School Refusal
Going to school is one of the most universal experiences of childhood — but for some kids, it becomes genuinely difficult. Research suggests school refusal affects roughly 5% of school-age children (Munkhaugen et al., 2017). It refers to a child or teen not attending school, or struggling to stay there, because of emotional distress (Tekin & Aydın, 2022).
It's worth distinguishing school refusal from truancy. Truancy typically describes unexcused absences and carries a more negative, behavioral connotation (Tekin & Aydın, 2022). School refusal is different: it involves a child staying home because of genuine emotional upset — like distressing feelings or physical symptoms — at the thought of going to school, and it happens with the parents' knowledge (Maynard et al., 2018). Research shows it affects boys and girls at similar rates and tends to emerge most often in early adolescence, though it can occur at other ages too (Munkhaugen et al., 2017).
Certain factors are associated with a higher likelihood of school refusal, including lower maternal educational attainment, physical or mental health challenges, an unsafe or unsupportive home environment, and parental unemployment (Munkhaugen et al., 2017). That said, these factors don't guarantee school refusal will happen, and it can occur in families without any of these risk factors present.
Missing school can carry both short- and long-term consequences, including learning and social difficulties and a higher risk of dropping out early (Maynard et al., 2018). Long-term, it's also been linked to a higher likelihood of mental health challenges, employment struggles, and difficulties in relationships later in life (Munkhaugen et al., 2017).
Conditions Related to School Refusal
School refusal isn't itself a psychiatric diagnosis. But in many cases, children who struggle with it are also dealing with an underlying mental health condition — often anxiety, a mood disorder, or a behavioral disorder (Tekin & Aydın, 2022). Anxiety disorders in particular — including social anxiety, generalized anxiety disorder, separation anxiety disorder, panic disorder with agoraphobia, and specific phobias — are commonly seen alongside school refusal (Maynard et al., 2018). Some children show anxiety symptoms that don't meet the full criteria for a diagnosis or may be dealing with depression instead (Maynard et al., 2018).
Because school refusal can stem from so many different underlying causes, it's important to understand what's driving it for each individual child in order to choose the right intervention (Inglés et al., 2015). When anxiety or depression is part of the picture, treating that underlying condition is a key part of helping a child return to school successfully (Inglés et al., 2015).
Anxiety
Everyone experiences anxiety — a state involving worry along with physical symptoms — and in moderate amounts, it's a normal part of life (APA, 2022). But when anxiety becomes especially intense or frequent, it may rise to the level of an anxiety disorder. Anxiety disorders are actually the most common category of psychiatric diagnoses in children and adolescents (Gallo et al., 2014). Here's a quick look at some of the anxiety disorders most often linked to school refusal:
• Separation anxiety disorder involves significant distress around being separated from a parent or other attachment figure. Children with this condition often struggle in school, socially, and within the family, and face a higher risk of anxiety disorders in adulthood (APA, 2022; Schneider et al., 2011).
• Social phobia (social anxiety disorder) is a common childhood anxiety condition involving intense worry about social situations. Like separation anxiety, it's linked to a higher likelihood of future psychiatric conditions (Melfsen et al., 2011).
• Specific phobias are long-lasting, intense fears tied to particular situations or objects, leading to significant anxiety or avoidance. They affect an estimated 3–5% of children and can lead to academic struggles, difficulty with everyday activities, and increased risk of other psychiatric challenges later on (APA, 2022; Wright et al., 2023).
• Panic disorder involves unpredictable panic attacks — sudden, intense episodes of anxiety — and is linked to greater social, academic, and family difficulties (APA, 2022; Gallo et al., 2014).
• Agoraphobia involves intense fear connected to real or anticipated experiences in certain situations or environments (APA, 2022).
• Generalized anxiety disorder (GAD) involves persistent, excessive worry that spans a wide range of everyday activities and concerns (APA, 2022).
Depression
Just as everyone experiences anxiety, everyone experiences sadness. Depression is different — it's an intense, persistent low mood that interferes with everyday functioning (APA, 2022). Someone with depression may experience a depressed mood, a loss of interest or pleasure in activities lasting at least two weeks, thoughts of death or suicide, trouble concentrating or making decisions, fatigue, significant weight changes, changes in physical activity levels, and disrupted sleep (APA, 2022). In children and teens, depression often shows up as irritability rather than sadness (APA, 2022).
Treating School Refusal
While school refusal can be addressed at any age, research suggests treatment tends to be more effective with younger children (Elliott & Place, 2019). This may be due to the added challenge of catching up on more complex schoolwork, greater symptom severity, or the increased independence that comes with age (Elliott & Place, 2019). Good outcomes typically depend on close collaboration between a child's caregivers, treatment providers, and school — and parents in particular play a central role in supporting their child through treatment (Ek & Eriksson, 2013).
Cognitive Behavioral Therapy (CBT) — a therapy approach that focuses on the connections between thoughts, feelings, and behaviors, and works to shift unhelpful thinking patterns — is the most commonly used treatment for school refusal, and is typically recommended before medication is considered (Elliott & Place, 2019; Heyne et al., 2001). CBT also has strong research support as a treatment for depression and anxiety more broadly (Ek & Eriksson, 2013). More specifically, studies have found CBT effective for social anxiety disorder (Schneider et al., 2011; Melfsen et al., 2011) and for specific phobias in youth (Wright et al., 2023).
Medication and family therapy may also play a role in treatment (Elliott & Place, 2019). Some research suggests incorporating family therapy alongside CBT can be especially helpful (Elliott & Place, 2019). When medication is used, it tends to be most effective for children whose school refusal is connected to depression or anxiety, with SSRIs and tricyclic antidepressants being the most commonly used options (Ek & Eriksson, 2013; Heyne et al., 2001).
If your child or teen is struggling with school refusal, know that you're not alone, and support is available. Reaching out to a therapist is a good first step toward understanding what treatment options might help your family.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
Ek, H., & Eriksson, R. (2013). Psychological factors behind truancy, school phobia, and school refusal: A literature study. Child & Family Behavior Therapy, 35(3), 228–248. https://doi.org/10.1080/07317107.2013.818899
Elliott, J. G., & Place, M. (2019). Practitioner review: School refusal: Developments in conceptualisation and treatment since 2000. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 60(1), 4–15. https://doi.org/10.1111/jcpp.12848
Gallo, K. P., Cooper-Vince, C. E., Hardway, C. L., Pincus, D. B., & Comer, J. S. (2014). Trajectories of change across outcomes in intensive treatment for adolescent panic disorder and agoraphobia. Journal of Clinical Child and Adolescent Psychology, 43(5), 742–750. https://doi.org/10.1080/15374416.2013.794701
Heyne, D., King, N. J., Tonge, B. J., & Cooper, H. (2001). School refusal: Epidemiology and management. Paediatric Drugs, 3(10), 719–732. https://doi.org/10.2165/00128072-200103100-00002
Inglés, C. J., Gonzálvez-Maciá, C., García-Fernández, J. M., Vicent, M., & Martínez-Monteagudo, M. C. (2015). Current status of research on school refusal. European Journal of Education and Psychology, 8(1), 37–52. https://doi.org/10.1016/j.ejeps.2015.10.005
Maynard, B. R., Heyne, D., Brendel, K. E., Bulanda, J. J., Thompson, A. M., & Pigott, T. D. (2018). Treatment for school refusal among children and adolescents: A systematic review and meta-analysis. Research on Social Work Practice, 28(1), 56–67. https://doi.org/10.1177/1049731515598619
Melfsen, S., Kühnemund, M., Schwieger, J., Warnke, A., Stadler, C., Poustka, F., & Stangier, U. (2011). Cognitive behavioral therapy of socially phobic children focusing on cognition: A randomised wait-list control study. Child and Adolescent Psychiatry and Mental Health, 5(1), 5. https://doi.org/10.1186/1753-2000-5-5
Munkhaugen, E. K., Gjevik, E., Pripp, A. H., Sponheim, E., & Diseth, T. H. (2017). School refusal behaviour: Are children and adolescents with autism spectrum disorder at a higher risk? Research in Autism Spectrum Disorders, 41–42, 31–38. https://doi.org/10.1016/j.rasd.2017.07.001
Schneider, S., Blatter-Meunier, J., Herren, C., Adornetto, C., In-Albon, T., & Lavallee, K. (2011). Disorder-specific cognitive-behavioral therapy for separation anxiety disorder in young children: A randomized waiting-list-controlled trial. Psychotherapy and Psychosomatics, 80(4), 206–215. https://doi.org/10.1159/000323444
Tekin, I., & Aydın, S. (2022). School refusal and anxiety among children and adolescents: A systematic scoping review. New Directions for Child and Adolescent Development, 2022(185-186), 43–65. https://doi.org/10.1002/cad.20484
Wright, B., Tindall, L., Scott, A. J., Lee, E., Cooper, C., Biggs, K., Bee, P., Wang, H. I., Gega, L., Hayward, E., Solaiman, K., Teare, M. D., Davis, T., Wilson, J., Lovell, K., McMillan, D., Barr, A., Edwards, H., Lomas, J., Turtle, C., Parrott, S., Teige, C., Chater, T., Hargate, R., Ali, S., Parkinson, S., Gilbody, S., & Marshall, D. (2023). One session treatment (OST) is equivalent to multi-session cognitive behavioral therapy (CBT) in children with specific phobias (ASPECT): Results from a national non-inferiority randomized controlled trial. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 64(1), 39–49. https://doi.org/10.1111/jcpp.13665