School refusal refers to intense fear of going to school that results in significant school absence. It is different from truancy where children do not typically engage in antisocial behavior, and they stay at home with the knowledge of the family despite their best effort to ensure school attendance. Approximately 1 to 5 percent of all school-aged children experience this problem and it can occur at all ages.¹

What are the signs of school refusal?

It is quite common for a child to miss some school during the year or have some anxiety about school activities like camp, sports days or test. However, school refusal is a more persistent problem that these kids may be absent for weeks or months.

Signs of school refusal are:

• Fearfulness, panic symptoms before school. Severity of symptoms ranges from able to leave home, but couldn’t proceed further when the child get closer to the school, to refuse to make any effort to go to school at all.
• Crying episodes, clinginess or pleads to stay at home
• Temper tantrums before school
• Frequent complaints of physical symptoms before or during school, e.g. headaches, stomach aches, nausea, vomiting, giddiness, chest or joint pains. Some children with severe symptoms might complain of limb weakness orhave recurrent fainting episodes.

These anxiety-fueled ailments often present shortly before it is time to leave for school and disappear quickly when the child is allowed to stay at home, only recur the next morning. They also tend to disappear magically on weekends or school holidays.

Some other warning signs of school refusal are:

• Frequent complaints about attending school
• Frequent absences on significant days e.g. exam days, extra-curricular activities, physical education class
• Frequent lateness to school. Some kids may have trouble the night before school with disturbed sleep pattern.

What causes school refusal?

There are many factors contributing to a child’s school refusal symptoms. Identifying the underlying cause will help to get the child back to school as soon as possible. Many of them might have underlying anxiety disorder and the following factors do contribute to school refusal behavior:

• Difficulties with transition e.g. moving to a new school, returning after a long school holiday or absence due to physical illness
• Separation anxiety – with significant others e.g. parent
• Specific fear about situations with performance elements, e.g. writing papers, presenting in front of the class or sport days
• Peer problems, e.g. teasing or bullying, conflict with friends or social isolation
• Conflict with teachers
• Learning difficulties
• “Type A” personality: Rigid, perfectionistic thinking of performing everything perfect. Frequently observed in distinction students
• Underlying anxiety disorder

 What are the sequelae of school refusal?

School refusal takes the child off from their developmental course. The longer the child is away from school, the more difficult it is for them to return and resume normal life. Ignoring school refusal problem and failure to deal with it completely can lead to more-serious problems later on.

Short term sequelae include:

• Poor academic performance
• Jeopardising peer relationship
• Family difficulties: Disruption to parent’s routine might create conflict, strain up child-parent relationship and might even affect family income when parent have to forgo their work to accompany child at home

Long term sequelae include:

• Exiting school early and academic underachievement
• Employment difficulties
• Increased risk of mental health problems

A study of 35 school-refusing kids aged 7 to 12 years old in 1997 showed that 20 to 29 years later, they received more psychiatric treatment and to have lived with their parents more often than the general population.²

What can I do to help my child?

When you notice your child shows school refusal behaviours and is not attending school persistently for 2 weeks, seek help from a mental health professional as soon as possible. It is a serious issue that is best managed early. The evaluation will reveal the reasons behind it and helps to plan management strategies that best suits your child’s scenario.

Mainstay of treatment is cognitive behavioural therapy (CBT), in which children learn to change negative thoughts and behaviour. Therapist will assist the child to develop skills necessary to handle their fear and face with life’s challenging moment. The most commonly used technique is desensitization and gradual exposure therapy, where children gradually face and manage their fears (figure 1).

Figure 1: Example for desensitization and gradual exposure technique for school refusals

 The following tips will also help you and your child:

 DO

• Emphasize the positive aspects of going to school, e.g. meet up best friends, playing at recess, learning favourite subjects and participating in favourite activities
• Talk with your child about fears and feelings, which help to reduce them. More importantly, highlight avoiding or running away from problems is not practical in the long run.
• Meet up with school teacher for clear communication about what’s happening. Positive relationship among parents and teachers is very important to help your child gradually return to school, with extra support and guidance.
• Assist and guide your child to establish a support system. Beside parents, other children, teachers and family members should also be in your child’s life.

DON’T

• Allow the child to miss school when he or she pleads to stay home. Be firm, the longer they have been out of school, the more difficult it is for them to return and resume normal life.
• Attend school with them, e.g. sit with them in the classroom. Your doctor or therapist might suggest waiting in the car or vicinity area at the beginning phase, but this is not going to be long-term.
• Help the child get medical leave if doctor has rule out significant illness underlying child’s physical complaint. This will re-inforce the sick role and promote school refusal behaviour.
• Provide access to enjoyable activities when your child stays at home, e.g. playing computer games, watching TV and reading comics. You need to engage your child in activities as closely as possible to approximate the activities at school, while trying to get him back to school.

Key messages 

• School refusal is a serious problem that needs to be managed
• CBT is very effective and most children with school refusal behaviour and anxiety disorder treated with CBT will have significant improvement.
• The longer your child is out of school, the poorer the prognosis. Seek help from mental health professional if your child is engaged in this behaviour for 2 weeks.

 Reference 

1. Burke AE, Silverman WK. The prescriptive treatment of school refusal. Clin Psychol Rev 1987;7:353-62.

2. Flakierska-Praquin N, Lindstrom M, Gillberg C. School phobia with separation anxiety disorder: a comparative 20- to 29-year followup study of 35 school refusers. Compr Psychiatry 1997;38:17-22.