By: Rachele A Merk, Ph.D., Boys Town Nevada Behavioral Health Clinic

Many children express reluctance to attend school at some point in their lives, making it one of the most common childhood behavior problems. However, reluctance, and then refusal, to go to school can lead to bigger problems and serious consequences if parents don't effectively respond.

The reasons children are reluctant to go to school vary. One common reason is high rates of school anxiety. Reluctance also tends to be worse after kids have been out on sick days or vacations because they have a hard time going back after missing or being on a break from school for a few days.

Sometimes, reluctance to attend school is just a temporary thing, and is easily remedied. For example, maybe your child had the flu and was out for a few days, and is now having a hard time going back to school. Suddenly your child is anxious, clingy and crying about all the homework he or she missed. Having a conversation with your child about why it's important to go to school, and easing his or her concerns might be all it takes to get things back on track.

A bigger problem occurs when reluctance transitions to outright refusal.

School refusal behavior is defined as a child refusing to attend school and/or having difficulty remaining in classes for an entire day. Refusal is an extreme pattern that causes real problems for a child (and his or her family), and there are a number of factors that make it different from normal avoidance. These include:

• How long a child has been avoiding school
• How much distress the child associates with attending school
• How strongly the child resists
• How much the child's resistance is interfering with his or her (and family) life

The consequences for missing school intermittently or over a lengthy period may include family conflict and stress, problems in learning and earning good grades, difficulty making and keeping friends, school dropout and delinquency.

There are a number of signs that indicate a child may be having difficulty attending and staying in school, including:

• Fear of specific things at school: tests, teachers, other kids, riding the bus
• Physical/somatic complaints
• Temper tantrums
• Refusal to get out of bed or get dressed
• Clinging to parents
• Asking the same questions over and over (Can I just stay home? Can't we do homeschooling?)
• Arriving late for school
• Crying in the classroom
• Asking to go to the nurse and then calling parents to be picked up
• Truancy/missing certain classes or leaving school before specific classes
• Missing school during test or presentation days
• Withdrawal, extreme shyness at school and different behavior in other classes (may indicate poor peer relationships or bullying)
  

 A child also may have a lot of "suspicious" sick days and/or make frequent trips to the school nurse. Anxiety can be shown in physical ways, so symptoms could be consistent with anxiety about attending or staying in school. In these situations, we recommend getting your child checked out by a pediatrician as it is important not to overlook a possible medical problem.

Understanding the Problem

To effectively address this behavior, the first step is to determine the reason for a child's reluctance or refusal to attend school. There are a range of possibilities and a child may report multiple reasons for not wanting to go.

One of the most extreme is an anxiety disorder. Nearly any of the following anxiety disorders could be the culprit, and refusing or resisting school may be just one symptom of the disorder.

• Separation Anxiety:  Fear over possible loss or separation from a parent (or caregiver) triggered by going to school.
• Selective Mutism:  A disorder in which a child speaks in a normal voice at home but is silent at school. Children with this disorder may refuse to go to school because they fear being forced to talk.
• Panic Disorder:  Fear of having an intense panic reaction in a situation where escape is difficult (like a classroom).
• Obsessive-Compulsive Disorder:  Characterized by intense obsessions and rituals and possibly triggered by school situations such as fear of contamination. Chronic worry about health and extreme perfectionism may also occur.
• Social Phobia:  Fear of being criticized or embarrassed by students or teachers in social or performance situations. Test anxiety is an example.
• Generalized Anxiety Disorder:  Chronic worry over multiple issues like being liked, grades, remembering homework, etc.
• Specific Phobia:  A common phobia that results in school refusal is emetophobia, or the fear of getting sick and vomiting that is triggered by the possibility of catching a virus or throwing up at school.

Other reasons for school reluctance or refusal can include:

• Bullying:  Verbal, physical or relational bullying
• Learning problems:  Such as specific learning disabilities, ADHD, expressive or receptive language problems, memory deficits
• Medical problems:  Chronic medical problems such as asthma, diabetes, cystic fibrosis, cancer, epilepsy
• Family stress/illness or conflict:  Chronic illness in the family, child needs to work to support the family

How Can I Help My Child?

Here are several steps you can take if your child is regularly reluctant to or refuses to go to school:  

• Obtain an assessment to determine the reason(s) and severity of the school refusal from a mental health professional who is familiar with school-based anxiety or school refusal.

Treatment providers who work with kids with school refusal issues often will use cognitive-behavioral therapy, which helps kids learn to manage their anxious thoughts and feelings and face their fears.

• Learn and use skills that can help reduce child and parent anxiety/distress.
• Reward your child's appropriate behavior of attending school and provide negative consequences for inappropriate, attention-seeking behavior such as tantrums and truancy.

Working with Your Child's School on a Plan for Attending and Staying in School

Identifying and working with appropriate school personnel to address your child's school refusal behaviors is another important step for parents to take. Areas to focus on include:

• Discussing the number of absences/amount of time missed.
• Reviewing your child's current grades, homework and credits.
• Discussing your child's current behaviors in school.
• Exploring possible barriers to school attendance (learning problems, peer problems).

• Becoming familiar with school rules regarding attendance and truancy, and the legal or disciplinary actions that can result when a child is not going to school.
• Making a plan and setting an expected timeline for your child's re-integration to school, while also considering possible obstacles.
• Discussing whether a 504 or IEP is appropriate for addressing learning and social-emotional issues that are interfering with your child's school attendance.

This guide was developed by integrating information from the following resources. Caregivers and school-based professionals are invited to consider these resources for additional information.

Books:

Kearney, C.A. (2007).  Getting your child to say "yes" to school:  A guide for parents of youth with school refusal behavior.  New York:  Oxford University Press.

Eisen, A.R., Engler, L.B., & Sparrow, J. (2006). Helping your child overcome separation anxiety or school refusal:  A step by step guide for parents. California: New Harbinger Publications, Inc.

Kearney, C.A., & Albano, A.M. (2007). When children refuse school:  A cognitive-behavioral therapy approach parent workbook. Oxford University Press.

Mayer, D.P. (2008). Overcoming school anxiety: How to help your child deal with separation, tests, homework, bullies, math phobia, and other worries. AMACOM.