Fighting School Refusal: An Introduction
“School refusal, what’s that?” an educated acquaintance once asked me when we were talking about education issues family’s face today.
By comparison, everyone has heard of childhood cancer, and car accidents that can kill or disfigure a child for life. Rare as they may be, that is no comfort to the family of a child stricken by these and other grave physical conditions.
School refusal, also called “school avoidance,” is a non-medical term for a child experiencing emotional distress so severe that it inhibits them from attending school, or classes within. It may not seem to be on par with serious medical illness, and it’s tempting to think that because it’s not a physical illness, things are still ok. However, in its severe presentations, school refusal can do no less than steer a child to a life path of adversity and hardship, and tear a well-meaning family apart.
Here is a summary of the consequences of school refusal in the medical literature:
Long-term consequences of school refusal include increased risk
of substance abuse, suicide attempts, risky sexual behavior, school
dropout, and social adjustment problems (Kaufman et al. 2004;
Maria da Conceição et al. 2006; Christle et al. 2007; Henry and
Huizinga 2007; Gottfried 2009). Furthermore, school refusal causes
significant economic burden associated with poor academic
performance, school attendance, future underemployment, and
increased risk of criminal prosecution (Egger et al. 2003; Heyne
and King 2004; Kaufman et al. 2004). Longitudinal studies following
children with school refusal attest to the risk for ongoing
mental health problems in late adolescence and adulthood (Berg
and Jackson 1985; Buitelaar et al. 1994; Flakierska-Praquin et al.
1997; McCune and Hynes 2005). Despite its prevalence and consequences,
there are few effective treatments for school refusal.1
A Post-Pandemic Crisis
Prior to the COVID-19 pandemic, rates of chronic absenteeism in U.S. schools hovered around 15 percent, already considered a crisis level, but spiked to 28.3% of students in 2022. In 2025, chronic absenteeism declined only 5.6% to 22.6% from the 2022 peak. Think about what this means: almost a quarter of U.S. students are chronically absent.2
Of course not all absences are based on the child’s anxiety. Distinction is drawn between school refusal when a child who wants to attend school can’t, versus truancy when a child is defiant to attending. No doubt there is some crossover between these categories, such as cases where anxiety-based resistance presents as defiance, and conversely when defiance presents as feigned anxiety. There are also cases based on other factors, such as parents not providing adequate support to ensure school attendance, or condoning absences. However, the rise of school refusal to acute levels since the pandemic is a harsh reality to be reckoned with.3
What does “There are few effective treatments for school refusal” Really Mean?
What does it mean to say, as does the article quoted above, that “There are few effective treatments for school refusal”? This point relates to that school refusal is not itself a medical diagnosis, so there is no cure specifically for it. Rather, there are underlying mental health conditions that produce the outcome of refusing school. Diagnoses like ADHD, anxiety, mood disorders, depression, and other conditions can all play into the picture. (Looking at it another way, evading or declining attendance without a underlying mental health condition is truancy, not school refusal.)
What this means is that the treatment for school refusal is to identify the underlying mental health conditions causing it, and treat and provide supports responsive to them. That is where the work begins, including in cases where families have already done work to diagnose and treat their child.
How Serious is a Child’s Case?
Here are some illustrations reflecting school refusal of increasing severity:
- A child has missed enough days for minor ailments over the course of the semester that parents receive a warning that their absences are close to the pace for being chronically absent. They have not being diagnosed with a mental health condition or learning disability, or receive special education supports.
- A child with an existing mental health diagnosis and learning disabilities is on an Individualized Education Plan (IEP) with a public middle school, and has lately been experiencing episodes where it appears they wanted to go to school, but couldn’t, such as getting in the car to drive to school, but not being able to get out when parents arrive.
- A child’s school middle school has implemented targeted interventions responsive to his/her health care evaluations and the child’s psychiatrist has adjusted their health care plan, but he/she is missing enough school to receive some incomplete or failing grades, and only advancing to the next grade due to grade retention policies.
- A child’s school refusal continues despite major intervention, such as changing schools, participating in Intensive Outpatient Programs (IOP), and/or partial hospitalization programs (PHP’s) targeted to school anxiety, jeopardizing their future due to consequences of a poor high school record, or of not graduating.
- After a myriad of major interventions, a child is at home rather than school for weeks or months, and parents’ efforts to return them to school are seemingly futile. Parents enroll them in an online school program in as desperate attempt to maintain their academic progress while struggling to evaluate remaining options.
The good news for those in earlier stages is there are many options and resources that may provide solutions. Discovery of undiagnosed or under-diagnosed conditions can lead to medication changes, new or enhanced special education plans, therapy programs, or school placements. A range of professionals can help a family in this effort, including therapists, doctors, neuropsychologists, educational consultants, and lawyers.
Here’s the catch: Some cases can progress to advanced states despite a family’s best efforts. Moreover, modern factors not yet fully understood, such as screen time proliferation, parents working from home, and pandemic era absence practices may also be contributing to the incidence of acute cases that seriously threaten a child’s future.
That leads to my inquiry. Parents have done everything they thought they could, and their child is still off track in going to school. They’ve spent countless hours and thousands of dollars, and their family life is in turmoil with the constant stress of a child at home on missed school days. What else can they do?
- Tobin, Reed, Taylor, and Block, A Systematic Review of Pharmacologic Treatments for School Refusal Behavior, Journal of Child and Adolescent Psychopharmacology, vol. 28, at p. 368 (2018) at https://pmc.ncbi.nlm.nih.gov/articles/PMC6909768/. ↩︎
- Malkus, From Attendance Crisis to Chronic Condition? Tracking Post-Pandemic Chronic Absenteeism into 2025, American Enterprise Institute (2026), at https://www.aei.org/research-products/report/from-attendance-crisis-to-chronic-condition-tracking-post-pandemic-chronic-absenteeism-into-2025/. ↩︎
- The increase in school refusal since the COVID-19 pandemic is examined as a global phenomenon. See, e.g., Lester KJ, Michelson D. Perfect storm: emotionally based school avoidance in the post-COVID-19 pandemic context. BMJ Mental Health. 2024;27:e300944. https://doi.org/10.1136/bmjment-2023-300944. Effects can be expected to vary between nations and may only be fully understood following long-term studies. See Mizuno, Nawa, Isumi, Doi, Morio, and Fujiwara, Association between COVID-19 pandemic and school refusal among elementary school children in Japan: difference-in-differences analysis. Frontiers in Public Health, vol. 20, May 2025, https://doi.org/10.1136/bmjment-2023-300944. ↩︎