Image credit: Adobe Stock

• 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 separating 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.

• 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. 

• 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.

• 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)

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

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, learning 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.

Assume that 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.

Screening Tools

Consider emailing (or printing out) the following forms for teachers to fill out:

• Preschool/Kindergarten Questionnaire
  https://www.shn.ca/wp-content/uploads/2019/06/3-preschool-kindergarten-questionnaire-CWSP.pdf
• School Questionnaire (6-18 years)
  https://www.cps.ca/uploads/issues/school-questionnaire-6-18years-CWSP.pdf

The forms have more detailed questions that can help in your assessment of school refusal.

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 to go to 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:

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:

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%

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).

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

• 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

If non-medication strategies have not been helpful, consider treating anxiety symptoms with an SSRI:

• Sertraline
• Escitalopram
• Citalopram
• Fluvoxamine
• Fluoxetine

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

• 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.

• 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.

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.

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).

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.

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