School Refusal & How To Help

Going to school is one of the most common experiences of childhood and adolescence. Despite this, children and adolescents may struggle to attend school. According to research, school refusal occurs in approximately 5% of the school age population (Munkhaugen et al., 2017). School refusal involves a child or adolescent not attending school or having difficulty remaining at school due to emotional challenges (Tekin & Aydin, 2022).

However, not all school avoidant behavior is school refusal. The term truancy may also be utilized when describing school refusal behaviors, though this refers more to unexcused school absences and is typically pejorative in nature (Tekin & Aydin, 2022). School refusal specifically involves a minor staying home from school due to emotional upset (e.g. unpleasant emotions or physical complaints) at the idea of going to school, with parents’ knowledge (Maynard et al., 2018). Research suggests that school refusal occurs equally in boys and girls, and that it most often occurs in early adolescence, though it can occur at other ages (Munkhaugen et al., 2017). 

There are some risk factors for school refusal identified through research. These factors include lower maternal educational attainment, mental and physical health challenges, unsafe/unsupportive home environments, and unemployment of parents (Munkhaugen et al., 2017). Although these are some of the risk factors related to school refusal, they do not predict school refusal, and school refusal can occur in youth without these risk factors. 

Youth who do not attend school are at-risk for short- and long-term consequences, such as learning and social challenges, and early school drop out (Maynard et al., 2018). There is also the risk of mental health challenges into later life, such as mental health challenges, difficulties maintaining employment, and marital challenges (Munkhaugen et al., 2017). 

Conditions Related to School Refusal

School refusal itself is not a psychiatric diagnosis. However, in many cases children and adolescents who experience school refusal may be impacted by a mental health disorder, such as anxiety, a mood disorder, or disruptive behavior disorders (Tekin & Aydin, 2022). Anxiety disorders, including social phobia, generalized anxiety disorder, separation anxiety disorder, panic disorder with agoraphobia, and specific phobias are commonly found in youth demonstrating school refusal (Maynard et al., 2018).

Youth experiencing school refusal may also present with anxiety symptoms that do not meet full diagnostic criteria, or a mood disorder such as major depressive disorder (Maynard et al., 2018). Given that there are a variety of causes, it is important to identify the function of school refusal for each child in order to intervene in the most effective manner (Inglés et al., 2015). When school refusal co-occurs with a diagnosis of anxiety or depression, treating any underlying mental health challenge is critical for supporting youth with school refusal behaviors (Inglés et al., 2015).

Anxiety

All humans experience anxiety, a state that involves worrying, as well as other physical symptoms (APA, 2022). While this feeling can be unpleasant, it is normal. Individuals who experience intense or frequent episodes of anxiety may qualify as having an anxiety disorder. There are various types of anxiety disorders, such as generalized anxiety disorder, specific phobias, social anxiety disorder, separation anxiety disorder, and panic disorder with agoraphobia. Anxiety disorders are the most common group of psychiatric diagnoses impacting children and adolescents (Gallo et al., 2014). Below is some brief information on anxiety disorders that are commonly associated with school refusal:

Separation anxiety disorder (SAD) involves marked distress related to separation from attachment figures, often parents (APA, 2022). Children with SAD generally experience challenges in school, in social relationships, and within family relationships, and are at increased risk for anxiety disorders in adulthood (Schneider et al., 2011). 

Social phobia is a common childhood anxiety disorder, which involves intense worry related to social situations (Melfsen et al., 2011). Similar to SAD, children with social phobia present with an increased risk for future psychiatric diagnoses (Melfsen et al., 2011). 

Specific phobias are fears that are long-lasting and intense, and are related to specific situations or objects, which lead to marked anxiety or avoidance of the situations and objects (Wright et al., 2023). Between 3 to 5 percent of children qualify for a diagnosis of specific phobia (APA, 2022). Individuals with a specific phobia experience a variety of adverse impacts, including academic challenges, difficulties with daily activities, and potential for additional psychiatric difficulties later in life (Wright et al., 2023). 

Panic disorder (PD) involves panic attacks, or intense periods of anxiety, that occur unpredictably (APA, 2022). As with other disorders mentioned above, individuals with PD are more likely to experience social, academic, and family challenges (Gallo et al., 2014)

Agoraphobia is an anxiety disorder characterized by intense fear related to either a real or expected experiences of various situations (APA, 2022).

Generalized anxiety disorder (GAD) is intense, enduring, excessive anxiety related to a wide range of activities or events (APA, 2022).

Although anxiety disorders can cause disruption to daily life, there are effective treatments. 

Depression

Just like anxiety, all humans experience sadness. Depression is an intense sadness that is long-lasting and negatively impacts day to day functioning (APA, 2022). Individuals with a diagnosis of depression may experience a variety of symptoms, including depressed mood, the loss of pleasure and/or interest in activities lasting for at least 2 weeks, thoughts of death or suicide, difficulty focusing or making decisions, fatigue, significant fluctuations in weight, changes in physical movement, and changes in sleep patterns (APA, 2022). In youth, depressed mood may instead present as an irritable mood (APA, 2022). Although depression can impact many areas of functioning, there are effective treatments available. 

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Treating School Refusal

Although it is possible to intervene with school refusal at any age, research has shown that it is more effective to intervene with younger children when treating school refusal (Elliott & Place, 2019). Potential reasons for this disparity include challenges reengaging in more complex school work, symptom severity, and increased independence (Elliott & Place, 2019). It is important for a youth’s caregivers, treatment team, and school to collaborate in order for best outcomes to be achieved (Ek & Eriksson, 2013). In particular, parents play an important role in treatment in order to support their child (Ek & Eriksson, 2013).

Cognitive Behavioral Therapy is a form of therapy that focuses on the interconnection of thoughts, feelings, and behaviors, and aims to alter unhelpful thinking patterns in order to change behavior. CBT is the most common approach to treating school refusal (Elliott & Place, 2019), and is recommended prior to psychopharmacological intervention (Heyne et al., 2001). CBT also has research support as a treatment for depression and anxiety (Ek & Eriksson, 2013). One study found support for disorder-specific CBT as an intervention for social anxiety disorder (Schneider et al., 2011), and research has demonstrated support for CBT as a treatment for social phobia in youth (Melfsen et al., 2011). There is also research support for CBT as an effective intervention for specific phobias in youth (Wright et al., 2023).

In addition, medication and/or family therapy may also be appropriate (Elliott & Place, 2019). Some research suggests that family therapy would be helpful to incorporate into CBT treatment programs (Elliott & Place, 2019). Medication as a component of treatment for school refusal has been shown to be most effective when children are experiencing depression and/or anxiety (Ek & Eriksson, 2013). The most common types of medication utilized are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (Heyne et al., 2001). 

If your child or adolescent is struggling with school refusal, it can be challenging. Reach out to a therapist at New York Behavioral Health to discuss what treatment options are available. 

References

American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders (5th ed., Text Revision). 

Ek, H., & Eriksson, R. (2013). Psychological factors behind truancy, school phobia, and school refusal: A literature study. Child & Family Behavior Therapy, 35(3), 228–248. https://doi.org/10.1080/07317107.2013.818899

Elliott, J. G., & Place, M. (2019). Practitioner Review: School refusal: Developments in conceptualisation and treatment since 2000. Journal of Child Psychology and Psychiatry, and Allied Disciplines60(1), 4–15. https://doi.org/10.1111/jcpp.12848

Gallo, K. P., Cooper-Vince, C. E., Hardway, C. L., Pincus, D. B., & Comer, J. S. (2014). Trajectories of change across outcomes in intensive treatment for adolescent panic disorder and agoraphobia. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 5343(5), 742–750. https://doi.org/10.1080/15374416.2013.794701

Heyne, D., King, N. J., Tonge, B. J., & Cooper, H. (2001). School refusal: Epidemiology and management. Paediatric Drugs3(10), 719–732. https://doi.org/10.2165/00128072-200103100-00002

Inglés, C. J., Gonzálvez-Maciá, C., García-Fernández, J. M., Vicent, M., & Martínez-Monteagudo, M. C. (2015). Current status of research on school refusal. European Journal of Education and Psychology, 8(1), 37–52. https://doi.org/10.1016/j.ejeps.2015.10.005

Maynard, B. R., Heyne, D., Brendel, K. E., Bulanda, J. J., Thompson, A. M., & Pigott, T. D. (2018). Treatment for school refusal among children and adolescents: A systematic review and meta-analysis. Research on Social Work Practice28(1), 56–67. https://doi.org/10.1177/1049731515598619

Melfsen, S., Kühnemund, M., Schwieger, J., Warnke, A., Stadler, C., Poustka, F., & Stangier, U. (2011). Cognitive behavioral therapy of socially phobic children focusing on cognition: A randomised wait-list control study. Child and Adolescent Psychiatry and Mental Health5(1), 5. https://doi.org/10.1186/1753-2000-5-5

Munkhaugen, Ellen & Gjevik, Elen & Pripp, Are Hugo & Sponheim, Eili & Diseth, Trond. (2017). School refusal behaviour: Are children and adolescents with autism spectrum disorder at a higher risk?. Research in Autism Spectrum Disorders. 41-42. 31-38. 10.1016/j.rasd.2017.07.001.

Schneider, S., Blatter-Meunier, J., Herren, C., Adornetto, C., In-Albon, T., & Lavallee, K. (2011). Disorder-specific cognitive-behavioral therapy for separation anxiety disorder in young children: A randomized waiting-list-controlled trial. Psychotherapy and Psychosomatics80(4), 206–215. https://doi.org/10.1159/000323444

Tekin, I., & Aydın, S. (2022). School refusal and anxiety among children and adolescents: A systematic scoping review. New Directions for Child and Adolescent Development2022(185-186), 43–65. https://doi.org/10.1002/cad.20484
Wright, B., Tindall, L., Scott, A. J., Lee, E., Cooper, C., Biggs, K., Bee, P., Wang, H. I., Gega, L., Hayward, E., Solaiman, K., Teare, M. D., Davis, T., Wilson, J., Lovell, K., McMillan, D., Barr, A., Edwards, H., Lomas, J., Turtle, C., Parrott, S., Teige, C., Chater, T., Hargate, R., Ali, S., Parkinson, S., Gilbody, S., & Marshall, D. (2023). One session treatment (OST) is equivalent to multi-session cognitive behavioral therapy (CBT) in children with specific phobias (ASPECT): Results from a national non-inferiority randomized controlled trial. Journal of Child Psychology and Psychiatry, and Allied Disciplines64(1), 39–49. https://doi.org/10.1111/jcpp.13665

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