Written by: Dr. Scott Moreland; Child, Adolescent, and Adult Psychiatrist
School Refusal Overview
School refusal occurs when a student will not go to school or remain in class for an entire day and frequently experiences significant distress about the idea of attending school. As much as 28% of school aged children in America refuse school at some point during their education. Most of the time this behavior is limited and does not require intervention but for 2 to 5% of children such behavior becomes a routine problem.
School refusal is considered more of a symptom than a specific disorder and may have different and multiple causes. This leads to a variety of clinical presentations as well as frequent associations with other disorders (i.e. Separation Anxiety Disorder, Generalized Anxiety Disorder, Depression, Learning Disabilities) that may also require intervention.
A comprehensive evaluation by a mental health professional is recommended to clarify the causes and various factors contributing to the behavior and identify any associated disorders. Once a clear diagnostic picture is established, an individualized treatment plan can be developed to address the positive and negative factors that tend to reinforce the school refusal behavior and associated conditions. With treatment, the prognosis is good.
Symptoms and Clinical Picture
School Refusal can happen at any age but most typically occurs in children aged 5-7 years and in those aged 10-12 years which are times of starting school or making the transition from elementary or middle school to high school.
Presenting symptoms can vary per child but typically fall into 2 types of behavior — internalizing or externalizing. The most common internalizing behaviors are physical complaints (e.g. stomach aches, nausea, tremors, fatigue and headaches), generalized worrying (“the worry wart”), panic symptoms, isolation and depression. The most prevalent externalizing behaviors are crying episodes, temper tantrums, verbal and physical aggression, and oppositional behavior. Typically, symptoms present the night before or the morning of school and improve on the weekends or if the child is allowed to stay at home.
Other behaviors include frequent pleas to stay home from school, repeatedly calling home when at school, and continually missing the bus to school.
Causes
The term ‘school refusal behavior’ encompasses the many reasons why youth have difficulties attending school. From simple avoidance because of the fear of public speaking, daily stomach aches in the morning to avoid a bully at school, to crying and daily pleas to stay home because of intense fear of separating from the primary caretaker, school refusal may serve different functions depending on the individual child.
These may include:
1. To avoid school-related situations that cause general distress such as anxiety, depression, or physiological symptoms (test taking, bathrooms, cafeteria, riding the bus) 2. To escape uncomfortable social situations (problems with peers and teachers, bullying, problems with peers and teachers, bullying, social phobia, delayed social skills, public speaking fears, shyness) 3. To receive attention from significant others outside of school (extra attention from the family, attention seeking behaviors, tantrums, clinginess, cries) 4. To pursue secondary gain outside of school (playing video games is more fun than school, truancy).
Symptoms may begin after a holiday or illness and can be triggered by stressful events at home or school. Divorce, jealousy over a new sibling, moving to a new house, parental fighting, parental illness, peer conflict, and/or bullying can precede school refusal.
Treatment
The primary treatment goal for children with school refusal is early return to school. The longer a child stays out of school, the more difficult it is to return. Once the various causes and contributing factors have been determined, a variety of cognitive behavioral interventions are used. These strategies include gradual reintroduction to school, relaxation training, cognitive restructuring (or reframing of negative thoughts), coping skills training and social skills training. An evaluation by a therapist, psychologist and/or psychiatrist with training and experience in treating children and adolescents is recommended.
Active involvement of the parents is an important factor for success as well as collaboration between parents, school personnel, primary care physicians and mental health care providers.
Underlying associated disorders should also be identified and treated. The most commonly associated disorders are separation anxiety, social phobia, simple phobia, panic disorder, major depressive disorder, dysthymia and adjustment disorder.
In individual children, medication can be an important part of an overall effective treatment plan especially if associated condition(s) are prominent or there is severe or debilitating anxiety or distress. Studies show that medications can be effective and safe in children with anxiety and mood disorders, but referral to a child and adolescent psychiatrist is recommended.
What you can do as a parent:
· If your child expresses concern about starting school, accompany your child on a visit to the school and meet the teacher before school starts. · It is very helpful to be able to enlist the school in helping the child feel less anxious. Identify a person who will assist you in implementing a system that will facilitate the child's ability to get over his/her anxiety and, most importantly, involve the teacher. · Do not deny the child's anxiety or worries, but acknowledge them and reassure him/her. · A child with separation anxiety breaks the heart of any compassionate person. Yet, the best remedy is to help the child to not give in to anxieties. As much as possible, you should prevent accommodating the child by allowing him/her to avoid separations. · But, you may ask, how can I do that if my child is so unhappy? Try to find ways to enable the child to go to school. For example, a child is likely to feel reassured if times are set for him or her to call the mother from school. In extreme cases, mothers may stay with the child in school, but for a specified length of time which is gradually reduced. · It is most important to tell the child exactly what s/he is to expect. There should be no "tricks" or surprises. For example, a child may be told that he should try to stay in school for only one hour, but after the hour he is encouraged or asked to stay longer either by the school or parent. This will backfire. The child will eventually refuse future arrangements for fear that they will be modified arbitrarily. Part of being anxious is fear of the unknown and the “what if?”. · Punishment does not work, but kind, consistent, rational pressure and encouragement do. · Do not quiz the child about why s/he feels scared. The child often does not know why. By not being able to provide an explanation, in addition to being anxious, the child feels guilty about not making sense of what is happening. Better to acknowledge that the fears make no sense and that the child has to fight them. · Be open to hearing about how your child feels. However, lengthy discussions about the child's problems are not always helpful and can be experienced as a burden by the child. The focus must always be that you want to help your child be free of worries and fears. · A child's reluctance to go to school can be irritating to parents. Expressing resentment and anger is counterproductive. And you won't feel the urge to do so if you adopt specific strategies to assist your child.
