A 14-year-old male came to clinic because he was worried about school. He had been in a car accident and had been out of school for a few weeks. He described initially going back to school and found it very physically tiring and he was behind in his classes. “It’s just really hard for me to get around the school and then I don’t know what is going on in my classes. I like seeing people but it’s really hard,” he stated. He went on, “It’s just easier for me to stay home and try to catch up, but I’m falling farther and farther behind. I’m not really sure what to do.” He and his parents describe how he tried to return to school for half-days, but this was too tiring for him. “It’s just easier for us to have him at home, so we don’t have to leave work to pick him up early,” his mother said. “I missed a lot of work because of the accident,” she confided. “We’ve tried to help him with his homework but he is behind his friends,” they stated. “The school had offered some tutoring but he’d have to be at school to do that,” his father went on. “I really don’t want to be in a class where everyone is so much farther ahead than me,” the teenager stated. He says he was sleeping better recently than he had after the accident, denied flashbacks or anxiety about the accident, or worries about his family.
The past medical history revealed that he had always been a little more anxious. “He’s the worrier in the family. He’s always been more worried about how he’ll do in the baseball game or on the test, but when it comes time to do those things he’s just fine,” they noted. The pertinent physical exam showed a well-appearing male. His vital signs were normal. He still had a cast on his left leg. Healing scars on his face and arms from lacerations were noted.
The diagnosis of school refusal along with anxiety, being behind academically, being deconditioned, and healing fractures were made. The pediatrician recommended several steps to gradually get him back into school. He recommended a meeting with his guidance counselor, school administration, parents and the teenager to figure out how to address the mobility issues at school so he wouldn’t be so tired, and develop a plan to gradually catch him up academically to his classmates. “You might be surprised how many other kids have had the same problems and the school can help. Maybe the first couple of days you will only go to school for a couple of hours and you can work in the library with one of the teachers. Then maybe increase this to half a day for another week. Then you might start to feel less tired and can stay longer the next week. I bet you probably have a friend or two in class who could leave a couple minutes before the bell and be able to push your wheelchair to your next class so you won’t have to use all your energy just getting around too. There are lots of possibilities,” the pediatrician said. “Maybe a friend or two could come over after school and you could do some school work or just hang out for a bit,” he went on. “I miss playing in the band and its first period in the morning” the boy offered. “We’ll maybe for the first couple of days, you can go to band, and afterward one of your friends can help you to the library to meet with a teacher. Band is a great thing to help you regain your strength, plus its always fun to make music,” he encouraged the teen. “I also think that it would be helpful to talk with a counselor about some of the worries you have in general and about school. I think that person can help you to learn some ways to better help yourself when you start being worried,” the pediatrician suggested.
The patient’s clinical course at followup 1 month later showed that the teen was in school for 1/2 day consistently. He was still behind in some of his classes but was making progress. He had one meeting with counselor and his cast was to be removed in ~2 weeks. “I’m still worried about my classes and being so far behind, but once my cast is off I think I’ll do better,” he stated. It was a slow process but over the next 6 weeks he eventually returned to school full-time consistently.
School within society is an institution designed to provide learning opportunities to students under the direction of teachers. The curriculum is usually designed to provide academic content in formal subjects necessary for the adult world (such as instruction in mathematics, language, science, social studies, arts, physical education) but also other knowledge and skills for the adult world (i.e. personal safety, communication skills, working in teams, etc.). Specific schools may or may not offer specific courses of instruction such as religious education, learning disability education, gifted/talented education, vocational education, etc.. In the developed and developing world, most individuals have attended some type of formal schooling at some time in their lives. Formal education is usually viewed as desirable even in locations where formal education may be less common as it is seen as an avenue for improved job opportunity, and economic and social improvement. All, or almost all students, at one point or another, wish they didn’t have to go to school. Absenteeism for some children becomes a problem. It affects ~ 1 of 7 children in the United States or ~6 million children.
School refusal (sometimes also referred to as school phobia or school avoidance) is most common in the 5-7 year olds and the 11-14 year olds, i.e. around the entry to school or middle school, but can occur at all school ages. School refusal often occurs after a time where the child has spent more time with the parent (school vacation or short illness) or after a stressful event such as a death in the family, or moving. Children entering school may be concerned about the new situation and appropriately are concerned about separating from their parents. This is a normal experience and usually improves within a short amount of time with reassurance and beneficial classroom experiences. Older children may have true fears about school based on their experiences such as bullying, violence or fearing a particular adult. Other children have continued separation issues from their parents and yet still want the school experience. This often occurs when parents are experiencing life stressors themselves such as an illness, death, divorce, loss of job etc.. Children may feel that they need to be with the parent more than being at school.
Children often have externalizing behaviors such as tantrums, sleep problems including nightmares and enuresis, obsessive-compulsive symptoms, and other fears. Physical complaints are common such as stomachache, headache, or sore throat, which often occurs on school mornings but improves as soon as the child is allowed not to attend school. Children may be more clingy, follow parents around the house and express excessive worry about the parent or other things such as monsters, weather events (i.e. tornados, lightening, etc..), fires, burglers, etc..
Once children start into a pattern of avoiding school and isolating themselves, it become more difficult to re-integrate. Understanding the underlying reason or reasons (often this is multifactorial), along with adult support (such as parents, general education and special education teachers, guidance counselors, school administrators, mental health providers, physicians, etc..) can assist the student to re-integrate and be successful at school. Communication and setting reasonable expectations are important. Reentry plans are important and can be simple or more elaborate. A slow-to-warm kindergartener may just need the kindergarten teacher to meet him at the school door for a few more days. A teenager returning after a traumatic event may need a gradual progressive plan that extends the amount of time and activities at school over 1 or more weeks. The student should know who they can talk with or where to go if they are feeling overwhelmed, but also should not excessively use those resources to get out of regular classroom activities. Other strategies include encouraging/enforcing regular routines at school and home, assigning a peer/buddy to assist the child, providing appropriate academic supports including flexible scheduling or alternative educational placements, addressing school/community safety issues, and encouraging extracurricular/community activities.
Truancy is different than school refusal as truant students do you not have emotional problems associated with going to school, often hide their absences from parents and authority figures, and are engaged in their preferred activities or may be involved in illegal activities. The juvenile justice system has as one of its goals to assist youth into developing other prosocial skills including returning to school. Homelessness also contributes to absenteeism but is not school refusal.
Reasons for school absenteeism include:
- School refusal/phobia
- Separation anxiety
- School/performance anxiety
- Generalized anxiety disorder
- Obsessive compulsive disorder
- Post traumatic stress disorder
- Panic attacks
- Other fears – agoraphobia
- Inadequate schooling/education
- Learning disabilities
- Physical illness, especially chronic illness
- Physical safety issues at school/community, including bullying and violence
- Parent related problem
- Mental illness
- Physical illness
- Poor parenting skills
- Lack of basic needs – food, clothing, shelter
- Stressful life events
- Mental health issues including anxiety, depression, personality disorders
- Substance abuse
- Poor social situation/environment
- Poor social skills
- Poor parenting skills/parental monitoring
- Inadequate schooling/education
- Learning disabilities
- Physical illness or pregnancy
- Lack of basic needs especially homelessness
*reasons often overlap with school refusal
Questions for Further Discussion
1. What parent education do you offer for separation anxiety in young children?
2. What often do you offer for teens who are behaviorally defiant?
- Age: Teenager
To Learn More
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Kidger J, Araya R, Donovan J, Gunnell D. The effect of the school environment on the emotional health of adolescents: a systematic review. Pediatrics. 2012 May; 129(5):925-49. Epub 2012 Apr 2.
American Academy of Child and Adolescent Psychiatry. School Refusal. Available from the Internet at https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Children-Who-Wont-Go-To-School-(Separation-Anxiety)-007.aspx (rev. 10/2013, cited 2/21/2017).
United States Department of Education. Chronic Absenteeism in The Nation’s Schools. Available from the Internet at https://www2.ed.gov/datastory/chronicabsenteeism.html (rev. 10/27/2016, cited 2/21/17).
Fernandez-Suarez A, Herrero J, Perez B, Juarros-Basterretxea J, Rodriguez-Diaz FJ. Risk Factors for School Dropout in a Sample of Juvenile Offenders. Front Psychol. 2016 Dec 26;7:1993.
National Association of School Psychologists. School Refusal: Information for Educators. Available from the Internet at http://www.nasponline.org/Documents/Resources%20and%20Publications/Handouts/Families%20and%20Educators/School_Refusal_Information_for_Educators.pdf. (cited 2/21/17).
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital