Does Your Child Have School Refusal Behaviour Or Just Playing Hookie?

By Dr. C. Farquharson-Deveaux, MD; Family Medicine Specialist, Diplomate, American Board of Family Practice

Summer vacation has ended and schools have re-opened for the new year. For some families the transition is smooth, while for others there may be more of a struggle than in past years, not only financially but also emotionally. One problem that can occur is a child's refusal to go to school. The fear of going to school was initially called 'school phobia' in 1941 and the term 'school refusal' came about more recently to describe problems in children who were so emotionally distressed about going to school to the point of not wanting to leave the security of home. About 1-5% of all school aged children suffer from this condition and although it can happen in any age group the 5, 6, 10 and 11 year olds are most often affected. It is equally common among boys and girls, and is also equally the same among the rich and poor.

It is important to differentiate between school refusal and truant or 'hooky' behaviour. Children with school refusal are unreasonably scared of going to school. They may pretend to be sick and will commonly complain of an illness such as a headache, tummy ache or sore throat on the morning of school that improves during the day while the child is at home but returns the following morning. They may also have temper tantrums, crying spells, panic symptoms, fearfulness and even threats of self-harm. Other problems they are likely to have include being worried about the safety of their parents/guardians and themselves, they may be afraid to be in a room by themselves, may be afraid of the dark, may have difficulty falling asleep by themselves and may have nightmares. Parents are aware of the absence from school as the child often persuades them to allow them to stay at home. The child feels safe and secure at home and would want to stay there, and also usually expresses a willingness to do schoolwork and complete assignments. Truant children on the other hand lack any type of anxiety or fear about attending school and just choose not to go. They will try to hide their absence from their parents/guardians and would frequently not stay home during school hours. They show absolutely no interest in schoolwork and are unwilling to conform to academic and behaviour expectations. Truant children also frequently show anti-social behaviour like lying, stealing, bullying and delinquency, and usually associate with other anti-social peers.

School refusal symptoms tend to develop slowly over time and most often start after a stressful event at home or school such as moving to a new home, the death of a family member, a dysfunctional family setting or being bullied. It may also begin after having been home for awhile, such as after a holiday, summer vacation or brief illness. Problems at home that can contribute to school refusal include parents who are anxious and may have social phobia, overdependence within the family structure, minimal interaction and communication between family members, social isolation with little interaction outside the family unit, and high amount of family conflict. Although school refusal itself is not considered a mental illness, children who are affected may have one or more psychiatric disorder like anxiety, depression, panic disorder, social phobia, adjustment disorder or post-traumatic stress disorder. The avoidance of school usually serves different functions depending on the child and may include coping with separation anxiety, may be a way of seeking attention, may be a way to avoid specific fears caused by the school environment (e.g., test-taking, bathrooms, teachers) or a way of escaping certain social situations (e.g., problems with other students and/or teachers), all of which worsen the longer the child is allowed to stay out of school.

If you feel your child may have school refusal it is very important to deal with it as soon as possible so that the exact cause of the fear can be found and they can receive timely and appropriate treatment. Failure to do so can lead to both short and long-term problems. Examples of short-term consequences include poor school performance, family difficulties and problems making friends and functioning appropriately in social situations.
Long-term problems include academic underachievement, employment difficulties and being more likely to have a mental illness. The extent of the intervention will depend on how severe the symptoms are. If they are mild it may only require the parents talking with the school teacher or guidance counselor. More severe symptoms will require assessment by a medical doctor to rule out an underlying illness and/or psychological evaluation and on-going sessions with a psychologist. It may also be necessary to have family intervention when necessary and possibly prescription medications for the child.

Parents/guardians have to be involved in the management of their child's condition to ensure success. They can also assist by not keeping the child out of school, escorting the child to school, providing positive reinforcement for school attendance and not giving positive reinforcement for staying at home like allowing the child to watch television or play video games when home from school. It is your responsibility to recognize these symptoms and ensure your child receives the proper care needed so that they can confidently return to school and prevent serious learning and social deficits that will hamper them for the rest of their lives.