School Refusal

Young girl isolatedSchool refusal, also known as school phobia or school avoidance, is a form of extreme anxiety related to attending school. According to the American Academy of Pediatrics, school refusal affects as many as 5% of children between the ages of 5 to 11. School refusal significantly impacts a child’s social, emotional, and educational development. However, with appropriate treatment interventions, symptoms of school refusal can be alleviated.

What causes school refusal?

School refusal often occurs in combination with other psychiatric disorders such as anxiety or depression. It may be triggered by stressful events at home or at school. The following is a list of some common triggers associated with school refusal.

  •  Fear of failure
  •  Social problems (i.e. bullying, teasing)
  •  Perceived negative relationship with child’s teacher
  •  Anxiety over using public bathrooms
  •  Changes at home (new baby, marital problems, divorce, death in the family or family of child’s friend)

What are common symptoms associated with school refusal?

Many children experiencing school refusal complain of physical ailments associated with attending school. These are often referred to as somatic complaints that occur in response to anxiety-producing stimuli. Common somatic complaints include chest pains, headaches, hyperventilation, dizziness, and stomach aches. Less common symptoms that usually have a physical basis include vomiting, fever, and diarrhea. It is important to note that the child may not know why he feels ill and may have difficulty communicating what is upsetting about school. Other symptoms associated with school refusal include panic attacks, extreme fear, crying, and temper tantrums. When a child is allowed to stay home from school, all symptoms of anxiety subside. However, the longer the child stays out of school, the more difficult it will be for him to return.

How does school refusal differ from truancy?

School attendance is mandated by state laws. States vary in the ages set for compulsory school attendance; however, all states hold parents legally responsible for ensuring that their children attend school. Punitive actions can be taken against parents for not sending their children to school. Schools typically work very closely with parents to monitor and track attendance. Children who are frequently absent from school due to truancy differ in several key features from students absent due to school refusal.

  • Students engaging in truancy try to hide the fact that they are not going to school. Parents are generally not aware of truant behavior when it is occurring. Students with school refusal ask/beg/plead parents to allow them to stay home.
  • Students who are truant from school typically go to another location away from home. Students with school refusal desire to stay at home.
  • Students with truant behavior generally do not show concern about school and may appear indifferent about attendance. Students with school refusal experience severe emotional distress related to school attendance and are often embarrassed about not attending school.

What should I do if my child is exhibiting symptoms associated with school refusal?

The first thing parents should do if they suspect school refusal is to take their child to a physician to rule out any underlying medical conditions that may explain the child’s somatic complaints. If the physician determines that there is no medical basis for your child’s physical ailments, the next step is to work to get your child back to regular school attendance. Depending on the severity of your child’s symptoms, the physician may refer your child for an assessment by a psychiatrist or psychologist.

In addition to a medical evaluation, parents should also talk with their child to help identify stressors related to school attendance. Many children may not be able to identify what is upsetting about school. However, if your child states reasons for not wanting to go to school, examine the validity of academic or social complaints. Talk with your child’s teacher, principal, and school psychologist to rectify any problems identified. Students struggling academically may have a disability requiring different types of instruction. Students who are victims of bullying need to feel safe at school. There are many legitimate reasons why a student may not want to go to school. Working to solve problem areas may help to alleviate your child’s anxiety.

What are the components of an evaluation for school refusal?

An evaluation for school refusal may include the following components in order to provide a complete view of your child’s behaviors.

  • Family/child interviews to determine history of onset and triggers
  • Medical history including medications (Some medications exacerbate separation anxiety in children which contributes to school refusal.)
  • School history
  • Physical exam
  • Clinical rating scales to evaluate areas including anxiety, depression, and peer relationships

What is the treatment for school refusal?

There are many possible treatment options for school refusal. Depending on the severity of your child’s symptoms, a combination of these treatments may be recommended to help your child overcome school refusal.

Family intervention: Behavioral strategies are most effective when they are used consistently. Family intervention can help to provide support to parents in working with their child’s school refusal.

Medication: Your child’s doctor may prescribe medication if there are significant concerns regarding underlying depression, anxiety, or social phobias.

Cognitive Behavior Therapy (CBT): The premise of CBT is that psychological problems are the result of how people evaluate or interpret situations, thoughts, and feelings. The goal of CBT is to reduce anxiety-provoking thoughts and replace them with more rationale thoughts. Negative thoughts are reduced by giving the individual coping statements.

In vivo exposure: In vivo exposure is a form of CBT where individuals are exposed to the feared object or situation and taught coping strategies to handle their fear. In the case of a student with school refusal, systematic desensitization (gradual introduction to the feared situation) may be necessary. The goal is to create a different reaction to the feared stimulus (school).

Example schedule of systematic desensitization with a student suffering from severe school refusal:

Day 1: Student gets ready for school. Parent takes student to school and school psychologist engages in a brief therapy session in the parking lot. Student then goes home with parent.

Day 2: Same as Day 1 with the addition of walking into the building with the parent and school psychologist.


Day 3: Same as Day 2 except parent does not accompany student into the building.

Day 4: Student stays at school for specified length of time (e.g. 30 minutes, one hour).

Day 5 on: Gradually increase the length of time student attends school working up to a full day.

Emotive imagery: Emotive imagery is a form of visualization used in systematic desensitization where the individual is encouraged to imagine the feared stimulus with a different reaction. The goal of using emotive imagery with a student suffering from school refusal is to help the child change negative thoughts and feelings associated with school attendance.

What can parents do?

Parent involvement is the most critical component in helping a child overcome school refusal. There are several things that parents can do to help their children through this process.

  • Avoid lengthy discussions or arguing with your child about going to school
  • Use matter-of-fact statements such as, “Your job is to attend school. My job is to make sure you get there.”
  • Pay attention to your own anxieties that may be feeding into your child’s school refusal
  • Be sympathetic and supportive when talking with your child. Acknowledge your child’s concerns, but insist on her return to school.
  • Do not engage in lengthy discussions about your child’s somatic complaints. Remember, if there is no physical basis for your child’s symptoms, they will usually disappear once your child is regularly attending school. When your child remains out of school, the severity of symptoms and panic level almost always increase making school attendance more difficult.
  • Meet with your child’s teacher, principal, school nurse, and school psychologist to develop a plan for getting your child back to regular school attendance. Work with the school to develop a reward system for reinforcing school attendance
  • Reassure your child that you will be home when he comes home, or clearly explain the after school plans. Make sure to stick to the plan so that your child knows what to expect.

What can school staff do?

It is critical for teachers and other school personnel to provide a safe and welcoming school environment. School staff can help students with school refusal by implementing some of the following interventions.

  • All schools should have zero tolerance for bullying and take accusations of bullying very seriously.
  • Help the student recognize triggers and teach relaxation strategies. Staff should cue the student to use these strategies when signs of anxiety are noticed.
  • Work with the child’s parent to develop a schedule of reinforcement
  • Allow brief phone calls home at scheduled intervals to reduce anxiety
  •  Carefully monitor child’s progress

The prognosis for overcoming school refusal is very good when students receive early and consistent interventions. School staff and parents working together can help children reduce school anxiety and succeed.

References:

Dornbush, M. P. & Pruitt, S. K. (1995). Teaching the Tiger. Hope Press; Duarte, CA.


Fremont, W. P. (2003). School refusal in children and adolescents. American Family Physician, 68(8), 1555-1561.

 

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