School Refusal

Although young children usually find going to school fun and exciting, one in four children may occasionally refuse to attend school.

• School refusal occurs when a student will not go to school or frequently experiences severe distress related to school attendance.
• Comprehensive treatment of school refusal, including psychiatric and medical evaluation when appropriate, is important since studies show that psychiatric disorders are the cause of a large percentage of students who fail to complete high school in the United States.
• Parents can do several things to help their child who refuses to attend school, and medicinal treatment may be necessary.
• With treatment, the rate of remission is excellent.
• A majority of children with school refusal who were treated with cognitive therapy were attending school at a one-year follow-up.
• School refusal is considered more of a symptom than a disorder and can have various causes.
• Treatment of school refusal includes several psychological approaches including cognitive behavior therapy along with systematic desensitization, exposure therapy, and operant behavioral techniques.
• Psychopharmacologic interventions (medicines that affect the mind and behavior) may be required for underlying depression, anxiety, or social phobias.
• Parents or other caregivers can do several things to control school refusal before it becomes a routine, troublesome behavior.
• When the behavior is fairly new and/or not routine, children often do very well with just a little help from parents and teachers.

Although young children usually find going to school fun and exciting, one in four children may occasionally refuse to attend school. Such behavior becomes a routine problem in a small percentage of children. Many children with school refusal have an earlier history of separation anxiety, social anxiety, or depression. Undiagnosed learning disabilities or reading disorders may also play a significant role in the development of school refusal.

Signs of a psychiatric disorder called separation anxiety disorder can include the following:

• School refusal
• Excessive worry about losing a parent; excessive worry that a parent might be harmed
• Excessive reluctance to be alone at any time
• Persistent refusal to go to sleep without a parent or other caretaker present
• Repeated complaints of physical symptoms whenever the child is about to leave a significant parental figure

These behaviors must begin before the child is 18 years old, must last for four weeks or longer, and must cause serious problems with academic, social, or other functioning in order to be called a disorder.

Some commonly cited reasons for refusal to attend school include the following:

• A parent being ill (Surprisingly, school refusal can begin after the parent recovers.)
• Parents separating, having marital problems, or having frequent arguments
• A death in the family of a friend of the child
• Moving from one house to another during the first years of elementary school
• Jealousy over a new infant sibling
• Excessive parental worrying about the child in some way (for example, poor health)
• Bullying can also be a cause of school refusal. Bullying is unwanted aggressive behavior among school-aged children involving a real or perceived power imbalance that is repeated or has the potential to be repeated over time. Bullying can include threats, intimidation, and/or attacking someone physically or verbally.
  • Signs that a child may be a victim of bullying include the following:
    • Unexplained injuries
    • Lost or damaged clothes, books, electronic items, jewelry
    • Decline in grades, especially in math and reading -- not interested in school work
    • Avoids school complaining of headaches, stomach pain, feels sick
    • Skips meals or binge eating -- may not eat lunch at school
    • Nightmares and trouble sleeping
    • Sudden loss of friends or avoiding social situations
    • Decline in self-esteem or feels helpless
    • New onset of self-destructive behaviors: runs away, hurts self, suicide threats
  • Effects of being bullied on the victim include the following:
    • Increased risk of depression
    • Increased risk of anxiety
    • Drop in grades and academic achievement
    • A child who is bullied retaliates with violence toward others

Other problems at school that can cause school refusal to include feeling lost (especially in a new school), not having friends, or not getting along with a teacher or classmates.

Refusal to go to school may happen at any age but most typically occur in children 5-7 years of age and in those 11-14 years of age. During these years, children are dealing with the changes of starting school or making the transition from elementary or middle school to high school. Preschoolers may also develop school refusal without any experience of school attendance.

Generally, the child or adolescent refuses to attend school and experiences significant distress about the idea of attending school. Truancy (absent from school without permission) may be due to delinquency or conduct disorder and can be differentiated from school refusal. The truant student generally brags to others (peers) about not attending school, whereas the student with school refusal, because of anxiety or fear, tends to be embarrassed or ashamed at his or her inability to attend school.

Signs of school refusal can include significant school absence (generally one week or more) and/or significant distress even with school attendance. Distress with school attendance may include the following:

• A child who cries or protests every morning before school
• An adolescent who misses the bus every day
• A child who regularly develops some type of physical symptom when it is time to go to school

If any of the signs or symptoms of school refusal occur, contact a healthcare professional.

Helpful tools to confirm the diagnosis of an anxiety disorder and the level of impairment include the following:

• The Child Behavior Checklist (CBCL)
• The SCARED (The Screen for Child Anxiety Related Emotional Disorders)
• The Children's Manifest Anxiety Scale
• Children's Global Rating Scale

Treatment of school refusal includes several psychological approaches including cognitive behavior therapy along with systematic desensitization, exposure therapy, and operant behavioral techniques.

• Cognitive behavior therapy: Derived from behavior therapy, the goals include the correction of maladaptive and inappropriate behaviors.
• Systematic desensitization: A technique by which the child is gradually helped to modify his or her emotionally distressing reaction to school so that eventually the child can return to school without experiencing distress.
• Exposure therapy: A technique by which the child is exposed in a stepwise fashion to increasing intensity and duration of the emotionally distressing event coupled with encouragement to modify maladaptive and inappropriate cognitions gradually enough that the child becomes able to tolerate the previously distressing experience (that is, school attendance) without distress.
• Operant behavioral techniques: These involve rewards for desired behaviors in order to increase their frequency.

Principles of Treatment

The goal of therapy is to help the student to restructure his or her thoughts and actions into a more assertive and adaptive framework to allow a rapid return to school. Therapeutic techniques include modeling, role-playing, and reward systems for positive behavior change. Play therapy for younger, less verbally oriented children helps to reenact anxiety-provoking situations and master them. Interpersonally oriented individual therapy, as well as group therapy, can be extremely helpful for adolescents to counteract feelings of low self-esteem, isolation, and inadequacy. Interpersonally oriented individual therapy centers on the person's maladaptive responses to interpersonal interaction (usually involves difficulty in interactions with other people).

What Can Teachers and School Staff Do?

Obviously, offering a welcoming and safe environment is the first and most important step. In addition, teachers and school staff should help the student identify and recognize the triggers for school refusal. Zero tolerance for bullying, available guidance staff, and opportunities to practice relaxation techniques can significantly reduce anxiety.

Psychopharmacologic interventions (medicines that affect the mind and behavior) may be required for underlying depression, anxiety, or social phobias.

• Serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), may be useful for underlying depression. Caution should be used when using such agents because in children and adolescents SSRIs may increase the risk of worsening depression, induce manic episodes with bipolar disorder (manic depression), and have been implicated with an association with new-onset suicidal ideation or behavior. Sudden discontinuation of Prozac can cause withdrawal-like symptoms that include agitation, anxiety, confusion, dizziness, headache, and insomnia.
• Drugs that mask anxiety symptoms (racing heart, sweaty palms), such as propranolol, can significantly reduce anxiety. Propranolol may also induce depression in vulnerable individuals, and it should not be used in the presence of asthma. Propranolol should also not be suddenly stopped because a hypertensive crisis (a severe, sudden increase in blood pressure that could lead to stroke) could ensue.

Cross-cultural considerations should be taken into account when determining the treatment of school refusal.

• Some students sent to boarding school may experience symptoms of physical illness caused by abrupt separation from family.
• These symptoms may include an inability to eat and hallucinations.
• Some Native American tribes call these symptoms "bad spirits." Native American students may experience a reversal of symptoms upon returning to their tribe, or with the assistance of a Native American healer.

After a visit with the child's pediatrician, a treatment plan should be developed. Consultation with a pediatric neurologist should be undertaken if there are any concerns about an underlying neurologic trigger.

• Consultation with a child and adolescent psychiatrist should be performed both for psychopharmacologic interventions as well as for confirmation of the diagnosis of school refusal.
• The consultation should also determine if other comorbid disorders (two or more disorders existing at the same time) require treatment and provide a comprehensive treatment plan.
• The psychiatrist can also conduct psychological therapy or refer the patient to a psychotherapist for this treatment.

Close monitoring of school attendance is imperative and performed in close collaboration with the student's family, the school staff, and the treating professionals.

Parents or other caregivers can do several things to control school refusal before it becomes a routine, troublesome behavior.

• Listening to the child's actual concerns and fears about going to school is important. Some of the reasons for refusing to attend school may include another child at school who is a bully, problems on the bus or carpool ride to school, or fears of inability to keep up with the other students in the classroom. These issues can be addressed only if they are known. On the other hand, making too big a deal of school refusal may promote the child's behavior to continue.
• Firmly getting the child to school regularly and on time will help. Not prolonging the goodbyes can help as well. Sometimes it works best if someone else can take the child to school after the parent or caregiver says goodbye at home.
• It truly helps to believe that the child will get over this problem. Discuss this issue with the child (the parent or caregiver needs to convince himself or herself of this before trying to convince the child).
• The parent or caregiver should reassure the child that he or she will be there upon the child's return from school; this should be repeated over and over, if necessary. Let the child know that the parent or caregiver will be doing "boring stuff" at home during the school day. Always be on time to pick the child up from school if you provide transportation rather than a school bus.
• Whenever events occur that could cause students to miss school (for example, traumatic events such as terrorism, school shootings, or other traumas), all attempts should be made to help students return promptly to school and to help them to feel safe at school.
• Supportive counseling is often made available at school in these circumstances so as to minimize reinforcement of school-avoidant behaviors and to prevent secondary gain from school refusal and should be encouraged for any student who wishes to have it. If the child simply refuses to go to school, some parents have found that decreasing the reward for staying home helps. For example, do not allow video games or television, or find out what work is being done in the school and provide similar education at home, when possible. This is especially if the "illness" seems to disappear once the child is allowed to stay at home. Restriction from sports teams or other nonacademic pursuits can also be employed as a consequence.

When the behavior is fairly new and/or not routine, children often do very well with just a little help from parents and teachers. Once school refusal becomes significant enough to be termed a disorder and has begun to go on for several weeks, the prognosis is still excellent with treatment.

American Academy of Child & Adolescent Psychiatry

American Psychological Association

American Academy of Family Physicians, School Refusal in Children and Adolescents

StopBullying.gov