School Refusal

School RefusalEpidemiology and Management

David Heyne,1 Neville J. King,2 Bruce J. Tonge3 and Howard Cooper1

1 Victorian Child Psychiatry Training Department, Department of Psychiatry, Faculty of Medicine,Dentistry, & Health Sciences, University of Melbourne, Melbourne, Victoria, Australia

2 Faculty of Education, Monash University, Melbourne, Victoria, Australia3 Centre for Developmental Psychiatry and Psychology , Faculty of Medicine, Nursing and Health

Sciences, Monash University, Melbourne, Victoria, Australia

Contents Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7191. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7212. Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7213. Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7224. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723

4.1 Tips for Identification and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7234.2 Cognitive Behavioural Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724

4.2.1 Child Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7244.2.2 Parent Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7264.2.3 School Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727

4.3 Pharmacological Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7274.3.1 Tricyclic Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7274.3.2 Selective Serotonin Reuptake Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7284.3.3 Other Pharmacological Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729

5. Overall Treatment Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7296. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 730

Abstract School refusal is differentiated from other attendance problems such as tru-ancy and school withdrawal. It is characterised by the child’s emotional upset atthe prospect of going to school, parental awareness of and antipathy toward theproblem, and an absence of significant antisocial behaviour in the child. Thechild’s emotional upset is frequently associated with an anxiety disorder, but itmay also be associated with a mood disorder. School refusal affects approxi-mately 1% of school children across the primary and secondary school levels.Severe and prolonged school refusal jeopardises the young person’s social, emo-tional and academic development, and may be associated with mental healthproblems in adulthood.

A first step in management involves efficient identification and the assessmentof contributing and maintaining factors. Clinical outcome studies support theefficacy of cognitive behavioural therapy (CBT). The psychosocial approachencompassed in CBT incorporates anxiety management training with the youngperson, behaviour management training with parents and consultation with school

THERAPY IN PRACTICE Paediatr Drugs 2001; 3 (10): 719-7321174-5878/01/0010-0719/$22.00/0

© Adis International Limited. All rights reserved.

personnel. Pharmacological treatments are commonly employed although empir-ical support for their use is limited. Tricyclic antidepressants and selective sero-tonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are the more commonlyused agents, with the latter having fewer associated adverse effects. It is suggestedthat the first line of treatment should be CBT, with simultaneous or subsequentpharmacological treatment contingent upon the response to CBT.

School refusal denotes a difficulty with schoolattendance that often causes distress for the family,and presents a challenge to education and mentalhealth professionals. While debates continue on thedefinition of school refusal and its relationship totruancy,[1] we contend that these are two types ofschool attendance problems which differ in a num-ber of important ways.

Firstly, truancy customarily entails an attemptto conceal nonattendance from the family[2] atsome stage in the history of the problem. The childexhibiting truancy may start out for school in themorning, but on failing to arrive there or to stay allday, the child will avoid going home. On the otherhand, the parents of the child exhibiting school re-fusal are well aware of the attendance problem[3]

and the child often remains at home. Secondly,whereas the nonattendance of a child exhibitingtruancy is usually intermittent, the child who ex-hibits school refusal may be away from school forweeks or months at a time.[3] Thirdly, the child whoexhibits school refusal is generally a good studentwith vocational goals requiring schooling, whilethe child exhibiting truancy is an indifferent stu-dent who dislikes school and frequently displays apoor standard of schoolwork.[3] Furthermore, chil-dren exhibiting truancy are more often diagnosedwith conduct disorder than with an emotional dis-order.[4]

The essential features of school refusal are en-compassed in a set of criteria developed by Berg etal.[5] and refined by Bools and colleagues:[6]

• when faced with the prospect of going to school,with reasonable parental pressure to attend, thechild displays severe emotional upset or com-plains of physical illness thought to have anemotional basis

• the child is usually at home with the parents oranother family member

• an absence of severe antisocial behaviour/conductdisorder.The specification that parents have made a rea-

sonable effort to secure their child’s attendanceserves to distinguish between school refusal andschool withdrawal, the latter being associated withparental irresponsibility in encouraging atten-dance.[7]

In a recent discussion, Berg[2] noted that thechild’s emotional upset may be confined to thesituation of leaving home to go to school, or it maybe part of a more general disorder characterised byanxiety and depression. Regarding the absence ofconduct problems, Berg[2] clarified that while somechildren who exhibit school refusal may displayaggressive and resistive behaviour, this is essen-tially confined to the home and it is in the absenceof other antisocial tendencies (such as stealing anddestructiveness) more characteristic of the childexhibiting truancy.

In all, the criteria provide a means of distin-guishing between mild fear of school as a normaldevelopmental phenomenon, and the serious con-dition of school refusal. They also help to make animportant distinction between school refusal as onetype of attendance problem, and truancy and schoolwithdrawal as two other attendance problems. It isto be acknowledged, however, that a small propor-tion of children may display characteristics of morethan one attendance problem.

It is also worth noting that some clinical re-searchers prefer the term ‘school refusal behaviour’which is taken to encompass both school refusaland truancy.[8,9] They contend that the category ofschool refusal behaviour, which is marked by mo-tivation to engage in alternative enjoyable activi-

720 Heyne et al.

© Adis International Limited. All rights reserved. Paediatr Drugs 2001; 3 (10)

ties during the school day, is typically consideredtruancy. Our clinical experience suggests that chil-dren exhibiting school refusal who have been ab-sent from school for some time also learn that thereare many advantages to not being at school. How-ever, we would not regard these patients as chil-dren exhibiting truancy, because they do not displaythe other characteristics of truancy as describedabove.

1. Epidemiology

Most commonly, school refusal prevalence ratesare reported to be about 1% of all school-aged chil-dren,[10,11] and 5% of all clinic-referred children.[4,10]

The notion that the number of children who exhibitschool refusal presenting to clinical settings is in-creasing finds support in the literature.[3,12,13]

However, as Gordon and Young[3] pointed out, thismay not be a function of a greater incidence butreflective of a greater awareness of the problemand propensity to refer for treatment.

School refusal is equally common in boys andgirls and it occurs throughout the range of schoolyears. Hersov’s[4] review suggested that school re-fusal is more common between 5 and 7 years of age,at 11 years of age, and from 14 years of age, res-pectively, corresponding to early schooling, changeof school and nearing the end of compulsory edu-cation. In a study of 63 children who exhibitedschool refusal, Last and Strauss[11] observed thatthe peak age range for referral was from 13 to 15years. In our own study of 61 children exhibitingschool refusal, the children were most commonlyin Year 7 (38%) or Year 8 (20%) [12 to 14 yearsof age] at the time of referral.[14] Other authorshave similarly suggested that school refusal has ahigher prevalence in preadolescence and adoles-cence relative to early or middle childhood.[15,16]

While it might be expected that school refusalwould be more common in children of lower intel-lectual ability, one of the larger and more method-ologically sound studies published has indicatedthat children exhibiting school refusal, as a group,showed a fairly normal distribution of intelli-gence.[17] Furthermore, there is no clear evidence

that learning disabilities are over-represented in thegeneral school refusal population. Socioeconomicstatus does not appear to be directly associatedwith the incidence of school refusal, with disparatefindings emerging from studies.[11,18] Likewise, re-ports on the occurrence of single parent families inschool refusal cases vary considerably.[11,19,20]

2. Clinical Features

A wide range of anxiety symptoms can be asso-ciated with school refusal. The symptoms mayvary over the course of the school refusal problemand, indeed, over the course of a school day. Theremay be little evidence of anxiety when the pressureto attend school is removed or on the weekend andduring school holidays. Even when attending, chil-dren exhibiting school refusal may appear to be-have normally, their fear seeming to have rapidlydissipated, but recurring the next day when it istime for school again.[2]

The anxiety may manifest behaviourally, physi-ologically and cognitively. At the behaviourallevel, one of the most obvious indications of thechild’s difficulty attending school is simply his/herrefusal to attend. In an effort to resist or avoidschool attendance the child’s noncompliance maytake the form of remaining in bed, refusing to getready, refusing to get into the car to travel to schoolor refusing to get out of the car on arrival at school.Complaining about school, crying, temper tan-trums and threats of self-harm or of running awaycommonly occur when pressure is exerted on thechild to attend. Other overt signs of fearfulness in-clude trembling, shaking and agitation.

Documented physiological symptoms associ-ated with the child’s anxiety about attendingschool include abdominal pain, nausea, vomiting,headaches, sweating, diarrhoea, dizziness, pallor,sore throat, fever and frequent urination. Theseusually appear in the morning, often elicited whenthe child is pressured to attend school. The morecommon physiological symptoms appear to beheadaches and stomach aches.[20,21]

The cognitive component of school refusal in-volves irrational fears about school attendance.

School refusal 721


Hersov[4] observed that ‘many children insist thatthey want to go to school and prepare to do so butcannot manage it when the time comes’. In thesesituations the children may overestimate the likeli-hood of anxiety-provoking situations occurring atschool and underestimate their own ability to copewith anxiety-provoking situations.

Clinical evaluation of the symptom clusters mayreveal an anxiety disorder. Although school refusalhas been found to occur in the absence of anxietydisorders,[6,22] and not all children with an anxietydisorder display school refusal behaviour,[11] theliterature reveals a strong link between school re-fusal and anxiety disorders. Common diagnoses in-clude separation anxiety disorder, generalised anx-iety disorder, social phobia, specific phobia andadjustment disorder with anxiety.

Age-related trends are evident in these diagno-ses. Separation anxiety is usually associated withschool refusal in younger children, while otheranxiety disorders, particularly phobias, are oftenassociated with school refusal in adolescents.[23]

When the child with school refusal displays a pho-bic response it is more often in relation to socialand evaluative situations (e.g. an excessive and/orirrational fear of being criticised or teased) than tospecific objects within the school situation.[15]

Reports of the prevalence of depressive symp-toms and depressive disorders in children exhibit-ing school refusal vary considerably. Studies ofchildren referred for treatment at a clinical settingand using more reliable procedures for diagnosingdepression, such as the Diagnostic and StatisticalManual of Mental Disorders (DSM)[24,25] criteria,suggest that between 13 and 21% of these childrenhave a depressive disorder or an adjustment disor-der with depressed mood.[11,14] As many as 50% ofchildren may display subclinical depression (i.e.presence of depressive symptoms, but falling shortof diagnostic criteria), often in association withanxiety.[14]

By definition, pervasive conduct problems arenot characteristic of school refusal. However, chil-dren exhibiting school refusal may become stub-born and argumentative, and display aggressive

behaviours when parents attempt to get them toschool.[4,26,27] More pervasive and persistent oppo-sitional behaviour, as encompassed in oppositionaldefiant disorder, has been reported in between 9and 21% of anxious children exhibiting school re-fusal.[14,28]

In summary, school refusal is symptomaticallyand diagnostically heterogeneous.[29] A range ofanxiety or phobic disorders may be diagnosed, andsymptoms or diagnoses of depressive disorders andoppositional defiant disorder may co-occur.

The onset of school refusal may be acute (e.g.sudden refusal to attend on the first day of a newterm) or chronic (e.g. increasing complaints aboutschool and reluctance to attend, eventually culmi-nating in refusal to attend). For some children ex-hibiting school refusal, nonattendance may be spo-radic, while others may have been absent fromschool for weeks or months.

3. Prognosis

Persistent absence from school can have nega-tive consequences on the child’s academic perfor-mance and educational development.[29,30] Thismay contribute to problems in educational adjust-ment in later school life and adulthood.[31] Difficul-ties with employment may arise,[10,29] although thereis some evidence to the contrary.[32,33]

School refusal also interferes with the child’ssocial development. Relationships with schoolpeers become disrupted and anxiety may spread tononschool-related situations such that the childwith school refusal is unable to leave the home.[21]

Long-term problems in social adjustment com-monly arise following school refusal,[20] includingsocial avoidance in adulthood.[10] Summing upseveral retrospective studies, Berg et al.[34] sug-gested that children exhibiting school refusal aremore prone to either agoraphobia or other neuroticdisorders in later life.

Studies following up school refusers between10 and 29 years after treatment, suggest that, rela-tive to the general population or control groups,children exhibiting school refusal are more likelyto have psychiatric disturbance or to seek help.[35-37]

722 Heyne et al.


Buitelaar and colleagues[23] found that 13 of 25 ado-lescent children who had exhibited school refusal,and were followed-up after 5 years, had DSM-definedpsychiatric disorders.

In a controlled study comparing treated and un-treated (wait-list) children exhibiting school re-fusal, King et al.[38] found that wait-list partici-pants showed minimal changes in emotionaldistress by post-treatment. While the design of thisstudy does not inform us of the long-term progno-sis for untreated children exhibiting school refusal,it demonstrates that in the short-term at least, theprognosis is poor. On the other hand, a 3- to 5-yearfollow-up of the participants who received cogni-tive behavioural treatment (CBT) revealed mainte-nance of treatment gains in 81% of treated chil-dren.[39]

The older child who exhibits school refusal isfrequently held to have a poorer prognosis. Vallesand Oddy’s[33] review of prognostic indicators sug-gested that the prognosis is worse for children ex-hibiting school refusal who are over 11 years of agewhen they receive treatment, those who have moresevere school refusal symptoms and those whohave accompanying psychiatric disturbances.Clearly, the early identification and successfultreatment of school refusal is essential.[29]

4. Management

Psychosocial approaches to the management ofschool refusal have included play therapy, psycho-therapy, family therapy and CBT. Of these, CBThas the most research support for its efficacy, andit is comparably less time consuming and lesscostly.[40] Following consideration of identifica-tion and assessment issues, we focus on CBT andpharmacological treatments for school refusal.

4.1 Tips for Identification and Assessment

Access a broad range of information sources.Much information can be gathered from parentsand school staff. Young people are often more re-luctant or incapable of identifying factors whichprecipitated or maintain their school refusal. Con-siderable time needs to be spent building rapport

with the young person before questioning aboutschool attendance.

Distinguish between cases of school refusal andtruancy, as the latter often necessitates an alterna-tive approach to intervention.[41]

Arrange a medical investigation of the child’sphysical health. Somatic complaints are commonanxiety-based symptoms associated with schoolrefusal. If the complaints have no organic basis thatmight legitimise the child’s nonattendance, and ifa temporal link between somatic complaints andreluctance to attend school is identified, then al-lowing the child to stay at home until feeling bettermay be quite unhelpful. The child’s avoidance ofschool may be powerfully reinforced at home (e.g.access to television and computer, time with par-ents or siblings, playing with pets). In managingnonattendance, parents often need reassurance thatthere is no organic basis to their child’s somaticcomplaints.

Determine the history of the nonattendanceproblem. Very recent and sporadic nonattendancein younger children is best ‘nipped in the bud’ withthe expectation conveyed to parents that they en-force the child’s regular attendance.[42] For long-standing absence and for attendance problems inolder children, a well-planned graded return toschool is warranted (see section 4.2).

Explore possible fears and anxieties, being awarethat they vary greatly between children (e.g. perfor-mance in schoolwork, using the school toilets, do-ing physical education, separation from parents,answering peers’ questions regarding absence, be-ing disciplined at school, family matters). A self-statement interview procedure[43] and school-specificself-report instruments are available to facilitatethis assessment.[44,45] Psychosocial interventionscan help children reduce anxiety and build confi-dence for handling specific situations.

In addition to harbouring exaggerated fears andanxieties, the child may be faced with real anddaunting challenges (e.g. learning difficulties, re-current bullying, social isolation). Such experi-ences warrant specific assessment and intervention,often focused at the school level. Occasionally a

School refusal 723


change of schools is warranted in order for optimalremediation of some difficulties.

Mood disorders co-occur with school refusal inup to about 20% of children exhibiting school re-fusal.[11,14,46] This is often a complicating factor inthe effective treatment of anxiety-based school re-fusal and may warrant specialist help.

4.2 Cognitive Behavioural Treatment

Contingent upon the practitioner’s time andcompetence in the delivery of CBT, an integratedtreatment programme is recommended over at least3 to 4 weeks. Typically, five to eight consultationsare conducted with the parents, six to eight consult-ations with the child and regular consultations arerequired with school staff. In some cases, more con-sultations with the family and school are required,and booster sessions may be warranted.[47]

Early consultations are aimed at the parents andschool staff developing relevant behaviour man-agement strategies, and the young person acquiringstrategies for managing anxiety and coping withschool attendance. School return should be sched-uled half-way through treatment. Subsequent con-sultations should focus upon trouble-shooting andfine tuning the use of the strategies.

As well as creating difficulties for the youngperson, school refusal causes considerable distressfor parents. Parents and children need to experi-ence a highly supportive relationship at the sametime as being engaged in an action-oriented inter-

vention in which the parents and children come tosee themselves as important change agents.

4.2.1 Child SessionsRelaxation training should be employed with

children who experience high levels of physiolog-ical arousal associated with school attendance. Itprovides a coping skill which children can employat high risk times such as preparing for school onthe day of return, approaching the school groundsand being asked questions by peers. By preventingor reducing discomforting feelings, children arebetter placed to employ the full range of CBT strat-egies learned. Table I presents approaches to relax-ation training.

The following should be considered with regardto relaxation training:• Children will respond differently to the various

forms of relaxation and it is important to helpthem discover which procedure they feel mostcomfortable with. This will help increase theirengagement in the training procedure and intheir own practice of relaxation.

• In each procedure ‘cue-controlled’ relaxationcan be achieved by having the client practice aparticular ‘cue’ at various points throughout theroutine. The cue might be: saying the word ‘re-lax’, ‘calm’, or some other word meaningful tothe client; breathing in to the count of three andout to the count of three; tensing and relaxingthe muscles in the dominant hand; picturing anespecially calming scene, etc. The aim is to en-

Table I. Relaxation training procedures for use with children with school refusal

Procedure Description Reference

PMR training for older children Modified version of adult-based PMR script for use with young people. PMR isa process of systematically relaxing the various muscle groups in the body

48

PMR training for younger children Uses visual imagery to engage younger children in PMR 49

Robot-Ragdoll technique A variation on PMR which is useful for active children who have difficulty sittingstill and engaging in the PMR routine

50

Autogenic relaxation training The client covertly repeats a series of physiologically oriented phrases read bythe therapist, enabling the client to induce a state of mental and physical calm

51

Guided imagery The practitioner guides the client through a series of imagined scenes(standardised or personalised) which evoke a sense of calm and relaxation

52,53 (examples ofstandardised scenes)

Breathing retraining The client learns to control their rate and depth of breathing in order tomanage tension and anxiety. This is a more transportable and inconspicuousform of relaxation

54

PMR = progressive muscle relaxation.

724 Heyne et al.


able the client to quickly induce a state of relax-ation with minimal time and effort through theuse of the cue alone. This can only be achievedwhen the cue has been sufficiently paired witha very relaxed state - usually after practising relax-ation daily for several weeks.

• There are, of course, many other activitieswhich children can find relaxing and beneficial(e.g. taking a bath, going for a walk, kicking thefootball, meditating, reading a book, listeningto music). The advantage of learning one of theprocedures listed above is that it allows theyoung person to develop a skill which can beefficiently employed in the management and re-duction of cognitive and physiological symptomsof anxiety, especially when ‘cue-controlled’ re-laxation has been developed.Children exhibiting school refusal who have

missed a lot of school are often anxious about an-swering peers’ questions about their absence. Thechild should be helped to brainstorm likely ques-tions and possible responses, and to gain practicein answering questions via role-play activities. Ad-dressing social competence is important whenschool refusal is related to social withdrawal (e.g.being isolated in the playground) or specific socialskills deficits (e.g. being uncertain about how tohandle teasing and bullying). Competence can beenhanced through the provision of information oneffective interaction,[55-57] practitioner modellingof the specific social skills and role-playing.

Much attention should be paid to identifying andmodifying the child’s anxiety-producing self-talk.Cognitions common to anxious children exhibitingschool refusal include:• an overestimation of the probability of negative

events (e.g. mother falling ill while I am at school)• underestimation of one’s ability to cope (e.g. I

won’t be able to give the talk in front of the class)• regarding negative events as catastrophic (e.g.

it is awful and unbearable when the teacher raisesher voice).The aim is to effect a change in the child’s emo-

tions and behaviour and mobilise him/her towardsschool attendance by replacing unhelpful self-talk

with coping self-talk. Anxious children also bene-fit from support in the use of self-reinforcing state-ments, as the children often tend to minimise theircoping efforts. For examples of cognitive therapywith children exhibiting school refusal, see Kinget al.,[58] Mansdorf and Lukens,[59] and Rollingset al.[60]

A graded reintroduction to school often makesschool return easier to manage (e.g. attending forone class on the first day, two classes the next day,etc.). Variations in gradation should be based onthe child’s level of anxiety and their preferred at-tendance plan. Two attendance plans based upongraded exposure are presented in table II, high-lighting possible variations in gradation. The plansoften need to be reworked during the course oftreatment. When the child’s anxiety is very high,imaginal desensitisation can occur prior to plannedschool return.[58] In some cases, children prefer toattempt a return to immediate full-time attendanceto reduce embarrassment associated with part-timeattendance.

With regard to the attendance plan, the follow-ing should be considered:• The hierarchical steps encompassed in an atten-

dance plan often need to be reworked during thecourse of treatment. While a few children mayprogress through the steps of the hierarchyfaster than anticipated, the majority will expe-rience some setbacks and need the encourage-ment and support of the practitioner in reviewingthe hierarchy.

• It is important that the first step be achievablefor the young person. An initial experience ofsuccess can build confidence and motivation tocontinue working through the attendance plan.

• Reward any level of success achieved by theyoung person, whether or not the nominatedstep was fully achieved. For example, praisingthe young person’s effort to get out of bed andto get dressed for school (short of arriving atschool) is more likely to be effective in the long-term than is an expression of disappointment.

• Implementation of the attendance plan often re-lies heavily upon the cooperation of school staff

School refusal 725


and the availability of parents on school morn-ings.All efforts made by the child to acquire and to

implement coping skills should be reinforced(drawing on social praise, privileges, and tangiblerewards). The attendance plan can be developed inconjunction with a contract of rewards adminis-tered by the practitioner (e.g. extra session time toplay games, a special tour of the clinical setting)and/or the parents.

The developmental level of the child who exhib-its school refusal has considerable impact upon themanner in which the treatment components are ad-dressed. For example, different relaxation proce-dures may be introduced (see table I) and CBTshould be approached differently.[50,61]

In each case, ‘show that I can’[62] tasks provideopportunities for children to do between-sessionpractice of the skills being learned (e.g. daily prac-tice of relaxation, making an effort to phone an-other child, keeping a diary of anxiety-producingthoughts).

4.2.2 Parent SessionsThe parents’ satisfaction with the child’s current

school/classroom placement should be explored.Plans for facilitating attendance can come unstuckif parents have lost confidence in the school. Achange of class/school may be warranted, espe-cially when there appear to be intractable difficul-ties between the family and school.

Parents should be encouraged to think aboutways in which they can reduce positive reinforce-ment for the child whilst he/she is at home duringschool hours (e.g. managing access to the televi-sion, computer, refrigerator, etc.). This reduces thesecondary gain that may otherwise strengthen thechild’s resolve not to attend school.

The date for the child’s school return should bedetermined collaboratively between the parentsand practitioner. Parents can advise their child ofthe plan several days prior to the date; longer peri-ods are likely to increase the child’s anticipatoryanxiety.

In the lead-up to school return, parents need tore-establish a smooth morning routine (i.e. waking

Table II. Examples of attendance plans based upon graded exposure for use with children with school refusal

Plan 1: Attendance plan developed with a secondary school student with moderate anxiety about school attendanceDay 1, Thursday Meet with teacher and two friends for 1 hour at the beginning of the school day

Day 2, Friday Attend classes one and two (until recess)

Day 3, Monday Attend classes one and two (until recess), as for previous Friday

Day 4, Tuesday Attend classes one to three

Day 5, Wednesday Attend classes one to four (until lunch)

Day 6, Thursday Attend classes one to five

Day 7, Friday Attend classes one to six (whole day)

Plan 2: Attendance plan developed with a primary school student highly phobic of the classroom situation1 Look at school photos

2 Walk half-way to school

3 Walk up to the school

4 Walk around the outside of the school

5 Walk around the school and inside the school gates

6 Meet with the class teacher for 30 minutes, parents present

7 Meet with the class teacher for 30 minutes, without parents

8 Attend empty class with teacher for 15 minutes

9 Attend empty class with teacher for 30 minutes

10 Attend regular class for 30 minutes

11 Attend regular class until lunch

12 Attend regular class for whole day

726 Heyne et al.


time, getting showered and dressed, breakfast).Difficulties encountered in the process may signalthe need to help parents acquire more effectivebehaviour management strategies.

Parents should be helped to acquire and employeffective behaviour management strategies aimedat reinstigating the child’s regular attendance.Strategies include instruction-giving, planned ig-noring of inappropriate behaviours (e.g. tantrums,arguing, feigning illness) and positive reinforce-ment of appropriate behaviours.

The necessary sequence of events on the day ofplanned return should be discussed in detail. Thisinvolves utilising a ‘hoping for the best while pre-paring for the worst’ strategy (e.g. how the child iswoken, what to do if the child does not willinglyget out of bed, escorting the child to school, pre-venting the child from running away). Parents maybenefit from some anxiety management strategiesto help them remain calm and focused when facil-itating attendance (e.g. relaxation, coping self-talk).

4.2.3 School ConsultationAll relevant school staff need to be informed of

the child’s school return and associated specialneeds (perhaps via a memo). Depending on thechild’s preference, classmates may also be advisedof his/her return and encouraged to be supportiveand to refrain from probing about nonattendance.

During the return process, the child should begreeted at school by one or two staff (ideally nom-inated by the child). Parents and staff should agreeupon a suitable time and place that will not causeembarrassment for the anxious child being droppedoff. Some ‘settling in’ time is helpful for highlyanxious children needing time and space to calmdown with a supportive staff member, prior to go-ing in to class. The child should be familiarisedwith the routine for the day/week and, as appropri-ate, introduced to some ‘support buddies’ and in-formed about reduced work expectations.

School staff should be encouraged to match spe-cial arrangements at school to the child’s currentneeds. It is important that the child’s experience ofschool is positive and supportive. Some arrange-

ments will be temporary in nature (e.g. supportbuddy system, reduced workload expectations, pos-itive reinforcement for attendance) while othersmay need to be longer-term (e.g. exemption fromlanguage class, academic remediation).

The child’s attendance and anxiety need to bemonitored closely during the first weeks. Unlessthe child is clearly unwell, it is recommended thathe/she remain at school when reporting somaticcomplaints. If the child absents him/herself fromschool, parents should be contacted and encour-aged to return the child to school.

Close liaison between the parents and school isimportant throughout treatment. The role of thepractitioner in this is to provide an increasing num-ber of opportunities for these two parties to nego-tiate arrangements without the mediation of thepractitioner (e.g. determining when the child pro-gresses from four classes per day to six classes perday, or when to increase expectations about thecompletion of homework).

4.3 Pharmacological Treatment

Pharmacological treatment is regularly employedin children exhibiting school refusal. However, thepractitioner should be cautioned that there is littlesound evidence from clinical studies for the effec-tiveness of the drugs commonly used.

4.3.1 Tricyclic Antidepressants

Research SummaryAn early randomised double-blind trial of the

tricyclic antidepressant (TCA) imipramine com-bined with some behaviour management trainingwithin ‘standard clinical practice’ (SCP) suggestedsuperior outcomes for the imipramine plus SCPgroup relative to the placebo plus SCP group.[63]

Three subsequent studies failed to demonstrate thateither imipramine or clomipramine were superiorto placebo,[64-66] although these studies containedsome methodological flaws.[67] Bernstein and col-leagues[68] recently reported a randomised double-blind trial of imipramine plus CBT versus placeboplus CBT. 63 adolescents exhibiting school refusalwith comorbid anxiety and major depression par-

School refusal 727


ticipated, and the CBT was conducted with the ad-olescents over eight sessions. After the 8-weektreatment those in the imipramine plus CBT groupdisplayed significantly improved attendance andsignificantly reduced emotional disturbance. Nev-ertheless, almost half of the adolescents in theimipramine plus CBT group were still not able toattend school at least 75% of the time. In a 1-yearnaturalistic follow-up study, the imipramine plusCBT group and the placebo plus CBT group werefound to be similar with respect to prevalence ratesof anxiety and depressive disorders.[69] No infor-mation on school attendance was reported at thefollow-up.

Adverse EffectsMost of the common adverse effects of TCAs are

a result of anticholinergic and antihistaminic ef-fects. Some are almost inevitably experienced, andmost of these are transient, including dry mouth,constipation, nausea, dizziness and postural hypo-tension, blurred vision, fine tremor, and sedation.Less common adverse effects include behaviouraldisturbances such as agitation or irritability, orneurological disturbances including tics or epi-lepsy. TCAs may delay electrical conduction in theheart and sudden death has been reported in twochildren taking imipramine, and six young peopletaking desipramine, an active metabolite of imipra-mine.[70-74] Therefore, children with a positivefamily history of heart disease or sudden deathshould have a thorough cardiovascular assessmentbefore TCAs are used.[75] Desipramine, which iscurrently being withdrawn from the Australianmarket, has been reported to be more toxic in over-dose than other TCAs,[76] and Riddle et al.[77] sug-gest that its use in children should be avoided. Theregular review of children taking TCAs should in-clude an inquiry regarding adverse effects andmeasurement of blood pressure and heart rate.Some authors recommend an electrocardiogramprior to treatment with TCAs and after dose in-creases to 3 mg/kg and then 5 mg/kg.[78] Medica-tion should be decreased or ceased if the QT inter-val corrected for heart rate (QTc) exceeds 0.425

seconds, if heart rate exceeds 130 beats per minute,or if blood pressure is >130/85mm Hg.[77]

4.3.2 Selective Serotonin Reuptake Inhibitors

Research SummaryThe increasing use of selective serotonin (5-

hydroxytryptamine; 5-HT) reuptake inhibitors(SSRIs) in the treatment of anxiety disorders inchildren exhibiting school refusal is largely basedupon the powerful anxiolytic effects evidenced inadult studies and upon clinical experience.[79,80]

There are no studies specifically investigatingSSRIs in a population of children exhibiting schoolrefusal. However, a randomised placebo-controlledtrial of the efficacy of an SSRI in 128 children aged6 to 17 years with separation anxiety disorder, so-cial phobia, or generalised anxiety disorder founda 79% response to fluvoxamine compared with a28% response to placebo.[81] Limited improvementswere sustained in the subsequent 6- to 8-monthopen label extension, as measured via the Paediat-ric Anxiety Rating Scale and the Clinician GlobalImpression Improvement Rating Scale.[81] There isstrong evidence of the efficacy of SSRIs in thetreatment of childhood obsessive-compulsive dis-order with positive results in controlled trials withfluoxetine, fluvoxamine, sertraline and paroxet-ine.[82-85] There is some less impressive evidenceof the efficacy of SSRIs in the treatment of adoles-cent depression.[86]

Adverse EffectsPatients often report no adverse effects with

SSRIs. Greenhill and colleagues’[81] study using flu-voxamine found headaches and increased irritabil-ity (known as ‘the activation syndrome’) to be themost common adverse effects. Less commonly,children reported apathy and indifference, insom-nia and nausea. The rare serotonin syndrome, withassociated temperature dysregulation, muscle ri-gidity, increased heart rate and blood pressure, anddelirium, is the most serious potential adverse ef-fect.

SelectionThe SSRIs appear to have similar levels of effi-

cacy and range of adverse effects. Aside from prac-

728 Heyne et al.


titioner familiarity (perhaps the most importantfactor), choice is most sensibly made on the basisof half-life and the presence of an active metabo-lite. Table III presents the characteristics of theSSRIs including half-lives and active metabo-lites.[87] Most SSRIs can be administered oncedaily. Both fluoxetine and paroxetine inhibit theirown metabolism and small increases in dose cancause larger increases in plasma concentrations.The active major metabolite of fluoxetine, norflu-oxetine, has a 10-day half-life. The standard rule isstart low and go slow.

4.3.3 Other Pharmacological AgentsWhile the benzodiazepines appeared promising

in nonblinded trials, published placebo-controlledtrials with children exhibiting school refusal oranxiety disorder have failed to clearly demonstratetheir efficacy.[79,88] Benzodiazepines are also ad-dictive, which should preclude their long-term usein children.

Buspirone (a serotonin 5-HT1A receptor agonist)has been shown in open label trials to improvesymptoms of anxiety in heterogeneous groups ofchildren,[89,90] but no controlled trials have yetbeen completed in children with anxiety disorder.

While β-adrenoceptor antagonists are used inthe treatment of anxiety symptoms in adults, thereis no empirical support to guide their use in chil-dren with anxiety.[79]

Antipsychotics have been used to treat severeanxiety in children, but there is no empirical evi-dence to support this practice, and there is potentialfor serious immediate and long-term adverse ef-fects. The use of antipsychotics is not justified un-less the school refusal is associated with psychosis

or the clinical situation calls for a high level ofsedation for a brief period.[80]

5. Overall Treatment Strategy

The first line of treatment in school refusal casesshould be CBT. CBT equips the child, parents andschool staff with strategies for managing currentand future difficulties, and it eliminates the poten-tial issues of adverse effects and dependence thatcan be associated with pharmacological treat-ments. This strategy matches Labellarte and col-leagues’[79] conservative algorithm for treatinganxiety disorders in children. Figure 1 depicts theinterconnectedness of the child, parent and schoolcomponents of the CBT approach.

Pharmacological treatment may supplementpsychosocial treatment when the child who exhib-its school refusal displays severe anxiety and de-pressive disorders. Alternatively, young peoplewho do not respond to the comprehensive and com-petent delivery of CBT may benefit from a pharma-cological approach. In some of the cases of severeemotional disturbance, pharmacological treatmentmay need to precede psychosocial treatment in or-der to facilitate participation in CBT.[79]

No medication stands out as the indisputablechoice. The evidence supporting the efficacy ofimipramine is stronger in this patient group, butunpleasant adverse effects are common and moreserious adverse effects are possible. The SSRImedications have weaker evidence of efficacy, butless commonly cause significant adverse effects. Ifthere is an inadequate response to either drug asecond opinion should be sought.[80]

Table III. Characteristics of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors

Drug Half-life(adults)a

Active metabolite Suggested starting dosagefor children

Suggested maintenancerange for children (mg/day)

Fluoxetine 1-4 days Yes 10mg three times/week 20-40

Sertraline 24 hours No 25mg in the morning 25-100

Fluvoxamine 16 hours No 25mg at night 50-100

Paroxetine 7-37 hours No 10mg in the morning 20-40

Citalopram 33 hours No 10mg in the morning 20-40

a Data in children and adolescents are limited.

School refusal 729


In the event of the preceding strategy being in-effective, alternate psychosocial interventions maybe warranted, alone or in conjunction with pharma-cological treatment. This may be particularly truefor children with severe depression unresponsiveto CBT and medication. To date, insufficient clin-ical research attention has been given to the out-comes of psychosocial interventions for depressedchildren exhibiting school refusal.[40]

Acute parental psychopathology or marital dis-tress may warrant primary clinical attention in or-der to prepare some parents for active participationin a child-focused CBT programme. Our researchshows that many mothers of children exhibitingschool refusal experience high levels of anxietyand depression and that this often decreases duringinvolvement in a child-focused CBT programme.[14]

In some cases, however, continued parental dis-tress is associated with a less successful outcomefor the young person and it is these cases in whichparents may need primary clinical attention.

6. Conclusions

School refusal is a challenging problem forhealth and education professionals. Left untreatedit poses a risk to the well-being of the young personin the short- and long-term. Of the psychosocialinterventions for school refusal, CBT has the mostempirical support. The use of various pharmaco-

logical treatments for anxiety and school refusalawaits justification via well conducted empiricalstudies, i.e. randomised placebo-controlled trialswith adequate sample size and long-term follow-up.[80] Comparative studies of the effectiveness ofpsychosocial and pharmacological treatments arealso required in order to make definitive statementsabout the effective treatment of school refusal.[80]

Presently, the preferred management strategy in-volves CBT as the first line treatment, with adjunc-tive or successive pharmacological treatment em-ployed as indicated.

Acknowledgements

The manuscript is based, in part, upon research conductedwith the support of the National Health and Medical Re-search Council (project grant 940572).

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Correspondence and offprints: Dr David Heyne, VictorianChild Psychiatry Training Department, Austin & Repatria-tion Medical Centre, Repatriation Campus, WaterdaleRoad, Heidelberg, VIC 3084, Australia.E-mail: [email protected]

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