Children's Hospital Colorado
Pediatric Mental Health Institute
Pediatric Mental Health Institute
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School Refusal Intervention

The modern academic load, heavy with homework, tests, projects and presentations can be stressful for many children. But for some children, simply attending school can be a daily struggle. Understanding the basics of school refusal and when to intervene are the first steps in preventing negative outcomes due to prolonged school absences.

What is school refusal?

Just as most adults may occasionally contemplate calling into work "sick," children may attempt to avoid school to skip a math quiz, test limits or simply for a break. However, school refusal refers to a more severe and consistent pattern of child-motivated refusal to attend school and/or difficulty remaining in classes for an entire day. These children may be completely absent from school, initially attend but leave early, attend school after behavioral problems in the morning (i.e. somatic complaints, tantrums) or exhibit clear distress on school days and plead to remain home.

Why do children refuse school?

All behavior happens for a reason: typically, it leads to more of something kids like or less of something they don't like. School refusal is no different. Research has identified four main reasons why a child may refuse to go to school:

  • To avoid situations at school that cause distress
    • Often observed in younger children who have a hard time identifying the specific source of school anxiety and want to avoid school completely
    • Common behaviors: somatic complaints, tardiness, constant pleas to stay home
  • To escape evaluation and/or school-based social situations
    • More common in older children and adolescents who are becoming acutely aware of the evaluative component of school (i.e. tests, oral presentation) and/or social situations (i.e. fitting in with peers, eating in the cafeteria)
    • Often presents during transition to middle or high school when children have to assimilate to new structures and demands
  • To gain attention from preferred adults/others (i.e. parents, grandparents, peers)
    • Most common for children age 5 to 9 who want to remain home to be with parents
    • Common behaviors: tantrums, running away from school, noncompliance
  • To have access to preferred out-of-school activities
    • Children refuse school to engage in more enjoyable activities (i.e. watching TV, playing video games)
    • These children often struggle with oppositional, defiant and/or rule-breaking behavior

In each of these cases, if children can avoid school they are inadvertently rewarded, either by reducing school anxiety or engaging in preferred activities. The longer a child is out of school, the stronger this reinforcement becomes and the harder it can be to reintegrate a child into school.

Early school refusal intervention and assessment

Early identification and intervention for school-refusing children is critical. Unaddressed school refusal has been linked to poor academic performance and peer and family relationship problems.

Assessment of school refusal behavior typically involves measuring days or periods of time a child is out of school. To start, ask for daily feedback from the school, talk with the teacher or counselor about their observations and look for patterns of absences. Additionally, a provider may administer the School Refusal Assessment Scale- Revised, a self- and parent-report measure that can help identify school avoidance and what might be driving this behavior.

Tips to give parents whose child refuses school

Students with school refusal often benefit from a consistent morning routine that evokes feelings of predictability and control. Incorporating calming activities into morning routines either at home, school or both can help families avoid problems with school refusal.

Many students also benefit from 'trial runs.' Review schedules, practice the drive to school or request to visit the school before the year begins or after the school day ends to practice. Providers can also advise parents to allow their child to remain at school for the entire expected time, regardless of their behavior or complaints. Allowing the student to escape school before the expected time will likely increase their distress the next time they face a similar situation. Consequences to school avoidance should be clear, consistent and non-rewarding. On missed days, students should not be allowed to engage in preferred activities, like video games or movies, and should instead be required to read, do homework or complete chores.

Lastly, providers should encourage families to build on small successes. Let parents know they can praise behaviors they want to increase and build slowly up to grade- or age-level expectations.

When to refer patients for school refusal

School refusal can be difficult to manage independently. Families struggling with this behavior may benefit from work with a mental health professional who can help identify and address the reason a child is avoiding school.

However, sometimes outpatient treatment is not enough. If a child is exhibiting prolonged school refusal behavior, the Partial Hospitalization Program at Children's Hospital Colorado can help. It is a 30-hour-a-week intensive, collaborative treatment program operated under the guidance of Children's Colorado's Pediatric Mental Health Institute. The program aims to identify reasons for school refusal, develop a comprehensive treatment plan to address school refusing behavior and help transition kids back into an academic environment. For more information, call our Partial Hospitalization Program intake coordinator at 720-777-7794.

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