Key Points
School refusal is a sign of distress, not simply defiance.
Anxiety is the most common cause, but ADHD, autism, depression, and other factors may contribute.
Prolonged avoidance can make returning to school harder.
Treatment should address the underlying cause, rather than simply forcing attendance.
CBT, school collaboration, and early intervention can improve outcomes.
When a child refuses to attend school, it is often a sign of emotional distress for reasons that may be difficult for the child to articulate to parents, or for parents to discern on their own. Although school refusal is typically associated with anxiety, it may also be related to depression, trauma, neurodevelopmental conditions, learning differences, or factors within the child’s school or home environment. This article offers parents guidance on how to understand school avoidance and when and where to seek help.
What Is School Refusal?
School refusal, also known as school avoidance, describes a pattern of behavior in which a child or adolescent has significant difficulty attending or remaining in school due to emotional distress. This often begins as reluctance to attend school, and can progress to repeatedly attending school late, leaving school early, or refusal to attend school at all. Children may show signs of avoidance while transitioning from home to school, such as becoming tearful, irritable, angry, or panicked, and others make it into the building but are unable to tolerate the full school day. As this pattern unfolds, it can become a significant source of distress not only for the child, but also for parents and other family members.
It is important to keep in mind that school refusal is not itself a psychiatric diagnosis. It describes a behavior that can arise for many different reasons. The prevalence of school refusal is estimated at 2–5% of school-age children and adolescents, and is more common in children with neurodevelopmental conditions such as autism spectrum disorder and ADHD, as well as anxiety and depressive disorders. However, the most common underlying cause of school refusal is anxiety, including anxiety disorders.
Signs of School Refusal in Children and Teens
Signs of school refusal can include emotional and behavioral signs of avoidance, as well as physical signs of emotional distress, including:
Repeated physical complaints on school mornings (stomachaches, headaches, nausea) that improve once the decision is made to stay home
Excessive worry or tearfulness the night before school or during the morning routine
Pleading, bargaining, or refusal to get ready for or leave for school
Anger, irritability, aggression, tearfulness or becoming withdrawn during morning routines, during the drive to school, or during drop-off
Escalating distress on Sunday evenings or after vacations
Willingness to do schoolwork at home but distress specifically about being physically present at school
Skipping class, frequent visits to the school nurse, or requests to come home early
What Causes School Refusal?
School refusal is thought to be a response to internal distress. The underlying causes of that distress can be due to aversive factors in the school environment, mental health symptoms and diagnoses, medical diagnoses, and/or factors at home and elsewhere. The following includes a brief summary of some of the more common known causes of school refusal.
Factors in the School Environment
Conflict with teachers or peers, including bullying, can lead to school refusal due to avoiding the situations or individuals associated with conflicts.
Differences in learning or academic proficiency, such as learning disorders (dyslexia, dyscalculia, dysgraphia) or learning gaps can lead students to avoid school due to finding the academic demands too challenging, which can be associated with feelings of anxiety, embarrassment or shame.
Children and adolescents who have traumatic experiences in the school environment may refuse school due to the school environment becoming a trauma reminder. Examples include harassment, discrimination, school violence concerns, and situations in which avoidance may reflect a realistic perception of danger.
Mental Health Factors
The most common mental health symptom associated with school refusal is anxiety. This can be due to school anxiety (anxiety regarding school performance), social anxiety (fear of being judged or disliked, which can lead to avoidance of social interactions, speaking up in class, and avoidance of eating in front of others), separation anxiety (fear of being separated from care givers due to worry that something bad will happen to them when they are separated), specific phobias associated with school, or generalized anxiety disorder. Learn more about anxiety in children here.
Children and adolescents with autism spectrum disorder may avoid school due to sensory sensitivities (such as to sound), finding social interactions in school overwhelming or anxiety provoking, difficulty with unpredictable transitions throughout the school day, and feeling exhausted by the need to mask or control their behaviors for the entire day. Learn more about signs of autism in children here.
Similarly, children and adolescents with ADHD may avoid school due to inability to meet the executive functioning demands of the school environment, which can lead to school anxiety, feeling they are receiving more instructions and redirection from their teachers than others, oppositional behavior that can co-occur with ADHD, and avoiding the experience of being reprimanded for impulsive behavior. Learn more about signs of ADHD in children and teens here.
Depression and other mood disorders can lead to school refusal due to loss of motivation, fatigue, social withdrawal, anhedonia and disrupted sleep.
Medical Factors that Contribute to School Refusal
Chronic illness can predispose children and teens to school refusal, partly due to the illness, and partly due to the medications used to treat illnesses, and understandable concern from parents regarding potential exposures in the school environment.
Sleep disorders, or chronic sleep deprivation, and circadian rhythm delays associated with adolescence, are common causes of school refusal in children and adolescents. Learn more about the impact of sleep on mental health here.
Somatic complaints, such as headaches, stomach pain, nausea or other physical symptoms, can be associated with other mental health symptoms, and can lead to school refusal as well.
Why Staying Home Makes School Refusal Worse
School refusal tends to get worse the longer a child stays home from school. This is likely due to school refusal being a type of avoidance behavior, similar to avoidance associated with anxiety disorders. The longer a child avoids school, the more distressing it becomes for them to attend school.
In addition, staying home from school may be reinforced if the home is more appealing than school. For example, if a child refuses to attend school, and spends most of his day engaged in video games, watching television, or other preferred activities, school refusal tends to last longer than for a child that has to do house chores, or homework, or some other non-preferred activity while staying home from school.
Related to this is the role of parental accommodation in reinforcing school avoidance. Parental accommodation refers to a behavior that parents demonstrate in response to a child’s distress. In response to a child refusing to attend school, parents can accommodate this refusal by providing attention to the behaviors associated with refusal, and by allowing their child to stay home, or come home early, instead of going to school, or staying in school for the duration of the school day. Parental accommodation is a very natural response to seeing a child in distress. With the best of intentions, parents may seek to reduce a child’s distress by helping them to avoid situations that trigger anxiety. Unfortunately avoidance just causes anxiety to last longer and become more difficult to treat.
Should Parents Force School Attendance?
While prolonged avoidance of school makes school refusal more difficult to treat, it is not always in the best interest of a child to categorically force them to attend school. When children avoid school due to aversive experiences, or due to undiagnosed or untreated conditions, forcing them to attend school without addressing the underlying condition may just lead to more anxiety and more distress. Working with a therapist and the school on gradual re-exposure to attending school daily can be more successful than a sudden return to a full-time schedule.
Evidence-Based Treatment for School Refusal
The strongest evidence base supports CBT (cognitive behavioral therapy) for improvement in returning to school in children and adolescents with school refusal. When anxiety disorders and/or depression are also present, CBT in combination with a medication that treats anxiety and depression can also be helpful in treating school refusal. Although no studies have directly addressed whether or not reducing parental accommodation can improve school refusal, it is likely that this can be helpful when anxiety is the underlying cause, based on evidence that reducing accommodation treats anxiety disorders more broadly.
What Parents Can do to Support Their Children
In general, when a child is struggling, the best place for a parent to start is from a place of gentle curiosity. Gentle means not forcing a conversation they are not ready to have, and it means asking questions in a way that won’t feel like an interrogation. The more you understand why going to school feels hard, the better you will be able to seek out helpers and other solutions.
Using positive reinforcement, such as labelled praise, or a reward system for attending school, can be more helpful than punishing children for school refusal. At the same time, it is important to not make staying home more rewarding than attending school.
It’s important to communicate with the school early on in the process, as they may be able to provide support in school for situations that are aversive, or they may be able to work on a modified school schedule while your child receives treatment.
And of course, it is important to seek consultation with your pediatrician for any physical/somatic symptoms, to ensure there isn’t a medical cause, rather than assuming those symptoms are due to anxiety or another mental health condition.
When Should You Seek Professional Help?
If you suspect that an undiagnosed medical or mental health condition, or a learning or intellectual disability is contributing to school refusal, seeking a diagnostic assessment from a medical professional is recommended. Reach out to your pediatricians for any medical concerns, such as somatic symptoms. Pediatric/child psychiatrists and pediatricians can diagnose and treat mental health conditions, including neurodevelopmental disorders such as autism and ADHD. Neuropsychologists can diagnose intellectual disabilities, learning disabilities, and neurodevelopmental disorders.
In addition, if school avoidance is prolonged or worsening, seeking professional help from a child or adolescent therapist, including school counselors, for evidence based therapy is recommended.
If you would like to explore medication options for mental health conditions contributing to school refusal, a pediatrician or child psychiatrist can discuss these with you.
Final Thoughts on School Refusal
School refusal is a behavior that arises out of some form of internal distress, rather than simply lack of interest in school, or disruptive behaviors. There are multiple possible causes for school avoidance, and parents are encouraged to communicate with the school early on, and seek professional help if they suspect a medical or mental health cause. With evidence-based treatment, such as CBT, attendance and functioning can substantially improve.
Frequently Asked Questions
Is school refusal always caused by anxiety?
No, although anxiety is the most common cause, depression, trauma, ADHD, autism, learning differences, and medical or sleep problems can all contribute.
Is school refusal the same as truancy?
Not clinically — school refusal involves emotional distress, usually with a parent aware of the absence, while truancy is a legal category based on unexcused absences regardless of cause. The two can still overlap in how a school handles them.
Should I let my child stay home when they're anxious?
It depends on the cause and severity, and is best worked out with a treating clinician. Prolonged time at home tends to make returning to school harder. A gradual, supported plan is usually more effective than either forcing full attendance or waiting it out indefinitely.
Can ADHD or autism cause school avoidance?
Yes. Executive-functioning demands, sensory overload, and social demands of a school day can all drive avoidance that looks similar to anxiety-based refusal but needs a different treatment approach.
When should we see a psychiatrist instead of a pediatrician or therapist?
Pediatricians should evaluate physical symptoms first; therapists provide evidence-based therapy for anxiety and related conditions. A child and adolescent psychiatrist is the right next step when a diagnosis needs clarification, another condition is suspected alongside anxiety, or medication is being considered.
Megan Bowers, MD, PhD is a child, adolescent, and adult psychiatrist specializing in neurodevelopmental disorders, and is the founder of Bowers Integrative Psychiatry and CEO and Medical Director of The Mind Grove TMS Center. Her work focuses on integrative approaches to mental health, combining evidence-based medication management with lifestyle and mind–body interventions.
The information provided on this website is for educational purposes only and is not intended as medical advice. It should not be used to diagnose or treat any condition. Please consult a qualified healthcare professional for individualized medical guidance. Use of this website does not establish a physician–patient relationship.
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If your child is struggling with school avoidance and you suspect a mental health or neurodevelopmental disorder is contributing, a free 15-minute introductory call is a good place to start. This conversation allows you to share what you are observing and learn how an integrative approach can help.
Bowers Integrative Psychiatry provides in-person appointments in Colorado Springs and telehealth throughout Colorado, Maryland, Montana, New York, Oregon, and Washington. View rates and fees or frequently asked questions for more information.
Selected References
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Sasaki Y, Usami M, Hakosima Y, et al. Preliminary findings on school refusal outcomes in children and adolescents following 1-year psychiatric outpatient treatment. Early Intervention in Psychiatry. 2026;20(3):e70156.
Maynard BR, Heyne D, Brendel KE, et al. Treatment for school refusal among children and adolescents: a systematic review and meta-analysis. Research on Social Work Practice. 2018;28(1):56-67.
Bernstein GA, Borchardt CM, Perwien AR, et al. Imipramine plus cognitive-behavioral therapy in the treatment of school refusal. Journal of the American Academy of Child & Adolescent Psychiatry. 2000;39(3):276-283.
Melvin GA, Dudley AL, Gordon MS, et al. Augmenting cognitive behavior therapy for school refusal with fluoxetine: a randomized controlled trial. Child Psychiatry & Human Development. 2017;48(3):485-497.
Lebowitz ER, Woolston J, Bar-Haim Y, et al. Family accommodation in pediatric anxiety disorders. Depression and Anxiety. 2013;30(1):47-54.
Lebowitz ER, Marin C, Martino A, et al. Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: a randomized noninferiority study of Supportive Parenting for Anxious Childhood Emotions. Journal of the American Academy of Child & Adolescent Psychiatry. 2020;59(3):362-372.
Li A, Guessoum SB, Ibrahim N, et al. A systematic review of somatic symptoms in school refusal. Psychosomatic Medicine. 2021;83(7):715-723.
Maeda T, Oniki K, Miike T. Sleep education in primary school prevents future school refusal behavior. Pediatrics International. 2019;61(10):1036-1042.
