Fast Five Quiz: Are You Ready to Face Back-to-School Health Concerns?

Germaine L. Defendi, MD, MS


August 19, 2014

"School refusal behavior" refers to a child-motivated refusal to attend school. This definition also applies to children who are unable to remain in school for the day. The behavior can be indicative of an emotional disorder in which anxiety or depression plays a predominant role. School refusal is a symptom and not a psychiatric diagnosis.

School refusal occurs in 1-5% of children. Peak ages for school refusal are 5-6 years and 10-11 years. These ages correlate with the initiation of kindergarten and the transition from elementary school to middle school, respectively. An increase in school refusal has also been reported in teenagers entering their freshman and sophomore years of high school.

Both boys and girls are equally affected, and no socioeconomic differences are reported. An assessment tool, the School Refusal Assessment Scale, has been established to help clarify the causes of the school refusal behavior. This tool requires involvement of the child, parent or parents, and teachers. External factors, such as bullying or intimidation among peers, may also play a role for some children.

Children with school refusal behavior have a greater risk for comorbid psychiatric illness. Separation anxiety disorder (SAD) is a more common anxiety disorder, affecting 22% of children with school refusal. Generalized anxiety disorder, major depressive disorder, and oppositional defiant disorder have also been described in these kids.

Clinical manifestations of SAD, along with school refusal, may include the following:

  • Reluctance to fall asleep without being near the primary attachment figure;

  • Excessive distress (eg, tantrums) when separation is imminent;

  • Nightmares about separation-related themes;

  • Homesickness (ie, a desire to return home or make contact with the primary caregiver when separated); and

  • Frequent physical or somatic symptoms, such as headache, palpitations, and abdominal pain.

For more on school refusal and SAD, read here.


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