Your Child, Anxiety, School Refusal and the Desire to Curl in a Fetal Position

If you are taking the time to read this post you are probably not having a minor problem with your child being anxious about school. There is a good chance you are having a 5-star wild-horses-can’t-drag-your-child-to-school problem. Anxiety is bad enough but when you throw in school you have an agonizing crisis.

If your child is either not going or fighting (as in emotional maelstrom) going to school this is called school refusal. Sometimes you will see it described as a school phobia. I prefer school refusal because the anxiety that causes the resistance may not be a “phobia” of school but of something else just triggered by school.

What Triggers School Refusal?

School refusal can happen at any age but most often happens at a couple of transitions. The first is when your child is first starting school around ages 5 and 6. The second is the change from elementary to middle school (in the US) around ages 10-11. In other countries the transition might be a year or so later to high school. The onset of the anxiety is usually around those or a similar major change. Changes like moving, a family crisis, a military deployment of a parent, etc. When school starts back after breaks or holidays can also trigger refusal. I remember with my own child the relief we would feel when school was out then the shock when it started back. The first time we thought, “Hey, maybe we are finally through this!” Then of course, the holiday ended….

What is the Purpose of the Refusal?

In the course of figuring out what to do, the first step is to determine the purpose of the refusal. Here are a few possibilities:

Avoiding anxiety-provoking stimuli. Examples can be avoiding feelings of panic, performance situations like public speaking or tests, separation from a parent, etc.
Social problems like having trouble making friends, being bullied, trouble with a specific teacher, etc.
Excessive desire for attention from a parent.
The option to stay at home and do things they would prefer like playing games, watching tv, etc.
A physical or medical reason like a chronic illness, a different mental illness or a sleep disorder.

This post is really about point one and parts of point two or any other purpose primarily related to anxiety. The other issues would require a different approach. So, if anxiety is behind the refusal what can you do?

Any Anxiety Disorder Could be the Driving Force

Nearly any anxiety disorder could be the reason for the refusal. In other words, refusing or resisting school may just be one symptom for the disorder. For example, if your child is struggling with separation anxiety disorder he might completely melt down on the way to school. However, the anxiety is about being separated from you and not because school itself is a problem. In other words, if you could stay with your child during class he might be happy as a clam at school.

Determine the Main Anxiety Disorder Causing the Refusal

If you determine anxiety is the purpose of the refusal, the next step is to determine the specific kind of anxiety problem. Here are some brief descriptions of relevant anxiety disorders with emphasis on school related concerns and links to more information:

Separation Anxiety: Fear over possible loss or separation from a parent (or caregiver) triggered by having to go or stay at school.
Panic Disorder: Fear of having an intense panic reaction in a situation where escape is difficult (like a classroom) or that would result in embarrassment because of the audience.
Obsessive Compulsive Disorder: Intense obsessions and rituals are characteristics of this disorder and may be triggered by school situations such as fear of contamination. Extreme perfectionism and chronic worry about health may be in this category as well.
Social Phobia: Fear or criticism or embarrassment by students or teachers triggered by social or performance situations. Test anxiety is an example of a performance related anxiety.
Generalized Anxiety Disorder: Chronic worry over multiple issues like grades, being liked, keeping the rules, remembering homework, etc.
Phobia: A common phobia that results in school refusal is emetophobia or the fear of getting sick and vomiting that is triggered by the possibility of catching a virus or throwing up while at school.

A professional should make a formal diagnosis but often parents are the first to arrive at a possibility for a variety of reasons. The most obvious reason is that you live with them! Also, kids often cannot describe why they are feeling afraid or they are reluctant to say but parents may be able to connect the dots. Sometimes kids minimize symptoms around clinicians or the clinicians only have a little bit of time with your child and may not get a full picture. Whatever the reason it is often up to mom and dad to get to the heart of the problem.

The Bottom Line: Disconfirm the Fear

If you zoom out the treatment for any anxiety disorder is roughly similar. The heart of successful treatment is to disconfirm the fear. In other words, you get better when you realize that whatever is so scary is not actually that scary. The downside is that it ain’t all that easy to do. (My southern is showing.) The upside is that your child can get better and there is a map through the difficult terrain. Learning to do something easy rarely changes your life in the way that learning something hard does. Anxiety forces people to learn things that will help every part of life. This way of learning is through cognitive behavior therapy. It is made up of several components and these apply to all kinds of anxiety. Additionally, there are times when medication may be helpful and you can read more here.

Okay, so you want to disconfirm the fear. That means changing how you think of it. That is the cognitive part of the treatment. Sometimes, changing thinking is all you need to resolve a problem. Often, however, you have to act and put something to the test to see what happens. That may be needed to confirm that something isn’t so dangerous. That is the behavior part of the treatment.

Different types of anxiety tend to have a cluster of underlying beliefs that are responsible for much of the fear. There are sometimes differences in these clusters so that is why figuring out the type of anxiety can be useful. For example, kids with separation anxiety tend to have catastrophic thoughts about something terrible happening to a parent while kids with social anxiety disorder are prone to negative mind reading. Learning to think differently is central to overcoming the fear and knowing the most common kinds of problem thinking will help you know what thoughts need addressing.

Putting a fear to the test by facing it is called exposure. When the feared outcome doesn’t happen that is pretty convincing. Often, it takes a lot of tests or “exposures” for the proof to sink in. Related to that is not doing things that would make facing it safer because that prevents the evidence of disconfirming the fear from taking place. This is called response prevention because you “prevent” the usual “response”.

With school refusal the thoughts that are creating the fear need to be challenged and the avoidant behavior has to reversed by facing it so that the fear can be put to the test. This is usually a gradual process of going back to school and facing whatever fears are triggered there.

One young elementary school age patient was completely refusing to go to school. He was too old/big to carry into class. A single mom was raising him and she worked full-time out of the home. Fortunately, his grandparents lived nearby and could help. The first step was persuading him that facing the fear could lead to overcoming the fear. For obvious reasons this is often a hard sale. No one, and I mean no one, likes to face his or her fear. Next, negotiate with the school. Unfortunately, his mom had to work with a very unsympathetic school administration. So mom fought this battle and was able to work it out for him to attend partially and also go to the nurse’s office when needed. His grandfather was available to escort him to school starting with partial days. Over the course of weeks the amount of time at school increased until he was able to attend full-time. This lasted for several anxiety-free years until he started high school. To everyone’s horror the anxiety came back. Happily, it was short-lived. The first week or two was tough but with some slight scheduling adjustments, he was able to continue and is now going to school without significant anxiety. He had the experience of exposure working before so with some encouragement he was able to trust the process and it went much faster.

So to recap: 1) find the purpose of the refusal, 2) determine the type of anxiety, 3) begin to develop a road map that will address the problem beliefs associated with that particular anxiety and start the process of facing the fears while returning to school. I have addressed what to do if that is not possible in another post that you can read here.

Obviously, the important details of what is included in the road map I have not included. There are too many variables. Here are some options that people consider. 1) Some parents with the time and inclination like to figure out how to do this on their own. Consider starting with a book like Face Your Fears by David Tolin, Freeing Your Child From Anxiety by Tamar Chansky or Worried No More by Aureen Wagner. 2) You should know that being both a parent and therapist is very difficult. (I know, that was my situation.) Certainly, not every loving parent has the gifting, inclination or time for this approach. Because of that you may want something designed for children to be used by children requiring only some oversight from parents. That is why we created Turnaround. As far as we know, there isn’t anything else similar to it. Lastly, because of severity, preference or nature of the situation parents may want a clinician to help. Two good sources for referrals are the IOCDF and ADAA.

How to get your anxious child back to school step-by-step

How to Help Your Anxious Child Battle Back-to-School Fears

Back-to-School Anxiety: Tips to help your child overcome school-related fears