Psychosocial Interventions for School Refusal Behavior: A Systematic Review and Meta-Analysis
School refusal behavior, a psychosocial problem characterized by severe emotional distress and anxiety at the prospect of going to school, affects approximately 5% of school-age children. School refusal is a complex problem with short and long-term adverse consequences for students, parents, and schools. Psychosocial interventions for students with school refusal behavior generally fall into one of four categories: behavioral approaches, cognitive-behavioral therapy (CBT), family therapy, and non-behavioral, non-CBT individual therapy; however, prior reviews tend to focus specifically on cognitive-behavioral interventions. Moreover, prior reviews are limited by a lack of comprehensive and systematic search processes and have been qualitative in nature. This systematic review improves and builds upon prior research by utilizing systematic and quantitative methods to examine the effects of school refusal behavior interventions on attendance and anxiety.
Methods: Systematic review methods, using Campbell Collaboration guidelines, were used to search, select, code, and analyze studies meeting eligibility criteria for this review. A comprehensive search strategy, comprised of searching 15 electronic databases and research registers, reference lists, and a comprehensive gray literature search produced eight experimental and quasi-experimental studies for inclusion. Meta-analytic methods were utilized to quantitatively synthesize results of the included studies using Comprehensive Meta-Analysis 2.0.
Results: Interventions included in this review were comprised of CBT (n=5) and non-CBT interventions (n=3) with primarily elementary students. The meta-analytic findings demonstrated an overall moderate, positive effect on attendance (g=.47) and anxiety (g=.62). A test of homogeneity revealed the effect size distribution was homogenous, thus the variability of effect sizes was no greater than what would be expected from sampling error alone. This result indicates that although studies differed on a variety of characteristics, none of those differences mattered in terms of the magnitude of effects found in those studies.
Conclusions and Implications: Findings suggest that students with school refusal behavior benefit from both CBT and non-CBT interventions in both reducing symptoms of anxiety and improving attendance. School social workers thus have a range of interventions from which to choose when intervening with students who are exhibiting school refusal behavior. Implications for practice and policy will be discussed.