A Parent’s Struggle: How to Approach School Refusal in Children and Adolescents

What is school refusal?

According to the Anxiety and Depression Association of American, “school refusal describes the disorder of a child who refuses to go to school on a regular basis or has problems staying in school.” It is estimated that 2 to 5 percent of kids will experience school refusal.

School refusal in school-aged children has become a frequent topic in both the psychological research and the popular media and is recognized as a distinct condition by more teachers and educators. School refusal treatment programs are now offered in behavioral health clinics around the country.

School refusal can take many different forms and there are two primary presentations to watch for.

Internalizing symptoms - often manifesting in somatic complaints such as a stomachache, shortness of breath, shakiness, racing heart, or a headache.

Externalizing symptoms - forms of acting-out behaviors in response to fears. These behaviors can include tantrums, disruption in the classroom, aggression towards others, and threats of harm. Internalizing and externalizing symptoms can occur both together or separately.

One way to understand school refusal is as a form of avoidance. Some examples of what children might be trying to avoid include but are not limited to:

• A bully
• A challenging social or academic situation
• A fear of failure
• A fear of leaving or being separated from the parent

If a child avoids the stressor by staying home from school, they feel immediately better, which then reinforces the avoidance. The problem with this pattern is that if we avoid what scares us, it becomes harder and harder to approach the feared situation or experience over time.

This is a real dilemma for parents. Because despite a desire to help their kids attend school, it can be easier for parents to let their child stay home and not get into the early morning power struggle. So, in order to approach the situation effectively it is important to have a plan in place to help guide the process.

Here are some guideposts to consider when creating a plan:

• Be curious. Try to understand the function of your child’s behavior by understanding the purpose it serves. For instance, does missing school prevent your child from facing classes that are too challenging and which make them feel less confident in their abilities? Does it keep them protected from a bully or feared social situation? Does it mean that they have the comfort of being home and spending more time with a parent? By understanding what underlies school refusal it is possible to feel more empathy for how much your child is struggling and what they need in order to feel better.
• Rule out any possible medical or psychological condition that may be contributing to the school refusal. For instance, consider a physical to address the child’s complaints of stomach pain. Have a therapist or psychiatrist screen for depression, anxiety, trauma, or substance use to determine whether there are issues that could be impacting the school refusal which require additional treatment considerations.
• Be a model. Model for your child that when things get difficult, it is important to find ways to improve the moment, either by using internal skills or by changing the environment and/or interacting differently with the environment. For example, let’s say you are stuck in morning traffic and your child sees that you are upset you will miss a meeting at work. Use some deep breathing to calm yourself physically, name your feelings, and then brainstorm solutions such as calling in to the meeting, following up with your boss later, asking for the meeting notes, etc. Your child will see an adult working effectively with their emotions to solve problems.
• Stay firm. Children must attend school regularly. But be creative and flexible in thinking about how they can utilize school resources to improve their experience. Problem solve together. Do their classes need to be reconsidered so there is less emphasis on AP credits? Does there need to be mediation with a classmate? Should there be check-ins with the school counselor throughout the day? Can there be a buddy system put in place?
• Consider implementing a reward system to shape positive behavior. Rewards for school attendance are things like the child earns a special activity with mom, or the chance to try out for the basketball team if they have attended school a certain amount of days.

At ERC/Insight, clients and their parents work closely with the therapist and the school to develop plans to help kids return to school and manage the stressors effectively. Therapists utilize skills-based therapies to give the child or adolescent the skills to handle their distress as well as skills to help them develop effective support systems.

Parents or care givers are also taught skills to help them more effectively help their child. In addition, an exposure and response prevention model is used in which a hierarchy of fears is created and addressed one challenge at a time, moving up the hierarchy from the least stressful to the most difficult:

1. Perhaps the first step is to have the child sit with the parent in the parking lot of the school and do some deep breathing.
2. The next challenge might be to go in the school and walk the halls while practicing mindfulness skills.
3. The next might be to attend school for a half day, for instance.

The objective is to help the child take manageable steps to build towards full school attendance. If your child is struggling with school attendance and you feel that the family could benefit from additional support, contact ERC/Insight for an assessment with a team of specialists trained to address this condition.

Finally, school refusal can be a complex condition and requires working closely with the therapeutic team, doctors, and the school to develop individualized plans that adequately address the child’s specific needs. Parents should feel positively about their role in helping their children work through school refusal, as they are an invaluable part of the process. To further support parents, consider utilizing additional resources listed below.