School Refusal in Children and

Adolescents

Wanda Fremont MD

Professor of Psychiatry
SUNY Upstate Medical University
(315) 464-3128
Fremont=@upstate.ed
u

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 Disclosures

Neither I nor my spouse have a relevant financial

relationship with a commercial interest to disclose.

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 SCHOOL REFUSAL CASE STUDY

HPI
• T.R. is a 11 y.o. with a history of asthma, allergies and anxiety,
who began to have more anxiety symptoms last year when she
entered middle school.
• She developed stomachaches, which caused her to miss school.
She was referred to a gastroenterologist. Medical workup was
negative.
• Her anxiety increased, and she had more difficulties going to school.
She refused to get on the school bus, and her father drove her to
school. When he dropped her off she cried and clung to father, not
wanting to leave his side. She developed panic attacks when he left
her.
• At school she avoided eating lunch in the classroom.
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 SCHOOL REFUSAL CASE STUDY

Social History
• Dad works at Wegmans and missed multiple days from work to
stay home with his daughter when she did not go to school. He
filed for FMLA due to missed days.
• TR lives with her biological parents, and younger 7 year old
brother
• She has friends, and enjoys spending time with them and going
to sleepovers.

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 SCHOOL REFUSAL CASE STUDY

Family History
• Dad has anxiety and history of panic attacks and is prescribed
Prozac. An uncle had schizophrenia, drug use and committed
suicide. T.R.’s paternal grandfather and several other
members of Dad’s family have anxiety.

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 SCHOOL REFUSAL CASE
STUDY past Medical History
• Asthma, Allergies and Atopic Dermatitis resulting in several ER
visits and followed by a Pulmonologist.
• Tonsillectomy/Adenoidectomy age 5
• Severe croup episode requiring ambulance trip to the ER and
epinephrine injection age 6

Medications: Albuterol Inhaler prn

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 SCHOOL REFUSAL CASE STUDY

• TR began to miss school. Initially she missed a few days of school a

month, but she then began missing one or two days a week of
school. She continued to complain of stomach aches and
headaches, and had crying spells and panic attacks on school days.
• T.R. was referred to a therapist, and began to meet regularly
with her. However, she continued to struggle with anxiety, and to
miss school frequently.
• TR’s parents met with her physician to discuss the possibility of her
staying out of school for a month to decrease her stress. They asked
her physician for a letter to excuse her from school for medical
reasons.
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 SCHOOL REFUSAL CASE STUDY

• TR’s
• T.R. saw met with the social worker regularly at school and began individual and
family therapy in June 2012. Since then, T.R. has continued with some
symptoms of anxiety but has attended school regularly, done well academically
and transitioned to 2 new schools. She has never been treated with medication.

• Some of her symptoms were helped by getting on the school bus with her dog,
eating her lunch at a special table outside the lunchroom, being met by the
school nurse at school drop off and being assigned to a kindergartener to walk to
her classroom as a job.
• T.R. saw met with the social worker regularly at school and began individual and
family therapy in June 2012. Since then, T.R. has continued with some
symptoms of anxiety but has attended school regularly, done well academically
and transitioned to 2 new schools. She has never been treated with medication.
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 Epidemiology
• Prevalence: 1-5%
• Boys = Girls
• Most common ages:
ages 5, 6 ages
10, 11
• No socioeconomic differences

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 School Refusal vs Truancy
Criteria for Differential Diagnosis of School Refusal and Truancy

School Refusal Truancy

Severe emotional distress about Lack of excessive anxiety or fear about
attending school: may include attending school
anxiety, temper tantrums,
depression or somatic complaints

Parents are aware of absence; child Child often attempts to conceal school absence
often tries to persuade parents to from parents
allow him or her to stay home

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 School Refusal vs Truancy (con’t)

Criteria for Differential Diagnosis of School Refusal and Truancy

School Refusal Truancy

Absence of significant antisocial Frequent antisocial behavior, including
behaviors such as juvenile delinquent and disruptive acts (lying,
delinquency. stealing), often in the company of other
antisocial peers

During school hours child usually During school hours child frequently does
stays home because it is not stay home and pursues more attractive
considered to be a safe and activities outside home
secure environment

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 School Refusal vs Truancy (con’t)

Criteria for Differential Diagnosis of School Refusal and Truancy

School Refusal Truancy

Child expresses willingness to do Lack of interest in schoolwork and
schoolwork and complies with unwillingness to conform to academic and
completing work at home behavioral expectations

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 Clinical Considerations
• Presentation: physical and/or psychological symptoms
• Symptoms frequently change over time

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 Clinical Features
• Gradual onset
• Symptoms may begin after a holiday, illness
• Weekends, vacations exacerbate symptoms
• Stressful events – home, school, peers may cause refusal

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 Clinical Features (con’t)
• Some children leave home, then have difficulties as they get
closer to school
• Some children make no effort to leave home
• Fear, panic symptoms, crying episodes, temper tantrums,
threats of self-harm, somatic symptoms

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 Somatic Symptoms

Somatic Complaints in School Refusing Children

Autonomic
Dizziness
Diaphoresis
Headaches
Shakiness/trembling
Palpitations
Chest Pains

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 Somatic Symptoms (con’t)
Somatic Complaints in School Refusing
Children
Gastrointestinal
Abdominal pain
Nausea
Vomiting
Diarrhea
Muscular
Back pain
Joint pain

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 Clinical Symptoms (con’t)
Symptoms present in morning, and improve if child
is allowed to stay home

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 Clinical Symptoms

THE LONGER THE CHILD IS OUT OF SCHOOL,

THE MORE DIFFICULT IT IS TO RETURN

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 Short-term Sequelae

• Poor academic performance

• Family difficulties
• Problems with peer relationships

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 Long-term Consequences

• Academic underachievement
• Employment difficulties
• Increased risk for psychiatric illness

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 Long-Term Sequelae

Long-Term Sequelae of School Refusing Children

(Flakierska-Praquin et al. 1997)
Outcome Prevalence (%)

Interrupted compulsory school 18%

Did not complete high school 45%
Adult psychiatric outpatient care 43%
Adult psychiatric inpatient care 6%
Criminal offense 6%

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 Long-Term Sequelae (con’t)

Long-Term Sequelae of School Refusing Children

Outcome Prevalence (%)

Still living with parents after 20-year follow-up 14%

Married at 20-year follow-up 41%

Number of children at 20-year follow-up

None 59%
One or more 41%

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 Associated Psychiatric Disorders
• School refusal is not a psychiatric diagnosis
• Emotional distress is significant
• Anxiety and depression most common
• Children: anxiety symptoms
• Adolescents: anxiety and mood disorders

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 Psychiatric Disorders in Children with School
Refusal (Bernstein et al 1991)

Diagnosis Percentage

Anxiety Disorders 54%

Separation Anxiety 20%
Anxiety Disorder, NOS 12%
Generalized Anxiety Disorder 8%
Social Phobia 6%
Panic Disorder 4.5%
Panic Disorder with Agoraphobia 3%
Agoraphobia .5%
Mood Disorders 52%
Major Depression 30%
Dysthymia 22%
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 Psychiatric Disorders in Children with School Refusal
(Bernstein et al.1991)

Diagnosis Percentage

Other disorders

Adjustment Disorder with mood/anxiety 26%

Learning Disorder 5.5%
ADHD 6.5%
Substance Abuse 2.5%

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 Etiology
• Heterogeneous and multi-casual
• Serves different functions depending on the child
• Avoidance of specific fears provoked by the school
environment
• Test-taking situations
• Bathrooms
• Cafeterias

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 Family Functioning
• Problems with family functioning contribute to school
refusal, however, few studies have systematically evaluated
and measured these problems
• Parents of children with school refusal have an increased rate of
panic disorder, agoraphobia and depression

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 Assessment
• Comprehensive evaluation
• Allocate sufficient amount of time
• More than one appointment may be needed
• Information from school, other health care providers
• Rule out underlying medical conditions

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 Assessment (cont.)
• Clinical Interview
• Family (child and parents together)
• Child
• Parents
• Complete physical examination

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 Assessment (cont.)
• Complete medical history
• History of onset and development of symptoms
• Associated stressors
• Sleep history
• School history
• Family psychiatric history

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 Assessment (cont.)
• Mental status examination including evaluation of
psychiatric problems and substance abuse
• Assessment of family dynamics and functioning

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 Assessment (cont.)
• Collaboration with school staff
• Review of school attendance records, report cards, and psycho-
educational evaluations

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 Treatment (cont.)
• Primary goal – early return to school
• Avoid writing excuses unless a medical condition makes it
necessary
• Treatment should focus on co-morbid psychiatric conditions,
family dysfunction, and other contributing factors

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 Treatment (con’t)
MULITMODAL, COLLABORATIVE TEAM APPROACH
Primary Care Provider
Child
Parents
School Staff
Mental Health Professional

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 Treatment
• Most effective:
Parent involvement
Exposure to school

• Must take into account:

Severity of symptoms Co-
morbid diagnosis Family
dysfunction Parental
psychopathology

• Few controlled studies have evaluated the efficacy of most treatments

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 Behavior Interventions (con’t)
• Systematic desensitization (graded exposure to the school environment)
• Relaxation training
• Positive reinforcement
• Social skills training

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 Pharmacologic Treatment
• Very few double-blind, placebo-controlled studies
• Use of SSRIs for anxiety and depression
• Duloxetine (SNRI) approved for Generalized Anxiety Disorder
• Fluoxetine (Prozac), Sertraline (Zoloft), and Fluvoxamine (Luvox), approved for
OCD
• Fluoxetine (Prozac) and Escitalopram (Lexapro) approved for depression

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 Pharmacologic Treatment (cont.)
• Treat underlying psychiatric disorder
• Multimodal treatment – always with psychotherapy interventions
• Psycho-education (child, parent, school personnel)
• Start low, go slow

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 Pharmacologic Treatment (con’t)
• Benzodiazepines used for short-term basis (few weeks max) for children
with severe school refusal

• Benzodiazepine may be initially prescribed with an SSRI to target acute

symptoms of anxiety. Once the SSRI has had time to produce
beneficial effects, the benzodiazepine should be discontinued

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 School Refusal Case Study T.R.

• T.R. and her family continued to meet with her therapist regularly.
Her therapist worked closely with her parents, school staff, and her
physician to collaborate care. Her physician did not write a letter to
excuse her from school.
• Some of her symptoms were helped by getting on the school bus
with her dog, eating her lunch at a special table outside the
lunchroom, being met by the school nurse at school drop off and
being assigned to a kindergartener to walk to her classroom as a job
• T.R. has continued with some symptoms of anxiety but has
attended school regularly.
• She has done well academically. She has never been treated ith
medication.
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 Summary
• School Refusal vs Truancy
• History and physical to r/o underlying medical condition
• Evaluate and treat psychiatric conditions
• Goal: early return to school
• Parents participation crucial
• Collaborative approach: family, PCP, teachers, mental
health professional

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 Websites

www.childanxiety.org
www.aacap.org
www.mentalhealth.samhsa.gov

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QUESTIONS?

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