Separation Anxiety Disorder and School Refusal in Childhood: Potential Risk Factors for Developing Distinct Psychiatric Disorders?

Sir: Separation anxiety disorder refers typically to younger children who are extremely unwilling to separate from major attachment figures (e.g., parents, grandparents, older siblings) or from home.¹ Separation anxiety disorder can dramatically affect a child's life and his parent's life by limiting the ability to engage in ordinary activities, for example, regular school attendance due to excessive worry about potential harm toward oneself or one's primary caregivers. School refusal is reported in about 75% of children with separation anxiety disorder, and vice versa, separation anxiety disorder is reported in about 80% of children with school refusal.² Furthermore, studies show that school refusal is significantly associated with anxiety and affective disorders.³ However, only few data suggest that separation anxiety disorder is a risk factor for developing psychiatric disorders when children grow up.⁴ To evaluate this hypothesis, we reexamined 10 school refusers who had been treated for separation anxiety disorder for ongoing school refusal, separation anxiety disorder, and further psychiatric disorders.

Method

Five male and 5 female former school refusers with separation anxiety disorder, who had been treated for 12 weeks with cognitive-behavioral therapy at the Department of Child and Adolescent Psychiatry of Innsbruck Medical University, Austria, were followed up until summer 2006. Follow-up assessment was conducted between 2 to 8 years (mean = 4.4 years) after their discharge. At follow-up, children were aged 9 to 14 years (mean age = 12.7 years) and lived in a community setting. History of separation anxiety disorder and school attendance were assessed in an interview with the patient and a parent. Separation anxiety disorder and other psychiatric disorders were evaluated with the children's version of the Diagnostic Interview for Mental Disorders in Children and Adolescents,⁵ a standardized lifetime diagnostic interview of psychiatric syndromes for children and adolescents according to DSM-IV diagnostic criteria, which is an expanded German version of the Anxiety Disorders Interview Schedule.⁶

Results

Persisting symptoms of school refusal were only seen in 1 boy. However, all children presented at least 2 psychiatric disorders, 1 of them presented 3, 2 of them presented 4, and 2 of them presented 5, with some psychiatric disorders in partial remission, including separation anxiety disorder. Psychiatric disorders that were found are attention-deficit/hyperactivity disorder (N = 6), oppositional defiant disorder (N = 4), conduct disorder (N = 1), major depressive disorder (N = 1), social phobia (N = 1), specific phobia (N = 3), panic disorder with agoraphobia (N = 3), obsessive-compulsive disorder (N = 3), and specific developmental disorders of scholastic skills (N = 2). Two children were rated with functional enuresis in complete remission.

At follow-up examination, all 10 subjects met DSM-IV criteria for at least 2 psychiatric disorders. Only 1 of 10 patients had persistent separation anxiety disorder. Three patients were fully remitted, whereas 6 patients were in partial remission of separation anxiety disorder. These results support the hypothesis that school refusers with separation anxiety disorder are at high risk for developing subsequent mental disorders. Further research should also clarify whether separation anxiety disorder is a specific risk factor for other anxiety disorders, or whether separation anxiety disorder in children is a general factor of vulnerability for a broad range of psychiatric disorders.^2,7 In conclusion, clinicians have to be aware that school refusers with separation anxiety disorder are predisposed for developing distinct psychiatric disorders and probably require further treatment even after remission of separation anxiety disorder.