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School RefusalAka: School Phobia, Anxious School Refusal

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  1. Epidemiology
    1. Affects up to 5% of school age children
    2. Most common in ages 5-6 years and 10-11 years
  2. Cause
    1. Separation anxiety
    2. Avoidance of school-associated fears
    3. Avoidance of uncomfortable social situations
  3. Risk Factors
    1. Family History of Panic Disorder
    2. Dysfunctional family factors
      1. Detachment or disordered cohesiveness within family
      2. Significant conflict among family members
      3. Isolated from community outside of nuclear family
  4. Clinical features
    1. Emotional distress regarding school attendance
      1. Fear or panic
      2. Crying
      3. Temper tantrums
      4. Somatic symptoms (e.g. Headache, Abdominal Pain)
    2. Child attempts to stay home during school
      1. Behavior targeted at persuading parents to allow this
      2. Often starts after holiday break or weekend
    3. Child willing to learn (does school work at home)
  5. Associated Conditions
    1. Anxiety Disorder
    2. Major Depression
    3. Learning Disorder
  6. Differential Diagnosis
    1. Truancy
      1. Child avoids school without parental consent
      2. Associated with antisocial behavior (lying, stealing)
  7. Assessment
    1. Evaluate for comorbid anxiety or Major Depression
    2. Evaluate for Learning Disorders (e.g. ADHD)
    3. Involve parents and teachers in evaluation
    4. School Refusal Assessment Scale
  8. Management: General
    1. Early Return to School is critical
      1. Refusal worsens the longer the child remains home
      2. Bring them back the next day after absence
      3. Praise them
      4. Enforce school routine while at home
        1. No television or video games
        2. Continue school work for each subject
    2. Behavior management
      1. Desensitize with progressive re-exposure to school
      2. Relaxation techniques
      3. Child keeps diary
      4. Cognitive-behavior therapy (confrontation of fears)
    3. Medical management (in combination with counseling)
      1. Selective Serotonin Reuptake Inhibitors (SSRI)
  9. Complications
    1. Short-term
      1. Poor academic performance
      2. Peer and family relationship problems
    2. Long-term
      1. Academic underachievement
  10. References
    1. Fremont (2003) Am Fam Physician 68:1555
    2. Hayne (2002) J Am Acad Child Adolesc Psychiatry 41:687
    3. King (2001) J Am Acad Child Adolesc Psychiatry 40:197

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