It's not unusual for children to complain about going to school and make excuses in an attempt to spend a day at home. However, for some children, the behavior becomes commonplace or even chronic. When the behavior results in the child missing multiple school days, children risk falling behind in academics and social development, and it can be indicative of an underlying mental health condition. "School refusal, which refers to a child who refuses to attend school and who identifies home as safer and more secure place, has been recognized for many decades," says Jayne Singer, PhD, clinical psychologist in Children's Hospital Boston's Developmental Medicine Center.
School refusal isn't a disorder; it's considered a symptom of a mental health condition or other underlying issue, and can have a number of different causes. "School refusal is not the same as truancy," says Dr. Singer. "Children who are truant aren't necessarily anxious or fearful, and they're probably not telling their parents or guardians about skipping school. That's quite different from school refusal, which is accompanied by emotional distress."
School refusal affects around 4 percent of school-aged children, with similar rates among boys and girls. While it can present in high school, it's more common in the elementary school years, when a child is between ages 5 and 11. Dr. Singer says many children report somatic symptoms like stomach aches and headaches and may have tantrums to avoid school. "These behaviors are often psychosomatic symptoms of the child's level of emotional distress, or in the case of tantrums, a behavioral expression of their intense desire to remain at home," she says.
Many children who engage in school refusal have an underlying emotional distress, like separation anxiety disorder. "They can be quite fearful and feel unable to separate from their parent or home or guardian—their safe environment," says Dr. Singer. These children may worry incessantly about what will happen to their parents while they are in school.
Other causes of school refusal include social anxiety, depression and posttraumatic stress disorder.
She cautions that school refusal is not always a symptom of a psychiatric disorder. "You need to consider that a child may be being bullied. Or maybe there is a specific event at school that's causing a specific anxiety," she says. Learning disorders can also result in an avoidance of school, since a child with a reading disorder can be extremely stressed by the process of learning to read.
While school refusal can present at any time, it commonly originates during times of transition—when a student starts a new grade, school or teacher or after experiencing significant change in home life, like a divorce or move.
In the short-term, school refusal can result in poor academic performance and pose difficulties with forming positive social relationships, says Dr. Singer. Children may find it hard to catch up with schoolwork and may struggle to fit in. In the long-term, it can lead to chronic academic underachievement. "If a child has several different bouts of long-term school refusal in the course of their school career, it can be very detrimental," she says. "The more often school refusal occurs, the more it might indicate risk for psychiatric issues, such as anxiety and depression."
Treatment depends on the cause of the school refusal. "I've known children who have developed school refusal after the death of a parent, and the child became very attached and clingy to the surviving parent," says Dr. Singer. "That requires very different management than a child who has a phobia of a fire alarm."
If a child is refusing to go to school, he should undergo a full medical and mental health assessment to determine the cause. Moving quickly to identify the root cause is crucial. "The longer the child is allowed to stay home, the harder it is for him to get back into the routine," says Dr. Singer.
If school refusal is a symptom of a psychiatric disorder, treatment should focus on addressing all of the contributants to the disorder. Children with anxiety-induced school refusal may be referred to a cognitive behavioral specialist, who can work on trying to help undo some of the child's specific fears. Patients are encouraged to tackle the feelings of anxiety, instead of avoiding them. "Things like yoga, deep breathing exercises, relaxation techniques and creative movement can help children master the physiological experiences of anxiety," says Dr. Singer. This can allow the child to understand links between their feelings and behavior.
Parents can help their child by setting up routines, like going to bed at the same time every night. "When a child is anxious, predictability is extremely helpful," says Dr. Singer. She also recommends parents identify a counselor at school that the child can go to if he feels scared or uncomfortable at school. If a child's school refusal stems from social fears, treatment should involve working on social skills. "Many schools have lunch bunches or social skills groups," she says.
Most important, says Dr. Singer, parents should not give in to their child's demands to stay home, but rather should collaborate with the school, medical and mental health providers and the child to create a safe and comfortable learning environment.
Make a referral:
Outpatient Psychiatry 617-355-6680;
Developmental Medicine 617-355-7025