Hi. I hope that I can give you some information that is useful and new to you. First, there is no diagnostic entity 'school phobia' as far as I know. Kids (school refusal, on the other hand, is recognized as a constellation of behaviors but is diffuse and very few studies have properly screened, followed and re-tested a representative sample of school refusers) are never afraid of school--you know, the building. So when diagnosing you must begin ruling out what we do recognize as disorders first. Begin with separation anxiety (equally seen as a disorder where the child is extremely fearful of leaving home/comfort as well as a mother who often has the child sleep with her, run errands, clean, do work with her, stay up late, often the husband is traveling or they are divorced, and eventually the mother exerts pressure on the kid to stay home and have fun); social phobia (remember, the key criteria is fear of scrutiny, not speaking in public); test anxiety (simple phobia of tests); fear of authority figures; a disorder that includes a component of perfectionism (in anxiety, GAD would typically be identified; however, with kids, OAD was a diagnosis that did a much better job in terms of the specificity, breadth, and uniqueness of symptoms; another choice is OCD though kids often hide if possible their symptoms and therefore you may see perfectionism but miss the bigger picture); selective mutism; ADHD; conduct disorder; early schizophrenia; an antecedent symptom cluster associated with adult avoidant personality disorder; bullying or any traumatic event that may cause a kid to not want to return to his/her class (possible PTSD; in addition to bullying, wetting pants in front of others, being humiliated in front of others, etc.); simple phobia of the dark (they don't sleep....and don't perform well in school. For some kids, that change in their performance causes them to want to stay home); lack of proper social skills (in highly intelligent kids, they see the gap between their lack of understanding/recognizing social cues and other kids' ease, and--again--depending on the kid, they will avoid school); major depressive disorder; an adjustment disorder that is acute and temporary, typically due to the environment (divorce, Hurricane Andrew here in Miami); rule out any physical problems that may make them look 'stupid' in class or be unable to keep up (vision, speech impediment); and I will stop here, but have a nagging suspicion there are other behaviors/disorders seen in school refusers that I am leaving out.

Once you have identified your purpose, your scope of responsibility and what you can and can't do (access records, talk to parents, observe children, give a diagnostic interview), then you'll be in a much better position to use the list above. The main point is, kids refuse school for a variety of reasons: typically, a phase is 'better' than a kid who never went to school easily, and many of my patients fit that profile. Its one of the indicators that there is a disorder (i.e., a referral for treatment would be appropriate), and if you can talk to the mother, its something she often emphasizes with little prodding: "How LONG has he had trouble going to school? Since EVER. Really. Since kindergarten..." and the kid is in 9th grade now. Also, kids who are willing to put themselves at risk to avoid school is important to note (for example, we treated a kid who had always been forced to go to school, and one day he'd had enough and jumped from his car while it was going 40 miles and hour; another example was an adolescent who turned out to have early schizophrenia, and a mother with impaired cognitive functioning, so he left everyday as if he were going to school, walked the 3 miles, walked back, snuck into the trunk of his mother's car, and stayed there for 8 hours. In Miami. In the heat. For years. And his mother never noticed). You'll get school refusers sent to your office/lab/referred for help mainly because its school and there are laws and tracking systems. Otherwise, there are even more examples of behavior that may have continued had the school not intervened: most mothers of boys/adolescents with conduct disorder have been at odds with teachers, other parents, their parents (who never fail to point out what they did to get into this situation which usually involves the father being unavailable and the mother being overwhelmed, unprepared and having to work), counselors, administrators, and so on well before you meet them. As you go through a diagnostic interview, structured or not, formal or informal, the mothers are defiant, hypervigilant to the possibility of another person saying they are not a good mother, unwilling to see their child in that light, so they will answer questions in such a manner that you would swear the kid was anxious, and then try to figure out which anxiety disorder they met criteria for. Many, many symptoms of school refusal are open to interpretation, or to put it another way, not specific enough to be sure what the actual motivation for the behavior is. Is it the kid, and he/she is afraid? Is it a kid who has conduct disorder? Is it a mother who depends on the kid for support, affection and company, and a kid who simply wants to make his/her mother happy? A kid who was traumatized but never told anyone, and isn't about to? A kid who seems so smart and prepared, but is acutely aware of how different he/she is, lacks friends, and begins to hate school?

I'm sorry this isn't organized into a decision tree, but it can be. And there are other anxiety experts, a handful of which have worked with enough school refusers that they have published some work. Look for it, as it may help you. Good luck,

Kelly

Great answer, hit many bases. Easily split into bullets. Our situation is a team that is called in by schools, families, child protection agencies, hospital eds (but requires guardian to approve of having an eval in most situations). So we don't get the temporary, phase ones, usually, since the schools and agencies have methods that work with some kids, maybe most. We get an enriched sample of real messes, although in the only two cases of childhood schizophrenia that have actually resolved, one client loved school, and the other was so disabled with negative symptoms at 19 (dxed at 14) that our team recommended to the mother that she enroll the youth in DMH services, among other reasons because the client would leave the school and walk a few blocks home, but the school was closing in a few months, and the next would have been riskier. So that one is a rarity. I would like to get some numbers for the general run of school refusers, as ours are typically separation anxiety (this is the medically fragile family member, and possibly part of the hoard-filled homes), more rarely MDD or a developed panic disorder, and our team has been tuning into stress reactions and PTSD as a the largest fraction of child-adolescent practice. The scenarios are much as you describe, except we have seven days to evaluate and refer (but with these cases often are called back in a few times).

You might want to take a look at:

Kearney, C. A., & Silverman, W. K. (1993). Measuring the function of school refusal behavior: The School Refusal Assessment Scale. Journal of Clinical Child Psychology, 22, 85-95.

and

Kearney, C. A. (2002). Identifying the function of school refusal behavior: A revision of the School Refusal Assessment Scale. Journal of Psychopathology and Behavioral Assessment, 24, 235-245.

Kearney and colleagues have identified four different functions of school refusal behavior: avoidance of negative affect, avoidance of social evaluation, efforts to obtain more attention and closeness with caregivers, and pursuit of tangible reinforcement. Each of these functions (and any given child may have more than one) calls for a different approach. Some children, depending on function, may benefit from strategies to reduce feelings of anxiety and depression. Others may benefit from social skill training. Others may benefit from improved parental limit-setting and contingency management.

There's a very good, straightforward discussion of how to manage these cases at:

Kearney, C. A., & Bates, M. (2005). Addressing school refusal behavior: Suggestions for frontline professionals. Children and Schools, 27, 207-216.

Hope that helps.

Yes, everyone goes back to Kearney on this. I am going to retitle my question as "refractory school refusers" although the relationship with separation anxiety continues to hold.

300.29 Specific Phobia - school.

I have worked with many chronic "school refusers." Some are phobic others are not. If they are phobic, a desensitization protocol worked very well. I have them list all of the situations that they avoid. I have them then rate each item on the list  from 1 to 10 for the severity of the anxiety associated and then sort from lowest to highest. I teach them a relaxation method if they don't know one. I then have them select an item to expose themselves to for a certain amount of time. I am sure you know the drill. Relax prior, predict the severity, expose, relax, rate the actual discomfort. Repeat. Once they experience a reduction in anxiety from repeated exposure; it becomes highly motivating and they are back in school within several months.

Thank you for valuable insight on school phobia when it is really phobia. I do think of a couple of cases where a panic disorder or true agoraphobia was involved, As we evaluate and refer, our team doesn't do actual treatment, but does a pretty coachable moment of referral and my parent support also involves education on treatment systems. I have a brief self-hypnosis relaxation I learned from a psychologist/hypnotist that I can show parents and kids, but will try describing  the exposure method (which in my reading I see more often as half of OCD treatment).