10.

1177/0145445503259263
BEHAVIOR
Kearney, Albano
MODIFICATION
/ FUNCTIONAL
/ January
PROFILES
2004 ARTICLE

The Functional Profiles

of School Refusal Behavior
Diagnostic Aspects

CHRISTOPHER A. KEARNEY
University of Nevada, Las Vegas

ANNE MARIE ALBANO

New York University School of Medicine

School refusal behavior is a common problem seen by mental health professionals and by educa-
tors but little consensus is available as to its classification, assessment, and treatment. This study
assessed 143 youth with primary school refusal behavior and their parents to examine diagnoses
that are most commonly associated with proposed functions of school refusal behavior. As
expected, results indicated that great heterogeneity in diagnoses marks this population. In gen-
eral, anxiety-related diagnoses were associated more with negatively reinforced school refusal
behavior; separation anxiety disorder was associated more with attention-seeking behavior; and
oppositional defiant disorder and conduct disorder were associated more with pursuit of tangible
reinforcement outside of school. These results are discussed within the context of classification,
assessment, and treatment of this population.

Keywords: youth; school refusal behavior; functions; diagnoses.

School refusal behavior refers to a child-motivated refusal to at-

tend school and/or difficulties remaining in classes for an entire day
(Kearney & Silverman, 1996). The behavior is one of the most com-
mon problems seen by clinical child psychologists, other mental-
health professionals, and educators. In fact, the problem may affect up
to 28% of youth at one time in their life (Kearney, 2001). School

Please address correspondence to Christopher A. Kearney, Department of Psychology, Univer-

sity of Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas, NV 89154-5030. e-mail:
ckearney@ccmail.nevada.edu.
BEHAVIOR MODIFICATION, Vol. 28 No. 1, January 2004 147-161
DOI: 10.1177/0145445503259263
© 2004 Sage Publications

147
148 BEHAVIOR MODIFICATION / January 2004

refusal behavior is a heterogeneous condition that is marked by many

different internalizing and externalizing behaviors. Examples in-
clude general and social anxiety, somatic complaints, depression,
fear, social withdrawal, noncompliance, aggression, running away,
and temper tantrums, among others. The problem is usually seen
equally among boys and girls and families of different racial groups
and socioeconomic statuses (Hansen, Sanders, Massaro, & Last,
1998; Last, Francis, Hersen, Kazdin, & Strauss, 1987; Last & Strauss,
1990; Last, Strauss, & Francis, 1987). The short-term and long-term
consequences of school refusal behavior can be devastating if the
problem is left unaddressed (Buitelaar, van Andel, Duyx, & van
Strien, 1994; Hibbett & Fogelman, 1990).
Because school refusal behavior is commonly presented to psy-
chologists and others, an acute need exists for effective classification,
assessment, and treatment strategies. Unfortunately, however, a pleth-
ora of terms has been devised over the years to describe this popula-
tion (e.g., school phobia, school refusal, truancy). This practice has
disrupted attempts at taxonomic consensus and impeded clinicians
who wish to gather information about what to do for a particular case.
In addition, little agreement is available in the literature about the best
methods of assessing and treating this critical population.
To partially address this conundrum, Kearney and colleagues
designed the term school refusal behavior to refer to all youth who
refuse school, including those with and without anxiety-based behav-
iors (Kearney & Silverman, 1990). In related fashion, specific param-
eters were established for different types of school nonattendance and
for pathways that could lead to chronic school refusal behavior and
dropout (see Kearney, 2001, 2003). These definitions and parameters
were meant to help build consensus in this snarled but important area.
To improve the classification of this population even further,
Kearney and colleagues developed a model that organizes youth with
school refusal behavior based on the primary reason why they are
refusing school (Kearney & Silverman, 1990, 1996). This strategy
was meant to supplement (or replace) taxonomic strategies based on
the forms of school refusal behavior, which can be problematic given
the extreme heterogeneity of this population. In essence, youth with
school refusal behavior were categorized according to function and
 Kearney, Albano / FUNCTIONAL PROFILES 149

were conceptualized as refusing school to (a) avoid school-related

stimuli that provoke a general sense of negative affectivity (i.e., anxi-
ety and depression); (b) escape school-related aversive social and/or
evaluative situations; (c) gain attention from significant others (e.g.,
parents); and/or (d) pursue tangible reinforcement outside of school
(e.g., shopping, playing with friends, or drug use). The first two func-
tional conditions refer to youth who refuse school for negative rein-
forcement, whereas the latter two functional conditions refer to youth
who refuse school for positive reinforcement. Of course, some youth
refuse school for multiple reasons as well.
This functional model was linked to assessment and prescriptive-
treatment strategies designed to help practitioners during the clinical
process. Kearney and Silverman (1993; see also Kearney, 2002a), for
example, designed the School Refusal Assessment Scale (SRAS)
with both child and parent versions to help clinicians identify primary
and secondary functions of a child’s school refusal behavior. The
SRAS has also been used to successfully predict the prescriptive-
treatment package is most effective for a particular child with school
refusal behavior (Kearney, 2002b; Kearney, Pursell, & Alvarez, 2001;
Kearney & Silverman, 1990, 1999). The scale is also useful for identi-
fying the treatments that will not be effective (Kearney & Silverman,
1999). Prescriptive treatments are largely cognitive-behavioral family
systems in nature, and include exposure-based techniques, cognitive
restructuring, contingency management and contracting, and com-
munication and peer refusal-skills training, among other techniques
(Kearney & Albano, 2000a, 2000b).
Although the functional model has been developed and expanded
over the years, few published data are available about the specific
forms of behavior that tend to comprise each functional condition. To
partially address this, the present article identifies primary and co-
morbid diagnostic categories that are associated with each functional
condition. This is done to help clinicians identify the primary reason
that a particular child is refusing school, as many clinicians continue
to rely heavily on the DSM-IV system in their daily practice (Ameri-
can Psychiatric Association, 2000).
Hypotheses for this study were derived on the basis of previous
data that indicated that certain functional conditions were related to
150 BEHAVIOR MODIFICATION / January 2004

certain diagnostic categories. Kearney and Silverman (1993) and

Kearney (2002a), for example, found that the first two functional con-
ditions, those indicating negatively reinforced school refusal behav-
ior, tended to be associated more with internalizing (e.g., anxiety or
depressive) disorders. In addition, youth refusing school for attention
tended to be associated more with separation anxiety disorder, and
youth refusing school for tangible reinforcement outside of school
tended to be associated more with externalizing (e.g., oppositional de-
fiant or conduct) disorders or no disorder. These associations were
thus expected in the much larger sample reported here.

METHOD

PARTICIPANTS

Participants were 143 youth with primary-school refusal behavior

and their families. The sample was 62.9% male with a mean age of
11.60 years (ages ranged from 5 years to 17 years; SD = 3.17). Race
was primarily Caucasian (89.5%) but also Hispanic (4.9%), African
American (3.5%), or Asian and other (2.1%). Youth were absent a
mean of 37.22% of school time at the time of assessment (SD = 32.19).
Families of these youth were generally dual parent (59.8%) with a
mean annual family income of $34,455 (SD = $25,487) and a mean
number of dependents of 2.30 (SD = 1.19). Youth and their families
were referred to university-based clinics in Nevada and Kentucky that
specialized in the assessment and treatment of youth with school
refusal behavior.

MEASURES

The following measures are commonly used to assess psycho-

pathology and the form and the function of school refusal behavior in
children.

Diagnostic interview. The Anxiety Disorders Interview Schedule

for Children-Child and Parent Versions (ADIS-C/P) (Silverman &
 Kearney, Albano / FUNCTIONAL PROFILES 151

Albano, 1996) were administered to youth and to parents to obtain

DSM-IV diagnoses for each child. For some youth, diagnostic data
were updated and revised from the original ADIS (Silverman &
Nelles, 1988). The ADIS-C/P versions have good interrater (r = .98
for ADIS-C; r = .93 for ADIS-P) and test-retest reliability (k = .76 for
ADIS-C; k = .67 for ADIS-P) (Silverman & Eisen, 1992; Silverman &
Nelles, 1988). A kappa coefficient for overall anxiety disorder using
combined ADIS-C/ADIS-P information has been reported to be .75.
(See Rapee, Barrett, Dadds, & Evans, 1994, and Silverman, Saavedra,
& Pina, 2001, for specific anxiety-disorder coefficients.)
The ADIS-C/P were administered to youth and parents, respec-
tively, by persons trained in using the interviews (see Silverman &
Nelles, 1988). Interviewers held a doctoral degree in or were ad-
vanced graduate students in clinical psychology. Diagnoses from
the ADIS-C, ADIS-P, and combined ADIS-C/P were derived. (see
Albano & Silverman, 1996, for specific procedures.) Clinical sever-
ity ratings of diagnoses were assigned on a scale ranging from 0
(none) to 8 (extreme). Primary (i.e., first) diagnoses were diagnoses
with the highest clinical-severity rating for a particular individual.
Comorbid (i.e., second through fifth) diagnoses were diagnoses with
less severe clinical ratings but those that also applied to a particular
individual.

School Refusal Assessment Scale (SRAS). A version of the SRAS

(Kearney, 2002a; Kearney & Silverman, 1993) was administered to
children (SRAS-C) and parents (SRAS-P) at the time of assessment.
The SRAS measures the relative strength of four functional condi-
tions for school refusal behavior: (a) avoidance of school-related stim-
uli that provoke negative affectivity, (b) escape from school-related
aversive social and/or evaluative situations, (c) attention from signifi-
cant others, and/or (d) tangible reinforcement outside of school. Chil-
dren and their parents (mother or father) completed child (SRAS-C)
and parent (SRAS-P) versions of the SRAS or its revision, respec-
tively (Kearney, 2002a; Kearney & Silverman, 1993). In cases where
only one parent was present, the SRAS-P was completed by that per-
son. In cases where both mother and father were present, two separate
SRAS-Ps were completed.
152 BEHAVIOR MODIFICATION / January 2004

The SRAS has adequate child test-retest (7-14-day; mean of r =

.68); parent test-retest (7-14-day; mean of r = .78); and parent-
interrater (mean of r = .59) reliability (Kearney & Silverman, 1993). A
revision of the SRAS also has adequate child test-retest (7-14-day;
mean of r = .68); parent test-retest (7-14-day; mean of r = .67); and
parent-interrater (mean of r = .54) reliability (Kearney, 2002a). Con-
current and construct validity for the scales has also been dem-
onstrated (Kearney, 2002a; Kearney & Silverman, 1993). Items are
available from Kearney (2002a), Kearney and Silverman (1993), or
Kearney and Albano (2000b).
The SRAS uses a Likert-type scale that ranges from 0 (never) to 6
(always) and that is scored by deriving the mean item value for each
functional condition. Unanswered questions are not counted. These
values are obtained for each administered version of the scale (e.g.,
child, mother, and father) and averaged. The highest scoring condition
is considered to be the primary maintaining variable for a child’s
school refusal behavior. For example, if mean item scores for each
functional condition were obtained from (a) a child’s SRAS (e.g.,
1.00, 2.00, 3.00, and 4.00); (b) a mother’s SRAS (e.g., 2.50, 3.50,
4.50, and 5.50); and (c) a father’s SRAS (e.g., 0.50, 1.75, 3.00, and
5.00), then the overall profile (i.e., means across each functional con-
dition) would be 1.33, 2.42, 3.50, and 4.83, respectively. Function
four (4.83; tangible reinforcement) would thus be regarded as the pri-
mary function of school refusal behavior. Conversely, function one
(1.33; avoidance of stimuli that provoke negative affectivity) would be
regarded as the least influential condition.

PROCEDURE

Youth with primary school refusal behavior and their families were
referred for assessment, at which time the ADIS and SRAS were
administered. Diagnoses from the ADIS-C were compared to SRAS-
C ratings, diagnoses from the ADIS-P were compared to SRAS-P rat-
ings, and diagnoses derived from combined child and parent reports
were compared to combined SRAS-C and SRAS-P ratings. It should
be noted that the function of a child’s school refusal behavior when
considering all SRAS reports together (i.e., child + parents) may be
 Kearney, Albano / FUNCTIONAL PROFILES 153

different from the function endorsed only by a child or only by a par-

ent. One youth refused to complete the interview but did complete the
SRAS-C. Chi-square analyses were used to evaluate the frequency of
specific diagnoses and of gender across different functional condi-
tions. A functional profile was considered mixed if two or more func-
tions were rated equal in strength.

RESULTS

PRIMARY AND COMORBID DIAGNOSES

Primary and comorbid diagnosis rates for the overall sample based
on combined child and parent reports are in Table 1. Separation
anxiety disorder was the most prominent diagnosis, although many
youth met criteria for other anxiety, mood, and disruptive behaviors as
well. Lack of diagnosis was also prominent in nearly one third of
cases. Almost one third (30.8%) of youth in the total sample (N = 143)
received a second diagnosis, 11.9% received a third diagnosis, 4.2%
received a fourth diagnosis, and 2.1% received a fifth diagnosis.
Examining youth who received only a primary diagnosis (n = 96),
45.8% received a second diagnosis, 17.7% received a third diagnosis,
6.3% received a fourth diagnosis, and 3.1% received a fifth diagnosis.

DIAGNOSTIC COMPARISONS ACROSS FUNCTIONS

Diagnostic distributions per function across child, parent, and com-

bined reports are in Table 2. Chi-square analyses regarding the com-
bined-report distributions revealed significant differences with
respect to separation anxiety disorder (χ2 = 42.48; p = .001);
oppositional defiant disorder (χ2 = 12.21; p = .016); major depression
(χ2 = 12.76; p = .013); conduct disorder (χ2 = 10.81; p = .029); pres-
ence of any anxiety disorder (χ2 = 23.53; p = .001); and presence of
oppositional defiant disorder or conduct disorder (χ2 = 16.54; p =
.002). Trends were found with respect to generalized anxiety disorder
(χ2 = 8.10; p = .088) and no diagnosis (χ2 = 8.34; p = .080). In general,
154 BEHAVIOR MODIFICATION / January 2004

TABLE 1
Diagnostic Overview and Comorbidity Based on
Combined Child and Parent Reports
Level of Diagnosis
Type of Diagnosis Primary Second Third Fourth Fifth

Separation anxiety disorder 22.4 2.1 0.7 0.0 0.0

Generalized anxiety disorder 10.5 9.8 6.3 0.7 0.0
Oppositional defiant disorder 8.4 5.6 1.4 1.4 0.0
Major depression 4.9 1.4 0.7 0.7 0.0
Specific phobia 4.2 0.0 0.7 0.0 0.7
Social anxiety disorder 3.5 4.2 0.0 0.7 0.0
Conduct disorder 2.8 1.4 0.0 0.0 0.7
Attention deficit hyperactivity disorder 1.4 1.4 0.7 0.7 0.0
Panic disorder 1.4 0.0 0.0 0.0 0.0
Enuresis 0.7 1.4 0.0 0.0 0.0
Posttraumatic stress disorder 0.7 0.0 0.0 0.0 0.0
Agoraphobia 0.0 1.4 0.0 0.0 0.0
Sleep terror disorder 0.0 0.0 0.0 0.0 0.7
No diagnosis 32.9

NOTE: Figures are percent of total sample size (N = 143). Diagnoses are ordered by prevalence
of primary diagnosis.

separation anxiety disorder was much more prevalent in the attention-

seeking group. Diagnoses of anxiety disorders tended to concentrate
in the negative-reinforcement functions (avoidance of school-related
stimuli that provoke negative affectivity [ANA] and escape from
aversive school-related social and/or evaluative situations [ESE]).
Diagnoses of disruptive behavior disorders tended to concentrate
in the pursuit of tangible reinforcement outside of school (PTR)
function.

OTHER COMPARISONS

Gender, age, and clinical severity ratings of primary diagnoses

were also examined across combined report functions. No gender dif-
ferences were found (percent of males per function 1-4, respectively:
61.4%, 55.5%, 62.5%, and 65.3%). With respect to age, however,
 Kearney, Albano / FUNCTIONAL PROFILES 155

TABLE 2
Diagnoses Across Functional Conditions
Function Based on Child Report
ANA ESE ATT PTR Mixed

Child report: All diagnoses

Separation anxiety disorder 8 0 18 3 0
Generalized anxiety disorder 6 4 5 7 1
Social anxiety disorder 4 3 2 2 0
Specific phobia 3 1 3 4 0
Major depression 3 2 0 1 0
Agoraphobia 2 1 1 0 0
Panic disorder 1 0 1 0 0
Attention deficit hyperactivity disorder 0 0 0 1 0
No diagnosis 12 1 17 47 8
Sample size 27 7 40 59 9

Function Based on Parent Report

Parent report: All diagnoses
Generalized anxiety disorder 14 7 8 12 1
Separation anxiety disorder 6 1 20 3 0
Oppositional defiant disorder 4 1 7 12 1
Major depression 5 4 0 3 0
Social anxiety disorder 5 4 2 1 0
Specific phobia 5 2 1 1 0
Attention deficit hyperactivity disorder 3 0 2 3 0
Conduct disorder 1 0 0 6 1
Enuresis 1 0 1 1 0
Panic disorder 2 0 0 0 0
Agoraphobia 1 0 0 0 0
Bipolar disorder 0 0 0 1 0
Posttraumatic stress disorder 1 0 0 0 0
Sleep terror disorder 0 1 0 0 0
No diagnosis 21 1 12 12 2
Sample size 51 12 37 38 5

Function Based on Combined Report

Combined report: All diagnoses
Generalized anxiety disorder 12 6 10 11 0
Separation anxiety disorder 7 0 25 4 0
Oppositional defiant disorder 1 1 8 14 1
Social anxiety disorder 5 4 2 1 0
Major depression 5 3 0 3 0

(continued)
156 BEHAVIOR MODIFICATION / January 2004

Table 2 (Continued)

Function Based on Combined Report

ANA ESE ATT PTR Mixed

Specific phobia 4 2 1 1 0
Conduct disorder 0 1 0 6 0
Attention deficit hyperactivity disorder 2 0 2 2 0
Enuresis 1 0 1 1 0
Panic disorder 2 0 0 0 0
Agoraphobia 2 0 0 0 0
Bipolar disorder 0 0 0 1 0
Posttraumatic stress disorder 1 0 0 0 0
Sleep terror disorder 0 0 1 0 0
No diagnosis 18 0 11 17 1
Any anxiety disorder 22 9 29 16 0
Any acting-out disorder 1 1 8 17 0
Sample size 44 9 40 49 1

NOTE: Numbers are total diagnoses (primary to fifth) given per child per functional condition.
Diagnoses are ordered by total number given. Sample size for child report reduced by one who
did not complete the interview, so School Refusal Assessment Scale report was counted in only
the combined report. ANA = avoidance of school-related stimuli that provoke negative
affectivity; ESE = escape from aversive school-related social and/or evaluative situations; ATT =
pursuit of attention from significant others; PTR = pursuit of tangible reinforcement outside of
school; Mixed = two or more functions were rated as equal in strength. Any acting-out disorder
includes oppositional defiant disorder and/or conduct disorder.

analysis of variance did reveal a significant difference (mean ages per

function 1-4, respectively: 11.84, SD = 2.72; 14.44, SD = 1.81; 9.20,
SD= 2.83; and 12.92 SD = 2.75; F[4, 138] = 13.96; p = .001). In gen-
eral, children tended to be younger if they refused school to avoid
stimuli that provoked negative affectivity or if they refused school for
attention. Children tended to be older if they refused school to escape
aversive social and/or evaluative situations or to pursue tangible rein-
forcement outside of school. Finally, with respect to clinical severity
ratings of primary diagnoses, analysis of variance revealed a signifi-
cant difference (mean diagnostic severity ratings per function, respec-
tively: 4.39, SD = 2.00; 3.00, SD = 0.00; 3.77, SD = 1.45; and 3.00 SD
= 0.95; F[4, 60] = 3.18; p = .03). In general, children tended to have the
most severe diagnoses if they refused school to avoid stimuli that
provoked negative affectivity.
 Kearney, Albano / FUNCTIONAL PROFILES 157

DISCUSSION

This study is one of a few to examine youth with general school

refusal behavior and not simply youth with anxiety-based absentee-
ism. In addition, the study is the first to examine diagnostic categories
across functions for a large sample of youth with general school
refusal behavior. Data indicate considerable heterogeneity in diagno-
ses. In addition, consistent with previous studies using smaller sam-
ples, internalizing disorders tended to be associated more with nega-
tively reinforced school refusal behavior, separation anxiety disorder
was associated more with attention-seeking behavior, and opposi-
tional defiant disorder and conduct disorder were associated more
with pursuit of tangible reinforcement outside of school. Generalized
anxiety disorder and social anxiety disorder did not clearly differenti-
ate the negative reinforcement functions (i.e., Function 1 and Func-
tion 2, respectively), as one might expect. However, these disorders
overlap considerably (e.g., anxiety and worry about social stimuli)
and a small sample size in the second group (escape from aversive
social and/or evaluative situations) may have hindered statistical
power.
From a classification standpoint, this study confirms that sole reli-
ance on diagnosis to organize youth with school refusal behavior is a
difficult task. As with many other samples—even those with anxiety-
based school refusal—considerable heterogeneity is evident and
much overlap is seen across proposed diagnostic subtypes (Bernstein
et al., 1997; Last et al., 1987; Last & Strauss, 1990). Instead, a better
strategy might be to consider both the forms and the functions of chil-
dren’s school refusal behavior when developing taxonomic systems
for this population. Ideas for developing consensus among different
groups that examine and treat youth with school refusal behavior have
been presented (Kearney, 2003).
From an assessment standpoint, the present study supports certain
directions that clinicians may wish to take during their evaluation pro-
cess. For example, if a clinician is hypothesizing that a youth may be
refusing school for negative reinforcement or to avoid aversive stimuli
at school, then support for this hypothesis may be found by examining
scores on the SRAS as well as anxiety and depressive diagnoses and/
158 BEHAVIOR MODIFICATION / January 2004

or elevated scores on standardized self-report questionnaires. Youn-

ger age and more severe diagnoses are also more likely if a child is
specifically refusing school to avoid stimuli that provoke negative
affectivity. In addition, behavioral observations of the child may be
useful. A particularly instructive observation is to examine the child
and family during their morning routine to note patterns of avoidance
and negative affectivity. Information from multiple sources is usually
considered most important for the negative reinforcement functions
due to the subjective nature of many of the child’s behaviors.
If a clinician is hypothesizing that a child is refusing school for
attention, then support for this hypothesis may be found by examining
scores on the SRAS as well as symptoms of separation anxiety disor-
der and younger age. It is important to note, however, that many youth
with attention-seeking-based school refusal behavior show more of
the externalizing symptoms of separation anxiety disorder such as
noncompliance (e.g., refusal to sleep alone or to attend school).
Although many of these children technically meet criteria for separa-
tion anxiety disorder, the actual problem, based on parent reports, is
often willful, manipulative, controlling behavior (e.g., tantrums) on
the child’s part. Much of this behavior is designed to coerce parents
into acquiescing to the child’s demands to stay home or go to work
with his or her parents. In other cases, however, actual separation anxi-
ety and excessive reassurance-seeking behavior may be present and
should be addressed.
If a clinician is hypothesizing that a child is refusing school for tan-
gible reinforcement outside of school, then support for this hypothesis
may be found by examining scores on the SRAS as well as examining
symptoms of oppositional defiant disorder or conduct disorder and
older age. The latter findings may suggest support for the traditional
concept of truancy, but many of these disruptive behaviors overlap
with misbehaviors related to school nonattendance (e.g., vandalism or
purchasing alcohol) or are designed to maintain the status quo within a
family (e.g., fighting to maintain parental noninterference). There-
fore, clinicians are encouraged to look beyond the traditional notion
of truancy and focus more on the child’s behaviors and enticements
outside of school as well as on the family’s problem-solving abilities
and motivation to change the current situation.
 Kearney, Albano / FUNCTIONAL PROFILES 159

From a treatment standpoint, the present study also supports cer-

tain directions that clinicians may wish to take during therapy. For
example, if a child is known to be refusing school for negative rein-
forcement, then treatment should focus on psychoeducation; reducing
negative affectivity (especially symptoms of various anxiety disor-
ders as well as depression); gradually reintegrating a child into school;
and somatic control exercises. For older children and adolescents,
cognitive restructuring or modeling and role play may be useful as
well. Given that negatively reinforced school refusal behavior is asso-
ciated with several anxiety and depressive disorders, clinicians must
also be sensitive of potential self-mutilation, suicidal ideation and
attempts, panic attacks, and uncontrolled worry, all common symp-
toms in this group.
If a child is known to be refusing school for attention, then treat-
ment should focus on parent-based contingency management to
reward appropriate behavior and punish inappropriate attention-
seeking behavior. Establishing daily routines and forced school atten-
dance may be necessary as well. Given that separation anxiety dis-
order is highly comorbid with this function, clinicians must also be
sensitive of potential worry about significant others; harm to oneself;
somatic complaints (actual or exaggerated); and difficulty being with
friends overnight—all common symptoms in this group.
If a child is known to be refusing school for tangible reinforcement
outside of school, then treatment should focus on family based proce-
dures to increase problem-solving ability (e.g., use of contracts) and
supervision of the child and to decrease incentives to miss school
(e.g., access to certain friends or activities). Given that oppositional
defiant disorder and conduct disorder are highly comorbid with this
function, clinicians must also be sensitive of potentially severe non-
compliance, aggression, and negativistic behaviors—all common
symptoms in this group (see Kearney & Albano, 2000a, 2000b).
Finally, many children display mixed functional and mixed diag-
nostic conditions, so assessment and treatment will necessarily have
to be complex. Many youth, for example, initially miss school due to
something aversive there but later refuse school as well because of the
intangible and tangible amenities of staying home. Other youth miss
school to be with their friends and later become worried about the
160 BEHAVIOR MODIFICATION / January 2004

prospect of returning to new classes and teachers. Treatment for these

children often requires an innovative assessment process and a mix of
prescriptive treatments (Kearney, 2002b; Kearney et al., 2001).
Future research in this area will need to address several remaining
questions. First, more information is needed on specific diagnostic
patterns (i.e., primary and comorbid diagnoses) that are associated
with particular functions of school refusal behavior. Second, more
information is needed about children with mixed functional profiles.
Finally, a greater mixture of functional and of diagnostic approaches
is needed in publications regarding school refusal behavior to maxi-
mize the utility of the information for clinicians. This study was par-
tially designed as a first step in this direction.

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Christopher A. Kearney is a professor of clinical child psychology at the University of

Nevada, Las Vegas. He is also the director of the UNLV Child School Refusal and Anxiety
Disorders Clinic. Kearney’s research focuses primarily on the classification, assess-
ment, and treatment of school refusal behavior and internalizing disorders in youth.

Anne Marie Albano is an assistant professor of psychiatry and director of the Anxiety
Disorders Clinical Research Service at the Child Study Center of the New York Uni-
versity Medical Center. Her research focuses primarily on developing empirically sup-
ported assessment and treatment protocols for youth with anxiety and other disorders.