It was the middle of a typical school day at Midway High School in Waco, Texas, and the hallways were packed with noisy clusters of teens, laughing and jostling and clanging locker doors, slowly wending their way to class.

But Morgan Smith wasn’t part of the clamor. The 15-year-old was in the restroom, hunched in a bathroom stall, frantically texting her parents over and over: “Please, please, please, you have to come get me!

Morgan, who qualifies as a GATE (Gifted and Talented Education) student, is articulate and self-possessed. She’s never been bullied and has lots of friends. So why does she dread school so much? She hates the constant noise and crowding. She isn’t crazy about some of her peers, either, many of whom she says are privileged and supercompetitive.

But Morgan’s reaction to school is about more than likes and dislikes — it’s a sensation of total panic. “As soon as I got to school, I would start worrying about having a panic attack and that would consume everything,” she recalls. “I’d sit in class and it would feel like something awful was going to happen if I didn’t get out of there. I was terrified. I’d shake and start freaking out. It was the worst feeling in the world.”

The panic made it impossible for Morgan to concentrate. “I’d get home and have no idea what the homework was,” she says. “I wouldn’t remember anything the teacher said in class because I was worrying so much.”

Many kids don’t like school, but for Morgan it was unendurable — every single day. “Sometimes it was worse in the morning, sometimes it was worse in the afternoon, some days it was bad all day,” she says. “I never had a day at school when I felt like, ‘I’m fine.’ The fear never left my head.”

Yes, there is a name for it

Morgan’s problem has a name: it’s a behavior known as “school refusal” — and it’s more common than you may think. In fact, school refusal is one of the most common childhood behavior problems, according to Chris Kearney, who directs the School Refusal and Anxiety Disorders Clinic at the University of Nevada, Las Vegas. Kearney estimates that eight to 10 percent of all school children exhibit school refusal behavior — and miss school as a result — at some point during their school career.

If you add the many kids who resist going to school but ultimately make it in the door, the number shoots up to 28 percent. “Some of the kids we work with show up at school, but they are complete terrors before they get there,” says Kearney. “They throw tantrums, they run and hide, they refuse to get dressed — getting them to school is miserable for their parents, but they show up at school and are marked as present.”

School refusal is hard to define precisely because it shows up in very different forms depending on the individual child. Kearney distinguishes “school refusal” from “school phobia,” which is fear-based and linked to fear of a specific object or situation at school, like the fire alarm or the class snake.

School refusal is a sign of broader anxiety — separation anxiety, social anxiety, or general anxiety. Sometimes kids with school refusal complain of physical symptoms like stomachaches or headaches, but not all kids who refuse school have physical complaints. Some kids throw tantrums before school every morning; others make it to school but have trouble staying in the classroom. Some kids refuse school after a disruption or crisis at home — a move, divorce, illness, or death in the family, for example — but in many cases, school refusal behavior has no obvious trigger.

To some, school refusal may sound like a fancy name for a standard-issue schoolkid whine — A kid who doesn’t like school? So what else is new? — one that a little tough love and smart parenting could easily fix. But the behavior is often a symptom of a more serious condition, and simply laying down the law and forcing the child to go to school is likely to make the problem worse.

School refusal isn’t just an invented pathology among over-indulged American kids, either. Kearney says he gets calls from educators and practitioners from around world. “We’ve heard from people in Japan, China, Sweden, Denmark, Canada,” he says. “School refusal seems to be pretty universal.”

Why kids say no to school

Why a particular child develops school refusal can be difficult to untangle. The causes can include psychological, developmental, and external factors like bullying — either alone or in combination. According to Kearney, most cases appear around the beginning of middle school. “Kids are going through the upheaval of puberty at the same time that they’re facing bigger challenges, both academically and socially. It’s a perfect storm,” he says.

But younger kids refuse school, too. According to educational consultant James Dillon, a former elementary school principal and author of No Place for Bullying, the reason for school refusal in the younger grades is typically developmental. A number of his students began refusing school at the age of nine or 10. “That’s the age when kids start figuring out that their parents have separate identities and that bad things can happen to people,” Dillon explains. “Some kids become overwhelmed with fear that something is going to happen to their parents when they are at school. They panic and cling to their parents and don’t want to go to school.”

Dillon says most of the students who developed school refusal weren’t unpopular or emotionally fragile. “These were kids who had a generally positive school experience,” he says. “Their parents would say, ‘What did I do wrong?’ But school refusal doesn’t have a single cause. It isn’t necessarily linked to a divorce or other problems at home. It just happens, and trying to identify a specific cause isn’t particularly productive.”

However, external circumstances at school, particularly bullying, can also trigger the problem — and in that case, it’s essential to get to the bottom of the issue. Dillon points out that for some tweens and teens, school refusal may be a rational reaction to an intolerable situation. “If a child is suffering peer abuse and bullying every day — and I don’t think adults realize how painful that can be — the best way for that child to protect himself is to not go to school.”

Santa Claus, space aliens, and school phobias

For many kids — in as many as two-thirds of cases, according to Kearney’s estimates — school refusal signals an underlying anxiety disorder. Morgan Smith, for example, has been diagnosed with obsessive-compulsive disorder, and she has always been tormented by fears. At age three, she was so worried about “that fat man coming down the chimney” that her parents had to tell her that Santa Claus wasn’t real. E.T., the friendly space alien, terrified her so much that she wouldn’t walk into a movie store if there was a poster or cardboard image of the character on the premises. She worries about germs and other contaminants and questions her mother before dinner every night about what she’s serving and how it’s been prepared. But of all her fears and phobias, her dread of school has been the most debilitating — and has had the most bruising effect on her family.

Since she started resisting school in sixth grade, Morgan’s parents have tried many alternative education paths, including private school, homeschooling, and online school. Last year, Morgan spent just three days at her new high school; she was so unhappy that her parents pulled her out and enrolled her in an online program. Her parents later found out that the program was difficult to navigate. Morgan fell behind but was afraid to tell her parents until it was too late. When her mother went to the site to see why Morgan had difficulty, she found the program confusing, too — and more appropriate for mature, self-motivated learners than for a teenager trying to learn on her own. Now, Morgan has to repeat 9th grade.

Morgan makes it clear that refusing school isn’t a matter of stubbornness — or even a matter of choice. She regrets all the school she’s missed, and her mother says the teen feels terrible about all the time and talent she’s wasted. “She told me that she wouldn’t wish this situation on her worst enemy,” her mother says.

School refusal takes its toll on families as well, as Morgan’s mother makes clear. “I spend all my time worried and stressed. The situation becomes your only focus, all you can do, all you can think about. Everyone in the family is affected.”

Super-stressed teens

Clinical psychologist and parenting expert John Duffy has his own theory about why so many kids refuse school, based on the many students he sees in his therapy practice in an affluent Chicago suburb. Although he’s been practicing in the area for 15 years, he’s seen a sharp increase in school refusal over the last five years.

“The high schools in this area are very high pressure,” says Duffy. “What I’m seeing is a lot of perfectionistic teenagers who are anxious about not doing well. They push themselves and their standards are very, very high. Some of these kids hit a wall emotionally and refuse to perform. Some kids show up at school but don’t try very hard. Others stop going to school altogether.”

One of Duffy’s patients blames her many school absences over the last few years on a variety of physical symptoms — even though her doctor has given her a clean bill of health. “She’s opting out,” says Duffy. “Her school is very challenging and she has older siblings who excelled academically, and I think she’s choosing not to participate. She doesn’t articulate that, she insists that there is something physically wrong with her that her doctors haven’t found yet, but many of the kids I work with do. More than half the time when I work with a teen who meets the diagnosis of school refusal they’ll tell me, ‘School is just too hard; there is too much pressure on me. I can’t do this.’”

School refusal is just one of the manifestations of teen anxiety that Duffy sees in his practice. Others include depression, drug abuse, and eating disorders. “These kids have hours of homework every night, ACT prep starts freshman year, they are supposed to be involved in tons of clubs and activities, they worry about getting into college, then finding a job after college,” says Duffy. “Fear and anxiety are driving our parenting, and we’re putting so much pressure on kids — some of them are buckling under it.”

What works?

Whatever the individual circumstances, experts agree that it’s important to take school refusal seriously — and to deal with it immediately. “The longer a child doesn’t go to school, the harder it is to go back,” John Duffy says. “Once you lose that habit for weeks on end, it gets harder to reestablish.”

The stakes are high. Even gifted students, like Morgan Smith, are likely to fall behind academically if they miss enough school, putting them at risk of staying back or dropping out of school altogether. And if a child has an anxiety disorder, it’s important to treat it early so the problem won’t grow worse.

“We consider school refusal an urgent situation,” says Kearney. Instead of approaching the issue with the more leisurely pace of traditional therapy, Kearney says his therapists treat school refusal as a crisis. “We meet with the family right away. And then we talk to the child every day on the phone, and we sometimes talk to the parents, too,” he explains. “We operate in an intense, compressed time frame to get the problem solved.”

Treatment of school refusal varies, depending on the child, but usually includes cognitive behavior therapy to help the child learn to manage anxiety. Kearney also works with families to establish routines, increase incentives for going to school, and minimize incentives for staying home (not allowing screen time on school days, for example). John Duffy says that, if a child’s anxiety is so severe that it inhibits therapy, he will often recommend that the child be evaluated for medication.

How schools can help – or hurt

Schools play an essential role in getting kids with school refusal back into the classroom. As an elementary school principal, Dillon worked closely with the school psychologist and with parents in school refusal cases. “In all the cases I dealt with, the parents needed a tremendous amount of support,” Dillon says. “Their kids would act so desperate, so needy, it would pull at their heartstrings. As principal, I was an authority figure so I could tell the child, ‘This isn’t your parents’ choice. You have to come to school.’ I’d be the bad guy and take the burden off the parents. When the kids saw it wasn’t a choice, things would gradually get better.”

Duffy and Kearney both say that effective treatment requires the cooperation of teachers and school administrators alike. Treatment often includes gradually increasing the child’s time in school. For example, the child might start by dropping in at school for 10 minutes one day, then attend one class a day, and very slowly increase time at school. It also helps if school administrators enforce in-school suspensions for misbehavior, so kids won’t act out in order to be sent home. “School refusal is a cry for structure,” says Duffy. “It lends structure when adults talk to each other and make it clear that, ‘We support you, we’re working together.’”

It can be a problem if school administrators are too strict — or too lenient. Duffy worked with one teen whose school was so rigid and punitive that the boy’s attitude was, “I’m not going to pass anyway, so why go?” But in the case of the teen with the multiple physical complaints, Duffy believes her school may be too accommodating. “With the best of intentions, they’ve gone out of their way to let her catch up with her work. So she hasn’t seen any real consequences for refusing school,” he says.

Duffy and Kearney both say that when parents, school officials, and practitioners work together to create structure and consistency for the child, treatment is usually effective.

In cases when a child is refusing school because of bullying or other threats at school, avoiding school may be the healthiest and smartest response to an untenable situation. If there are signs of bullying, it’s essential to make sure your child is safe. (Find out more about what to do if your child is being bullied.)

New year, fresh start

For some kids, leaving traditional school may be the best and only solution.

Last spring, when it became clear that Morgan Smith would have to repeat 9th grade, she and her mother, Kim, thought they’d run out of options. Morgan was working with a tutor, but it was putting a financial strain on the family. Whenever her mother mentioned going back to high school, Morgan broke down in tears.

Then Kim heard about a charter school that had small classes and a flexible schedule. She took Morgan to see the school over the summer, and it seemed like it would be a good fit. The principal welcomed the teen, and assured her that she could leave the classroom whenever she felt overwhelmed. Morgan was hopeful that she could make it work at the new school and that she could catch up with the work she’d missed.

But by the second day of school, Morgan knew she was in the wrong place. Most of the other students seemed to have discipline problems. It was a rough crowd, and Morgan felt intimidated and out of place. One boy taunted her for being a “good girl.” When her mother went to pick her up that second day, Morgan was waiting for her at the curb. “She put on a brave face at first because we all wanted it to work so badly,” her mother said. “But we both knew she wasn’t going back.”

Then Kim heard about a homeschooling co-op that would allow Morgan to follow a prescribed curriculum at her own pace. Now Morgan accompanies her mother to work every day at the beauty salon where she has a spray tanning business. There, Morgan works on her schoolwork for half the day; her mother checks her daily assignments, and the teacher who organized the homeschooling co-op makes sure she stays on track. Morgan is hoping to catch up on the 9th grade work she missed over the course of a few months and, if she can, graduate from high school in two years.

It’s only been a month, but so far the new arrangement seems to be working. When her schoolwork is done for the day, Morgan helps out in the salon answering phones, updating the salon’s Facebook page and Twitter account, creating business cards — she even modeled for a recent photo shoot. She is also pursuing her music passion, taking weekly voice and piano lessons.

Morgan’s panic attacks have stopped and her mother says she enjoys the conviviality of the salon, which caters mostly to older women who’ve been getting their hair done there for years. “She’s around people all day and she likes it,” her mother marvels. “Every day someone different comes in, and she gets a new spin on the world. I call it the ‘school of life.’”

Her mother believes that therapy has helped Morgan, as has the anti-anxiety medication her therapist prescribed. But she is convinced that if Morgan went back to high school, all the problems would start up again. “It would be a setback. She was so down on herself then, and now I’m amazed by how her confidence has picked up. Just the other day she told me, ‘I never thought I was going to be better. I never thought I could heal myself.’ It’s the first time I’ve seen her happy in a long while.”