[5][4] Academic literature estimates that school refusal occurs in 1–2% of the general population and in 5–15% of youth who are referred to clinics.
[2] Because school refusal behavior is a multifaceted issue, there is not a single valid measure or assessment method for diagnosis.
[7] Assessment first involves measuring and evaluating the number of days the child is absent, late, or leaving school early.
[5] The assessment aims to (1) confirm that the behavior represents school refusal as opposed to truancy or legitimate absence, (2) evaluate the extent and severity of absenteeism, (3) the type(s) and severity of emotional distress, (4) obtain information regarding the child, family, school, and community factors that may be contributing to the behavior, and (5) use the information obtained to develop a working hypothesis that is used for planning appropriate interventions.
[4] Tools used to obtain information about school refusal behavior include clinical behavioral interviews, diagnostic interviews, self-report measures of internalizing symptoms, self-monitoring, parent- and teacher-completed measures of internalizing and externalizing problems, review of attendance record, and systematic functional analysis.
Children may also exhibit externalizing symptoms such as nausea, vomiting, sweating, diarrhea, or difficulties breathing as a result of their anxiety.
[4] Other externalizing symptoms include defiance, aggression, tantrums, clinging to a parent, refusing to move, and/or running away.
[9] Short-term negative consequences of school refusal for the child include distress, social alienation, and declining grades.
[3] Problematic school absenteeism is also associated with illicit drug use (including tobacco), suicide attempts, poor nutrition, risky sexual behavior, teenage pregnancy, violence, injury, driving under the influence of alcohol, and binge drinking.
[2][5] School refusal behavior includes absenteeism due to a broad range of potential causes.
The School Refusal Assessment Scale identifies four functional causes: (1) avoiding school‐based stimuli that provoke negative effects, (2) escaping aversive social and/or evaluative situations, (3) pursuing attention from significant others, and/or (4) pursuing tangible rewards outside of school.
[8] Gradual onset emerges over time as a few sporadically missed days become a pattern of non-attendance.
Within the literature the risk factors are typically condensed into four categories: individual, family, school, and community.
[6] Some scholars also emphasize the importance of helping the child manage social, emotional, and behavioral problems that are the result of prolonged school nonattendance.
[15][4][12][16] There has been little consensus on the best method for organizing and classifying children demonstrating school refusal behavior.