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Many children experience some degree of “backtoschool anxiety” as the school year begins. Typical stressors may
include worries about making new friends, managing new or difficult teachers, increased academic workload, or being
away from parents, or transitional issues, such as starting at a new school or moving into middle or high school.
Whereas some schoolrelated anxiety is normal, excessive anxiety and worry can negatively affect a child’s functioning
at school, as well as with peers and at home.
In general, the sources of schoolrelated anxiety vary on the basis of the age and developmental level of a child.
Younger children often experience anxiety about separating from parents or being away from home. A common worry
might be, “What if something bad happens to me while I am at school and away from my parents?”
Some children and adolescents may struggle with schoolwork owing to undiagnosed learning disabilities. As a result,
these kids develop anxiety regarding academic performance.
Adolescents transitioning to middle or high school may worry about being in a new school environment and coping with
increased school and homework demands. Common worries might include, “What if my new teacher is mean?” or
“What if I can’t understand the new schoolwork?”
Adolescents may also worry about social acceptance and making friends. Such concerns as “Will any of my friends be
in my class?” “Will I look stupid in front of my peers?” or “Who will I sit with at lunch?” are common. Often, these
adolescents feel intensely scrutinized and worry that they are embarrassing themselves. Even college students moving
away from home for the first time may experience increased homesickness and fears about being independent.
Overall, the most common diagnoses for youth with schoolavoidance behaviors include separation anxiety disorder
(22.4%), generalized anxiety disorder (10.5%), oppositional defiant disorder (8.4%), depression (4.9%), specific phobia
(4.2%), social anxiety disorder (3.5%), and conduct disorder (2.8%).
[1]
Telltale Signs of Schoolrelated Anxiety
Children and adolescents with schoolrelated anxiety usually exhibit a range of behaviors that may indicate excessive
fear of school. Young children, especially preschoolers, frequently talk about their fear of school and may ask for
repeated reassurance from parents: “Can you stay at school with me?” or “Do I have to go?”
Most children will occasionally complain about attending school, but daily complaints, or a child resisting getting out of
bed or getting ready for school, may suggest high levels of fear. Some children may manifest physical symptoms of
anxiety, such as headaches or stomachaches. Children may even vomit in the morning in anticipation of going to
school.
[2] Additional symptoms of schoolrelated anxiety include excessive clinginess with parents, difficulty sleeping, or
fear of sleeping alone.
School Refusal
For some children, anxiety about attending school may become so severe that they may begin to refuse to attend
school altogether. School refusal is defined as children’s refusal to regularly attend school owing to significant emotional
distress (often anxiety and fear) related to going to school.
[3]
Managing BacktoSchool Anxiety
Samantha Morrison, PhD; Anthony C. Puliafico, PhD
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School refusal differs from truancy in that truant children generally have no feelings of fear toward school, but instead
often feel angry or bored with it. Children and adolescents exhibiting schoolrefusal behavior can present as
oppositional, although it is important to keep in mind that their behavior is primarily intended to help them avoid a highly
anxietyprovoking situation.
Children or adolescents may be exhibiting schoolrefusal behaviors if they demonstrate any of the following: lengthy
absences from school, chronic tardiness to school, severe misbehavior in the morning in an attempt to miss school,
skipping certain classes or periods during the school day, attending school but then attempting to leave during the day,
or displaying unusual distress at school and begging to go home or not return to school.
[4]
Children exhibiting schoolrefusal behavior may be absent from school for weeks or even months. Some children may
demonstrate consistent school avoidance, whereas others exhibit “intermittent” avoidance, such as missing 23 days
per week.
According to Kearney and Albano,
[5]
there are four main motivations for children and adolescents who exhibit schoolrefusal
behavior:
1. Avoidance of anxiety caused by schoolrelated situations. Children may avoid specific schoolrelated situations
because they provoke high anxiety and distress.
2. Avoidance of negative social evaluation associated with going to school. Children and adolescents may avoid
social or evaluative situations (eg, talking to peers, public speaking, gym class); have a history of negative social
interactions and bullying; or have increased somatic complaints (headaches, stomachaches, nausea, diarrhea),
especially on school days.
3. Increased attention for avoiding school. Children and adolescents may have tantrums or demonstrate verbal and
physical aggression to avoid attending school or getting out of bed in the morning. They may also be
noncompliant with directives, run away from home or school, or demonstrate excessive reassuranceseeking or
clinging to parents in the morning. These behaviors may elicit attention from parents or other individuals, which
may be reinforcing.
4. Receipt of tangible rewards when avoiding school. Children and adolescents may receive reinforcement when
they stay home and do not go to school, including extra sleep, watching TV, playing video games, and spending
time with friends.
Many children refuse school for two or more reasons.
[5] For example, some children may initially avoid school owing to
anxiety, but then realize the attractiveness of staying home and thus refuse school because staying out of school is
reinforcing. Conversely, some children avoid school because they are reinforced by staying home, but subsequently
face increased anxiety about new classes, teachers, and peers upon returning to school. A helpful assessment tool to
identify the function of schoolrefusal behavior is the School Refusal Assessment ScaleRevised (SRASR).
[6]
Approximately 5%28% of children will exhibit some degree of schoolrefusal behavior.
[2] School refusal commonly
occurs at times of transition, such as entering middle and high school.
Schoolrefusal behavior may not only cause significant educational, social, and developmental problems for the child
but can also significantly affect the family (eg, through increased family conflict or parents missing increasing amount of
work). Shortterm consequences of school refusal include incomplete schoolwork and academic failure, alienation from
peers, legal and financial difficulty, missed time from work, and substantial family and parent/school conflict. Longterm
sequelae of school refusal include potential school dropout, delinquency, economic deprivation, later occupational and
marital problems, and need for further psychiatric assistance in adulthood.
[1]
Besides missing schoolwork, children and adolescents who avoid school miss valuable opportunities to develop and
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practice social skills, foster close friendships with classmates, experience feelings of accomplishment and mastery, and
receive recognition for their skills and talent. Of note, anxious children and teens who miss school cannot gather
evidence that challenges their unrealistic and catastrophic fears.
SchoolRefusal Interventions
Treating school refusal requires a multifaceted approach and incorporates childbased techniques, parent management,
and schoolbased consultation to establish accommodations to help facilitate a smooth reintegration back into the
school setting. Childbased approaches include teaching anxiety management skills, such as relaxation, breathing
retraining, cognitive therapy, and exposurebased practices, to gradually reintroduce a child to school.
[7] Childbased
interventions may also involve social skillbuilding, roleplaying, and problemsolving ways to manage anxietyprovoking
stressors at school.
Parentbased interventions include parent training and contingency management techniques, specifically techniques
emphasizing the importance of morning and evening routines, providing positive reinforcement for school attendance,
providing attentionbased consequences for school nonattendance (eg, early bedtime, limited time with parents at night,
no access to reinforcers, and loss of privileges) reducing excessive questioning from or reassuranceseeking behavior
on the part of the child, and engaging in forced school attendance under strict conditions.
[7] Other familybased
techniques include developing contracts to increase incentives for school attendance and decrease incentives for
nonattendance, or escorting a child to school and classes.
Gradual reintroduction is the preferred approach and may involve a return to school starting with lunchtime, favorite
classes, or in an alternative setting (eg, the guidance counselor’s office), and then gradually increasing demands and
expectations for attendance as the child progresses in treatment. Helpful schoolbased interventions to facilitate school
attendance may include a modified school day or workload, having a trusted teacher or counselor for support at school,
and use of an “anytime” pass allowing the child to leave the classroom to use the bathroom or speak with a counselor
when needed.
A child exhibiting schoolrefusal behavior should remain at school to the greatest extent possible and not be allowed to
return home unless he is experiencing significant medical issues (eg, cyclical vomiting, temperature of 101°F or higher
as determined by a thermometer). If a child with schoolrefusal behavior is experiencing somatic symptoms, such as
stomachaches or headaches, these symptoms should be managed within the school setting. Oftentimes, these somatic
symptoms are caused by anxiety, and remaining in the anxietyprovoking situation will ultimately lead to reduction in
anxiety and associated physical symptoms.
If a child is unable to remain in the school building and must return home, he or she should only be allowed to complete
schoolwork; leisure activities, such as television, video games, and sleeping, should be prohibited. Children who refuse
to attend school should also be expected to wake up and get dressed as if they were going to school and try to simulate
the school day to the greatest extent possible. This will help children to maintain the rhythm of the school day.
Strategies to Discuss With Parents
Most parents of children who engage in school refusal work tirelessly to reduce their child’s anxiety and facilitate a
return to school. These parents are often forced to choose between relieving a child’s distress in the short term, often by
allowing him or her to miss school, or requiring their child to fully attend school and contributing to the child’s high
anxiety and distress. It is important for parents to keep in mind that allowing a child to avoid school may relieve his or
her distress in the short term but will only reinforce the child’s anxiety, thus making it stronger and longerlasting.
There are several strategies that mental health professionals can encourage parents to implement in supporting a child
with school anxiety. Parents should remind their child of previous successes with mastering new or anxietyprovoking
situations. They should acknowledge their child’s fears but also focus on the positive aspects of getting back to school.
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Parents should be supportive yet firm. They should not reward their child’s protests, crying, or tantrums by allowing him
or her to avoid going to school. Instead, in a calm tone, they can say, “I can see that going to school is making you
scared, but you still have to go. Tell me what you are worried about, so we can talk about it and figure out how to make
it less scary.” Parents should also limit a child’s access to any reinforcers (eg, television, video games, or extracurricular
activities) when they are refusing to attend school.
Another strategy to reduce school anxiety involves making the “gettingready time” a positive experience. To make the
morning less frantic, it is helpful for a child to get organized in the evening by reminding him or her to choose clothes,
find supplies, and complete homework assignments before bedtime. In addition, it is important to maintain or return to
the sleep schedule that a child keeps when fully attending school.
It is also important to emphasize the positive aspects of being at school, such as seeing friends, making new ones,
learning new things, and going on special trips. We want to increase a child’s investment in being part of their school
community.
It is important for parents to allow their child to develop problemsolving skills. It is impossible to predict every situation
that could occur at school. Encouraging a child to think through how they can solve a problem on their own (for
instance, when they cannot find their class) helps them develop confidence in their problemsolving abilities.
Parents should avoid giving reassurance, but instead problemsolve and plan. Children often seek reassurance that bad
things will not happen in order to reduce their worry. It is important not to assure them with “Don’t worry” or “Everything
will be fine.” Instead, encourage the child to think of ways to solve his or her problem—for example, “If [the worst]
happens, what could you do?” or “Let’s think of some ways you could handle that situation.” This gives the opportunity
to coach the child on how to cope with (and interpret) both real and imagined scary situations.
If for several weeks, a parent has tried these strategies and the child’s anxiety is beginning to interfere with her
enjoyment of other areas of her life, or is leading to significant impairment in academic, social, or home functioning, then
it may be time to have them evaluated by a mental health professional.
References
1. Kearney CA, Bensaheb A. School absenteeism and school refusal behavior: a review and suggestions for
schoolbased health professionals. J Sch Health. 2006;76:37. Abstract
2. Kearney CA. School Refusal Behavior in Youth: A Functional Approach to Assessment and Treatment.
Washington, DC: American Psychological Association; 2001.
3. Kearney CA, Silverman WK. The evolution and reconciliation of taxonomic strategies for school refusal behavior.
Clinical Psychology: Science and Practice. 1996;3:339354.
4. Kearney CA. Bridging the gap among professionals who address youth with school absenteeism: overview and
suggestions for consensus. Professional Psychology: Research and Practice. 2003;34:5765.
5. Kearney CA, Albano AM. When Children Refuse School: A CognitiveBehavioral Therapy Approach. New York,
NY: Oxford University Press; 2007.
6. Kearney CA. Identifying the function of school refusal behavior: a revision of the school refusal assessment
scale. J Psychopathol Behav Assess. 2002;24:235245.
7. Kearney CA. Dealing with school refusal behavior: a primer for family physicians, workable solutions for unhappy
youth and frustrated parents. J Fam Pract. 2006;55:685692. Abstract
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Medscape Psychiatry © 2015 WebMD, LLC
Any views expressed above are the author’s own and do not necessarily reflect the views of WebMD or Medscape.
Cite this article: Managing BacktoSchool Anxiety. Medscape. Oct 20, 2015.
