School avoidance occurs when children and teens repeatedly stay home from school or are repeatedly sent home from school, because of emotional problems or because of aches and pains that are caused by emotions or stress and not by medical illness.
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Ben missed a lot of school because of his stomachaches. His stomach felt especially bad on Monday mornings. Often, while he was getting dressed for school, he felt as if he might throw up. His mother didn't want him to go to school if he was sick. On days he stayed home, Ben got back into bed, and by lunchtime he felt much better. But by the next morning, he felt miserable all over again. He managed to get himself to school sometimes, but it was getting harder and harder. He would be embarrassed if he threw up on the bus. Ben's doctor had examined him and found him to be in excellent health despite his stomach pains. Still his stomachaches continued, and Ben's mother had started to worry about how many school days he was missing.
What Is School Avoidance?
Ben has school avoidance, a common condition among schoolchildren and adolescents. Sometimes called school "phobia" * (FO-bee-a) or school refusal, school avoidance is a pattern of missing school for symptoms that are caused by emotions or stress, rather than physical illness. School avoidance is different from truancy (TROO-an-see), which is a pattern of repeated unexcused absences from school. The student who is truant, or skips school, is neither at home nor at school. In school avoidance, the student stays home.
What Causes School Avoidance?
There are two main reasons someone has school avoidance. One reason is that the student feels anxiety (ang-ZY-eh-tee), fear, or worry about some aspect of going to school or about leaving home. The other reason is that there is some benefit, or a secondary gain, to staying home from school.
* phobia is an intense, persistent, unreasonable fear of (and avoidance of) a particular thing or situation.
Anxiety-related school avoidance
Most children have some anxiety about attending school for the first time. This is known as "separation anxiety." It is not surprising when separation anxiety occurs when a child is about to enter kindergarten or first grade. For many children this is the first time they are away from home or separated from their parents. But some children have separation anxiety that lasts beyond the expected age. Children who have recently been through other difficult separations, such as divorce, or the death of a parent, or the illness of a family member, may have an especially difficult time leaving home to go to school.
Children with school avoidance may have headaches, stomachaches, chest pain, or other symptoms brought on by the stress of separation. These pains are real, but they are caused by the body's response to stress and not by an illness. Usually, a checkup by the doctor finds the child or teen to be in good physical health. Students with anxiety-related school avoidance are often good students and like school, but because of their stress-related symptoms, they feel that they need to stay home.
Some students with school avoidance may have anxiety about school itself. They may worry about grades, about being bullied, about being called on by the teacher in class, or about having to undress for gym. Some schools have rules about when students may use the bathroom, and this may be a worry to children who may need to go more often. Dirty school bathrooms without enough privacy or issues about safety may be real concerns for some children.
In many cases, anxiety-related school avoidance begins with an upsetting event that happens at school, for example, being teased or experiencing something disturbing in class. Students who are shy and sensitive by nature and those who have an overprotective parent may be more likely to have anxiety-related school avoidance.
Secondary-gain school avoidance
Not all children and teens with school avoidance are anxious or shy. Some may simply find that it is more comfortable staying home than attending school. This is called secondary-gain school avoidance. "Secondary gain" is a term that refers to the bonus or positive side of something unpleasant. For example, though it is unpleasant to be sick, it may be pleasant to watch television during the day and to have meals in bed. Another secondary gain of being sick might be not to have to do homework or having the personal attention and care of a parent at home.
Secondary-gain school avoidance often starts with an illness that lasts for a few days and causes the student to miss school. The student may get behind in homework and begin to think about how hard it will be to catch up. To avoid the hard work ahead, the student may stretch out the illness a bit longer. Receiving the secondary gains of sympathy, the care and attention of parents, and the fun of watching daytime TV can contribute to school avoidance. Lenient parents or parents who do not view school as important can contribute to secondary-gain school avoidance. Sometimes students exaggerate symptoms or claim to have symptoms they really do not have (like sore throat or leg pain) just to avoid school.
How Is School Avoidance Diagnosed?
School avoidance is diagnosed when a student has repeatedly missed school due to aches and pains or other symptoms, and a careful checkup by the doctor has found the student to be in good health. The doctor will check for school avoidance by evaluating the pattern of symptoms and asking about stresses. The doctor may explain how stress can cause certain physical symptoms and may have the student keep track of symptoms by writing them down.
Ben's doctor asked him about some of the worries that were on his mind lately. Ben mentioned that since his parents had divorced last year and his dad had moved across town, he had started to worry about his mom being lonely. He had seen her cry a lot this year, and it made him sad. He said he missed his dad and wished they could be a family again, but without the arguing. Although he looked forward to the weekends he spent with his dad, he was sad that his mom had to spend weekends alone. Ben's doctor explained how people could get stomachaches from stress and sadness. She asked Ben to keep track of his stomachaches in a diary, and she told him to go to school anyway. She gave Ben and his mom the name of a therapist who would help him talk about his feelings and about how to adjust to all the changes in his family.
How Is School Avoidance Treated?
The first step in treating school avoidance is to help the student get back to school right away. The longer a student avoids school, the harder it is to return. Students with anxiety usually need reassurance that they are in good health. Students and their parents are helped by taking a "yes but" approach. The symptoms are real, but are not cause to miss school. Parents are guided about what symptoms are grounds to stay home, and find ways to help a student attend school despite discomfort caused by aches and pains. The treatment often includes a plan for what to do when the student begins to feel ill at school. The plan may be for the student to go to the nurse's office to lie down for 5 to 10 minutes and then return to class, but not to go home. Medications to treat anxiety may be helpful in some cases.
Another important part of treatment may involve working with school personnel to solve problems that are causing anxiety, such as bullying or lack of privacy in bathrooms. Students who have separation anxiety or generalized worry may benefit from counseling to learn to cope with painful feelings or loss. The usual treatment for students with secondary-gain school avoidance also is to return to school right away. Clear limits, appropriate expectations, and support for regular school attendance are critical factors for successfully addressing the problem.