Understanding School Refusal

– by Heather Day, MA, LMHC, Clinical Supervisor, Lynnfield Outpatient Center

 The term “school refusal” describes the situation when a child refuses to attend school on a regular basis, or has problems staying in school for the day. Children may complain of physical symptoms shortly before it is time to leave for school, or repeatedly ask to visit the school nurse.

When we talk about school refusal, we often fixate on the goal of getting the child back to school at all costs.  School refusal, however, is a symptom rather than a condition itself, because children often communicate their needs through behavior, before they develop more language-based self-expression. We need to explore further in order to better understand the possible underlying mental health issues that may be manifesting in school refusal.

What behaviors do children exhibit? 

Children suffering from school refusal disorder may express somatic complaints, such as stomach pains, nausea, gastrointestinal issues, and general sensations of being unwell that appear physical in nature.

Every child is unique, but a few possible issues that could be underlying or contributing to the refusal to attend school are bullying, social phobias, separation anxiety, public speaking, test anxiety, or other social-emotional issues.

What can a parent do to help? 

It is always a good idea to rule out any underlying medical condition that could be present.  Once that step has been completed, parents need to recognize that helping their child will take a multi-tiered approach.

They should not feel isolated in addressing school refusal. It is important to reach out to the child’s school team (guidance staff, school psychologist, teachers, coaches) to enlist their help in developing a consistent messaging of validation, effective communication, reasonable accommodations, and resiliency, so the child can manage distress incrementally, with appropriate supports.

A multi-discipline approach

School refusal is multi-dimensional in nature and therefore requires a multi-discipline approach involving school personnel, family, primary care/prescriber, and other providers, such as a therapist.

Systematic desensitization (e.g., gradual exposure to the school environment) using relaxation, contingency management, and imagery is critically important.

Cognitive-behavioral therapy, which teaches individuals how to confront anxiety and modify negative thoughts, can also be very important as it empirically supports treatment based on exposure therapy principles.

Tips on how to get conversations started with youth

• Instead of, “How was your day?” you could ask questions like “Who did you sit next to at lunch? What was the high and the low of the day? What was the activity in gym class or art class?  What made you laugh today? What made you sad or disappointed?”
• Don’t overthink eye contact. Kids might look away because they are embarrassed, it is a difficult topic, or a way to manage their emotions.  If they are drawing but also talking, that is a good sign.
• Play a board game, take a walk together, or go for a long drive. Kids share more information when there is less pressure and more emotional space to feel secure in talking.

This article first appeared in Inspiring Health Teens, a guide published by A Healthy Lynnfield (AHealthyLunnfield.org), a coalition focused on preventing substance use and providing access to treatment and recovery resources.