GET THE CHILD BACK INTO SCHOOL IN STEPS, WITH THE SCHOOL IN THE PLAN
School Refusal - StatPearls (NCBI Bookshelf NBK534195) - https://www.ncbi.nlm.nih.gov/books/NBK534195/
The treatment is a graded return, agreed with the parents and the school, and a physician's most powerful action is refusing to write the sick note. No drug row is offered: the article's sertraline regimen is a child-psychiatry prescription that needs monitoring this article does not describe, and its benzodiazepine paragraph carries a figure that cannot be right for a child (see the caution below).
- IT IS A SYMPTOM, NOT A DIAGNOSIS - refusing school is not itself an emotional disorder; it can be how an anxiety disorder shows itself. So the question is what it is a symptom of - anxiety, bullying, learning difficulty, something at home, or something at school.
- THE TELL IS THE TIMING - what these children present with is fear, panic, bouts of crying, tantrums, threats to harm themselves, and bodily symptoms that arrive in the morning and ease off once the child is allowed to stay at home. A stomach ache that is gone by ten o'clock on a school day and absent at weekends is the pattern.
- AND SOME CHILDREN GET AS FAR AS THE GATE - some set off in the morning and grow more anxious the nearer they get, until they can go no further. Others will not set off at all.
- THE HEADACHE AND THE TUMMY ACHE ARE REAL, AND THEY ARE NOT A DISEASE - where a child who will not go to school comes with physical complaints, your job is to explain that the body is expressing distress, and that no physical illness underlies it. Examine the child properly once, then stop investigating.
- DO NOT WRITE THE NOTE - a doctor should not write a note excusing a child from school unless a medical condition genuinely requires them to be at home. Every note bought with a stomach ache makes the next morning harder, and this is the single request a physician will be under most pressure to grant.
- PARENTS OFTEN COVER FOR IT, SO ASK DIRECTLY - nobody knows how many children miss school through anxiety, because parents so often cover for them, ringing the school to say the child is ill. That happens most where the anxiety comes out through the body, as a headache or a pain in the stomach. Ask how many days have actually been missed this term.
- WHAT THE TREATMENT ACTUALLY IS - there is a range of exposure-based treatments with evidence behind them: cognitive behaviour therapy, educational support, medication, and sometimes work with the parents and the teachers together. The behavioural parts are relaxation training; systematic desensitisation, meaning graded exposure to school; emotive imagery; teaching social skills; and contingency management. Graded exposure means a step a week, agreed in advance, not a battle each morning.
- A YOUNGER CHILD MAY NEED NOTHING MORE THAN THE ADULTS AGREEING - a small child with only mild fear, anxiety or low mood can often work through it with the parents directly, helped by the staff at school to get past what frightens them, and may need nothing else at all.
- WHO NEEDS MORE THAN THAT - therapy involving the child, the parents and the school staff may be needed where there is another psychiatric diagnosis alongside, where the absence has run on a long time, or where social skills are lacking. What is called for then is a team working together across settings: you, the child, the parents, the school, and the other mental-health professionals involved.
- WHAT A PHYSICIAN'S OWN ROLE IS - explaining the condition to the child and the parents, keeping an eye on any medication, and helping arrange a referral for more intensive psychotherapy.
- NO SSRI IS PRESCRIBED FROM HERE - the article does say that the selective serotonin reuptake inhibitors (SSRIs) have taken over from the tricyclics as the first drug treatment for anxiety disorders in childhood, and it gives a sertraline titration. It also concedes that controlled, double-blind studies of SSRIs in children are few, and it says nothing at all about the suicidality monitoring that starting an antidepressant in a child requires. Starting one needs a child mental-health assessment and planned review, so no prescribing row is written and the titration is not reproduced here.
- A BENZODIAZEPINE FIGURE IN THIS ARTICLE IS NOT SAFE TO USE, AND IT IS NOT PRINTED - the article gives paediatric starting doses for clonazepam and lorazepam and then states a lorazepam maintenance figure that is an adult-scale amount, several times what any child should receive. It is therefore treated as unusable and no number from that paragraph appears anywhere here. The article's own warnings stand: a benzodiazepine may be used briefly in a child whose school refusal is severe; it is stopped once the SSRI has had time to work, because of the risk of addiction and of side effects; and those side effects are many - sedation, disinhibited behaviour, irritability, and impaired thinking. If a child seems to need one, that is a psychiatric referral, not a prescription from here.
- TAKE SELF-HARM TALK AT FACE VALUE - threats of self-harm are on the article's own list of presenting symptoms. Ask about it plainly, and refer urgently if the answer is yes rather than treating it as part of the tantrum.
- THE OUTLOOK IS GOOD, AND MISSING SCHOOL IS STILL COSTLY - school refusal frequently resolves as the child grows, fading away without leaving anything behind, so the outlook is generally good. But long stretches of missed schooling hold a child back in maturity - cognitively, psychologically and socially. Waiting it out is not free.