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What child hasn't dreaded September, the end of summer and the return to school. But for some kids, the prospect of school produces a level of fear so intense that it is immobilizing, resulting in what's known as school-refusal behavior.
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School refusal, a major fear among children heading back to school,
is explained by Andrea Petersen.
These are the kids who may be absent for weeks or months. Some may cry or scream for hours every morning in an effort to resist leaving home. Others may hide out in the nurse's office. Some kids who miss school are simply truant—they'd just rather be doing something else. And sometimes there are genuine reasons to fear school, because of bullying, for example. But in about two-thirds of cases, a psychiatric problem, most commonly an anxiety disorder, is the cause, according to research led by Christopher A. Kearney, professor and director of clinical training at the University of Nevada, Las Vegas.
Anywhere from 5% to 28% of children will exhibit some degree of school-refusal behavior at some point, including truancy, according to Dr. Kearney, a leading authority on the behavior, and other experts. For kids with anxiety-fueled school refusal, the fear is real and can take time to overcome. Families may struggle for months to help a child get back into the classroom. Ignoring the problem, or failing to deal with it completely, can lead to more-serious problems later on.
School-refusal behavior isn't just a U.S. phenomenon: Researchers from France to Finland have studied it, and it has garnered particular attention in Japan, a country known for academically rigorous schooling.
The problem affects the whole family. "If your kid doesn't go to school, it is hard for you to keep your job," says Helen Egger, assistant professor in the department of psychiatry and behavioral sciences at Duke University Medical Center, Durham, N.C. Kids are at heightened risk when starting a new school, and especially when entering middle school. "It is the perfect storm with the onset of puberty, a huge transition and a much wilder academic environment," says Dr. Kearney.
Classroom Coaxing
Exposure therapy helps by having a child gradually confront what scares him. A possible scenario:
Well-meaning parents can make things worse, psychologists say, by allowing an anxious child to miss school, attending school with them as, for example, a classroom volunteer—or home-schooling. Such accommodations send the message that school is too scary for the child to handle alone and the fear is justified. "Overprotective parents rush in way too quickly to shield them from any experience that creates distress," says Karen Cassiday, a clinical psychologist and the owner of the Anxiety and Agoraphobia Treatment Center in Chicago, Ill.
Untreated, a child with school-refusal behavior is likely to fall behind academically, which can then lead to more anxiety. And there may be longer-term consequences. A 1997 study, published in Comprehensive Psychiatry, followed 35 7- to 12-year-olds treated for school refusal. Twenty to 29 years later, they were found to have had more psychiatric treatment and to have lived with their parents more often than a comparison group.
Some kids with unresolved anxiety may go on to self-medicate with alcohol and drugs. A 2004 study in the Journal of Consulting and Clinical Psychology followed 9- to 13-year-olds who were treated for an anxiety disorder. Seven years after treatment, those who still had the disorder drank alcohol more days per month and were more likely to use marijuana than those whose disorder had resolved.
School refusal "takes the child off their developmental course," says Anne Marie Albano, associate professor of clinical psychology and psychiatry at Columbia University, New York. "They are not going to grow in an age-appropriate way."
What Happens When They Grow Up
People who experience school-refusal behavior and anxiety disorders in childhood may face serious ramifications in adulthood, psychologists say and studies show:- Depression: Young people ages 14 to 24 who had social anxiety were almost three times as likely to develop depression later on than those without the anxiety disorder.
- Psychiatric treatment: A study of school-refusing kids showed that about 20 to 29 years later they received more psychiatric treatment than the general population.
- Alcohol, drug use: A study of children ages 9 to 13 with an anxiety disorder showed that those who still had the disorder seven years after treatment drank alcohol more often and were more likely to use marijuana than those whose disorders had resolved.
- Different life choices: Psychologists say they've seen young adults with persistent anxiety make fear-fueled choices that can have longterm effects, such as selecting a less-rigorous college or a less challenging career.
Kids with school-refusal behavior may have separation anxiety, a fear of being away from their parents, or a social phobia, an inordinate fear of being judged, being called-on in class or being teased. A specific phobia—fear of riding the bus, walking past a dog or being out in a storm—may be present. Other children are depressed, in some cases unable to get out of bed.
Because many kids complain of headaches, stomachaches or other physical symptoms, it can be difficult to tell whether anxiety, or a physical illness, is to blame. One indicator: Anxiety-fueled ailments tend to disappear magically on weekends.
In February 2009, Kathy Jones's youngest son, Garrett, then 10, started complaining of headaches. Doctors prescribed migraine medication, but it didn't help and Garrett began begging to miss school. "Every single day there was a reason he shouldn't have to go to school. He'd say, 'Mom, I'm sick, my head hurts, I'm sure I have the flu, my teacher hates me, I hate my teacher,' " says Ms. Jones, who lives in Las Vegas. By April, she had quit her job and was going to school with her son, pulling up a chair next to his desk. "He was the star of the football team, the guitar player, a straight-A student—and now, the minute we'd step into the parking lot he'd shake and start to cry."
Cognitive behavioral therapy, in which patients learn to change negative thoughts and behavior, is the main treatment for school-refusal behavior and the anxiety disorders that often underlie it. The primary technique is exposure therapy, where kids gradually face and master their fears. Ms. Jones brought her son to the Child School Refusal and Anxiety Disorders Clinic at the University of Nevada the following October. His therapist had him attend his favorite class, gym, while his mother waited in the car outside. After about 10 days, he added his second-favorite class, art. Garrett's therapist also taught him relaxation techniques and breathing exercises to help him cope with anxious feelings.
Every week or two, he added another class. He had many setbacks, but by April 2010, Garrett was back at school full-time. So far this year he has missed just one day, Ms. Jones says.
CBT is very effective. Recent studies have shown that about half to 70% of kids with anxiety disorders treated with CBT will have a significant improvement in function and decrease in their symptoms. Some specialized school-refusal clinics have success rates that are even higher.
Antidepressants such as Zoloft (sertraline) or Prozac (fluoxetine) are often prescribed for children with anxiety disorders, although their use in children is controversial.
Psychologists stress the importance of seeking treatment quickly—after as little as two weeks of missed school. "The longer they've been out of school, the poorer the prognosis," Dr. Kearney says.
Write to Andrea Petersen at andrea.petersen@wsj.com
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