Frequently Asked Questions About School Refusal

Q: What is school refusal?

A: Sometimes children and adolescents have difficulty attending school on a regular basis. When absences are reasonable (e.g., due to illness), missing school is appropriate. When young people fail to attend school for other reasons, the term "school refusal" is used to describe these occasions. School refusal includes the following circumstances:1

  • Child or adolescent refuses to attend school, which may lead to prolonged or repeated absences
  • Child or adolescent usually does not try to hide absences from parents (i.e., remaining at home during school hours, rather than skipping school with friends)
  • Child or adolescent becomes upset (e.g., excessive anxiety or sadness, temper tantrums, unexplained physical symptoms) about having to attend school
  • Caregivers try (or have tried) to force the child or adolescent to attend school

School refusal can come on suddenly or escalate gradually. Young people can exhibit a number of behaviors when confronted with the requirement to attend school when they do not want to:1, 3

  • Temper tantrums
  • Intense emotional displays
  • Complaints about school
  • Threats to run away or harm oneself
  • Physical complaints (e.g., illness, headache, stomachache)
  • Irrational beliefs about what might happen at school
  • Nightmares and insomnia
  • Excessive worry about safety-related issues
  • Clinginess

Sometimes children and adolescents will refuse to go to school or will skip school because of behavioral problems as seen in Oppositional Defiant Disorder or Conduct Disorder. In addition to resources for these disorders, you may also find information posted under Self-Help Resources to be helpful. More information about truancy.

Q: Why do young people refuse to go to school?

A: There are a number of factors that cause or contribute to school refusal:1,3

  • Breaks from school when children become closer to a caregiver (e.g., after a summer break or a holiday vacation)
  • New challenges at school
  • Anxiety symptoms or an anxiety disorder, including Separation Anxiety Disorder, which is more common in young children, or school phobia or Panic Disorder, which is more common in older children and adolescents. More
  • Major changes (e.g., deployment, moving or changing schools)
  • Significant stressors (e.g., death of pet or loved one, divorce)
  • Bullying
  • Tests or oral presentations
  • Athletic performance
  • Undressing for showers in gym class
  • Not getting along with teachers or peers

Allowing children to stay home from school can further contribute to school refusal behavior. For example, staying home is more fun: No homework, easy access to television and/or a computer, more time with parent(s), etc. Also, a young person gets to avoid any negative or uncomfortable things that have happened at school or avoid something uncomfortable that they think might happen at school. The more a child or adolescent avoids school the more it reinforces their belief that they cannot cope at school. By staying home and avoiding school, children and adolescents may also become progressively withdrawn from peers, and may become anxious about other situations in life (e.g. leaving the house, being around peers in other settings), and are at risk for developing symptoms of depression.1

Q: How common is school refusal?

A: Although many children and adolescents may refuse to attend school from time to time, it is estimated that between one and five percent of school-aged young people suffer from significant problems with school refusal. Boys and girls seems to be equally affected.1,2

Q: Is school refusal a mental disorder?

A: No, according to the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV) school refusal is not a mental disorder. However, children who refuse to go to school may be suffering from a mental disorder, such as an Anxiety or Depressive Disorder.1 Typically there is an anxiety component underlying school refusal, however young people who are refusing to attend school do not necessarily meet criteria for an Anxiety Disorder.

Q: Do children outgrow school refusal?

A: Once school refusal has developed into a regular pattern it has become a significant problem. Children or teens are not likely to "outgrow" the problem, particularly if they are continually allowed to avoid school-related problems and/or fears by staying home. Like many anxiety-related issues, the more the feared situation is avoided the worse the problem becomes. Symptoms are likely to improve over time for families and young people, who receive treatment or learn coping strategies that they regularly practice while attending school.

Q: What treatments are helpful for school refusal?

A: When treating school refusal, the primary treatment goal is to get children to return to school as soon as possible.1 Cognitive-behavioral interventions are well-researched and effective treatments for school refusal. Treatment varies by the age of a child and situational factors impacting the problem (e.g., divorce, bullying, phobias, etc.). Treatment generally includes the following:2

  • Education about school refusal
  • Relaxation skills to cope with fear
  • Social skills training to learn how to interact effectively with peers and teachers
  • Cognitive techniques to address maladaptive thoughts (e.g., "Everyone will laugh at me," "I’m not smart," "I’m afraid that you are going to die while I’m at school," etc.)
  • Gradual exposure to feared situations, whereby the child learns to be less afraid

Parents learn to consult and problem-solve with school staff about their child’s difficulties and play an active role in the young person’s treatment. For instance, parents can find out what teachers are observing (e.g., any bullying, changes in the difficulty of assignments, problems getting along with other children, etc.). Teachers can try implementing strategies at school, such as giving the child special attention when the child walks in the door, allowing the child to be student of the week, etc.

During a child’s treatment for school refusal, parents also learn how to effectively respond to school refusal behaviors (e.g., praising the successful demonstration of coping skills during practice sessions and ignoring tantrums or excessive physical complaints).

If a child or adolescent meets criteria for an Anxiety Disorder, treatment for that specific disorder is available.

Medications, such as some antidepressants and antianxiety medications, may be helpful for addressing anxiety symptoms in children. However, the American Academy of Child and Adolescent Psychiatry does not recommend that medications be used as a first line or stand-alone intervention for pediatric anxiety.5 In some cases medications may be used in conjunction with a cognitive-behavioral interventions. Not all medications work the same for everyone; therefore it is important that you consult with your pediatrician or a child psychiatrist to determine which medication (if any) is best for your child.

Q: How do I locate a professional to treat school refusal?

A: You can contact any of the following organizations, which have referral capabilities:

Q: Do I have to see a specialist in order to get help?

A: Caregivers can learn a number of tools on their own for coping with school refusal behaviors. Check out the self-help tools offered on this site. If your PCM believes it is necessary to seek specialty care, they will be able to assist you to that next level of care. Sometimes family, friends, or clergy can be excellent sources of support when facing a challenging behavioral change at home.

Q: Is school refusal a covered TRICARE benefit?

A: TRICARE policy for reimbursement requires that services must be medically necessary for a diagnosed psychological disorder. The disorder must be one referenced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and must be of a severity not only to cause the patient distress but also to interfere with the patient’s usual activities. Treatment for school refusal, independent of a diagnosed psychological disorder is not a covered TRICARE benefit.

TRICARE beneficiaries who have a diagnosable psychological disorder are eligible for eight behavioral health care visits per year without a referral or pre-authorization. Active duty military personnel always need a referral for care outside a military treatment facility. More

References:

1Heyne, D.  (in press). School refusal. In J. E. Fisher & W. O’Donohue (Eds.). Practitioner’s guidelines for evidence based psychotherapy. New York: Kluwer.

2Burke, A. E., & Silverman, W. K. (1987). The prescriptive treatment of school refusal. Clinical Psychology Review, 7, 353-62.

3American Academy of Child and Adolescent Psychiatry (2004). Children who won’t go to school. Fact Sheets For Families, 7. Accessed 4/18/06.

4Fremont, W. P., (2003). School refusal in children and adolescents. American Family Physician, 68, 8, 1555-1560.

5American Academy of Child and Adolescent Psychiatry (1997). Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy Child Adolescent Psychiatry, 36(10suppl).