Applied Evidence

Dealing with school refusal behavior: A primer for family physicians

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Workable solutions for unhappy youth and frustrated parents.


 

References

 

Practice recommendations

 

  • You can help assess forms of a child’s school refusal behavior as well as reinforcers that maintain the problem (B).
  • All youths with school refusal behavior should be assessed for severe anxiety and depression (C).
  • You can treat medical conditions associated with school refusal behavior, provide pharmacotherapy for severe anxiety and depression, and work with school-based personnel and a clinical child psychologist to gradually reintroduce a child to school and address comorbid educational, psychological, and familial problems (A).

Nathan is a 13-year-old boy referred by his parents to a family physician for recent school refusal behavior. Nathan has had difficulty adjusting to middle school and has already been marked absent one-third of school days this academic year. These absences have come in the form of tardiness, skipped classes, and full-day absences. Nathan complains of headaches and stomachaches and says he feels upset and nervous while in school. His parents, however, complain that Nathan seems fine on weekends and holidays and seems to be embellishing symptoms to miss school. Nathan’s parents are concerned that their son may have some physical or mental condition that is preventing his school attendance and that might be remediated with medication.

Child-motivated refusal to attend school or to remain in classes for an entire day is not that uncommon. The problem affects 5% to 28% of youths at some time during their lives and is often referred first by parents to the attention of a family physician.1-2

The behavior may be viewed along a spectrum of absenteeism ( FIGURE), and a child may exhibit all forms of absenteeism at one time or another. In Nathan’s case, for example, he could be anxious during school on Monday, arrive late to school on Tuesday, skip afternoon classes on Wednesday, and fail to attend school completely on Thursday and Friday.

In this article you will learn characteristics of school refusal behavior to watch for and assess, and treatment strategies for youths aged 5 to 17 years. You will also find advice and techniques to offer parents.

FIGURE
A child may exhibit each behavior on this spectrum at different times

Characteristics of youths with school refusal behavior

School refusal behavior is a term than encompasses all subsets of problematic absenteeism, such as truancy, school phobia, and separation anxiety.3 Children and adolescents of all ages, and boys and girls alike, can exhibit school refusal behavior. The most common age of onset, however, is 10 to 13 years. In addition, youths who are entering a school building for the first time, especially elementary and middle school (as was the case for Nathan), are at particular risk for school refusal behavior. Little information is available regarding ethnic differences, although school dropout rates for Hispanics are often considerably elevated compared with other ethnic groups.4-5

 

School refusal behavior covers a range of symptoms, diagnoses, somatic complaints, and medical conditions (TABLES 1-3).6-12 Longitudinal studies indicate that, if left unaddressed, school refusal behavior can lead to serious short-term problems such as distress, academic decline, alienation from peers, family conflict, and financial and legal consequences. Common long-term problems include school dropout, delinquent behaviors, economic deprivation, social isolation, marital problems, and difficulty maintaining employment. Approximately 52% of adolescents with school refusal behavior meet criteria for an anxiety, depressive, conduct-personality, or other psychiatric disorder later in life.13-16

TABLE 1
Common symptoms that could signal school refusal behavior

 

INTERNALIZING/COVERT SYMPTOMEXTERNALIZING/OVERT SYMPTOM
DepressionAggression
Fatigue/tirednessClinging to an adult
Fear and panicExcessive reassurance-seeking behavior
General and social anxietyNoncompliance and defiance
Self-consciousnessRefusal to move in the morning
SomatizationRunning away from school or home
WorryTemper tantrums and crying

TABLE 2
Primary psychiatric disorders among youths with school refusal behavior

 

DIAGNOSISPERCENTAGE
No diagnosis32.9
Separation anxiety disorder22.4
Generalized anxiety disorder10.5
Oppositional defiant disorder8.4
Major depression4.9
Specific phobia4.2
Social anxiety disorder3.5
Conduct disorder2.8
Attention deficit/hyperactivity disorder1.4
Panic disorder1.4
Enuresis0.7
Posttraumatic stress disorder0.7
Source: Adapted from Kearney and Albano (2004).

TABLE 3
Rule out these somatic complaints and medical conditions commonly associated with school refusal behavior

 

SOMATIC COMPLAINTMEDICAL CONDITION
Diarrhea/irritable bowelAllergic rhinitis
FatigueAsthma and respiratory illness
Headache and stomachacheChronic pain and illness (notably cancer, Crohn’s disease, dyspepsia, hemophilia, chronic fatigue syndrome)
Nausea and vomitingDiabetes
Palpitations and perspirationDysmenorrhea
Recurrent abdominal pain or other painHead louse infestation
Shaking or tremblingInfluenza
Sleep problemsOrodental disease

Getting to the bottom of school refusal behavior

If a child has somatic complaints, you can expect to find that the child is (1) suffering from a true physical malady, (2) embellishing low-grade physical symptoms from stress or attention-seeking behavior, or (3) reporting physical problems that have no medical basis. A full medical examination is always recommended to rule out organic problems or to properly treat true medical conditions.

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