Separation Anxiety and School Refusal Workup

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

To help prevent secondary complications, do not be overzealous in the workup for a physical etiology of the somatic problems; however, do be prudent.

Various structured or semistructured interview scales aid in confirming a diagnosis of separation anxiety, while laboratory studies and physical examinations help to rule out other symptom sources.

Sleep studies may have utility if a significant history of difficulty initiating or maintaining a normal sleep cycle is reported. One study used parent questionnaires to elucidate cross-sectional and longitudinal relationships among variables related to sleep patterns and both social-emotional problems (i.e., internalizing, externalizing, and dysregulation) and healthy social development (i.e., social competence) at 6, 12, and 18 months across 5 cohorts of children for a total of 117 mother-child dyads. Young children were more likely to have higher anxiety, depression, and separation distress scores when they slept less total time and also went to sleep later; the study did not determine the directionality of the association. [28]


Lab Studies

Consider the following tests to rule out possible conditions in patients with suspected separation anxiety, school refusal, or both only when clinically pertinent and age relevant.

Triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) tests can be run to rule out thyroid abnormalities.

A 2-hour postprandial glucose can be performed to rule out type I or type II diabetes mellitus.

Titer measurements can be performed for antistreptococcal antibodies (ASO titer), Babesia (to rule out babesiosis), Lyme disease, and rickettsial illness (eg, Rocky Mountain spotted fever). This can be especially important in patients with a history that includes fever, rash, or sore throat with incomplete or no treatment (with antibiotics), and a history of acute change in personality or anxiety or obsessive features.

Blood levels of lead and other heavy metals, such as mercury, can be measured to rule out lead or heavy metal poisoning (abdominal pain).

A complete blood count (CBC) and measurements of hematocrit (Hct) levels and hemoglobin (Hgb) concentrations can be performed to rule out the presence of anemia (for example, as a cause of abdominal pain.)

Urine screening for drugs of abuse can be used to rule out stimulant or steroid abuse.


Imaging Studies

If other information suggests brain tumor or seizure disorder, perform appropriate imaging studies (eg, magnetic resonance imaging [MRI], computed tomography [CT] scanning, positron emission tomography [PET] scanning).

Obtain an echocardiogram with functional examination to rule out mitral valve prolapse or other structural cardiac abnormalities (eg, regurgitation).


Behavioral Assessment

Functional behavioral assessment should include specific observations of the child's symptoms and behaviors; note frequency, intensity, location, and proximity to caregiver.


Structured Interviews

Perform a structured or semistructured interview to determine whether a risk of suicidal ideation is present.

Structured or semistructured interview scales are extremely helpful in confirming the clinical diagnosis and should be administered by clinically experienced personnel (eg, child and adolescent psychiatrists, developmental and behavioral pediatricians, clinical psychologists, social workers). The following are examples of structured or semistructured interview scales used to assess anxiety disorders in children and adolescents:

  • Schedule for Affective Disorders and Schizophrenia for School-Age Children–Epidemiologic Version-5 (K-SADS-E5)

  • Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL)

  • Diagnostic Interview for Children and Adolescents Revised (DICA-R)

  • National Institute of Mental Health Diagnostic Interview Schedule for Children (DISC)

  • Anxiety Disorders Interview Schedule for Children (ADIS)

  • The Hamilton Anxiety Rating Scale

  • The Anxiety Rating Scale for Children (Revised)

  • Multidimensional Anxiety Scale for Children (MASC)

  • Revised Children's Manifest Anxiety Scale

  • Visual Analogue Scale for Anxiety (Revised)

  • Interview Schedule for Anxiety Disorders for DSM-IV (Child Version)

  • Social Anxiety Scale for Children (Revised)

  • Child Behavior Checklist

  • Selective Mutism Questionnaire