School anxiety and school refusal are experienced by around 28% of children and can negatively impact both academic and social functioning. As a consequence of the Covid-19 pandemic, the incidence rates of school refusal have increased within the last few years and prevalence rates of school-related anxieties surged once students were able to resume in-person learning. Our school and mental health systems are continuing to feel the ripple effects of this rise in school anxiety. The start of a new school year can signal an increase in school-related anxieties and precipitate increases in school refusal rates. School refusal is generally a multi-layered issue, but it can be successfully addressed and treated with the help of a mental health professional. The following article will provide some information on school anxiety and school refusal and the treatment process will be outlined.

School refusal is a behavioral symptom of anxiety. It is not a formal psychiatric diagnosis, but it can occur alongside of a variety of mental health conditions, learning problems, and medical issues. School anxiety often co-occurs with anxiety disorders, Obsessive-Compulsive Disorders, depression, learning disabilities, chronic pain, and autoimmune disorders (among other issues). While anxiety disorders are twice as common in females as compared to males, prevalence rates for school anxiety and refusal are equal amongst boys and girls. Peak times for school anxiety and refusal to present include the transitions into kindergarten, junior high, and high school. These peak times are concurrent with developmental milestones (such as entering puberty), increased academic demands, increased importance of peer interactions and relationships, and a host of other novel situations. Times of transition and change (whether positive or negative) can increase the baseline level of stress, which may permeate into anxiety territory. Potential warning signs that may point to the presence of school anxiety and the possibility that school refusal behaviors will be demonstrated include:

• Irregular attendance, increased truancy
• Increased physical complaints and/or sleep disturbances
• Frequent visits to the school nurse and/or calls home
• Increased reliance on parents, which may be developmentally inappropriate
• Complaints of feeling “stressed out” and overwhelmed
• Low motivation/procrastination on schoolwork, missing/incomplete assignments
• Spending excessive amounts of time on schoolwork and studying (may or may not include neglect of other important activities)
• Being easily triggered by school-related reminders, particularly on Sundays, towards the end of winter and spring breaks, and during the month of August
• Negative comparisons of self against peers and having unrealistic expectations
• Social isolation and/or negative peer interactions both inside and outside of school and on social media

Students will identify many reasons why they cannot attend school, with some of the most common reasons being physical complaints and sleep issues. Around 80% of students who display school refusal behaviors will claim that they are too ill (stomachache, headache, etc.) and/or too tired to go to school. Poor sleep often exacerbates anxious symptoms and physical complaints. Half of these students will endorse experiencing daily physical symptoms and/or nightly sleep disturbances. It is not uncommon for anxiety to manifest as physical symptoms, especially in younger children who generally do not have the language capacity to articulate their emotional experiences. Often, there will be a remittance of symptoms over the weekend (until Sunday night rolls around). Other children and teens may worry about their academic performance and claim that they are not prepared to give their presentation, submit their paper, take the exam, etc. Some students may identify interpersonal reasons for not attending school, such as bullying, not fitting in, not having anyone to sit with during lunch, fighting with peers, etc.

One of the primary functions of school refusal is avoidance. Students may be attempting to avoid negative emotions (anxiety, fear, boredom, sadness), uncomfortable physical sensations (often resulting from anxiety), aversive social situations, negative evaluation by peers and/or teachers, etc. The problem with avoidance is that it breeds more avoidance, which inflames anxiety and consequently increases the difficulty of returning to school. In some cases, children and teens may be obtaining a secondary gain from missing school, such as receiving special attention from parents, being able to access their devices all day, getting to eat special/favorite foods, not having to do homework or chores, etc. In essence, staying home from school is negatively reinforcing (please see our previous blog entry – Understanding the Cycle of Anxiety – for further information), which means that the individual is obtaining some sort of benefit from the behavior. In the case of school anxiety and school refusal, the benefit that is experienced is the decline of anxious feelings that results from being able to remain at home during the school day. Unfortunately, this negative reinforcement also promotes the message that: “The only way I can deal with my anxiety is to avoid school.” Whatever reason is cited for missing school, it is important to remember that repeated absences will only compound the original problem and will likely cause more problems to arise in the long run. Furthermore, none of the cited reasons can be successfully resolved by remaining at home.

The treatment for school anxiety and school refusal is a multi-pronged approach that consists not only of therapeutic interventions, but also incorporates interventions at both school and at the individual’s home. It requires close collaboration between mental health professionals, parents/family, and teachers and school counselors/social workers/psychologists. Home-based interventions focus on modifying the home environment and parents’ responses to school anxiety and school refusal so that the atmosphere is non-reactive and facilitates school attendance. Nighttime and morning routines are adjusted to make things as organized and streamlined as possible (and therefore less likely to be derailed by anxiety or acting-out behaviors). Parents are taught how to respond (and how to refrain from responding) to behaviors exhibited by their child or teen in their attempts to remain at home. An important part of home-based interventions is the development of a rewards and contingency system to help motivate the child or teen to work towards achieving the treatment objectives.

School-based interventions are an integral part of the treatment to address school anxiety and school refusal. The overarching goal is to resume school attendance as soon as possible. At first, this may require a scaled back target, whereby the child or teen only attends a single class. Time in school is steadily increased (generally every two to three days). Mental health professionals work closely with schools to develop an alternative schedule for students as they are building up the time they spend in the school building. Therapists coach teachers on how to respond to anxiety behaviors displayed in school. It is key that the child/teen receives consistent responses from all of the involved adults (therapist, teachers, parents, coaches, etc.). Within the classroom, students may require interventions such as preferred seating (near the door, back of the class, or near the teacher), access to their coping skills, having a nonverbal signal to make the teacher aware that they need a break, creating a structured plan to catch up on missed assignments, etc.

Therapy-based interventions consist primarily of Exposure and Response Prevention (ERP) with the aim of full attendance at school (please see our previous blog entry — What is Exposure and Response Prevention (ERP) – for more information about this treatment). A rewards and contingency system is implemented to aid progression towards attainment of goals. Parent training is highly emphasized during treatment. Therapists will often travel to the family’s home in the mornings to help coach parents in the moment as they help their child to prepare for the upcoming school day. Mental health professionals address other co-occurring conditions and school-related challenges that are contributing to or showing up alongside of school anxiety. Thus, in addition to ERP, treatment may focus on stress management, problem solving skills, emotion regulation, distress tolerance skills, pain management, social skills, improving study habits, etc.

The overarching goal of this three-pronged approach to treatment is to support the child or teen, NOT to support his/her anxiety. Often parents and/or teachers may have a difficult time enforcing expectations when they observe that the child or teen is emotionally distressed or struggling in some other way. Responding with increased accommodation, frequent communication about distress, inconsistent follow through, early pick-ups from school, etc. are all well-intentioned responses, but actually serve to strengthen the anxiety. The only way out of anxiety is to go through it by learning to confront one’s fears and use strategies to work through the discomfort. Thus, the treatment for school anxiety (and other anxiety conditions) requires a big picture perspective: What is best for the child or teen in the long run? How can we best support his/her growth? The reality is that no one can be happy or healthy when they are unable to function in important life areas. Therefore, the student, teachers and school personnel, parents, and mental health professionals need to work collaboratively to effectively address anxiety and remove the obstacles standing in the way of healthy academic and/or interpersonal functioning. Above all, treatment must strive to empower the student and build his/her confidence to tackle school anxiety as well as any other challenges that may arise.

Working closely with a mental health professional at The OCD & Anxiety Center in Oak Brook and Orland Park, IL can help to manage school-based and other various types of anxieties. Effective mental health care is instrumental to not only improving health and overall well-being, but also enhancing functioning in important life areas, such as academic functioning and social engagement. To address obstacles standing in the way of school attendance and to increase successful academic engagement, please contact our office at (630) 522-3124 and schedule your first appointment with one of our anxiety experts.

Click here for more information on Childhood Anxiety Treatment.

Dr. Ashley Butterfield is a licensed psychologist at The OCD & Anxiety Center in Oak Brook, IL.  She specializes in Cognitive Behavioral Therapy and Exposure and Response Prevention Therapy for anxiety, OCD, and anxiety-related disorders. She is comfortable working with children and adults and is able to provide treatment both in the office and outside of the office, wherever anxiety happens.