School Avoidance

School avoidance occurs when children and teens repeatedly stay home from school or are sent home from school for emotional reasons or claims of illness.

Malingering

School avoidance can be confused with malingering. Malingering is purposefully faking a physical or mental illness to obtain something in return, such as money or drugs, or to avoid completing a responsibility, such as household chores or homework. This behavior is seen in normal children, students, and adults. It is not a mental disorder, although it can coexist along with some mental disorders. The difference with malingering is that it is an act. It does not cause physical symptoms brought on by the stresses associated with school avoidance.

Ben's Story

Ben missed a lot of school because of his stomachaches. His stomach felt especially bad on Monday mornings. Often, while he was getting dressed for school, he felt as if he might throw up. His mother did not want him to go to school when he was sick. On days he stayed home, Ben got back into bed and by lunchtime he felt much better. By the next morning, however, he felt miserable all over again. He managed to get himself to school sometimes, but it was getting harder and harder. He would be embarrassed when he threw up on the bus. Ben's doctor had examined him and found him to be in excellent health despite his stomach pains. Still his stomachaches continued, and Ben's mother worried about how many school days he was missing.

What Is School Avoidance?

School avoidance is a condition that occurs in up to 5 percent of all school-age children. School avoidance is more common in children who have separation anxiety * . The disorder affects boys and girls equally. Sometimes school avoidance is called school phobia * or school refusal. School avoidance is a pattern of missing school for symptoms that are caused by emotions or stress rather than physical illness. School avoidance is different from truancy (TROO-an-see), which is a pattern of repeated unexcused absences from school. The student who is truant, or skips school, is neither at home nor at school. In school avoidance, the student stays home.

What Causes School Avoidance?

There are two main reasons students have school avoidance. One reason is that the student feels anxious * about some aspect of going to school or about leaving home. The other reason is that there is some benefit, or a secondary gain, to staying home from school.

Anxiety-related school avoidance

Children with school avoidance may have headaches, stomachaches, chest pain, or other symptoms brought on by the stress of separation. These pains are real, but they are caused by the body's response to stress and not by an illness. Usually, a doctor performing a checkup finds the child or teen to be in good physical health. Students with anxiety-related school avoidance are often good students and like school, but because of their stress-related symptoms, they feel that they need to stay home.

Some students with school avoidance may have anxiety about school itself. They may worry about grades, being bullied, being called on in class by the teacher, or having to undress for gym. Some schools have rules about when students may use the bathroom, which can concern children who may need to go more often. Children with severe distress about going to school might fit the criterion for social anxiety disorder, which is abnormal fear or anxiety lasting for at least six months.

In many cases, anxiety-related school avoidance begins with an upsetting event that happens at school, for example, being teased or experiencing something disturbing in class. Students who are shy and sensitive by nature and those who have an overprotective parent may be more likely to have anxiety-related school avoidance.

School Failure

Unlike school avoidance, school failure is a process in which a student slips behind classmates educationally. This process leads to disconnection from the education system. Usually, the student drops out of school before graduating. The student does not lack the ability to attend school successfully but rather is unwilling to apply behaviors needed to be successful in the school setting. Similar to school avoidance, school failure is seen more often during school transition periods or after moving with family and entering a new school. Evidence of school failure includes failing grades, along with emotional, behavioral, or learning problems. Reasons for school failure include depression, anxiety, problems in the family, learning disabilities, and social factors such as homelessness, poverty, and the inability to speak English.

Secondary-gain school avoidance

Not all children and teens with school avoidance are anxious or shy. Some may simply find that it is more comfortable staying home than attending school, which is called secondary-gain school avoidance. Secondary gain refers to the bonus or positive side of something unpleasant. For example, although it is unpleasant to be sick, it may be pleasant to watch television during the day and to have meals in bed. Another secondary gain of being sick might be not having to do homework or having the personal attention and care of a parent at home.

Secondary-gain school avoidance often starts with an illness that lasts for a few days and causes the student to miss school. The student may fall behind in homework and begin to think about how hard it will be to catch up. To avoid the hard work ahead, the student may stretch out the illness a bit longer by exaggerating symptoms or claiming to have signs of illness that they don't really have. Receiving the secondary gains of sympathy, the care and attention of parents, and the pleasure of watching daytime television can contribute to school avoidance. Lenient parents or parents who do not view school as important can also contribute to secondary-gain school avoidance.

How Is School Avoidance Diagnosed?

Ben's doctor asked him about recent worries he had. Ben mentioned that since his parents had divorced the previous year and his dad had moved across town, he had started to worry about his mom being lonely. He had seen her cry a lot this year, and it made him sad. He said he missed his dad and wished they could be a family again —but without the arguing. Although he looked forward to the weekends he spent with his dad, he was sad that his mom had to spend weekends alone. Ben's doctor explained how people could get stomachaches from stress and sadness. She asked Ben to keep track of his stomachaches in a diary but to go to school anyway. She gave Ben and his mom the name of a therapist who would help Ben talk about his feelings and about ways to adjust to all the changes in his family.

How Is School Avoidance Treated?

The first step in treating school avoidance is to help the student get back to school as soon as possible. The longer a student avoids school, the harder it is to return. Students with anxiety usually need reassurance that they are in good health. Students and their parents are helped by taking a “yes, but” approach: Yes, the symptoms are real, but they are not a reason to miss school. Parents are guided about what symptoms are grounds for staying home and how to find ways to help their child attend school despite discomfort. The treatment often includes a plan for what to do when the student begins to feel ill at school. The plan may be for the student to go to the nurse's office to lie down for five to 10 minutes and then return to class, but not to go home. Psychotherapy and behavioral techniques to cope with school-related stress are often helpful.

Another part of treatment may involve working with school personnel to solve problems that are causing anxiety, such as bullying * or lack of privacy in bathrooms. Students who have separation anxiety or generalized worry may benefit from counseling to learn to cope with painful feelings or loss. The usual treatment for students with secondary-gain school avoidance is to return to school right away. Clear limits, appropriate expectations, and support for regular school attendance are critical factors for successfully addressing the problem.

See also Antisocial Personality Disorder • Anxiety and Anxiety Disorders: Overview • Bullying • Conversion Disorder • Depressive Disorders: Overview • Factitious Disorder • Fears and Phobias • Somatoform Symptom Disorder • Stress and Stress-Related Illness

Resources

Books and Articles

Joyce-Beaulieu, Diana, and Michael L. Sulkowski. Cognitive Behavioral Therapy in K-12 School Settings: A Practitioner's Toolkit. New York: Springer Publishing Company, 2015.

Willard, Christopher. Mindfulness for Teen Anxiety: A Workbook for Overcoming Anxiety at Home, at School, and Everywhere Else. Oakland, CA: New Harbinger Publications, Inc., 2014.

Websites

American Academy of Pediatrics. “School Avoidance.” (accessed July 6, 2016).

Anxiety and Depression Society of America. “School Refusal.” http://www.adaa.org/living-with-anxiety/children/school-refusal (accessed July 6, 2016).

Organizations

American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098. Telephone: 847-434-4000. Website: http://www.aap.org (accessed March 30, 2016).

* separation anxiety is a condition diagnosed when children show clinical signs of anxiety, such as unrealistic and repeated concerns about being harmed, when separated from their parent or primary caretaker.

* phobia (FO-bee-a) is an intense, persistent, unreasonable fear of (and avoidance of) a particular thing or situation.

* anxiety (ang-ZY-e-tee) is a condition marked by a sense of dread, fear of the future, or distress over a possible threat to a person's physical or mental well-being.

* bullying is unwanted and repeated aggressive behavior from one child or teen toward another. Bullying gives the bully real or imagined power over others.

  This information is not a tool for self-diagnosis or a substitute for professional care.