When A Child Refuses To Go To School

The fear of going to school was first termed as « school phobia »in 1941.
An alternative term, « school refusal » was used in Great Britain later.
It affects 1-5 % of all school-aged children with an equivalent sex distribution (rate similar between girls and boys).
It is most frequent in children aged 5 to 6 years and 10 to 11 years but it can occur at all ages.
It can affect all socio-economic classes.

Features
This is a serious emotional problem that is stressful for children, families and school personnel.
It. has important sequels on the child's social, emotional and educational development.
It is characterized by the following :

• The child displays moderate to severe emotional distress about attending school. He may manifest body symptoms like headache, abdominal pain, dizziness, palpitations, chest pain, etc…
  He can also have anxiety, fearfulness, panic attacks, temper tantrums, etc…
  Some children start experiencing the symptoms at home, some others are able to leave the house but they have new onset or worsening of manifestations when the bus gets near the school.
  The child gets better if he is allowed to stay or to return home. However, he can have the same symptoms the next morning if he is obliged to go to school.
  These symptoms have gradual onset, they might begin after a prolonged stay at home such as after an illness, a holiday or a vacation.
  Stressful events at home or school or with peers may contribute to school refusal.
  The longer the child stays out of school, the more difficult it is for him to return.

• The child does not try to conceal absence from his parents.
• The latter are aware of his absence and the child tries to persuade them to allow him to stay home
• During school hours, the child usually stays home because it is considered a safe and secure environment.
• The child is very willing to do school work and he complies with completing work at home.
• The child does not have significant antisocial behaviors such as juvenile delinquency, stealing or lying.

Consequences

Short term sequels include :
Poor school performance
Family difficulties
Problems with peer relationships .

Long term sequels include :
Academic underachievement ,
Employment difficulties ,
Increased risk for psychiatric illness such as anxiety or depression.

Causes

School refusal should be considered as a multi-causal syndrome.
It may serve different functions depending on the individual child:

- The child may try to avoid specific fears provoked by the school environment like test taking ...

- He may be trying to escape from some social situations like problems with classmates or teachers.

- He may be experiencing separation anxiety from caregivers or he may be manifesting attention seeking behaviors like crying spells or somatic complaints.

These manifestations worsen over time if the child is allowed to stay home

Problems with family functioning contribute to school refusal among children.

Evaluation

Evaluation of children with school refusal should involve multiple aspects including:

Medical history and physical examination with appropriate tests to make sure that the body or somatic symptoms are not caused by some organic problem.

• School history and peer relationships
• Associated stressors
• History of onset and development of school refusal symptoms.
• Interview with the child and family
• Identification of specific factors responsible for school avoidance.

Collaboration with school staff in regards to assessment and treatment is necessary for successful management.

Treatment

The primary goal for children with school refusal is early return to school.

Physicians should avoid writing excuses for children to stay out of school unless a medical condition makes it necessary for them to stay home.

The physician should also explain the physical symptoms the child might be experiencing are a manifestation of a psychological distress rather than an organic illness.

When a child is younger and displays minimal symptoms of fear, anxiety and depression working directly with parents and school personnel without direct intervention with the child may be sufficient treatment.

If the child's difficulties include prolonged school absence, deficits in social skills, child therapy with parents and school staff involvement is indicated.

Treatment options include:

• education and consultation
• behavioral strategies such as graded exposure to school environment
• family intervention
• Possible pharmacotherapy, which is used in combination with the above modalities.

It is important to remember that early recognition and intervention are crucial for a good outcome.