School Refusal in Children and Adolescents
Am Fam Physician. 2003 Oct 15;68(8):1555-1561.
School refusal is a problem that is stressful for children, families, and school personnel. Failing to attend school has significant short- and long-term effects on children's social, emotional, and educational development. School refusal often is associated with comorbid psychiatric disorders such as anxiety and depression. It is important to identify problems early and provide appropriate interventions to prevent further difficulties. Assessment and management of school refusal require a collaborative approach that includes the family physician, school staff, parents, and a mental health professional. Because children often present with physical symptoms, evaluation by a physician is important to rule out any underlying medical problems. Treatments include educational-support therapy, cognitive behavior therapy, parent-teacher interventions, and pharmacotherapy. Family physicians may provide psychoeducational support for the child and parents, monitor medications, and help with referral to more intensive psychotherapy.
School refusal is a serious emotional problem that is associated with significant short- and long-term sequelae. Fear of going to school was first termed school phobia in 1941.1 An alternative term, school refusal, was used in Great Britain to define similar problems in children who did not attend school because of emotional distress.2 Children with school refusal differ in important ways from children who are truant (Table 1), although the behaviors are not mutually exclusive.
TABLE 1 Criteria for Differential Diagnosis of School Refusal and Truancy
Criteria for Differential Diagnosis of School Refusal and Truancy
Severe emotional distress about attending school; may include anxiety, temper tantrums, depression, or somatic symptoms.
Lack of excessive anxiety or fear about attending school.
Parents are aware of absence; child often tries to persuade parents to allow him or her to stay home.
Child often attempts to conceal absence from parents.
Absence of significant antisocial behaviors such as juvenile delinquency.
Frequent antisocial behavior, including delinquent and disruptive acts (e.g., lying, stealing), often in the company of antisocial peers.
During school hours, child usually stays home because it is considered a safe and secure environment.
During school hours, child frequently does not stay home.
Child expresses willingness to do schoolwork and complies with completing work at home.
Lack of interest in schoolwork and unwillingness to conform to academic and behavior expectations.
Approximately 1 to 5 percent of all school-aged children have school refusal.3 The rate is similar between boys and girls.4,5 Although school refusal occurs at all ages, it is more common in children five, six, 10, and 11 years of age.6 No socioeconomic differences have been noted.7
The onset of school refusal symptoms usually is gradual. Symptoms may begin after a holiday or illness. Some children have trouble going back to school after weekends or vacations. Stressful events at home or school, or with peers may cause school refusal. Some children leave home in the morning and develop difficulties as they get closer to school, then are unable to proceed. Other children refuse to make any effort to go to school.
Presenting symptoms include fearfulness, panic symptoms, crying episodes, temper tantrums, threats of self-harm, and somatic symptoms8 that present in the morning and improve if the child is allowed to stay home (Table 2). The longer the child stays out of school, the more difficult it is to return.9
TABLE 2 Somatic Symptoms in Children with School Refusal
Somatic Symptoms in Children with School Refusal
Short-term sequelae include poor academic performance, family difficulties, and problems with peer relationships.10 Long-term consequences may include academic underachievement, employment difficulties, and increased risk for psychiatric illness (Table 3).11,12
TABLE 3 Long-Term Sequelae in Children with School Refusal
Long-Term Sequelae in Children with School Refusal
Interrupted compulsory school
Did not complete high school
Adult psychiatric outpatient care
Adult psychiatric inpatient care
Still living with parents after 20-year follow-up
Married at 20-year follow-up
Number of children at 20-year follow-up
One or more
Associated Psychiatric Disorders
School refusal is not a formal psychiatric diagnosis. However, children with school refusal may suffer from significant emotional distress, especially anxiety and depression.13
Children with school refusal usually present with anxiety symptoms, and adolescents have symptoms associated with anxiety and mood disorders.14 The most common comorbid psychiatric disorders include separation anxiety, social phobia, simple phobia, panic disorder, post-traumatic stress disorder, major depressive disorder, dysthymia, and adjustment disorder (Table 4).7,13,15
School refusal should be considered a heterogeneous and multicausal syndrome. School avoidance may serve different functions depending on the individual child.16 These may include avoidance of specific fears provoked by the school environment (e.g., test-taking situations, bathrooms, cafeterias, teachers), escape from aversive social situations (e.g., problems with classmates or teachers), separation anxiety, or attention-seeking behaviors (e.g., somatic complaints, crying spells) that worsen over time if the child is allowed to stay home.
Psychiatric Disorders in Children with School Refusal
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Problems with family functioning contribute to school refusal in children; however, few studies have systematically evaluated and measured these problems. Parents of children with school avoidance and separation anxiety have an increased rate of panic disorder and agoraphobia.17
Dysfunctional family interactions that correlate with school refusal include overdependency, detachment with little interaction among family members, isolation with little interaction outside the family unit, and a high degree of conflict.18 Communication problems within families, problems in role performance (especially in single-parent families), and problems with family members' rigidity and cohesiveness also have been identified.19,20
Because children with school refusal present with a wide variety of clinical symptoms, a comprehensive evaluation is recommended. School refusal is a complex problem, and physicians must allocate a sufficient amount of time to the patient to make an accurate assessment and recommend effective interventions. Often, more than one appointment is needed.
The evaluation should include interviews with the family and individual interviews with the child and parents. Assessment should include a complete medical history and physical examination, history of the onset and development of school refusal symptoms, associated stressors, school history, peer relationships, family functioning, psychiatric history, substance abuse history, and a mental status examination. Identification of specific factors responsible for school avoidance behaviors is important. Collaboration with school staff in regards to assessment and treatment is necessary for successful management (Table 5). School personnel can provide additional information to aid in assessment, including review of attendance records, report cards, and psychoeducational evaluations.
TABLE 5 Assessment of School Refusal
Assessment of School Refusal
Complete medical history and physical
Clinical interview with child and parents
History of onset and development of symptoms
Family psychiatric history
Mental status examination including evaluation for psychiatric problems and substance abuse
Assessment of family dynamics and functioning
Collaboration with school staff
Review of school attendance records, report cards, and psychoeducational evaluations
Psychologic assessment tools (e.g., clinical rating scales, self-report scales, parent and teacher report instruments)
Several psychologic assessment tools (e.g., teacher and parent rating scales, self-report measures, clinician rating scales) have been developed to provide additional information about the child's general functioning at home and at school. These tools may be used by a physician, but because of time constraints, a school psychologist or mental health counselor should administer these scales whenever possible. Generalized scales (e.g., Child Behavior Checklist,21 Teacher's Report Form22) identify areas of difficulties. Specific rating scales assess for symptoms and severity of psychiatric problems, including anxiety and depression. Although these scales are used frequently in children with school refusal, their clinical usefulness in developing effective treatment strategies has not been demonstrated.
More specific assessment scales to measure symptoms of school refusal have been developed recently. They provide functional and symptomatic assessment of refusal behaviors and therefore provide more valuable information. The School Refusal Assessment Scale (Table 6, online)23 includes a child, parent, and teacher form and examines school refusal in correlation to negative and positive reinforcers. This scale has been reported to have high reliability and validity.23,24
Items from the School Refusal Assessment Scale-Revised
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The primary treatment goal for children with school refusal is early return to school. Physicians should avoid writing excuses for children to stay out of school unless a medical condition makes it necessary for them to stay home. Treatment also should address comorbid psychiatric problems, family dysfunction, and other contributing problems. Because children who refuse to go to school often present with physical symptoms, the physician may need to explain that the problem is a manifestation of psychologic distress rather than a sign of illness. A multimodal, collaborative team approach should include the physician, child, parents, school staff, and mental health professional.
Treatment options include education and consultation, behavior strategies, family interventions, and possibly pharmacotherapy. Factors that have been proved effective for treatment improvement are parental involvement and exposure to school.25,26 [Reference 25—Evidence level B, uncontrolled trial] However, few controlled studies have evaluated the efficacy of most treatments. Treatment strategies must take into account the severity of symptoms, comorbid diagnosis, family dysfunction, and parental psychopathology.
A range of empirically supported exposurebased treatment options are available in the management of school refusal. When a child is younger and displays minimal symptoms of fear, anxiety, and depression, working directly with parents and school personnel without direct intervention with the child may be sufficient treatment. If the child's difficulties include prolonged school absence, comorbid psychiatric diagnosis, and deficits in social skills, child therapy with parental and school staff involvement is indicated.
Behavior approaches for the treatment of school refusal are primarily exposure-based treatments.27 [Evidence level B, lower quality randomized controlled trial (RCT)] Studies have shown that exposure to feared objects or situations reduces fear and increases exposure attempts in adults.28 These techniques have been used to treat children with phobias and school refusal. Behavior techniques focus on a child's behaviors rather than intrapsychic conflict and emphasize treatment in the context of the family and school.
Behavior treatments include systematic desensitization (i.e., graded exposure to the school environment), relaxation training, emotive imagery, contingency management, and social skills training. Cognitive behavior therapy is a highly structured approach that includes specific instructions for children to help gradually increase their exposure to the school environment. In cognitive behavior therapy, children are encouraged to confront their fears and are taught how to modify negative thoughts.
Traditional educational and supportive therapy has been shown to be as effective as behavior therapy for the management of school refusal.29 [Evidence level B, lower quality RCT] Educational-support therapy is a combination of informational presentations and supportive psychotherapy. Children are encouraged to talk about their fears and identify differences between fear, anxiety, and phobias. Children are given information to help them overcome their fears about attending school. They are given written assignments that are discussed at follow-up sessions. Children keep a daily diary to describe their fears, thoughts, coping strategies, and feelings associated with their fears. Unlike cognitive behavior therapy, children do not receive specific instructions on how to confront their fears, nor do they receive positive reinforcement for school attendance.
Child therapy involves individual sessions that incorporate relaxation training (to help the child when he or she approaches the school grounds or is questioned by peers), cognitive therapy (to reduce anxiety-provoking thoughts and provide coping statements), social skills training (to improve social competence and interactions with peers), and desensitization (e.g., graded in vivo exposure, emotive imagery, systematic desensitization).
Parental involvement and caregiver training are critical factors in enhancing the effectiveness of behavior treatment. Behavior interventions appear to be equally effective with or without direct child involvement.25 [Evidence level B, lower quality RCT] School attendance and child adjustment at post-treatment follow-up are the same for children who are treated with child therapy alone and for children whose parents and teachers are involved in treatment.
Parent-teacher interventions include clinical sessions with parents and consultation with school personnel. Parents are given behavior-management strategies such as escorting the child to school, providing positive reinforcement for school attendance, and decreasing positive reinforcement for staying home (e.g., watching television while home from school). Parents also benefit from cognitive training to help reduce their own anxiety and understand their role in helping their children make effective changes. School consultation involves specific recommendations to school staff to prepare for the child's return, use of positive reinforcement, and academic, social, and emotional accommodations.
Pharmacologic treatment of school refusal should be used in conjunction with behavioral or psychotherapeutic interventions, not as the sole intervention. Interventions that help children develop skills to master their difficulties prevent a recurrence of symptoms after medication is discontinued.
Very few double-blind, placebo-controlled studies have evaluated the use of psychopharmacologic agents in the treatment of school refusal, although several controlled studies are in progress. Problems with sample sizes, differences in comorbidity patterns, lack of control of adjunctive therapies, and differences in medication dosages have resulted in inconclusive data in trials of pharmacologic agents in the treatment of school refusal.30,31 Earlier studies of tricyclic antidepressants failed to show a replicable pattern of efficacy.
Selective serotonin reuptake inhibitors (SSRIs) have replaced tricyclic antidepressants as the first-line pharmacologic treatment for anxiety disorders in children and adolescents. Although there are few controlled, double-blind studies of SSRI use in children, preliminary research suggests that SSRIs are effective and safe in the treatment of childhood anxiety disorders and depression.32,33 [Reference 32—Evidence level B, nonrandomized study] Fluvoxamine (Luvox) and sertraline (Zoloft) have been approved for the treatment of obsessive compulsive disorder in children. SSRIs are being used clinically with more frequency to treat children with school refusal.
Benzodiazepines have been used on a short-term basis for children with severe school refusal. A benzodiazepine initially may be prescribed with an SSRI to target acute symptoms of anxiety; once the SSRI has had time to produce beneficial effects, the benzodiazepine should be discontinued. Side effects of benzodiazepines include sedation, irritability, behavior disinhibition, and cognitive impairment. Because of the side effects and risk of dependence, benzodiazepines should be used for only a few weeks.34
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