Essential Back to School Guide for Addressing School Avoidance

By Lucille Carr-Kaffashan, PhD & Jerry Barone, ESS Chief Clinical Officer

This September, for the first time in over 18 months, many students in the United States rejoined all their classmates and teachers for 5 full days per week of in-person learning. While many students were eager to return to bustling classrooms, gyms, and cafeterias, and to reconnect with peers and teachers, others were dreading the first day of the fall semester and all its inherent stimulation. Both full quarantine and hybrid schedules necessitated by the Covid-19 pandemic allowed previously school avoidant youngsters to be removed from in-school academic and social stressors, while taking comfort in being close to home and caregivers. There is every reason to expect that school-related anxiety will spike along with the pattern of behaviors that constitute school avoidance.

District personnel are also concerned that many new cases of school avoidance will be identified this fall. Some students will resist the return to more structured and demanding school days. Various stressors associated with the pandemic could also fuel school avoidance, not the least of which are uncertainty and fear related to the surge of Delta variant cases, the controversies surrounding certain precautions such as mask wearing, and the unavailability of vaccines for children under 12.

Effective School Solutions (ESS) has a long history of treating school avoidance within the various Multi- Tiered Level of Supports (MTSS) programs that it offers to districts throughout the country. The following suggestions are garnered from research-based standards of care, and from the collective experience of ESS’s own clinical experts.

What is School Avoidance?

School avoidance is a pattern of refusing or avoiding school, not of schoolwork per se, and is a complex syndrome influenced by temperament, genetics, cognitive factors, and family environment.

It often occurs after a precipitating event (e.g., a parent’s illness, a bullying incident, a move to a new home or school, or a prolonged absence from school), and in many cases is best understood as an anxiety disorder related to separation anxiety.

Problem behaviors associated with school avoidance often begin the night before a school day, with a child expressing anxiety, showing resistance, or complaining of illness. Most mornings bring protests and a refusal to get out of bed, or to get on the bus, and may include temper tantrums and threats of self-harm. When in school, the student may frequently visit the nurse’s office and/or request to call home. Students experience uncomfortable feelings such as anxiety or panic when in school, and many develop physical symptoms, such as dizziness, headaches, nausea, vomiting, trembling, rapid heart rate, or chest, back, and stomach pains. These symptoms usually improve once the child is allowed to stay home.

What Causes School Avoidance?

There are many factors that contribute to the development and maintenance of school avoidance, and it is critical to have a mental health professional conduct a comprehensive assessment before creating an intervention strategy. The School Refusal Assessment Screening (SRAS) tool is especially useful in this process.

There are four primary reasons that students avoid school:

• To avoid school-related stimuli that cause discomfort or anxiety (e.g., noisy cafeterias, bus rides, fire drills, crowded hallways). This is common in younger students and accounts for about 33% of school avoiders.
• To avoid real or perceived social judgment. This accounts for approximately 8% of school avoiders, especially in the 11 to 17 year-old age group, and includes avoidance of bullying, teasing, academic demands such as tests and public speaking, and changing in locker rooms.
• To seek attention from parents or caregivers. Approximately 24% of school avoiders fall in this category, and it is common in 5 to 10 year-old students, especially after a significant change, stressor, or trauma.
• To seek tangible rewards outside of the school environment (e.g., access to video games, ability to sleep in, to work at a job, to use drugs, or to socialize). About 35% of school avoiders are included in this group, and it is most common in 11 to 17 year-olds.

It is, of course, possible (and likely) that more than one of the above factors are involved in any given student’s school avoidant behavior. The most effective intervention plans will target each relevant factor: for example, gradual exposure and desensitization for school-related anxiety, with medication as needed; social skills training and cognitive-behavior therapy to treat social anxiety; trauma-focused interventions for students reacting to a major stressor or change; and coaching to help parents discontinue behaviors that inadvertently reward school avoidance.

Patterns of school avoidance can also be manifestations of and/or co-occur with other significant mental health disorders such as Generalized Anxiety Disorder (GAD), Depression, Bipolar Disorder, or Post Traumatic Stress Disorder (PTSD). If any of these or other mental disorders are present it is imperative that these symptoms be targeted as well with therapy, and medication as appropriate.

It is, we hope, abundantly clear by now that school avoiders are not truant, but rather have significant mental health issues. These youngsters experience anxiety and depression, seek their parents’ permission to stay home, and usually complete their schoolwork. Truant students, on the other hand, are not responding to anxiety, typically hide absences from parents, infrequently complete schoolwork, and often exhibit other issues such as drug use, lying, and defiance. So, a good rule of thumb is that when faced with a school avoidant student, call the therapist first, not the administrator!

Effective Treatments for School Avoidance

There are three evidence-based treatment approaches that are highly effective for reducing anxiety and school avoidant behavior: Cognitive Behavior Therapy (CBT), Dialectical Behavior Therapy (DBT) and a Trauma-Informed Approach. Since there is overlap in these approaches, it is likely that experienced therapists will include aspects of all three in treating any specific student.

CBT is an effective mental health treatment for many clinical problems and targets the cycle of self-defeating thoughts that give rise to anxiety that in turn contributes to school avoidance. “I can’t handle it, the kids will be mean to me, school’s too hard, I’m not smart enough” are thoughts/beliefs that give rise to anxiety, panic, and mood dysregulation, and these lead to behaviors such as delaying, resisting, throwing tantrums, avoiding, and seeking reassurance. Avoidance compounds the problem over time since research has shown that it plays a major role in increasing anxiety while decreasing confidence and the ability to tolerate uncomfortable emotions.

In addition to helping students and parents learn the relationship among thoughts, feelings, and behaviors, and restructuring these relationships, CBT also focuses on rewarding desired behaviors while ignoring or punishing undesirable ones. Concepts from the “third wave” of CBT, known as Acceptance and Commitment Therapy (ACT) are also critical to the recovery process. These include learning to expect, accept, and tolerate uncomfortable emotions as a normal part of life, while not allowing these emotions to deter us from the life goals and values to which we have committed.

Dialectical Behavior Therapy (DBT) is based on both CBT principles and Eastern philosophies such as mindfulness, acceptance, and the adoption of a dialectical perspective, that is, embracing the philosophy that two opposite concepts or feelings can both be true and exist simultaneously. For example, it is possible and desirable to welcome change, and at the same time to appreciate and value yourself as you are in the present (“we all are perfect as we are, and we also could do better”). The model highly values the acceptance and tolerance of emotions, and the ability to validate both oneself and others.

A multi-faceted approach, DBT combines mindfulness practice, the building of interpersonal skills, and the improvement of self-regulation by enhancing distress tolerance and emotion regulation skills. It is highly effective in the treatment of individuals with varied diagnoses, helping to reduce anxiety, depression, self-harm, suicidal impulses, and emotional dysregulation while increasing interpersonal skills and self-esteem. One module specific to adolescents and their parents is known as “Walking the Middle Path” whereby students and parents learn to validate each other’s feelings, work towards synthesis, and avoid extremes of reaction.

Schools and therapy programs that have adopted a Trauma-Informed Approach cultivate an awareness of how traumatic experiences affect students’ emotions and conduct. Behaviors that adults often find off-putting (e.g., loudness, aggression, non-communicativeness, daydreaming, disengagement) are viewed as survival mechanisms that students cling to because they have worked in the past to keep potentially unsafe people away and/or to cope with an unbearable stress such as abuse/neglect or the exposure to violence. The validation of the student’s experience, along with an expression of understanding that “undesirable” behaviors are the result, not the cause, of a student’s troubles are critical to helping the student begin to heal from trauma.

A Trauma-Informed Approach is also extremely important for helping teachers and other district staff who experience secondary trauma because of their exposure to so many traumatized students over the years. Feelings of helplessness and burnout are common in teachers who have been challenged year after year with educating and supporting students with trauma histories.

Crafting Your District’s Response Plan

School avoidance has a major impact on a student’s education, creates family conflict, and drains school district resources, so it is in everyone’s best interest to identify and aggressively treat this serious mental health problem. Everyone has a role in addressing school avoidance: school personnel, the student and his/her parents, and the treating clinician.

A checklist for the school district’s roles and responsibilities includes the following:

• Develop criteria for case identification, including such data points as the number of days missed in a month or marking period and the number of consecutive days missed, and past history of school avoidance.
• Consider and address possible triggers for a student’s avoidance behavior, e.g., a history of bullying, conflictual relationships between specific students, a child’s sensory issues, classes/subject areas that a student finds especially difficult.
• Identify the school team to be involved with each student’s intervention plan: teachers, guidance counselors, administrators, clinical staff, school nurse.
• Develop communication guidelines for the team.
• Identify resources and create a template to map out and track student intervention plans.
• Coordinate the efforts of the school team, the student and family, the clinician(s), and community resources.
• Collect data to monitor and evaluate student progress.
• Create a “safe room” where anxious/school avoidant students can take a break to re-regulate.
• Provide ongoing professional development for teachers as well as mental health supports.

A checklist for the student and his/her family includes the following:

• Co-create and agree to implement the Intervention Plan.
• Commit to behavior changes specified on the Intervention Plan.
• Communicate regularly with school and clinical team members.
• (Parents) Promptly arrange for medical appointments to rule out medical problems, and assure that any identified medical issues are treated.
• (Parents) Refill any prescribed medications in a timely manner and comply with physician’s instructions about dosage and administration schedule.
• (Parents) Facilitate morning and evening coaching calls and home visits as needed; follow coaching recommendations to avoid the inadvertent reinforcement of school avoidance.
• (Parents) Create and stick with predictable home routines. These include sleep and eating schedules, daily exercise, homework and recreation times, time to socialize, etc.
• (Parents) Agree upon and follow through with rewards for attending school.

A checklist for the treating clinician includes the following:

• Co-create Intervention Plan and help student and parents identify possible barriers to success.
• Teach CBT/DBT mindfulness, self-regulation, distress tolerance, cognitive restructuring, and interpersonal effectiveness skills.
• In collaboration with student/family and school personnel, create and conduct a gradual exposure plan that might include shortened school days, modified schedules, distress tolerance skills, and a “safe” place in the school where school avoidant students can ground themselves and self-regulate.
• Provide coaching to help parents learn how to reinforce desired behaviors while ignoring or creating consequences for avoidance-related behaviors.
• Facilitate open and frequent communication amongst all stake holders.

A checklist for classroom teachers includes the following:

• Collaborate closely with school-based mental health counselors to understand and support each student’s intervention plan.
• Create, post, and frequently re-state classroom rules to establish a sense of safety and structure.
• Start each class or subject/activity change with a mindfulness minute that helps everyone re-set and re-focus.
• Incorporate movement into the classroom at regular intervals to discharge body tension and to clear the mind.
• Encourage students to express and validate a wide range of feelings, and to practice resilient self-talk such as “it is ok to be nervous”, “I can feel nervous and still do my schoolwork and enjoy my friends”.
• Greet school avoidant students enthusiastically when in school, recognizing small successes, creating in-school incentives for attendance.
• Check in with parents to encourage consistent home routines.

This fall will bring daunting challenges for school administrators, teachers, and counselors, as well as for parents and children struggling to resume their “normal” activities despite ongoing uncertainty related to the pandemic. All stake holders, however, need to be aware that time is of the essence here. The longer you wait to address the issues associated with school avoidance, the more difficult it may be to treat. The words of Dr. Anne Marie Albano, Director of Columbia University’s Clinic for Anxiety, sound the alarm: “I suggest addressing issues that are impacting school attendance within two weeks of their initial onset”.