School Anxiety and Refusal: Symptoms, Causes, Consequence, and Treatment

School anxiety refers to a distress response that occurs in teenagers due to overwhelming feelings related to the school environment. The American Academy of Child and Adolescent Psychiatry (AACAP) states that school anxiety affects roughly 5-10% of school-aged children, contributing to symptoms like absenteeism and academic struggles.

The symptoms of school anxiety include persistent stomach aches, headaches, avoidance behaviors, and social withdrawal, which severely impact school attendance. According to a study by Julian Elliott and Maurice Place titled “Children in Difficulty,” published in Routledge (2012), symptoms include physical and emotional reactions impacting school attendance.

The key causes of school anxiety include bullying, academic pressures, and underlying anxiety disorders exacerbated by social and performance expectations. According to the National Institute of Mental Health (NIMH), approximately 32% of adolescents experience some form of anxiety disorder, with school anxiety being one of the leading contributors to school refusal behaviors in youth.

The consequences of school anxiety in teenagers lead to academic decline, social isolation, and increased risk of developing further mental health disorders in adulthood. School anxiety contributes to lifelong cognitive health risks.

The treatments for school anxiety include cognitive-behavioral therapy (CBT), exposure therapy, and sometimes medication to reduce anxiety and support school reintegration. According to a study by the American Psychological Association, 2019, titled “Effective Treatments for Anxiety Disorders in Children and Adolescents, Cognitive-behavioral therapy (CBT) is one of the most effective treatments for school anxiety, showing significant success in helping students manage symptoms and improve school attendance.

What Is School Anxiety?

School anxiety is  a psychological distress response that causes students to develop intense fear and avoidance behaviors toward school, often manifesting as a “fear of school” or “school phobia.” This anxiety impacts regular attendance, with students feeling an overwhelming sense of discomfort at the idea of facing school each day. 

According to a study by Zaky titled “School Refusal and Psychiatric Disorders in Children: Prevalence and Risk Factors,” published in the Egyptian Journal of Health Care (2020), school refusal due to anxiety is prevalent in about 2% of school-aged children and accounts for approximately 5% of referrals for pediatric mental health concern.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), school anxiety coexists with separation anxiety from parents, further intensifying the reluctance to attend school. Students experiencing this type of anxiety report significant distress when separating from their primary caregivers, creating a cycle of resistance and fear toward the school environment.

Bullying is another primary trigger for school refusal, as students who face harassment or social exclusion develop heightened anxiety and fear of being in the school setting, which leads them to avoid it altogether. 

School violence, especially school shootings, is among the leading triggers for school anxiety and refusal. There have been at least 58 school shootings in the United States so far this year as of October 15. The incidents left 28 people dead and at least 72 other victims injured, according to CNN’s analysis of events reported by the Gun Violence Archive, Education Week, and Everytown for Gun Safety. Teenagers become anxious, fearful, and traumatized for their lives, refusing to go to school.  

Additionally, school anxiety is linked to symptoms such as stomachaches, headaches, and social withdrawal, making students’ school performance suffer as they struggle to cope with their internal stressors. 

As per DSM-5, students with school refusal also exhibit symptoms of generalized anxiety disorder, panic attacks, or physical complaints, which collectively create a severe aversion to school settings.

What Are The Symptoms Of School Anxiety?

The symptoms of school anxiety are physical, emotional, and behavioral in nature. Physically, students experience stomach aches, headaches, and nausea, while emotionally, they feel persistent fear and worry about attending school. Behaviorally, students exhibit school refusal, avoidance of social interactions, and even school phobia. 

According to Hill and Mrug in a study titled “Association between School Refusal Behavior and Physiological Symptoms,” common symptoms of school anxiety include headaches, stomachaches, nausea, and dizziness, which are especially prevalent in the morning when students are pressured to attend school 

The physical symptoms of school anxiety include:

• Stomach aches: Anxiety about attending school causes digestive issues, with stomach aches often serving as a tangible response to stress. This physical symptom frequently justifies staying home, reinforcing avoidance behavior.
• Headaches: Students experience tension headaches, a direct result of prolonged anxiety about school. These headaches lead to further distress and avoidance, worsening school anxiety over time.
• Dizziness: Feelings of dizziness arise from intense anxiety, especially in social settings or high-stress environments like school, making attendance seem overwhelming.
• Fatigue: Anxiety disrupts sleep patterns, resulting in chronic fatigue. This tiredness reduces a student’s resilience, making school-related tasks appear more daunting and contributing to a cycle of anxiety.
• Muscle tension: Physical tension, especially in the shoulders or back, is a common response to anxiety. This persistent discomfort reinforces the idea that school is a stressful place, deterring attendance.

The emotional symptoms of school anxiety include:

• Fearfulness: A profound, ongoing fear of school interactions or settings drives students to avoid school, associating it with a distressing and hard-to-cope-with environment. According to the Centers for Disease Control and Prevention (CDC), during the 2017–2018 school year, there were 67 school-associated violent deaths in the United States, including 51 homicides and 16 suicides.
• Irritability: Increased sensitivity and frustration about school-related tasks or interactions heighten the stress surrounding school, intensifying anxiety and impacting relationships with peers and teachers.
• Excessive fear: Extreme fear of failure or social judgment often leaves students feeling vulnerable, which escalates anxiety and reinforces the impulse to stay away from school.
• Worry: Persistent worry about school challenges or social interactions leads students to dread attending school, making it feel like an insurmountable obstacle.
• Hopelessness: Feelings of hopelessness arise when students believe they are incapable of managing school demands, further deepening school anxiety and promoting avoidance.

The behavioral symptoms of school anxiety include:

• School refusal: Refusing to go to school is a common behavioral outcome of severe anxiety. It serves as an immediate way to escape a feared environment but worsens long-term anxiety and avoidance.
• Avoidance of schoolwork: Anxiety about academic failure or criticism leads students to disengage from schoolwork, which contributes to falling behind academically and increases overall school-related anxiety.
• Social withdrawal: Anxiety-driven isolation prevents students from forming positive relationships, creating a perception that school is a hostile environment, which worsens their reluctance to attend.
• Clinginess: Clinging to parents stems from separation anxiety and a lack of comfort in the school environment, leading to a cycle where students depend on home as a “safe space,” further fueling school anxiety.
• Frequent absences: Missing school due to anxiety is a form of escape, but this avoidance intensifies anxiety, making each return to school increasingly challenging.

What Are The Causes Of School Anxiety?

The causes of school anxiety include bullying, school shootings, academic pressures, social isolation, separation anxiety, and family dynamics. These factors create stressors that lead students to view school as a source of fear and discomfort. 

Consequently, students struggle to attend regularly, which increases anxiety over time. According to a study by Kearney titled “School Refusal Behavior in Youth: A Functional Approach to Assessment and Treatment,” published in the American Psychological Association (2001), “school refusal often stems from anxiety linked to peer interaction, performance expectations, and family factors.”

The common causes of school anxiety include:

• Bullying: Experiencing bullying both physically and on social media creates a hostile school environment, leading students to associate school with fear and distress. This ongoing threat fosters avoidance behaviors and escalates anxiety, resulting in school refusal.
• Academic hardships: High expectations for grades and testing performance place immense pressure on students, causing them to feel inadequate or fearful of failure. This fear becomes overwhelming, intensifying their anxiety around school-related tasks and attendance.
• Trauma: Exposure to traumatic events, either within or outside the school environment, leaves students more vulnerable to anxiety, as they perceive school as unsafe or overwhelming. This perceived threat leads to avoidance and exacerbates school anxiety.
• Social anxiety: Struggling with social interactions makes school a highly stressful environment, especially in large groups or public settings. Social anxiety in school students is associated with the need for popularity, which is fueled by social media use. According to the National Institute of Mental Health (NIMH), approximately 9.1% of U.S. adolescents aged 13-18 experience social anxiety disorder, with 1.3% suffering from severe impairment. Students with social anxiety avoid school to escape potential embarrassment or judgment, further fueling school-related fears.
• Separation anxiety: For some students, being away from their parents triggers intense distress, leading to school refusal as a means to avoid separation. This dependence on home as a “safe space” perpetuates a cycle of anxiety, especially in early adolescence.
• Generalized anxiety disorder: Chronic worry that extends beyond specific situations results in students feeling anxious in nearly all school settings. According to the Centers for Disease Control and Prevention (CDC), approximately 9.4% of children aged 3–17 years have been diagnosed with anxiety disorders. This heightened anxiety about various school-related scenarios makes regular attendance and engagement challenging.
• Chronic health conditions: Physical conditions like asthma or diabetes increase worry about managing health needs at school, adding to the stress of daily attendance. This worry leads to school avoidance as students attempt to prevent situations they fear might worsen their health.

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What Are The Consequences Of School Anxiety?

The consequences of school anxiety include academic decline, social isolation, behavioral issues, and an increased risk of developing long-term mental health disorders. These consequences affect the student’s academic performance, social relationships, and behavior in school. 

A significant impact is seen in students’ lack of interest in studies, where anxiety shifts their focus from learning to coping, causing them to view school as unnecessary and unrelated to their goals. 

According to a study by Egger, Costello, and Angold titled “School Refusal and Psychiatric Disorders: A Community Study,” published in the Journal of the American Academy of Child & Adolescent Psychiatry (2003), approximately 28% of students with high anxiety report chronic absenteeism and declining academic performance. Attendance becomes irregular, as students with high anxiety levels show short attendance patterns and frequently miss school, which exacerbates their academic difficulties. 

School anxiety worsens symptoms commonly associated with ADHD, such as difficulty concentrating, restlessness, and impulsivity, as anxious students struggle to manage stress in academic settings. This heightened anxiety mimics or intensifies ADHD symptoms, leading to challenges in attention and behavior regulation in school environments.

School anxiety also leads to incomplete homework, as students struggle to engage with assignments outside of the school environment. This causes them to fall behind and increases stress over time. 

Behaviorally, students display disruptive or bad behavior stemming from frustration and an inability to cope. This affects the classroom environment and alienates them from their peers and teachers. 

This social isolation creates bad relationships and reduces support systems that would otherwise facilitate learning, making grasping new concepts more challenging. 

According to a study by McShane, Walter, and Rey titled “Functional Outcome of Adolescents with School Refusal,” published in Clinical Child Psychology and Psychiatry (2004), students with high anxiety levels often display poor attendance and increased academic challenges due to disengagement and incomplete homework, which limit their academic and social development.

What Are The Treatments For School Anxiety Disorder?

The primary treatments for school anxiety are psychotherapy, medication, school interventions, and after-school programs. CBT is commonly used to help students manage anxiety through coping skills and gradual exposure to school settings, while medication is prescribed in severe cases to alleviate symptoms. 

The treatments for school anxiety disorder include the following:

Psychotherapy 

Psychotherapy, particularly cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT) is a core treatment for school anxiety that focuses on identifying and challenging negative thought patterns while teaching coping skills to help students manage anxiety in school settings. 

According to a study by Maynard et al. titled “Psychosocial Interventions for School Refusal,” published in Campbell Systematic Reviews (2015), “CBT has been shown to increase school attendance by 40-60% in students with anxiety-driven school refusal, providing measurable relief from school-related distress.”

DBT is used for more intense emotional responses, including mindfulness and emotional regulation techniques. These therapies help students gradually confront school-related fears and reduce avoidance behaviors, improving both attendance and engagement in school. 

Medication

Medication is prescribed for students with severe school anxiety symptoms that interfere with daily functioning and cannot be fully managed through psychotherapy alone. Common medications include selective serotonin reuptake inhibitors (SSRIs) like fluoxetine and sertraline and benzodiazepines like alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin), which target anxiety by stabilizing serotonin levels in the brain. The appropriate dosage of anti-anxiety medications for children varies based on the specific medication, the child’s age, weight, and overall health, according to the National Institute of Mental Health (NIMH),

According to a study by Ginsburg et al. titled “Treatment of Anxiety Disorders in Youth with SSRIs,” published in the Journal of Clinical Psychiatry (2011), “SSRIs, when combined with CBT, improve anxiety symptoms in over 50% of school-age children, enhancing their ability to attend school regularly and engage with peers.

This biochemical support alleviates physical symptoms, such as headaches and stomachaches, helping students better manage school-related stressors.”

School Interventions

School interventions are structured programs within the school environment that support students dealing with school anxiety. These include accommodations like flexible schedules, safe spaces for emotional regulation, and supportive interactions with school counselors.

According to a study by Lyon and Bruns titled “School-Based Interventions for Anxiety in Children,” published in School Psychology Review (2012), students participating in school interventions showed a 30% improvement in attendance and a significant reduction in anxiety symptoms.

By creating a less threatening environment, these interventions reduce anxiety triggers, making school a more approachable space for students.

After-School Programs

After-school programs provide additional support outside regular school hours, offering structured environments where students develop social skills, receive homework assistance, and practice coping strategies. 

As reported by Durlak and Weissberg in their study titled “The Impact of After-School Programs That Promote Personal and Social Skills,” published in American Journal of Community Psychology (2007), “students involved in after-school programs demonstrated a 20% improvement in coping with school-related anxiety and more consistent attendance.”

These programs help ease the transition back into school routines for students with school anxiety by building confidence in a less formal setting.

How To Deal With School Anxiety?

To deal with school anxiety effectively, students benefit from a combination of structured routines, coping strategies, and support networks. Establishing consistent routines helps students feel prepared, reducing anxiety about the unknown aspects of school. 

According to a study by Kendall et al. titled “Cognitive-Behavioral Therapy for Anxiety in Youth: A Randomized Clinical Trial,” published in the Journal of Clinical Child & Adolescent Psychology (2008), students using structured coping strategies reported a 40% reduction in anxiety symptoms, resulting in improved school attendance and engagement.

Techniques like deep breathing, mindfulness exercises, and positive self-talk enable students to manage in-the-moment stressors. Engaging parents and school staff in providing emotional support further eases students’ transition into a positive school experience. 

How Do Parents Help Their Children With School Anxiety?

Parents help their children with school anxiety by offering emotional support, creating a stable home routine, and encouraging open communication about school-related fears. By validating their child’s feelings and showing understanding, parents reduce feelings of isolation. 

According to a study by Lyon and Silverman titled “Parent-Based Interventions for School Anxiety,” published in Child Psychiatry and Human Development (2015), children who received parental support and structured routines showed a 30% decrease in anxiety-related absenteeism.

Establishing a consistent morning and evening routine helps the child feel more prepared and less anxious about the school day. Additionally, collaborating with school staff to implement supportive strategies further reinforces the child’s confidence. 

How Do Teachers Help Their Children With School Anxiety?

Teachers help students with school anxiety by creating a supportive classroom environment, recognizing signs of anxiety early, and offering accommodations that reduce stress. Through strategies like clear communication, structured lesson plans, and regular check-ins, teachers alleviate students’ worries and make school more manageable. 

According to a study by Richards and Schofield titled “School-Based Support for Students with Anxiety,” published in the Journal of School Psychology (2016), students with teacher support reported a 25% improvement in class participation and comfort in school.

Collaborating with counselors and parents to develop tailored support plans also aids in addressing each student’s needs. 

What Type Of Anxiety Is School Anxiety?

School anxiety is classified as a form of situational or specific anxiety where the primary source of distress is tied to the school environment and activities. It shares symptoms with generalized anxiety disorder (GAD), social anxiety disorder (SAD), and separation anxiety disorder (SAD), all of which include physical symptoms like stomach aches and headaches, avoidance behaviors, and intense worry. 

According to a study by Bernstein et al. titled “School Anxiety and Related Disorders in Youth,” published in Clinical Psychology Review (2013), students with school anxiety exhibit overlapping symptoms with GAD and SAD, especially regarding social fears and physical complaints.

Is Feeling Sick Every Morning Normal In School Anxiety?

Yes, feeling sick every morning is a common symptom of school anxiety. Students with school anxiety experience physical symptoms like nausea, stomachaches, and headaches as their bodies react to the stress associated with school. 

These physical symptoms are directly linked to their heightened levels of anxiety about school. This regular physical discomfort reinforces their fear and reluctance to attend, creating a cycle of avoidance. 

Can School Anxiety Cause Depression?

Yes, prolonged school anxiety causes depression in students. When anxiety about school remains unaddressed, it leads to feelings of helplessness, low self-worth, and social isolation, all of which are risk factors for depression. 

According to the Centers for Disease Control and Prevention (CDC), in 2021, more than 4 in 10 (42%) of high school students felt persistently sad or hopeless, and nearly one-third (29%) experienced poor mental health. This compounding effect of school anxiety intensifies over time, impacting the student’s overall mental health.