The Doctor is in—

Questions and answers about behavioral and
emotional problems in children

CARRIE SYLVESTER, MD, MPH

aFall 1996

What can be done about school refusal or school phobia?

Each school year our clinic is asked to assist parents whose children refuse to go to school or have vague physical complaints preventing school attendance. Please review the features of school phobia and management of this disorder.

Dr. Carrie Sylvester responds:

Deciding whether a child is having a problem leaving home or a problem going to school can be quite difficult. Early psychoanalytic discussions agreed on the term school phobia for children who had such difficulty leaving their mothers that they acted as if they feared school. School refusal, the preferred British nomenclature, is a more accurate term to describe the same problem and is gaining acceptance in the United States. The term school refusal covers a broader range of causes for the behavior and is more useful in communicating with parents.

School refusal should be distinguished from truancy in which a child avoids school without parental knowledge. Truancy is more associated with the development of antisocial personality disorder and criminality. When both parents work outside of the home, they may not know that their child is at home due to school refusal rather then being truant somewhere else. Also, a child who is truly afraid of a bully or something else at school may leave home and then hide somewhere until it is time to come home. Unfortunately, this may be especially true in the current urban and suburban circumstance of weapons and gang influences in schools.

Other factors within the school can cause children to avoid school in a typically phobic manner. Factors such as a truly pathological teacher are fortunately rare. More important possibilities in adolescents as well as in younger children are language disorders and learning disabilities. Subtle forms of such difficulties are frequently missed by school personnel if a child is acting out intense frustration in a socially unacceptable manner.

A number of epidemiological features have been described for school refusal. Boys are more commonly truant, whereas school refusal occurs equally in boys and girls. It seems to have a bimodal distribution being most frequent in young children and early teens. It does happen in families with no discernable difference in approach to chores, socializing, and travel. Interestingly, parents may be older, raising the issue of parental difficulty separating from a "precious" child. Children of agoraphobic women, who are afraid to leave their homes, are more likely to refuse to attend school. Children of agoraphobic women can also be highly competent and serve as the mother’s link to the outside world. Thus, factors in the child must be evaluated even when a parent is impaired. Contrary to one popular idea, only children are not affected more frequently than children with siblings. A child may begin refusing to attend school without apparent precipitating factors, but a change in school, especially with intensified academic demands, can precipitate symptoms. Other stressful events at home or in the peer group may also be associated with onset of school refusal. These children may simply avoid particular days that are most stressful, usually after weekends or holidays.

A range of psychiatric diagnoses can be responsible for or associated with school refusal. The following are most commonly found alone or in combination in school refusal clinic samples: separation anxiety disorder, generalized anxiety disorder, major depression, or dysthymic disorder, a subacute depression of at least one year’s duration in children and adolescents. In community sample studies, the practice of interviewing parents about children makes it difficult to ascertain the validity of estimates of anxiety and depressive symptoms because parents may underestimate these symptoms in the face of difficult behavior.

Children who are simply school refusing rarely present with associated conduct disordered, or antisocial, behavior such as significant stealing, fire setting, cruelty, running away, or substance abuse. This distinction can be difficult to make in adolescents who may have developed some deviant behaviors as a response to unrecognized or untreated recurrent depression. A sympathetic approach to the adolescent, inquiring about irritability, difficulty concentrating, and morbid thoughts or hopelessness, may facilitate an appropriate referral. It is important to remember that several studies have found more severe, but treatable, anxious and depressive psychopathology in school refusers who are entering adolescence.

Some parents are irresponsible about their children’s school attendance. Thus, it is important to ask what efforts the parents have made to ensure that the child goes to school. Ian Berg has demonstrated a clear connection between absence from school and poor social circumstances, as well as lack of parental interest in the child’s education, in studies of community samples. By the time most parents bring this problem to a physician’s attention, they have tried to make the child attend school; however, they may not have completely accepted the extent of the child’s psychological difficulties. That is especially understandable when the reaction is almost entirely confined to the situation of having to attend school, is expressed as refusal and determined resistance without the obvious fearfulness, or is mainly in the form of vague physical complaints without any discernable cause. Other parents may focus on the above complaints in the pediatrician’s office, but are actually afraid of putting too much pressure on an anxious or depressed child. In either case, parents are coming to their pediatrician for support in facing these difficulties and help with a referral. That usually becomes apparent as the symptoms of anxiety and depression are systematically reviewed.

The principal aim of treatment is return to school because many of these children substantially improve once regular school attendance is restored. One major issue in treatment can be convincing parents that early return to school is important and necessary. They may think that there is something wrong with the school or that the child is too ill to go to school. Systematic desensitization may help. That may take the form of one to two weeks of gradual reintroduction to school. Parents should be consistent in taking the child to school and picking him up when promised. The parent may need to accompany the young child initially for part of the day and then gradually move further away and be there for only a brief time.

There is ongoing scientific scrutiny of the efficacy of newer agents for the various disorders that express as school refusal, but results of studies of medical management of school refusal per se remain inconclusive. Also, the most current pharmacological management is off-label and is most prudently approached by a referral to a child and adolescent psychiatrist.

Placement in a special school or residential environment is rarely necessary to ensure attendance by these children unless there is significant associated psychiatric illness in the child or parent.

Finally, the most difficult issue to address in a pediatric setting is the parent who is having difficulties in separation from the child. Such parents will need considerable support to remain in treatment. They may need more than one referral as they may find fault with even the most sensitive psychotherapeutic efforts to return their child to school.

FOR FURTHER READING

1. Allen AJ, Leonard H, Swedo SE: Current knowledge of medications for the treatment of childhood anxiety disorders. J Am Acad Child & Adolesc Psychiatry 1995;34:976–986.

2. Berg I, Butler A, Franklin J, Hayes H, Lucas C, Sims R: DSM-III-R disorders, social factors and management of school attendance problems in the normal population. J Child Psych and Psychiatry 1993;34:1187–1203.

3. Naylor MW, Staskowski M, Kenney MC, King CA: Language disorders and learning disabilities in school-refusing adolescents. J Am Acad of Child & Adolesc Psychiatry 1994;33:1331–1337.

TOP