Symptoms and Signs of School Refusal

Medical Author: John P. Cunha, DO, FACOEP
Medically Reviewed on 8/1/2022

Doctor's Notes on School Refusal

School refusal is a psychological symptom that occurs when a student refuses to go to school or regularly experiences severe distress related to school attendance. School refusal can occur at any age but it is most often seen in children 5-7 years of age and 11-14 years of age. Some causes of school refusal may include an earlier history of separation anxiety, social anxiety, or depression; undiagnosed learning disabilities or reading disorders, parental illness, parental marital problems, death in the family, moving, jealousy over a new infant sibling, and bullying. 

School refusal is considered more of a symptom than a disorder and can have a number of causes. The child refuses to attend school and experiences significant distress about the idea of attending school. Signs of school refusal may include

  • significant school absence (generally one week or more),
  • significant distress with school attendance,
  • embarrassment or shame at the inability to attend school,
  • crying or protesting every morning before school,
  • missing the bus every day (in adolescents), and
  • regularly developing some type of physical symptom when it is time to go to school.

What Is the Treatment for School Refusal?

The treatment of children with school refusal involves a combination of behavioral treatments, educational support, and medical treatments when necessary. Health care providers must rule out any medical cause of the frequent physical symptoms that children have in order to avoid school. After this is complete, a multidisciplinary team including the parents/caregivers, teachers, mental health professionals, and health care providers will need to collaborate on a care management plan.

Physicians should avoid writing notes and parents should avoid seeking excuses for children to stay out of school unless medically necessary. Efforts should be made to make going to school fun or something the child looks forward to doing.

Treatment plans for school refusal behavior may include the following:

  • Behavior treatments
    • Graded exposure to the school environment 
    • Relaxation training 
    • Emotive imagery  
  • Cognitive behavior therapy (CBT)
    • Children are exposed to their fears and are taught how to modify negative thoughts
  • Child therapy
    • Involves relaxation training, social skills training, and desensitization to the school environment
  • Parent-teacher collaboration in cases of school refusal and avoidance is critical
    • Parents learn strategies to help ease the child’s anxiety about going to school and learn the triggers for the physical complaints that children manifest

In cases of school refusal where psychological disorders such as anxiety and depression play a large role in the behavior, medical treatment with anxiety or depression drugs may be necessary. 

Selective serotonin reuptake inhibitor (SSRI) antidepressants and benzodiazepines are the most commonly prescribed drugs for school refusal patients.

REFERENCE:

Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.