What is School Refusal? School refusal is not a formal psychiatric diagnosis; it’s a pattern of behavior.1 When children are reluctant or refuse to attend school, for emotional reasons, we call it school refusal.2 There are many reasons why children refuse school, and varying levels of severity. Severity can range from frequent complaints about going to school, part or full day absence, and absences that last for entire weeks of school or more.3 Some children may leave home in the morning and develop difficulties as they get closer to school or class, where other students may refuse to make any effort to go to school.1 School refusal can happen at any time, but more often occurs during a major change in a child’s life.3 What are signs? Absence or extreme reluctance to attend school or class is the major defining criteria in school refusal. The onset can be gradual, or sudden, and occurs in approximately 2%-5% of school-age children.1,3 The following may also be seen in children with school refusal: High rates of physical complaints (stomach aches, headaches). Frequently asking to go to the nurse’s office. Physical symptoms improve during the day if the child is allowed to stay home. Frequent complaints about attending school Frequent tardiness or unexcused absences Absences on significant days (tests, speeches, physical education class) Frequent requests to call or go home Excessive worrying about a parent when in school Crying about wanting to go home Concerns about transition periods at school (such as classroom to cafeteria, or riding the school bus) Morning tantrums, a child may engage in morning battles before school, which can include crying, yelling, kicking, or running away School refusal can sometimes occur in children who also have a psychiatric disorder such as anxiety and depression, but other children will have no other accompanying disorder. Children struggling with school refusal do not attempt to hide the problem of school absence from parents, nor do they display aggressive behavior in school, stealing, lying, or destructiveness, which over time can be a sign of a more serious conduct disorder. What causes School Refusal? If your child is refusing to attend school, a professional will work to determine what function this behavior is serving. Usually avoiding school serves any one or many of these functions: avoidance of fears provoked by the school environment, escape from aversive social situations, relief from separation anxiety, and indulgence of attention-seeking or reward-seeking behaviors.1 The following are some factors that can contribute to school refusal:1,3 Anxiety over separation from a parent Anxiety about performance situations (taking tests, giving speeches, athletic performance), these children worry about being embarrassed or humiliated in front of their peers. Social anxiety, these children worry about social interactions with peers and/or teachers and are uncomfortable in social situations and may dread socializing with classmates. Major change in a child’s life (starting kindergarten, moving from elementary to middle school) Stressful events (recent move, changing schools, death of a loved one, parental divorce, academic difficulties) A co-existing psychiatric disorder such as a mood disorder or anxiety disorder Bullying, some children fear being bullied and want to avoid situations that are physically threatening, or where they may be teased or left out by other children. Opportunity to gain time and attention with parents or caretakers Opportunity to enjoy fun activities if allowed to stay home What can be done to treat School Refusal? Early return to school is the treatment of choice.4 If left untreated, school refusal can cause significant stress for parents. Prolonged periods of school refusal can lead to a lack of academic progress, failure to develop social relationships, and family conflict (including lost time at work for parents).3 The longer a child stays out of school, the more difficult it is to return. Treatment may include educational-support therapy, cognitive behavioral therapy, and parent-teacher interventions.1 Some interventions that may be used with children include:1,3 Desensitization: Increasing exposure to the school environment in small steps including use emotive imagery Relaxation training to help a child as they approach school or are approached by peers Social skills training to improve social competence and interactions with peers Setting up rewards or contingencies based on school attendance Goal-setting Teaching children to use helpful thoughts and actions when they are worried or fearful Parent training may include:2,3 Developing a smooth morning and evening routine Providing attention for positive behaviors and school attendance. Establishing disincentives for nonattendance, and ignoring negative behaviors Removing the ability to partake in desirable activities during school hours including watching tv, playing video games, or engaging in other fun activities Communication skills training to reduce conflicts at home Resources: 1 American Family Physician 2 International Journal of Behavioral Consultation and Therapy 3 National Association of School Psychologists 4 Archives of Disease in Childhood
