School Refusal in Anxiety-Disordered Children and Adolescents CYNTHIA G. LAST, PH.D,

AND

CYD C. STRAUSS, PH.D.

Abstract. The characteristics of anxiety-based school refusal were examined in 63 school refusing children and adolescents referred to an outpatient anxiety disorder clinic. Patients were assessed on sociodemographic, diagnostic, and personality variables, as well as familial history of school refusal. Results suggest that there are two primary diagnostic " subgroups" of school refusers-separation anxious and phobic. Phobic school refusers had a later age of onset and showed more pervasive (severe) school refusal than separation anxious school refusers. By contrast, separation anxious school refusers were more likely than phobic school refusers to have mothers who had a history of school refusal problems. The implications of these findings are discussed. J. Am. Acad . Child Adolesc. Psychiatry, 1990,29, 1:31-35. Key Words: school refusal, anxiety disorders, children. School phobia is a relatively widespread disturbance which often poses significant and serious short- and long-term consequences . The prevalence rate for the general population of all school-age children is about 1%, and rates among clinically referred children range from 3 to 8% (Eisenberg, 1958; Kahn and Nursten, 1962; Kennedy, 1965; Smith, 1970; Miller et al., 1972). School refusal often is associated with emotional distress, family disruption, inadequate peer relationships, and poor academic performance with possible failure (Chazan, 1962; Berg et al., 1969; Hersov , 1972). Long-term consequences may include an increased risk for later psychiatric illness, employment difficulties, and social impairment (Warren, 1960; Berg et al., 1974; Berg et al., 1976; Waldron, 1976). Historically, children who avoid going to school due to fear or anxiety associated with school attendance have been lumped together under the general heading of "school phobia. " However, clinicians and researchers involved with anxiety-disordered children have noted that school refusal, due to anxiety, may accompany a variety of childhood anxiety disorders, not limited to, but including, phobic disorders (Last and Francis, 1988; Gittelman and Last, 1989). In a previous report, the present authors compared children with DSM-III-R diagnoses of separation anxiety disorder and phobic disorder; the phobic children were fearful specifically of some aspect of the school environment ("school phobic") (Last et al., 1987). The investigation was aimed at determining the validity of the distinction between the two disorders by examining sociodemographic , comorbid, and familial variables. While results generally support the distinction between the two disorders, the study also served to emphasize that not all separation anxious children present with school reluctance or refusal (about 75% showed such behavior in the authors' sample). Thus,

not only is anxiety-based school refusal not pathognomonic of a particular childhood anxiety disorder (i.e., its presence in both separation anxiety and phobic disorders), but not all children with a particular anxiety disorder will show this behavior. The current investigation was designed to expand the examination of anxiety-based school refusal in anxiety-disordered children using a different methodological approach or point of departure. Children presenting with school refusal were identified among consecutive referrals to the outpatient clinic for anxiety disordered children, and then the prevalence of DSM-1II-R anxiety diagnoses was observed among the sample. In this way, the present study becomes the first to execute an empirical examination of the diagnostic composition of anxiety-based school refusers using the DSM-III-R classification system. In addition, sociodemographic features, associated psychopathology, personality variables, and familial history of school refusal were assessed; the authors then determined whether particular diagnostic subgroups of school refusers could be differentiated based on these measures .

Method During a 21-month period (September 1986 through May 1988), 145 children and adolescents were evaluated at the Child and Adolescent Anxiety Disorder Clinic, Western Psychiatric Institute and Clinic. Of the 145 patients, 63 (43.4%) presented with anxiety-based school refusal. The 63 school refusers are the subject of this report. All patients were assessed by a child clinical psychologist with a modified version of the Kiddie-SADS (Puig-Antich and Ryan, 1986). The interview obtains ratings for individual symptom items (e.g., school refusal) and permits diagnosis of both current and past psychopathology using DSM-III-R criteria. Accuracy of diagnosis for all of the patients was ensured by using a consensus procedure: information obtained from the interview was verbally presented to a second psychologist (C.L.). In the few instances where the two psychologists could not agree on diagnosis for a particular child, additional interviewing of the parent and/or child was conducted until a consensus diagnosis was reached. In addition to this procedure, interrater reliability for school refusal and

Accepted August 30, 1989. From the Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine . This research was supported in part by grant #MH4002I from the National Institute of Mental Health. Reprint requests to Dr. Last , Nova University, 3111 University Drive, Suite 307, Coral Springs, FL 30065. . 0890-8567/90/2901-0031 $2.OO/O© 1990 by the American Academy of Child and Adolescent Psychiatry.

31

LAST AND STRAUSS

DSM-III-R diagnoses were determined by having a second clinician independently score audiotapes of approximately one-third (N = 22) of the Kiddie-SADS interviews. Agreement for the presence of anxiety-based school refusal (Kiddie-SADS ratings of 3 or greater) was 100%. Kappa coefficients for DSM-III-R anxiety diagnoses and major depression were as follows: separation anxiety disorder: 0.81 (N = 9); social phobia: 1.00 (N = 10); simple phobia: 1.00 (N = 8); panic disorder: 0.83 (N = 4); overanxious disorder: 0.88 (N = 6); avoidant disorder: 1.00 (N = 1); major depression: 0.83 (N = 4). Information on demographic variables, diagnoses (current and past), and symptom severity ratings were obtained from the Kiddie-SADS. Dependency and maternal overprotection was assessed through administration of the Self-Administered Dependency Questionnaire (SADQ) (Berg, 1974), which was completed by the children's mothers prior to the Kiddie-SADS interviews. The questionnaire separately assesses child dependency ("actual" scores) and maternal overprotection (' 'preferred" scores) for each offour factors: (1) affection (e.g., "Did he/she come close to you for affectionate contact?"); (2) communication (e.g., "Did he/ she talk things over with you and ask your help with what was going on with his/her friends?"); (3) assistance (e.g., "Did he/she either make his/her own bed or clean up his/ her room?"); and (4) travel (e.g., "Did he/she spend time with you at home when he/she could be out?"). The presence of childhood school refusal in the mothers was assessed through direct interview using anxiety sections from the Kiddie-SADS. These data were obtained from a subsample of the school refusal group (N = 24) who participated in an ongoing study of psychiatric illness in the families of anxiety-disordered children (Last et al., submitted for publication); the low participation rate for mothers is primarily a reflection of the later start date for this project. Interviews of the mothers concerning their own childhood psychopathology were performed by a clinician who was blind to the children's diagnoses. Interrater reliability for the presence of school refusal in the mothers was assessed by having a second clinician score audiotapes of approximately one-quarter (21 %) of the interviews. Agreement was 100%. A sample of 63 never psychiatrically ill children, matched for age (within 1 year) and sex to the school-refusing children, and their mothers were recruited from the community via mailings using the Cole's directory. Never psychiatrically ill children were recruited to serve as a comparison group for statistical analysis of results from the SADQ and for rates of maternal childhood school refusal. Control children were evaluated with the Kiddie-SADS and offered participation in the study only if they did not meet DSMIII-R criteria for any current or past psychiatric disorder and had no history of mental health contact. Since the control children were not initially matched to the school refusing children on socioeconomic status, and since SES differences potentially might affect findings on the self-report measures and rates of familial psychopathology, the two groups of children were compared for Hollingshead ratings (Hollingshead, unpublished manuscript). The two main groups

32

H,------------" 12

--,

11 10

10

11

12

13

1..

1~

16

11

Age

FIG.

1. Age at intake for school refusing children.

significantly differed (X2 = 34.90, df = 4, p < 0.001), with never psychiatrically ill children, on the whole, tending to be from families of higher socioeconomic stratas. This sociodemographic difference was addressed further in subsequent analyses (see Results section). Results Demographic Characteristics The age of the school refusing children at intake ranged from 7 to 17 years, with a mean age of 13.5 (SD = 2.4). A histogram depicting the age at intake (see Fig. 1) reveals that the peak age range for referral of this problem to the clinic is from 13 years to 15 years, 11 months. Some elevation also was noted at age 10, but before this age very few cases were assessed, despite the fact that the clinic accepts referrals for children from the age of 5. Of course, these data do not permit conclusions regarding the age distribution of school refusal in general (which only would be possible from an epidemiological sample); however, they do provide information regarding the age at which children are referred for clinical services. Age at onset also was examined for the DSM-III-R anxiety disorder associated with school refusal (see below). On the average, onset was 2 years before referral (X = 11.3, SD = 3.3). The pubertal status and sex distribution were roughly equivalent, with slightly more postpubertal (60%) and female (59%) children. Almost all (89%) ofthe school refusers were Caucasian. Approximately one-half of the children came from lower socioeconomic status (Hollingshead ratings of IV or V) families (53%) and from single-parent households (51 %). Kiddie-SADS ratings of school refusal severity indicated the following distribution for the sample: mild (misses 1 day in 2 weeks): 23%; moderate (misses 1 day per week): 22%; severe (misses several days per week): 17%; and extreme (pervasive refusal, missed weeks of school): 38%.

DSM-III-R Diagnosis The DSM-III-R anxiety disorder diagnosis associated with school refusal for each child was examined. As indicated J.Am.Acad. Child Adolesc. Psychiatry, 29:1 .Jan. 1990

SCHOOL REFUSAL TABLE 1. DSM-III-R Anxiety Disorders Associated with School Refusal

Separation anxiety disorder Social phobia Simple phobia Panic disorder Post-traumatic stress disorder

N

%

24

19

38.1 30.2

14

22.2

4

6.3 3.2

2

TABLE 2. Comorbid Diagnoses'

Anxiety disorders Overanxious disorder Social phobia Simple phobia Avoidant disorder Major depression No concurrent disorder

N

%

16 8 8 7 8 16

25.4 12.7 12.7 11.1

12.7 28.6

Disorders with a prevalence less than 10% have been omitted from this table. a

in Table I, separation anxiety disorder was the most common diagnosis. Social phobia was a close second, followed by simple phobia. Other less common anxiety diagnoses included panic disorder and post-traumatic stress disorder. In all but three cases, the anxiety diagnosis associated with school refusal was the primary anxiety diagnosis, which was defined as the anxiety disorder that was most impairing and targeted first for intervention. Comorbidity

Additional DSM-lll-R disorders for the sample are presented in Table 2. As can be observed, overanxious disorder was the most common comorbid diagnosis, present in onequarter of the school refusers. Social phobia (nonschool related), simple phobia (nonschool related), avoidant disorder, and major depression also were observed, each in approximately 10% of the group.

TABLE 3. SADQ Scores for School Refusers and Never-P sychiatrically-Ill Controls Actual School Refusers Affection" Communication Assistance" Travel"

5.6

5.5 6.3< 10.1

Preferred

Controls 5.6 4.7 5.1

9.1

School Refusers

Controls

7.1

7.4

9.4 b

7.9

3.6 8.8

3.1

9.2

Note: Actual scores reflect child dependency while preference scores reflect maternal overprotection. a Means adjusted for significant age effect. b versus controls, F = 4.51, df = 1, p < 0.04. c versus controls, F = 7.90, df = 1, p < 0.006.

Previous Episodes of Illness

Ten (16%) of the children had a past episode of separation anxiety disorder and/or school refusal. Past episodes of major depression were present in 16 (25%) of the children, two of whom also had a current episode. Thus, the lifetime prevalence of major depression (number of cases with current and/or past diagnosis) in the sample was 34.9% (N = 22). Over one-half (57%) of the sample had no previous psychiatric illness of any type. Dependency and Maternal Overprotection

Results from the SADQ for school refusers and matched never psychiatrically ill controls are present in Table 3. Data are presented on 54 of the 63 school refusers because several mothers failed to complete the measure. Although schoolrefusing and control children were initially matched for age (within 1 year), once missing data were deleted a statistically significant l-year age difference was present between the two groups. As indicated above (see Method section), the two groups also differed in respect to their SES composition. In light of these sociodemographic differences, analysis of covariance, with age and SES as the covariants, was used to analyze results. While age was found to be related significantly to scores on three of the four factors (see Table 3), SES was not found to be related significantly to any of the factors. Results revealed two statistically significant differences between the two groups. Actual scores indicated that school refusers requested more assistance from their mothers than control children. Preference scores indicated that the mothl.Am.Acad. Child Adolesc. Psychiatry, 29:1 .Jan. 1990

ers of school refusers preferred more communication with their children than the mothers of controls. Maternal History of School Refusal

The presence of school refusal in the childhood histories of mothers of school-refusing children (N = 24) was compared to that of mothers of never psychiatrically ill children (N = 60). Results were in the expected direction, 33.3% and 10.0%, and statistically significant (Fisher's exact test, one-tailed, p < 0.01). Because there was a significant age difference between the two groups with the reduced sample of school refusers, and because the SES composition of the two groups differed, logistic regression was used to evaluate the effects of group on maternal school refusal status when controlling for the age and SES differences. A significant effect (p = 0.025) was observed for maternal school refusal status when controlling for age and SES in this manner. Comparison of Diagnostic Subgroups

School refusers with a DSM-III-R diagnosis of separation anxiety disorder (N = 24), social phobia (N = 19), and simple phobia (N = 14), the three most common anxiety diagnoses associated with school refusal in our sample (see Table 1), were compared on each of the variables examined in our study. The three groups significantly differed with respect to age at intake and age at onset (F = 14.32, df = 2, P < 0.0001; F = 15.71; df = 2, P < 0.0001, respectively). Pairwise

33

LAST AND STRAUSS

comparisons showed that the SAD children were significantly younger at intake (11.7) and at onset (8.7) than children in the social phobic (14.8 and 12.4) and simple phobic (14.2 and 12.9) groups (age at intake: p < 0.0005 and p < 0.001, respectively; age at onset: both p < 0.0005). The two phobic groups did not differ with respect to these variables. As would be expected, a similar significant pattern emerged for pubertal status (overall X2 = 18.40, df = 2, p < 0.0001; SAD vs. social phobia: X2 = 15.22, df = 1, p < 0.0001; SAD vs. simple phobia: X2 = 4.19, df = 1, P = 0.04). No significant differences emerged for sex or racial distribution, or for marital or socioeconomic status of the child's parents. Examination of comorbidity and past illness did not reveal significant differences among the three groups of school refusers, nor did the measure of dependence/maternal overprotection (SADQ). By contrast, K-SADS ratings of the severity of school refusal yielded the following: SAD: 33% severe/extreme; social phobia: 63% severe/extreme; simple phobia: 69% severe/extreme (X2 = 5.84, df = 2, p = 0.05). Pairwise comparisons showed that the SAD group differed from the social phobic (X2 = 3.79, df = 1, p = 0.05) and simple phobic (X2 = 4.38, df = 2, p < 0.04) groups but that the two phobic groups did not differ from each other. Finally, examination of maternal history of school refusal was conducted by comparing the SAD groups with a combined phobic group, which was necessary because of the relatively small number of mothers in the school refusal group who participated in this part of the project. Comparison of the two groups of school refusers indicated that mothers of SAD children (6/8, 75%) were more likely than mothers of phobic children (2/11, 18%) to have a history of anxiety-based school refusal (Fisher's exact test, twotailed, p < 0.03). Because of age-of-onset differences for SAD and phobic school refusers (see above), the authors were interested in determining the possible effect of this variable on the maternal school refusal findings. However, the small N precluded a statistical examination of this question using multivariate techniques.

Discussion Almost one-half of the children evaluated at the Child and Adolescent Anxiety Disorder Clinic during the past 21 months showed anxiety-based school refusal. Observation of the sociodemographic characteristics of this sample of school refusers indicated that the disturbance is prevalent in children of all ages (although more common in children 10 years of age and older), both sexes, and at all socioeconomic levels. Examination of the diagnostic composition of the group showed that the three anxiety disorders most commonly associated with school refusal were separation anxiety disorder, social phobia, and simple phobia. Overanxious disorder was the most common co-occurring psychiatric disorder, present in one-quarter of the children. For the most part, the present findings for depression, dependency/maternal overprotection, and familial history of school refusal show a pattern of results consistent with those recently obtained by Granell de Aldaz et al. (1987) in a 34

nonclinically referred sample of school refusers. In this study, Granell de Aldaz et al. found that school refusal status could be predicted by depression, dependency, and history of refusal in the family. Although comorbid major depression was relatively infrequent (13%) in the present sample, when examining lifetime prevalence of the disorder (current and! or past cases combined), the rate of depression was approximately 35%. While the lifetime prevalence of depression was high, it should be noted that the rate is roughly equivalent to that shown for other anxiety populations, e.g., separation anxiety, avoidant, and overanxious disorders (Last et aI., 1987; Francis et al. , submitted for publication; Strauss et aI., 1988). Thus, it remains unclear whether major depression is associated specifically with school refusal, or whether it is associated with childhood anxiety disorders in general. The present data also suggest that specific forms of dependency (i.e., need for assistance) and maternal overprotection (Le., need for communication) are problematic for school refusers; however, it remains to be determined whether problems with dependency/overprotection are specific to anxious school refusers or characteristics of anxiety disordered children, irrespective of school refusal status. Finally, a relationship between maternal history of school refusal and child school refusal status was observed. The present findings for maternal school refusal appear to be related specifically to the presence or absence of school refusal in the child, and not to the presence or absence of anxiety disorder, since the mothers of nonschool refusing but anxiety disordered children show rates of school refusal close to that of normal controls (17%, N = 51). Comparison of the main diagnostic subgroups of school refusers-separation anxious, social phobic, and simple phobic-indicated that separation anxious school refusers differ from phobic school refusers, but that the two types of phobic school refusers do not differ appreciably from each other. Phobic school refusers have a later age of onset and show more pervasive (severe) school refusal than separation anxious school refusers. By contrast, separation anxious school refusers are more likely than phobic school refusers to have mothers who have a history of school refusal problems. Interpretation of findings for maternal school refusal is problematic because of the age-at-onset differences observed for separation anxious and phobic school refusers, since earlier age-at-onset for some psychiatric disturbances is associated with increased familial psychopathology. However, given the phenomenological differences between separation anxious and phobic school refusers, i.e., fear of being separated from mother verus fear of a particular situational aspect of the school environment, it is not all that surprising that the former group showed a greater maternal history for school avoidant behavior. More specifically, it may be that school refusal due to separation anxiety has a pathogenesis tied to the mother-child relationship (i.e., maternal communication focusing on separation anxious concerns and reinforcement of dependent/avoidant behavior in the child), while phobic related school refusal has a pathogenesis related to specific circumstances or events in the school environment (Le., academic and/or social concerns). l.Am.Acad. Child Adolesc. Psychiatry, 29:1 .Jan. 1990

SCHOOL REFUSAL

In the current DSM-lII-R classification system there is no method or procedure available for denoting whether a child has anxiety-based school refusal. The present data indicate that school refusal is quite prevalent among clinically referred anxiety-disordered children and adolescents. Given the negative social and academic consequences of school absenteeism, as well as the probable treatment implications of such behavior, the communication of information regarding school refusal in a childhood diagnostic system would seem of considerable import. Also of future importance would be to determine whether the two primary diagnostic subtypes of anxious school refusers-separation anxious and phobic-respond similarly to treatment modalities typically used for intervention with this population. Psychosocial and psychopharmacological outcome studies with "school phobic" children have failed to distinguish among them by diagnosis, and thus have not determined whether treatment response is related to diagnosis (Gittelman-Klein & Klein, 1971; Berney et al., 1981; Blagg and Yule, 1984). This issue is of particular interest in regard to the administration of imipramine hydrochloride, which has been purported to work specifically via reductions in separation anxiety (Gittelman-Klein and Klein, 1971, 1980). References Berg, 1. (1974), A self-administered dependency questionnaire (S.A.D.Q.) for use with mothers of school children. Br. J. Psychiatry, 124:1-9. - - Butler, A. & Hall, G. (1976), The outcome of adolescent school phobia. Br. J. Psychiatry, 128:80-85. - - Marks, 1., McGuire, R. & Lipsedge, M. (1974), School phobia and agoraphobia. Psychol. Med., 4:428-434. - - Nichols, K. & Pritchard, C. (1969), School phobia-its classification and relationship to dependency. J. Child Psychol. Psychiatry, 10:123-141. Berney, T., Kolvin, 1., Bhate, S. R. et al. (1981), School phobia: a therapeutic trial with clomipramine and short-term outcome. Br. J. Psychiatry, 138:110-118.

J.Am.Acad. Child Adolesc. Psychiatry, 29:1,Jan. 1990

Blagg, N. R. & Yule, W. (1984), The behavioral treatment of school refusal-a comparative study. Behav. Res. Ther., 22:119-127. Chazan, M. (1962), School phobia. Br. J. Educ. Psychol., 32:200217. Eisenberg, L. (1958), School phobia: a study in the communication of anxiety. Am. J. Psychiatry, 114:712-718. Gittelman, R. & Last, C. G. (1989), Anxiety Disorders in Children. Developmental Clinical Psychology and Psychiatry Series, ed. A. Kazdin. Newbury Park: Sage Publications. - - Klein, D. (1971), Controlled imipramine treatment of school phobia. Arch. Gen. Psychiatry, 25:204-214. - - Klein, D. F. (1980), Separation anxiety in school refusal and its treatment with drugs. In: Out of School, ed. L. Hersov & 1. Berg. New York: John Wiley & Sons. Granell de Aldaz, E., Feldman, M. A., Vivas, E. & Gelfand, D. M. (1987), Characteristics of Venezuelan school refusers toward the development of a high-risk profile. J. Nerv. Mental Dis., 175:402407. Hersov, L. A. (1972), School refusal. Br. J. Med., 3:102-104. Kahn, J. H. & Nursten, S. P. (1962), School refusal: a comprehensive view of school phobia and other failures of school attendance. Am. J. Orthopsychiatry, 32:707-718. Kennedy, W. A. (1965), School phobia: rapid treatment of fifty cases. J. Abnormal Psychol., 70:285-289. Last, C. G. & Francis, G. (1988), School phobia. In: Advances in Clinical Child Psychology: Volume II, ed. B. Lahey & A. Kazdin. New York: Plenum Publishing Corp. - - - - Hersen, M., Kazdin, A. E. & Strauss, C. C. (1987), Separation anxiety and school phobia: a comparison using DSM-ll1 criteria. Am. J. Psychiatry, 144:653-657. Miller, L. C., Barrett, C. L., Hampe, E. & Noble, H. (1972), Comparison of reciprocal inhibition, psychotherapy, and waiting list control for phobic children. J. Abnormal Psychol., 79:269-279. Puig-Antich, J. & Ryan, N. D. (1986), Schedule for Affective Disorders and Schizophrenia for School-Age Children (6·16) (K-SADSP). Fourth Working Draft. Smith, S. L. (1970), School refusal with anxiety: a review of sixtythree cases. Can. Psychiatr. Assoc. J., 126:815-817. Strauss, C. C., Last, C. G, Hersen, M. & Kazdin, A. E. (1988), Association between anxiety and depression in children and adolescents with anxiety disorders. J. Abnormal Child Psychol., 15:5768. Waldron, S., Jr. (1976), The significance of childhood neurosis for adult mental health. Am. J. Psychiatry, 133:532-538. Warren, W. (1960), Some relationships between the psychiatry of children and of adults. J. Mental Sci., 106:815-826.

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School refusal in anxiety-disordered children and adolescents.

The characteristics of anxiety-based school refusal were examined in 63 school refusing children and adolescents referred to an outpatient anxiety dis...
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