Transcription:
What is School Refusal and How to Handle It?

Dr. Greg Fritz: Back to school time is just around the corner and it brings with it many emotions. Kids are excited to see friends and meet their new teachers, but there also may be butterflies and nerves. Feeling to get back into a routine for returning students is normal. But when that anxiety becomes debilitating, some children refuse to go to school to avoid those feelings. Frequently, there are associated symptoms of headaches and stomach aches, so it's important to take these symptoms seriously and rule out serious underlying physical illness by meeting with your child's pediatrician. Usually, these symptoms don't disappear entirely, but the pediatric evaluation allows us to remove them from center stage, so to speak. It's important to note as well that your child is not alone in feeling this way sometimes. As many as 5% of students in the US engage in school refusal at some point during their schooling. And the truth is parents can feel powerless to help their. So, what can you do? Today, we're going to be talking with Dr. Jennifer Herren, a psychologist at Bradley Hospital who specializes in treating children for school refusal.

Dr Greg Fritz: Welcome,

Dr. Greg Fritz: Dr. Herren.

Dr. Jennifer Herren: Thank you so much for having me. Please call me Jenny.

Dr. Greg Fritz: Jenny it is. This is Mindcast: Healthy Mind, Healthy Child, a podcast from the mental health experts at Bradley Hospital, the leaders in mental healthcare for children. I'm Dr. Greg Fritz with my colleague, Dr. Anne Walters.

Dr. Anne Walters: Jenny, so glad you could join us. Here at Bradley, I know we've treated many children and families for school-related anxiety. And so we thought this would be an important topic to cover on Mindcast. As Greg mentioned, we recommend talking to a pediatrician to rule out any physical illness that could be related to symptoms. Everyone needs to be confident that we're not missing something serious that needs medical treatment. Once that's been accomplished, therapy can be remarkably effective in getting kids back on track and back in school. So to orient our listeners, what is school refusal?

Dr. Jennifer Herren: So school refusal is when children or adolescents have difficulty consistently attending school for the full day or even partial days. Most kids have some reluctance to go to school at one time or another. But kids with school refusal have difficulty showing up persistently and it's usually associated with a significant deal of distress for them. So this may mean that they are missing days consecutively or what I think of as the creep, where they may miss one day one week, a couple of days another week. And then, before you know it, they're not getting to school at all. And so if we think about the DSM-5, which gives us psychiatric diagnoses, school refusal is not a specific disorder, but is commonly associated with a number of anxiety disorders, such as separation anxiety, social anxiety, panic disorder, generalized disorder and OCD. So the list can go on and on.

Dr. Greg Fritz: So tell us about, if you would, the ways in which anxiety drives school refusal, and the importance of understanding the function of school avoidance behaviors.

Dr. Jennifer Herren: Absolutely. So, as humans, when we feel anxious, our natural tendency is to want to avoid a situation or escape a situation. And so when there's anxiety triggers in the school environment, kids naturally want to either avoid going to school or leave school early or to escape school. And when this happens, they experience relief, that anxiety feeling goes away. And this is a really powerful reinforcer, which makes it more difficult for them to get back to school in the future.

And so what happens is avoidance works in the short term. But in the long term, it makes it more difficult to get back to school and kids miss out on the opportunity to learn, that they can handle being at school, they can tolerate those feelings of distress and get through the day. And so when we think about function or the reason why for school avoidance, we really want to think about this in order to best tailor treatment, because there's many reasons why a kid may avoid going to school.

Dr. Anne Walters: As somebody that does this work a lot, do you see differences in themes over time for reasons why? You know, we wonder sometimes I guess if there are factors in the news that are causing more anxiety for children. Maybe during the pandemic, it was about health issues. What are your thoughts about that?

Dr. Jennifer Herren: Yeah, absolutely. We certainly can see that there might be particular triggers or times where kids have more like generalized anxiety where there's more information coming out, that they may have more difficulty. So with COVID, I did see an increase of kids being worried about contracting illness or spreading illness to other kids. We see that with school violence, unfortunately, that there might be an exacerbation in worries about being a victim of school violence. And so, we recognize that these worries may ebb and flow over time and we would address them similarly in trying to help get kids back to school, no matter what the reason is for the anxiety.

Dr. Greg Fritz: So what are some of the reasons that kids may want to avoid school?

Dr. Jennifer Herren: There are so many different reasons. Every child is a little bit different in terms of why they might avoid school. So while I primarily deal with anxiety contributors to school avoidance, there are other reasons such as depression or oppositional behavior or targeting or bullying that's happening in the school environment. So it's really important I encourage parents to be curious, to ask their kids, to try to not assume in understanding why a kid is having trouble getting to school, but to open the door for a dialogue. So if a child is being bullied, for instance, we would really want to ensure there is appropriate intervention and that the child is going back to a safe environment. We also see school refusal happen around different times of transition. So it's September, so parents may be facing this very issue right now with kids having difficulty after summer vacation. And maybe they're going to a new school. They're moving from elementary into middle school, or they've been home for winter break or an extended illness. And so these times of vulnerability can often prompt and be a vulnerable time for kids to have difficulty going to school.

For more anxiety-related reasons, which I see all the time in my office, there are just a number of concerns that may lead to school avoidance behaviors. So we're thinking for a kid that has panic attacks and maybe had a panic attack in the school environment, they may be worried about having another panic attack. For kids that have perfectionism or performance-related worries, that can certainly be a trigger around grades. For kids with social anxiety, getting called out in class unexpectedly. Or navigating the dreaded lunchroom, for some kids, that's a great environment. For other kids, that's really anxiety-provoking for them. And so there are many different reasons that could contribute to a kid being avoidant of school. So be curious, don't make assumptions.

Dr. Greg Fritz: Yeah. And that certainly the therapeutic work has to be directed toward the child's own particular reasons, rather than the other theoretical reasons that are possible, but not relevant for that kid.

Dr. Jennifer Herren: Absolutely. We want to tailor treatment to be individualized to that particular child and their core fear, so what's driving their own anxiety.

Dr. Anne Walters: So what does that look like, the sort of a typical day in the life? What's it like when a child comes to see you in your office? Can you give us a sense of what it might look like?

Dr. Jennifer Herren: Sure. When a kid is presenting to my clinical practice who's experiencing school refusal behaviors, I start out with that thorough assessment. So I spend time getting to know the child, getting to know the family, understanding what might be driving that school avoidance. And then, beyond that, even though the individual therapy will look different, the principles, the guiding principles are similar. So I use what's called cognitive behavioral therapy and a specific type called exposure therapy. And what that involves is the child slowly taking manageable steps to reintroduce them into the school environment or to face the parts of school that are anxiety-provoking in very manageable steps.

Let's take a kid that's in elementary school that hasn't been to school in a while, so has been avoiding school, it may feel too hard to jump into an entire day back at school and very anxiety-provoking. So if you compare this to running a marathon, we're not going to go out and run the full 26 miles, right? We're going to want to start with that first maybe even fourth of a mile. And so what that looks like in practice is planning with family around. We do them in the office when we can, but planning to do exposures. And so that could look like driving past the school. It could look like driving to the school and sitting in the parking lot, walking around the campus, going into the school environment after hours or before school and then, going into school for maybe a briefer amount of time, such as an hour in the day, and then slowly increasing the amount of time there in school until it becomes more tolerable. And this gives them the opportunity to learn that, "Hey, in fact, I can handle going to school and I can cope with this situation." And so, that's kind of really specific to the school.

If there are other drivers to their anxiety, let's take a kid with social anxiety that feels very nervous about answering questions unexpectedly or talking to unfamiliar people or peers, we may also do exposure work in the community or in the office to help build their confidence around handling those types of situations. So when they return to the school environment, they're feeling better prepared and they have that experience from practicing in the office and the community as well.

Dr. Anne Walters: And I think that makes a lot of sense. It kind of goes back to what you were saying about being curious, because sometimes we'll have kids come into treatment who are going to school, but they're sitting in the guidance office all day. And so, it's kind of school refusal in that they're not in class, but there must be something different maintaining the inability to go into the classroom specifically, right?

Dr. Jennifer Herren: Right. Exactly. So maybe there's a particular subject or a teacher, getting called on. And so for some kids, it's about getting them in the door and just being at school. But then, the next part of exposure is reintroducing them and getting them back into the classes that feel more difficult for them.

Dr. Greg Fritz: Say something about the timeframe. I mean, obviously, it's different one child from another. But what are you thinking when you have a child, an average child, present to you? About how long this is gonna take and how many sessions?

Dr. Jennifer Herren: You're going to hear my favorite answer, it depends. Of course, it depends. And I think the goal is the more kids practice, the easier it gets. And so if you are able to consistently practice, we're hoping this is meant to be more of a shorter term treatment, that's actively involved in doing these exposures on a daily basis. And so, hopefully, within weeks to months, kids are back and acclimated and in the school environment. Certainly, there are some exceptions where kids may be doing the practice in between our meetings, it's really difficult and they might benefit from a higher level of care. And so we have programs here at Bradley Hospital that offer Monday through Friday daily treatment that can really provide that additional support to kids that are struggling to do this in between traditional weekly outpatient therapy.

Dr. Anne Walters: How do you loop in the child's school? Are there particular ways that administrators or teachers can help with these situations?

Dr. Jennifer Herren: That's an excellent question. I would recommend looping in the school as early as possible. The more a child misses school, the harder it is to get back. It really becomes a vicious cycle and school personnel, administrators, teachers can really be helpful collaborators and problem-solvers and really allies in this work. Some examples of ways school staff have been helpful in cases that I treat are having someone come and help with the transition of the child, leaving the car and getting into the school building or having the opportunity to have a five-minute check-in with the school staff at the very beginning of the day or a point person, whether it's a guidance counselor, a social worker, a school psychologist that they can go to and check in if they need a short break and then to return to class.

The other thing to consider is when kids miss, and this is particularly important for adolescents and in middle school and high school, they miss curriculums, so they're missing academics. And getting further behind a lot of times increases the stress and the anxiety about returning to school. And so our school staff and teachers can help us problem solve ways to try to mitigate this stress and whether that's extensions in terms of classwork, whether it's a reduction in classwork, whether it is additional tutoring, all of these may be helpful in trying to help the child get back caught up in terms of their academic work.

Dr. Anne Walters: I think it's so important for families to remember too, that schools have a lot of experience in working with kids that are feeling anxious in school. And sometimes, really simple interventions are just right there and available. I'm thinking of kids maybe who are just getting into middle school and they just really need to practice how to open their locker, because it's so complicated when you've never had to do that or worried about forgetting to bring things to class, so maybe they go leave class a little early, you know, so many things that schools can offer that aren't a huge ask really.

Dr. Jennifer Herren: Exactly. And I've treated kids that weren't going to school at all, because they were worried about eating in the lunch room. They were worried about vomiting or a peer vomiting, and being able to start out with being able to eat in a private space for lunch and getting to school, and then slowly working up to being able to resume eating lunch in the bigger cafeteria, then became a treatment target.

Dr. Greg Fritz: So say something, if you would, about the role of the parents in this treatment. I'm sure it's important.

Dr. Jennifer Herren: Yes, it's very important. In fact, I believe it's a critical ingredient and needed for this treatment. And parents really should be included in treatment planning and problem-solving about how to best help the kids. Parents are the ones that are needing to set those firm limits around getting the kids to school on a daily basis. This is exhausting. It's hard for parents. It can certainly impact families more broadly in terms of family conflict, parents' ability to get to work on time. And so as a provider, I'm talking to parents about how they're responding to kids and what are the ways I can support them around setting these limits when their child is experiencing anxiety or physical symptoms of anxiety, which is hard for them to see. So I like to partner with parents and helping them get to the point where, even though it's hard, that they're feeling more confident in their ability with setting these limits.

I think the other piece we need to involve parents in is planning. When they do refuse to go to school, what happens next? And so, maybe for a child that has a lot of complaints around physical illness, there might be a plan around what are the reasons why we would not have them go to school and go to the doctor instead. And that can be a great role for the pediatrician to play in developing that list of reasons why. Or for some kids, not only are they having relief of anxiety by not going to school, then they're home and they have access to a lot of preferred activities, things they enjoy like TV, video games. And so we talk with parents a lot about how to make home more schoollike, so a little bit more boring, less reinforcing for the kids.

Dr. Greg Fritz: Terrific. We really appreciate your insights and thanks so much for being here with us today. It seems to me that the fallout due to the pandemic knows no bounds and that we're seeing children disproportionately affected by them. Kids who may have had anxiety before the pandemic may have embraced virtual learning wholeheartedly. And now, they must return to in-person schooling without any consistent supports in place. Or on the flip side, perhaps there were students that weren't anxious before, but now have developed some anxieties due to the shutdowns. Either way, this discussion is sure to be helpful to parents and will provide them with some tools to draw from if they notice these behaviors in their kids. So thank you so much for being here with us today. We're very grateful.

Dr. Jennifer Herren: Thank you so much for having me.

Dr. Greg Fritz: And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library at bradleyhospital.org/podcast for topics of interest to you. This is Mindcast: Healthy Mind, Healthy Child, a podcast from the experts at Bradley Hospital. I'm Dr. Gregory Fritz with my colleague Dr. Anne Walters, and we both thank you for listening.