Psychosocial Interventions for School Refusal with Primary and Secondary School Students: A Systematic Review

This Campbell systematic review assesses the effects of psychosocial interventions for school refusal. The review summarizes the findings from eight studies. Medium quality evidence shows that cognitive‐behavioural therapy (CBT) increases school attendance but has no effect on anxiety. The effect of the psychosocial interventions on anxiety was not statistically significant. The effects on attendance were significant. Several risks of bias were present in most studies included in the review, which could upwardly bias the estimated effects. Many included studies did not clearly describe how they randomly assigned participants to treatment or control groups. Therefore, the current estimate of treatment effects from the eight rigorous studies should be treated with caution. Executive Summary/Abstract BACKGROUND School refusal is a psychosocial problem characterized by a student's difficulty attending school and, in many cases, substantial absence from school (Heyne & Sauter, 2013). It is often distinguished from truancy, in part because of the severe emotional distress associated with having to attend school and the absence of severe antisocial behavior. Truancy, on the other hand, is not typically associated with emotional distress and is commonly associated with severe externalizing behavior. The emotional distress associated with school refusal is often in the form of fear or anxiety, and sometimes in the form of depression. School refusal occurs for about 1‐2% of young people, and estimates among clinically referred youth are considerably higher. There is substantial heterogeneity in both the presentation of school refusal and its associated risk factors. Significant adverse consequences may occur in the short‐ and long‐term, including school dropout and problems with social adjustment. Family members and school staff are also affected by school refusal. The most commonly studied interventions for school refusal are behavioral approaches and cognitive‐behavioral therapy (CBT). The overarching aim of these interventions is the reduction of the young person's emotional distress and an increase in school attendance to help the young person follow a normal developmental pathway (Heyne & Sauter, 2013). Behavioral interventions include exposure‐based interventions, relaxation training, and/or social skills training with the student, and contingency management procedures with the parents and school staff. CBT manuals additionally focus attention on the identification and modification of maladaptive cognition that may maintain the young person's emotional distress and absenteeism. In some instances parent cognition is also targeted. Other interventions have been used to treat school refusal (e.g., psychodynamic treatment, family therapy, medication) but CBT has been the most studied intervention and most prior reviews have focused on CBT and/or behavioral interventions. While prior reviews have found some support for CBT and behavioral interventions for reducing anxiety and/or improving attendance, the reviews have been mixed (Maynard et al., 2013). Prior reviews have also been limited to published research, have not adequately assessed the quality of evidence, and have primarily employed either qualitative or vote‐counting methods for synthesizing study outcomes. No prior meta‐analysis of interventions targeting school refusal has been located. OBJECTIVES The purpose of this review was to inform practice and policy by evaluating the effects of psychosocial interventions for school refusal. The following research questions guided this study: Do psychosocial interventions targeting school refusal reduce anxiety? Do psychosocial interventions targeting school refusal increase attendance? SEARCH METHODS Electronic searches were conducted in 15 databases and 4 research registers, and internet searches were conducted for conference proceedings and other grey literature. Searches were conducted using the following keywords: (anxiety OR “school refus*” OR “school phobia”) AND (attendance OR absen*) AND (evaluation OR intervention OR treatment OR outcome OR program) AND (student* OR school* OR child* OR adolescen*). Reviews of reference lists of included studies and prior reviews and personal contact with authors of prior studies of school refusal were also conducted to identify potential studies for this review. SELECTION CRITERIA Published or unpublished studies assessing effects of psychosocial interventions to improve attendance or reduce anxiety with school‐age youth who met criteria for school refusal were included in this review. To be eligible for inclusion in this review, studies must have been conducted or reported between January 1980 and November 2013 and employed an experimental or quasi‐experimental design. In addition, studies must have used statistical controls or reported baseline data on outcomes regardless of study design. Studies that assessed effects of medications only or studies conducted in residential treatment centers were excluded from this review. DATA COLLECTION AND ANALYSIS Titles and abstracts of the studies found through the search procedures were screened for relevance, and those that were obviously ineligible or irrelevant were screened out. Documents that were not obviously ineligible or irrelevant based on the abstract review were retrieved in full text for final eligibility screening. Two reviewers independently screened the full‐text articles for inclusion. Studies that met eligibility criteria were coded independently by two coders. Two review authors also independently assessed the risk of bias in each study using the Cochrane Collaboration's ‘Risk of Bias’ tool (Higgins et al., 2011). Coders met to review the coding agreement and any discrepancies were discussed and resolved by consensus. Effect sizes were calculated in Comprehensive Meta‐Analysis (CMA) version 2.0 (Borenstein, Hedges, Higgins, & Rothstein, 2005). We adjusted for differences at baseline by computing the pre‐test effect size and subtracting it from the post‐test effect size. The standardized mean difference effect size statistic, employing Hedges' g to correct for small sample size bias (Hedges, 1981), was used. When an author used more than one measure of an outcome, an effect size was calculated for each measure and a mean ES was calculated so each study contributed only one effect size per study for each outcome. Four meta‐analyses were performed; two meta‐analyses were performed to synthesize studies assessing effects of psychosocial interventions on anxiety and attendance and two were performed to synthesize effects of studies assessing effects of medication in combination with psychotherapy on anxiety and attendance. A weighted mean effect was calculated by weighting each study by the inverse of its variance using random effects statistical models. We assessed statistical heterogeneity using the Q ‐test and I 2 statistic. Several moderator and sensitivity analyses were planned, but due to the small number of studies included in this review and lack of heterogeneity, we limited additional analyses performed. RESULTS A total of eight studies examining effects of interventions on anxiety or attendance with 435 school‐age participants exhibiting school refusal were included in this review. Six studies examining effects of psychosocial interventions and two studies assessing comparative effects of psychosocial interventions with and without medication met inclusion criteria for this review. Six of the included studies were randomized controlled trials (RCT) and two were quasi‐experimental design (QED) studies. The majority (75%) of the studies were published in peer‐reviewed journals. Five of the interventions took place in a clinic setting, one in the school, one in the school and home and one in an undisclosed sett