Refusing to go to school is a stressful issue for children, families and school staff. School failure has significant short- and long-term effects on children`s social, emotional and educational development. Dropping out of school is often associated with comorbid psychiatric disorders such as anxiety and depression. It is important to identify problems at an early stage and plan appropriate interventions to avoid further difficulties. The assessment and management of school refusals requires a collaborative approach that involves the primary care physician, school staff, parents and a psychiatrist. Because children often experience physical symptoms, evaluation by a doctor is important to rule out underlying medical conditions. Treatments include educational supportive therapy, cognitive behavioural therapy, parent-teacher interventions and pharmacotherapy. Family doctors can provide psychoeducational support to the child and parents, monitor medications, and help refer patients to more intensive psychotherapy. Children who are more likely to drop out of school have certain characteristics in common.
These include: Ingul, J. M., Klöckner, C. A., Silverman, W. K., & Nordahl, H. M. (2012). School absenteeism among adolescents: modelling of social and individual risk factors. Child. Adolescence.
Opined. Health 17(2), 93-100. doi:10.1111/j.1475-3588.2011.00615.x Place, M., Hulsmeier, J., Davis, S. and Taylor, E. (2002). Coping mechanisms for children who refuse school. J. Res. Spec. Educ. needs 2, 1 to 10.
doi:10.1111/j.1471-3802.2002.00167.x Stressful life events such as moving or starting a new school can trigger a school refusal, among other things. Other reasons include the child`s fear that a parent will hurt themselves once they are in school, or the fear that they will not do well in school, or they may be afraid of another student.  Refusal to attend school usually occurs after returning from school due to illness or vacation. It may also be followed by a stressful family event, such as divorce, illness or injury to parents, the death of a family member, or a move to a new school. As a rule, refusal to go to school develops gradually, with children becoming more and more fiercely opposed to school attendance over time. Psychiatrists believe that in young children, the motivating factor is often the desire to stay with parents or caregivers rather than avoid an uncomfortable situation at school. In older children or if the refusal to go to school occurs suddenly, it may be related to avoiding a stressful situation at school such as bullying, teasing, harsh criticism from teachers, or it may be followed by a humiliating event such as vomiting in class. The longer a child stays away from school, the harder it is for them to come back. The assessment should include interviews with the family and individual interviews with the child and parents. The assessment should include a complete medical history and physical examination, history of onset and development of school refusal symptoms, associated stressors, educational history, peer relationships, family duties, psychiatric history, history of substance abuse, and a mental status review. It is important to identify the specific factors responsible for school avoidance behavior. Cooperation with school staff in terms of assessment and treatment is necessary for successful management (Table 5).
School staff can provide additional information to facilitate the assessment, including verification of attendance records, transcripts and psychoeducational assessments. Dysfunctional family interactions that correlate with school refusal include over-dependence, detachment with little interaction between family members, isolation with little interaction outside the family unit, and high levels of conflict.18 Communication problems within the family, role fulfillment problems (especially in single-parent families), and problems with rigidity and cohesion of family members were 19.20 Symptoms of school refusal usually appear gradually. Symptoms may begin after a vacation or illness. Some children have difficulty returning to school after weekends or holidays. Stressful events at home or at school or with peers can result in school refusal. Some children leave home in the morning and develop difficulties as they approach school and cannot continue. Other children refuse to go to school. Malcolm, H., Wilson, V., Davidson, J. and Kirk, S. (2003).
Absence from school: study of its causes and effects in seven LEAs. United Kingdom: Department for Education and Skills. Research Report 424. Kearney, C. A. (2008b). An interdisciplinary model of youth truancy to inform professional practice and public policy.