eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Anxiety Disorder, Separation Anxiety and School Refusal: Follow-up

Author: Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Consultant, Child Guidance Resource Centers, Early Elementary Education Program, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia
Contributor Information and Disclosures

Updated: Dec 3, 2008

Follow-up

Further Outpatient Care

  • Weekly individual and family behavioral therapy, including cognitive-behavioral methods, is recommended to practice overcoming resistance to normal separation as well as to practice communicating differently as a family.
  • Play therapy can be extremely helpful, especially for children who have had to undergo medical procedures or surgery.

Deterrence/Prevention

  • Psychoeducation with the family so that the child is rewarded for developmentally appropriate actions and does not receive secondary gain from the symptoms of school refusal or separation anxiety disorder
  • Preparation of children before medical or surgical procedures to help them feel less helpless in the situation

Complications

  • Truancy
  • Major depression
  • Substance abuse or dependence

Prognosis

  • The prognosis is good with early detection and treatment involving the family of the child.

Patient Education

  • Note that prevention of separation anxiety and school refusal begins with professional recognition of excessive attachment disorder and dynamics. Such prevention begins during yearly checkups in the pediatrics office, with discussions of healthy separation techniques. Educate families regarding healthy ways to deal with the inevitable stresses that occur in families with children and healthy ways to deal with sibling rivalry.
  • Recommend support for parents who may also have concurrent mental health or substance abuse issues. Address family violence prevention. Address any parental issues related to a sense of loss or feeling of abandonment or loneliness once the child or adolescent returns to a normal level of functioning and no longer requires the intense level of interaction with the parent or parents.
  • For excellent patient education resources, visit eMedicine's Anxiety Center and Mental Health and Behavior. Also, see eMedicine's patient education articles Anxiety, Panic Attacks, Hyperventilation, and School Refusal.

Miscellaneous

Medicolegal Pitfalls

  • Medically necessary homebound school instruction is not recommended in this situation because it may prolong the child's symptoms and increase the severity of symptoms because of secondary gain increases. The child must return to school as quickly as is medically and socially possible.
  • Return to other normal duties should be recommended gradually to prevent the child and family from intensifying anxiety and prematurely dropping out of treatment. School attendance, however, is not negotiable.
  • Prevention of school anxiety and refusal includes the following activities:
    • Trials of brief separations between parent and child before the first day of school
    • Visitation to a new school or classroom before classes start
    • Positive preparation for the first day of school
      • Procurement of school supplies
      • Arrangement of suitable familiar transportation arrangements to get to school
      • The possibility of setting up, in advance, phone time to call home to prevent undue anxiety
 


More on Anxiety Disorder, Separation Anxiety and School Refusal

Overview: Anxiety Disorder, Separation Anxiety and School Refusal
Differential Diagnoses & Workup: Anxiety Disorder, Separation Anxiety and School Refusal
Treatment & Medication: Anxiety Disorder, Separation Anxiety and School Refusal
Follow-up: Anxiety Disorder, Separation Anxiety and School Refusal
References
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Further Reading

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Keywords

school phobia, separation anxiety disorder, excessive anxiety, severe distress, tantrums, nightmares, extreme homesickness, psychosomatic symptoms, clinging behavior, daycare, depression, suicide, truancy, skipping school, school refusal, learned helplessness, transient developmental fears, posttraumatic stress disorder, anhedonia, insomnia, feelings of worthlessness, occult serologic streptococcal infection, hyperthyroidism, hypothyroidism, mitral valve prolapse, asthma, depressive-spectrum disorders, diabetes mellitus, Lyme disease, Rocky Mountain spotted fever

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Contributor Information and Disclosures

Author

Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Consultant, Child Guidance Resource Centers, Early Elementary Education Program, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia
Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

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Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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