Merck Manual

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School Avoidance


Stephen Brian Sulkes

, MD, Golisano Children’s Hospital at Strong, University of Rochester School of Medicine and Dentistry

Reviewed/Revised Apr 2023

School avoidance occurs in about 5% of all school-aged children and affects girls and boys equally. It usually occurs between the ages of 5 and 11.

The cause of school avoidance is often unclear, but psychologic factors (eg, anxiety, depression Depressive Disorders in Children and Adolescents Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by clinical criteria... read more ) and social factors (eg, having no friends, feeling rejected by peers, being bullied Bullying Children and adolescents may engage in occasional physical confrontations, but most do not develop a sustained pattern of violent behavior or engage in violent crime. Children and adolescents... read more ) may contribute. If school avoidance behaviors escalate to the point at which a child is missing a lot of school, the behaviors may be an indication of more serious problems such as a childhood depressive disorder Depressive Disorders in Children and Adolescents Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by clinical criteria... read more or one or more of the anxiety disorders Overview of Anxiety Disorders in Children and Adolescents Anxiety disorders are characterized by fear, worry, or dread that greatly impairs the ability to function normally and that is disproportionate to the circumstances at hand. Anxiety may result... read more , particularly social anxiety disorder Social Anxiety Disorder in Children and Adolescents Social anxiety disorder is a persistent fear of embarrassment, ridicule, or humiliation in social settings. Typically, affected children avoid situations that might provoke social scrutiny ... read more , separation anxiety disorder Separation Anxiety Disorder Separation anxiety disorder is a persistent, intense, and developmentally inappropriate fear of separation from a major attachment figure (usually the mother). Affected children desperately... read more , and/or panic disorder Panic Disorder in Children and Adolescents Panic disorder is characterized by recurrent, frequent (at least once/week) panic attacks. Panic attacks are discrete spells lasting about 20 minutes; during attacks, children experience somatic... read more . A differentiating factor is that children with school avoidance manifest difficulties only in relation to school, whereas with other disorders, children also have symptoms that involve other areas of their life. A sensitive child may be overreacting with fear to a teacher's strictness or rebukes. Changes in classroom staffing or curriculum can precipitate school resistance in children with special education needs.

Younger children tend to manifest somatic complaints (eg, stomachache, nausea) or make excuses to avoid school. Some children directly refuse to go to school. Alternatively, children may go to school without difficulty but become anxious or develop physical symptoms during the school day, often going regularly to the nurse’s office. This behavior is unlike that of adolescents, who may decide not to attend school (truancy—see School Problems in Adolescents School Problems in Adolescents School constitutes a large part of an adolescent’s existence. Difficulties in almost any area of life often manifest as school problems. Learning disorders may manifest for the first time as... read more ); chronic truancy is often present in children with a conduct disorder Conduct Disorder Conduct disorder is a recurrent or persistent pattern of behavior that violates the rights of others or violates major age-appropriate societal norms or rules. Diagnosis is by clinical criteria... read more .

In the absence of a significant underlying disorder, school avoidance tends to result from

  • Poor academic performance

  • Family difficulties

  • Difficulties with peers

Most children recover from school avoidance, although some develop it again after a real illness or a vacation.

Home tutoring generally is not a solution. Children with school avoidance should return to school immediately so that they do not fall behind in their schoolwork. If school avoidance is so intense that it interferes with the child's activity and if the child does not respond to simple reassurance by parents or teachers, referral to a mental health practitioner may be warranted.

Treatment of school avoidance should include communication between parents and school personnel, regular attendance at school with in-school counseling (if available), and sometimes therapy involving the family and child with a psychologist. Therapy includes treatment of underlying disorders, adaptation of the school curriculum for children who have learning disability or other special education needs, and behavioral techniques to cope with the stresses at school.

NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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