School refusal and social anxiety

School refusal is when a child or teenager is too distressed to go to school, and their parents know they are at home. It is not the same as skipping school in secret. Social anxiety is one common reason: fear of being called on in class, eating in the canteen, changing for PE or facing classmates. The longer a child stays home, the harder going back becomes. A gradual return, planned with the school and with professional help where needed, works better than waiting.

Why it happens

School refusal has many possible causes, and often more than one at once:

• social anxiety: fear of being judged, laughed at or put on the spot;
• bullying or falling out with friends;
• separation anxiety, especially in younger children;
• low mood or depression;
• learning difficulties, or unmet needs such as autism or ADHD;
• problems at home.

Some clinicians argue that social anxiety is a major, under-recognized cause of school refusal, but that is an opinion piece. Good figures on how often social anxiety is the cause are missing.

Bullying deserves a careful check. In teenagers, being bullied predicts later social anxiety, and social anxiety predicts later bullying. So ask, and ask the school, before assuming it is “just anxiety”.

Why it matters

Missing school cuts a young person off from friends and learning, and makes the fear grow. In Norway, teenagers who screened positive for social anxiety were less likely to finish upper secondary school by age 21. In Sweden, social anxiety in the teenage years was linked to more sick leave as young adults. Acting early gives your child the best chance.

What helps

A plan, not a wait. Children rarely “feel ready” while they are still avoiding. Confidence usually follows going, not the other way round.

Work with the school. Ask for a meeting with the head of year, special needs coordinator or school counsellor. Agree on:

• a named adult your child can go to;
• a quiet place to go if anxiety peaks;
• small changes for a while, such as not being asked to read aloud, or arriving before the crowds;
• how missed work will be handled, so it doesn’t pile up;
• how the school will deal with any bullying.

A step-by-step return. For example:

1. Get up, dress and have breakfast as on a school day.
2. Drive or walk to the school gate, then go home.
3. Go in for one lesson the child finds easiest.
4. Stay for the morning.
5. Stay for a full day with breaks in the quiet room.
6. Full days, then add the harder parts, such as lunch in the canteen.

Move up when a step feels manageable. Expect some bad days.

Therapy. CBT is the most studied treatment. A review of 8 studies with 435 young people found that therapy, mostly CBT, helped them attend school more. It did not clearly reduce their anxiety more than the comparison groups. The authors said the evidence is limited. If social anxiety is the main driver, CBT for social anxiety is the best-supported choice. See therapy for children and teens.

What makes it harder

It is natural to want to protect a distressed child. But some kinds of help make avoidance easier:

• letting them stay home “just today” every morning;
• making home days fun, with screens and treats all day;
• calling the school to excuse them from every hard task.

These are called accommodation: changing family life to help a child avoid what they fear. In a study of 425 anxious children, more accommodation went with more problems in daily life. That study can’t prove cause and effect, but reducing accommodation is a core part of parent-based treatment. See how parents can help.

Getting help

Talk to your child’s doctor if:

• your child has missed more than a few days because of anxiety;
• they have stomach aches or headaches every school morning;
• they seem low, withdrawn or hopeless.

UK guidelines (NICE) say professionals should look out for anxiety in children who avoid school, and that treatment can be offered at home, at school or in community settings.

If your child talks about hurting themselves or not wanting to be alive, get help the same day. See crisis lines.