How to Manage School Refusal 11/15/2018

Families often present to their primary care providers when their children are refusing to go to school. School refusal can happen for a variety of reasons. Some school refusal may be time-limited, but most children who are refusing to go to school on an extended basis have an underlying psychiatric concern such as major depression, generalized anxiety, separation anxiety, oppositional defiant disorder and conduct disorder.

These are the 4 main reasons for school refusal:

  1. school situations that make the child feel anxious or depressed
  2. social or academic performance pressures at school
  3. attention from family members
  4. rewards for staying home

Academic or social challenges may be quite varied, but can include concerns about bullying by peers, issues related to gender dysphoria and other challenges.

A child may not directly refuse to go to school, but rather may complain about nonspecific physical symptoms, like stomachaches, nausea, headaches, general malaise to avoid the stress experienced at school. It is thus important to rule out medical causes for those complaints as well as to concurrently assess for underlying psychosocial or psychiatric conditions. If a child presents with clinically significant symptoms of depression and anxiety, it will be important to treat those symptoms with therapy and possibly medication as part of the treatment interventions—whether for a somatic problem or a psychosocial one.

School refusal can have serious consequences. In the short term, a child can fall behind academically. There can be increased family arguments about school attendance. School refusal can cause stress on the family, both in terms of childcare concerns and lost income from missing work. In the long term, there is an increased risk of school dropout, violent behavior, and unemployment.

The main goal of intervention is to get the child back to school as soon as possible. Being away from school is highly reinforcing. An effective team should include the child, parent, school and therapist. Therapy using CBT techniques can be helpful for the child to determine the reasons for refusing to go to school, so that those reasons can be addressed. Establishment of an exposure plan should be made and implemented to re-engage the child with the school. An example is to start with driving to school but not going in, then moving to attending school for a brief part of the day during a non-stressful time, and increasing time in school from there. It may be helpful for the school and family to establish a 504 plan to reduce stressors and anxiety about attending school. Other ideas include asking the school to front load with preferred activities and allowing the child time to settle into the classroom before the school day starts. It is important to ask parents to make staying at home as undesirable and “boring” as possible, i.e., not allowing television and video games and making the child complete schoolwork and chores if he is home.

It is our hope that this primer on school refusal is helpful for primary care providers to have a better idea of how to proceed when a family presents with a child who is refusing to go to school.



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