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School Avoidance and Refusal: Information for Primary Care

Summary: For some students, attending school becomes so overwhelming, that the student refuses to attend. Such children may often present to primary care providers, as they may complain of physical complaints (such as headaches, stomach aches) that keep them from attending school. For most children, school attendance is important for healthy development, hence the importance of timely intervention. Primary care providers can help by ruling out any medical conditions that are contributing; exploring why the student is refusing school; assist with referrals to more specialized mental health services if required.
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Case 1: Separation anxiety

  • Mackenzie is a 10-yo female who presents to your clinic with medical complaints which are leading her to miss school.
  • She has always had difficulty seperating from her mother.
  • However, this year, things have gotten to the point where she has not attended school for several weeks now. Stressors include a new school, and parental separation.
  • Somatic symptoms include headaches and stomach aches that start on Sunday night before school on Mondays, but improve when the decision has been made to allow her to stay home for the day.

Case 2: Major depression

  • Mohamed is a 13-yo male brought to see you due to increased school absences this term.
  • Parents are frustrated that Mohamed has been avoiding school, as they feel that he is otherwise well.
  • Mohamed has low mood as well as problems with sleep, concentration, energy and appetite.
  • Stressors include recent breakup with a girlfriend, compounded by the fact that many of the peers are school have sided with his girlfriend and are now hostile to him. 

Definitions 

  • School avoidance/refusal: Difficulties attending school associated with emotional distress such as anxiety or depression. Older terms include school phobia.
  • Truancy: Unexcused absence from school, such as when a child leaves for school, but then skips off school to hang out with friends, or engage in anti-social activities.

Epidemiology

  • School-refusal behaviour occurs in 5-28% of children/youth (Kearney, 2001)
  • Peak age of school refusal occurs at age 12-14, i.e. Gr. 7-8 (Heyne et al., 2001)

Clinical Presentation

School refusal behaviours range along a continuum from mild to severe:

 

Mild       Severe

Attends school, but expresses distress to parents, and begs to not attend

Attends school, but obstacles to getting the child to school, e.g. delaying morning routines, or outright refusal

Attends school, but obstacles to getting the child to school cause regular late arrival

Attends school, but frequently misses classes, parts of the day, or whole days

No longer attending school

What Causes School Refusal?

  • When a child starts missing school, parents will often start with behavioural approaches such as rewards and punishments for a child to attend school.
  • However, this is not helpful when there are emotional or other issues causing the school refusal.
  • For this reason, by the time a child is seeing a health professional, other approaches will most likely need to be considered.
  • Deep down, every child wants to do well, attend school and please their parents.
  • If a child cannot attend school, then it is usually because there is some obstacle getting in the way.
  • Health professionals can help by trying to figure out the root causes that makes it hard for a child to attend school and address those issues.

History / Assessment of School Refusal

  • Deep down, every child wants to do well and succeed, which includes being able to attend school.
  • If a child is unable to attend school, then the goal is to 1) figure out what issues/stresses keep the student from being able to attend, and 2) come up with a plan to deal with those issues/stresses.
  • The clinician might ask:
    • “I’m going to guess that deep down, you probably want to be able to go to school. So if you are not able to go, there is probably something making it hard to go.”
    • “What makes it hard for you to attend school?”  
    • “What parts of the school day are hardest for you?” (this will give you a clue as to the discomfort relates more to academics or social time)
       
  • Classic triggers/ stressors, along with possible questions that you might ask a child/youth:

School

 

  • Academic stresses

How stressful is the school work been?

Do you find the work difficult?

How stressed do you get about projects and tests?

  • Social anxiety

Do you feel very self-conscious in the classroom or walking the halls? 

Would it be easier for you to do work if you were in a room with less people?

Any problems with public speaking, such as presentations in front of the class?

  • Peer issues such as conflict, rejection or bullying

How are things with your peers and classmates?

Do you have friends or acquaintances at school?

How do you spend lunch hour and recess?

Any bullying? Any people that are mean to you?  

  • Teachers

How are things with your teachers?

Do you feel they care?

  • Returning to school after time away from school such as weekends, vacations or illness

Has there been a recent break from school?

  • New school building for the first time (such as kindergarten, middle school or high school)

Is this a new school for you?

 

Home

 

  • Separation from parent

Is it difficult to be away from your parents?

Do you worry about them many times a day?

  • Family/marital conflict

Is there stress between your parents?

DDx

  • Rule out medical issues that might be contributing such as:
    • Mononucleosis: Any problems with fever, sore throat, enlarged tonsils, fatigue, swollen lymph nodes, pharyngeal inflammation, palatal petechiae? 
    • Thyroid problems: Any problems with low energy, cold intolerance?
    • Vision/hearing isses: Any problems seeing the board? Any problems hearing the teacher?
       
  • Rule out mental health conditions such as:

 

Mental health conditions

 

Would you say your child is anxious in general? How so?

Is it hard for your child to be away from home Or family?

  • Generalized anxiety disorder

Does your child tend to worry about sorts of things, including things that should be “adult worries”?  ? When worried, does your child get physical symptoms, e.g. headaches, stomaches, etc.?

Is your child excessively shy? What things are hard to do because of this? Asking questions in class? Eating in front of other people?

  • Panic Disorder

Are there episodes of extreme anxiety that happen out of the blue? From start to finish, what do you notice?

Any problems with mood/irritability? Are there problems with sleep? Appetite? Concentration? Energy?

Any problems with inattention? Hyperactivity? Impulsivity?

Is there a strong pattern of trouble following rules and being defiant and oppositional?

  • Antisocial / Conduct Disorder

Are there behaviours which violate the rights of others? Aggression towards others? Aggression towards animals? Aggression towards property, i.e. vandalism?

Are there problems with social skills? Are there problems with narrow interests? Problems with seeing other people’s perspectives?

Is there hypersensitivity with sound? To touch? To movement?

  • Learning disabilities: Having learning disabilities such as math, reading, or language disabilities can make it extremely stressful to attend school, thus leading to avoidance

Does the student have significantly more problems learning certain subjects, e.g. math, reading, languages such as English/French?

  • Language impairments

Does the student have significant issues understanding language or expressing themselves using words?

Is the child's excessive use of technology (such as video games) contributing to the avoidance of school?

Does the excessive use contribute to family or individual problems?

Have there been difficulties getting the child/youth to limit their use?

Comorbidities

  • In students with school refusal, mental health conditions are extremely common (Kearney & Albano, 2004):
    • Specific phobia 54%
    • Separation anxiety disorder 22%
    • Generalized anxiety disorder 11%
    • Oppositional defiant disorder 8%
    • Major depression 5%
    • Social anxiety disorder 4%

Complications of School Refusal

  • School refusal can lead to serious consequences such as stress on child and family, lack of access to social, academic, mental health, and vocational supports; mental health problems later in adolescence; increased chance of incarceration; reduced social functioning/academic performance and poverty.
  • Students in the lowest 25% of their class in reading are 20 times more likely to drop out than the other 75% (U.S. Department of Education, 2003).

Investigations

  • Standard investigations to rule out medical causes of anxiety or somatic complaints (e.g. fatigue) such as:
    • TSH for thyroid
    • Mononucleosis testing
    • Iron indices for low iron
    • Vitamin B12/folate for nutritional deficiencies

Physical Exam

  • Physical exam is to rule out medical causes that may be contributing to the school refusal.

Management

  • For simple cases
    • For a child who has been out of school for only a short period of time (e.g. less than a week), it is often possible to simply return the child back to school without significant reintegration plans.
       
  • More complex cases
    • For a child who has been out of school a longer period, it is usually best to have a multi-modal treatment plan that involves child, family and the school
       
  • Liaise with the school
    • Ideally communicate with the school personnel involved such as guidance counselor, vice-principal / principal, teacher(s), school social worker, etc, whether by telephone or writing letters
    • Explore the possibility of a step-by-step, gradual reintegration plan, ideally with input from the student
    • For example
      • School designates key personnel who can connect and form a relationship with the student
      • Student attends 1-class a day for a period of time, then if that is successful…
      • Student attends 2-classes (or a half-day), and if that is successful, can move up eventually to full days
      • School work may be done in a designated area (such as an ‘achievement centre’ or guidance office) if return to full class is too anxiety-provoking at the beginning
         
  • Consider referral to mental health services such as
    • Private practice counseling/therapy (e.g. registered psychotherapists, certified clinical counselors, psychologists, social workers)
    • Publicly funded mental health services
       
  • Parental counseling
    • Ensure that parents have a strong relationship with their child; children feel more secure to separate, when they feel they have a secure base
    • Ensure parents spend regular 1:1 time with their child, during which time, they put down their devices, have face contact with one another, and the child is able to express thoughts/feelings which are then validated by the parent
    • See if parents can provide support such as
    • Accompanying child to school in the morning
       
  • Ensure there are specific management plans to address any issues such as
    • Attention deficit hyperactivity disorder (ADHD)
    • Learning difficulties
    • Stresses about school, e.g. if a child is being bullied, ensure there is a plan to deal with this
    • Address any perpetuating (i.e. contingency) factors
       
  • Non-attendance is often unintionally reinforced by allowing fun or comforting activities while the child stays home.
    • Since electronic activities such as TV, computer and video games are highly entertaining and distracting, the child should not be allowed to use them during school hours if the child stays at home
    • Parents should be cautious about extra one-on-one time during the school day if the child stays home from school, as this can be reinforcing in separation anxiety; rather, consider having the parent spend one-on-one time outside of regular school time
    • Have a “when-then” system of natural consequences
      • E.g. “When” the child attends school, “then” at the end of the day the child may have natural consequences such as free time (i.e. privileges) and watch TV or computer time

Medications for Anxious Children

  • If non-medication strategies have not been helpful, consider treating anxiety symptoms with an SSRI:
    • Sertraline
    • Escitalopram
    • Citalopram
    • Fluvoxamine
    • Fluoxetine

Common FAQs and Scenarios with School Refusal

Q. My child attends school, but while at school, says he wants to come home. Should I allow him to come home?

 

A. In general, a child should stay at school, and not be sent home unless there are medical symptoms such as:

  • Fever
  • Severe diarrhea
  • Acute flu-like symptoms
  • Intense pain due to medical problems

Case 1: Separation anxiety

  • Mackenzie is a 10-yo girl brought in to see you for medical complaints which are leading her to miss school.
  • You provide some basic education about anxiety.
  • You explain how anxiety is feeling unsafe, and that many things may have contributed to this child feeling unsafe, such as being a sensitive child to start with, which makes this child more vulnerable to stressors such as school and the parental separation.
  • As a basic principle, you recommend that mother ensure she spend 1:1 time with the child outside of school hours to ensure they have a strong attachment relationship, as secure attachments are the single most important resiliency factor for all mental health issues.
  • You write a letter to the school informing them about the anxiety, and help recommend local mental health resources for the family.
  • After a few months of seeing a therapist for the anxiety, they report that things are markedly improved.

Case 2: Major depression

  • Mohamed is a 13-yo male brought to see you due to increased school absences this term.
  • You note that Mohamed is having difficulties related to peer stresses, and as a result, is feeling depressed and having difficulties attending school.
  • You provide some basic education about depression to the family.
  • You explain how the most important resiliency factor for depression, is for a child to feel deeply connected to those that can provide unconditional acceptance, which are his parents.
  • You explain how their son may be experiencing mood problems, because he turns to peers for their acceptance, however the problem is that peers are inconsistent, and cannot provide unconditional acceptance.
  • You recommend that ideally, each parent spend spend 1:1 time with their son outside of school hours, and provide unconditional empathy, validation and acceptance, so that their son’s emotional needs can be met primarily by more reliable parents, as opposed to less reliable peers.
  • Luckily, parents have coverage for private services, so you tell them how they can find a mental health professional in private practice to provide more target treatment for Mohamed depressive symptoms.

References

  • Kearney, C. & Albano,A. (2004). The functional profiles of school refusal behavior:  Diagnostic aspects. Behavior Modification, 28, 147-161.
  • Kearney, C. (2001). School refusal behavior in youth: A functional approach to assessment and treatment. Washington, DC: American Psychological Association.

About this Document

  • Written by Dr. O. Macleod (psychiatrist) and members of the eMentalHealth.ca Primary Care Team, which includes Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician), and M. Cheng (psychiatrist).

Disclaimer

  • This information is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your qualified expert or health provider.
  • Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

Creative Commons License

  • You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works).
  • View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca

 

Date Posted: Dec 23, 2015
Date of Last Revision: May 23, 2017

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