School refusal: A ‘sore throat’ or something more?

It’s time to get dressed for school and your daughter is giving you that sad face—again. “I don’t feel well,” she moans, although she was perfectly fine last night. When you try and convince her to get up, a look of sheer terror crosses her face. You’d let her stay home but this is the fifth time this month—and aside from her complaints, she’s not displaying any other symptoms. So what’s going on?

“School refusal, which affects around 4 percent of school-aged children, refers to a child who refuses to attend school and who identifies home as safer and more secure place,” says Jayne Singer, PhD, clinical psychologist in Children’s Hospital Boston’s Developmental Medicine Center. While it’s not unusual for children to make excuses to avoid going to school, when it becomes commonplace or even chronic, children risk falling behind in academics and social development.

Refusing to go to school often begins during times of transition—when a student starts a new grade, school or teacher or after experiencing significant change in home life, like a divorce or move. Although high-schoolers can experience school refusal, it’s more common in the elementary school years, between the ages of 5 and 11. School refusal is not the same as truancy, cautions Singer. “Children who are truant aren’t necessarily anxious or fearful and they’re probably not telling their parents or guardians about skipping school,” she says. “That’s quite different from school refusal, which is accompanied by emotional distress.”

There are a number of causes of school refusal, ranging from phobias to bullying. Some children may have an underlying emotional issue, like separation anxiety disorder. “Children can be quite fearful and feel themselves unable to separate from their parent or home or their guardian—their safe environment,” says Singer. Some children may worry incessantly about what will happen to their parents while they are in school. Other psychological causes of school refusal include depression and posttraumatic stress disorder. “Some children just don’t feel like they can get up and cope with the demands of going into school,” says Dr. Singer. “It’s too overwhelming.”

But school refusal is not always a symptom of a psychiatric disorder. “You need to consider that a child may be being bullied. Or maybe there is a specific event at school that’s causing a specific anxiety,” she says. Learning disorders can also result in an avoidance of school. “A child who has a reading disorder but it hasn’t been identified can be made extremely stressed by the process of learning to read,” she says.

Is your child sick or avoiding school for other reasons?

Whatever the cause, school refusal can have serious repercussions if not addressed head on. Children may find it hard to catch up with schoolwork and may struggle to fit into the school’s social environment.

So what can parents do? “Treatment really depends on the root cause, so moving quickly to identify it is crucial,” says Singer. “A child who’s afraid to leave her mother requires very different management than a child who has a phobia of a fire alarm.”

Singer says parents should bring the child to get a full medical and mental health assessment as soon as possible. “The longer the child is allowed to stay home, the harder it is for the child to get back into the routine of feeling comfortable in school,” says Singer.

Children with anxiety-induced school refusal may be referred to a cognitive behavioral specialist, who can work on trying to help undo some of the child’s specific fears. Patients are encouraged to tackle the feelings of anxiety, instead of avoiding them. “Things like yoga, deep breathing exercises, relaxation techniques, creative movement can help children master the physiological experiences of anxiety,” she says, and allows the child to become relaxed enough to understand links between their feelings and behavior.

Parents can help their child by setting up routines, like going to bed at the same time every night. “When a child is anxious, predictability is extremely helpful,” says Singer. She also recommends parents identify a counselor at school that the child can go to if they feel scared or uncomfortable at school. If a child’s school refusal stems from social fears, treatment should involve working on social skills. “Many schools have lunch bunches or social skills groups where kids get together and develop their friendship building skills,” she says.

Most importantly, says Singer, parents should not give in to their child’s demands to stay home, but rather should collaborate with the school, medical and mental health providers and the child to create a safe and comfortable learning environment.  “The sooner you can get them back in school, the better,” she says.