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.
Anxiolytics or antidepressants. Pharmacotherapy research for school refusal behavior is in its infancy. Some investigators have found, however, that a tricyclic antidepressant (TCA) such as imipramine, 3 mg/kg/d, may be useful in some cases20,21—generally for youths ages 10 to 17 years with better attendance records and fewer symptoms of social avoidance and separation anxiety.22 Researchers speculate that TCAs, which are not always effective in children, may influence symptoms such as anhedonia or sleep problems that contribute to school refusal behavior.
With respect to substantial child anxiety and depression without school refusal behavior, researchers have focused on selective serotonin reuptake inhibitors (SSRIs). In particular, fluoxetine, 10 to 20 mg/d, fluvoxamine, 50 to 250 mg/d, sertraline, 85 to 160 mg/d, and paroxetine, 10 to 50 mg/d, have been useful for youths with symptoms of general and social anxiety and depression.23,24
Youths often do not respond to these medications as well as adults do, however, because of the fluid and amorphous nature of anxious and depressive symptomatology in children and adolescents. Careful monitoring is required when treating youth with SSRIs, which have been associated with an increased risk of suicidal behavior.
Psychological techniques. Sophisticated clinical controlled studies have addressed the treatment of diverse youths with school refusal behavior.25-28 Options for this population may be arranged according to function or the primary reinforcers 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 ages 9 to 17), 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 behavior2 and are useful for treating general anxiety and depression 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 (such as 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 general29 but have been applied less frequently than child-based techniques to youths with school refusal behavior.
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.30 As with parent-based techniques, family-based techniques have received strong support in the literature in general, but have been applied less frequently than child-based techniques to youths with school refusal behavior.
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 regular classrooms may then proceed.
If possible, a child should remain in school during the day and not be sent home unless intense medical symptoms are present.30 A recommended list of intense symptoms includes:
- frequent vomiting
- temperature >100° F
- severe diarrhea
- acute flu-like symptoms
- extreme medical conditions such as intense pain.
Case continued: a full-time student.
A structured diagnostic interview and other behavioral assessment measures show that Nathan meets criteria for generalized anxiety disorder. He worries excessively about his social and academic performance at school and displays several somatic complaints related to anxiety. His treatment thus involves a two-pronged approach:
- sertraline, 50 mg/d, which has been found to significantly reduce symptoms of generalized anxiety disorder in youths ages 5 to 17.
- child-based anxiety management techniques and family therapy to increase incentives for school attendance and limit fun activities during a school day spent at home.
His therapist and family physician collaborate with school personnel to gradually reintroduce Nathan to a full-time academic schedule.
- Copies of the child and parent versions of the School Refusal Assessment Scale-Revised are available at www.jfponline.com/Pages.asp?AID=4322&UID=.
- King NJ, Bernstein GA. School refusal in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2001;40:197-205.
- Kearney CA. School refusal behavior in youth: a functional approach to assessment and treatment. Washington, DC: American Psychological Association; 2001.
- Kearney CA, Albano AM. When children refuse school: a cognitive-behavioral therapy approach. Parent workbook/therapist’s guide. New York: Oxford University Press; 2000.