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Wednesday, February 29, 2012

Why doesn't my child want to go to school?

    Usually in the Fall, I get 1-2 calls a week for children and teens who are "refusing" to go to school. It seems common for Kindergartners and 1st-graders, 7th graders, and Freshman, but it can be any age. The onset seems to be after Summer, after Winter break and Spring Break, and after some sort of subjective negative event at school, such as being made fun by someone, either a peer or a teacher. Some studies show the peak onset between ages 10-12 but indicate that symptoms of anxiety began around ages 6-7.


   I categorize three types of reasons why kids refuse to go to school: avoidance, refusal, and a combination of avoidance and refusal. School avoidance (SA) is primarily caused by fear, anxiety and frustration, while school refusal (SR) is primarily caused by anger, tension, and frustration. In some cases, kids may have both fear and anger about school.


There are significant differences between
children who refuse to go to school compared
with those who try to avoid going to school.
  There are no medications that have been approved by the FDA for school avoidance or refusal. It is crucial to differentiate between SA and SR. Children presenting with SA may benefit from Cognitive Behavioral Therapy (CBT) along with Child Behavior Management. Children suffering from SR may also benefit from CBT, but Child Behavior Management (aka Parent Management Training or Behavior Modification) is probably the best approach.

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 Some children are too young for CBT but younger children rarely need anything more than Child Behavior Management. There is no evidence that family therapy, play therapy, art therapy, or client-centered therapy will help children with SA or SR return to school anytime soon. However, family therapy may be worth trying in some cases.

  Parents should be active participants in CBT and Child Behavior Management. For CBT to be effective, homework will need to be completed and repetition of techniques is necessary; children and teens cannot be expected to do CBT on their own, and they cannot be expected to recall or share relevant information in sessions with parental support. Furthermore, children and teens cannot be expected to take notes during CBT sessions and tell their parents about the techniques and expectations. Also, parents must be involved in goal setting.

  Child Behavior Management is very effective for children and teens. The problem is that few therapists know enough about behavior modification and effective parenting in order to give good advice and training for parents. Most of the parenting books, shows, and therapists (that I have heard about, so bear that in mind), give advice that has no scientific basis, and it seems to be based on Anecdote, Ideology, Myth, or Suspicions (AIMS). I've been embarrassed about some of the stories that I've heard where parents have said that there were told to do things like "take away all their toys and make them earn them back," or "take away their bedroom door," or excessive time-outs.

  When it comes to SR and SA, punishments will rarely, if ever work. Unfortunately, that tends to be the first reaction of parents and the first advice of friends, family, and many professionals. School staff often say that "your child is just making bad choices." It's very common for people to over-simplify the problem or place blame on the children using negative labels or concepts: "willful," "defiant," "lazy," "disrespectful," and so on.


Parents and school staff put an enormous amount of
pressure on teens to get back to school. This adds to their
anxiety, guilt and shame and for some teens, this can make
the problem worse. For some cases, patience is necessary
and school will just have to wait.
  Another mistake some parents make is to allow their child or teen to stay home due to vague or non-serious symptoms, like "stomach aches," "headaches," "nausea" (with no fever), or low-grade fevers (anxiety can increase body temperature enough for this). If your child has a history of SA or SR, or anxiety or negative attitudes towards school, or test anxiety, social anxiety, or performance anxiety, then you should consider that they are avoiding or refusing school in order to cope with their emotions - not because they're ill. Any health symptoms should be discussed with their pediatrician, but SA and SR concerns should be mentioned, too. Many parents have said that their pediatrician has recommended sending the child to school with a plan to see the school nurse if things get worse and then let the nurse handle it from their; however, it's important to share SA and SR concerns with the school nurse.

  Keeping a child or teen home even for one day can make the problem much worse. Especially on the days of the week that tend to be difficult, such as Monday and Tuesday, test days, speech days, and other times when a child or teen may have increased demands. Many times, a single parent is expected to get an unwilling child to school on their own. I strongly recommend calling in backup much sooner than later. Delayed responses in getting support can lead to increasingly negative interactions between a parent and child. Also, bringing in backup right away sends a message to the child or teen that SA and SR behaviors are not going to be tolerated.

  Many parents "hate to see their child suffer" with anxiety, so they keep them home, hoping the anxiety will go away. It often does go away as the week progresses; most kids love Fridays, for example, because they associate it with the start of the weekend and relaxation. It's important to know that avoidance will make anxiety much worse while exposure will actually alleviate anxiety. The problem is that anxiety will become worse before it gets better.

 Child Behavior Management (CBM) can be a humbling experience for many parents. For some reason most parents (including myself) get defensive of our ways and ideas about parenting. Either moms or dads can be closed-minded and stubborn. I've seen enough open-minded moms and dads and closed minded moms and dads to know that it has less to do with gender and more to do with other factors. CBM is usually effective by itself when done correctly. However, many parents fail to implement plans as recommended, they wait too long to implement the plans, they quit the plan too soon, or they fail to follow-up as required during the initial stages of implementation.

  Most parents I have worked with do implement plans correctly and quickly and the results are wonderful. It's very rewarding to everyone involved to see a child go from SA to attending school - sometimes overnight. Kids with SR usually need more help getting over their anger and frustration. Sometimes they've been misdiagnosed with ADHD when in fact their refusal to attend school (or do homework) is a way of expressing their anger, either at their parents or peers. Medications like Adderall may increase irritability and aggressive behaviors and instead of helping the situation, it can make things worse.

  When looking for a therapist to work with, consider asking if they are familiar with parent management training (child behavior management, behavior modification), CBT, and possibly family therapy. Medications, if used at all, should probably be a last resort and parents should be sure to be fully educated on the potential side effects, risks and benefits. To date, most medications are not well researched when it comes to children or teens for short term use and definitely not for long-term use (over one year).

Mental Health Disclaimer: The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

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