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"I'm Not Going to School Today"

How teaching kids resiliency – and empowering parents – can get kids and teens back to school.

By Dr. Shalene Kennedy, MD, Child & Adolescent Psychiatrist - March 2017

Few parents escape the occasional hassle of having to nudge a sleepy child or irritable teen to get up and get ready for school. But for some families, that hassle has turned to downright dread.

Their kids are missing days or even weeks of school, with mounting mental, physical, academic and social consequences. As attendance declines, desperation and, at times, shame, can increase. Parents or guardians ask themselves, what’s wrong with my child? What more can I or we do? Where can we get help? Meanwhile, busy teachers question how to keep absent kids academically on track, while still tending to other classroom students.

This article will identify what’s behind school refusal, and how giving kids, parents and teachers the proper tools can help right the ship.

Why Kids Refuse School

No matter what you call it – school phobia, school avoidance, school refusal – it’s a growing problem. To be clear, school refusal, per say, is not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the go-to textbook for diagnosing mental health conditions.

However, school refusal is a symptom of a bigger-picture problem, almost always associated with one or more psychiatric conditions. Nearly 75 percent of my clinic’s patients struggle with some degree of school avoidance. The reasons vary by patient. The clinic’s first priority is to pinpoint them.

We follow a methodical process to identify the root cause or causes of why a child is refusing school. First, we rule out medical conditions, like sleeping disorders, vitamin deficiencies and diabetes. Then we review mental health issues, which might include depression, anxiety, social phobia, conduct disorder, eating disorders, addictions or other conditions caused by family dynamics, trauma or bullying. Sometimes, the cause is both mental and physical.

We’re seeing more kids at younger ages addicted to gaming or video streaming services. A child stays up late using technology as an avoidance tool and, eventually, the screen’s glow confuses the sleep signals in the brain. That can lead to a sleep disorder.

The American Academy of Pediatrics reports the most common reasons kids or teens avoid school is concern about grades, homework, relationships with teachers, anxieties over social pressure, or legitimate fears of teasing, bullying or violence. Younger kids may also have worries about toileting in a public bathroom. No matter the age, stress can manifest physically as headaches, stomachaches, hyperventilating, nausea or dizziness.

The Problem is Rampant

Most people can agree that school refusal didn’t really exist a generation ago. It was rare for kids to flat-out stonewall their parents. But times have changed for kids, parents and educators.

For kids, there’s more pressure to be high achievers academically, athletically and socially (or at least on social media). Our competitive society emphasizes perfection, and our technology can make the slightest blunders embarrassing public knowledge in a click. Bullying, whether in person or cyberspace, is also growing. About 80 percent or more of the kids and teens I see have had major problems with social conflicts on social media.

Parents, though well intentioned, can intensify things, says Chad Cartier, a licensed professional clinical counselor at Aris Clinic in Woodbury, MN. He has worked with kids and teens for over a decade and says parents often don’t know what to do. Some avoid the issue all together because of the emotional battleground. They’re tired of pleading and arguing, not sure what to do, or how to enforce consequences. They’re afraid of showing up late to work or missing it entirely to monitor their child at home. Other parents, he says, over-identify in being their child’s friend.

He sees some common denominators among school-avoidant kids and their parents.

“We’re seeing a lot of kids who lack resiliency skills. Their parents quickly step in to solve their kid’s problems, rather than teaching their child the skills to do so.” Cartier sees a trend: Parents who treat their kids as victims and, at times, give them too much decision-making power. He believes that can eventually lead to a big clash of entitlement and reality, now and into adulthood.

“In the metro area, parents are quick to fault a school, pull-up anchor, and try a different traditional school, online school, or even homeschooling.” He says this doesn’t solve underlying issues, and the latter two options rarely work for kids who are already academically behind.

The Affect on Teachers

Most teachers are pressed for time and resources. Giving special attention to keep a student (or several) with spotty attendance from falling behind can wear on anyone’s patience. Yet, teachers can feel reluctant to be honest about a student’s behavioral and mental issues with a parent or parents.

Sometimes, parents are in denial, or everyone might be avoiding taking the next, intensive step, like developing a comprehensive independent education plan (IEP). It takes a multi-disciplinary team to create an IEP that effectively meets a student’s educational, behavioral and mental health needs. But enlisting the help of external behavioral and mental health professionals can free up teachers and school counselors who have limited time and resources.

When to Seek Help

I advise parents to begin “first-level” interventions after a child or teen has three school absences not caused by valid illness or significant medical condition. That means seeking the help of a weekly outpatient mental health professional (therapist). If the struggle continues, I recommend looking at the next level of care.

Most parents know when the situation feels out of control. The pleading has turned to arguing, the school is threatening to file truancy charges against the parents, and no one is sure what to try next. By then, the stress is affecting the entire family. That’s when I tell parents it’s time to bring their child in for an immediate assessment and be evaluated for the next level of care.

That may include a structured outpatient program. Traditional mental health centers see patients on a weekly or less frequent basis. Aris specializes in one aspect of pediatric behavioral health called an intensive outpatient program (IOP). It’s meant for kids struggling with emotional and behavioral health issues that cause significant difficulties in their families, schools and/or communities.

Rather than attend their regular school, kids come to the clinic Monday through Friday to develop resiliency skills to be more successful when they return to school. They receive a full day of professional therapy, medication management and flexible educational services in a structured environment. Patients typically transition back to their regular school environment within eight weeks.

Teaching Kids Resiliency

Without question, the longer a child or teen stays home from school, the more difficult his or her eventual return will be. Aris has good success in helping kids of all ages and abilities return to regular attendance. But, it requires a methodical approach.

We begin by conducting a complete evaluation to pinpoint the reasons why a child is avoiding or refusing school. Once the student officially enters the Aris IOP, the staff uses a thorough approach to help the child and family. The goal is to teach kids resiliency and empower parents to follow through on limits and rewards, along with addressing any underlying problems in the family system that could exacerbate school avoidance.

Once Aris staff gets familiar with a child’s core issues, they focus on helping the child develop and use coping strategies for numerous scenarios. I call it a “resiliency toolbox.”

We start by helping kids identify their school stress level, on a scale of one to ten, throughout their school history. We ask, ‘What was it like in elementary school, middle and high school? Then we’ll look at how we can begin rewiring their mindset. Sometimes this involves adding, modifying or removing psychiatric medications, under a child psychiatrist’s close monitoring. At Aris, treatment also involves self-care strategies, like yoga, mindfulness walks and interacting with the clinic’s therapy dog.

Anyone considering higher-level treatment should ask about age separation among patients. A center or clinic should not use the same approach for elementary kids, middle schoolers and older teens.

“We separate kids into three age groups, so that we can tailor their care,” says Cartier. “For example, we know that teens do best in peer group situations, which is a steppingstone to individual therapy where staff can fine-tune care. For much younger kids, treatment can include play therapy.”

Empowering Parents

Simultaneously, a therapist should work with parents, sharing progress and gradually developing a comprehensive aftercare plan tailored to the child.

Parents often need a green light to parent. I see a lot of parents who are paralyzed in setting and enforcing limits. Our goal is to empower them. They generally have a good internal compass and know how to parent. They just need coaching in establishing rules, consequences and rewards. Though effective management of school refusal involves more than simply doling out consequences, there will be little motivation to attend unless the immediate benefit of staying home is removed. Kids should first be meeting basic expectations before using their favorite toy, a phone, gaming, or going shopping with friends.

Problematic avoidance behavior will not all together vanish just because a teen walks through the front doors of a clinic. It is assumed that the problems bringing families to the clinic will naturally follow along into the clinic environment. The difference is that kids and parents have a team of professionals ready to help respond to the avoidance with new, healthier strategies.

If kids or teens still refuse school, parents need a next-step plan. That could include considering care within a more restrictive facility, allowing the truancy process to stipulate treatment, or calling law-enforcement if a child threatens harm upon him or herself, or others.

A Successful Transition Back to School

Returning to school full-time after a lengthy absence isn’t easy for most students. If not handled well, it can be academically overwhelming and socially awkward. It can also be challenging for schools. It’s essential to have a strong transition plan.

My staff partners with the school and develops a plan to close the escape hatches. By then, the student will have practiced his or her resiliency tools, and parents and educators will have plans in place for home and school.

In addition, a therapist should coach its client on how to answer peers’ questions, such as “Where have you been?” Sometimes, that means simply responding, “I’ve been trying out a different school” or “I had to have some medical tests. But I’m feeling better now.”

We all want these kids and teens to feel better, stronger and more resilient.

(Dr. Shalene Kennedy is a child and adolescent psychiatrist. She is the founder of Aris Clinic, a pediatric behavioral health center that treats kids and teens throughout the Twin Cities and western Wisconsin.)