Children and adolescents who refuse to attend school should not be given doctors' sick notes. In the current issue of Deutsches Ärzteblatt International (Dtsch Arztebl Int 2010; 107), child and adolescent psychiatrist Martin Knollmann and colleagues explain the causes of school avoidance and describe measures to tackle the problem.
Truancy assumes psychiatric relevance only if it occurs frequently and is accompanied by psychiatric symptoms. Children typically play truant for the first time at the age of about 11 years, whereas anxiety related school avoidance occurs in children as young as 6 years. School avoiders seem to be exposed to more stressful life events, but physical disorders such as asthma or obesity may also play a part.
In contrast to truancy, of which parents are usually unaware, children displaying school avoiding behavior often stay at home. They often express fears and anxieties, especially in the morning, and complain of diffuse physical symptoms.
The authors assume that a proportion of 5% to 10% of children is regularly absent from schools in Germany. How many of these children have mental health problems is not known. In adolescents, school avoidance is clearly more common than in children, and some studies have shown that boys are affected twice as often as girls.
In school avoidance, the primary objective of treatment is to quickly re-establish regular school attendance. Sick notes or prescriptions for residential care breaks are usually not advisable because the child's behavior may deteriorate as a result.
Appropriate treatment options include cognitive behavior therapies, in combination with antidepressants if required. Exclusively child and adolescent psychiatric treatment, however, is usually not sufficient; those children who are affected need a support network consisting of school staff, youth services, and medical professionals.