School Refusal: A Complete Guide

How Common Is School Refusal?

According to the American Family Physician, school refusal occurs in approximately 5% of all school-age children. Children affected by this issue may end up chronically absent from school and fall behind on assignments and tests.

This issue can occur at any age, but children in certain age groups are more likely to resist going to school. For instance, children aged 5 to 6 starting school for the first time have higher rates of school reluctance.

Pre-teens often tend to have a higher susceptibility to school avoidance as well. School refusal in this age group is often due to concerns about fitting in. Students in this age group may find interests away from school (such as video games) more appealing than the pressures of school.

School refusal occurs equally among boys and girls. However, sexuality can affect school avoidance and chronic absenteeism. A study published in the Journal of School Psychology found that students who identify as LGBTQ+ reported more unexcused absences than their heterosexual classmates.

School refusal can lead to multiple absences during the academic year. In severe cases, students may miss weeks or months due to their fears. Often, when a child misses school for an extended period, they’ll feel more reluctant to return.

Causes of School Refusal

Various factors can trigger school refusal. Most children with the condition have an underlying issue behind their reluctance to school, and often for several reasons at once.

Although each child is different, some of the most common causes of school refusal include the following.

Distress in School Settings

Children may feel stressed by certain situations while in a school setting. They may report feeling bad at school and can’t clearly identify what’s bothering them.

Young children may not like how other classmates interact with them or feel stressed by a teacher who raises their voice in the classroom. They may also be reluctant due to issues with transitions. For example, the child may feel stressed when traveling from the bus to school or changing classes.

Separation Anxiety

Some children experience intense separation anxiety. The strength of their feelings can make it hard to leave home every morning and attend school.

Children with separation anxiety find it challenging to be away from their parents for extended periods of time. They may even fear something terrible may happen to their caregivers when they are away from home. Some children naturally outgrow separation anxiety the longer they attend school.

Stressful Life Events

Any external stress could affect whether a child wants to go to school or not.

For instance, children can experience stress when starting at a new school after a family move. Also, children may act out and stop going to school when there’s violence at home or if parents are going through a divorce.

Fear of Something Bad Happening

Although children should feel protected at school, that’s not always the case. Kids may fear that something negative may happen to them on school grounds. Fear can stem from a previous incident, such as bullying or threats made by peers.

Fears related to academic performance can spark school avoidance. Children may worry about getting bad grades or failing an upcoming test. Students may have an aversion to public speaking and wish to refrain from giving presentations in front of the class.

Children may also worry about their safety at school. Over 300,000 children have been exposed to gun-based violence while at school. After news about a mass shooting at a school, it’s not unusual for children to feel fear about returning.

Traumatic Experiences

Children who have experienced traumatic events, such as abuse, bullying, injuries, or a school shooting, may develop school phobia if any of these incidents occur on school grounds.

Due to such trauma, children may have a negative association with the environment and wish to avoid going. Children may also not want to go to school if they don’t feel protected by staff members.

For instance, if a child is physically assaulted on school grounds and the administration doesn’t adequately punish the offender, the student may feel like the school isn’t safe.

If a student isn’t feeling secure, the school needs to be notified. Staff and caregivers must collaborate to ensure a child feels protected while in school.

Seeking Attention

A child may avoid school to seek attention from caregivers or loved ones.

This behavior can be a way for the child to communicate feelings of insecurity, loneliness, or a desire for more nurturing interactions from trusted adults in their life.

Fun Activities Outside of School

Kids may prioritize engaging in enjoyable activities outside of school because they perceive these activities as more appealing or rewarding than attending classes.

Symptoms of School Refusal

The symptoms of school refusal can vary depending on the individual child. Any underlying factors will also impact symptom severity. The most common sign of school avoidance is when children express their reluctance to attend school. However, caregivers may also notice the following symptoms.

Physical Symptoms

Children with school avoidance may complain of physical symptoms, especially before the school day begins. Symptoms can include stomach pain, headache, nausea, diarrhea, fatigue, and dizziness.

The physical complaints may be real or exaggerated by the child. Since the child is “sick,” caregivers may feel obligated to allow the student to miss school. If the child is permitted to stay home, the symptoms may subside.

Emotional Symptoms

Children with school refusal often experience intense feelings over school. Students may demonstrate signs of anxiety, depression, or panic. The stress of school may lead to acting out and bouts of crying or screaming. Children may throw tantrums and make threats of self-harm.

Avoidance Behaviors

Children with chronic absenteeism will actively try to avoid going to school. They may express willful behaviors to escape attending school since it causes them anxiety.

They may flat-out refuse to leave the house or fall to the ground in protest. Despite such behavior, if children do end up at school, they may ask to go to the nurse often to get out of class.

Children with school avoidance may not always experience the same intensity of feelings. For example, symptoms may worsen if they are stressed about an upcoming test.

Identifying School Refusal in Children and Teens

Assessing school refusal requires a professional evaluation. The assessment should involve collaboration among caregivers, teachers, and mental health professionals. Caregivers and teachers should not ignore chronic absenteeism.

According to the American Academy of Family Physicians, students who miss more than 5% of school days are at risk for academic and social issues.

By missing school often, grades are likely to drop, and the child may need extra help understanding the material covered during class time. Kids who miss a lot of school can also struggle with friendships.

To identify school avoidance and take action, caregivers, educators, and professionals will likely engage in a plan that includes the following steps.

Review of Medical and School Records

A thorough review of medical records should occur before any other assessments are made. Health records can help rule out any medical conditions contributing to chronic absenteeism.

For instance, children with learning disabilities may feel stress about school because of their inability to focus and complete their assignments.

A review of school records can show patterns in a child’s academic history. For instance, the child may miss a lot of school around the period when standardized testing is typically done.

Observation and Interviews

Observing a child’s behavior in school will add valuable insights into the reasons behind their phobia. Professionals can watch the child and monitor interactions with peers and staff. Such observations may help identify any potential triggers at school.

Mental health professionals should interview the child, parents, and teachers. During these interviews, professionals aim to find out the stressors contributing to school avoidance.

Questionnaires and Assessments

Questionnaires and standardized assessments can be helpful tools for gathering information about the child’s mental state. They may reveal if a child has expressed any feelings about school.

The assessments may use a numbered scale to assess a child’s emotions. The parents, child, and teacher often fill out the questionnaires. Sample questions may include:

• How frequently do you stay home from school because talking to other kids is hard?
• How often would you rather be home with your parents than at school?
• How much would you rather be taught by your parents than go to school?

Collaboration With School Staff

Collaboration between school staff, including teachers, counselors, and administrators, can lead to a better understanding of the current school environment.

Staff may know firsthand any challenges the child may face during the school day. Teachers witness social interactions and may have noticed issues with peers. Educators can also give feedback on academic performance. A student’s struggles in a particular class may cause school reluctance.

How Is School Refusal Different From Truancy?

One key thing to remember is that school refusal is different from truancy. Truancy refers to deliberately skipping school. Truancy has often been linked to antisocial behaviors. However, it’s easier to confirm the reasons behind frequent absences if they are evaluated by a professional.

Students with school refusal tend to have serious emotional distress about going to school. They don’t attempt to conceal their emotions and instead try to convince their parents to allow them to miss school. They usually stay home for the day if they don’t attend school.

In comparison, some students deliberately skip school and won’t show signs of anxiety and stress about attending. In these cases, students don’t usually let parents know about plans to skip school.

Instead, they pretend to attend. In order to avoid detection, they will likely not stay home during the school day. Their avoidance doesn’t stem from a phobia.

Tips for Parents

Supporting children with school refusal will always require a team effort between school staff, caregivers, and mental health professionals. The following suggestions can help parents encourage their children to overcome school refusal.

Get Involved Immediately

Although you may assume a child’s unwillingness to attend school is a phase, don’t ignore the problem. Early intervention will help prevent school avoidance from getting more serious.

School refusal post-pandemic is a national crisis. It should be taken seriously and treated as something that requires immediate intervention to address.

Identify Any Underlying Issues

Listen to your child and encourage them to talk about their specific concerns about attending school. Do they complain about a particular teacher? Did they recently lose a friend?

Attempt to identify any triggers that could cause them to feel anxious during the school day. Remember to share this information with your child’s doctors.

Validate Your Child’s Experiences

It’s important to validate your child without trying to minimize the challenge. When listening to your child, convey that you understand their anxiety while emphasizing the importance of working through it.

For example, you can say, “I hear how hard it is for you to give a presentation in front of the class. I know it’s scary, but I also know you’ll be able to do it.”

Communicate and Collaborate With School Staff

If you notice your child is anxious about going to school, contact the school’s guidance counselor and your child’s teacher. Share your concerns and ask for support.

The staff may suggest ways to make school less stressful for your child. Advocate for your child if you believe any mistreatment during school is the cause of their refusal to attend.

Be Firm About School Attendance

Although it can be difficult to witness your child’s distress, you must emphasize the importance of attending school.

Remember to validate your child’s feelings and tell them you understand why they’re nervous or scared. Explain that you will help them face their fears and that you will always listen to their feelings.

Help Your Child Find Meaningful Aspects of School

Is there a subject they find enjoyable? A particular teacher they connect with? Do they have a friend they could join on a sports team? It can be helpful for your child to find one aspect of school to look forward to.

Make Staying Home Dull

If your child has school refusal, you don’t want to make time at home fun—limit screen time and create a schedule for the day. The child may otherwise look forward to lounging in bed or having extended screen time.

Parents should avoid letting their kids sleep or play video games during school hours to prevent reinforcing school refusal behaviors and ensure that education remains a priority.

You may even reach out to the school to ask for any assignments your child is missing and request they finish the assignments during the day.

Seek Professional Help if Needed

If your child’s school avoidance persists or symptoms affect their daily routine, you should make an appointment with your pediatrician. Explain the situation to the pediatrician and request a referral to a mental health professional specializing in school refusal.

Tips for Educators

In collaboration with caregivers and mental health professionals, educators also play an important role in supporting kids with school refusal. The following suggestions can provide educators with tips to help children overcome this challenge.

Recognize the Signs of School Avoidance

Teachers should pay close attention to any children who are frequently absent from school. Teachers may also notice recurrent requests to go to the nurse.

Children may complain of physical symptoms, such as stomach pain and headaches. If a teacher notices avoidance behavior, the first step is to reach out to parents to determine if the student is experiencing school refusal.

Create a Supportive Classroom Environment

Openly communicate with the child and try to alleviate fears about going to school. Give age-appropriate resources to help them overcome their fears.

Collaborate With Parents

Work closely with caregivers to understand their child’s specific challenges. You can recommend strategies to support a child’s return to school. Keep the caregivers updated on the child’s academic progress and classroom behaviors.

Implement Accommodations

Teachers and school personnel may need to put accommodations in place to help support any students struggling with school refusal. For instance, the child may require extended time on assignments or flexible class scheduling.

The school should also permit the child access to any counseling resources available.

The school nurse should also receive guidance on how to help a child with school avoidance. The child may feel ill due to anxiety about school, and the nurse should know what to do if the situation arises.

How Is School Refusal Treated?

Effective treatment for school refusal involves a comprehensive approach, aiming to address the underlying cause of chronic absenteeism.

The plan should also give support to all involved, including parents and caregivers. Although a treatment plan for the child is essential, parents often need therapy as well.

Cognitive Behavior Therapy

Cognitive behavior therapy (CBT) is a highly effective treatment approach for school refusal. The goal of CBT is for people to challenge negative thought patterns and find coping strategies when faced with stressful situations.

Therapists will ask children to talk about their fears associated with school and will come up with exercises to reduce stress levels.

CBT for school refusal also commonly uses exposure therapy techniques. This form of treatment allows mental health professionals to gradually expose patients to their fears in a controlled setting.

The therapist will start by exposing the student to less stressful school-related situations. Gradually, the student may face more challenging school situations with a therapist’s help.

Educational-Support Therapy

Educational-support therapy is a type of treatment that combines informational presentations and psychotherapy sessions to help children overcome their fears about attending school.

With this approach, professionals provide information to parents and caregivers to help them learn more about the importance of school attendance. Students and caregivers also learn about coping strategies for stressful situations.

Children are encouraged to freely discuss their fears and feelings about attending school. For this type of treatment, professionals don’t practice exposure therapy techniques—the goal is to provide support and information to children and caregivers.

However, for some children, treatment without any exposure therapy can make it challenging for them to complete the return to school.

Medications

Depending on the age and diagnosis of the student, psychiatrists may recommend medication along with talk therapy. Medications can help address underlying disorders, such as anxiety and depression.

Selective serotonin reuptake inhibitors (SSRIs) are often the first type of medication used for students who are refusing to attend school. SSRIs, like sertraline, are intended to help reduce anxiety symptoms. When prescribing medication, providers start patients on an introductory dose and eventually increase it to a therapeutic level.

Benzodiazepines may be used in conjunction with SSRIs to address school refusal, but these types of medications are typically only given on a short-term basis.

Parent and Teacher Interventions

Getting parents on board is crucial to successfully treating school refusal. Although parental involvement is vital for all ages, it’s especially needed to address school refusal for children in elementary school. Parents should attend and participate in all therapy sessions with their children.

During therapy, parents are likely to receive behavior management tools. For instance, therapists may ask caregivers to focus on positive reinforcement for school attendance. Parents can undermine progress if they unknowingly provide positive reinforcement when a child stays home from school.

Parents may get recommended individual therapy sessions to help reduce their own anxieties. During the sessions, they can start understanding how to support their child as their child returns to school.

Caregivers should inform the child’s teachers about the child’s school refusal as well as any treatment the child receives to address the issue. The school may also provide resources to help the child, such as counseling sessions. The school has a responsibility to provide a supportive environment to help the child feel comfortable and safe.

Kids cannot be expected to walk confidently back into school after learning a few coping strategies. We need children to build up tools to fight against anxiety, and for their caregivers to set up and stick to consequences, rewards, and environmental shifts that increase the chances for their children to be successful.