School Refusal/Avoidance

Dr. Jonathan Dalton, Director of the Center for Anxiety and Behavioral Change in Rockville, MD, explains why kids avoid school and what can be done to help them. He says: “We don’t treat anxiety; we treat avoidance.”

Anxiety-based school refusal is a phenomenon that affects between 5 and 28% of children at some point during their education. It occurs when a child or adolescent experiences a very high level of anxiety/distress when they are asked to attend school. This anxiety results in active avoidance of school (i.e., refuses to attend) or marked distress when they are forced to attend.

School refusal often occurs or worsens following a stressful event, such as a death or illness in the family, divorce or separation, or illness in the child or adolescent that has resulted in an accumulation of missed schoolwork. School refusal is not a diagnosis, it is a symptom, and is associated with many mental health disorders, including:

  • Separation Anxiety Disorder
  • Social Anxiety Disorder
  • Panic Disorder
  • Specific Phobias (including a phobia of vomiting)
  • Adjustment Disorders
  • Post Traumatic Stress Disorder (PTSD)
  • Obsessive Compulsive Disorder

In addition, many youth who actively avoid school have unidentified neurodivergencies such as:

  • Autism
  • Attention Deficit Hyperactivity Disorder (ADHD)
  • Processing Speed Disorders
  • Working Memory Disorders
  • Specific Learning Disorders (Dyslexia, Dysgraphia, Dyscalculia)

We often find that comprehensive assessment of school-avoiding youth to examine the possibilities of these differences  is extremely important in helping to inform an effective intervention plan and to advocate for appropriate school accommodations and/or school placement.  We find that the treatment approaches and interventions need to be very different for our neurodivergent youth than our neurotypical youth.  Since the pandemic, approximately half of the youth who present to CABC for treatment have (often unidentified) neurodivergencies.

In addition, we commonly work with children and teens who experience school avoidance in the context of:

  • Dysautonomia (POTS)
  • Ehler-Danlos Syndrome (EDS)
  • Autoimmune Disorders (especially Narcolepsy and related disorders)
  • Chronic Pain (especially Chronic Daily Migraine)
  • Abdominal Pain (IBS, IBD, Idiopathic Pain, etc.)
  • Nerve Pain (neuropathy)
  • Chronic Fatigue Syndrome

Helping the child and their family learn the often counterintuitive approaches to helping youth with chronic health conditions maintain school attendance while honoring their suffering  is paramount in helping these individuals return to the rhythm of life, including all the benefits of attending school.

We offer a comprehensive treatment program for school refusal, which consists of four main components. These components include specialized assessment of the school refusal, child-focused behavioral treatment, parent management training, and school consultation.

During the assessment phase, care is taken to understand the nature of the anxious avoidance, the underlying function(s) of the school refusal, and to provide diagnostic clarification. The child-focused treatment consists of psychoeducation, coping skills training, and direct exposure (in a controlled, gradual format) to situations that the child/adolescent fears. Parent management training (PMT) is conducted in a 6-week parent group and provides education to parents regarding evidence-based skills and techniques that can be utilized (many of which are counterintuitive) to help reduce the child’s experience of anxiety and to improve school attendance. Lastly, the school consultation component consists of a school meeting and to discuss specific methods and accommodations that the school personnel can utilize to assist the child in their rapid reintegration into school, and ongoing consultation to maintain school attendance.