Diagnostic Considerations

Various disorders and behaviors are symptomatic of separation anxiety and school refusal, while others can mimic them. In addition, various social situations can bring about symptoms similar to those of separation anxiety and school refusal. Examples include the following:

Inappropriate academic placement
Avoidance of school because of fear of violence (eg, gang-related violence) or teasing
Truancy
Conduct disorder
Substance abuse or dependence
Depression
Grief reaction
Brain tumor (especially if associated with vision or coordination impairment)
Communication disorder (not otherwise specified)

Note that depressed or anxious children are commonly teased.

A recent study^[27]of 865 Norwegian high school students found that anxious youths who refuse to attend school may have many adverse factors that aggregate to culminate in their refusal to attend school.

This study^[27]of a group of highly anxious nonattenders found that they tended to have more panic symptoms and possibly an earlier experience of an unsafe school environment. They also possibly had greater overall psychiatric severity (of anxiety), a lack of resiliency, and certain personality traits, such as a tendency to interpret life events in a more "negative" fashion, which might also have combined with them initially feeling more unsafe in school.

This group overall felt less well than their peers and had fewer friends (possibly more social anxiety), and they also had experienced more family stress and trauma; their parents had a more negative attitude towards school achievement. However, this group reported that they experienced less bullying, which is likely related to nonattendance in school.^[27]

They also reported a slightly higher level of use of marijuana and narcotics compared with youths with anxiety who attended school, who appeared to possibly have a higher rate of alcohol use.^[27]

Differential Diagnoses

Workup

American Psychiatric Association. Section II Anxiety. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. 5th. American Psychiatric Association Publishers; 2013.
Manassis K. Silent suffering: understanding and treating children with selective mutism. Expert Rev Neurother. 2009 Feb. 9(2):235-43. [QxMD MEDLINE Link].
VAN Agt H, Verhoeven L, VAN DEN Brink G, DE Koning H. The impact on socio-emotional development and quality of life of language impairment in 8-year-old children. Dev Med Child Neurol. 2011 Jan. 53(1):81-8. [QxMD MEDLINE Link].
Kossowsky J, Pfaltz MC, Schneider S, Taeymans J, Locher C, Gaab J. The separation anxiety hypothesis of panic disorder revisited: a meta-analysis. Am J Psychiatry. 2013 Jul 1. 170(7):768-81. [QxMD MEDLINE Link].
Bögels SM, Knappe S, Clark LA. Adult separation anxiety disorder in DSM-5. Clin Psychol Rev. 2013 Jul. 33(5):663-74. [QxMD MEDLINE Link].
Hella B, Bernstein GA. Panic disorder and school refusal. Child Adolesc Psychiatr Clin N Am. 2012 Jul. 21(3):593-606. [QxMD MEDLINE Link].
Maeda N, Heyne D. Rapid Return for School Refusal: A School-Based Approach Applied With Japanese Adolescents. Front Psychol. 2019. 10:2862. [QxMD MEDLINE Link].
The Therapeutic Relationship in Cognitive-Behavioral Therapy and Pharmacotherapy for Anxious Youth.Cummings CM, Caporino NE, Settipani CA, Read KL, Compton SN, March J, et al. The Therapeutic Relationship in Cognitive-Behavioral Therapy and Pharmacotherapy for Anxious Youth. J Consult Clin Psychol. 2013 Jun 10. June 2013. [QxMD MEDLINE Link].
Kearney CA. School absenteeism and school refusal behavior in youth: a contemporary review. Clin Psychol Rev. 2008 Mar. 28(3):451-71. [QxMD MEDLINE Link].
Melvin GA, Dudley AL, Gordon MS, Klimkeit E, Gullone E, Taffe J, et al. Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial. Child Psychiatry Hum Dev. 2016 Aug 2. [QxMD MEDLINE Link].
Baker M, Lindell SG, Driscoll CA, Zhou Z, Yuan Q, Schwandt ML, et al. Early rearing history influences oxytocin receptor epigenetic regulation in rhesus macaques. Proceedings of the National Academy of Sciences of the United States of America. 2017 Oct 31. xx:xx.
Rogers CE, Sylvester CM, Mintz C, Kenley JK, Shimony JS, Barch DM, et al. Neonatal Amygdala Functional Connectivity at Rest in Healthy and Preterm Infants and Early Internalizing Symptoms. J Am Acad Child Adolesc Psychiatry. 2017 Feb. 56 (2):157-166. [QxMD MEDLINE Link].
Bagnell AL. Anxiety and separation disorders. Pediatr Rev. 2011 Oct. 32(10):440-5; quiz 446. [QxMD MEDLINE Link].
Redlich R, Grotegerd D, Opel N, Kaufmann C, Zwitserlood P, Kugel H, et al. Are you gonna leave me? Separation anxiety is associated with increased amygdala responsiveness and volume. Soc Cogn Affect Neurosci. 2015 Feb. 10 (2):278-84. [QxMD MEDLINE Link].
Egger HL, Costello EJ, Angold A. School refusal and psychiatric disorders: a community study. J Am Acad Child Adolesc Psychiatry. 2003 Jul. 42(7):797-807. [QxMD MEDLINE Link].
Knollmann M, Knoll S, Reissner V, Metzelaars J, Hebebrand J. School avoidance from the point of view of child and adolescent psychiatry: symptomatology, development, course, and treatment. Dtsch Arztebl Int. 2010 Jan. 107(4):43-9. [QxMD MEDLINE Link]. [Full Text].
Burke AE, Silverman WK. The prescriptive treatment of school refusal. Clin Psychol Rev. 1987. 7(4):353-362.
McShane G, Walter G, Rey JM. Characteristics of adolescents with school refusal. Aust N Z J Psychiatry. 2001 Dec. 35(6):822-6. [QxMD MEDLINE Link].
Lyon AR. Confirmatory factor analysis of the School Refusal Assessment Scale - Revised in an African American community sample. J Psychoeduc Assess. 2009 Nov 22. 20(10):1-13. [QxMD MEDLINE Link]. [Full Text].
Brookmeyer KA, Fanti KA, Henrich CC. Schools, parents, and youth violence: a multilevel, ecological analysis. J Clin Child Adolesc Psychol. 2006 Dec. 35(4):504-14. [QxMD MEDLINE Link].
King NJ, Bernstein GA. School refusal in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2001 Feb. 40(2):197-205. [QxMD MEDLINE Link].
Bowen RC, Offord DR, Boyle MH. The prevalence of overanxious disorder and separation anxiety disorder: results from the Ontario Child Health Study. J Am Acad Child Adolesc Psychiatry. 1990 Sep. 29(5):753-8. [QxMD MEDLINE Link].
Cooklin AR, Giallo R, D'Esposito F, Crawford S, Nicholson JM. Postpartum Maternal Separation Anxiety, Overprotective Parenting, and Children's Social-Emotional Well-Being: Longitudinal Evidence From an Australian Cohort. J Fam Psychol. 2013 Jul 8. [QxMD MEDLINE Link].
Meadow R. Mothering to death. Arch Dis Child. 1999 Apr. 80(4):359-62. [QxMD MEDLINE Link]. [Full Text].
Granell de Aldaz E, Vivas E, Gelfand DM, Feldman L. Estimating the prevalence of school refusal and school-related fears. A Venezuelan sample. J Nerv Ment Dis. 1984 Dec. 172(12):722-9. [QxMD MEDLINE Link].
Kearney CA, Sims KE, Pursell CR, Tillotson CA. Separation anxiety disorder in young children: a longitudinal and family analysis. J Clin Child Adolesc Psychol. 2003 Dec. 32(4):593-8. [QxMD MEDLINE Link].
Ingul JM, Nordahl HM. Anxiety as a risk factor for school absenteeism: what differentiates anxious school attenders from non-attenders?. Ann Gen Psychiatry. 2013 Jul 25. 12(1):25. [QxMD MEDLINE Link].
Mindell JA, Leichman ES, DuMond C, Sadeh A. Sleep and Social-Emotional Development in Infants and Toddlers. J Clin Child Adolesc Psychol. 2016 Aug 5. 1-11. [QxMD MEDLINE Link].
Viana AG, Beidel DC, Rabian B. Selective mutism: a review and integration of the last 15 years. Clin Psychol Rev. 2009 Feb. 29(1):57-67. [QxMD MEDLINE Link].
Suveg C, Aschenbrand SG, Kendall PC. Separation anxiety disorder, panic disorder, and school refusal. Child Adolesc Psychiatr Clin N Am. 2005 Oct. 14(4):773-95, ix. [QxMD MEDLINE Link].
Ohira I, Urao Y, Sato Y, Ohtani T, Shimizu E. A pilot and feasibility study of a cognitive behavioural therapy-based anxiety prevention programme for junior high school students in Japan: a quasi-experimental study. Child Adolesc Psychiatry Ment Health. 2019. 13:40. [QxMD MEDLINE Link].
Hu D, Yu ZL, Zhang Y, Han Y, Zhang W, Lu L, et al. Bumetanide treatment during early development rescues maternal separation-induced susceptibility to stress. Scientific reports. 2017 Sep 19. xx:xx.
Carpenter KL, Angold A, Chen NK, Copeland WE, Gaur P, Pelphrey K, et al. Preschool anxiety disorders predict different patterns of amygdala-prefrontal connectivity at school-age. PLoS One. 2015. 10 (1):e0116854. [QxMD MEDLINE Link].
Price RB, Siegle GJ, Silk JS, Ladouceur CD, McFarland A, Dahl RE, et al. Looking under the hood of the dot-probe task: an fMRI study in anxious youth. Depress Anxiety. 2014 Mar. 31(3):178-87.
Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. 2006 Jan. 163(1):41-7. [QxMD MEDLINE Link].
Linares LO, Martinez-Martin N, Castellanos FX. Stimulant and atypical antipsychotic medications for children placed in foster homes. PLoS One. 2013. 8(1):e54152. [QxMD MEDLINE Link]. [Full Text].
Wei C, Hoff A, Villabø MA, Peterman J, Kendall PC, Piacentini J, et al. Assessing Anxiety in Youth with the Multidimensional Anxiety Scale for Children. J Clin Child Adolesc Psychol. 2013 Jul 11. [QxMD MEDLINE Link].
Balderston NL,Hsiung A,Ernst M,Grillon C. Effect of Threat on Right dlPFC Activity during Behavioral Pattern Separation. Neuroscience. September 2017. 32:xx.