School avoidance: Improving child and youth mental health care

You have seen these kids. She sits silently, looking down at her feet. Occasionally, she shuffles them back and forth. Her bangs hang over her eyes. She is 12 years old. Her mom, exhausted, does her best to relay the story, dripping with a lack of resources for a child who was first avoiding and is now refusing to attend school. Or the 7-year-old crouching in the corner of the exam room, who is known to avoid school and has become physically aggressive with a teacher. Or the 15-year-old who rarely leaves their bedroom, especially for school.

Let’s not mince words. Many of our children are suffering. This often presents in our offices with a chief concern of school avoidance or refusal.

As with all our patients, we want to make the correct diagnosis to provide appropriate treatment. There are numerous underlying causes of school avoidance, including anxiety and mood disorders, neurodevelopmental conditions, eating disorders, learning disabilities, chronic medical conditions, social environment, and bullying. Learning disabilities and neurodevelopmental conditions have an increased risk of associated anxiety disorders, in which case both the underlying cause and the anxiety need to be addressed.[1,2]

In 2023, more than 20% of youth missed school because of mental health challenges, up from 15% in 2018.[3] The rate of anxiety disorders in children and youth and the proportion who rate their mental health as fair or poor have been increasing for over a decade. An estimated 42 000 children in BC have a diagnosed anxiety disorder, and 95 000 have a diagnosed mental health disorder. Less than half receive treatment.[1-3] 

As physicians, we may feel overwhelmed or underequipped to provide the appropriate team-based care for our young patients with school avoidance and mental health difficulties. These are complex situations and conditions with multifaceted treatment recommendations that may include psychoeducation, cognitive-behavioral therapy, pharmacotherapy, and specific supports and/or interventions to address the underlying causes.

Fortunately, in BC, we have some effective resources for physicians and patients:

• Pathways has clinical guidelines and referral information for child and youth mental health (https://pathwaysmedicalcare.ca).
• Compass Mental Health provides clinical advice and educational resources, including a three-part series for supporting students with school avoidance (www.compassbc.ca). 
• If school avoidance is being caused by anxiety or attention-deficit/hyperactivity disorder, then consider a referral to Confident Parents: Thriving Kids, a free telephone-based parent coaching program for elementary school–aged students (https://welcome.cmhacptk.ca). 
• Assessment at the local child and youth mental health intake clinic can assist by providing recommendations leading to diagnosis, treatment, and support (www2.gov.bc.ca/gov/content/health/managing-your-health/mental-health-substance-use/child-teen-mental-health/mental-health-intake-clinics).
• Foundry provides comprehensive mental health services for young people aged 12 to 24 years, virtually and as walk-ins, with no referral required (https://foundrybc.ca). 
• Involving the patient’s school counselor can help address difficulties at school, provide individual counseling, and link to community resources.
• Kelty Mental Health Resource Centre is a valuable resource for patients, families, and school professionals to support students with school avoidance (https://keltymentalhealth.ca). 
• Joining the Shared Care Committee’s Child and Youth Mental Health and Substance Use Community of Practice enables physicians to participate in educational sessions and interact with others who have an interest in child and youth mental health (https://sharedcarebc.ca/our-work/spread-networks/cymhsu-community-of-pra...). 

As the Council on Health Promotion’s most recent policy statement points out, BC’s current mental health system is complex and fragmented, as it falls under the shared responsibility of three ministries: health, children and family development, and education and child care. To ensure families can access services when and where needed, the BC government should prioritize seamless, collaborative, and multidisciplinary care through the development of a child and youth mental health framework, with measures to improve access to timely, effective, and culturally safe care.[2]

What can we do right now to help our patients? Even with the current inadequate system of care, we as individual physicians can provide a great deal of support to our young patients with school avoidance, including exploring the underlying causes. We can listen, validate, diagnose, provide psychoeducation, and mobilize resources. We can reinforce positive routines, such as healthy eating, regular sleep patterns, sufficient exercise, and limited screen time. We can stay connected with our patients as they travel what is a slow and tortuous journey.

School avoidance is solvable. System changes to achieve this are an ethical imperative.
—Selena Lawrie, MD, CCFP
Council on Health Promotion member
—Aven Poynter, MD, FRCPC
Council on Health Promotion member 

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This article is the opinion of the authors and not necessarily the Council on Health Promotion or Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

References

1.    Klein B, Rajendram R, Hrycko S, et al. Anxiety in children and youth: Part 1 – Diagnosis. Canadian Paediatric Society position statement. Paediatr Child Health 2023;28:45-51. Accessed 9 May 2025. https://cps.ca/en/documents/position/anxiety-in-children-and-youth-diagnosis.
2.    Bobbitt S, Kawamura A, Saunders N, et al. Anxiety in children and youth: Part 2 – The management of anxiety disorders. Canadian Paediatric Society position statement. Paediatr Child Health 2023;28:60-66. Accessed 9 May 2025. https://cps.ca/en/documents/position/anxiety-in-children-and-youth-management.
3.    Doctors of BC. Improving child and youth mental health care. Policy statement. 26 February 2025. Accessed 9 May 2025. www.doctorsofbc.ca/advocacy-policy/policy/improving-child-youth-mental-health-care.