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School Refusal

By Elizabeth Stachulski, LCPC,CEDS-S

When It’s More Than Just Difficult Mornings

School refusal is a very real, life-interrupting disorder affecting between two- and five-percent of school-aged children. School refusal is characterized by outright refusal to go to school on a regular basis, and/or by the child having problems in the classroom or school environment.

School refusal can take many different forms, and there are two primary presentations:

  • Internalizing symptoms – often manifesting in somatic complaints such as a stomachache, shortness of breath, shakiness, racing heart or a headache.
  • Externalizing symptoms – forms of acting-out behaviors in response to fears. These behaviors can include tantrums, disruption in the classroom, aggression toward others and threats of harm.

Internalizing and externalizing symptoms can occur both together or separately. One way to understand school refusal is as a form of avoidance. Some examples of what children might be trying to avoid include but are not limited to:

  • A bully
  • A challenging social or academic situation
  • A fear of failure
  • A fear of leaving or being separated from the parent

If a child avoids the stressor by staying home from school, they feel immediately better, which then reinforces the avoidance. The problem with this pattern is that if we avoid what scares us, it becomes harder and harder to approach the feared situation or experience over time. This is a real dilemma for parents, because despite a desire to help their kids attend school and thrive, it can be easier for parents to let their child stay home and not get into the early morning power struggle. The reality is that school refusal may be a symptom of a deeper issue like an anxiety, mood or trauma disorder. For some families, school refusal can become a severe condition requiring intensive support to address the
underlying behavioral health concerns and enact real behavioral change. 

To support these families, Pathlight offers an innovative School Refusal Partial Hospitalization Program (PHP) for adolescents that targets school refusal through daily intensive treatment and a collaborative, evidence-based approach. A team of mental health and education experts works closely with patients, parents and school personnel to address underlying anxiety and oppositional behaviors associated with school refusal. Interventions include:

  • Exposure Response Prevention (ERP) exposes adolescents to thoughts, images and situations that elicit an anxious response. Guided exposures provide opportunities to create a hierarchy of fears, methodically work through each experience to build mastery and decrease anxiety over time.
  • Dialectical Behavior Therapy (DBT) addresses the oppositional and/or behavioral symptoms that have prevented the adolescent from effectively engaging in school. Core skills such as mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance help manage defiant behaviors, improve academic achievement and develop healthy relationships.
  • Daily educational support emphasizes completion of classroom assignments and executive functioning skills training. When appropriate, daily treatment can be customized to allow for partial school attendance.
  • Parent involvement in weekly multi-family DBT groups and ERP skills trainings help caregivers learn how to effectively support their adolescents and overcome barriers to school reintegration.  

The objective of treatment is to help the child take manageable steps to build toward full school attendance and engagement.

Written by

Elizabeth Stachulski, LCPC,CEDS-S

Elizabeth Stachulski is the Clinical Director of Child & Adolescent Eating Disorder and Mood and Anxiety Residential and Partial Hospitalization Programs at Eating Recovery Center and Pathlight…