School Phobia and School Refusal

There is no one picture of the school-refusing child. Some children who display SRB fail to attend school fully and completely. Other children may initially attend school in the morning but call their parents to be picked up early, frequently because they have somatic complaints (e.g., nausea, headaches). Another group of children who display SRB may attend school and even manage to stay there all day. However, it is a chore each morning to get these children to school because of the severe problem behaviors (e.g., temper tantrums, crying, pleading) exhibited. Another group of children with SRB similarly attend school, but they experience high levels of distress while in school, leading to regular pleas to remain home in the future. These are not distinctive patterns of SRB, however; it is not uncommon for children to display more than one such pattern at a given time. Nor is it uncommon for children to move in and out of varying patterns over time.

The heterogeneity of SRB also is manifested in the diagnostic picture. Research has documented the clinical features of children who display SRB by evaluating these children with structured diagnostic interviews and deriving Diagnostic and Statistical Manual (DSM) diagnoses. For example, Cynthia G. Last and Cyd C. Strauss (1990) investigated DSM-III-R anxiety disorder diagnoses in sixty-three school-refusing youth (ages seven to seventeen years). The most common primary diagnosis was separation anxiety disorder (n=24), followed by social phobia (n=16), and simple phobia (n=14). Children with SRB also frequently display multiple (comorbid) diagnoses (Kearney, Eisen, and Silverman 1995). The main implication of these findings is that a number of the clinical features that characterize SRB are the same as those that characterize diagnoses that accompany a given SRB case (e.g., excessive avoidance if criteria for phobic disorder are met).

Even more heterogeneity may exist among children who meet criteria for a particular DSM diagnostic category. For example, although school might be considered a circumscribed and specific stimulus for children with SRB who meet primary diagnosis for specific phobia, school phobia actually covers several different types of specific stimuli, such as hallway, classroom, gymnasium, pool, fire alarm, or school bus (Kearney, Eisen, and Silverman 1995). Identifying the specific phobic object or event thus also becomes important to consider when assessing SRB in children with a primary diagnosis of specific phobia.

Heterogeneity among children with SRB also is apparent in terms of the presence (yes/no) and types of somatic symptoms or complaints that children may report. Although somatic symptoms or complaints are frequently the main reason why parents feel they need to keep their children at home rather than force attendance, not all children report somatic symptoms. In a sample of adolescent school refusers (n=44) who were comorbid with anxiety and depression, many (32%) but not all participants reported somatic complaints (Bernstein et al. 1997). The specific somatic complaints varied across the youth and included autonomic (e.g., headaches, sweatiness, dizziness) and gastrointestinal (e.g., stomachaches) symptoms. These findings highlight the importance of inquiring about somatic complaints (presence/absence and type) among children with SRB.