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. The phenomenon has increased significantly since the pandemic. Many children who are refusing to go to school have an underlying mental health concern. The most common mental health concerns related to school refusal are depression, generalized anxiety, separation anxiety, oppositional defiant disorder and conduct disorder. A child could be feeling depressed or anxious about school, either because of academic or social challenges. The child or adolescent could be experiencing bullying by peers. A teen might be experiencing issues related to gender dysphoria. These are the 4 main reasons for school refusal:
1. school situations that make the child feel anxious or depressed
2. social or performance pressure at school
3. attention from family members
4. rewards for staying home
A child may not directly refuse to go to school but rather complain about nonspecific physical symptoms, like stomachaches, nausea, headaches, general malaise. It is important to rule out medical causes for those complaints as well as to assess for underlying depression and anxiety. If a child presents with clinically significant symptoms of depression and anxiety, it will be important to treat those symptoms with therapy and/or medication as part of the intervention for school refusal.
School refusal can have serious consequences. In the short term, a child can fall behind academically and socially isolate. School refusal can cause stress on the family, both in terms of childcare concerns and lost income from missing work. There can be increased family arguments about school attendance. 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. An exposure plan can be established 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 might be helpful for the school and family to establish a 504 plan or IEP to include modifications and accommodations to reduce stress and anxiety about attending school. Other ideas include asking the school to front load the day 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 to schoolwork and chores if they are home. Parents should remain empathetic but firm about attending school. They can make supportive statements about being confident that they can handle their fears and that physical symptoms of anxiety can be unpleasant but are not dangerous. Learning this firsthand can be empowering for a child.
It is our hope that this article 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.
References:
https://www.health.harvard.edu/blog/school-refusal-when-a-child-wont-go-to-school-2018091814756
https://emedicine.medscape.com/article/916737-overview
http://www.icontact-archive.com/EgL5tWDi-1Vzgy8mgidW95HZi-TkFFRv?w=4
AUTHOR: Charmi Patel Rao MD, DFAACAP
Co-Medical Director, Vista Hill Foundation
Health Science Clinical Professor, UCSD Department of Psychiatry
President, San Diego Academy of Child and Adolescent Psychiatry