School Refusal and Avoidance in Youth

School refusal is fairly common in children and adolescents, with approximately 5% to 28% of youth engaging in school refusal at some point. These difficulties present fairly equally across sex, race and socioeconomic groups. Although school refusal can potentially present at any time, it is most common during times of transition, such as during a divorce or when starting middle or high school.

Mental health comorbidities are common in youth who are refusing to attend school, with approximately 50% of these youth also meeting criteria for a mental health diagnosis. The most common mental health comorbidities include separation anxiety disorder, generalized anxiety disorder, depression, attention-deficit/hyperactivity disorder (ADHD), learning disorders and oppositional defiant disorder. When left untreated, youth who engage in school refusal are at risk for a variety of negative life outcomes, including academic underachievement, school dropout, social isolation and poorer physical and mental health.

Screening for School Refusal

The most evidence-based approach to assessing and treating school refusal is based in a functional model. This model focuses on understanding and treating the function of the behavior. That is, what variables can explain why a patient is refusing to attend school? Kids and teens tend to avoid school for one or more of the following reasons:

1. Avoiding things and situations that provoke negative emotions
   • This might include avoiding school because they experience strong negative emotions or somatic symptoms at school.
   • Youth in this category are often struggling with mental health comorbidities, particularly anxiety and depression.
2. Escape from averse social and evaluative situations
   • An example might be avoiding school due to difficulties with peers and bullying, anxiety about group activities and stress with evaluative situations (such as tests).
   • Youth in this category are more frequently struggling with learning or intellectual disabilities, social difficulties, anxiety and depression.
3. Attention
   • A child might want to avoid school if it allows them to receive attention from primary caregivers.
   • Youth in this category often exhibit more problematic behaviors in the morning as well as more problematic behavioral difficulties overall.
4. Positive tangible reinforcement
   • Sometimes a child won’t go to school in favor of more preferable activities, such as hanging with friends, watching TV and sleeping.
   • This category is often associated with the most chronic school refusal behaviors and is regularly associated with family conflict and problematic family dynamics.

One particularly effective tool for screening youth for school refusal is the School Refusal Assessment Scale, which is a free online resource. Kids and parents can complete this 24-item screening measure to assess the possible presence of each of the functional conditions listed above.

Treatment for School Refusal

If a patient is positively identified as engaging in school refusal, pediatric providers should develop interventions based on the function of the school refusal. For example, if a child is refusing to attend school because they get attention from parents when they stay home, speak with parents about reducing the attention they are giving their child for their school refusal. Help parents develop a system that allows their child to earn one-on-one attention for successfully attending school.

If a child is missing school because of academic difficulties, partnering with the school to ensure they are getting the necessary academic supports is critical. If a child is missing school because of access to tangible reinforcers, such as video games, encourage parents to restrict access to these when a child is refusing to attend school. Any subsequent access would be contingent on school attendance. Additional ideas for parents to prevent or address school refusal in their child include:

• Maintaining clear expectations that their child attend school regularly. This is the most important advice providers can give parents related to school refusal. It is also very important that providers not give school excuse letters for patients who are engaging in school refusal.
• Keep goodbyes short and positive.
• During times of high stress or transitional periods, keep schedules and expectations consistent.
• Provide the child with rewards and positive attention for good behavior, rather than only reacting when the child begins engaging in behaviors they should not.
• Eat meals as a family and engage in regular check-ins with the child to see how things are going at school.

If a child continues to present with significant school refusal behaviors after implementing the above recommendations, providers should consider referring the patient to receive mental health treatment. Well-established treatments for school refusal are very effective in reducing these concerns in youth.

Cognitive behavioral treatment is the most effective approach. This involves teaching a child and parent specific skills that can help the child learn to cope with the thoughts, emotions and behaviors associated with their school refusal.

Systematic desensitization is typically a core component of treatment, as is contingency management. It may be necessary to explore treatment for psychiatric comorbidities, including medication management, as well as establishing appropriate academic interventions, such as an individualized education plan (IEP) or 504 plan. If providers are concerned about a patient and would like to make a referral for psychiatric evaluation and treatment, they can refer families to the following:

• Children’s Hospital Colorado’s Pediatric Mental Health Institute provides evidence-based, family-focused comprehensive mental health services. For more information, providers can call 720-777-6200.
• For additional Colorado mental health services, visit the behavioral health webpage for the Colorado Department of Human Services.

Additional Resources for school avoidance

• Society of Clinical Child & Adolescent Psychology
• American Academy of Child & Adolescent Psychiatry
• National Association for School Psychologists