A detailed history and examination is important, and in most cases an attempt should be made to return the child to school as soon as possible - this will always require careful discussion first.
The child's anxieties should be acknowledged. If these are realistic, like bullying at school, then the school should be asked to take sensible steps accordingly. Parents will need advice on adopting a firm, non-hostile approach. Liaison must be established with school, educational social worker (ESW) and educational psychologist. Teachers must be involved so that the child is welcome back to school and not punished for non- attendance. Liaison with the GP is crucial as families may try and circumvent plans by getting a sick note.
In young children with acute and recent onset, firm directive methods usually work ie explaining to parents that even if their child seems very anxious they must be made to go to school and they will settle very quickly once this is done. The parents, with or without the ESW, should return the child (in spite of protests), as soon as possible.
In more difficult cases behavioural methods such as graded exposure to feared situations and/or control of environmental reinforcers, eg elimination of rewards for being at home and rewards for attendance, may be used in close collaboration with parents and school. A graded return to school, in steps which the child and parents can manage is often used. More resistant cases, especially where a lot of schooling has been missed, may need special educational provisions with or without residential treatment.
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