Separation Anxiety and School Refusal Treatment & Management

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

The goal of treatment is to facilitate the child returning to normal developmental functioning. The child with separation anxiety needs to be able to tolerate normal separation from caregivers without distress or impairment of functioning. The child or adolescent with concomitant school refusal should return to school as quickly as is medically and socially possible and consistently attend school without subjective experiencing of distress.

Placing the child on homebound instruction is contraindicated because it may prolong the child's symptoms and increase the severity of symptoms because of secondary gain increases.

Return to other normal duties should be recommended gradually to prevent the child and family from experiencing intensified anxiety and prematurely dropping out of treatment.

The behavioral approach to treatment of school refusal includes: graded return to school (i.e., gradual exposure and response prevention) for those youth with significant anxiety symptoms and for youth without a behavioral/psychiatric condition causing or exacerbating the school refusal, rapid return to school, which can be understood as a flooding approach. Maeda and Heyne in Japan found 85% attendance rates in 28 responders out of a total of 39 school-refusing adolescents who participated in a flooding rapid return approach that involved key school staff and parents to facilitate return to school within 4 weeks of refusal; physical escort was sometimes needed. Maeda and Heyne's findings also suggest that the wait-and-see approach chosen by 23 of the total 62 youth did not result in a return to school as none of the youth returned to school from that group. [7]


Relaxation Techniques

Relaxation techniques with participant modeling and subsequent reinforced practice are often more effective when used before cognitive-behavior therapy techniques, because the patient is more likely to continue with therapy if anxiety does not increase at the start of therapy. [29]


Cognitive Therapy

Cognitive behavioral therapy is associated with the shortest duration of treatment (mean 6 mo) and best outcome, with some studies showing 83% of children attending school at 1-year follow-up.

Cognitive therapy attempts to restructure the child's thoughts and actions into a more assertive and adaptive framework. Also included are systematic desensitization and exposure and operant behavioral techniques to facilitate successful separation of the child from the parent, as well as a rapid return to typical life, such as attendance of school close to 100% of the time.

Identification and recognition (including being able to articulate the feeling) of somatic symptoms related to anxiety, as well as the creation of a new functional response to deal with symptoms, are central to successful behavior change.

Modeling, role-playing, relaxation techniques, and reward systems for behavior change are examples of cognitive-behavioral therapies.

The "Coping Cat" manualized cognitive behavioral therapy (CBT) approach has been useful and cross-culturally effective; this technique can be performed on a computer, which is often more appealing to children. [30]

Ohira et al. advocate a more universal approach in schools, as has been done in Japan, to try to prevent the occurrence or decrease the severity of anxiety disorders. [31]


Psychological Therapy

In the psychodynamic approach, a child-oriented and trained mental health professional usually delineates the psychological rationale (whether conscious or unconscious) for the child's symptoms and behaviors. Individual psychodynamic therapy (play used as the modality for younger or nonverbal children) at least twice a week results in the best outcome (>70% improvement). More frequent treatment of 3–4 times per week for 6 months helps the child or adolescent work through feelings and reactions to the upsetting situations and encourages the child or adolescent to behave in a different manner.

Family therapy includes obtaining history of family members for psychosomatic symptoms, anxiety disorders (eg, agoraphobia), depression, and alcoholism as well as facilitating communication to change dysfunctional patterns within the family. These patterns may serve to maintain the child feeling unable to separate from attachment figures (eg, loyalty conflicts). These family actions may cause the family to unwittingly encourage the child in the ill role.


Social Therapy

Social therapy includes gathering history regarding other factors that may have an impact on or explain the child's behavior. Determine if the child is refusing school for nonseparation issues, such as avoiding the school bully or gang, hiding academic problems (ie, developing abdominal pain on test day only), or refusing school because of anticipation of school failure. (See History.)

These symptoms usually reflect other factors that contribute to the child not wishing to attend school, such as learning disorders or inappropriate school placement.


Pharmacologic Therapy

Pharmacologic therapy should be used along with other therapies in an adjunctive manner when the level of functional impairment is moderate to severe, to prevent further loss of function and to facilitate or hasten positive outcomes of behavioral interventions. (See Medications.)

Before and during a trial of fluoxetine (Prozac), the only selective serotonin reuptake inhibitor (SSRI) approved by the US Food and Drug Administration (FDA) for use in patients younger than age 18 years, the clinician must closely monitor the patient for new-onset self-harm or suicidal behavior or ideation.

Non-FDA approved agents that may be helpful to reduce anxiety include beta-adrenergic blocking agents (contraindicated in persons with asthma), alpha-adrenergic agonists (eg, clonidine, guanfacine), SSRIs (eg, sertraline), and nonbarbiturate agents for anxiety (eg, buspirone, gabapentin, hydroxyzine).

Placebo-controlled studies by the FDA have shown that the risk of self-harm and potentially suicidal behavior is 1.5-3.2 times greater with paroxetine or venlafaxine and other serotonin-norepinephrine reuptake inhibitors (SNRIs), except for fluoxetine, sertraline, and citalopram, than with placebo. The FDA requires a black box warning because of this increased risk.

Although initial studies showed improved response to paroxetine (Paxil), this medication should be used only in patients older than 18 years (for adjunctive pharmacologic treatment) and with caution, because it must be dosed twice daily to prevent withdrawal symptoms that seem to be associated with increased risk of new-onset suicidality or self-harm.

Future directions may include the use of bumetanide to ameliorate maternal separation-induced susceptibility to stress. [32]


Medical Care

Research evidence [33] from fMRI studies of anxious youth that found altered behavioral performance on the dot-probe task (including the use of the dot replacing a neutral or fearful face [33] possibly due to altered neural mechanisms of threat disengagement) have led to current research trials targeting neural mechanisms of threat disengagement through the use of video games, by increasing integration across the rostrodorsal anterior cingulate cortex (rdACC) and limbic regions with the goal to be successful disengagement of threat reactivity in the rdACC. [34]




No diet has been proven helpful. No vitamin supplements have been proven helpful, although vitamin B-6 and magnesium seem to have been given to children with a multiplicity of behavioral disorders without benefit and potential harm (nerve impairment [anosmia], intestinal difficulties).



No restrictions on activity apply.



Consultation with child and adolescent psychiatrists or behavioral/developmental pediatric specialists is helpful to coordinate treatment efforts and reduce unnecessary medical procedures. This also helps in gathering a complete history, including information from parents, teachers, school staff, and peers.



Preparation of children before medical or surgical procedures to help them feel less helpless in the situation. Play therapy can be extremely helpful, especially for children who have had to undergo medical procedures or surgery.

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 (eg, read books such as Wemberly Worried, First Day Jitters, Garmann’s Summer, The Berenstain Bears Go to School, and No Copycats Allowed)

The last item above, positive preparation, includes procurement of school supplies, arrangement of suitable familiar transportation for the child to get to school, and, possibly, the establishment, in advance, of phone time to call home to prevent undue anxiety, as well as to provide the child an opportunity to discuss any concerns or worries he or she may have related to starting or returning to school.