Dealing with School Refusal

Dr. Robert ZambranoPresenter: Robert Zambrano, Psy. D.
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Dr. Zambrano discussed some of the underlying anxieties that cause school refusal and gave appropriate interventions.  He also covers a collaborative approach between parent, student and school.


  1. NJCTS says:

    How would you help a student with school refusal who is cognitively impaired and may also have some mental illness issues?

    • dr.robzam says:

      IN answer to the question “How would you help a student with school refusal who is cognitively impaired and may also have some mental illness issues?

      First you’d have to assess if the child is in the right school setting. Depending on the degree of cognitive impairment, you would want to make sure that the child is in a school that is equipped to handle the child’s needs and willing to provide reasonable accommodations.

      I always say that in terms of the mental illness aspect, the school responsibility is to provide reasonable accommodations, but child should also have their own individual therapist to deal with the mental illness issues.

      If you are talking about a person with cognitive impairment who also has mental illness, then you make sure you work with a therapist with expertise in both. For example, some children with Autism/Aspergers may also have a tic disorder. Due to my lack of expertise in Autism spectrum disorders, I often refer out to an expert in those areas, in spite of my expertise with tic disorders.

  2. NJCTS says:

    What are some good cover stories you have suggested to kids?

    • dr.robzam says:

      Typically things like “I was sick”, “We had a family emergency but I’d rather not talk about it.”, etc.

      We find that most people don’t pry beyond that. If they do, we teach people to be assertive enough to stick with “I’d rather not talk about it” and then help the student deal with their preoccupation with being judged or the center of attention using cognitive therapy concepts.

  3. NJCTS says:

    How does a parent/teacher answer the question “Why is this happening to me? My brothers and sisters are fine?”

    • dr.robzam says:

      Usually, we talk about ways in which other people are different and ask the same questions. “Why are some people blind?” “Why did some siblings get illnesses and others don’t”. There is no real answer to this question. Sometimes life is random and unfair.

      However, when people ask that question, what they are really expressing is some form of self pity. Its okay and normal to feel that way when something random and unfair happens to you, but then we work on focusing on the person’s strengths and talents or things they can control, and accepting the things that they can’t.

  4. NJCTS says:

    How does a school deal with the question from parents about using medication to help? Our experience has been to steer clear of this and recommend the suggestions mentioned in your presentation.

    • dr.robzam says:

      I think its absolutely appropriate to suggest that there are medication options that some people find helpful, and perhaps it might be good to talk to their family doctor or a psychiatrist about them. Usually when people react badly to the suggestion is because they are feeling pressured or worried that you will judge them. Don’t let that stop you from sharing the info or suggestions and letting the family figure out what to do with it.

  5. NJCTS says:

    What medications have you seen be effective for children struggling with anxiety/school refusal/OCD

    • dr.robzam says:

      Let me start by saying that I am not a medical doctor (nor do I play one on TV). However, typically with anxiety disorders you go with antidepressant SSRI or SNRI medications like Prozac, Zoloft, Paxil, Luvox, etc. These have relatively low side effect profiles, aren’t addictive, and are difficult to overdose on. I’m unaware of any long term longitudinal studies that suggest they are harmful in the long term. Of course, all medications have the potential for side effects, so consult your doctor. Also, remember that SSRI typically take 4 to 6 weeks to take their full effect. Unfortunately, a lot of people give up before that time. Furthermore, after 4 to 6 weeks is there isn’t sufficient response, you may have to increase the dosage, which might mean another 4 to 6 weeks before the new dosage fully kicks in.

      There are also Benzodiazapine medications like Xanax, Klonopin, Ativan, etc. They are fast acting and can be taken when one anticipates being in an anxious situation. However, these medications can be addictive over time and can be overdosed on. When combined with other substances (drugs, alcohol, sleep aids, etc) they can be very dangerous. Also, consult with your doctor!

  6. NJCTS says:

    How long is “too long” to allow a student to stay home for a middle school student? Can a student with a “severe” panic disorder NOT attend school due to fear of a panic attack, while outside of school is a pitcher on 3 travel baseball teams with no problems?

    • dr.robzam says:

      Here’s another question with no easy answer. There is no “too long”. I have some kids in treatment who never return to school on a full time basis but function very well with homeschooling, on line learning, etc. This isn’t optimal, but its better than no education at all. If the child has been in a good treatment and been compliant with efforts at therapy but still is unable to return to school, you may have to seriously consider non-traditional schooling. That being said, there should be some deadlines established for when the child should be compliant with certain steps (i.e. you have two weeks to accomplish a specific goal and if you accomplish it we move forward. If you don’t we address the reasons why.)

      That fact that a child can function well in one environment but not well in another is not evidence what the child is faking it or not motivated. Perhaps the child feels trapped in school, struggles with academics, has social problems, etc. There can be any number of triggers in a school environment that trigger panic that don’t occur on the baseball diamond. I would NOT consider pulling the child from baseball if he is unable to make it in to school. I would consider it if the child is being uncooperative with therapy and not trying to address the issues that keep him out of school.

  7. NJCTS says:

    If child has significant generalized anxiety disorder and is fearful of many things, with school being one of them, does this affect your treatment plan?

    • dr.robzam says:

      It certainly would factor in. We’d have to prioritize which anxiety to focus on first, and it isn’t always the anxiety that is the most disruptive or important (i.e. getting back to school). Perhaps we start with something easy and if the child experiences success, they may get motivated and build confidence in their ability to deal with anxiety across various situations.

  8. NJCTS says:

    Is there a correlation between a child being addicted to the internet/video games/social networking which then leads to poor sleeping patterns & subsequently school refusal. What approach would be effective especially when parents don’t set limits?

    • dr.robzam says:

      Although I can’t sight any specific studies, it seems logical to assume that if someone is refusing school because of extreme fatigue in the morning due to staying up all night with internet/video game based behavior (or any other behavior for that matter) that it should be addressed.

      Limit setting is important, but you’d be surprised how many people are bad at it. Nagging and yelling at your kids is not limit setting. Setting a clear, consistent expectation and then enforcing a consequence if expectations are not met is.

      For example, we might tell the child we are concerned about their internet/gaming, but as long as they wake up without a fight and function well in school we will leave them be. However, if the child shows a decline in these areas, the ideal consequence is we with hold access to these devices until compliance is achieved.

  9. NJCTS says:

    How common is it to have a student who is challenged by anxiety and school refusing to be self medicating w/some mood altering drug (alcohol/cannabis/etc)

    • dr.robzam says:

      It very common and can complicate treatment significantly because CBT focuses on teaching people to experience their anxiety and learn to challenge it/cope effectively. Self medication is quite the opposite. Its an avoidance technique that prevents the student from learning that they have the tools within themselves to manage that anxiety and builds the false belief that the substance is the only way to deal with the issues. By the way, this also serves as a potential argument against fast acting medications like Xanax, Ativan, Klonopin, etc., but that’s a wider debate that I will save for another day.

  10. NJCTS says:

    What if your teenager refuses to be involved in therapy but still has significant anxiety at school?

    • dr.robzam says:

      You can lead a horse to water….

      I don’t advise anyone to force their child into a therapy that they aren’t motivated to participate in. The best you can do is discuss your concerns and observations on the child’s behaviors and why you think they need help, and offer to provide help when the child is ready to receive it.

      As a therapist, I always tell parents to tell their children that the decision to participate in therapy is up to them but to encourage them to at least meet with a therapist once to see what suggestions they can offer, and if what they are offering sounds helpful, you leave it up to them to make a 2nd appointment.

      If the child’s issues are severe enough and causing significant impairment in functioning (i.e. not attending school, losing friends, major decline in grades, etc.) then the child should be made to attend at least an initial evaluation and hear what the therapist has to offer. You can then use rewards and consequences as motivation for continued therapy, but once again only if there is significant impairment.