Back-to-School Challenges: Evaluating the Patient with School Refusal
By Debra Koss, MD
Although we still have a month of summer fun in the sun, retailers are beginning to signal the return to school. We can anticipate that students will experience a certain degree of apprehension as they consider meeting new teachers and classmates, getting back to the structure of a classroom, and resuming daily homework. However, most students will adjust to these experiences with modest support from family and teachers. As physicians, we must prepare for those students who experience greater difficulty with this transition back to school. Understanding school refusal and being prepared to evaluate and treat emerging symptoms should be part of our back-to-school preparation.
Clinical Example:
Camila is a 10-year-old fifth-grade student who presents to her pediatrician for evaluation of recurrent abdominal pain. The pain started one month ago, at the end of August. She denies any preceding illness or trigger. Abdominal pain is often accompanied by nausea. She denies any vomiting or change in bowel habits. She denies any change in diet or exercise. She describes greater difficulty falling asleep and staying asleep. Camila reports that stomachaches make it difficult to concentrate on schoolwork. The Mother reports that Camila has been visiting the school nurse daily and frequently calls her asking to be picked up early. Mother also reports that Camila has refused school for the last three days, describing increased stomach ache. Mother sees no evidence of weight loss, vomiting, diarrhea, or fever. She reports Camila has been asking her to stay with her at bedtime until she falls asleep. Mother also reports that Camila started 5th grade in a new school building with 6th and 7th graders and didn’t know many of the other students assigned to her homeroom. Her first day at school was difficult as she ate lunch by herself and was teased by 8th graders for sitting in the wrong seat on the school bus. Mother recalls that the last time Camila had this much difficulty starting school was in the first grade.
School refusal describes a pattern of refusing to go to school or problems staying at school. Students may complain about going to school, make frequent requests to call home or leave early, delay preparing for school each morning, or simply refuse to go to school. School refusal is not a disorder. Rather it is a symptom that may be associated with many other psychiatric diagnoses, including Separation Anxiety Disorder, Social Anxiety Disorder, Generalized Anxiety Disorder, Major Depression, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Post-Traumatic Stress Disorder, and Adjustment Disorder.
School refusal affects approximately 1 to 5% of school-age children; boys and girls are equally affected. Symptoms are most common between 5-6 years old and again at 10-11 years old. An episode of school refusal may begin after some disruption in the school schedule, for example, after an illness or a school holiday. An episode may also be triggered by stressful events at home or school.
Students who experience school refusal often have difficulty describing what is causing their discomfort. Instead, they frequently complain of physical symptoms such as headaches, abdominal pain, nausea, palpitations, and joint pain. Symptom onset is gradual and often results in frequent visits to the school nurse or pediatrician, but physical evaluation is generally unremarkable.
Evaluation of a student with school refusal should begin with a detailed review of symptom onset and any associated stressors. Next steps include a clinical interview with the child and parents, a complete medical history and physical examination, and an assessment of family functioning. Psychological assessment tools, such as clinical rating scales, can identify signals for possible psychiatric diagnosis. Finally, collaboration with the school should include a review of school records, including grades and psychoeducational assessments, and input from school staff.
Interested in learning more about the evaluation and treatment of school refusal to support your patients? Please attend a webinar hosted by the NJPPC:
Back to School Challenges: Evaluating the Patient with School Refusal. The webinar will take place on Tuesday, August 13, 2024, at 12 pm. CME credit and MOC Part 2 points are available as part of NJPPC membership.
To become an NJPPC member, click here to register: https://tinyurl.com/4t7e767e
Already an NJPPC member? Register for the Webinar here: https://njaap.zoom.us/webinar/register/WN_dTwbTL27S_GCe1XcJMApOQ
Author Profile:
Debra E. Koss, MD
Clinical Assistant Professor, Department of Psychiatry Rutgers-RWJMS
NJPPC Project Manager for the New Jersey Psychiatric Association