School refusal

Sunday, six forty-five, Bashundhara. The driver is waiting downstairs, the tiffin is packed, and Oishi, 11, is curled on her bed holding her stomach. “Ammu, it really hurts. I’m not lying.” Her father, already late for a meeting, says she seemed fine last night. Her Dadi, from the next room, announces that it is gas, and that in her day children walked two miles to school with real stomach aches.

By ten, the pain has gone. By Thursday evening, it is back. On Fridays and through the winter holidays, Oishi eats parathas, plays badminton with her cousins on the roof and laughs at her Dadi’s stories. Two paediatricians have found nothing wrong. She has missed nineteen days this term.

Her parents have tried rewards, threats and a new school bag. Her mother wonders if she is being manipulated, then feels terrible for wondering. Last week, in the car outside the school gate, Oishi whispered that she feels sick in assembly, and that the girls in her section have a group she is not in.

An illustration drawn from common experience. The people are invented; the pattern is not.

Understanding school refusal

School refusal is not truancy. The child is not hiding the absence; she is too distressed to go, or to stay. The physical symptoms are real: stomach aches, headaches, nausea and dizziness are common, and they often ease once the child is allowed to stay home, which is what makes the pattern so hard to break. Underneath there is very often anxiety, such as separation anxiety, social anxiety, generalised anxiety or a specific fear, and sometimes low mood, bullying or learning difficulties. A review of recent studies found school refusal common in autism and ADHD, as well as in anxiety and depressive disorders. School refusal is a sign, not a diagnosis, and the cause needs to be found.

Signs and symptoms of school refusal

• Physical complaints on school mornings that vanish at weekends and holidays
• Distress, tears or pleading the night before school
• Frequent calls from school, or asking to come home early
• Avoiding assembly, the canteen or particular classes
• Mentions of being left out, teased or bullied

Treatment for school refusal

A review of 148 studies found that the physical symptoms in school refusal were usually not explained by a physical disease, that anxiety was the most common cause, and that referral was often delayed. A separate systematic review found links between school refusal and separation, generalised and social anxiety and specific phobia. Assessment therefore looks at the child’s anxiety, mood, learning and friendships, alongside a sensible physical check. Cognitive behavioural therapy (CBT) for school refusal combines a gradual, planned return to school with skills for managing anxiety, and works closely with parents and teachers; it does not help every child, and a review notes that one third to two thirds of adolescents do not achieve regular attendance with current CBT and combined treatments, so care is often adjusted and extended. Parents matter too: a systematic review linked school refusal with parents’ own mental health and with how the family functions, so parents are part of the work, without blame.

What getting better can look like

For Oishi, it might be a teacher who meets her at the gate, a first week of half days, a seat away from the group that leaves her out, a plan her Dadi agrees not to undo, and one ordinary Sunday when the stomach ache comes, is acknowledged, and she goes anyway.

Common questions about school refusal

Why does my child get stomach aches before school?

Stomach aches on school mornings that disappear at weekends are a common sign of anxiety about school. The pain is real, not invented. After a doctor has checked for physical causes, it is worth looking gently at what is worrying the child, such as friendships, bullying, teachers or schoolwork.

Should I let my anxious child stay home from school?

Staying home often relieves anxiety in the short term but can make returning harder over time. A gradual, supported return, planned with the school while the anxiety itself is treated, is the approach used in CBT for school refusal. A child psychiatrist or psychologist can help design the plan.

When to see a psychiatrist

If your child has missed school repeatedly because of distress or physical complaints, seek an assessment early; the longer the absence, the harder the return can become. If a child talks about harming herself, seek help the same day, or call 999.

Care here is personal: built around your history, your health and what you want to change, and reviewed with you as it goes.

Sources

• Li et al., Psychosomatic Medicine, 2021 (PMID 33951013)
• Finning et al., Child and Adolescent Mental Health, 2019 (PMID 32677217)
• Heyne, Zeitschrift fur Kinder- und Jugendpsychiatrie und Psychotherapie, 2022 (PMID 36111580)
• Di Vincenzo et al., Italian Journal of Pediatrics, 2024 (PMID 38816858)
• Chockalingam et al., Child Psychiatry and Human Development, 2022 (PMID 35397716)