My Child Refuses To Attend School. What Do I Do?

How can I get my child back into school?

Though school refusal can present quite differently across children and the presentation can change over time, typically the child doesn’t just wake up one day and decide they are no longer attending school. Most often school refusal behaviors begin and escalate gradually, though there have been some cases in which they begin suddenly in reaction to major trigger, like an intense bullying incident or god forbid a school shooting. Regardless of the trigger or triggers the child often feels “paralyzed” by fear, resulting in a fight or flight response, causing them to react negatively to the school environment. It can present behaviorally, like social withdrawal, school avoidance, anhedonia, cognitively, like inattention, rumination of fears, and physiologically, like  panic attacks, stomachaches, and headaches. In fact, somatic symptoms (that is, physical symptoms of anxiety or stress) are very high with rates ranging fro 27 to 80% (stomach pain, headache, nausea, vomiting, body pain, dizziness, GI distress, fatigue). At home, may start to see tantrums or physical complaints the night before or in the morning prior to school. Sometimes you will notice that your child starts to spend a lot of time in the nurse or school counselor’s office or start begging to be picked up from school or agreeing to go in only for select periods. Additionally, school refusal can also coincide with or result in secondary changes in behavior that weren’t present before like social isolation, suicidal ideation, poor academic performance, drug use, aggression, or eating or sleeping changes. School refusal affects anywhere between 5 and 15% of the clinical population, and has increased in recent years, sharp rise during/after pandemic. School avoidance and physiological pain and anxiety tend to emerge around 5th-10th grades.

Identifying school refusal can be complicated because school refusal in itself is not a disorder or label, and is not in the ICD or DSM. It is important to differentiate between school refusal and truancy by understanding the underlying motivation. For example, are they just avoiding on certain occasions to spend time with friends or ditch classes for the mall? Or are they showing a persistent fear of attending school and feel as though they “can’t” attend as opposed to just “not wanting to.” It is important to differentiate between school avoiders and truants because the consequences required are so different. Children who choose to be truant from school may require some form of discipline or intervention, while school avoiders typically require emotional support and validation. School avoidant children typically have emotional distress associated with attending school but want to please and ultimately finish schooling in some capacity.

So why do we think school refusal occurs in some students and not others? Well, as you might imagine, this is not a straightforward answer by any means but let’s review some of the research to help us understand. Sometimes feeling misunderstood or singled out by teacher, bullying from peers can cause a child to feel unsafe in their classroom. Sometimes a child fears attending school because of a lack of friends/exclusion (can become a self-fulfilling prophecy when missed consistent school) or a fear of harm to self (OCD, fear of shooting, fear of illness etc.). Additionally, 40-50% have a psychiatric diagnosis and more are neurodivergent.
School avoidant children are more likely to carry diagnoses of generalized anxiety, depression, OCD, panic disorder, separation anxiety, social anxiety, emetophobia (fear of self or others vomiting), PTSD, stuttering, ADHD, ASD, learning disorder, and selective mutism. As such, many are likely to have some form of learning difference, maybe coupled with embarassment, and maybe avoidance of challenging school work, maybe bored and frustrated, missing work, behind in work, etc.

I think it is important to note some of the common characteristics of the parents of school avoidant children, but I want to make it clear this is not to blame or judge these parents, just to bring awareness to things that are often outside of the parents control and parents may be able to seek additional support for. Some predictors of school refusal include: parental psychopathology, family discord, and discipline or perceived punishment at home. Children with school refusal tend to have more anxious and depressed parents, but it is hard to say which was true first, in terms of when symptoms started for parents. Some parents may have poor coping mechanisms dealing with stress or fear themselves, and when fear is present, negative thinking can begin and be reinforced in combination with poor coping strategies. School avoidant children often experience more overprotection, more parental control, less social involvement, less autonomy, and more fear of the world. The reason this is all important to discuss and understand is because it can become a cycle of negative affect and coping with stress placed upon a stressed child and stressed parents which snowballs into a much worse situation, as school refusal can be negatively reinforced (removing aversive stimulus) or positively reinforced (sleep late, parent attention, video games, etc.). The avoidance of school helps the child (and sometimes the parents) in the short-term but harms them in the long-term.

Alright, so now that we understand a bit of what school refusal can look like and how it may come to be, I want to spend the next bit of time discussing what can be done to support the child at home and at school. From an emotional perspective, it is important to send the message to your child that you love and support them unconditionally and that you are “in this together.” It is always beneficial for parents to acknowledge and validate feelings and not to shame or guilt their child. It is also helpful to understand avoidance in the context of a neurodiverse child and consider sensory needs and tithing of their behaviors part of a disorder, rather than a “bad” behavior.

Be prepared for child to potentially become withdrawn or aggressive when you remove accommodations or change behaviors within the home and be prepared to support them through it. Try to have patience and not to judge what you may not entirely understand. Punishment does not correct anxiety, just adds additional fear; however, that does not mean you cannot discipline for things unrelated to the school avoidance of course. It is not generally helpful to force child out of bed and make demands. On the other hand, parents should try not to provide excessive reassurance to child. Parents cannot “fix” child’s anxiety and should try to avoid “rescuing” them from school unless absolute necessary. Encourage child to rely on school staff for support. The goal is to develop confidence in the child so they can manage their anxiety independently.

In some cases, it can be helpful to provide your child with choices and put the decision in their control, in the case that you believe they are capable of returning to school. In general, make clear to your child that unless there is an acute medical or mental health reason, school is not optional but can be modified as necessary. Try not to make any decisions about school attendance the night before. Attempt a compromise, if your child is willing to go to school parking lot, then you will revisit feelings and not force them into school or place guilt upon them. This may remove some of the pressure off them and lessen the “battle.” You cannot force a child to school if they are in an active fight or flight state, you must wait until the child is able to self-regulate, even if that may be inconvenient for parents responsibilities, which is of course a very tough spot to be in. But, if you rush the child back to school too quickly, it can backfire. If you child is unable to attend school, don’t ignore your child are act disappointed, but do give reasonable responsibilities for the day. Important to maintain academic responsibility as much as possible while they are out of school. It is helpful to explain to children that their feelings are often temporary and can revisit the plan to return to school over time. As you can see, the “right” thing to do may vary depending on the motivating factors and where the child is in their school refusal journey, so you cannot really give universal advice for these children, but it is important to know what your child may need at any given point in their recovery. You are ideally trying to find a balance between being supportive, helpful, and understanding and productive, while not enabling and maintaining reasonable functional and academic expectations.

The good news is that there are a number of well-established interventions for school avoidant children. The only downside is that the intervention needs to be well-matched with the child and/or family, depending on the motivating and maintaining factors of the avoidance, which can be challenging at times. So let’s talk about some of these options and who they may be most appropriate for. Cognitive-behavioral therapy (CBT), CBT can be helpful to address irrational or negative thinking patterns and has been shown to be effective for about 50-60% of patients, dialectical behavior therapy (DBT) is often helpful if there is underlying anger, aggression, and/or interpersonal or family difficulties, acceptance and commitment therapy (ACT) to help children come to terms with their emotions and choose behaviors that are consistent with their long-term goals, exposure and response prevention (ER/P) if there is an OCD or related diagnosis, exposure therapy for specific fears (e.g., emetophobia, fear of certain objects within the school setting), Mindfulness-based stress reduction (MBSR) to help pay attention to both emotional and physical sensations within the body and remain present to their experiences and calming the body, Emotional awareness and expression therapy (EAET) for chronic pain/illness, which provides psychoeducation about the connection between stress and pain in the brain and allows the child to face uncomfortable feelings and/or trauma that may play a role in maintaining their physical pain, biofeedback which can be helpful for both anxiety/panic and physical pain/discomfort to bring awareness to how the child can be in control of their own body, and SPACE (Yale child study) evidence-based approach for anxiety-related school refusal in which parents increase support but decrease accommodations/enabling. Family therapy can often helpful in additional to individual counseling when there is either significant parents and/or sibling discord, when parents disagree on how to respond to the child’s school refusal, or when parents seem to be struggling with managing their own emotions. Additionally, there can be a stigma associated with school refusal in some cases, preventing action. It is so important to include both parents equally in therapy and re-attendance plan and it can be extremely challenging for the child if the parents themselves do not agree on approach and intervention for school refusal.

In terms of medication, antidepressants (any kind of SSRIs or SNRIs) are most commonly prescribed for those with school avoidance but depends on their diagnostic profile. Parents may need to advocate for a comprehensive evaluation and/or multidisciplinary team, as many families who first visit pediatricians or other medical doctors, maybe only receive treatment for the physical symptoms and on the other hand, sometimes the child will only receive psychiatric care with no support or validation for physical symptoms. Additionally, many children who are school avoidant have reverse sleep schedules (sleep during day), because they feel anxiety and inability to calm self at night and/or feel nighttime is the only safe or guilt free time, require strict boundaries around sleep hygiene and routine, and sometimes benefit from non-addictive sleep aids or supplements. For extreme psychiatric cases, Some children who have acute psychiatric struggles will require intensive outpatient or partial hospitalization program (IOP/PHP) or even inpatient, especially if suicidal ideation or lack of sleep/eating. In terms of psychological or neuropsychological assessment, there is one school avoidant specific measure, the School Refusal Assessment Scale-Revised (SRAS-R), which may help with characterizing the child’s struggles. Additionally, these evaluations can help clarify co-occurring diagnoses that may explain the underlying motivation for the avoidance. If there is a learning or developmental disorder, the child may require proper diagnosis in order to receive proper tutoring and school supports. As mentioned, a large portion of children who exhibit school refusal are neurodivergent, and often times their differing strengths and needs play a significant role in feeling that school is unsafe or aversive.

Now what about the child’s school? How can they help? Improving professional development and psychoeducation for school staff regarding school refusal and what signs to look for will be critical, as early intervention in home and school is key. School staff are in a unique position to identify suspected emotional/behavioral difficulties and school aversiveness. For example, being late to school consistently may be one of the first signs. It is also important for school staff to understand and differentiate between excused and unexcused absences, especially since sometimes staff may jump to blame the parent without having all the information or understanding the child’s diagnoses. Schools can assist from home or from first moment on school campus, depending on the state/district. It can be very helpful to find one staff member at school that your child trusts and it is definitely recommended that coordination between school and clinical teams are consistent. For children with academic aversion, they may required a formal evaluation conducted by the school to support learning needs and validate struggles. Some school districts even have alternative programs available for school refusal. School refusal assessments would likely be very helpful, similar to the recent emergence of school threat assessments. If a child does attempt returning to school, the school must ensure that they have appropriate modifications/accommodations and all staff have reasonable expectations. Schools can legally alter attendance policy for a particular student when there is a re-integration plan, and parents can receive parent counseling/training at home or remotely, as well as specialized instruction, specialized placement, or other supports.

Lastly, it is crucial to be proactive at both home and school, as it can be harmful to child if parents and school are contentious. The family-school partnership is crucial for progress and promotes generalization of coping skills. So how can you be the best advocate for your child when it comes to their educational needs and working productively with their school? If you are concerned about child’s willingness to attend school or aversion to school, call an IEP meeting immediately. The school is still responsible to help child, even if they refuse to step foot on school grounds, and since school staff are permitted to evaluate child in a neutral space (e.g., library, admin building), if child does not feel safe returning to the school building. If you do not feel your child’s school team is addressing your concerns, can include special education director and/or superintend in the IEP meeting. Parents can request homebound instruction if necessary but this should also co-occur with re-integration strategies or proper placement. Homeschooling may be a good option for some, as long as there is social interaction opportunities and reduced avoidance of academics and social situations. Some children may require therapeutic school or therapeutic boarding school when there is acute psychiatric need. Parents can always consider hiring an educational advocate or special education lawyer. Also, don’t worry too much about truancy letters, as they are often sent automatically. And finally, there are two other great resources for parents are the International Network for School Attendance (INSA) and the School Avoidance Alliance.