Children Who Won't Go To School
Separation Anxiety & School Refusal
What to do when children refuse to go to school--

The timing of separation anxiety can vary widely from child to child. Some kids may experience it later, between 18
months and 2-1/2 years of age. Some may never experience it. And for others, there are certain life stresses that
can trigger feelings of anxiety about being separated from a parent (e.g., a new child care situation or caregiver, a
new sibling, moving to a new place, tension at home).

Going to school usually is an exciting, enjoyable event for young children. For some it brings intense fear or panic.
Parents should be concerned if their child regularly complains about feeling sick or asks to stay home from school
with minor physical complaints. Not wanting to go to school may occur at anytime, but is most common in children
5-7 and 11-14, times when children are dealing with the new challenges of elementary and middle school. These
children may suffer from a paralyzing fear of leaving the safety of their parents and home. The child's panic and
refusal to go to school is very difficult for parents to cope with, but these fears and behavior can be treated
successfully, with professional help.

School refusal is:  

·     equally common among boys and girls and is most likely to occur between age 5 to 11

·     highest when schools reopen after summer  

·     defined as the behavior of resisting or refusing to attend a specific class or to stay in school for an entire day

·     may be accompanied by one or more of the following behaviors: complaints about stomach pain, headache, or
nausea before or during school; crying before and during school; frequent visits to the school nurse; temper
tantrums; specific fears; anxiety or sadness   

School "refusers" tend to:

·     feel that others see them in a negative way

·     become unduly self-conscious and avoid social situations in which they fear others may criticize them or make
fun of them behind their back

·     have negative and troublesome relationships with their peers

·     get teased by mischievous children or harassed by a bully   

·     be reluctant to go to school because of an appearance and self-esteem problem, or social "image" problem
prompted by a school rumor or being let down by a friend

·     be depressed and experience significant difficulty in getting up and getting out of bed in the morning.   
Refusal to go to school often begins following a period at home in which the child has become closer to the parent,
such as a summer vacation, a holiday break, or a brief illness. It also may follow a stressful occurrence, such as the
death of a pet or relative, a change in schools, or a move to a new neighborhood.

Children with an unreasonable fear of school may:

·     feel unsafe staying in a room by themselves

·     display clinging behavior

·     display excessive worry and fear about parents or about harm to themselves

·     shadow the mother or father around the house

·      have difficulty going to sleep

·     have nightmares

·     have exaggerated, unrealistic fears of animals, monster, burglars

·     fear being alone in the dark

·     have severe tantrums when forced to go to school

School refusers otherwise tend to be compliant, well-behaved, and academically smart kids.  Unlike truants, they
stay home only with their parents' knowledge.  Generally, they have a close relationship with one or both parents.  
Overall, they are good kids. So the question arises why does a child who wants to comply with the parents' wishes
and be good, drive them nuts in the morning when it's time to get ready for school?  

Children refuse to go to school for a reason, and we parents should determine what that reason is.

Such symptoms and behaviors are common among children with separation anxiety disorder. The potential
long-term effects (anxiety and panic disorder as an adult) are serious for a child who has persistent separation
anxiety and does not receive professional assistance. The child may also develop serious educational or social
problems if their fears and anxiety keep them away from school and friends for an extended period of time.

When fears persist the parents and child should consult with a qualified mental health professional, who will work
with them to develop a plan to immediately return the child to school and other activities. Refusal to go to school in
the older child or adolescent is generally a more serious illness, and often requires more intensive treatment.

Excessive fears and panic about leaving home/parents and going to school can be successfully treated.

For children who refuse to go to school in order to avoid a difficult social encounter, teach them effective social
behaviors such as, learning to say "no" assertively, seeking help from adults, and making new friends.  Seek help
from school authorities if there is a genuine concern for the safety of your child.   

Don't make staying home more rewarding than going to school.  Eliminate or reduce all incentives for staying home.  
On the contrary, attach rewards and incentives to going to school and staying there throughout the school hours.  

Having investigated the possible causes and offered your support as a parent, you may have to "push" your child
out to school.  You may have to learn to ignore the tantrums, complaints, and the pleading to "let me stay home just
for today."  .    

Children who are clinically depressed or who suffer from an anxiety disorder need professional help. Some
medications cause sluggishness and may make it difficult for a child to be alert and active in morning. In such event,
consult your doctor.   
TABLE 1

Criteria for
Differential
Diagnosis of
School Refusal and Truancy


Truancy--

Lack of excessive anxiety or fear
about attending school.

Child often attempts to conceal
absence from parents.

Frequent antisocial behavior,
including delinquent and disruptive
acts (e.g., lying, stealing), often in
the company of antisocial peers.

During school hours, child
frequently does not stay home.

Lack of interest in schoolwork and
unwillingness to conform to
academic and behavior
expectations.


School Refusal--

Severe emotional distress about
attending school; may include
anxiety, temper tantrums,
depression, or somatic symptoms.

Parents are aware of absence;
child often tries to persuade
parents to allow him or her to stay
home.

Absence of significant antisocial
behaviors such as juvenile
delinquency.

During school hours, child usually
stays home because it is
considered a safe and secure
environment.

Child expresses willingness to do
schoolwork and complies with
completing work at home.
TABLE 2

Somatic Symptoms in Children
with School Refusal


Autonomic--

Dizziness
Diaphoresis
Headaches
Shakiness/trembling
Palpitations
Chest pains                


Gastrointestinal--

Abdominal pain
Nausea
Vomiting
Diarrhea


Muscular--

Back pain
Joint pain
TABLE 3

Items from the School Refusal Assessment Scale-Revised


Items from child version--

How often do you have bad feelings about going to school because you are afraid of something related to school (e.g.,
tests, school bus, teacher, fire alarm)? (1)

How often do you stay away from school because it is hard to speak with the other kids at school? (2)

How often do you feel you would rather be with your parents than go to school? (3)

When you are not in school during the week (Monday to Friday), how often do you leave the house and do something fun?
(4)

How often do you stay away from school because you feel sad or depressed if you go? (1)

How often do you stay away from school because you feel embarrassed in front of other people at school? (2)

How often do you think about your parents or family when you are in school? (3)

When you are not in school during the week (Monday to Friday), how often do you talk to or see other people (other than your
family)? (4)

How often do you feel worse at school (e.g., scared, nervous, sad) compared with how you feel at home with friends? (1)

How often do you stay away from school because you do not have many friends there? (2)

How much would you rather be with your family than go to school? (3)

When you are not in school during the week (Monday to Friday), how much do you enjoy doing different things (e.g., being
with friends, going places)? (4)

How often do you have bad feelings about school (e.g., scared, nervous, sad) when you think about school on Saturday and
Sunday? (1)

How often do you stay away from places in school (e.g., hallways, places where certain groups of people are) where you
would have to talk to someone? (2)

How much would you rather be taught by your parents at home than by your teacher at school? (3)

How often do you refuse to go to school because you want to have fun outside of school? (4)

If you had fewer bad feelings (e.g., scared, nervous, sad) about school, would it be easier for you to go to school? (1)

If it were easier for you to make new friends, would it be easier for you to go to school? (2)

Would it be easier for you to go to school if your parents went with you? (3)

Would it be easier for you to go to school if you could do more things you like to do after school hours (e.g., being with
friends)? (4)

How much more do you have bad feelings about school (e.g., scared, nervous, sad) compared with other kids your age? (1)

How often do you stay away from people in school compared with other kids your age? (2)

Would you like to be home with your parents more than other kids your age would? (3)

Would you rather be doing fun things outside of school more than most kids your age? (4)


Items from parent version--

How often does your child have bad feelings about going to school because he/she is afraid of something related to school
(e.g., tests, school bus, teacher, fire alarm)? (1)

How often does your child stay away from school because it is hard for him/her to speak with the other kids at school? (2)

How often does your child feel he/she would rather be with you or your spouse than go to school? (3)

When your child is not in school during the week (Monday to Friday), how often does he/she leave the house and do
something fun? (4)

How often does your child stay away from school because he/she will feel sad or depressed if he/she goes? (1)

How often does your child stay away from school because he/she feels embarrassed in front of other people at school? (2)

When your child is in school, how often does he/she think about you or your spouse or family? (3)

When your child is not in school during the week (Monday to Friday), how often does he/she talk to or see other people
(other than his/her family)? (4)

How often does your child feel worse at school (e.g., scared, nervous, sad) compared with how he/she feels at home with
friends? (1)

How often does your child stay away from school because he/she does not have many friends there? (2)

How much would your child rather be with his/her family than go to school? (3)

When your child is not in school during the week (Monday to Friday), how much does he/she enjoy doing different things
(e.g., being with friends, going places)? (4)

How often does your child have bad feelings about school (e.g., scared, nervous, sad) when he/she thinks about school on
Saturday and Sunday? (1)

How often does your child stay away from places in school (e.g. hallways, places where certain groups of people are)
where he/she would have to talk to someone? (2)

How much would your child rather be taught by you or your spouse at home than by his/her teacher at school? (3)

How often does your child refuse to go to school because he/she wants to have fun outside of school? (4)

If your child had fewer bad feelings (e.g., scared, nervous, sad) about school, would it be easier for him/her to go to school?
(1)

If it were easier for your child to make new friends, would it be easier for him/her to go to school? (2)

Would it be easier for your child to go to school if you or your spouse went with him/her? (3)

Would it be easier for your child to go to school if he/she could do more things he/she likes to do after school hours (e.g.,
being with friends)? (4)

How much more does your child have bad feelings about school (e.g., scared, nervous, sad) compared with other kids
his/her age? (1)

How often does your child stay away from people in school compared with other kids his/her age? (2)

Would your child like to be home with you or your spouse more than other kids his/her age would? (3)

Would your child rather be doing fun things outside of school more than most kids his/her age? (4)

================================================================================================

I = avoidance of stimuli that provoke negative affectivity;  
2 = escape from aversive social or evaluative situations;
3 = pursuit of attention;
4 = pursuit of tangible reinforcement.

Adapted with permission from Kearney CA. Identifying the function of school refusal behavior: a revision of the School
Refusal Assessment Scale. J Psychopathol Behav Assess 2002;24:235-45.
Treatment

The primary treatment goal for children with school refusal is early return to school. Physicians should avoid writing
excuses for children to stay out of school unless a medical condition makes it necessary for them to stay home.
Treatment also should address comorbid psychiatric problems, family dysfunction, and other contributing problems.
Because children who refuse to go to school often present with physical symptoms, the physician may need to
explain that the problem is a manifestation of psychologic distress rather than a sign of illness. A multimodal,
collaborative team approach should include the physician, child, parents, school staff, and mental health
professional.

Treatment options include education and consultation, behavior strategies, family interventions, and possibly
pharmacotherapy. Factors that have been proved effective for treatment improvement are parental involvement and
exposure to school. However, few controlled studies have evaluated the efficacy of most treatments. Treatment
strategies must take into account the severity of symptoms, comorbid diagnosis, family dysfunction, and parental
psychopathology.

A range of empirically supported exposure-based treatment options are available in the management of school
refusal. When a child is younger and displays minimal symptoms of fear, anxiety, and depression, working directly
with parents and school personnel without direct intervention with the child may be sufficient treatment. If the child's
difficulties include prolonged school absence, comorbid psychiatric diagnosis, and deficits in social skills, child
therapy with parental and school staff involvement is indicated.

BEHAVIOR INTERVENTIONS

Behavior approaches for the treatment of school refusal are primarily exposure-based treatments. Studies have
shown that exposure to feared objects or situations reduces fear and increases exposure attempts in adults. These
techniques have been used to treat children with phobias and school refusal. Behavior techniques focus on a child's
behaviors rather than intrapsychic conflict and emphasize treatment in the context of the family and school.

Behavior treatments include systematic desensitization (i.e., graded exposure to the school environment), relaxation
training, emotive imagery, contingency management, and social skills training. Cognitive behavior therapy is a highly
structured approach that includes specific instructions for children to help gradually increase their exposure to the
school environment. In cognitive behavior therapy, children are encouraged to confront their fears and are taught
how to modify negative thoughts.

EDUCATIONAL-SUPPORT THERAPY

Traditional educational and supportive therapy has been shown to be as effective as behavior therapy for the
management of school refusal. Educational-support therapy is a combination of informational presentations and
supportive psychotherapy. Children are encouraged to talk about their fears and identify differences between fear,
anxiety, and phobias. Children are given information to help them overcome their fears about attending school.
They are given written assignments that are discussed at follow-up sessions. Children keep a daily diary to describe
their fears, thoughts, coping strategies, and feelings associated with their fears. Unlike cognitive behavior therapy,
children do not receive specific instructions on how to confront their fears, nor do they receive positive
reinforcement for school attendance.

Child therapy involves individual sessions that incorporate relaxation training (to help the child when he or she
approaches the school grounds or is questioned by peers), cognitive therapy (to reduce anxiety-provoking thoughts
and provide coping statements), social skills training (to improve social competence and interactions with peers),
and desensitization (e.g., graded in vivo exposure, emotive imagery, systematic desensitization).

PARENT-TEACHER INTERVENTIONS

Parental involvement and caregiver training are critical factors in enhancing the effectiveness of behavior treatment.
Behavior interventions appear to be equally effective with or without direct child involvement. School attendance and
child adjustment at post-treatment follow-up are the same for children who are treated with child therapy alone and
for children whose parents and teachers are involved in treatment.

Parent-teacher interventions include clinical sessions with parents and consultation with school personnel. Parents
are given behavior-management strategies such as escorting the child to school, providing positive reinforcement
for school attendance, and decreasing positive reinforcement for staying home (e.g., watching television while home
from school). Parents also benefit from cognitive training to help reduce their own anxiety and understand their role
in helping their children make effective changes. School consultation involves specific recommendations to school
staff to prepare for the child's return, use of positive reinforcement, and academic, social, and emotional
accommodations.

PHARMACOLOGIC TREATMENT

Pharmacologic treatment of school refusal should be used in conjunction with behavioral or psychotherapeutic
interventions, not as the sole intervention. Interventions that help children develop skills to master their difficulties
prevent a recurrence of symptoms after medication is discontinued.

Very few double-blind, placebo-controlled studies have evaluated the use of psychopharmacologic agents in the
treatment of school refusal, although several controlled studies are in progress. Problems with sample sizes,
differences in comorbidity patterns, lack of control of adjunctive therapies, and differences in medication dosages
have resulted in inconclusive data in trials of pharmacologic agents in the treatment of school refusal. Earlier studies
of tricyclic antidepressants failed to show a replicable pattern of efficacy.

Selective serotonin reuptake inhibitors (SSRIs) have replaced tricyclic antidepressants as the first-line
pharmacologic treatment for anxiety disorders in children and adolescents. Although there are few controlled,
double-blind studies of SSRI use in children, preliminary research suggests that SSRIs are effective and safe in the
treatment of childhood anxiety disorders and depression. Fluvoxamine (Luvox) and sertraline (Zoloft) have been
approved for the treatment of obsessive compulsive disorder in children. SSRIs are being used clinically with more
frequency to treat children with school refusal.

Benzodiazepines have been used on a short-term basis for children with severe school refusal. A benzodiazepine
initially may be prescribed with an SSRI to target acute symptoms of anxiety; once the SSRI has had time to produce
beneficial effects, the benzodiazepine should be discontinued. Side effects of benzodiazepines include sedation,
irritability, behavior disinhibition, and cognitive impairment. Because of the side effects and risk of dependence,
benzodiazepines should be used for only a few weeks
.