A Study of School Absenteeism and Student Well-being in Elementary Schools

School absenteeism is a growing problem among children and youth, often associated with complex and varied causes. Anxiety and sadness are common challenges for children and can impact their functioning in many areas, including school performance. Early intervention regarding anxiety and sadness in a school context can be crucial for improving students' school experience and coping skills. The EMOTION intervention has been tested in two randomized controlled trials, where the intervention group showed a significant reduction in symptoms of anxiety and sadness compared to the control group. However, the intervention has not been investigated in relation to school attendance in larger studies. Furthermore, since 2017, several primary schools in Oslo have established interdisciplinary attendance teams. Assessing user satisfaction with these teams is essential for improving efforts with children struggling with school attendance. Thus, the Coping@School study aims to undertake a comprehensive mapping and evaluation of interventions that may contribute new knowledge in addressing emerging issues related to school attendance.

GENERAL BACKGROUND School Absenteeism In a Norwegian study of students in grades 6 to 10 across seven municipalities, 3.6% reported that their absenteeism was related to school refusal. This indicates that at least one student in every class shows signs of school refusal or is at risk of developing it. Schools and PPT report a rise in school refusal, according to, and other studies suggest that problems related to school absenteeism begin early in a student's educational journey (Hancock et al., 2013). Absenteeism can result from the school environment (such as social belonging, motivation, bullying, teaching methods, and teacher support), familial factors (such as parents' mental health and involvement), and individual factors concerning the child (for example, low self-esteem and emotional difficulties such as anxiety or sadness). Patterns of absenteeism are established and escalate over time, contributing to increasing knowledge gaps and symptoms of emotional distress. Belonging to school, friends, and self-confidence in solving challenging situations may thus diminish. It is therefore essential to identify challenges early so that a negative trajectory can be reversed before negative patterns are established and school attendance is difficult.

In a report, it is mentioned that academic challenges and school-related stress are among the factors influencing students' absenteeism. This can diminish opportunities for education and future income. According to Sintef (2012), school absenteeism can also lead to socioeconomic costs if it results in a lack of connection to the labor market in adulthood. The societal economic costs due to school dropout were estimated at approximately five billion Norwegian kroner for each annual cohort in Norway in 2010. A more recent economic analysis from 2021 revealed that social exclusion, defined as high school dropout rates, costs Norway a minimum of 73 billion annually due to lost income, benefits, and premature death. Addressing school absenteeism is therefore critical from a socioeconomic perspective in addition to the consequences it has for individuals.

The new education act has introduced stricter requirements for following up on absenteeism. Among the most important changes is the obligation for municipalities and counties to ensure that students with absenteeism from education are followed up. This obligation applies to all absenteeism, starting from the first day a student is absent from instruction. Effective systems and routines for registering various types of absenteeism, identifying absenteeism patterns, following up on absent students, and cooperating with families must be in place. The follow-up of absenteeism must be tailored to the cause, duration, and frequency. Interventions may be necessary for children who are sad or anxious, as this can also contribute to difficulties with school attendance. This must be considered in light of the education act, particularly Chapter 12 concerning school environment and Chapter 10 addressing adapted education and individual adjustments.

The national professional guidelines for school health services for youth emphasize that school health services should collaborate with schools to plan and implement initiatives that promote well-being and health. School-based interventions targeting risk factors for absenteeism are therefore vital. School health services should be involved early in following up on students with concerning absenteeism and can provide interventions aimed at triggering difficulties such as anxiety and sadness. Anxiety and Sadness Anxiety disorders rank among the most common mental health issues among children and youth, with estimates suggesting that between 5.6% and 18.1% of children may develop an anxiety disorder before they turn 18.. Depression likewise represents a prevalent condition among children and youth, with estimates of between 1-2% of children and between 3-8% of adolescents likely to experience this condition. Studies also suggest that between 9-12% of children exhibit symptoms of anxiety and depression that interfere with daily functioning, even if they do not meet the criteria for diagnosis. Both problems represent a significant public health concern. The challenges associated with anxiety and depression negatively impact children across many areas of life, potentially complicating their relationships with peers and family members. A close relationship exists between anxiety and school absenteeism. In studies examining school refusal, it is common for between 50% and 60% of participants to meet criteria for an anxiety disorder, with an even greater number experiencing sub-threshold symptoms. Sadness and depression are similarly prevalent among those struggling with school attendance; in a population study, 14% of school refusers also had a diagnosis of depression. Sub-threshold symptoms such as sleep difficulties and fatigue/loss of energy were also prevalent.

Research indicates that anxious and sad children and adolescents are less likely to receive help than children with externalizing disorders. Implementing interventions within the school setting offers an opportunity to identify and reach children who might otherwise receive little assistance for their challenges. Should this approach increase school attendance and reduce potential dropout, several crucial societal missions would be fulfilled.

The EMOTION intervention is an evidence-based intervention aimed at children exhibiting elevated levels of anxiety and/or depression symptoms. The program has been evaluated in two randomized controlled trials, demonstrating significant reductions in symptoms for participating children.

Relationship Between School Attendance/Functioning and Anxiety/Sadness Given the correlation between participation and functioning at school and anxiety/sadness, it is essential to investigate if an intervention like EMOTION could also contribute to the reduction of problems associated with school attendance, improve school functioning, while simultaneously maintaining reductions in symptoms of anxiety and sadness as demonstrated in previous studies. To date, only a pilot study (N = 4) has been conducted exploring whether anxious and sad children also show improved school attendance following participation in a mastery group. Results from this study are summarized in a thesis at the Department of Psychology, University of Oslo, indicating a reduction in reported school refusal behaviors after participating in the intervention, as reported by both the children themselves and their parents. This suggests increased school attendance following participation in the mastery group. However, testing interventions for children with emerging school absenteeism is still novel and has been seldom explored in previous research. Existing studies primarily focus on children and youth with established difficulties with school absenteeism. Gaining insights into the efficacy of this intervention concerning school attendance, school functioning, and symptoms of emotional distress is therefore vital. This study will also incorporate user satisfaction to further evaluate the interventions. Assessing user satisfaction in relation to both such interventions and attendance teams in schools is a new approach that aims to provide a more comprehensive understanding of the measures targeting children with emerging difficulties in school attendance. This way, the study will contribute valuable knowledge in addressing the needs of this group of children.

MAIN OBJECTIVES OF THE STUDY Objectives The primary objective of the study is twofold, encompassing a preventive perspective and a user perspective. Within the preventive perspective, the goal is to conduct coping groups aimed at children who are beginning to experience difficulties related to school attendance and who exhibit higher levels of anxiety and sadness than their peers. The study seeks to evaluate changes in school attendance and functioning, as well as in anxiety and/or sadness. Moreover, it aims to explore the potential reasons behind these challenges from the parents' perspective. The user perspective will be assessed by mapping user satisfaction related to both the coping groups (reported by children, parents, and group leaders) and the attendance teams at schools (reported by teachers, professionals in PPT/school health services, and school leadership). Throughout the study, a comprehensive understanding of interventions aimed at addressing emerging difficulties in school attendance will be achieved.

Research Questions:

1 a) Will children participating in a coping groups demonstrate increased school attendance and improved school functioning immediately following the intervention (T2) and after six months (T3) compared to baseline (T1)?

1. b) Will children participating in a coping group report comparable changes in symptoms of anxiety and/or sadness as reported by parents, children, and teachers, immediately following the intervention (T2) and after six months (T3) compared to previous studies of the intervention (benchmarking)? 2. a) How do parents, children, and group leaders evaluate their satisfaction with participation in the coping group aimed at increasing school attendance?

2 b) To what extent are participants in the attendance team (contact teachers, school leaders, school health services, counselors in special education services) satisfied with the function and use of the attendance team? 3) What are parents' perceptions of the causes of their children's difficulties with school attendance, and what support and assistance do they seek from the school and other agencies? DESIGN AND METHODS Design This study will employ a one-group pretest-posttest design to examine changes in school attendance and functioning, as well as changes in symptoms of anxiety and sadness before and after the intervention is implemented. User satisfaction with the EMOTION intervention aimed at enhancing school attendance, as well as with the attendance team, will also be investigated.

Children aged 9 to 13 years (grades 4 to 7) (N = 112) who are struggling with school attendance and functioning and exhibit slightly higher levels of anxiety and sadness than their peers (see also Section 3.3 below) will be invited to participate in the coping groups at elementary schools in Oslo. All schools will implement an attendance team to monitor school attendance and absences. The children will be assessed for participation prior to the coping group, immediately after the intervention, and six months later (see detailed assessment procedures below).

Procedure for Identification and Selection of Participants The identification and selection of children will be based on experiences from the evaluations conducted of the EMOTION interventi