Diseases & Conditions


School Avoidance

Avoiding school occurs in about 5% of all school-aged children and affects girls and boys equally. It is most likely to occur between ages 5 and 6 and between ages 10 and 11.

The cause is often unclear, but psychologic factors (such as anxiety and depression) and social factors (such as having no friends, feeling rejected by peers, or being bullied) may contribute. A sensitive child may be overreacting with fear to a teacher's strictness or rebukes. Younger children tend to fake illness or make other excuses to avoid school. The child may complain of a stomachache, nausea, or other symptoms that justify staying home. Some children directly refuse to go to school. Alternatively, the child may go to school without difficulty but become anxious or develop various symptoms during the school day, often going regularly to the nurse's office. This behavior is unlike that of adolescents, who may decide not to attend school (truancy, playing "hooky" (see Problems in Adolescents: School Problems ).

School avoidance tends to result in poor academic performance, family difficulties, and difficulties with the child's peers. Most children recover from school avoidance, although some develop it again after a real illness or a vacation.

Home tutoring is generally not a solution. A child with school avoidance should return to school immediately, so that he does not fall behind in his schoolwork. If school avoidance is so intense that it interferes with the child's activity and if the child does not respond to simple reassurance by parents or teachers, referral to a psychologist or psychiatrist may be warranted.

Treatment should include communication between parents and school personnel, regular attendance at school, and sometimes therapy involving the family and child with a psychologist. Therapy includes treatment of underlying causes as well as behavioral techniques to cope with the stresses at school.

What Are Stress-Related Behaviors?

Each child handles stress differently. Certain behaviors that help children deal with stress include thumb sucking, nail biting, and, sometimes, head banging.

Thumb sucking (or sucking a pacifier) is a normal part of early childhood, and most children stop by the time they are 1 or 2 years old, but some continue into their school-age years. Occasional thumb sucking is normal at times of stress, but habitual sucking past the age of about 5 can alter the shape of the roof of the mouth, cause misalignment of teeth, and lead to teasing from other children. Occasionally, persistent thumb sucking can be the sign of an underlying emotional disorder.

All children eventually stop thumb sucking. Parents should intervene only if their child's dentist advises them to, or if they feel their child's thumb sucking is socially unhealthy. Parents need to gently encourage the child to understand why it would be good to stop. Once the child signals a willingness to stop, gentle verbal reminders are a good start. These can be followed by symbolic rewards put directly on the thumb, such as a colored bandage, fingernail polish, or a star drawn with a nontoxic colored marker. If necessary, additional measures, such as a plastic guard over the thumb, overnight elbow splinting to prevent a child from bending it, or “painting” the thumbnail with a bitter substance can be used. However, none of these measures should be used against the child's will.

Nail biting is a common problem in young children. The habit typically disappears as the child gets older, but is typically related to stress and anxiety. Children who are motivated to stop can be taught to substitute other habits (for example, twirling a pencil).

Head banging and rhythmic rocking are common among healthy toddlers. While alarming to parents, the children do not seem to be in distress and actually appear to derive comfort from the activity.

Children usually outgrow rocking, rolling, and head banging between 18 months and 2 years of age, but repetitive actions sometimes still occur in older children and adolescents.

Children with autism and certain other developmental problems also may bang their heads. However, these conditions have additional symptoms that make their diagnosis apparent.

Although children almost never damage themselves by these behaviors, this possibility (and the noise) can be reduced by pulling the crib away from the wall, taking off the wheels or placing carpet protectors under them, and applying a padded crib bumper to the inside of the crib.

Last full review/revision February 2003

Source: The Merck Manual Home Edition