General Information (including ICD-9/-10 Codes)

Description :

  • partial or total inability to go to school, based on unwarranted fear of school and/or inappropriate anxiety about leaving home

Also called :

  • school avoidance, school phobia, separation anxiety disorder

ICD-9 Codes :

  • 309.21 separation anxiety disorder

ICD-10 Codes :

  • F93.0 separation anxiety disorder of childhood

Definitions :

  • truancy - refusing to go to school for reasons unrelated to anxiety about school attendance

Types :

  • young age - abrupt onset, more likely to be separation anxiety
  • older age - insidious onset, associated with social withdrawal and depression

Who is most affected :

  • all ages affected, but two peaks of incidence
    • ages 6-7 at the start of school life
    • ages 12-15 at the start of middle school or high school
  • boys and girls equally affected
  • youngest child in family is most likely to be affected

Incidence/Prevalence :

  • 1-2% school-age children suffer from school refusal
  • 3-4% are absent on grounds of truancy

Causes and Risk Factors

Causes :

  • many children have multiple causes and diagnoses
  • fear of leaving home
    • separation anxiety disorder (50-80% of anxious refusers)
    • generalized anxiety disorder (may be called overanxious disorder in children)
    • social phobia, also called avoidant disorder
    • agoraphobia with or without panic disorder
    • adjustment disorder
  • fear of some aspect of school - school phobia
    • simple phobia (e.g. toilets, corridors, test-taking situations)
    • physically or psychologically abusive students (bullies)
    • psychologically abusive teachers
  • fear of feeling exposed or embarrassed at school
    • social phobia
    • learning disability - staying home to avoid the sense of failure

Pathogenesis :

  • some children may have inborn vulnerability or predisposition for development of emotional disturbances, including school refusal

Likely risk factors :

  • especially problematic after time away from school (e.g. new school year, after vacations, after prolonged illness)
  • change of school
  • passive and dependent child and stressor

Complications and Associated Conditions

Complications :

  • short-term complications
    • poor academic performance with loss of education - half of school refusers underachieve academically
    • peer relationship problems
    • family difficulties
      • strained relationships between parent and child
      • children may be accused of "making up" their symptoms, leading to further strain
  • long-term complications
    • fewer opportunities for higher education
    • employment problems
    • social difficulties
    • increased risk for later psychiatric illness

Associated conditions :

  • mood disorder, especially depression
  • increased incidence of anxiety and mood disorders in the family

History

Chief Concern (CC) :

  • poor school attendance
  • vague symptomatology

History of Present Illness (HPI) :

  • younger school refusers
    • sudden or unexpected clinging to mother
    • fearfulness, excessive crying, anxiety, temper tantrums
  • older school refusers - social withdrawal, depression
  • somatic complaints - headache, recurrent abdominal pain, dizziness, nausea, diarrhea, limb pain, insomnia, fatigue, frequent micturition
    • symptoms become more severe as the time to leave for school approaches
    • symptoms resolve if the child is allowed to remain at home
  • separation anxiety disorder normally resolves by age 5
  • phobic school refusers have a later age at onset and have more severe symptoms
  • truant children
    • have absences from school which are intermittent, brief, without the knowledge of the parents, and reflect a lack of interest in schoolwork and an unwillingness to conform to accepted behaviors
    • miss school because of rewarding experiences provided out of school (e.g. watching television, playing with friends)
    • may engage in stealing, antisocial and destructive behaviors

Past Medical History (PMH) :

  • typically no significant past medical history

Family History (FH) :

  • parents at increased risk for psychiatric illness, mainly anxiety and depression

Social History (SH) :

  • youngest child in the family more likely to be affected

Physical

General Physical :

  • normal physical exam

Diagnosis

Making the diagnosis :

  • symptom diary may establish pattern of symptoms associated with school refusal
  • normal physical exam and testing (if pertinent) may rule out organic causes
  • criteria for school refusal (school avoidance)
    • severe difficulties in attending school or refusal to attend school
    • severe emotional upset, including somatic complaints, when faced with going to school
    • staying at home with knowledge of the parents
    • absence of significant antisocial behavior
  • diagnostic criteria for separation anxiety disorder, simple phobia and social phobia
    • DSM-IV-TR criteria for separation anxiety disorder
      • developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom child is attached with 3 of 8:
        • persistent and excessive worry about losing, or possible harm befalling, major attachment figures
        • persistent and excessive worry that untoward event will lead to separation from major attachment figure
        • persistent reluctance or refusal to go to school or elsewhere because of fear of separation
        • persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
        • persistent reluctance or refusal to go to sleep without being near major attachment figure or sleep away from home
        • repeated nightmares involving theme of separation
        • repeated complaints of physical symptoms when separation from major attachment figure occurs or is anticipated
        • recurrent excessive distress when separation from home or major attachment figure occurs or is anticipated
      • duration at least 4 weeks
      • onset before 18
      • distress or impaired functioning
    • DSM-IV-TR criteria for simple phobia
      • marked and persistent fear that is excessive or unreasonable, cued by presence or anticipation of specific object or situation
      • exposure to phobic stimulus provokes immediate anxiety response
      • patient recognizes fear as excessive or unreasonable
      • phobic situation avoided or endured with intense anxiety or distress
      • interferes with functioning or marked distress
    • DSM-IV-TR criteria for social phobia
      • marked and persistent fear of 1 or more situations in which patient is exposed to unfamiliar people or possible scrutiny, fear of doing something humiliating or embarrassing or showing anxiety symptoms
      • exposure to feared social situation provokes anxiety
      • patient recognizes fear as excessive or unreasonable
      • phobic situation avoided or endured with intense anxiety or distress
      • avoidant behavior interferes with occupational functioning, social activities, or marked distress about having fear
      • if < 18 years old, symptoms persist > 6 months
      • fear not due to physiological effect of substance or another mental disorder and is unrelated to comorbid medical conditions

Rule out :

  • other emotional disorders
    • mood disorder, especially depressive disorder
    • schizophrenia (e.g. "voices" saying not to attend school)
  • learning disability, pervasive developmental disorder
  • truancy
  • undiagnosed medical condition

Testing to consider :

  • no specific testing necessary (unless warranted by specific findings on history and exam)
  • some testing may be useful for assurance for some parents

Prognosis

Prognosis :

  • the longer a child remains out of school, the harder it is to return (increased anxiety, increased fear of missed schoolwork, reactions of classmates, and embarrassment at facing the teachers)
  • 25% of school refusal situations (including truancy) remit spontaneously or are rapidly dealt with by parents
  • separation anxiety disorder normally resolves by age 5
  • poor prognostic indicators
    • refusal occurs in adolescence
    • chronic refusal
    • concomitant depression
    • child with low intellectual ability
  • increased risk for psychiatric morbidity in adulthood
    • adults with history of school refusal have an increased risk of panic disorder, anxiety, agoraphobia, and "neuroticism"
    • adults with a history of school refusal have persisting psychiatric problems compared to general population; cohort study of 35 patients meeting criteria for separation anxiety disorder and treated for school phobia at ages 7-12 followed for 20-29 years, compared to matched controls from general population (35) and non-school refusal child psychiatric population (35); as adults, school phobia cases had more psychiatric consultations than general population controls and lived with their parents more often (14% vs. 0), controls with other child psychiatric disorders were not statistically different (9% lived with their parents); adults with history of school phobia had fewer children than either control group (Compr Psychiatry 1997 Jan-Feb;38(1):17)

Treatment

Treatment overview :

  • reassure parents their child is not physically ill and obtain parental support for treatment
  • immediate return to school
    • parents must help their child face a distressing experience to overcome their anxiety about the event
    • have the child brought to school by someone who will not "give in"
  • avoid removal from school (e.g. hospitalization, home schooling)
  • discuss with principal and teachers so they know about the situation and can cooperate with treatment plan
  • behavioral therapy may be necessary for chronic school refusers or children with high levels of anxiety
  • antidepressants may reduce anxiety symptoms and improve school attendance

Counseling :

  • for parents and child
  • behavior therapy - considered by some authors to be most appropriate for school phobia
    • flooding
      • forced return is particularly appropriate for cases with acute onset and no prior history of similar problems
      • less advisable with chronic refusal or high levels of anxiety
    • systematic desensitization - have child return for activities that cause minimal anxiety
    • contingency plans
    • emotive imagery
    • no controlled trials of behavior therapy (other than cognitive-behavioral therapy) identified
  • cognitive-behavioral treatment (CBT)
    • CBT may be more effective than wait-list control for improving school attendance; 34 children with school refusal randomized to CBT (6 sessions with child and 5 sessions with parent over 4 weeks) vs. wait-list control, mean proportion of school days attended increased from 61% during 2 weeks before CBT to 93% during 2 weeks after CBT in CBT group, mean proportion of school days attended increased from 40% to 56% during similar periods in control group; CBT improved clinician ratings compared to control, no differences in teacher or parent ratings (J Am Acad Child Adolesc Psychiatry 1998 Apr;37(4):395); CBT group had higher baseline school attendance than control group so treatment benefit may be overestimated (DynaMed commentary)
    • CBT and supportive therapy had similar benefits in comparison trial; 56 children with school refusal randomized to CBT vs. supportive therapy ("educational-support therapy" which addressed child's feelings but did not provide encouragement or instructions to address fears) for 12 weeks; both groups had similar improvements in return to school and anxiety symptoms; all 9 dropouts were in CBT group (J Am Acad Child Adolesc Psychiatry 1998 Apr;37(4):404)
    • cognitive behavioral therapy (CBT) effective for childhood and adolescent anxiety disorders (level 1 [likely reliable] evidence)
      • systematic review of 13 randomized trials of CBT (at least 8 sessions, protocol-based) vs. waiting list or attention control in 809 children and adolescents ages 6-19 years with DSM or ICD anxiety diagnosis (excluding simple phobia, obsessive compulsive disorder and post-traumatic stress disorder)
      • trials included community or outpatient subjects with anxiety of mild to moderate severity
      • response rates for remission of any anxiety diagnosis 56% for CBT vs. 28.2% for control (NNT 3, 95% CI 2.5-4.5)
      • similar outcomes with individual CBT, group CBT and family/parental CBT
      • Reference - systematic review last updated 2005 Aug 23 (Cochrane Library 2005 Issue 4:CD004690)
    • family-focused CBT may reduce anxiety more than child-focused CBT (level 2 [mid-level] evidence)
      • 40 children ages 6-13 years with anxiety disorders (27 had separation anxiety disorder) were randomized to family-focused CBT (Building Confidence Program) vs. child-focused CBT with minimal family involvement
      • both intervention included coping skills training and in vivo exposure; family-focused CBT also included parent communication training
      • family-focused CBT associated with greater improvements in child anxiety ratings by independent evaluators and parents, but no significant differences between groups in improvements in child ratings
      • Reference - J Am Acad Child Adolesc Psychiatry 2006 Mar;45(3):314

Medications :

  • short-term anxiolytics may be necessary
  • antidepressants may reduce anxiety symptoms and improve school attendance
    • fluvoxamine effective for anxiety disorders in children; study of 128 children 6-17 with social phobia, separation anxiety disorder, or generalized anxiety disorder without improvement after 3 weeks of psychological treatment; grouping of these multiple disorders appears legitimate since 66% of these children had social phobia, 59% had separation anxiety disorder, and 57% had generalized anxiety disorder so there was considerable overlap; children randomized to fluvoxamine (increased by 50 mg/day weekly to maximum 250-300 mg/day) vs. placebo PO for 8 weeks, fluvoxamine group had greater improvement in symptom scores (p < 0.001), 76% vs. 29% had response on global improvement scale (p < 0.001, NNT 3), 8% vs. 2% discontinued drug due to adverse effects (NNH 16) (N Engl J Med 2001 Apr 26;344(17):1279), editorial can be found in N Engl J Med 2001 Apr 26;344(17):1326, commentary can be found in N Engl J Med 2001 Aug 9;345(6):466, commentary recommending psychotherapy as first-line option can be found in POEMs in J Fam Pract 2001 Aug;50(8):719
    • addition of imipramine to CBT improved school attendance; 63 adolescent school refusers with major depression or anxiety disorder were all treated with cognitive behavioral therapy (CBT) and randomized to imipramine vs. placebo for 8 weeks; 25% dropout rate but similar in both groups, no intent-to-treat analysis; school attendance (measured in percent hours of school attended per week) improved significantly more with imipramine (from 28% to 70%) than placebo (from 17% to 28%), depression significantly improved with imipramine (J Am Acad Child Adolesc Psychiatry 2000 Mar;39(3):276)

Consultation and referral :

  • child psychologist
  • child psychiatrist for chronic refusers

Follow-up :

  • monitor school attendance

Prevention and Screening

Prevention :

  • not applicable

References including Reviews and Guidelines

General references used :

Reviews :

Patient Information

Patient information :