Treating School Refusal in Youth

It can sometimes be hard to tell when a child is displaying school refusal and when they simply don't want to go to school. Our pediatric mental health experts, Jerrica Cherry, LPC, and Benjamin Mullin, PhD, provide guidance below about how to identify, screen for, assess and treat school refusal in kids and adolescents.

What is school refusal?

School refusal is a complex and distressing behavior seen in children and adolescents, marked by a persistent reluctance or refusal to attend or remain in school. This behavior goes beyond typical school-related anxiety or occasional avoidance. It manifests as chronic and consistent, disrupting daily routines and significantly impacting social and academic performance. School refusal behaviors can appear as complaints of physical symptoms like headaches or stomach aches, emotional distress or outright refusal to attend school.

Children may refuse to attend school for various reasons, each stemming from a specific need or concern:

• Anxiety: Fear of separation from parents or anxiety about academic or social situations is a common reason for school refusal. While this type of avoidance behavior is a natural response to anxiety, it actually worsens anxiety over time and makes it more difficult to return to school.
• Academic challenges: Difficulty with schoolwork or feeling overwhelmed by academic demands can lead to school refusal. Older children and adolescents might avoid school to escape evaluations, such as tests and presentations. This tendency is particularly common during transitions, like moving to middle or high school, when kids meet new structures and expectations.
• Gaining attention: For some children, refusing school is a way to stay home with preferred adults, such as parents or grandparents. Associated behaviors include tantrums, running away from school and noncompliance.
• Accessing preferred activities: Some children refuse school to engage in more enjoyable activities, such as watching TV or playing video games. These children often display oppositional, defiant or rule-breaking behavior.

In each of these cases, avoiding school can inadvertently reinforce the child by reducing their anxiety or allowing them to engage in preferred activities. The longer a child stays out of school, the stronger this reinforcement becomes, making reintegration more difficult. Prolonged school refusal can lead to academic setbacks, social withdrawal and an increased risk of developing mental health disorders if not addressed promptly and effectively.

Screening for school refusal

Early identification and intervention for school refusal are crucial, as unaddressed issues can lead to poor academic performance and problems with peer and family relationships. Effective assessment of school refusal behavior involves tracking the number of days or periods a child is absent from school. Parents and caregivers can begin by requesting daily feedback from the school and discussing observations with the teacher or counselor to identify patterns of absences. A provider may also use the School Refusal Assessment Scale-Revised, a self- and parent-report tool, to help pinpoint the reasons behind the avoidance behavior and guide appropriate interventions.

Assessment and intervention for school refusal

Treating school refusal in children involves a multifaceted approach tailored to the underlying causes of the behavior. Effective treatment often begins with a thorough assessment to identify the specific factors contributing to the refusal, such as anxiety, academic challenges or social issues. After providers identify the underlying cause, a pediatric mental health provider can implement an intervention tailored to address the specific reasons behind the school refusal.

Evidence-based intervention for school refusal includes several key elements. Children who experience anxiety about school may benefit from a gradual reintroduction plan, positive reinforcements for staying at school, and clear, consistent expectations for attendance. Keeping a child at school for the expected time, regardless of behaviors and complaints, can also reduce avoidance behaviors, which tend to increase anxiety over time.

If a child chooses to stay home from school, the supervising caregiver should strive to make the home experience as unrewarding as possible.  This means that the daytime hours should be as similar to school as possible, with the expectation that the child complete schoolwork in a quiet setting, such as at the dining room table. Caregivers should also limit access to tangible rewards such as video games or screens, and only restore access once the child makes the decision to resume attending school.

Creating a supportive and structured environment at school, including gradual reintroduction and collaboration with teachers and counselors, can ease the transition back to the classroom.

Addressing school refusal can be challenging and complex. Consulting with a licensed mental health professional can be beneficial in identifying underlying behaviors and developing a collaborative, comprehensive plan to facilitate the child’s reintegration into school. Additionally, addressing any comorbid conditions, such as depression or learning disabilities, and improving family dynamics, can further enhance the effectiveness of the intervention.

Additional resources

• Children’s Hospital Colorado’s Pediatric Mental Health Institute provides evidence-based, family-focused comprehensive mental health services. For more information, providers can call 720-777-6200.
• For additional Colorado mental health services, visit Colorado’s Behavioral Health Administration.