II. Epidemiology
- Affects up to 5% of school age children
- Most common in ages 5-6 years and 10-11 years
III. Cause
- Separation Anxiety
- Avoidance of school-associated fears
- Avoidance of uncomfortable social situations
IV. Risk Factors
- Family History of Panic Disorder
- Dysfunctional family factors
- Detachment or disordered cohesiveness within family
- Significant conflict among family members
- Isolated from community outside of nuclear family
V. Clinical features
- Emotional distress regarding school attendance
- Fear or panic
- Crying
- Temper tantrums
- Somatic symptoms (e.g. Headache, Abdominal Pain)
- Child attempts to stay home during school
- Behavior targeted at persuading parents to allow this
- Often starts after holiday break or weekend
- Child willing to learn (does school work at home)
VI. Associated Conditions
VII. Differential Diagnosis
-
Truancy
- Child avoids school without Parental Consent
- Associated with antisocial behavior (lying, stealing)
VIII. Assessment
- Evaluate for comorbid anxiety or Major Depression
- Evaluate for Learning Disorders (e.g. ADHD)
- Involve parents and teachers in evaluation
- School Refusal Assessment Scale
IX. Management: General
- Early Return to School is critical
- Refusal worsens the longer the child remains home
- Bring them back the next day after absence
- Praise them
- Enforce school routine while at home
- No television or video games
- Continue school work for each subject
- Behavior management
- Desensitize with progressive re-exposure to school
- Relaxation Techniques
- Child keeps diary
- Cognitive-behavior therapy (confrontation of fears)
- Medical management (in combination with counseling)
X. Complications
- Short-term
- Poor academic performance
- Peer and family relationship problems
- Long-term