Introduction from differing professional identities and perspectives (Kear- ney & Graczyk, 2014). Debates around terminology have Children and Young People (CYP) of school age have been prevalent since the behaviour was first named “neurotic both a right and a legal obligation to receive an education refusal” by Jung in 1913. Early literature tends to use the (United Nations, 1989; Education Act, 1996). When a CYP term “school phobia” (Johnson, Falstein, Szurek, & Svend- does not attend school for an extended period, it can nega- sen, 1941) due to the dominant belief at the time that the tively impact on academic outcomes (Department for Educa- school environment was eliciting a phobic reaction within tion [DfE], 2011) and social–emotional development (Kear- the child. Although this term is still used by some profes- ney, 2001) and can create a greater risk of mental health sionals today, it is generally considered overly specific as it ffi di culties later in life (Flakierska-Praquin, Lindström, & implies a statistically significant clinical level of anxiety that Gillberg, 1997; King, Heyne, Tonge, Gullone, & Ollen- is unrepresentative of many refusing to attend school (Lyon dick, 2001). According to the Education Act (1996), par- & Cotler, 2007). ents are responsible for ensuring their child receives a full- Since the 1960s, attempts have been made to distinguish time education, and local authorities (LAs) have the power between “school refusers” and “truants” (Berg, Nichols, & to use legal action against them if they do not. This can cre- Pritchard, 1969). “School refusal” was seen as anxiety based, ate a complex and often emotionally challenging situation in whereas “truancy” reflected a desire to engage in activities al- cases where a CYP is refusing to attend school (Gulliford ternative to school. This distinction has since reduced within & Miller, 2015). Although some CYP will spontaneously academic literature, as some CYP who are not attending return to school without intervention, for others the situation school do not meet criteria for either school refusal or tru- is more complex, with many layers requiring attention (Kear- ancy, and others have elements of both (Lauchlan, 2003). ney, 2008). If CYP are supported to manage their anxieties Nevertheless, the distinction still remains within the UK le- and attendance, this has the potential to strengthen resilience gal system, clearly evident in guidance around attendance to cope with later life’s challenges, pressures and obstacles ff on many LA websites. Through the Education Act (1996), (Gulliford & Miller, 2015). E ective intervention is, there- LAs were given powers to address persistent school absence fore, essential to ensure academic success, promote positive through measures such as parenting contracts, parenting or- social and emotional development, and develop resilience for ders, prosecution and penalty notices. These measures are later life. commonly used with those whose non-attendance is not per- ceived to be anxiety based, as the behaviour is, instead, School Refusal Behaviour viewed as a form of defiance. On the other hand, if the non- Debates Around Terminology attendance is perceived as being due to anxiety, the CYP is more likely to receive psychological support (Lyon & Cotler, The complexity around school refusal behaviour is re- 2007). flected in the multitude of definitions, typically stemming In more recent academic literature, umbrella terms such as 1 2 LEE “school refusal behaviour” have been used to encompass all earlier research has focused on aspects of the home envi- forms of non-attendance. This said, some argue that terms ronment that may influence a child’s non-attendance (e.g., such as “school refusal” can create a within-child view of Bernstein & Borchardt, 1996; Bernstein, Warren, Massie, the behaviour, reducing perceptions that the behaviour can & Thuras, 1999), more recent research has highlighted el- change (Nuttall, 2012). Additionally, the word “refusal” is ements of the school environment that may impact on on- seen to construe the CYP’s behaviour as willful and delib- set and severity of school refusal behaviour. These include erate. Some authors, therefore, argue for the use of more school environments with high occurrences of bullying or neutral terms such as “chronic non-attendance” (Lauchlan, disruption, streaming policies where pupils with challeng- 2003), and “extended school non-attendance” (Pellegrini, ing behaviour are placed together, and excessively formal, 2007). The aim of these terms is to move away from a hostile or impersonal pupil–teacher relationships (Lauchlan, “within-child” focus, and instead place attention on the sys- 2003). Although causes of school refusal behaviour may tems around the child when understanding and addressing stem from a multitude of factors within different systems, a the behaviour (Pellegrini, 2007). The author agrees that a study by Malcolm, Wilson, Davidson, and Kirk (2003) found more neutral term is necessary to avoid incorrect hypotheses the perceived cause of the behaviour varies between individ- around the cause of the behaviour. However, it is difficult to uals. CYP and parents often cite school-based factors as a define at what point the non-attendance becomes “extended” cause, whereas LA and school staff commonly state family- or “chronic”. These terms may also exclude certain groups based factors. As highlighted by Pellegrini (2007), for EPs of CYP, including those who strongly resist school but are at- who work with all of these parties, the competing discourses tending, or those whose behaviour takes the form of chronic can create tensions and a challenge for collaborative work- lateness. Therefore, although a more neutral term would be ing. Part of the role of the EP may, therefore, be to help form preferable, within this article the author is choosing to use the a shared understanding. term “school refusal behaviour”, as captures a wide range of As school refusal behaviour is now viewed in literature as need without hypothesising a cause. This is defined as “ab- heterogeneous and multi-causal (L. Atkinson, Quarrington, senteeism from school and difficulty going to or staying in & Cyr, 1985), rather than stemming from one source, the school” (Kearney & Silverman, 1993, p. 85). It is clear that focus has shifted from attempts to label the phenomenon to, continued efforts into an appropriate universal label would instead, looking at the functions behind it. Kearney and Sil- help to create a shared understanding among professionals. verman (1993) propose four main functions of school refusal Without this, terminology is likely to create a barrier in the behaviour: development of successful interventions (Elliott, 1999). 1. to avoid anxiety related to attending school; Prevalence 2. to avoid social situations that cause anxiety; A lack of shared definition among researchers has resulted 3. to seek attention and/or to reduce feelings of separa- in varying estimates around the prevalence of school refusal tion anxiety; and behaviour (Elliott, 1999). This is further compounded by the differences in definitions and reporting of absences among 4. to gain a rewarding experience. schools and LAs (Kearney, 2008). Despite this, tentative Identifying the function underlying school refusal be- estimates within UK literature suggest around one to two haviour can help to enhance predictions of absenteeism per cent of the school-age population are affected (Baker & (Kearney, 2007) and, therefore, support intervention plan- Bishop, 2015). Prevalence is largely unaffected by gender, ning and a more preventative approach. At the same time, social class and academic ability (Berg, 1996, as cited in El- this model is perhaps limited as it does not account for CYP liott, 1999), but is higher among secondary school pupils, whose behaviours are multi-causal or for the influences of particularly those who have just transitioned from primary children’s thought processes (Maric, Heyne, MacKinnon, school (Elliott, 1999; Gregory & Purcell, 2014). Onset may Widenfelt, & Westenberg, 2013) on non-attendance. Addi- also be triggered by a traumatic or critical event (Torrens tionally, this model does not consider systemic factors, such Armstrong, McCormack Brown, Brindley, Coreil, & McDer- as homelessness and poverty,