Prolonged school non-attendance in adolescence poses a significant public health concern. Adverse outcomes for adolescents who have missed out on the social and academic benefits of high school include mental health disorders and economic, social and relationship difficulties that may persist into adulthood. Healthcare professionals are often consulted in cases of prolonged school non-attendance. Diagnosis and management of specific physical and mental health problems must be the health professional's initial priority, with the subsequent development of a management plan to assist with school reintegration. Using a specific framework, an understanding of the factors contributing to a young person's school non-attendance can be developed. Intervention leading to a successful return to school has the potential to lower the risk of associated long-term adverse health outcomes.
- Adolescent Health
- Chronic Fatigue Syndrome
- General Paediatrics
- Multidisciplinary team-care
- School Health
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- Adolescent Health
- Chronic Fatigue Syndrome
- General Paediatrics
- Multidisciplinary team-care
- School Health
Most young people will be absent from school for short periods during their high school years. For a small group of young people, however, prolonged school non-attendance becomes a significant issue.1 This group is of relevance to health professionals for a number of reasons. While chronic health problems can have a detrimental effect on school attendance and educational achievement, there is increasing evidence that health outcomes in adolescence and early adulthood are linked to educational opportunities.2 Optimising young people's access to education has therefore been highlighted by the WHO as a key strategy in improving health outcomes for this group.3
For an individual, school non-attendance may indicate the presence of a known chronic illness that is not being managed appropriately or, alternatively, an unrecognised condition that requires diagnosis and treatment. Prolonged non-attendance is associated with a number of adverse health and social outcomes, both short and long term,4–8 while school attendance and connectedness are protective against a range of health risk behaviours in adolescence.9 Intervention leading to successful school reintegration therefore has the potential to produce considerable benefit for the young person. This review considers the evidence surrounding the association between health outcomes and prolonged school non-attendance in adolescence. It also provides clinicians with a practical approach to the management of prolonged school non-attendance, with the focus on young people in high-income countries. The recommendations are based, where possible, on the published literature and on the experience of the authors and colleagues working in centres across Australia.
Several terms have been used to describe absence from school, including school non-attendance, school absenteeism, school absence, school phobia, school refusal and truancy. For this review, the term school non-attendance will be used to encompass any pattern of behaviour resulting in persistent absence from school.10 Prolonged school non-attendance has been defined as non-attendance for more than 20% of the school year (equivalent to an average of one whole day per week) over three consecutive school terms.1 In the UK, the Department for Education has adopted the term ‘persistent absence’ that refers to absence for more than 15% of the year.11 Such definitions are necessary for the purposes of research and data collection. However, we recommend that health professionals working with young people enquire about school attendance routinely and intervene as soon as a pattern of sustained school non-attendance appears to be developing.12
In Australia and the UK, schools are required to record non-attendance, which may be classed as either authorised or unauthorised. Authorised absences for health reasons are those in which the young person has an apparently valid explanation for the absence (eg, an injury, a medical appointment or hospital admission). Unauthorised absences are those that are not accompanied by any such clear justification. However, for young people with chronic illness, the distinction between authorised and unauthorised absence may not always be clear. In the UK, the Department for Education's publications on non-attendance now focus on absence from school irrespective of whether or not this is authorised.11
School phobia or school refusal are terms that have been used to indicate a situation in which a young person's non-attendance is associated with significant anxiety.4 ,6 ,7 Typically the young person's family is aware of the non-attendance. Conversely, truancy involves a deliberate decision by the young person to stay away from school, usually accompanied by a lack of parental knowledge. Rather than being associated with anxiety, truancy tends to be linked with externalising conditions such as conduct disorder and other disruptive behaviour disorders and/or social conditions such as homelessness or poverty.4 ,13 ,14
Factors associated with prolonged school non-attendance
The primary role of a health professional involved in the assessment of young people with prolonged school non-attendance is to identify whether there is a specific diagnosis, medical or psychiatric, to account for the non-attendance. If the diagnosis is clear (eg, asthma or type I diabetes), the focus will be on optimising the medication regimen and the young person's adherence to treatment. Prolonged school non-attendance is a common feature of chronic fatigue syndrome (CFS), and this diagnosis should always be considered.15 Diagnostic criteria for CFS, such as those produced by the Centers for Disease Control and Prevention criteria and the Royal College of Paediatrics and Child Health, exist and aid the clinician to differentiate CFS from presentations of psychiatric and developmental disorders with physical symptoms.16 The latter include affective disorders such as anxiety and depression, inattentive or disruptive behaviour disorders (ADHD, oppositional defiant disorder, conduct disorder) or specific learning difficulties. In practice, there is often overlap between these conditions with depression and anxiety frequently associated with other chronic illnesses in adolescence.17
A study in the UK by Jones et al1 reported that 2% of secondary school students were absent from school for >20% of the school year for explained ‘medical reasons’. A small number of these had been diagnosed with specific medical conditions such as asthma and malignancy.1 Asthma and respiratory illnesses are a leading cause of non-attendance worldwide, with young people with asthma missing 1.5–3.0 times more school days than those without asthma.18 ,19
The majority of students with non-attendance in the study by Jones reported frequent physical symptoms, such as headache, nausea and tiredness, with no clear organic diagnosis.1 Somatic complaints among young people with prolonged school non-attendance typically include headache, abdominal pain, nausea or vomiting, fatigue, sweating, light-headedness, back pain, shortness of breath and menstrual symptoms.4 ,20 These symptoms tend to be frequent in young people with anxiety-based school non-attendance.14 ,20 Nearly half (45%) of the students with non-attendance reported in Jones’ study had been diagnosed with a psychiatric condition within the last year. Diagnoses included anxiety, depression, obsessive-compulsive disorder, oppositional defiant disorder and ADHD.1 Egger et al also reported that the most common diagnoses for young people with anxiety-based school non-attendance include depression and separation anxiety disorder.20 In the same study, the most common diagnoses for young people with truancy included conduct disorder, oppositional defiant disorder and depression.20
School non-attendance has been linked to a range of health risk behaviours, such as substance use, smoking, binge drinking and high-risk sexual behaviour.21–26 Contextual risk factors, with an indirect effect on school attendance, also need to be considered. These include homelessness and poverty,27 ,28 teenage pregnancy,4 school violence and victimisation,29 school connectedness, parental involvement and family and community values.
It may not always be possible for health professionals to identify a precise reason to explain school non-attendance. In these situations, it may help to consider whether non-attendance is primarily related to avoidance of specific situations and emotions or conversely whether it is associated with positive rewards.4 Examples of the former include avoidance of negative emotions such as anxiety or avoidance of distressing situations such as bullying or examinations. Examples of positive reinforcement leading to school non-attendance include increased attention from parents/grandparents or the opportunity to engage in more enjoyable pursuits (eg, shopping, hanging out with friends, watching television). In the absence of a specific medical or psychiatric diagnosis, this framework can be helpful in making sense of the behaviour (school non-attendance) and developing a management plan.
School climate is significantly correlated with school attendance and health behaviour.30 Young people who feel connected to their school are less likely to engage in a range of health risk behaviours.9 Students in smaller classes, more challenging courses and those experiencing more positive relationships with teachers are less likely to leave school.31 Parental involvement in their child's education is commonly liked to academic achievement and attendance.4 Family and community values surrounding education will also have a significant impact. In a study from Kenya, provision of free school uniforms to girls led to students remaining enrolled in school for longer and a reduction in the incidence of teenage pregnancy.32 While it is not possible to generalise this finding to high-income countries, it is an example that lends support to the WHO's focus on education as a key to optimising health outcomes for young people.3
Outcomes of school non-attendance
Prolonged school non-attendance is a risk factor for a number of adverse health outcomes in adolescence, along with evidence of associations with various economic, psychiatric, social and marital problems in adulthood.4 As mentioned above, there is an association in adolescence between school non-attendance and substance use, smoking, binge drinking and driving under the influence of alcohol, high-risk sexual behaviour and teenage pregnancy, violence, unintentional injury and suicide attempts.4 ,5 ,21–26 Longer term there is evidence of an increased incidence of psychiatric disturbance in adult life, with around 30% of young people with prolonged school non-attendance experiencing adjustment disorders in adulthood.6 School refusal has been identified as a key predictor for the persistence of separation anxiety disorder into adulthood.7 ,8 There is some evidence, however, that young people who receive intervention may be at less long-term risk.33 ,34
An approach to the management of school non-attendance
There remains a paucity of published evidence to guide health professionals in the management of prolonged school non-attendance in adolescence. The following practical approach is based on the available literature and on the experience of the authors and colleagues working in centres across Australia.10
Assessment and management of school non-attendance involves a systemic approach, with consideration of the individual, family, school and peers. Health professionals should aim to understand what lies behind the school non-attendance in order to contribute to the design of a management plan to assist successful school reintegration. Diagnosis and management of any specific physical and mental health problems is the initial priority. This may require review by a mental healthcare professional. Once appropriate management is instituted, its effect on school attendance can be monitored.
In those cases of young people with somatic complaints where organic pathology has been largely excluded, a rehabilitative approach is recommended, with a focus on return to normal function.35–37 Return to normal function includes a return to school. Involvement of a multidisciplinary team, where possible, with input from nursing, physiotherapy, occupational therapy, psychological medicine and education support staff is beneficial. Clear goals of management should be decided upon, with the ultimate goal being a successful return to school.
Collaboration and communication between school staff, health professionals and the family is important, with all parties, including the young person, involved in the development of a return-to-school programme. It may be appropriate for the health professional to take on the role of case management, particularly in the more complex cases. Communication with school helps to clarify the nature of the diagnosis, to provide advice on a reasonable expectation for school attendance and to formulate a clear plan to allow education staff to manage symptoms that arise at school. A school conference, attended by the health professional, along with a written management plan, can assist in this communication.
In cases of prolonged school non-attendance, gradual school reintegration, with time spent at school increasing slowly over a period of weeks, may be necessary. Rather than focusing on academic achievement, the agreed primary goals of initial return to school can include re-establishing contact with peers, interacting socially and returning to the routine of attending school. A modified and manageable plan for academic work is advisable, to avoid the additional pressure of achieving specific academic goals on initial return to school. Once the young person has begun to return to school, there is little evidence that a specific type of academic intervention is more effective than another in maintaining attendance, although a systematic review demonstrated that vocational-oriented and supplemental academic training programmes showed some superiority in small randomised controlled trials.38
The primary responsibility for management of young people with prolonged school non-attendance lies with the school. However, a health professional who has established a rapport with the young person and his/her family can assist the young person in following the return-to-school programme. It may also be useful for the young person to discuss the return to school with the health professional in anticipation of problems that may arise, such as what to say to friends and what to do when feeling unwell at school.
Involvement of student support services at each individual school adds another layer of support and contact for the young person and their family. One or two clearly nominated and trusted points of contact at the school allow the young person to access support when needed. Similarly, identification of a ‘safe place’ at the school for times of stress or physical illness will help the young person feel supported. Some schools may institute a ‘hall pass’ to allow students time out from the class when experiencing difficulties. Discussion and modification of the young person's curriculum may be necessary, to focus on core subjects, but also to include study/rest periods and time in non-core subjects that the young person may enjoy. The overall aim of such intervention is to allow the young person to remain at school for longer periods. A modified curriculum can also include provision of teaching in the home, or additional tutoring, if such services are available.
In certain situations where health problems have been associated with particularly long periods of absence from school, some centres, including our own, recommend an elective inpatient admission for rehabilitation. This type of intervention has been instituted for young people with chronic fatigue and chronic pain syndromes.35 ,36 As well as goals for rehabilitation across other meaningful occupational domains, a goal of re-establishing school attendance in the hospital setting can be included, before beginning the gradual return to the young person's own school.37 One study showed that, following a multidisciplinary inpatient rehabilitation programme for adolescents with CFS, 78% of the cohort were attending school full time (at 5-year follow-up) compared with 94% attending school for less than 50% of the time prior to engagement in the programme.36 This was a small observational study, without a control group for comparison. Given the intensive resources required for an inpatient approach, there is a need for further research (eg, comparison with an outpatient day programme) to evaluate this type of intervention.
Prolonged school non-attendance in adolescence is complex and represents a critical public health problem due to the range of associated adverse poor outcomes, both short and long term. Health professionals are frequently consulted in cases of school non-attendance as medical reasons are often cited for the absence. A comprehensive review is crucial in order to identify any medical or psychiatric diagnosis and to direct appropriate management. Health professionals are in a key position to coordinate a structured, collaborative approach with the young person, their family and the school to work towards school reintegration. Research studies evaluating the outcomes of school reintegration programmes are necessary to identify examples of best practice and optimise the use of available resources.
Contributors DNP conceived the idea for the paper. SH wrote the first draft. Both authors contributed to revisions of the paper and to the final draft.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
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