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Introduction
Anxiety-based school refusal1 occurs among approximately 1 to 2% of young people and between 5 and 16% of clinic-referred youth (Heyne and King, 2004). It causes significant distress for a young person, their family, and school staff, and it jeopardizes the young person's development (Berg, 2002). Follow-up studies of clinically-referred young people presenting with school attendance problems indicate a risk for ongoing social and mental health problems in late adolescence (Buitelaar, van Andel, Duyx and van Strien, 1994) and in adulthood (Berg and Jackson, 1985; Flakierska-Praquin, Lindstrom and Gillberg, 1997; McCune and Hynes, 2005). Continued effort to better understand the nature of school refusal and to enhance treatment effectiveness is imperative (Heyne, 2006; King, Tonge, Heyne and Ollendick, 2000).
Characteristically, school refusal comprises a behavioural component (e.g. avoidance of school; Heyne and King, 2004; Ollendick and King, 1990), an affective component (e.g. anxiety, fear, depression: Bernstein, 1991; Buitelaar et al., 1994; Egger, Costello and Angold, 2003; Hansen, Sanders, Massaro and Last, 1998; MacShane, Walter and Ray, 2001), and a physiological component (e.g. headaches, stomach pain, nausea: Bernstein et al., 1997; Egger et al., 2003; Honjo et al., 2001). To a lesser extent, cognitive factors have been associated with school refusal (Heyne, 2006). In an uncontrolled study, school refusers were found to have low expectations about their ability to cope with stressful situations associated with school attendance (Heyne et al., 1998). Place, Hulsmeier, Davis and Taylor (2000, 2002) described school refusers as having a tendency to interpret problems as insoluble and to have a general pessimistic outlook, but such conclusions were based on a small sample (n = 17) and in the absence of a control group. Published case reports of school refusers also point toward the cognitions of potential relevance in understanding and treating school refusal. Anderson and colleagues (1998) reported that a 13-year-old boy expected negative reactions from the other children at school (e.g. "I know they're going to tease me") and Mansdorf and Lukens (1987) reported that a 12-year-old girl had the thought "the teachers might pick on me because of my absences". Moreover, Kennard, Ginsburg, Feeny, Sweeney and Zagurski (2005) suggested that the negative automatic thoughts of school-refusing youth were a major...