School Refusal: Home and School-Based Interventions

School refusal is a growing challenge that schools and families are facing in the years following the COVID-19 pandemic.  Treatment of school refusal requires a combination of targeted parent training focused on not accommodating anxious thoughts and behaviors, counseling support focused on cognitive behavioral therapy, and a strategic gradual reintegration plan.  

What is school refusal?

School refusal is when a child refuses to attend school, often linked to anxiety (e.g., separation anxiety, social anxiety) or behavioral disorders (e.g., oppositional defiant disorder). Students exhibiting school refusal often display physical complaints, such as stomachaches, used to justify staying home.

Why Homeschooling or Online School May Not Be Beneficial

For anxious students, these options avoid rather than address anxiety. Success requires learning to manage anxiety in real-world settings, which homeschooling or online school likely does not provide.

Why would the doctor write the student an absence excusal for a month if it wasn't good for him?

Many doctors do not have training or experience in the area of school refusal.  Therefore, with the best intentions, some doctors seek to alleviate the source of the anxiety, which is going to school, by allowing the child to "have a break" from school for several weeks or months.  However, this typically exacerbates the issue and the child has an even greater desire not to return to school because they are concerned that other students will ask where they have been.  Additionally, because the student loses the routine of going to school, staying home becomes a habit.  

Parent Interventions

An effective research-based school refusal intervention is the Supportive Parenting for Anxious Childhood Emotions (SPACE) model (Lebowitz et al, 2013).  This approach acknowledges that parents' instinct to want to protect their child from feeling anxious can cause them to engage in protective accommodating behaviors that unintentionally prevent the child from building the skills necessary to move outside of their comfort zone and cope with their anxiety.  The following are examples of parents accommodating their child's challenges:

• The child is anxious about social situations or wants to avoid situations that cause negative feelings.  

  • • • • Therefore, in an attempt to protect the child from feeling anxious, the parent allows the child to avoid social interactions by allowing them to stay home from school, parties, and events.

• The child seeks constant reassurance and assistance from parents.  

  • • • • Therefore, the parent constantly praises the child and minimizes or contradicts corrective feedback that the child receives from other adults, including teachers.

• The child responds by yelling, arguing, or withdrawing when asked to engage in non-desired activities (such as doing chores, homework, etc.).  

  • • • • In order to avoid conflict and stress, the parent stops asking the child to do chores around the house, does not provide corrective feedback, and does not require them to study or keep up with schoolwork. 

• The child frequently calls the parent from the health office asking to be picked up because of headaches or stomachaches. 

  • • • • In an effort to care and support their child, the parent comes and picks up the child from school, brings them home, and allows them to engage in preferred activities (video games, watching TV, etc.).  

Once parents are taught how to identify the accommodations that they are making for their children, mental health professionals (such as school counselors, school psychologists, or therapists) can guide the parents in learning how to stop engaging in these accommodations.  Parents must be aware that this is a very long (several months) process and that must be implemented consistently and that the child's reactions may become worse before they get better.  The mental health professionals can assist this process by teaching the parents how to explain to the child what accommodations they are stopping, why they are stopping, and how parents can communicate to the child that they will support them in overcoming their fears and challenges.  

Breaking Free of Child Anxiety and OCD: A Scientifically Proven Program for Parents by Eli Lebowitz is highly recommended to guide parents through the SPACE approach.

School-Based Interventions

If the student has an IEP then the IEP team must determine what specific services are necessary to support reintegration as well as the least restrictive environment in which to address the student's needs.  In conjunction with parents ceasing accommodating behaviors, school-based interventions must include counseling support as well as the development of a reintegration plan back to school. These interventions are described in detail below.

Counseling

Cognitive behavioral therapy (CBT) has been found to be effective for students who exhibit anxiety and school refusal behaviors.  Generally, CBT involves psychoeducation (understanding/rating feelings and conceptualizing that the objective is to cope with rather than eliminate anxiety), cognitive restructuring (challenging false or inflated perceptions), goal setting, relaxation training/coping strategies, developing problem-solving skills (e.g., teaching the child how to respond to unexpected questions or social situations), and gradual exposure.  

The purpose of counseling is to provide the child with a mental health toolbox that they can use when they begin to reintegrate into the school environment.  

Reintegration

A planned and systematic gradual reintegration plan must be developed collaboratively between the parents, the school, the child's mental health providers, and the child.  

Reintegration piggybacks on the coping strategies that the student has learned in counseling, as these strategies will need to be used to address anticipatory anxiety that the child will likely be feeling prior to reintegration activities.  The school and mental health professionals can then work with the child to identify a time of day and an activity that would be least anxiety provoking.  If the student has been taught in counseling to rate their level of anxiety of a scale of 1-10 (10=most severe) then the team can begin with a time or activity that is rated as a 5.

• For example, if the student feels overwhelmed by crowds and school begins at 8:00 then the student could begin reintegration by arriving at school at 8:30 and going to the office to see his counselor, remain there for 15 minutes working on coping strategies, and then return home.  

This process would continue daily until the student's level of anxiety is reduced to approximately a 3 rating for two sessions in a row, at which point the activity or the length of the activity can be intensified to the point that the student's anxiety is back up to a 5.

• For example, the student's length of time in the counselors office may be increased to 30 minutes.

This process of increasing the intensity of explores and progressing further into reintegration based on the student's decreasing anxiety level will continue until the student is beginning to increase proximity to classes (for example, going with the counselor and standing outside a preferred class for 5 minutes) and eventually sitting in classes (for example, going into a class for 15 minutes) for increasingly extended lengths of time.  Positive reinforcement should be provided after each successful attempt.

Note that this is a slow process that cannot be rushed without risking regression.  The process of having the student attend school for a full day may take months or even greater than a year.  

Parent Training/Social Work Services

Ongoing parent training is necessary during the reintegration process.  This includes continuing to work with parents on not accommodating student anxieties/behaviors and coping with/managing their own protective instincts and anxieties related to their child.

Conclusion

School refusal behaviors are complex and require strategic and collaborative interventions provided by both parents, mental health providers, and the school (which may include the mental health providers).  The interventions must be implemented systematically and patience is key, as successful intervention may take months or years.

At FAPE Consulting, we specialize in psychoeducational, social-emotional, and behavioral assessments, designed to help children access school and succeed educationally.  Additionally, Dr. Ihori is trained to provide SPACE therapy.   Contact us to schedule an assessment or to learn more about our services.