Ryan, age 12, has missed almost three weeks of school so far. He complains of nausea and headache most school days and has to be cajoled into getting out of bed, but his mother says he is fine on weekends. The mother, who is eight months pregnant, is frantic; she can’t afford to take any more time off work before she delivers.
School refusal can have serious consequences. On the short term, the child falls behind academically, both the child and the family experience disruption and distress, and there can be legal and financial ramifications. Long-term consequences for school refusers include violent behavior, school dropout, early marriage, and unemployment.1
“The main goal of treatment is to get the child back to school as soon as possible,” says Lisa Hunter Romanelli, PhD, REACH Institute CEO and clinical psychologist. “Being absent from school is highly reinforcing.”
Like many school refusers, Ryan presents somatic complaints. After you rule out physiological causes–not only for these complaints but also for any underlying conditions that can produce depression or anxiety–what’s next?
To assess Ryan’s mental health, you can use the tools you received in your REACH training. Research suggests that up to 90% of young people who refuse to go to school have a psychiatric disorder.2 Common diagnoses include separation anxiety disorder, general anxiety disorder, oppositional defiant disorder, major depression, and specific phobias.3
In addition to assessing any underlying psychiatric disorder, you can begin to identify cognitive strategies to help the student get back to school quickly by figuring out why he avoids school. The School Refusal Assessment Scale – Revised is available for free from Oxford Clinical Psychology as interactive PDFs in parent and child versions.
These tools help you sort out the relative strength of four reasons for school refusal:
You’ll probably also see relevant family dynamics during the office visit. If Ryan’s mother expresses anxiety about her son’s fragile health or says that Ryan plays video games all day, those are likely factors that reinforce Ryan’s behavior.
So, now that you have a handle on Ryan’s issues, how will you make it possible for him to go back to school?
“A collaborative approach involving the child, parent, school, and a mental health therapist is the best strategy,” says Dr. Hunter Romanelli. She recommends enlisting a mental health therapist with expertise in cognitive behavioral therapy (CBT) to help children manage their anxiety and face their fears. A CBT therapist will also help parents learn strategies to manage their children’s behavior.
School staff are a vital part of the care management team. The school liaison can work with the child, parent, and therapist to develop an exposure plan. Through this plan, the child is gradually reintroduced to the school environment. The first step of an exposure plan might be driving to school, but not entering. From there, the child might work up to going into the school and then attending a “safer” part of the school day, such as lunch or a favorite class.
For severe cases of school refusal with an underlying anxiety or depressive disorder, treatment with an anxiolytic or antidepressant may be indicated. Your REACH tools can help you choose an optimal medication and first dosage.
The following books recommended by Brian Chu, PhD, associate professor of clinical psychology at Rutgers University, may be helpful for parents:
This article about school refusal and separation anxiety may be useful for you:
1 Kearney, C.A. (2006). Dealing with school refusal behavior: A primer for family physicians. 2006; J Fam Pract. 55(8):685-692. https://www.mdedge.com/jfponline/article/62306/pediatrics/dealing-school-refusal-behavior-primer-family-physicians
2 Ek, H, Eriksson R. Psychological factors behind truancy, school phobia, and school refusal: A literature study. 2013; Child & Family Behavior Therapy, 35(3):228-248. https://doi.org/10.1080/07317107.2013.818899
3 Chu, BC. Encouraging your child: Home and school solutions for great attendance and making the most of life [PDF].2017.
“I came into the course as a general pediatrician with no training or experience in pediatric mental health management Following the course, I now feel empowered, equipped and most importantly, supported to go back home and implement meaningful change in my practice.”