The Anxiety of School Avoidance

School avoidance (also known as school refusal) is not a recognized mental health diagnosis in the current Diagnostic and Statistical Manual for Mental Disorders (DSM 5).¹ Yet extensive research on this type of avoidance confirms its links to emotional disorders—specifically anxiety disorders.²

At the school I help oversee, this research led us to train our entire staff team in the neuroscience of anxiety. When we understand anxiety is a primal survival mechanism to fear, an evolutionary response designed to keep us safe, we create empathy and compassion for our students, many of whom have been out of school for months, even years.

Through the lens of anxiety, we view school avoidance not as a choice our students are making but as an organic response to fear gone awry.

How Anxiety Works

When presented with a situation the brain perceives as scary or dangerous, the limbic system (where the amygdala, the alarm system for the brain, resides) sends a signal to the body telling it to prepare to fight/flight/freeze for its life.³ Put in the context of our evolutionary past, it's like the brain is telling the body, "A lion is chasing you!"

For many children with school avoidance, there was an initial stressor—a falling out with a friend, a significant loss, or bullying—that triggered their fear response. Once safety is reestablished and the threat is removed, the limbic system should stop telling the body it is in danger.⁴ Yet for many students with school avoidance, their brains continue to tell their bodies that school is a lion they must fight/flight/freeze from. The brain then stores the memory of the stressful/scary event to avoid future danger.⁵

The more times the limbic system tells the body that school is dangerous, the more entrenched the belief becomes.⁶ The brain creates a new pathway: School is a lion to be avoided at all costs.

The Way Through is Through

Understanding the pathophysiology of anxiety offers so much hope. The brain has neuroplasticity, the ability to change and adapt over time, and can relearn school is not a lion.⁷

Mastery of Anxiety through Habituation

Source: Dr. Aureen P. Wagner, PhD

Experts tell us anxiety is an overestimation of threat, and an underestimation of a person's ability to handle the threat.⁸ Re-engaging with school means we must expose students to the trigger causing the anxiety (school) in an effort to retrain the brain what they perceive as dangerous is not.⁹ Therapeutic interventions such as cognitive behavioral therapy (CBT) and exposure response prevention (ERP) are empirically based and well-suited to this type of work.^10,11

We must ask students to be brave—to “do things scared” and trust that they will be safe. There is no actual lion, and as they are exposed to school, their distress will decrease as the limbic system relearns to not activate.¹²

The Way Through is Together—Without Shame and Blame

This requires a full team approach. What the research on school avoidance outlines clearly is that everyone must work together to build trust, regain safety, and support the student.¹³ Educators, caregivers, outside professionals, and the student must collaborate on a supportive plan to begin exposure to the lion that is school.

Unlike typical ERP and CBT work, where participants have a choice to engage in exposures, students do not have a choice. They are mandated by law to attend school daily and as such, they must have agency over how they face their lion.

This process can feel particularly slow and challenging for adults. At our school, we find everyone feels pressure to move quickly. As educators, we care deeply about our students—but we also have laws and mandates around school attendance that we are obligated to follow.

Caregivers are often missing work, feeling terrified of watching their children struggle, and worrying about their child’s safety if pushed too hard. Outside professionals are trying to navigate the family and educational system while remaining client-focused.

The whole team must give themselves permission to slow down, meet the student where they are at, and lead with Dr. Ross Greene’s belief that “kids do well if they can.” If a student is struggling to re-engage, everyone must believe it is not because they don’t want to, but because, as Dr Greene says, they are “lacking a skill, not the will” to do so.¹⁴

The team must also be vigilant for what, per the American Psychological Association, professionals are in danger of: resorting to shame, blame, and stigmatizing language when they feel stressed or reach the end of their abilities.¹⁵ The qualitative data we have as a school team is that this language only erodes trust and entrenches school avoidance.

Anxiety Essential Reads

Coping with Financial Market Anxiety

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Reframe: It's a Symptom, Not a Behavior

For this reason, our school team uses the term “school avoidance,” not “school refusal.” Refusal implies blame and choice. If a student is unable to push back on the anxiety and appears stuck, we consider this a symptom, not a behavior, and wonder how we can support them differently.

We want to know if the student has the correct DSM-5 diagnosis. Research indicates there are other diagnoses in addition to anxiety that are associated with school avoidance, such as depression and mood disorders.¹⁶ We find if a student doesn't have the correct diagnosis, they may not be accessing the correct therapeutic intervention.

We also had a group of students who did not have a known trigger for their school avoidance. They often seemed terrified to separate from their caregivers, presenting with intense separation anxiety and intrusive thoughts that their caregivers may be harmed while they are at school.

In these cases, we recognized this as a hallmark of Pediatric Acute Onset Neuropsychiatric Syndrome and Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep (PANS/PANDAS).¹⁷ We began wondering if our other students with school avoidance had medical rule-outs as the DSM5 calls for in the differential diagnosis.¹⁸ The more curious we became, the more students began to access new diagnoses and new treatments—and began to attend school again.

Every student deserves to feel better, and not feel terrified daily trying to go to school. Leading with intellectual curiosity, empathy, understanding, and true teamwork is how we help them do this.