Applied Evidence

Dealing with school refusal behavior: A primer for family physicians

Author and Disclosure Information



Treating youths with school refusal behavior

Should you choose to address more than a diagnosed physical condition contributing to school refusal behavior, various resources are available to you. Medications have proven useful in alleviating severe cases of anxiety and depression. And cognitive management techniques can be applied to the child, the parents, and the family together.

Treatment success will be better assured, too, if you work closely with school personnel and a clinical child psychologist to gather and share information, coordinate a plan for returning a child to school, and address familial and comorbid psychological problems that impact attendance.

When to consider anxiolytics or antidepressants

Pharmacotherapy research for school refusal behavior is in its infancy. However, some investigators have found that tricyclic antidepressant such as imipramine may be useful in some cases20-21—generally for children with better attendance records and fewer symptoms of social avoidance and separation anxiety.22

With respect to substantial child anxiety and depression without school refusal behavior, researchers have focused on selective serotonin reuptake inhibitors. In particular, fluoxetine, fluvoxamine, sertraline, and paroxetine have been useful for youths with symptoms of general and social anxiety and depression,23,24 However, youths often do not respond to these medications as well as adults because of the fluid and amorphous nature of anxious and depressive symptomatology in children and adolescents.

Useful psychological techniques

Sophisticated Level 1 clinical controlled studies on treatment of diverse youths with school refusal behavior have appeared in recent literature.25-28 Options for this population may be generally arranged according to function or the set of reinforcers primarily maintaining absenteeism:

  • Child-based techniques to manage anxiety in a school setting
  • Parent-based techniques to manage contingencies for school attendance and nonattendance
  • Family-based techniques to manage incentives and disincentives for school attendance and nonattendance.

Child-based anxiety management techniques include relaxation training, breathing retraining, cognitive therapy (generally for youths aged 9–17 years), and exposure-based practices to gradually reintroduce a child to school. These techniques have been strongly supported by randomized controlled trials specific to school refusal behavior (see above) and are useful for treating general anxiety and depression in these youths as well.

Parent-based contingency management techniques include establishing morning and evening routines, modifying parental commands toward brevity and clarity, providing attention-based consequences for school nonattendance (eg, early bedtime, limited time with a parent at night), reducing excessive child questioning or reassurance-seeking behavior, and engaging in forced school attendance under strict conditions. Parent-based techniques have received strong support in the literature in general, but have been applied specifically to youths with school refusal behavior less frequently than child-based techniques.

Family-based techniques include developing written contracts to increase incentives for school attendance and decrease incentives for nonattendance, escorting a child to school and classes, and teaching youths to refuse offers from peers to miss school.29 As with parent-based techniques, family-based techniques have received strong support in the literature in general, but have been applied specifically to youths with school refusal behavior less frequently than child-based techniques.

Gradual reintroduction to school

A preferred approach to resolve school refusal behavior usually involves gradual reintegration to school and classes. This may include initial attendance at lunchtime, 1 or 2 favorite classes, or in an alternative classroom setting such as a guidance counselor’s office or school library. Gradual reintegration into a regular classroom setting may then proceed.

If possible, a child should remain in the school setting during the day and not be sent home unless intense medical symptoms are present.30 A recommended list regarding the latter includes frequent vomiting, bleeding, temperature greater than 100°F, severe diarrhea, lice, acute flu-like symptoms, or an extreme medical condition such as intense pain.

The outcome for Nathan

Using a structured diagnostic interview and other behavioral assessment measures, Nathan’s psychologist concluded that the teenager met criteria for generalized anxiety disorder. He worried excessively about his social and academic performance at school and displayed several somatic complaints related to anxiety. His treatment thus involved a two-pronged approach.

Nathan’s physician placed him on a regimen of sertraline, 50 mg/d, which has been found to significantly reduce symptoms of generalized anxiety disorder in youths aged 5 to 17 years. In addition, Nathan’s psychologist implemented child-based anxiety management techniques as well as family therapy to increase incentives for school attendance and limit fun activities during a school day spent at home. The physician and psychologist collaborated with school personnel as well to gradually reintroduce Nathan to a full-time academic schedule.


Next Article: