Helping Kids Who Want to Avoid School

Ruth McDonald, MD
Vice President, Associate Chief Medical Officer
Seattle Children’s Hospital

More than 25% of all youth will engage in some degree of school avoidance during their school years. This can range from complaints and threats to avoid school to actually missing school for extended periods of time.

We call it school avoidance* when a student is not attending school to avoid an averse feeling, experience, or stimulus in that environment, despite being medically OK to attend. This is different from truancy, when a student doesn’t attend school in order to do something they find more fun or interesting – like engage in deviant peer group activities.

Common concerns that lead to school avoidance include:

  • Anxiety
  • Depression
  • Behavioral difficulties (i.e., compliance)
  • Chronic pain
  • Chronic fatigue
  • To escape from school situations that cause distress (like riding on the school bus, a teacher, or a particular class or area of school)
  • To escape from unpleasant social or performance situations (like playing or working with peers, speaking or reading in front of the class, attending assemblies)

It is contraindicated to enroll students who are school avoidant in online or homeschool programs because it removes the opportunity for them to overcome the issues causing their hesitancy to attend school. Youth who are removed from school to accommodate their avoidance tend to have poorer outcomes.

The indicated treatment is a mixture of cognitive behavioral therapy (CBT) for the student and behavior management training (PMT) for the parent(s) or guardian(s). CBT can help the student address problematic cognitions, work on facing difficult situations, and practice more adaptive behaviors in the face of difficult emotions. Parent management training can guide caregivers on moving their child back to regular school attendance and setting contingency plans for attendance and nonattendance.

Consider referring the patient a mental health provider if the behavior has been occurring for more than two weeks. Reasons for referral can include really difficult mornings for families, even if youth are not technically missing any school.

* Note: While the community at large often refers to this as school refusal, many families bristle at that term, so we call it school avoidance.