How to Understand School Refusal

Attending school is usually seen as a precondition for academic, social, and emotional learning. However, school absenteeism is a problem in many countries and covers different types of authorized or unauthorized absences and a myriad of reasons. An authorized absence is when there is a satisfactory explanation for the youth’s absence, while unauthorized absence is usually understood as school attendance problems (SAPs). The main aim of this article is first to investigate define, describe, and discuss school refusal (SR) and how SR differs from other concepts of SAPs, and the secondary aim is to understand SR using different theoretical perspectives. The article outlines this aim based upon a review of international research in this field and uses the systemic integrated cognitive approach and school alienation theories to explain how SR might emerge and develop. The review indicates that SAPs involve many types, concepts, definitions, and reasons. The most frequently used concepts are school refusal behavior, truancy, school refusal, and school withdrawal. Based on the review, the article argues for a common understanding of these concepts among all stakeholders. We suggest a narrow definition of SR to enhance clarity and agreement and propose that the systemic integrated cognitive approach and school alienation theory are relevant to the understanding of SR. A common understanding among all stakeholders is the importance of identifying and intervening in specific types of SAPs. By using a systemic integrated cognitive approach and school alienation theory, identification and interventions can be targeted at an early stage of the development process of SR.


INTRODUCTION
The main aim of this article is to define, describe, and discuss school refusal (SR) and how SR differs from other concepts of school attendance problems (SAPs) based upon a review of international research. Furthermore, we present an explanation of how SR might emerge and develop by using different theoretical perspectives: perspectives that must be investigated in further research. Several years ago, Pilkington and Piersel claimed that "school refusal is a normal avoidance reaction to an unpleasant, unsatisfying, or even hostile environment" (1991, p. 290). By using a combination of a systemic integrated cognitive approach and the theory of school alienation, the aim is to integrate these perspectives to understand how SR might emerge and develop, including an interplay between several individual and environmental factors.
Attending school is important for youths' 1 development, and school is considered to be the primary social arena that creates "citizens" (Pellegrini, 2007). The many negative consequences of school absenteeism are widely described in Kearney et al. (2019), Finning et al. (2019a) and Finning et al. (2019b). However, school absenteeism is a problem in many countries (e.g., Heyne et al., 2019a;Heyne et al., 2019b;Gren-Landell et al., 2015). A myriad of concepts exists to describe school attendance problems (SAPs), but there is a lack of consensus regarding these concepts. Kearney et al. (2019) describe and discuss categorical and dimensional approaches for school attendance and school absenteeism. Their aim was "to set the stage for a discussion of a multidimensional, multi-tiered system of supports pyramid model as a heuristic framework for conceptualizing the manifold aspects of school attendance and school absenteeism" (Kearney et al., 2019). Therefore, like Kearney et al. (2019), we believe there is a need for a common understanding among stakeholders with agreement about risk factors and how to identify and intervene in the case of youths with SAPs. This is in line with the mission of the International Network for School Attendance (INSA) (established March 2018), which is to promote school attendance and reduce SAPs by compiling, generating, evaluating, and disseminating information, assessment, and intervention strategies (https://insa.network/). However, in this article, we focus on the understanding of the concept SR, and we briefly describe other terms of SAPs.
School absenteeism covers all types of SAPs and refers to both authorized/excused/legal and unauthorized/unexcused/illegal absence (e.g., Malcolm et al., 2003;Reid, 2008). Authorized absence is claimed to constitute 80 percent of school absenteeism (Kearney, 2008a) and occurs when youths have permission from an authorized representative of the school. It includes a satisfactory explanation, often due to illness, holidays, or emergencies in the family. These absences are usually selfcorrective.
Unauthorized absence is not recorded as illness or permission from the school and includes all unexplained or unjustified absences (Dalziel and Henthorne, 2005). Reid (2008) claims that schools' attempts to distinguish between authorized and unauthorized absences are at best unhelpful because schools and parents apply the regulations in different ways and mask the scale of the problem. Authorized absence might therefore be masked unauthorized absence, and the distinction might therefore not be very helpful to include, meaning that we in the future should focus on school absence and not authorized/ unauthorized as the starting point of research, assessment, and reporting.
This phenomenon is exemplified in a study by Havik et al. (2015a) in which subjective health complaints (headache, stomachache, muscle pain, feeling unwell, or feeling tired/ worn-out) emerged as the most frequently self-reported reasons for school absence among 6-10th graders. Is this authorized or unauthorized absence, and does it make a difference? Ricking and Schulze (2019) claimed that every failure to attend school should be taken seriously, whether it is authorized or unauthorized. Teachers, parents, researchers, and other stakeholders are concerned about the potential consequences of long-term unauthorized absence or SAPs, which might impair youths' learning and development. Over the years, different concepts have been used to describe and define SAPs, and different risk factor profiles are associated with these concepts. Moreover, these concepts are defined differently by researchers, which leads to confusion and difficulties in comparing the results of previous studies.

Concepts of School Attendance Problems
The most common concepts related to child and parentalmotivated SAPs are school refusal behavior (SRB), truancy (TR), school withdrawal (SW), and school refusal (SR). SAPs encompass a broader concept than SRB, as SAPs include all kinds of unexcused absence, including school exclusion (school-initiated absenteeism), and SW, while SRB only includes child-motivated absence. For an overview of these and other concepts of SAPs, see Heyne et al. (2019a) and Kearney et al. (2019). Table 1 presents a short description of concepts included in the current article. Some characteristics of each concept indicate differences/similarities between them. Different disciplines have focused on different aspects of SAPs. Psychologists have been mostly concerned with mental health problems from a clinical perspective, criminology has focused on law and justice, and educators have focused on school-related factors for SAPs. When reviewing previous literature from different fields, it is important to be aware that concepts might be value laden and might carry different connotations, e.g., TR and criminality vs. SR and psychiatry. Truants often seem to be condemned and given punishments, corrections, and sanctions, while SR seems to elicit more acceptance, sympathy, nonpunitive assistance, understanding, and appropriate treatment than TR (Lyon and Cotler, 2007). This labeling might affect responses from adults (Torrens Armstrong et al., 2011) and influence access to professional services and interventions (Lyon and Cotler, 2007).
"One of the key issues when considering "school absenteeism" and "truancy" is to understand correctly the meaning and definition of the terms. This is not quite as simple as it sounds" (Reid, 2005, p. 59). Some of the concepts of SAPs are broad (e.g., SRB), including more than one type of attendance problem, while others are narrow (e.g., SR). It is important to understand that SRB is a wider concept than SR, as SRB includes SR, attention-seeking behavior and separation anxiety, and TR. In the following, the most frequent concepts of child-and parent-motivated absence will be described in more detail: school refusal behavior, truancy, school withdrawal, and school refusal.

School Refusal Behavior
SRB was first introduced in 1993 as an overarching construct to describe a spectrum of child-motivated school absenteeism, defined as "child-motivated refusal to attend school or difficulties remaining in school for the entire day" (Kearney and Silverman, 1999, p. 345). SRB may or may not be related to emotional distress about school (Kearney et al., 2019). Kearney (2001) describes four functions that primarily maintain SRB. The first two functions are related to negative reinforcement, often seen as SR. These functions are: 1) to avoid stimuli that provoke a sense of general negative affectivity (i.e., distress, anxiety, depression), and/or 2) to escape aversive social and/or evaluative situations (i.e., tests, oral presentation in class, peer interactions). Regarding these functions, absence is maintained because it is reinforced (negatively) by the absence of negative effects experienced at school or the lack of social evaluative situations at home that create anxiety. The other two functions are related to positive reinforcement: 3) to pursue attention from significant others (e.g., parents), which may be related to somatic complaints or tantrums, and/or 4) to pursue tangible reinforcement outside of school (e.g., sleeping, being with friends) (Kearney and Silverman, 1996). Function 3 is seen as attention-seeking behavior and separation anxiety, while function 4 is related to TR. This indicates that SRB serves as an umbrella term (Kearney et al., 2019), for several concepts of SAPs such as TR and SR and attentionseeking behavior and separation anxiety, but does not include SW, which is parental-motivated (parent-initiated) absenteeism.

Truancy
There is no uniform definition of TR, and TR has different meanings for different people (Sutphen et al., 2010;Gentle-Genitty et al., 2015;Keppens and Spruyt, 2017). TR is often used as a synonym for unauthorized/unexcused absence from No specific school problems. The parents know their child is not in school.

SR
Absence related to strong negative emotions while at school (or prior to school).
Want to attend but have negative emotions prior to or while at school. Associated with internalizing symptoms and mental health problems (anxiety, depression, and psychosomatic complaints). Problematic emotion regulation, negative thinking, low self-efficacy, and limited problem solving.
The parents know their child is not in school.
Limited school-home cooperation. Educational difficulties.
Frontiers in Education | www.frontiersin.org September 2021 | Volume 6 | Article 715177 compulsory education or absence without permission or without parental consent or knowledge (e.g., Malcolm et al., 2003;Sheppard, 2007). Other definitions of TR are "absence from school for no legitimate reason" (Stoll, 1990) and "absences which pupils themselves indicated would be unacceptable to teachers" (Malcolm et al., 2003). In total, 16 studies were included in a review of TR interventions; two provided no definition of TR, and 11 different definitions were used across the other 14 studies (Sutphen et al., 2010). This demonstrates the wide variety of TR-definitions. Despite this conceptual confusion, there are some characteristics of truants that seem to be present in most studies: lack of interest in school, defiance of authority, conduct disorder, behavioral difficulties, and a lack of anxiety or fear related to school (e.g., Hersov, 1960;Berg et al., 1993;Elliott and Place, 1998). Moreover, findings from a community sample by Egger et al. (2003) suggest that pure TR is associated with depression, oppositional defiant disorder, and conduct disorder. However, Dembo et al. (2016) also found great variation in mental health problems among truants and noted the importance of recognizing and addressing all mental health problems in TR. Parents of truants are usually not aware of the fact that their child is not present at school because the child attempt to hide their absence from parents and teachers. Keppens and Spruyt (2017) identified three different classes of truants in their study: 1) homestayers, 2) traditional truants, and 3) condoned social truants. Parents of the first group knew their child was not in school (40 percent), which might be related to SW (see the section about SW). This finding is supported by Reid (2002), who found that some parents knew about their child's truancy but gave, for example, tacit approval or false notes. In the second group, the parents were unaware of the truancy because the child was not at home (33 percent). The third group was truant together with other youths and stayed away from home and school (27 percent). This indicates that TR is a mixed group, and therefore, several definitions of TR exist.

School Withdrawal
SW is absence motivated or initiated by parents, also labeled parentally condoned absence, parent-motivated or parentinitiated absence. These absences are a result of parents keeping or withdrawing their child at home for their own reasons and/or needs (e.g., Malcolm et al., 2003;Reid, 2005;Thambirajah et al., 2008). These reasons might include parents who have mental or somatic illnesses; parents in need of the child's help to take care of younger siblings, run errands, and help the family with income; parents who do not value education; religious reasons; parents who are incapable of taking care of their child; parents who keep their child out of school because they fear situations in school that might be hurtful for their child; or parents who have a critical opinion of the school, the teacher, and/or the education provided (Kearney, 2008a;Thambirajah et al., 2008). Five categories of SW are identified based on Reid's work in the field for more than 30 years (Reid, 2002): 1) parents who have an antieducation perspective (belligerent); 2) laissezfaire (weak) parents who support any actions taken by their child; 3) frustrated (failed) parents who have failed in their efforts to get their child to school; 4) desperate (anxious) parents who need their children at home to look after them; and 5) adjusting (vulnerable) parents who are young, single, or come from ethnic minority backgrounds.
SW might be difficult to identify because few youths will return to school and say, "Mum told me not to go to school" (Reid, 2005). These reasons might be underreported since parents disguise this type of absence with messages or permissions related to sickness or other legal reasons (e.g., Kearney and Albano, 2000). SW has a great diversity and low level of research activity (Ricking and Schulzehe, 2019), which makes its prevalence rates unclear. However, parent-approved absence is found to be the largest category of school absence and rates vary from 44 to 93 percent of total absences in England, depending on the methodology used (Reid, 2002). The highest rates of SW have been found among girls and ethnic minority groups. Sheppard (2005) found that two-thirds of youths aged 12-13 asked their parents to permit their school absence occasionally or more often, and illness was the most common excuse. Reid (1999) includes parental-condoned absence as one type of TR when parents agree to the absence for various reasons. Moreover, SW is separate from child-motivated absence, which is an important distinguishing factor for interventions and treatment.

School Refusal
SR describes youths who refuse to attend school, leave during the school day, present protests, pleas, or tantrums prior to school, and/or have somatic symptoms associated with attending school (e.g., King and Bernstein, 2001). In a Norwegian study, SR was defined as "child-motivated non-attendance related to emotional distress experienced in connection with academic or social situations in school" (Havik et al., 2014). SR is due to emotional difficulties such as general and social and separation anxiety, worry, distress, and sadness (Elliott and Place, 2019). School phobia is a related concept and refers more specifically to fear-based SAPs such as avoidance of a specific object at school or related to school (e.g., alarm or bus) that leads to absenteeism (Inglés et al., 2015). Characteristics are related to a set of criteria for SR provided by Berg that separate SR from SW (based on criterion [e]) and from TR (based on criteria [b], [c], and [d]). These criteria are a) reluctance or refusal to attend school, often leading to prolonged absences; b) staying at home during school hours with parental knowledge rather than concealing the problem from parents; c) experience of emotional distress at the prospect of attending school (e.g., somatic complaints, anxiety and unhappiness); d) absence of severe antisocial behavior; and e) parental efforts to secure their child's attendance at school (Berg et al., 1969;Bools et al., 1990;Berg, 1997Berg, , 2002. Related to these criteria, some important characteristics are typical of SR youths: they typically remain at home with their parents' knowledge, their parents have made efforts to secure school attendance, the youth wish to attend but struggle to do so, they usually display emotional distress associated with attending school, and they show no signs of antisocial behavior. Moreover, "school refusal occurs when stress exceeds support, when risks are greater than resilience and when 'pull' factors that promote school non-attendance overcome the 'push' factors that encourage attendance" (Thambirajah et al., 2008, p. 33).

History of School Refusal
SR is not a new concept, and various related concepts have been developed to describe youths who refuse to attend school. The concepts have changed over the years, but the meaning of the concepts has remained the same. The first mention in the literature was by Jung (1913Jung ( /1961, who referred to these youths as showing "neurotic refusal". Broadwin (1932) described "a special form of truancy" associated with neurosis in which a child wants to stay at home because of an intense fear of something happening to his/her mother. A few years later, "school phobia" was described as a "deep-seated psychoneurotic disorder fairly sharply differentiated from the more frequent and common delinquent variety of school truancy" (Johnson et al., 1941, p. 702). Johnson subsequently claimed that school phobia was a misnomer because the underlying etiology was usually separation anxiety (Johnson, 1957). School phobia is an outdated concept used to refer to a child's intense anxiety about being at school. In 1945, Klein described for the first-time youths who refused school or were reluctant to attend school (Klein, 1945). The concept of SR was first introduced by Hersov (1960). Over the years, there has been emerging acceptance that emotionally based school avoidance may be caused not only by separation anxiety but also by other forms of anxiety and/or depression. SR was later used more frequently by practitioners and researchers (e.g., Burke and Silverman, 1987;Last and Strauss, 1990;King et al., 1995;Last et al., 1998).

Prevalence of School Refusal
Since the definitions of SR are not similar in all research, the prevalence rates are unclear. The rates vary because previous research defines SR differently (broadly or narrowly), uses different samples (clinical or community based), and includes few or several respondents (i.e., students, teachers, parents, or a combination). However, prevalence rates of SR are usually estimated to be 1-2 percent of the general population and 5-15 percent in clinical-referred samples of youth, and rates are equal between genders (Egger et al., 2003;Heyne and King, 2004). In a community sample of 6-10th-graders, 3.6 percent reported signs of emerging SR (Havik et al., 2015a). This may indicate that one youth in each class of 25 might be at risk of developing SR. Moreover, the prevalence of SR seems to be higher among preadolescents and adolescents than among children (Elliott and Place, 1998;Heyne et al., 2002), and referral for established SR is more common among adolescents (Heyne and Sauter, 2013). As SR often emerges over time, all teachers and school staff will encounter attendance problems, which requires knowledge about SR among teachers at all grade levels.

Theoretical Perspectives to Understand School Refusal
How to understand the development and maintenance of SR and how schools should manage SR depend on the theoretical perspective used. Previous research on SR is mainly from a clinical perspective, which highlights individual and/or family factors for SR. However, more integrated approaches have recently been suggested to understand SR because of the myriad reasons associated with SR (e.g., Ingul et al., 2012;Havik, 2015). Moreover, the links among individual, family, and school factors must be recognized (e.g., Egger et al., 2003;Wilkins, 2008;Shilvock, 2010). A widely used theory to understand youths' problems in school is the theory of stress and coping (Lazarus, 2006) or the systemic integrated cognitive approach (Havik, 2015). Another theory is school alienation theory (Hascher and Hadjar, 2018), which is relevant for SR to some extent. Recently, an ecological agency framework has been used to understand school absenteeism as it considers the interplay of contextual factors and how these factors influence a student's decision to engage in absenteeism (Kipp and Clark, 2021). This theory has much in common with the theories presented in the current article.

Systemic Integrated Cognitive Approach
When demands in school and life are beyond youths' capacity to cope, youths might experience school and life situations as stressors, especially if they do not believe in their own abilities to cope with the stressor. Refusal to attend school might be the only remaining coping strategy. Lazarus's cognitive appraisal model of stress and coping (Lazarus, 2006) is helpful to understand why some youths use avoidance as the coping strategy to address stressors (demands, stress, anxiety, and related negative emotions), while others display more appropriate behavior, such as problem-solving and/or emotion-regulation coping strategies.
The "systemic integrated cognitive approach" visualizes the interplay between individual and environmental factors that influence youths' development (e.g., Lazarus, 2006;Bronfenbrenner and Morris, 2007). According to this approach, based on youths' perceptions of themselves, their school, their home/parents, and other environmental factors outside of home and school (e.g., neighborhoods, national policy, and societal pressures), they will appraise the current situation, resulting in emotions and behavior. If the appraisal is "I cannot cope or manage this situation", the results are likely to be negative emotions and avoidance behaviors, eventually leading to SR. The links between SR and individual, family, and parental factors have been reported in previous studies (e.g., Lyon and Cotler, 2007;Havik, 2015;Ingul et al., 2019). School is an important ecological context for students' development (Bronfenbrenner and Morris, 2007), including peers and friends. In the model, peers (or any other factor) could be a source of support or stress for youth. To fully understand SR, a combination of an ecological model inspired by Bronfenbrenner's bioecological model (Bronfenbrenner and Morris, 2007) and Lazarus's cognitive appraisal model of stress and coping is valuable. The systemic/ecological approach integrates the interactions between individual and different contextual factors, including both demanding/stressful and protective factors. By including a cognitive appraisal process, the coping process is included in the model.
Using this model to understand the development of SR and the interplay between individual, school, and family factors is underlined. For example, situations at home or in school are perceived differently by each youth based on individual factors and previous experiences. In different situations, the cognitive appraisal process focuses on youths' ability to cope with the stressful situation. SR might be the result of avoiding situations at school that are perceived to exceed the individual's ability to cope. Individual differences in psychiatric symptoms, negative thinking, and self-efficacy are important and must be assessed because they explain why different youths react differently to the same situation or environment.

Theory of School Alienation
SR youths struggle in different situations in school, and there is an increased awareness of the role of school factors in SR (Knollmann et al., 2010;Havik et al., 2015b;Havik, 2015). School factors related to SR might be unpleasant teachers (e.g., fear of the teacher and/or a lack of teachers' support), a negative school/classroom climate/environment, and/or peer problems (e.g., bullying, friendship problems, and loneliness). School alienation is defined as "a specific set of negative attitudes towards social and academic domains of schooling comprising cognitive and affective elements. While the cognitive dimension relates to youths' appraisals of the school environment, the affective dimension relates to their feelings. These negative attitudes develop and change over time in terms of a state and can solidify into a disposition" (Hascher and Hadjar, 2018, p. 175). School alienation is a complex phenomenon that might lead to negative consequences, such as poor academic performance, learning difficulties, school disengagement, behavioral problems, and withdrawal from the educational system (Buzzai et al., 2021). School alienation theory might therefore be of relevance to the understanding of SR. To our knowledge, school alienation has not been investigated in relation to SR; however, youths might be alienated from school in general or from specific aspects of school, such as learning, teachers, or peers, which might lead to a process of increased distancing from different aspects of school (Morinaj et al., 2020). Moreover, related to the findings from a study among Italian students (Buzzai et al., 2021), the role of mastery orientation and learned helplessness related to the feelings of school alienation might also be of importance for SR.
Alienation from learning refers to a lack of enjoyment and interest in learning for the student, including experiencing boredom during the learning process. Because youths who refuse school are likely to enjoy learning and usually do not have more learning difficulties or lower grades/marks than others, we do not expect that alienation from the domain of learning is relevant for emerging SR; however, it might be relevant in the long run as youths lose academic learning, moreover it might be relevant for their mastery orientation and learned helplessness (Buzzai et al., 2021). The teacher domain is associated with both social and academic aspects of school. The social aspect refers to supportive/unsupportive teacher-student relationships, while the academic aspect refers to teaching. Students who are alienated from teachers might experience a lack of support from their teachers or fear their teachers, both of which are factors related to SR (e.g., Archer et al., 2003;Egger et al., 2003;Havik et al., 2014Havik et al., , 2015bBaker and Bishop, 2015). The peer domain is also related to the social aspect of school and involves the relationships between peers and how they get along, support, and motivate each other (Morinaj et al., 2020). If a student feels alienated from peers, he or she might feel lonely, isolated, and withdrawn. Because students with SR often struggle in relation to peers and friends (e.g., Place et al., 2000Place et al., , 2002McShane et al., 2001;Archer et al., 2003;Egger et al., 2003;Havik et al., 2014Havik et al., , 2015b, the peer domain might explain why some students refuse to attend school. As claimed by Place et al. (2002), these students might need to improve their peer relations and social functioning to be able to stay in school or return to school.
School alienation might also be related to the vicious cycle of SR (Thambirajah et al., 2008). According to Thambirajah et al., three factors may influence students' ability to attend school. First, when youths are absent, they may lose friends and experience social isolation, and they lose opportunities to improve their peer relations and social skills (peer domain). Second, youths may fall behind in their schoolwork, making their return to school more difficult and reinforcing their fear of failing at school (domain of learning). The third factor indicates that youths' levels of anxiety and depression might increase due to avoidance of difficult situations, which initially reduces anxiety but increases it in the long run. Depressive symptoms such as social isolation emerge, and the risk of failing school increases (Thambirajah et al., 2008). SR might be understood as a combination of the theories of systemic integrated cognitive approach and school alienation (see Figure 1), in which a youth, with his/her individual factors, encounters situations in school and life that lead to negative appraisals related to school, learning, and social situations at school as predicted by the systemic integrated cognitive approach. The process of school alienation related to the peer domain and the domain of learning has then started. These appraisals and the emerging alienation will in turn produce increased negative feelings and avoidance of different situations in school, leading to emerging SR and stronger negative appraisals. Over time, this might increase alienation from learning, teachers, and peers, and SR might be established.

Development of School Refusal
SR occurs along a continuum, with different expressions and episodes at different times (e.g., Kearney, 2006). This means that SR might be expressed in ways visible only to parents, such as episodes before the child attends school (e.g., pleas for absenteeism and misbehavior or tardiness in the morning to avoid school). Other expressions, such as absenteeism from school, are visible to teachers (e.g., periodic repeated absenteeism or skipping classes). The expressions visible only to parents are related to the concept of school-reluctant youths, who may want to avoid school but do attend. Although they attend school, these youths exhibit distress related to loneliness, negative affect, and greater severity of anxiety symptoms (Jones and Suveg, 2015). School reluctance might be the first sign of SR development and is related to emerging SR (explained previously), but this link must be investigated in further research using longitudinal designs.
SR usually develops along a continuum of different expressions and episodes, indicating that SR might begin to develop before a youth is absent from school, and teachers and other school personnel may not be aware of the problem until the youth is absent from school (Kearney, 2008a). School personnel are the first professionals to recognize the problem when youths do not attend or show signs of other attendance problems. However, the youth and his/her parents may have struggled for a long time at home before any visible signs appear at school. Therefore, parents and school personnel need information and knowledge about the emergence and development of SR. Parents should be encouraged to contact the school or relevant help services if they notice episodes and expressions that might represent emerging SR problems, other school-related problems, or changes at home. In this way, school personnel might be able to assess stressful and demanding situations in school at an early stage and prevent the development of established SR through adequate and tailored interventions.

The Association Between School Refusal and Mental Health Disorders
SR is not listed as a diagnostic category in the international classification systems of the ICD-10 (World Health Organization, 1993) or DSM-V (American Psychiatric Association, 2013). Although SR is not a diagnostic term, many SR youths are likely to meet diagnostic criteria for a specific phobia, generalized anxiety, social anxiety disorder, or separation anxiety disorder; moreover, some display symptoms of depression and might even meet the criteria for a diagnosis (e.g., Bernstein, 1991;Hella and Bernstein, 2012). In studies of clinical samples, approximately 50 percent of referred school refusers meet the full diagnostic criteria for one or more anxiety disorders (e.g., Bernstein, 1991;McShane et al., 2001). Furthermore, approximately three-quarters of children who are referred with separation anxiety disorder have at least one episode of SR (Egger et al., 2003;Kearney and Albano, 2004). In non-clinical or community samples, SR youth also meet the criteria for emotional disorders. In one study, half of the 100 children with severe SAPs met the criteria for a psychiatric disorder, and those categorized with SR often had generalized neurotic disorders (Bools et al., 1990). In another study of 80 children who had missed more than 40 percent of a term, half of them met the criteria for a psychiatric diagnosis (Berg et al., 1993). In a community sample, SR was significantly and strongly associated with anxiety disorders, school-related fears, and performance anxiety (Egger et al., 2003). Results from systematic review by Finning et al. (2019a) provide evidence of associations between SR and separation, generalized, and social anxiety disorders, as well as simple phobia.
In referred samples of SR, approximately 50 percent were diagnosed with depressive disorders (e.g., McShane et al., 2001). A systematic review by Finning et al. (2019b) provides evidence for an association between depression and poor school attendance, particularly absenteeism, unexcused absences/ truancy, and school refusal. Moreover, depressive disorder was significantly associated with SR, and these youths reported significantly more symptoms of trouble falling or staying asleep and fatigue (Egger et al., 2003). The same study indicated the rates of psychiatric disorders to be three times greater among children with pure anxious SR than among those without attendance problems. However, another study indicates that not all adolescents with symptoms of emotional problems, such as anxiety, are absent from school (Ingul and Nordahl, 2013). This suggests that mental health problems can be expected quite frequently among SR but are not a necessary condition for the development of SR. Due to a lack of longitudinal studies and a lack of high-quality research (Finning et al., 2019b), we do not know whether mental health problems lead to SR or vice versa. Ingul et al. (2012) claim that an accumulation of risk factors might increase the total burden for youths, eventually leading to absenteeism, like SR. The authors also claim that the balance between risk and protective factors might change over time, leading to SR, which is in line with predictions based on the theory of a systemic integrated cognitive approach. This suggestion underlines the need to assess all risk factors for youths who refuse to attend school. This is, of course, an important issue for any type of SAPs. The results of a doctoral thesis by Havik (2015) demonstrated the importance of school factors for SR. Demanding factors in school that are beyond youths' capacity to cope might present stressors leading to absenteeism, and SR might occur even when controlling for youths' emotional stability (Havik et al., 2015b).

DISCUSSION
Some important issues to consider for the understanding of SR are presented in the current article. These include descriptions and characteristics of the most common types of SAPs, the use of a narrow or broad definition, and theoretical perspectives to understand how SR might emerge and develop. In this article, we argue for the use of a narrow definition of SR which will be discussed more deeply.

School Refusal and Other Concepts
Different concepts and definitions of SAPs exist, and researchers, practitioners, parents, and media seem to use them interchangeably and understand them as synonymous. In research, these concepts have been understood and defined differently, which makes it difficult to compare results. Whether to use an overarching construct (e.g., SRB) or a narrow concept that differentiates between types has been an ongoing discussion among researchers and practitioners in many countries (e.g., Elliott and Place, 2012;Havik et al., 2015aHavik et al., , 2015bHeyne et al., 2015). There are arguments for both approaches. A broad concept is suggested because of the overlap between TR and SR, which is found in 5-17 percent of cases and is often labeled the "mixed group" (Berg et al., 1985;Bools et al., 1990;Berg et al., 1993;Egger et al., 2003;Steinhausen et al., 2008). In contrast, we argue for a narrow concept despite the overlap between the different types because different risk factors, behaviors, psychological symptoms, and mental health disorders are associated with TR and SR (e.g., Egger et al., 2003;Knollmann et al., 2010;Havik et al., 2015aHavik et al., , 2015bHeyne et al., 2019a).
One question is whether SR, at least in the media, has replaced all types of SAPs to some extent and whether SR is often used to describe students with unauthorized absences from school rather than as one type of SAP defined by Bergs' criteria for SR (1997). Moreover, SRB is sometimes abbreviated as SR, even SRB is an umbrella term and includes SR, attention-seeking behavior and separation anxiety, and TR. The confusion related to concepts might lead to a misunderstanding of students' characteristics because an inaccurate assessment of risk factors potentially leads to incorrect interventions and treatment. If we understand SR youths as lacking motivation or engagement and being unwilling to attend school, as is the case for most truants, interventions might be inappropriate, because SR youths are usually motivated and willing to attend school. Furthermore, if parents do not exert sufficient effort to ensure that their child attends school and this is not recognized, interventions at school might have less effect. Therefore, we suggest the use of a narrow definition of SR, as indicated, for instance by the criteria of Berg (e.g., 1997).
As "school refusal is a normal avoidance reaction to an unpleasant, unsatisfying, or even hostile environment" (Pilkington and Piersel, 1991, p. 290), a combination of a systemic integrated cognitive approach and the theory of school alienation, might integrate these perspectives to understand how SR develop, which includes an interplay between several factors (Figure 1).

How School Refusal Emerges and Develops in line With the Systemic Integrated Cognitive Approach and the School Alienation Theory
Most youths with mental health disorders and other risk factors attend school on a regular basis. However, some struggle and experience stressful situations in school and/or life in general, and some might gradually develop school reluctance and emerging SR. When anxiety, risk, and stress factors are stronger than support and protective factors, this imbalance might lead to SR over time (Thambirajah et al., 2008). This is in line with the systemic integrated cognitive approach and school alienation theory (see Figure 1). This figure visualizes the interplay between individual and environmental factors that influence youths' development over time. This approach explains stressful appraisals and negative emotions and might be helpful to fully understand the complexity of SR. Both demanding and supportive factors in school, as well as parental/family and individual factors, are related to SR. It is important to consider how SR youths cope with stressors (e.g., Place et al., 2002). SR is associated with several risk factors, such as anxiety and/or depression, negative thoughts, low self-efficacy for coping, and ineffective strategies to solve problems. Therefore, youths' coping strategies and skills must be understood, and if necessary, youths should be helped to change their coping strategies.
When environmental factors at school and/or home are demanding, this might lead to negative appraisals and stressful, negative emotions. Parents, peers, and teachers are sources of support for youths' development and provide important support for dealing with stressful situations. As youths grow older, peers are usually their most important support. When SR is established, youths might be isolated from their peer network because they stay at home when their peers are at school. SR youths might need interventions to improve their peer relations and social functioning. The theory of alienation is relevant to explain how SR develops because as SR emerges, some youths might become alienated from learning, teachers, and/or peers (Morinaj et al., 2020), eventually leading to established SR.
The combination of the theory of systemic integrated cognitive approach and school alienation is useful because these theories 1) cover and integrate both individual and contextual factors; 2) explain how SR might develop over time, starting with a stressor that might lead to negative appraisal, which develops over time and leads to avoidance; in turn, avoidance reinforces this negative appraisal and gradually leads to alienation and established SR; 3) indicate the importance of the balance between risk and protective factors; 4) include coping strategies and the importance of coping with stressors, such as regulating emotions and seeking support; and hence, 5) help us to pinpoint important factors for assessment and interventions. Furthermore, these theories suggest that every SR youth is unique. Therefore, interventions need to be tailored based upon a thorough assessment of all the contributing risk, protective, and maintaining factors to develop a case formulation for each youth. However, these theories in relation to SR have not yet been researched and should be investigated in future studies.
It is important to note that a "mixed group" exists and that these youths often have multiple problems and more severe mental health disorders than "pure" TR or SR (e.g., Egger et al., 2003), indicating a need for treatment and coordinated interventions. However, the frequently cited study by Egger et al. (2003) is a cross-sectional study. There is a possibility that TR and SR develop from emerging attendance problems via pure SR or TR to mixed problems as the complexity in these cases increases over time. This indicates that the field would benefit from longitudinal studies investigating the development of SAPs to better understand the developmental pathways. There is also an overlap between SR and SW that involves youths with unresolved dependency relationships, usually with their mothers (Christogiorgos and Giannakopoulos, 2014). These findings indicate that there might be more than one "mixed group", and SAPs develop differently in each case. Therefore, although we advocate for differentiating between types of SAPs, individuals may have characteristics of several types.

CONCLUSIONS AND SUGGESTIONS FOR PRACTICE
The main aim of the current article was to define, describe, and discuss SR and to show how SR differs from other concepts of SAPs and how SR emerges and develops by using different theoretical perspectives. As many concepts exist, all stakeholders should agree upon one definition of SR to be able to prevent, identify, and intervene in emerging and established SR. Different characteristics and risk factors exist for SRB, TR, SW, and SR; therefore, these concepts should be separated. We suggest using a narrow definition of SR in line with Berg's criteria, as they separate SR from TR and SW. By using a narrow, clear, and common definition, it is easier for schools, youths, parents, and other services to communicate cooperatively and plan interventions for SR youths and for researchers to compare results. Further research should investigate the developmental pathways of SR in relation to the combination of the theory of systemic integrated cognitive approach and school alienation, to fully understand how emerging problems might become established SR over time, which, if left "untreated", might become a mixed, complex, and debilitating problem.
Previous research indicates that parents, students, and school personnel understand the characteristics, reasons, and development of SR differently. This might have consequences for cooperation and agreement in interventions for SR youth. In a study among parents of SR youth, parents felt that they were blamed by the school for the problems (Havik et al., 2014). This finding indicates the importance of and need for good, clear, and respectful communication, collaboration, and common goals of interventions between the school, parents, youth, and other services to address the factors that might cause and/or maintain SR. It "takes a team" to work with SR (Brand and O'Conner, 2004). One suggestion is therefore to establish a school-attendance team (SAT) (Ingul et al., 2019), working with SAPs using a multi-tiered system (Kearney and Graczyk, 2014;Kearney, 2016) to promote regular attendance for all students (Tier 1), targeted interventions for at-risk students (Tier 2), and intense and individualized interventions for students with chronic absenteeism (Tier 3), including how SR might emerge and develop in terms of the theory of systemic integrated cognitive approach and school alienation.

AUTHOR CONTRIBUTIONS
The first draft of the article was written by TH, and JI contributed feedback and comments on all versions. Both authors read and approved the final article.