Having heard that the number of children refusing to attend school has suddenly reached 300,000 over the period of the COVID-19 pandemic, I have a strong feeling that something is very strange.^*1 Starting with this posting, I intend to write three articles on the topic of what is strange about the issue of school avoidance.

I have felt that there was something strange about it for some time and then when I happened to see a news article on social media recently, I could no longer remain silent. The article introduced the views of a physician of internal medicine whose clinic specializes in treating children who refuse to attend school and claims that 98.5% of his cases are "due to some sort of mental disorder."^*2

Going Back 45 Years

Reading the article, I had a strong feeling of déjà vu. It was similar to what I had felt about 45 years ago when I became a pediatrician. At the time, school "absenteeism" was called "school refusal" or "school anxiety" and they were considered to be legitimate illnesses. In English, there was also the diagnosis of school phobia which indicated insecurity regarding school caused by background factors reflecting a problematic father-child relationship. At the hospital where I worked at the time, children who refused to attend school were hospitalized for a rather considerable length of time and received medical treatment for their condition under the care of a psychologist or pediatric neurologist.

With the passing of time, the diagnostic term "school refusal" has become no longer used because it does not reflect the actual condition, and today, the condition is not given a diagnostic name, but is referred to as "non-attendance at school". Furthermore, although mental disorder is often a background factor, it has become recognized that there are various reasons for non-attendance. This is what I have learned from the many children I have seen at my office as outpatients due to absenteeism, and also corroborates with the experience and understanding of the teachers at "free schools (alternative educational institutions)" who have interacted with children who do not attend school. According to a textbook on pediatrics used in the United States, school avoidance affects 1%-2% of the total number of children and approximately half of this percentage (0.5%-1% of all children) have an anxiety or mental disorder.^*3 However, according to the above-mentioned physician, "The total number or percentage is not clear, but it appears that the cause of the condition of 98.5% of the 130 children who do not attend school (including those who express strong resistance) and have been treated at my clinic, can be attributed to a mental or psychiatric disorder." He also stated, "Many mental illnesses are hidden behind non-attendance at school, and it is necessary to see non-attendance itself as a 'symptom' of mental illness." As such, it is difficult to agree with the view that suggests that nearly all cases are mental or psychiatric disorders.

The other day, a non-profit organization in Shiga Prefecture that works with children with school attendance issues conducted a survey of a large number of the children and asked the reasons for not attending school.^*4 According to the highest results (multiple answers allowed), 30% of the children cited relationships with teachers (fear of teachers, etc.). I am sure there are children among them who can be considered to have anxiety disorders, but the doctor's article mentioned above gave many people who read it the preconception that "non-attendance at school is a mental illness," and I think that is fraught with danger.

• *1 Ministry of Education, Culture, Sports, Science and Technology " FY2020 Survey Results on Issues in Student Guidance such as Problem Behavior and Refusal of Students"
  https://www.mext.go.jp/a_menu/shotou/seitoshidou/1302902.htm (in Japanese)
• *2 Nikkan Gendai DIGITAL, "'School refusal is a mental illness' says the director of Japan's first school refusal clinic! Is there a cure?" March 10, 2024.
  https://www.nikkan-gendai.com/articles/view/life/336983 (in Japanese)
• *3 Robert M. Kliegman, 2007. Nelson's Textbook of Pediatrics. 18th edition. Philadelphia, PA: Saunders.
• *4 Kitade, A., "'Teachers' cited as top reason for truancy in survey by west Japan group." The Mainichi, November 17, 2023.
  https://mainichi.jp/english/articles/20231116/p2a/00m/0na/024000c