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Of course, the child's refusal to attend school may often have overlapping functions. Also, the measure may be less valuable when considering severe or chronic cases where many contextual influences may operate Kearney, Clearly, academic pressures, often exacerbated by high stakes testing, can lead to unbearably high levels of anxiety Connor, , ; Denscombe, ; Putwain, Negative peer experiences can also be influential and this century has seen greater recognition of the pervasive trauma associated with bullying.

Developmental differences in children who have experienced adversity

Cyberbullying is a relatively new form of bullying involving the use of everyday electronic devices and social media platforms. The understandings that school personnel have about the reasons for a student's school refusal are also likely to affect the manner in which they respond. These place upon the student varying degrees of blame, victim status and legitimacy. Although it is currently unclear how such understandings impact upon future refusal behaviour, it would seem likely that the school will be more accommodating of any need for special arrangements if the student is perceived as a victim of factors beyond their control.


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Thus, assessment should not only identify the reasons behind should refusal but also consider how understandings of these may impact upon the willingness of school staff to be maximally supportive to the child. The overarching aim of intervention is the reduction of the young person's emotional distress and an increase in school attendance, outcomes that will help them follow a normal developmental pathway. There are several factors that may contribute to the greater difficulty encountered in intervening with older children.

Adolescent refusers tend to have a greater sense of autonomy than younger children that can help them to refuse adult strictures. A wide range of treatments can be deployed depending upon individual need. Many treatment approaches incorporate a focus upon contextual factors in both the home and in school that may increase or alleviate anxiety see Elliott, , p. Elliott noted that Cognitive Behaviour Therapy CBT had largely replaced psychoanalytic approaches as the preferred method of treatment for school refusal. In a series of more recent reviews, this approach has also been found to be effective in alleviating a range of anxiety disorders for young people e.

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However, because of the need to intervene swiftly with such cases, there were no waiting list controls, rendering judgement as to treatment effectiveness difficult to determine. Their intervention employed manualised CBT therapy supplemented by family work, inpatient support involving graduated exposure and training in the productive use of leisure time. Significant gains were found in school attendance with reduced comorbid mental health problems.

However, the absence of a control group did not permit conclusions to be drawn about the role of the treatment itself. Despite this, support from controlled trials for the value of parental involvement as part of CBT programmes is modest. However, there were some improvements in subsequent school attendance. Helpful guidance for undertaking such work is provided by Swan, Kagan, Frank, Crawford, and Kendall The reviewers noted that risks of bias which could have increased effect sizes were present in most of the studies. Interestingly, findings from this study showed that gains made in respect of attendance were not mirrored by decreases in anxiety levels.

Of course, achieving reintegration to school is likely to raise the child's anxiety, whereas remaining at home may often result in lower levels of distress. Researchers, therefore, need to be explicit about whether the primary outcome sought in their intervention studies is reduction in anxiety or increased school attendance.


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  4. A generation later, these issues are still unresolved. These authors point out that we are still ignorant as what are the key ingredients of CBT, and what is the best sequence for combining elements of the programme, or how and why treatments work. For example, it is unclear under which circumstances exposure should precede, or follow, skills training. Such practices may be seen as potentially vulnerable to litigation, particularly as evidence of its efficacy and appropriateness has been largely absent in the research literature.

    The influence of the family is a key factor to consider in developing a treatment plan and, as Berg observed, it is only when the child realises that parents are determined to effect their return to school that real progress tends to be made. Clearly, involving the family in the intervention, alongside school staff, is likely to be essential in most cases Doobay, Instead, family work is now often seen as more appropriately embedded within a CBT programme e. Reconciling this debate is problematic as few studies have reported on the value of medication for this problem. Selective serotonin reuptake inhibitors SSRIs are regarded as the pharmacological treatment of choice for anxiety disorders in children and adolescents because of their effectiveness and safety profile.

    Studies have reported mixed results as to whether a combination of medication with CBT offers any additional clinical benefits for school refusal. Despite this, for each group, attendance remained at a level that was inadequate for effective schooling and there was no evidence that augmenting CBT with fluoxetine improved attendance or psychological functioning.

    Kearney and Graczyk have suggested that the treatment of all forms of problematic absenteeism could operate effectively within a Response to Intervention RTI framework. Crucially, following detailed assessment of progress, decisions about future action are primarily a consequence of how the child has responded to earlier intervention.

    Insufficient progress typically leads to more structured, more intense, more specialised, more individualised forms of intervention. RTI does not specify which forms of intervention should be utilised, only that this should have a strong supportive evidence base.

    Kearney argues that an RTI approach may be particularly valuable for problematic school absenteeism because its key components involve: early identification, functional assessment of problem behaviours and monitoring of progress following intervention. It also advocates the adoption of interventions that have empirical support, are compatible with other multitier approaches, and have a focus upon teamwork.

    It is hardly surprising therefore that attempts to use this structure to address school absenteeism are now beginning to surface. In the case of reading disability, for example, an RTI approach can typically involve a range of professionals involved in education — classroom practitioners, specialist teachers, school educational psychologists and speech and language therapists.

    Here, professional roles and particular expertise relevant to the issue are widely known, there is a clear and logical instructional hierarchy, and movement through the tiers can operate relatively smoothly. For school absenteeism there is potential involvement from a much wider range of service providers such as education, psychology, psychiatry, social work and juvenile justice whose referral patterns, focus and approach may differ considerably. Thus, appropriate and timely movement through tiers, based upon the child's response to assistance from these various agents, will present a much greater challenge.

    While Kearney's comprehensive and multisystemic approach to the broader concept of school refusal behaviour is laudable, the difficulties noted above, which Kearney readily acknowledges, suggest that its operation is unlikely to be a realistic proposition in the foreseeable future for the vast majority of the readers of this review.


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    The many different understandings of school refusal render it difficult to speak with confidence about likely prognosis. In relation to internalising conditions related to school refusal, the lifetime prevalence for anxiety disorders has been estimated to be To depict the geographic dispersion of corporal punishment use, prevalence, and disparities, we merged OCR data with school district and state boundaries using ArcGIS software version This software allowed us to map the use of corporal punishment aggregated to either the district or state level.

    Even when corporal punishment is legally permitted in a state, school district superintendents and individual school principals within districts can decide whether to use corporal punishment as a form of discipline. Table 2 presents the percentage of schools in each state that reported using corporal punishment on at least one child; these rates are then mapped in Figure 1. States that legally permit school corporal punishment are largely clustered in the southeastern United States.

    As is clear from both the table and figure, the nexus of school corporal punishment is located in the contiguous states of Arkansas, Alabama, and Mississippi, with more than half of schools in each state using corporal punishment. The percentage of schools using corporal punishment progressively decreases among the states that radiate out from this nexus.

    Legality of corporal punishment and percentage of public schools reporting any corporal punishment by state. Percentage of schools reporting corporal punishment, and percentage of children attending schools using corporal punishment, by state in the — school year. Data source: U.

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    Department of Education, Office for Civil Rights b. In a given state, the percentage of schools that use corporal punishment tells us little about the proportion of students potentially affected by it. It could be the case that corporal punishment is isolated in districts with fewer students, with the result that few students are actually at risk of receiving corporal punishment.

    To examine this issue, we calculated the proportion of all students in a state who attended a school that used corporal punishment; these values are also presented in Table 2. However, there is substantial between-state variation. In comparing the two columns in Table 2 , the percentage of schools using corporal punishment and the percentage of children attending schools using corporal punishment are roughly equal in most states.

    However, for Arkansas, Oklahoma, Texas, and Georgia, the proportion of schools using corporal punishment exceeds the proportion of students who attend those schools by more than two percentage points, indicating that, on average, schools using corporal punishment in these states serve fewer students than schools that do not use it. Given the between-state differences in prevalence of school corporal punishment, it is important to examine the within-state variation to determine whether corporal punishment usage and prevalence is clustered in particular areas of these states.

    Figure 2 presents prevalence of corporal punishment at the district level. Each district is coded according to the highest school-level rate of corporal punishment in that district, or the percentage of all enrolled students who were corporally punished at least once.

    Prevalence of School Corporal Punishment in the 2011–2012 School Year

    Use of corporal punishment by school district maximum percentage of students corporally punished at a district school. These districts are geographically scattered around each state, indicating that frequent use of school corporal punishment in these states has largely been eliminated in these states.

    Around half of all students in Alabama, Arkansas, and Mississippi attend schools that use corporal punishment. Alabama, Arkansas, and Mississippi are a different story, however: This suggests that corporal punishment is still frequently used in a sizable percentage of the districts in these three states. Figure 2 is yet another illustration that school districts generally appear to be phasing out corporal punishment— except those in Alabama, Arkansas, and Mississippi, where its use remains widespread.

    Table 3 presents the number of children attending public schools in each state where corporal punishment is legal that were subjected to corporal punishment in the — school year, with the total number coming to , students. It is important to note that the OCR data track the number of children, not the instances of discipline; multiple instances of corporal punishment of the same child are not represented in the data.

    Thus, this total is likely an underestimate of the number of instances of corporal punishment in the United States that year. Number and percentage of students within each state that actually received corporal punishment in the — school year. Corporal punishment is permitted in 19 states, but it is much more pervasive across schools in some states, particularly Alabama, Arkansas, and Mississippi, where half of all students attend schools that use corporal punishment. Mississippi has the highest proportion of children experiencing school corporal punishment, where 1 in every 14 children is subject to corporal punishment in a single school year.

    The CRDC survey asked school administrators to report how many children received corporal punishment during the — school year by race or ethnicity, gender, and disability status. To examine disparities by race, we computed a ratio of the proportion of Black students who were corporally punished to the proportion of White students who were. We were not able to calculate ratios for other racial and ethnic groups because of insufficient subgroup sizes.

    To ensure that we were only including schools that used corporal punishment as a regular form of school discipline, we considered that a school used corporal punishment if the administrator reported corporal punishment of 10 or more students in that school year. The disparity ratio for gender was calculated as the proportion of boys who were subject to corporal punishment divided by the proportion of girls who were, while the disparity ratio for disability status was calculated as the proportion of disabled students who were corporally punished over the proportion of nondisabled students who were.

    Disparity ratios were not calculated for schools that lacked adequate representation at least 15 students in either of the groups being compared. There were a few schools for which a ratio could not be calculated because either the numerator or denominator was 0; in other words, despite having both groups represented at the school, only members of one group received corporal punishment. In those instances, we assigned the top-coded disparity measure i. Using these methods, we were able to calculate disparity measures by race for 1, schools from districts , by gender for 3, schools from 1, districts , and by disability status for 3, schools from 1, districts.

    Each ratio reflects the increased probability of a child in one group Black, male, or a student with a disability experiencing corporal punishment as compared to a child in the comparison group White, female, or a student without a disability. Of those, 53 did not have a school with adequate representation of students with and without disabilities. Disparity ratios calculated for 1, school districts. Ratios higher than 1 indicate that students with disabilities were more likely to be corporally punished than students without disabilities. Racial disparities in use of school corporal punishment by district are presented in Figure 3.

    The figure includes a table of the percentage of districts that fall into each category of disparity ratios, as well as a map of districts coded according to the highest ratio reported for a school in that district. Both the table and the figure reveal that racial disparities in school corporal punishment are widespread, with disparities largest in Alabama and Mississippi.