Separation Anxiety and School Refusal Differential Diagnoses

Updated: Feb 12, 2020
  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
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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