School refusal, or school phobia, is an anxiety-driven condition and a rising public health concern. In France, it accounts for around 5% of pediatric psychiatric consultations. Unlike truancy or school exclusion, which typically occurs without anxiety and is often associated with behavioral disorders such as oppositional defiant disorder, school refusal is marked by intense fear and emotional distress, emphasizing the need for early recognition and intervention.

Clinical Features

The condition often manifests as nonspecific clinical signs, including abdominal pain, headaches, nausea, vomiting, sleep disturbances, diarrhea, dizziness, fatigue, and palpitations.

Although not recognized as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, anxious school refusal is often associated with psychiatric disorders such as social or specific phobias, generalized anxiety disorder, depressive disorders, oppositional defiant disorder, posttraumatic stress disorder, or adjustment disorder.

A French retrospective study conducted via an online survey of parents found that 88% of children with anxious school refusal had a concurrent psychiatric diagnosis, most commonly depression (33%) or social phobia (28%).

Another study showed that these children have a threefold higher risk for psychiatric disorders, particularly social anxiety and depressive episodes.

Diagnostic criteria include:

• Refusal to attend school linked to emotional distress.
• Absences not concealed from parents.
• Absence of antisocial behavior.
• Partial or complete school absence despite parental efforts.

The condition usually appears at the beginning of primary school or during adolescence and affects both boys and girls equally.

Risk Factors

One study highlighted the link between school refusal and unfavorable family contexts, including poverty, residential instability, neglect, and family violence.

A French study found that one quarter of children had experienced a serious illness or bereavement (24%), a change of school (23%), moving houses (16%), or parental divorce (12%). Additionally, 62% reported academic pressure, 48% reported bullying, and 16% reported physical violence in schools. More than half of the parents (52%) reported problematic screen use in their children.

Another study showed a significant association between anxious school refusal and cyberbullying, with victims of cyberbullying seeking to escape their online aggressors.

Furthermore, low self-esteem, including negative perceptions of social skills, has been linked to anxious school refusal.

Treatment and Outcomes

The management of this condition requires a multidisciplinary approach to care. Medicopsychological support may address somatic symptoms through relaxation or meditation. Individual psychotherapy is recommended, with cognitive-behavioral therapy showing particular benefit through gradual exposure to the school environment.

Pharmacologic treatment with anxiolytics or antidepressants should be considered, and hospitalization is sometimes necessary, particularly in adolescents.

At school, adjustments such as flexible timetables and quiet spaces help children return to school. A parent association, created in 2008 in France, also supports families and professionals.

Short-term consequences included poor academic performance (31%), relational difficulties (34%), family conflict (43%), school dropout (25%), risky behaviors such as addiction, and suicide attempts.

Between 30% and 50% of these adolescents later develop psychiatric disorders in adulthood, including anxiety, depression, and personality disorders.

Role of Healthcare Professional

A French study showed that the first professional consulted by nearly half of young people was a general practitioner.

Early identification and prompt action regarding school phobia are key to reducing its impact on social and academic development. In younger children, school refusal is often linked to somatic illness; recognizing this during consultation allows parents and schools to work together to ease the distress and support regular school attendance. Adolescents, health professionals, and schools can intervene by addressing bullying, implementing flexible timetables, and recommending psychiatric care.

This story was translated from Univadis France.