School refusal: "Ma, I Don't Wanna Go to School!"

By Robert P. Chayer, MD

Fall can be a time of the year that involves a variety of emotions for children and teens as they head off to school – many for the first time or even the last time as seniors. There can be a blend of eager anticipation of new challenges and of reconnecting with old friends. Or, there maybe some sadness and irritability about having to give up the freedom of summer and its flexible schedules and fewer responsibilities. Many parents are familiar with prying grumbling, sleepy children out of bed to launch them off to school as August turns into September. Sometimes this process can be more than just an annoyance – it can become almost impossible, and a child may not be attending school at all. Parents, through their own frustration or at the urging of the child's school, may call their pediatrician or primary care provider to discuss their child's refusal to attend school.

Introduction

School refusal is an issue for about 1 percent of children in primary care settings and 5 percent of children who present to mental health settings. The "diagnosis" is easy: the child won't go to school without a fight. Determining the cause and the appropriate treatment require more thought.

The term "school refusal," while not a DSM IV diagnosis, is used to refer to children who consistently avoid school or will attend school only with much coercion and in the face of much distress. This idea is descriptive but provides the parents or professionals involved little help in knowing what to do about it. Mental health diagnoses related to this condition may include anxiety disorders such as separation anxiety disorder, school phobia, social anxiety disorder, adjustment disorders, depression or oppositional defiant disorder, or these issues may involve no diagnosis at all. So, how does one go about developing a plan to get things back on track?

Many researchers in this area advocate for a system that examines the function that the behavior of not going to school serves as the key to appropriate intervention. The behavior of refusing school may serve either the purpose of avoiding negative reinforcement or seeking positive reinforcement. Those avoiding negative reinforcement may include children who are extremely anxious in social settings, children who are seeking to avoid bullying or conflict with teachers, children who become extremely anxious in testing situations or those who become significantly anxious when separated from a parent. In other words, the child's behavior is for the purpose of avoiding distress. Children that seek positive reinforcement from school refusal may be looking to receive attention from parents and significant others through their behaviors or those who may be engaged in other behaviors outside of school that they have determined to be much more enjoyable. The latter behaviors may be more consistent with the term "truancy." There is little distress involved. The child may be trying to hide the behavior from his or her parents and may be much more likely to be out of the home and involved in antisocial behaviors like lying, stealing and substance abuse. Here the behavior is to seek out what seems most pleasurable.

Clinical features

No one typical pattern is associated with school refusal. Onset of symptoms usually are gradual. The refusal behavior can occur at any age, but there are times when it is most common. One study shows increased reports between the ages of 5 to 6 and 10 to 11, which correspond to beginning kindergarten and middle school. Also, stress may result in times of increased risk. An example might be a change in schools or a change of schedule following an extended holiday. There is no indication that the problem is more common in boys or girls or in different socioeconomic classes.

Anxiety disorders are more common in those who seek to avoid stressors at school. These children may express more in the way of somatic complaints. Physical complaints can include autonomic symptoms such as dizziness, headache, palpitations and chest pain. Gastrointestinal complaints of abdominal pain, nausea, vomiting and diarrhea are common as are musculoskeletal complaints such as back and joint pain. Concurrent mood symptoms may be more prevalent in adolescents. Those who avoid school to seek more pleasurable situations elsewhere tend to be older, more defiant and have more conduct problems. 

Understanding the family function can be important as well. Overdependency, detachment with little interaction between family members, isolation with little contact with those outside of the family and high levels of conflict all have been suggested as increasing risk of school refusal.

Evaluation

Before the physician or other health care provider can develop a plan to address the child's absence, it is important to do a comprehensive evaluation. The evaluation may involve a number of professionals including the primary care provider, school staff and mental health professionals. As many children present with numerous somatic complaints, a thorough physical exam is important to rule out physical illness. Mental health professionals' evaluations should include interviews with the child and the parents, exploring events precipitating the symptoms, concurrent stressors, history of previous school performance, peer relationships, family function, psychiatric history, substance abuse history and a mental status exam. Collaboration with school personnel is very important as well to provide academic records, observations of social and family interactions and any available psychological or academic testing data.

Treatment

The primary goal for treatment is for the child to return to school as soon as possible. The longer a child is out of school the more difficult returning becomes. Just as a collaborative approach is used for assessment, a similar approach is important for treatment. The primary care provider, the child, the parents, the school staff and the mental health provider all need to work in concert for the best outcome.

Treatment options include education and support, behavioral strategies, family therapy and perhaps pharmacotherapy. Education and support can involve the child, parents and school professionals. Children are encouraged to explore their feelings and are provided with information to develop strategies to return to school. Behavioral strategies may include controlled reintroduction to school, relaxation training and social skills training depending on the nature of their anxiety. Additionally, cognitive strategies may be employed to help children confront fears and modify negative thoughts. Parents can benefit from cognitive strategies to address their own anxieties and to understand their role in making the process successful. Parents also can use behavior management strategies including escorting the child to school, providing positive reinforcement for attendance and decreasing positive rewards for staying home, particularly for children who are not motivated by anxiety. Collaboration with school staff increases consistency and therefore the likelihood of success. Medication may play a role for children with excessive anxiety. Older studies looked at the benefit of Imipramine in school refusal with mixed results. More recent evidence points to selective serotonin reuptake inhibitors (SSRIs) as being very effective in treating childhood anxiety; and SSRIs now are used more frequently to treat anxiety in combination with psychotherapy. Additionally, benzodiazapines may be useful in combination with SSRIs to target acute anxiety as medications like sertraline may take up to 6 weeks to be fully effective.

Conclusion

School refusal can create a difficult situation, but when the issue is addressed in a comprehensive, collaborative fashion by the child, parents, primary care provider, school professionals and a mental health provider, the child's potential for academic and social success can be realized.    

Robert P. Chayer, MD, is a pediatric psychiatrist at Children's Hospital of Wisconsin. He also is an assistant professor of Child and Adolescent Psychiatry at the Medical College of Wisconsin and a member of Children's Specialty Group.

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