Understanding School Refusal: Tips for Families and Caregivers

It is common for students to want to skip school from time to time. In some cases, an occasional mental health day can be helpful! But it is important to know the difference between needing a short break from school, wanting to avoid a specific situation, and refusing to go to school because of mental health concerns.

“For kids and teens with school refusal, the stress and overwhelm is likely a more long-standing issue that may also be accompanied by anxiety or depression,” explains Elizabeth Easton, PsyD, CEDS, national director of psychotherapy at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “It’s less likely due to one situation and more likely the combination of many stressors that they do not feel capable of successfully managing.”

If your child or adolescent is repeatedly asking to skip school or is having trouble staying in school while they’re there, then you might be experiencing school refusal.

What is school refusal?

School refusal is seen as a symptom of mental health distress rather than a diagnosable condition. School refusal may be associated with mental health conditions such as:

• Anxiety disorders
• Depression
• Eating disorders
• Post-traumatic stress disorder

School refusal has become a frequent topic in both psychological research and popular media. In recent years, it has become more widely recognized by educators.

"I think educators and mental health professionals are learning more about how mental health impacts children's behavioral reactions,” says Dr. Easton. “The pandemic led to a great disruption in the typical education system and the resulting mental health crisis, especially for our youth. As kids struggled to return to school and face academic pressures, the direct link between mental health and school refusal seemed to become more overt.”

Because of its prevalence, school refusal is now addressed in behavioral health programs around the country -- including here at ERC Pathlight.

Signs and symptoms of school refusal

School refusal can take many forms, and there are two primary presentations to watch for: internalizing symptoms and externalizing symptoms. Internalizing and externalizing symptoms can occur together or separately.

Internalizing symptoms often manifest in somatic complaints, such as stomachache, shortness of breath, shakiness, racing heart or headache.

Externalizing symptoms are behavioral reactions in response to fears. This can include tantrums, disruption in the classroom, aggression toward others and threats of harm.

Causes of school refusal

In many cases, school refusal is a form of avoidance. Examples of what children might be trying to avoid include:

• Bullying
• Challenging social or academic situations or pressures
• Fears of failure
• Fears of leaving or being separated from the parent/caregiver

If a child avoids the stressors 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 and caregivers. While they want their child to attend and thrive in school, they also don’t want to watch them go through the emotional turmoil each morning when it’s clear that they are struggling. So, in order to approach the situation effectively, it is important to have a plan in place to help guide the process.

Tips for parents to address school refusal

“With compassionate, patient and curious caregivers, in conjunction with skilled mental health professionals, kids can get back to academic functioning and learn to manage their stress differently,” explains Dr. Easton.

If you and your child are struggling with school refusal, here are some guideposts to consider when creating a plan.

1. Be curious.
Try to understand the function of your child’s behavior by understanding the purpose it serves. 

• Does missing school prevent your child from facing classes or academic pressures that are too challenging, causing them to have less confidence in their abilities?
• Does it keep them protected from bullying or from a feared social situation?
• Does it mean that they have the comfort of being home and spending more time with a parent?

By understanding the challenges that underlie school refusal, it is possible to feel more empathy for how much your child is struggling and determine what they need in order to feel better.

2. Rule out any possible medical or psychological condition that may be contributing to the school refusal. 
For instance, consider a physical exam to address your child’s complaints of stomach pain. Have a therapist or psychiatrist screen for depression, anxiety, trauma or substance use to determine whether there are issues that could be impacting the school refusal that require additional treatment considerations.

3. Be a model. 
Model for your child that when things get difficult, it is important to find ways to build resiliency and regain a sense of safety (either by using internal skills or interacting differently with the environment). For example, let’s say you are stuck in morning traffic and your child sees that you are upset because you will miss a meeting at work. Use some deep breathing to calm yourself physically. Your child also sees that you name your feelings and then brainstorm solutions such as calling in to the meeting, following up with your boss later or asking for the meeting notes. By seeing you effectively name and work through your emotions, your child will be better equipped to do the same when faced with triggers at school.

4. Empathize with expectations.
Children need to attend school regularly. Be creative and flexible in thinking about how they can utilize school resources to improve their experience. Problem-solve together.

• Should their classes be changed so there is less emphasis on highly challenging coursework? 
• Should there be a mediation with a classmate? 
• Should there be check-ins with the school counselor throughout the day? 
• Can a buddy system be put in place?

5. Reinforce and shape positive behavior.
Rewards for school attendance may include access to a special activity or earning the chance to try out for the basketball team if the child has attended school a certain number of days.    

“As long as you are working with providers who know how to work directly with avoidance, ultimately helping the child 'avoid avoidance' as a strategy to manage distress, progress can be made and functioning restored,” shares Dr. Easton. “Give it time, and don't give up.”

School refusal interventions: Our treatment approach

At ERC Pathlight, we target school refusal through 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.

Some of the interventions that we utilize within the program include:

• Exposure and response prevention  (ERP). This exposes kids and teens 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. (For example, the first step could be to have the child sit with the parent in the parking lot of the school and do some deep breathing. The next challenge might be to go inside the school and walk the halls while practicing mindfulness skills. The next might be to attend school for a half day, and so on.)
  Learn more about ERP.
   
• Dialectical behavior therapy (DBT). This 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 the child to manage defiant behaviors, improve academic achievement and develop healthy relationships.
  Learn more about DBT.
   
• 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.
  Learn about ERC Pathlight’s educational specialists.
   
• Family involvement and education helps caregivers learn how to effectively support their adolescents and overcome barriers to school reintegration.
  Join one of our free online support groups for caregivers.

The objective of treatment is to help the child take manageable steps toward full school attendance and engagement. If your child is struggling and your family would benefit from additional support, call ERC Pathlight for a free, confidential assessment today at 877-825-8584 or fill out this form:

Contact a member of our team now.

Clinically reviewed by Elizabeth Easton, PsyD, CEDS, and Maggie Moore, MA, LMFT.