School refusal behavior in children and adolescents: a concept analysis

School refusal behavior (SRB) is increasingly recognized across educational, pediatric, and mental health settings, yet its conceptual boundaries remain unclear, and the term is frequently conflated with school refusal, truancy, school withdrawal, school exclusion, and broader school attendance problems. This study used Walker and Avant's concept analysis method to clarify the meaning, defining attributes, antecedents, consequences, and empirical referents of SRB. PubMed, Web of Science, Scopus, and PsycINFO were searched for English-language literature published through January 2026, supplemented by Google Scholar and manual citation searching. A total of 100 sources were included and analyzed through iterative comparison of conceptual definitions, recurrent characteristics, contextual conditions, outcomes, and indicators used in research and practice. The analysis showed that SRB has evolved from earlier anxiety-centered descriptions toward a broader behavioral and functional construct. Four defining attributes were identified: difficulty initiating, sustaining, or completing school attendance or participation; young person-expressed attendance difficulty; aversive school-related experiences or emotional distress; and heterogeneous avoidance- or reinforcement-related maintaining functions. Antecedents were distributed across individual, family, peer and interpersonal, and school-contextual domains, while consequences extended across academic, psychological, social, family, and service-related domains and may accumulate over time. Empirical identification requires the integration of observable attendance patterns, emotional, behavioral, and somatic responses, functional assessment, and contextual information from young people, caregivers, and school personnel. Moving beyond the summary of existing definitions, this analysis proposes an integrative framework that distinguishes the observable form of attendance difficulty from its emotional presentation, maintaining functions, and ecological context. SRB is therefore best understood as a persistent or recurrent, young person-expressed pattern of disrupted school attendance or participation that is clinically meaningful but cannot be reduced to a single diagnosis, cause, or attendance threshold. By clarifying what constitutes SRB and how it differs from other forms of school attendance problems, this framework may support earlier recognition of emerging attendance difficulties, more comprehensive assessment of underlying needs, and better coordination among mental health professionals, families, and schools.