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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

September 2016

Anxiety and School Refusal in Children

It is common for children to struggle with some degree of anxiety during certain periods, such as their first experience of going to school or a transition between schools. But when symptoms become more extreme or persistent than is typical, or get in the way of academic performance or social development, a child may be exhibiting signs of separation anxiety disorder — which sometimes leads to school refusal.

The best way to minimize the ill effects of separation anxiety disorder and prevent or reverse school refusal behavior is to address a child’s anxiety issues early in the primary care setting, and to refer such patients for behavioral health care when necessary. 

Separation anxiety disorder

Most young children develop a healthy attachment to parents and caregivers and exhibit clinging behavior toward them, as well as a sense of worry when they are separated from them and left in unfamiliar settings. However, when this fear of separation from home or loved ones continues for longer than four weeks or causes significant distress that impedes a child’s ability to function, it could be separation anxiety disorder. Separation anxiety, which affects approximately 4 to 5 percent of children in the United States ages 7 to 11, becomes clinically significant and requires professional attention when it leads to severe behavioral or  physical symptoms, such as:

  • Difficulty sleeping without being near a parent or caregiver
  • Throwing tantrums when faced with separation
  • Nightmares about being separated
  • Excessive homesickness
  • Unrealistic worries about bad things happening to the child or a caregiver
  • Headaches or stomachaches

School refusal

Many children with separation anxiety disorder demonstrate signs of school refusal, which is manifested by a child regularly displaying an aversion to going to, or staying in, school. Children with school refusal issues often complain of physical symptoms shortly before having to leave for school, or asking to visit the school nurse.

In addition to separation anxiety disorder, there are several other potential reasons for school refusal in children, such as stress related to academic achievement, fear of bullying, marital problems between parents, or shyness/social phobia. What separates school refusal from truancy is that truancy is typically motivated by boredom or a sense of defiance, whereas school refusal stems from anxiety or fear. A truant child is likely to brag about skipping school, but children exhibiting school refusal behavior are often embarrassed about their reluctance to go to school.
Treatment for separation anxiety and school refusal

It is important to screen children in the primary care setting for anxiety disorders and associated behaviors like school refusal from an early age. If necessary, you may feel the need to refer a pediatric patient to a behavioral health specialist to treat separation anxiety or manage school refusal. Treatment options may include psychotherapy, anti-anxiety medication, or a combination of both — but therapy alone is the most common option and is often effective.

How Optum/UBH can help your patients — For complex clinical situations, Optum/UBH is available to provide consultative assistance. Practitioners can call the Optum/UBH Physicians Consultation Service at 800-292-2922. To refer a patient for behavioral health services and to facilitate the coordination of care, call Optum at 888-777-4742.

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