The term “school refusal” used to be more or less synonymous with truancy, invoking a picture of kids hanging out on the street corner, or holed up in their bedrooms playing video games.

While it is true that some game-playing might well be involved, it’s important to understand that school refusal is not the same as playing hooky. It isn’t driven by the allure of having fun outside of school, but rather by an aversion to school itself.

Problematic patterns

Everyone resists going to school once in a while, but school refusal behavior is an extreme pattern of avoiding school that causes real problems for a child. School refusal is distinguished from normal avoidance by a number of factors:

How long a child has been avoiding school

How much distress she associates with attending school

How strongly she resists

How much her resistance is interfering with her (and her family’s) life

Including all these aspects is important, because a child can still have school refusal even if she attends school most days. I’ve worked with kids who have missed only a day or two of school, but they’ve been tardy 30 times because their anxiety is so extreme it keeps them from getting to school on time. Kids with school refusal might also have a habit of leaving early, spending a lot of time visiting the nurse, or texting parents throughout the day.

Suspicious sick days

Often kids with school refusal will start reporting unexplained symptoms like headaches or stomachaches. Anxiety does manifest in physical ways, so their symptoms could be indicative of that. As a parent, the first thing you want to do in this situation is get your child checked out by a pediatrician; you don’t want to overlook a medical problem. But it may be that going to school is her problem.

Sometimes resistance to attending school is just a little blip on the radar, and it can be easily remedied. Maybe your child had the flu and was out for a good amount of time, and now she is having a hard time making the transition back to school. Suddenly she’s getting clingy and anxious about all the homework she missed.

In this scenario, it is important not to prolong time at home. Instead, you want to have a conversation with the teacher and with your daughter. You want to be able to tell her, “We’ve talked to your teacher, and he knows you were sick. I know you’re worried, but he understands. It’s time to get back to school.” Then she returns to school and often things go relatively smoothly.

Similarly, some kids in school experience blips of anxiety after vacations. The key point is to get children back in school as soon as possible.

More serious concerns

When school refusal starts to become a bigger problem—it’s going on for numerous days, weeks or even months—you should reach out and ask for help. This includes kids who go to school but only attend partial days because they are spending a lot of time in the nurse’s office and getting sent home early from school.

Understanding the problem

For more serious cases of school refusal, the first step in treatment is getting a comprehensive diagnostic assessment. While school refusal is not a diagnosable disorder, it often accompanies disorders like separation anxiety, social anxiety, depression or panic disorder. A complete assessment helps treatment professionals understand what is underlying school refusal, allowing them to tailor therapy to your child’s particular situation.

Listen up

It’s also possible that something specific is happening at school, like bullying or a difficult class. This doesn’t mean you should immediately jump in and ask your child who doesn’t want to go to school, “Who’s bullying you?” But it is important to know what is going on in your child’s life. You should expect to hear what her teacher is like and how homework is going. You should also have a sense of the kids your child is hanging out with. These are all things that should come up in everyday conversation. And if your child mentions that something happened that day, perk your ears and put down whatever you were doing and listen in a nonjudgmental way, because it could be important.

Reaching out

Treatment providers working with kids who have school refusal will often use cognitive behavioral therapy, which helps kids learn to manage their anxious thoughts and face their fears. While kids who are anxious might disagree, the best way to get over anxiety is actually to get more comfortable with feeling anxious. Kids need the chance to see that they can attend school and their worst fears won’t happen. Exposure therapy, which reintroduces kids to the school environment gradually, is very effective at this. In the very beginning of treatment, this might mean driving by the school or walking through its empty halls on the weekend. From there kids can work up to attending one or two classes and then eventually attending a full day towards the end of treatment.

It’s best to be proactive and catch school refusal as soon as you can. Unfortunately, the longer a child misses school, the harder it is to get back in the routine, because being absent is very reinforcing. I have worked with families that describe getting ready for school like it’s a battle complete with huge tantrums. Sometimes the morning gets so challenging and exhausting that mom and dad just give up and say, “Fine, stay home; I’ll go pick up your homework.” It’s a very understandable situation, but again, letting it continue puts kids one day further from being back at school. It is important for parents to know that the sooner the child gets back to school the better, and reaching out for help is an important first step.