Ten top tips - school refusal

1. Clarify whether this is school refusal or truanting

School refusal is not a psychiatric disorder but a pattern of behaviour with many causes. It is the refusal to attend school usually staying at home, with parental knowledge, where the child feels safe. Truanting is leaving school, usually without parental knowledge, commonly with friends. Children who truant are not scared to go to school in the same way that children with school refusal are and they may show other antisocial behaviours e.g. lying and stealing.

School refusal occurs in 1-5% of all school aged children¹. The rate is similar between sexes² and peaks at three ages – at 5-7 years with starting school, at 11 years with transition to secondary school and at 14 years and older.³

2. Complete a comprehensive assessment

This should include interviews with the parents and child together and then individually. The history should include any difficulties in school, issues within the family and psychiatric history. A physical examination should be performed to exclude underlying physical illness (see tip five). Additional information from school, such as attendance records, would aid assessment.

3. Consider using a child specific rating scale

Scales to assess symptoms of anxiety and depression in children may be used. Examples include the mood and feelings questionnaire (MFQ) and the Spence children’s anxiety scale (SCAS). These are useful aids to diagnosis and can measure severity over time.

4. Enquire about possible triggers

Examples of triggers include:

a recent period off school due to a physical illness
a transition at school
a recent stressful event e.g. house move, falling out with friends, death of pet or relative.

5. Rule out an underlying physical illness

Children commonly complain of physical symptoms such as headaches, tummy aches and sore throats as a reason to miss school so it is important to exclude physical causes first. Asking parents to keep a diary may help distinguish emotional causes from physical causes. Symptoms may appear on certain days, disappear if the child stays home and they may be absent on weekends.

Remember some physical symptoms can also be due to anxiety or depression.

6. Consider factors within school that may be contributing

Common factors include

bullying
recent arguments with friends or teachers.
if the child is struggling academically.
recent changes of teacher or classroom.

7. Is there an underlying psychiatric disorder?

The most common underlying psychiatric diagnosis is anxiety. This can take the form of a specific phobia (e.g. the bus journey to school, sitting exams, using toilets at school), separation anxiety (fear of leaving a parent), a social phobia (fear of social situations) or a generalised anxiety disorder (anxiety about all aspects of their life).

School refusal can also result from depression, adjustment disorders (e.g. after a bereavement or parental separation) or post traumatic stress disorder. It is important to exclude autism or any underlying learning disability which may lead a child to fear school.

8. Assess whether parents are contributing to the problem

Children may want to stay at home to care for a relative with chronic illness or after a hospital stay. If parents have alcohol or drug dependency problems the child may feel responsible and want to care for them. If there is domestic violence a child may feel the need to protect their parent. Could the child be experiencing abuse and therefore be kept off school to keep it hidden?

Parents may keep their child at home to help with chores or to keep them company. Consider the parent’s mental health and whether their anxiety may be contributing.

9. Give parents advice on supporting their child

Parents must keep encouraging their child to attend school. Advise parents to keep calm and take time to listen to their child’s worries.

The longer an absence from school the more difficult reintegration becomes. Absences cause children to fall behind both academically and socially. Health professionals should not write medical letters justifying school absence. Parents should meet with school staff as soon as possible to plan a reintegration programme. A diary may help detect any patterns, like refusal being more common when certain lessons take place.

10. Refer to Child and Adolescent Mental Health Services (CAMHS) if psychological issues are present

A multi-agency approach will be necessary, including the child and family, GP, school staff and mental health professionals. Treatment options include behavioural strategies, family therapy, specific cognitive behaviour therapy (CBT) for any underlying depression or anxiety and in the most severe cases medication (antidepressants). Medication should be given alongside therapeutic input and not used in isolation.

Dr Kay Harvey is a consultant child and adolescent psychiatrist in Huddersfield, South West Yorkshire Partnership NHS Foundation Trust.

References

Burke AE, Silverman WK. (1987) The prescriptive treatment of school refusal. Clinical psychology review, 7 (4); 353-362
Granell de Aldaz E, Vivas E, Gelfand DM, Feldman L. (1984) Estimating the prevalence of school refusal and school-related fears. A Venezuelan sample. Journal of nervous and mental disease, 172 (12); 722-729
Heyne D, King NJ, Tonge BJ, Cooper H. (2001) School refusal; epidemiology and management. Paediatric drugs, 3 (10); 719-732