Jack Maypole, MD
Jack Maypole, MD
Comprehensive Care Program, Boston Medical Center

“I Ain’t Going!”

What to do when a child refuses to go to school

There was no doubt that Daniel had issues. I had known this 12-year-old for about a year, and as I understood it, his family had helped address a number of longstanding medical conditions through doctors’ visits, surgery and what was predicted to be a short convalescence. And yet, there I was, seeing him in my exam room hearing that he had not returned to school six weeks past his anticipated date.

“Wow,” I said. “That’s a long time. What kept you home so long?”

Evidently, lots.

“I had headaches,” Daniel said, “and my legs were hurting sometimes. And there were kids who were teasing me; I didn’t want to go.” When we dug a little deeper, it became clear that, for Daniel, bullying by other students had become intolerable. While his medical problems had abated, fear and embarrassment from taunting made him feel terrible. Like many kids, he somatized these emotional stresses—perceiving and expressing them as vague and unpleasant ills. Worried, his mom obliged by keeping him home.

Boy Depressed at School MeetingSchool refusal, known interchangeably as school phobia or school avoidance, is a surprisingly common phenomenon. While many children are excited to go to kindergarten or to see their friends again after a summer, about 5 percent of school-age children persistently resist or avoid going to school, to the point where they don’t go at all.

It can be a really big deal, and lead to a vicious circle. Kids become upset about some aspect of leaving home or going to school, parents keep them home where they feel safe. While Daniel’s case was linked clearly to his medical issues and procedure, more often, the underlying reasons for school refusal aren’t obvious. How to recognize it?

Separation anxiety is a fact of life—to a point. It is considered developmentally appropriate for children to fuss and cling when they are leaving their parents or caregivers until about the age of 4. However, certain children view going to school (or even talking about it) with dread, sadness or anxiousness. In identifying the child with school refusal, parents and pediatricians may observe these symptoms over weeks or, as in Daniel’s case, months.

Some children have difficulties with transitions and new situations. These more temperamental kids will usually adapt within a week or two of entering or re-entering a classroom. For other children, so-called “anxious school refusal” may be evident from the first day of school, or it may appear in later grades. And, as in many things pediatric, there can be a range of behaviors or manifestations, as well as reasons behind their absences from school.

Children with school refusal are more likely to have had early emotional trauma, such as separation from family members due to death or divorce. Rates of school refusal are higher in families whose members have histories of emotional, psychiatric or anxiety disorders. In Daniel’s case, there may be a bona fide medical reason to trigger a child’s absenteeism. School-age children may internalize stress or anxiety, reporting symptoms that are vague and notably confined to school days. These children may complain of headaches, dizziness, stomach upset or fatigue—in the absence of “harder” physical findings, such as fever, cough, vomiting or diarrhea.

For other children and adolescents, school refusal may evolve into what pediatrician Perri Klass expertly describes as “behaviors of motivation.” Keep these ideas in mind:

  • Educators, family members and other caregivers should assure that remaining home does not become its own reward (food! cable! attention!) or that larger issues are not complicating a child’s ability to return to school.
  • The grownups need to ascertain if there are ongoing, active concerns such as bullying, social conflicts or academic struggles.
  • Primary care providers can assist in opening channels of communication between home and school to see if other underlying issues are afoot. Along the way, medical causes for recurrent absences should be ruled out.

These are not matters to be taken lightly: 25 to 50 percent of children with school phobia have an associated behavioral or emotional problem, including anxiety disorders and depression. In a 2009 study of Japanese children with chronic daily headaches and school phobia, these issues were found to have an accompanying psychiatric disorder. Longer term, up to 40 or 50 percent of children with school refusal—who don’t get treatment or support—are at risk of not completing high school.

Treatment works, and takes time. Research has shown that children and adolescents (and sometimes, their families) who are identified and treated do best with well-delineated plans focused on getting kids back in the classroom. Families, primary care providers, educators and mental health staff must partner and communicate constantly to establish reasonable goals and parameters. Phone calls? Email? Text messages? Check, check, check. Repeat absences may require a doctor’s visit, and agreement that any time home is without fanfare or pampering (sorry, no Xbox). With persistence, patience, understanding and the proper treatment for each child, school becomes an offer they can’t refuse.

Related Reading:

AAP guidelines on school avoidance

“Understanding School Refusal,” NYU Child Study Center

“When a Doctor’s Note for a Student Doesn’t Help,” by Perri Klass, New York Times