Asore throat. Acoughso bad it kept him up all night. Another sore throat. A weekend visit to the emergency room.“Can I just get a note for the school?” his anxious mother would ask, and I would print it out and sign it.
But I didn’t grasp the extent of the situation until I got a call from the school nurse. If my patient missed another couple of days, she told me, he would be required by law to repeat first grade; the school year wouldn’t count. Would I please make sure I was giving him all those absence notes for a very good reason?
School refusal— any kind of absenteeism, fromphobiato truancy, that can be traced to the child’s own actions and wishes— is at the very intersection of education,psychologyandpediatrics. So it should be a good place for teachers,psychologistsand pediatricians to work together.
In fact, though, as the pediatrician who should have been the first to notice the problem, I was pretty clueless. My patient was an anxious and somewhat quirky child— I had talked to his mother about the possibility of a developmental evaluation, but we had agreed to wait and watch him in first grade. In fact, he was avoiding things in school that made him uncomfortable— interactions on the bus, jostling on the playground. He was avoiding academic moments where someone might find out he was struggling. And he was sticking close to his mother, so she could keep an eye on him and he could keep an eye on her.
Dr. Helen Egger, a child psychiatrist and epidemiologist at Duke University Medical Center, has studied the relationship between school refusal and conditions like depression andanxiety disorder. About a quarter of the childrenin her studywho showed school refusal behavior hadanxietyproblems. And as she told me,“it can be as strongly associated with depression as with anxiety.”
As a developmental-behavioral pediatrician at Johns Hopkins, Dr. Barbara Howard sees the more extreme cases of school refusal— among them, children whose school days are complicated by medical or learning problems. Some have difficulty from the first day of kindergarten because they aren’t ready to separate from their parents or because they are particularly anxious, she told me; they need help with initial adjustment.
“We should be careful not to set kids up who are anxious,” she said.“Make sure they can take their favorite fuzzy bear with them.”
And when children are anxious about returning to school, she continued, it’s especially important to ask them whether there are particular problems— a bully, a bathroom with no doors on the stalls. Even so, finding and fixing such a problem doesn’t necessarily confer the coping skills an anxious child needs to feel comfortable in school.
The taxonomy of school refusal— from school phobia to truancy— is complicated, and it has changed over time. Experts now tend to break down the behaviors by motivation.
Children may avoid school because they are trying to avoid negative feelings, like anxiety and depression, or negative experiences, like exams or troubling social interactions. On the other hand, they may be pursuing some positive reward— a parent’s attention, the chance to play video games all day or, for older kids, more illicit pleasures.
And there is overlap, the experts point out: a child who misses a great deal of school for reasons that look like truancy may become increasingly anxious— and embarrassed— about going back. In fact, missing school intensifies both the academic pressures and the social pressures that are waiting when a child returns, setting up a dangerous cycle in which the more you’re absent, the more you want to stay out.
The important distinction is in the response.“If you have a child that’s very anxious, you’re going to use a lot of anxiety management techniques,” saidChristopher A. Kearney, professor and director of clinical training in the department of psychology at theUniversity of Nevada, Las Vegas. With the reward-seeking group, he continued,“increase incentives for going to school and supervision outside of school.”
If we look at school as children’s work, then absenteeism becomes a kind of red flag, a signal that something has gone wrong in a child’s health or emotional life, or within the family or in the school itself.
It’s the pediatrician’s job, of course, to make sure vague physical complaints don’t actually signal an undiagnosed disease. School absenteeism can be a marker for poor medical care, or for inadequate management of a chronic illness, likeasthma.
“It’s not a diagnosis, school refusal,” Dr. Egger said.“It’s not a disorder; it’s a symptom.” But it’s an important symptom, with consequences that can be harsh. It should send parents— and pediatricians, educators and psychologists— looking for ways to help.
The pediatrician, she continued, should ask,“Is this a primary issue around attending school that we can just address, or is this an indication of another disorder: anxiety, depression, sleep, somatic complaints?”
My patient didn’t have to repeat his grade. The school agreed to let him make up some of the time he had missed. And, he got the learning evaluation he needed, followed by classroom interventions that made a significant difference in his ability to learn. (I also suggested individual counseling for mother and son. He went, but missed many appointments; she refused.)
So what started with vague sore throats and nagging coughs ended with a list of important tasks for a long cast of characters. The school environment had to change. The child had to learn new coping skills. His mother had to change her approach to minor illnesses.
And his pediatrician had to wise up.
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