drop-off zone but when the time comes to take those fateful last steps they either become angry and defiant or tearful and distressed. The school refuser makes no secret of their inability to attend school. They will often say that they want to go to school but can’t.
This is in marked contrast to the truant whose absences are not anxiety-based and who hides the fact that they are not attending school. Unlike the school refuser the truant will engage in alternate behaviours when not at school, such as spending the day with friends, shopping or walking the streets of the city.
Parents of school refusers often report overt anxiety symptoms shortly after the child gets home from school. Parents report a variety of symptoms including moodiness, aggressive outbursts, unwillingness to complete homework, reduced appetite, excessive worry, changes in sleep patterns and reluctance to engage in bedtime routines as it signals the end of the day and the imminent start of another school day. These symptoms are often worse on Sunday nights and a day or two before the beginning of a new school term as the child has had several days away from school and has had time to distance themselves from the anxiety associated with going to school. Many parents dread the beginning of a new term for this very reason.
Anxiety and school refusal
In order to best understand school refusal we must have a solid understanding of child anxiety. Up to 80% of school refusers meet criteria for some form of anxiety disorder whether it be separation anxiety, generalised anxiety or social anxiety.2
According to the DSM-5, anxiety is the anticipation of future threat, while fear is the emotional response to a real or perceived imminent threat. Although these two states overlap they also differ in that fear is more often associated with surges of autonomic arousal necessary for the fight or flight response, while anxiety is more often associated with muscle tension and vigilance in preparation for a future danger. While anxiety disorders (separation anxiety disorder, generalised anxiety disorder and social anxiety disorder) have a high rate of comorbidity, they can be differentiated by examination of the types of situations that are feared or avoided. Separation anxiety is at its core a fear of being separated from a significant person who is believed to offer comfort, safety and support. Social anxiety is characterised by marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Generalised anxiety disorder, on the other hand, is characterised by excessive worrying about a number of events or activities. For the purposes of simplicity I will use the umbrella term ‘anxiety disorder’ throughout this book and where necessary will venture into specific anxiety disorders as the need arises.
Anxiety disorder is a commonly occurring mental health disorder that affects approximately 14% of the population3 or one in seven people, which means that we all know at least one or two people who suffer with this disorder. Its severity can range from mild (where the person can still attend school/work), right through to severe (where the person is challenged to leave their home). It is characterised by persistent, excessive worry that hinders logical thinking and action. Individuals with anxiety disorder typically overestimate the perceived danger in situations and become either overly cautious or avoidant. In the case of school refusal, the child has often experienced a negative situation at school (i.e., bullying, failed assessment task) and avoids a reoccurrence of the incident by avoiding school. The longer the child is away the greater the perceived danger becomes causing symptoms to become ever more severe. Symptoms as listed in the DSM-5 are typically characterised by restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
This does not mean that the remaining 86% of the population are anxiety-free as anxiety is part of everyday life. Think, for example, of the last time you attended the dentist or entered a meeting with your employer, which you suspected, would not end well. That dread, that hollow sick feeling in your stomach, the clammy hands, the racing thoughts, the tightness in your throat and chest, is your body telling you that your anxiety is on the rise and that you are not coping. Anxiety can also be triggered by everyday occurrences like the traffic on the way to work, arguments with our loved ones, and children who will not get ready for school. For most people (86%) these feelings of distress/anxiety/stress will subside once the situation is resolved but for some (14%) this return to equilibrium is not easily achieved. For these people everything that goes wrong in their day (no matter how small) adds to the existing high levels of anxiety until eventually the body can take no more and a panic attack ensues. Yep that’s right: a panic attack doesn’t just come out of nowhere, it is a result of persistent anxiety that builds and results in an abrupt surge of intense fear or discomfort that leads to panic symptoms. So, your child’s frenzied tantrum at 8am has been building for hours and sometimes even days. A panic attack is the body’s way of saying ‘too much stress, can’t manage it any more, let’s get rid of it’. That is why, after a panic attack, the sufferer often reports feeling tired, sleepy and worn out. A panic attack is the emotional equivalent of a pressure cooker with a blocked outlet valve.
Now imagine these intense feelings in a child who has been worried about going to school since the day before (obvious signs of not coping often begin around dinner time) and suddenly it’s not surprising that they lash out at the well-meaning parent or carer who is trying to get them to school. Fear (which is what the child feels when they’re told they’re going to school) provokes a fight, flight, or freeze response. The child will either argue back, lash out and flee to their room or the playground area, (if at school), or say nothing and have rivers of tears flowing down their cheeks. This is normally where parents become frustrated, angry or completely disheartened and eventually give into the child’s pleas resulting in another day off school and more feelings of failure for everyone involved. Every day that a parent or caregiver gives into the child’s pleas and reasons for not attending school, we reinforce their fear and teach the child that the louder they scream, the harder they plead and the more plausible their reasons, the more likely we are to give in. This does not mean that the child is innately devious or manipulative, they are simply using whatever is at their disposal to achieve their desired goal: not going to school and hence reducing their level of distress. Rather than allowing this self-destructive behaviour to continue we, as service providers and parents, need to provide the child with the knowledge and skills to recognise their symptoms of anxiety and manage them in a way that empowers and rebuilds self-esteem.
A good analogy of this would be teaching a child to swim. Initially the child is afraid of the water, especially if they have had a bad experience, and may cry and cling to the parent as they enter the water. Their instincts are to hold on to their carer for dear life. If the carer does not encourage the child to begin to let go, it is highly likely that the child will never learn to swim and may in fact develop a real fear of water. However, if the carer reassures the child and tolerates their cries and praises even the slightest of achievements the child begins to believe that they are capable. Progress will, of course, be very slow but if every time the carer gets into the pool there is an expectation that the child will pick up where they left off the last lesson progress will begin to occur.
Just as the swimmer is slowly encouraged and expected to master their water skills so must we expect the school refuser to return to school. It is important that we all understand that the school refuser will not miraculously get up one day having mastered their anxiety and gladly go to school. Learning to master their anxiety symptoms comes from learning what anxiety is, how it presents, what can be done to control it and real-life exposure that is done at a pace the child can handle. Just like the swimmer, we must always expect that the following day will be a slight improvement on the day before. This is how empowerment and self-esteem is built no matter what the challenge may be.
Returning a child to school can be a monumental task taking enormous time and energy on the part of parents, teachers, psychologists and of course the child (who may initially not like any of these people very much). The early stages of returning a child to school can be a thankless and heart wrenching ordeal but an integrated team approach can produce positive, long-term outcomes as I have evidenced in my 30 years as a psychologist.
What does school refusal look like?
Let’s look at an example of school refusal compiled from multiple case