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School Refusal

School Refusal Quick Overview

School refusal occurs when a student will not go to school or frequently experiences severe distress related to school attendance. Comprehensive treatment of school refusal, including psychiatric and medical evaluation when appropriate, is important since studies show that psychiatric disorders are the cause for a large percentage of students who fail to complete high school in the United States. Parents can do several things to help their child who refuses to attend school, and medicinal treatment may be necessary. With treatment, the rate of remission is excellent. A majority of children with school refusal who were treated with cognitive therapy were attending school at a one-year follow-up. School refusal is considered more of a symptom than a disorder and can have various causes.

What Causes School Refusal?

Although young children usually find going to school fun and exciting, one in four children may occasionally refuse to attend school. Such behavior becomes a routine problem in a small percentage of children. Many children with school refusal have an earlier history of separation anxiety, social anxiety, or depression. Undiagnosed learning disabilities or reading disorders may also play a significant role in the development of school refusal.

Signs of a psychiatric disorder called separation anxiety disorder can include the following:

  • School refusal
  • Excessive worry about losing a parent; excessive worry that a parent might be harmed
  • Excessive reluctance to be alone at any time
  • Persistent refusal to go to sleep without a parent or other caretaker present
  • Repeated complaints of physical symptoms whenever the child is about to leave a significant parental figure

These behaviors must begin before the child is 18 years old, must last for four weeks or longer, and must cause serious problems with academic, social, or other functioning in order to be called a disorder.

Some commonly cited reasons for refusal to attend school include the following:

  • A parent being ill (Surprisingly, school refusal can begin after the parent recovers.)
  • Parents separating, having marital problems, or having frequent arguments
  • A death in the family of a friend of the child
  • Moving from one house to another during the first years of elementary school
  • Jealousy over a new infant sibling
  • Excessive parental worrying about the child in some way (for example, poor health)
  • Bullying can also be a cause of school refusal. Bullying is unwanted aggressive behavior among school-aged children involving a real or perceived power imbalance that is repeated or has the potential to be repeated over time. Bullying can include threats, intimidation, and/or attacking someone physically or verbally.
    • Signs that a child may be a victim of bullying include the following:
      • Unexplained injuries
      • Lost or damaged clothes, books, electronic items, jewelry
      • Decline in grades especially in math and reading -- not interested in school work
      • Avoids school complaining of headaches, stomach pain, feels sick
      • Skips meals or binge eating -- may not eat lunch at school
      • Nightmares and trouble sleeping
      • Sudden loss of friends or avoids social situations
      • Decline in self-esteem or feels helpless
      • New onset of self-destructive behaviors: runs away, hurts self, suicide threats
    • Effects of being bullied for the victim include the following:
      • Increased risk of depression
      • Increased risk of anxiety
      • Drop in grades and academic achievement
      • Child who is bullied retaliates with violence toward others

Other problems at school that can cause school refusal include feeling lost (especially in a new school), not having friends, or not getting along with a teacher or classmates.

Medically Reviewed by a Doctor on 1/11/2016

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Patient Comments & Reviews

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School Refusal - Treatment

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School Refusal - Experience

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School Refusal & Separation Anxiety

The child or adolescent and his or her family, school staff, and primary-care physician should work together to design a plan to accomplish a gradual return to developmentally expected function in settings such as school, sports, and social events. It is very important to acknowledge the level of distress that the child or adolescent feels.

Utilizing positive reinforcement aids in encouraging the child's return to the feared situation and becoming comfortable with anticipated brief separations from parents and caregivers.

Read What Your Physician is Reading on Medscape

Anxiety Disorder: Separation Anxiety and School Refusal »

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), separation anxiety is a fairly common anxiety disorder that consists of excessive anxiety beyond that expected for the child's developmental level related to separation or impending separation from the attachment figure (eg, primary caretaker, close family member) occurring in children younger than 18 years and lasting for at least 4 weeks.

Read More on Medscape Reference »

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