*In general, more clear-cut symptoms like vomiting, diarrhea, fever or weight loss, which are likely to have a physical basis, are uncommon.

School refusal symptoms occur most often on school days. When these children are examined by doctors, no true illnesses are detected or diagnosed. However, since the type of symptoms these children complain of can be caused by a physical illness, a medical examination should usually be part of their evaluation.

Most often, school-avoiding youngsters do not know precisely why they feel ill, and they may have difficulty communicating what is causing their discomfort or upset. But when school-related anxiety is causing school avoidance, the symptoms may be ways to communicate emotional struggle with issues like:

• Fear of failure
• Problems with other children (for instance, teasing because they are
  "fat" or "short")
• Anxieties over toileting in a public bathroom
• A perceived "meanness" of the teacher
• Threats of physical harm (as from a school bully)
• Actual physical harm
• Loss of a loved one
• Fear of loss of loved on or home while at school

What can be done?

As a first step, the management of school avoidance involves an examination by a doctor who can rule out physical illness and assist the parents in designing a plan of treatment. Your child may need to see a physician when he has to stay home because of a physical illness. Your pediatrician might help ease your child's transition back to school by writing him a note verifying that he had some symptoms that kept him from attending school. This can keep your youngster from feeling embarrassed or humiliated.

After the pediatrician gives your child a clean bill of health:

• Talk with your child about the reasons why he does not want to go to school.
• Consider all the possibilities and state them.
• Be sympathetic, supportive and understanding of why he is upset.
• Try to resolve any stressful situations the two of you identify as causing his worries or symptoms.
• Acknowledge that you understand your child's concerns, but insist on his/her immediate return to school. (The longer your child stays home, the more difficult eventual return to school will be.)
• Let your child know that school attendance is required by law.
• Your child will continue to exert some pressure upon you to let him stay home, but you must remain determined to get him back in school.

If your child's anxieties are severe, a step-wise return to school may be beneficial. For example: On day one, he might get up in the morning and get dressed, and then you might drive him by the school so he can get some feel for it before you finally return home with him. On day two, he might go to school for just half a day, or for only a favorite class or two. On day three, he can finally return for a full day of school.

If your child stays home, be sure he/she is safe and comfortable, but he/she should not receive any special treatment. Symptoms should be treated with consideration and understanding, and your child should remain supervised.

It is important to make a commitment to be extra firm on school mornings, when children complain most about their symptoms. If your child is well enough to be up and around the house, then he/she is well enough to attend school.. Once your youngster begins to attend school regularly, the physical symptoms will probably disappear.

Discuss your child's school avoidance with the school staff, including teachers, the principal and the school nurse. Request help from the school staff for assistance while your child is at school. If a problem like a school bully or an unreasonable teacher is the cause of your child's anxiety, become an advocate for your youngster and discuss these problems with the school staff.

While you might try to manage school refusal on your own, if your youngster's school avoidance lasts more than one week, you and your child may need professional assistance to deal with it. If your child's school refusal persists your doctor may recommend a consultation with a child psychiatrist or psychologist.

Even if your child denies having negative experiences at school or with other children, his/her unexplainable physical symptoms should motivate you to schedule a medical evaluation.