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What We Treat

School Refusal

What is School Refusal?  

School refusal is when a child refuses to attend school or has difficulty staying in school for the duration of the school day. School refusal can occur at any age; it may begin as early as pre-k or as late as high school. School refusal becomes problematic when the child misses school on a regular basis; the frequency of the refusal is not as important as the fact that the child regularly struggles with attending school as expected and experiences emotional, interpersonal or academic difficulties as a result.  

What Does School Refusal Look Like?

Though the ultimate result of school refusal is nonattendance, school refusal behaviors are not uniform and can vary widely. There is usually fear or distress associated with going to school, though not all children express their distress outwardly. Instead, a child may feign illness, stonewall, tantrum, beg or bargain, or simply refuse to get out of bed despite prompting and encouragement. Children refusing school usually seek to be allowed to stay at home, where there is comfort and stability and they do not have to face or manage negative emotions associated with attending school. Young people who refuse to attend school due to anxiety commonly present with physical complaints, which may mask or distract from the real issue. Common somatic complaints include GI distress (stomachache, vomiting, diarrhea), headaches, dizziness, increased heart rate/palpitations, chest pain, shaking, and even fainting.  

Are School Refusal and School Truancy the Same? 

School truancy is distinct from school refusal in several ways. In school truancy, the child often does not express fear or anxiety about attending school and may skip school or leave school without parents or teachers knowing. The child often attempts to conceal their absences in school truancy. During school hours, a truant student does not usually go to or stay at home. Instead, the student may engage in antisocial behaviors, including lying, stealing, or experimentation with illicit substances while they are not in school.  

What Causes School Refusal?  

Causes for school refusal can be varied and are usually multifactorial. There are, however, several psychiatric reasons for ongoing refusal which tend to be most common in cases of school refusal:  


Anxiety is often a significant factor in school refusal. In younger children, we may see separation anxiety at school drop-off, when the child does not want to depart from their caregiver. Young children may exhibit crying, tantrums, or inconsolable emotional behavior that seems to respond only to comfort from the caregiver or removal from school. Older children can also have difficulty separating from their caregiver, though separation anxiety in older children is more common if they are acclimating to a new school environment or adjusting to another significant transition or life change. Students may also refuse school if they are having difficulty managing crowded spaces (cafeterias, classrooms, auditoriums) or are avoiding specific phobias occurring in school (e.g. using a public bathroom alone, being called on spontaneously in class). Social anxiety can also lead to school refusal for those who feel too nervous to be among peers for fear of scrutiny and rejection. Many adolescents who refuse school have excessive worry about their academic performance, the amount of work they are assigned, their academic standing among peers, and how their future prospects (like college admissions) may be defined by their academic achievement.  


Many young people struggle to attend school in the context of significant mood-related symptoms. Though they are often thought of as disorders of adolescence and adulthood, mood disorders can and do occur in early childhood and can impact children who are as young as 4 and 5 years old. Symptoms of depression that can interfere with school attendance can include low energy, low motivation, poor sleep, and feelings of fatigue which make it very difficult to get out of bed. Others may find that their depressive symptoms make them very irritable or angry, making it difficult for them to tolerate being around others, manage frustration, and move through their day without conflict. Long-term depressive symptoms – otherwise known as Dysthymia – can cause depression-related school refusal to go on for protracted periods and lead to students falling far behind in their studies.  


Enduring a traumatic event, whether in school or at home, can have a profound impact on a young person’s functioning. Children may be faced with threats to their physical and emotional safety from peers and respond by withdrawing and avoiding these threats. School safety concerns are common and some young people may seek a “safety transfer” so that they can attend a school away from those who threaten harm. Children may also begin to refuse school if they experience a frightening event there, like an active shooter or bomb scare. Children may have difficulty attending school after traumatic events at home, as well. Parental divorce, serious illness or death of a caregiver, domestic violence, natural or manmade disasters, and scary events like break-ins or house fires can cause children to feel that if they leave home, something bad might happen because they weren’t there to stop it or protect loved ones.  

ADHD and Learning Disabilities 

Some children refuse to attend school due to unrecognized and unmet learning needs. Many children suffer quietly and experience shame and embarrassment because they don’t understand or follow what is being taught. Seeing peers advance through concepts that are too hard or confusing can be very demoralizing for a student and lead to refusal. Many children with special learning needs or ADHD can feel as though something is wrong with them that cannot be fixed. Some students with learning disabilities or ADHD feel that school just isn’t “for them” and that they will never be able to succeed there. If a child is shy or feels that they will be reprimanded or embarrassed by asking for help, they can fall increasingly farther behind their peers academically, compounding fear that they are incapable or that they will never “get it.”  

Family Systems Issues 

School refusal is almost always multifactorial, and family dynamics and discipline techniques used at home can be very important to resolving persistent school refusal. Many parents struggle to manage defiance in their children and do not know how to respond in a way that will elicit desired behaviors. Parents of children who refuse to attend school may feel lost, stuck, and as though they have no options. Parents of older children can feel particularly helpless, as they cannot physically force their child to attend school and feel that there is no recourse. Some parents resort to the use of corporal punishment or excessive disciplinary practices in an attempt to get their child to attend school. These techniques do not work to resolve school refusal and can compound issues at home by putting significant strain on the caregiver/child relationship.  

How Can I Manage My Child’s School Refusal?

Families who struggle to elicit school attendance from their children can benefit from family or individual therapeutic support. Through thorough assessment and time spent with the child and their caregiver(s), therapists can elucidate what is driving a child’s school refusal and help the child and their family to address contributing factors. Additionally, if it is suspected that a child is suffering from mood-, anxiety-, ADHD-, or trauma-related symptoms, psychiatric consultation can be extremely helpful. Psychiatric assessment with a qualified professional will usually include interviews with caregivers and the child to identify symptoms and interventions to alleviate them. Suggested interventions may include psychotropic medication to treat mental health symptoms contributing to school refusal. However, a psychiatric provider may also recommend other interventions, including specific therapy modalities, academic accommodations (which may include smaller classrooms, more individualized attention, additional individual academic support, or a therapeutic school setting), activities to build social skills, or further specialized assessment (neuropsychological and psychoeducational testing can be illuminating).