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Goodbye Summer, Hello School (Refusal)
After a long hot summer, children in Maryland are now officially back to school. We will devote the next few issues of the BHIPP newsletter to address school-related topics, such as educational services, intellectual and learning disabilities, bullying, and in this issue – school avoidance.
School refusal among children and adolescents is not uncommon and may present in different ways. Some children may skip certain classes, while others may have lengthy absences or chronic tardiness. Exhibiting problematic behaviors in the morning in an attempt to avoid or miss school, as well as pleading with parents to stay home are also not unusual.
Children and adolescents may attain positive reinforcement for missing school if they are permitted to engage in activities they enjoy such as sleeping late or watching television while at home. Often, youth are attempting to escape school-based situations that evoke fear or anxiety, such as interacting with others, tests/classwork, transitions between classes, or teachers or peers with whom they have difficulty. If left unaddressed, school refusal may lead to significant short- and long-term consequences including distress, academic decline, isolation from peers, family conflict, and financial difficulties.
Individual and/or family therapy may be of benefit. Cognitive Behavioral Therapy (CBT), utilizing exposure (gradual practice engaging in the activity that creates anxiety, with relaxation practice) are particularly useful in these cases.
Additionally, it is important that students, parents, and school staff work closely together to gather and share information, develop a plan for the child to return to school, and identify issues that may be contributing to absences such as comorbid medical problems or familial issues. Families may also consider incentives for school attendance while eliminating positive reinforcement for staying home. Some youth may benefit from a 504 Plan or an IEP (Individualized Education Program) which may allow for the school to put a behavioral plan in place and provide support to the youth while at school. It is very important to get the child back to school as soon as possible; home and hospital is not typically recommended in these situations.
Some children who present with school avoidance may also meet criteria for an anxiety or depressive disorder, such as Separation Anxiety Disorder, Generalized Anxiety Disorder, Social Anxiety Disorder, or Major Depressive Disorder. In severe cases of anxiety or depression, medication may be helpful. Pediatric primary care providers are encouraged to reassess the patient’s current anxiety and depressive symptoms by using screening tools such as the SCARED and the PHQ-9. Based upon the results of the screening, providers should consider referral for psychotherapy and/or initiating medication depending on the severity of the symptoms and underlying diagnoses. In very severe cases of school avoidance, day hospital treatment may be indicated. If medication is utilized, it is important to treat the underlying anxiety or mood disorder, rather than using PRN medications, which could result in the patient (and the family) becoming dependent on medication exclusively.
In summary, treatment of school refusal often requires a multi-faceted approach, of which medication is just one component. The combination of therapy, family management techniques, collaboration with school personnel, and medication (as necessary) is most effective for sustained results.
-Dr. Nicole Gloff and Dr. Joyce Harrison, BHIPP Consultants
References:
- AAP Council on School Health - School Refusal, Phobia, and Avoidance: The Pediatrician’s Dilemma Link
- Child Mind Institute - When Kids Refuse to Go to School Link or PDF
- Cincinnati Children’s - School Refusal Link
- Healthychildren.org (AAP) - School Avoidance Link or PDF
Resources:
- Screen for Child Anxiety Related Disorders (SCARED) Link
- Patient Health Questionnaire (PHQ-9) PDF
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