Non-attendance at school, although infrequent in the general population, may result in referral to child mental health services. Many of these children show anxious symptoms, but school phobia is uncommon and only one of a range of reasons for school non-attendance. (14>
Such children are characterized by seeking the comfort of home, preferring to remain close to parental figures, especially during school hours. There is evidence of emotional upset, often with a high level of somatic complaints. These children do not attempt to conceal the problem from their parents and in many respects present no other burden to family life. There are virtually no antisocial tendencies except in severely worried children where defensive aggression may be used to prevent attendance.
On psychiatric examination, many such children meet the criteria for one or more anxiety disorders, the most frequent being separation anxiety disorder. A small proportion may meet criteria for other disorders, including depression (generally mild). Physical symptoms are very evident in the presentation and include abdominal pain, frequency of micturition, anorexia, diarrhoea, pallor, and headache. They may be limited to mornings, reflecting the somatic consequences of physiological arousal associated with specific anticipatory worry about school. Invariably, the physical and emotional symptoms recede if avoidance is allowed.
Boys and girls are equally affected at any school age, but the transition from primary to secondary school represents a critical period for risk of this behaviour. There is no association with social class, intelligence, or academic ability. The youngest in a family of several children is more likely to be affected and the parents are somewhat more likely to be older than expected. Onset tends to be gradual in the main, with reluctance and difficulties increasing over weeks or months and signs and symptoms generally increasing from waking in the morning to going to school. Occasionally, cases occur after time away from school following illness or accidents; some onsets are acute and precipitated by a severe undesirable life event, a few episodes may even occur without obvious precipitants or previous history of reluctant attendance. The latter cases suggest a more school-based aetiology such as peer group difficulties or even teacher-child problems.
Severe or persistent absenteeism is generally associated with older adolescents, lower levels of fear, and less active families. (15> In such cases, the diagnosis may be truancy rather than school refusal. Truancy is associated with antisocial behaviour rather than emotional symptoms. Compared with anxious school refusers, truants hide their school non-attendance from their parents.
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