Separation Anxiety and School Refusal Clinical Presentation

Updated: Feb 12, 2020
  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
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The onset and development of symptoms, as well as their context, help to establish the diagnosis of anxiety disorder. Noting whether anxiety is stimulus-specific, spontaneous, or anticipatory; whether the symptoms result in avoidant behavior (ie, degree of constriction of daily life) that is clinically significant and disabling; and whether social and familial reinforcers of symptoms are present is helpful.

In assessing patients with separation anxiety, school refusal, or both, the patient’s history must be obtained from multiple informants, including the patient, parents or caregivers, and other pertinent persons, such as teachers and coaches. Screen for features of depression (eg, anhedonia, insomnia, feelings of worthlessness) and ask the child directly about symptoms.

Pertinent educational, developmental, and family or social history should be obtained, including any family history of anxiety disorders and a history of separations and losses, school attendance, academic functioning, presence of environmental stressors, the patient’s degree of involvement with his or her peer group, and the patient’s social competence.

Age-related manifestations

Separation anxiety disorder manifests slightly differently in different age groups. Children younger than 8 years tend to present with unrealistic worry about harm to their parents or attachment figures and school refusal.

Children aged 9–12 years tend to present with excessive distress at times of separation (eg, sleepaway camp, overnight school trips).

Adolescents aged 12–16 years more commonly present with school refusal and somatic problems involving autonomic symptoms, such as headaches, dizziness, lightheadedness, sweatiness, or GI or musculoskeletal symptoms (eg, stomachache, nausea, cramps, vomiting, or muscle or body aches [such as back pain or muscle tension]).

In general, younger children may be referred more often than older children, because the somatic symptoms seen in adolescents may not be as clearly correlated with situations of imminent or actual separation from attachment figures.

Family history

Family history is extremely helpful in elucidating precipitating factors and should be obtained in a therapeutic manner so that the family feels that the interviewer understands the emotional stress and is responsive to it.

In the family assessment, the style of relatedness of the family should be described; enmeshed versus disengaged family stressors, including losses (especially if proximate to the start of symptoms), and family history of anxiety, alcoholism, somatoform, or mood disorders should be noted.

Family history of school refusal (especially in mothers) is also helpful because it may correlate with separation anxiety disorders in the child.

A history of prominent anxiety symptoms in either the child or parents in certain situations (eg, preanesthesia, perianesthesia) may correlate with phobic or anxious symptoms in the child at a different time (ie, postanesthesia).


Physical Examination

Generally, somatic symptoms associated with separation anxiety, such as palpitations or abdominal pain, have no clear physical origin. However, a careful physical examination with appropriate blood work is recommended to rule out physical causes, including occult serologic streptococcal infection, hyperthyroidism, hypothyroidism, mitral valve prolapse, asthma, or GI infection, inflammation, bleeding, or ulceration.

Assure the child and his or her family that somatic symptoms are indicators of a problem that is serious and requires attention. Psychological interventions should proceed simultaneously with medical evaluations.



Transient developmental fears (eg, fear of the dark) are generally normal and do not interfere with normal functioning or result in long-term developmental difficulty; however, studies show a subgroup of children who do not meet the criteria for diagnosis of an anxiety disorder but who may have substantial impairment later in life. Studies of children who, in first grade, present with significant symptoms of anxiety (enough to cause clinically significant impairment in social and academic functioning) reflect a correlation with significant impairment in reading and math achievement 5–6 years later. Complications of separation anxiety can also include the following: truancy, major depression, and substance abuse or dependence. Long-term follow-up studies of children successfully treated for school refusal because of separation anxiety reveal that some children have continued impairment of social functioning (ie, social and affective constriction), despite having returned to school. This may reflect the long-term impairment and morbidity and unchanging dysfunctional parent-child interaction at home. [26, 27]