School Refusal And Separation Anxiety

Historically, the term "school phobic" was employed to describe children who exhibited anxiety regarding school attendance. Severe anxiety and somatic symptoms such as dizziness, stomachaches, and nausea that keep the child at home were described. the parent, concerned with the child's health and anxiety, were often reluctant to force attendance. It was not clear, however, that in all cases the child actually feared the school situation. Thus, some workers questioned the use of the term school phobia to describe the disorder. Indeed, many cases of school phobia appeared instead of be due to a fear of separation from the mother and home. This theme, that avoidance of school may be just one manifestation of the larger fear of separation, has long been popular. Thus, some worker suggested the more comprehensive term "school refusal" and this term has become. however, this term may be taken to imply a conscious decision by the child to refuse to go to school, a perspective that does not seem applicable to all cases. Thus, there is still much conceptual disagreement and terminology confusion in the literature.

The DSM-IV category of separation anxiety disorder is intended to describe children with excessive anxiety regarding separation from a major attachment figure and/or home. Diagnostic criteria include eight symptoms involving worry or distress and related sleep and physical problems. These symptoms are associated with concerns of separation from or worry of harm befalling major attachment figures. Reluctance or refusal to go to school is one of these eight symptoms. However, a child need not exhibit this behavior to receive the diagnostic since only three of the eighth symptoms need be present to receive the diagnosis. Thus, not all children with separation anxiety disorder exhibit school refusal. In addition, as suggested by the term school phobic, not all school refusers need show separation anxiety. Some children, for example, may fear some aspect of the school experience. The latter group might be diagnosed under the specific phobia or social phobia categories. Studies of clinic-referred children support a distinction between separation-anxious and phobic school refusers. Also, youngsters who refuse school often meet the diagnostic criteria for multiple disorder.
School refusal is often differentiated from truancy. Truants are usually described as absent on an intermittent basis, often without parental knowledge. The School refuser, in contrast, is usually absent for continuous extended periods, during which time the parents are aware of the child's being at home. Also, truants are often described as poor students who exhibit other conduct problems such as stealing and lying. However, the considerable co-occurrence of anxiety and conduct disordered problems in children has led some to suggest that the refuser/truant distinction may not be a useful one.
We have chosen to describe school refusal and separation anxiety together since much of what has been written about the problem of school refusal and its etiology has derived from a separation anxiety perspective. In addition, given that compulsory education laws require all children to attend school, it seems likely that many children with separation anxiety would also have problems with school attendance. To the extent that school refusal is related to a phobic reaction to some aspect of the school situation, the considerations regarding specific and social phobias would apply.

Behavior Disorders of Childhood by Rita Wicks-Nelson & Allen C. Israel

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