Ask the School Psychologist: What is school refusal?

(Chelsea Update would like to thank Kristin Krarup-Joyce for the information in this story.)

Each year, approximately 2-5 percent of children refuse to go to school due to anxiety or depression.

Previously referred to as school phobia, school refusal includes kindergarten students with relatively mild separation anxiety and more severe cases where a student misses weeks or months of school because of debilitating anxiety or depression.

Because of the serious long-term social and educational consequences associated with missing school, the problem needs to be addressed promptly and aggressively with a team approach that includes teachers, parents, administrators, and support staff.

Development of School Refusal
School refusal is often the result of separation anxiety, social anxiety, or performance anxiety (e.g., about speaking in front of others), or anxiety related to test-taking, athletic competition, or academic difficulties.

Students may refuse to attend school to escape from a situation that causes anxiety or to gain attention from a parent or other caregiver. School refusal has been found to occur more often after vacations, weekends, or at the beginning and end of the school year. Events that prompt school refusal include the death of a loved one, a prolonged illness, moving or changing schools, entering kindergarten, and the transition from elementary to middle school. The problem is more severe in older children than younger children.

Characteristics of Students with School Refusal
Anxiety, depression, and physical complaints are frequently associated with school refusal.

Anxiety
Students with school refusal often exhibit separation, social/performance, or more generalized anxiety reactions as well as other anxiety disorders.

Separation anxiety. Students with separation anxiety, which is most common in younger children, become preoccupied with thoughts of harm befalling a loved one and are overly dependent on parents and other caregivers. They may cry, kick, or run away to avoid coming to school. Many young children experience separation anxiety in preschool or when starting kindergarten.

However, if the behavior continues for weeks or even months, it is more serious and needs to be promptly addressed.

Social/performance anxiety. Students with social/performance anxiety worry about what others think, are concerned about how they will be judged, and fear humiliation.

Depression
Depression may be the cause of school refusal behavior for some students. Common characteristics of depression in children and adolescents include depressed mood, lack of interest in activities, irritability, difficulty getting along with others, rebellious or risk-taking behavior, sleep difficulties, physical complaints, fatigue or lethargy, feelings of inadequacy or excessive guilt, difficulty concentrating or indecisiveness, and thoughts of death or suicide.

For students who refuse to go to school, the presence of depression is associated with more severe symptoms than for those students with anxiety alone. Many students suffer from both anxiety and depression, two disorders that often occur together.

Physical Complaints
School refusers frequently express physical complaints (headaches, stomach aches) without the presence of a medical condition. Some students ask to go to the nurse’s office on a daily basis with complaints about stomach aches or headaches.

Sometimes an actual illness, like asthma, contributes to a pattern of school refusal. Here, a student’s asthma may be the initial reason for school absence. Later, anxiety about returning to school serves to maintain the school avoidance, even after the student recovers physically.

School staff should consult with the child’s physician to determine if there are any restrictions for the child at school. If there is no medical reason for staying home, the child should be in school.

Common Warning Signs
It is critical that both parents and educators learn to recognize common warning signs of school refusal and respond quickly.

These include:
Frequent unexcused absences or tardiness;
Absences on significant days (tests, speeches, physical education class);
Frequent requests to go to the office despite no apparent signs of illness
Frequent requests to call home or go home during the day
Major family event/trauma
Sleep difficulties
Difficulty concentrating
Depressed mood or irritability
Difficulty or resistance to getting out of bed in the morning to go to school despite no apparent signs of illness

Next time: how do we help students with school refusal problems?

Adapted from the National Association of School Psychologists