School Refusal and Psychiatric Disorders: A Community Study

School Refusal and Psychiatric Disorders: A Community Study HELEN LINK EGGER, M.D., E. JANE COSTELLO, PH.D., AND ADRIAN ANGOLD, M.R.C.PSYCH. ABSTRACT Objective: To examine the association between anxious school refusal and truancy and psychiatric disorders in a community sample of children and adolescents using a descriptive rather than etiological definition of school refusal. Method: Data from eight annual waves of structured psychiatric interviews with 9- to 16-year-olds and their parents from the Great Smoky Mountains Study were analyzed. Results: Pure anxious school refusal was associated with depression (odds ratio [OR] = 13, 95% confidence interval [CI] 3.4, 42) and separation anxiety disorder (OR = 8.7, 95% CI 4.1, 19). Pure truancy was associated with oppositional defiant disorder (OR = 2.2, 95% CI 1.2, 4.2), conduct disorder (OR = 7.4, 95% CI 3.9, 14), and depression (OR = 2.6, 95% CI 1.2, 56). Of mixed school refusers (children with both anxious school refusal and truancy), 88.2% had a psychiatric disorder. They had increased rates of both emotional and behavior disorders. Specific fears, sleep difficulties, somatic complaints, difficulties in peer relationships, and adverse psychosocial variables had different associations with the three types of school refusal. Conclusions: Anxious school refusal and truancy are distinct but not mutually exclusive and are significantly associated with psychopathology, as well as adverse experiences at home and school. Implications of these findings for assessment, identification, and intervention for school refusal are discussed. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(7):797 807. Key Words: anxious school refusal, truancy, epidemiology, psychopathology. Clinicians and researchers have commonly divided children who fail to go to school into two groups: those who stay home from school because of fear or anxiety, and those who skip school because of a lack of interest in school and/or defiance of adult authority (King and Bernstein, 2001). The behavior of the first group has variously been called school refusal, anxious school refusal, school phobia, or a variant of separation anxiety disorder (SAD), while the behavior of the second group has been called truancy. The terms used to describe nontruant school refusal reflect early conceptualizations of the etiology of the behavior (for a review see Kearney and Silverman, 1996). A variant of truancy arising from fear rather than delinquency was identified in the 1930s and 1940s (Broadwin, 1932; Partridge, 1939), with Johnson Accepted January 21, 2003. From the Center for Developmental Epidemiology in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center, Durham, NC. This project was supported by NIMH grants MH-02016 and MH-48085. Dr. Egger receives support from an NIMH Career Development Award (5K23- MH-02016) and a NARSAD Young Investigator Award. The authors acknowledge the assistance of Jane Duncan in the preparation of this paper. Reprint requests to Dr. Egger, Developmental Epidemiology Program, DUMC Box 3454, Durham, NC 27710; e-mail: hegger@psych.mc.duke.edu. 0890-8567/03/4207 0797 2003 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.CHI.0000046865.56865.79 et al. (1941) coining the term school phobia, defined as an anxious fear of school caused by the child s and mother s separation anxieties (Johnson et al., 1941). Most definitions of anxious school refusal/school phobia used in recent studies exclude children with antisocial features, including truancy, or those who meet criteria for conduct disorder (CD), reflecting the assumption that anxious school refusal and truancy are mutually exclusive (Berg, 1992; Berg et al., 1969; Kearney and Silverman, 1995). Hersov (Hersov, 1960a,b) conducted one of the first studies to use descriptive, rather than etiologically derived definitions of school refusers and truants. He concluded that truancy was an indication of CD, while school refusal was a manifestation of an emotional disorder, with anxiety more prominent than depressive symptoms, findings that have been broadly replicated in subsequent studies (King and Bernstein, 2001). Hersov s conclusion that refusal to attend school was not a discrete clinical entity but rather an aspect of behavior in either an emotional disorder or a behavioral disorder is reflected in the DSM, where anxious school refusal and truancy are symptoms, rather than distinct diagnoses (American Psychiatric Association, 1994). A persistent reluctance or refusal to go to school because of fear of separation is a symptom of SAD. Often truant from J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003 797

EGGER ET AL. school is a symptom of CD if it began before the age of 13. Fear of school can be an aspect of a specific phobia, if the avoidance of school is caused by excessive or unreasonable fear of a specific stimulus. Recent clinical studies point to three types of anxious school refusers (King and Bernstein, 2001): those with separation anxiety (Bernstein and Garfinkel, 1986; Kearney and Silverman, 1996; Last et al., 1987), those with simple or social phobia (Last et al., 1987), and those who are anxious and/or depressed (Agras, 1959; Bernstein, 1991; Bernstein and Garfinkel, 1986; Gittelman-Klein and Klein, 1973; Kolvin et al., 1984; Tisher, 1983). There are few studies of school attendance problems and psychopathology in nonclinical settings. In a study by Bools et al. (1990), half of 100 children with severe school attendance problems met criteria for an ICD-9 psychiatric disorder, with the truants more likely to have CD and the anxious school refusers more likely to have anxiety disorders. Berg et al. (1993) assessed 80 children who had missed more than 40% of a term. Half met criteria for a DSM-III-R psychiatric diagnosis. Both studies identified a significant subset of children with both anxious school refusal and truancy (9% in Bools et al.; 5% in Berg et al.), challenging the idea that anxious school refusal and truancy are exclusive of each other. In Bools et al., 11% of the mixed refusers had CD alone, 22% had an emotional disorder alone, and 33% had mixed conduct and emotional problems. Kearney and colleagues have argued that descriptive definitions of school refusal, free of assumptions about etiology or associated psychopathology, are critical to understanding the associations between children s refusal to attend school and psychiatric disorders (Kearney and Silverman, 1996). Community studies are needed to understand these associations prior to referral to mental health providers. The primary purpose of this report is to examine the association between school refusal and DSM-IV psychiatric disorders using definitions of school refusal that do not presuppose the etiology (e.g., separation fears or phobias), the relationship with psychopathology (e.g., by excluding those with CD), or the relationship between types of school refusal in a population-based sample of children. A secondary aim was to examine the association between school refusal and specific fears, sleep difficulties, and somatic complaints because these symptoms have been linked to school refusal. The associations between difficulties in peer relationships and adverse experiences at home and school and school refusal were examined primarily to explore whether these risk factors might be contributing to a child s fear/resistance to attending school or leaving home. METHOD Sample The Great Smoky Mountains Study (GSMS) is an ongoing, longitudinal study of the development of psychiatric disorders in youths living in North Carolina. Full details of the study design can be found elsewhere (Costello et al., 1996). Briefly, a representative sample of 4,500 children aged 9, 11, and 13 years, recruited through the Student Information Management System of the public school systems of 11 counties in western North Carolina, was selected using a household equal probability design. A screening questionnaire, consisting mainly of questions about behavioral problems, was administered to a parent (usually the mother), by telephone or in person. All children scoring above a predetermined cut point, plus a 1-in-10 random sample of the rest, were recruited for detailed interviews. The response rate at the first wave was 80% (N = 1,422). The composition of the GSMS sample is as follows: 44.4% female, 55.6% male; 69.9% white, 22.4% Native American, 6% African American, 0.2% Asian, 0.5% Hispanic, and 1.1% other; education attainment of primary parent: without high school diploma, 18.9%; high school diploma, 57.2%; some college, 25.3%; degree from 4- year college or more, 14.5%; 34.3% had a family income below the federal poverty level. In this report, we analyzed data from eight yearly waves of the GSMS. In all, the sample included 6,676 annual observations on the 1,422 children aged 9 through 16. There were 517 observations for the 9-year-olds, 500 for the 10-year-olds, 996 for the 11-year-olds, 753 for the 12-year-olds, 942 for the 13-year-olds, 883 for the 14- year-olds, 1,228 for the 15-year-olds, and 856 for the 16-year-olds. The age variability reflects the fact that partial cohorts were funded at certain points in the study. Measures The child and primary caretaker were separately interviewed about the child s psychiatric status using the Child and Adolescent Psychiatric Assessment (CAPA) (Angold et al., 1995), which generated a wide range of DSM-IV diagnoses. The reference period was the 3 months prior to the interview (Angold et al., 1996). Diagnoses and symptom scales were generated by computer algorithms. All diagnoses, except for attention-deficit/hyperactivity disorder (ADHD) (which was based on parent report alone), were based on combined information from both the parent and child. The test-retest reliability (Angold and Costello, 1995; Costello et al., 1998) and construct validity of the CAPA have been wellsupported (Angold and Costello, 2000). Variables As with psychiatric diagnoses, school refusal status was based on combined information from both the parent and the child. The school refusal groups were defined using items from two sections of the CAPA. The school/work performance and behavior section addressed truant behaviors and the worry/anxiety over school attendance and separation anxiety section focused on anxious school-refusing behaviors. General absenteeism was not obtained for the children, but rather school resistance and nonattendance was based on the combination of relevant variables in these two sections. In both sections of the CAPA, a specific requirement of a half-day of absence was required 798 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003

SCHOOL REFUSAL COMMUNITY STUDY to meet criteria for the school nonattendance items. The school refusal variables were defined in the following way: Anxious school refusers were defined as those children who failed to reach or left school because of anxiety or children who resisted attending school because of anxiety so vigorously that they had to be taken to school by their parent at least once during the primary period. Four variables were included: school nonattendance (of at least a half-day s duration) due to worry/anxiety; staying home mornings from school because of anxiety; failing to reach school or leaving school and going home; and/or having to be taken to school because of worry and anxiety about attending school. Truants were defined as children who failed to reach or left school without the permission of school authorities, without an excuse (such as illness), and for reasons not associated with anxiety about separation or school at least once in the primary period. Four variables were included: skipping at least one-half day at school for reasons other than separation or school anxiety; staying home mornings; having to be taken to school to ensure arrival for reasons other than anxiety or emotional disturbance; and failing to reach school or leaving school before dismissal. Mixed school refusers were children who had been both anxious school refusers and truants during the 3-month primary period. Pure anxious school refusers endorsed only anxious school-refusing behavior and pure truants endorsed only truant behavior in the primary period. Non school refusers were children who did not resist or refuse to attend school for either reason during the primary period. Unfortunately, we did not have access to information from the school administration or teachers about the children s absences, school behavior, or school functioning. We also did not have information on mental retardation or learning disabilities. The DSM-IV psychiatric disorders (American Psychiatric Association, 1994) considered in this report included SAD, generalized anxiety disorder, simple phobia, social phobia, panic disorder, depression (major depression, depression-not otherwise specified, or dysthymia), CD, oppositional defiant disorder, ADHD, and substance abuse. We also examined the association between school refusal and specific fears and anxieties, sleep difficulties, and somatic complaints because these symptoms have been noted in the literature to be associated with school refusal. The associations between school refusal and peer relationships, as well as a broad portrait of psychosocial vulnerabilities, were also examined, to examine the hypothesis that adverse peer, school, and home experiences might contribute to the development of a child s fears and resistance to attending school and/or leaving his/her parent. We used a 26-item vulnerability scale created to reflect ongoing difficulties in the child s life and family that has been shown to be associated with psychiatric disorders (Costello et al., 2002). It included items that previous studies have identified as risk factors for school refusal. The scale included family environment problems, family relationship problems, and parental psychopathology. The 26 items are listed in Table 5. Data Analysis The principal statistical procedure used was logistic regression. To obtain properly adjusted estimates of the population parameters, we used the generalized estimating equations implemented in SAS PROC GENMOD. We used robust variance estimates (i.e., sandwich-type estimates), together with sampling weights, to adjust the standard errors of the parameter estimates to account for the two-phase sampling design and generate unbiased population parameter estimates and produce appropriate odds ratios (ORs) and 95% confidence intervals (CIs) (Diggle et al., 1994; Pickles et al., 1995). We also introduced a random effect to account for correlations between the scores of each individual across waves. The use of multiwave data with the appropriate sample weights thus capitalized on the multiple observation points over time, while controlling for the effect on variance estimates of repeated measures. We used both univariable and multivariable models to examine the association between school refusal and psychiatric disorders. The univariable models examined whether the different types of school refusal predicted the presence of a specific psychiatric disorder. In the multivariable models, we controlled for the effects of comorbidity by including the other major Axis I disorders as predictor variables, enabling us to determine the amount of the variance that was accounted for by a particular disorder. In all of the models, we controlled for the effects of age and gender, as well as for the other types of school refusal. Percentages reported were all weighted population estimates. Where cell sizes are given, they represent unweighted numbers of individuals in the sample. RESULTS Prevalence The 3-month prevalence of overall anxious school refusal was 2.0% (n = 165) and of truancy was 6.2% (n = 517). Anxious school refusers were 6.8 times more likely than children without anxious school refusal to be truant (OR = 6.8, 95% CI 3.1, 15; p <.0001). A quarter of anxious school refusers and 8.1% of truants were mixed school refusers (0.5% prevalence; n = 35). Table 1 describes TABLE 1 Characteristics of Three Types of School Refusal Mean Age of Frequency (Half- Prevalence Gender (F/M) Mean Age Onset Days Missed) Pure ASR 1.6% (130) 52.1%/47.9% 12.3 b 10.9 4.2 Pure truancy 5.8% (482) 34.9%/65.1% a 14.7 c 13.1 6.6 Mixed school 0.5% (35) 48.1%/51.9% 13.0 ASR: 10.9 Total: 34 refusal Truancy d : Due to anxiety: 16 Girls: 14.8 Due to truancy: 18 Boys: 10.6 Note: Weighted percentages (unweighted n). ASR = anxious school refusal; OR = odds ratio. a OR = 1.9 (1.3, 2.9), p =.002. b More common in younger children, OR for age in years = 0.8 (0.7, 1.0), p =.009. c More common in older children, OR for age in years = 1.6 (1.4, 1.7), p <.0001. d OR = 2.8 (1.5, 4.4), p =.0008. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003 799

EGGER ET AL. the prevalence, gender, and age characteristics and frequency of the three subtypes of school refusal. Psychopathology Table 2 presents data on the prevalence of psychiatric disorders in children with school refusal and the results of models testing whether school refusal predicted the presence of specific psychiatric disorders. The models labeled sole diagnosis (uncorrected) did not control for the effects of comorbid psychiatric disorders on the relationship between school refusal and the specific disorder. The models labeled multiple diagnoses (corrected), controlled for the effect of comorbid psychiatric disorders on the relationship between a specific diagnosis (e.g., SAD) and the subtypes of school. A quarter of children with pure anxious school refusal and with pure truancy had at least one psychiatric disorder, compared with 6.8% of children without school refusal. Nearly 90% of the children with mixed school refusal had a psychiatric disorder. We also found that accounting for the effects of comorbidity revealed different patterns of association between school refusal and psychopathology than were seen if only a single psychiatric diagnosis was examined. For example, all of the psychiatric disorders except panic disorder, ADHD, and substance abuse were found to be associated with pure anxious school refusal in an uncorrected model. Yet when we controlled for the effects of comorbid disorders, only depression and SAD remained significantly associated with pure anxious school refusal. Because simple and social phobia have been found to be associated with anxious school refusal in clinical studies, we examined why they both dropped out of the pure anxious school refusal multivariable model. Social phobia was highly predictive of simple phobia (OR = 75, 95% CI 10, 547; p.0001) and depression (OR = 6.3, 95% CI 1.2, 32; p =.03). When social phobia was removed from the multivariable model, the association between anxious school refusal and simple phobia was again significant (OR = 5.2, 95% CI 1.7, 16; p =.004). When simple phobia and depression were removed from the model, social phobia was significantly associated with pure anxious school refusal (OR = 4.0, 95% CI 1.6, 11; p =.004). The difference between the uncorrected and corrected models was not as stark for pure truants. In the multivariable model, CD, depression, and oppositional defiant disorder were associated with pure truancy. Only substance abuse dropped out. All of the disorders were associated with mixed school refusal in the uncorrected models, while in the corrected model SAD, CD, ADHD, panic disorder, and substance abuse were significantly associated with mixed school refusers. There were no significant age or gender effects on the association between the three types of school refusal and psychopathology. Associated Characteristics Symptoms Associated With School Refusal. Table 3 examines the association between three groups of symptoms (fears and worries, sleep difficulties, and somatic complaints) and school refusal. While pure anxious school refusers had significantly higher rates of separation fears and worries than children without anxious school refusal, the rates ranged from 5% to about 18%, suggesting that anxious school-refusing behavior was not synonymous with separation fears and worries. The only separation symptom significantly associated with the mixed school refusal was fear of what will happen at home while at school, which was found in 40% of these children. The other prominent fear for both the pure anxious school refusers and mixed school refusers was fear specific to the school situation. Again, these fears must be considered in light of the data in Table 4 on these same children s experiences with bullying and their difficulties in peer relationships. None of the fears and worries was significantly associated with pure truancy. Differing patterns of sleep difficulties were associated with the three types of school refusal, with nightmares and night terrors prominent in the mixed school refusers, depression-associated sleep symptoms associated with the pure truants, and depression and separation-associated sleep difficulties associated with the pure anxious school refusers. Somatic complaints were found in a quarter of pure anxious school refusers, 42% of the mixed school refusers, and very few of the pure truants. No significant age or gender effects were found for the associations detailed in Table 3. Peer Relationships. Table 4 shows the associations of school refusal with difficulty in peer relationships. The pure anxious school refusers appeared to have the most difficulty in peer relationships. They were significantly shyer, experienced being bullied or teased, and had difficulty in their peer relationships both because of withdrawal and increased conflict more often than nonschool refusers. The mixed school refusers were not more likely to be shy, but there was a trend suggesting that they were 800 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003

SCHOOL REFUSAL COMMUNITY STUDY Weighted Percentage (Unweighted n) With Disorder Pure TABLE 2 School Refusal and Psychiatric Disorders OR (CI) and p Values From Univariable (Uncorrected) and Multivariable (Corrected) Models Pure Anxious School Refusal Pure Truancy Mixed School Refusal Anxious Mixed Non- Sole Multiple Sole Multiple Sole Multiple School Pure School School Diagnosis Diagnoses Diagnosis Diagnoses Diagnosis Diagnoses Refusers Truants Refusers Refusers (Uncorrected) (Corrected) (Uncorrected) (Corrected) (Uncorrected) (Corrected) Any diagnosis 24.5% 25.4% 88.2% 6.8% 3.0 (1.8, 5.2) Not applicable 3.6 (2.4, 5.4) Not applicable 49 (21, 116) Not applicable (37) (134) (21) (490) p <.0001 p <.0001 p <.0001 SAD 10.8% 0.3% 14.4% 0.8% 11.0 (4.9, 24) 8.7 (4.1, 19) 1.0 (0.2, 4.1) 1.0 (0.2, 5.1) 19 (3.3, 110) 19 (5.3, 72) (30) (3) (4) (70) p <.0001 p <.0001 p = 1.0 p =.9 p =.001 p =.002 GAD 2.2% 0.6% 3.4% 0.8% 2.9 (1.0, 8.0) 0.2 (0.0, 1.4) 0.7 (0.2, 2.0) 0.2 (0.0, 1.1) 4.4 (1.0, 19) 1.3 (0.2, 11) (8) (6) (3) (57) p =.05 p =.1 p =.5 p =.06 p =.04 p =.8 Simple phobia 2.1% 0.2% 0 0.2% 11.0 (3.3, 39) 1.9 (0.2, 19) 0.6 (0.1, 3.8) 1.7 (0.1, 21) No cases (5) (2) (9) p =.0001 p =.5 p =.6 p =.7 Social phobia 3.2% 0.2% 0 0.5% 6.6 (2.6, 17) 1.4 (0.2, 9.7) 0.3 (0.1, 1.4) 0.2 (0.0, 8.4) No cases (11) (2) (22) p =.0001 p =.8 p =.1 p =.4 Panic 0.3% 0.2% 11.6% 0.2% 2.0 (0.2, 17) 0.4 (0.0, 5.6) 0.7 (0.1, 3.7) 0.2 (0.0, 4.2) 38 (11, 135) 5.7 (1.1, 31) (2) (3) (2) (18) p =.5 p =.5 p =.7 p =.3 p <.0001 p =.04 Depression 13.9% 7.5% 15.5% 1.6% 10 (4.1, 26) 13 (3.4, 42) 3.9 (1.9, 8.0) 2.6 (1.2, 5.6) 8.5 (3.1, 23) 0.8 (0.2, 2.7) (22) (31) (8) (118) p <.0001 p =.0001 p =.0002 p =.01 p <.0001 p =.7 ADHD 1.3% 0.5% 13.1% 0.9% 0.9 (0.2, 4.3) 0.8 (0.2, 3.1) 0.8 (0.3, 2.5) 0.5 (0.1, 2.0) 16 (2.2, 104) 13 (1.2, 132) (3) (5) (1) (99) p = 0.8 p =.8 p =.7 p =.3 p =.004 p =.03 ODD 5.6% 9.7% 17.9% 2.3% 2.3 (1.2, 4.4) 1.1 (0.5, 2.6) 3.8 (2.2, 6.5) 2.2 (1.2, 4.2) 8.8 (1.6, 47) 2.9 (0.2, 34) (16) (67) (8) (254) p =.009 p =.8 p <.0001 p =.01 p =.01 p =.4 CD 5.0% 14.8% 43.4% 1.6% 2.6 (1.2, 5.6) 1.9 (0.9, 4.2) 8.4 (4.4, 16) 7.4 (3.9, 14) 32 (9.5, 110) 17 (4.2, 66) (13) (79) (12) (180) p =.01 p =.1 p <.0001 p <.0001 p <.0001 p <.0001 Substance abuse 0 4.9% 13.1% 0.8% 3.1 (1.3, 7.1) 1.7 (0.6, 4.9) 25 (5.3, 119) 4.9 (1.4, 18) (36) (5) (44) No cases p =.0009 p =.3 p <.0001 p =.02 Note: Bold values have p.05. OR = odds ratio; CI = confidence interval; SAD = separation anxiety disorder; GAD = generalized anxiety disorder; ADHD = attention-deficit/ hyperactivity disorder; ODD = oppositional defiant disorder; CD = conduct disorder. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003 801

EGGER ET AL. TABLE 3 Symptoms Associated With School Refusal Pure Anxious Mixed Non School School Refusers Pure Truants School Refusers Refusers Weighted % OR (CI) Weighted % OR (CI) Weighted % OR (CI) Weighted % (n) p Value (n) p Value (n) p Value (n) Fears and worries Worries about leaving home 5.1% 15 (5.1, 47) 0.2% 2.4 (0.5, 12) 0.5% 1.3 (0.1, 19) 0.3% for school (14) p <.0001 (2) p =.3 (1) p =.8 (16) Fear of what will happen 16.7% 9.5 (4.5, 20) 0.5% 0.5 (0.2, 1.2) 40% 39 (6.5, 237) 1.7% at home while at school (27) p <.0001 (5) p =.1 (9) p <.0001 (112) Worry about harm befalling 17.7% 3.0 (1.5, 6.0) 4.3% 1.3 (0.6, 3.1) 6.1% 1.1 (0.3, 3.6) 4.8% parent (40) p =.001 (28) p =.5 (5) p =.9 (377) Worry about calamitous 5.5% 2.9 (0.9, 9.7) 0.6% 1.1 (0.4, 3.1) 1.4% 0.8 (0.1, 6.8) 1.4% separation from parent (9) p =.8 (6) p =.8 (1) p =.8 (90) Fear specific to school 35.5% 20 (10, 39) 0.7% 0.4 (0.2, 1.0) 54% 51 (14, 186) 2.4% p <.0001 p =.05 p <.0001 Performance anxiety 6.7% 4.5 (1.6, 12) 0.8% 0.6 (0.2, 1.5) 1.4% 0.9 (0.1, 7.6) 1.5% (14) p =.004 (8) p =.3 (1) p =.9 (103) Social anxiety 8.5% 2.1 (0.7, 6.1) 1.8% 0.6 (0.2, 1.9) 14.2% 4.6 (0.7, 31) 3.6% (17) p =.2 (10) p =.4 (2) p =.1 (190) Sleep difficulties Night terrors 18.1% 2.0 (0.7, 6.1) 13.5% 1.1 (0.6, 1.8) 31.6% 4.0 (1.6, 9.9) 9.7% (23) p =.2 (68) p =.8 (11) p =.003 (716) Nightmares 13.5% 1.6 (0.7, 3.9) 2.4% 0.6 (0.2, 1.8) 34.4% 7.4 (1.9, 28) 5.5% (27) p =.3 (18) p =.4 (10) p =.004 (392) Trouble falling or staying asleep 31.5% 2.6 (1.5, 4.5) 19.4% 1.6 (1.0, 2.3) 33.3% 2.4 (0.5, 10) 13.7% (45) p =.001 (104) p =.03 (12) p =.3 (888) Fatigue 12.1% 4.7 (1.9, 12) 10.4% 3.1 (1.7, 5.8) 15.3% 4.0 (1.5, 11) 3.2% (19) p =.001 (44) p =.0004 (8) p =.007 (188) Reluctant to sleep alone 8.1% 9.4 (2.9, 31) 0.2% 1.0 (0.2, 5.6) 10.2% 15 (2.0, 118) 0.7% (13) p =.0002 (2) p = 1.0 (1) p =.009 (45) Rises to check on family during 25.9% 6.4 (2.7, 15) 3.7% 1.4 (0.5, 4.3) 10.7% 2.9 (0.3, 7.6) 4.0% the night (35) p <.0001 (21) p =.3 (2) p =.3 (275) Somatic complaints with separation or school attendance Headaches and stomach aches 26.5% 22 (10, 45) 0.7% 0.8 (0.3, 1.9) 42.0% 52 (14, 194) 1.4% (41) p <.0001 (7) p =.6 (9) p <.0001 (99) Note: n = unweighted n; bold values have p.05. OR = odds ratio; CI = confidence interval. TABLE 4 Peer Relationships and School Refusal Non School Pure Anxious School Refusers Pure Truants Mixed School Refusers Refusers Weighted % OR (CI) Weighted % OR (CI) Weighted % OR (CI) Weighted % (n) p Value (n) p Value (n) p Value (n) Shy with peers 28.2% 2.5 (1.3, 4.6) 10.3% 1.0 (0.6, 1.7) 6.7% 0.7 (0.4, 1.3) 11.8% p =.005 p =.9 p =.3 Bullied/teased 28.9% 2.6 (1.3, 4.9) 8.5% 1.4 (0.7, 2.6) 31.2% 2.8 (0.7, 11) 9.6% p =.004 p =.3 p =.1 Difficulty making friends 18.9% 3.2 (1.5, 6.8) 5.6% 1.8 (0.9, 3.6) 17.8% 4.3 (0.8, 23) 4.8% because of withdrawal p =.003 p =.1 p =.09 Difficulty making friends 17.5% 4.5 (2.1, 9.7) 3.9% 1.3 (0.6, 2.7) 34.1% 11 (2.8, 41) 3.3% because of aggression p <.0001 p =.5 p =.0006 Conflictual peer relationships 27.0% 3.0 (1.3, 6.7) 16.2% 2.4 (1.3, 4.1) 22.1% 2.6 (0.7, 10) 8.7% p =.007 p =.003 p =.2 Note: n = unweighted n; bold values have p.05. OR = odds ratio; CI = confidence interval. 802 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003

SCHOOL REFUSAL COMMUNITY STUDY more likely to be teased or bullied. They also had difficulty making friends. The only significant association for the pure truants was that they were 2.4 times as likely to have conflictual relationships with their peers compared with nontruants. No significant age or gender effects were found for the associations detailed in Table 4. Stressors and Psychosocial Vulnerabilities. Table 5 shows the weighted percentage of children with school refusal who had experienced each of the 26 psychosocial vulnerabilities. In boldface type with ORs and p values are those vulnerabilities found to predict the three types of school refusal in multivariable models that controlled for the contribution of all of the vulnerabilities. The vulnerabilities associated with pure anxious school refusal were living in a single-parent home, attending a dangerous school, and having a biological or nonbiological parent who had been treated for a mental health problem. Pure truants were significantly more likely to live in an TABLE 5 School Refusal and Psychosocial Vulnerabilities Non School Pure Anxious School Refusers Pure Truants Mixed School Refusers Refusers Poverty 37.1% (47) 31.3% (179) 52.4% (16) 19.1% (1604) Trend 3.7 (0.8, 18); p =.1 Observed impoverished home 1.6% (5) 3.4% (28) 1.0% (2) 1.6% (152) 5.9 (1.7, 20); p =.005 Four or more siblings 2.5% (6) 4.8% (40) 0.5% (1) 3.4% (304) Time in foster care 4.9% (5) 3.2% (15) 3.3% (3) 1.9% (150) Moved > 4 times in last 5 years 9.0% (15) 7.0% (50) 41.3% (9) 7.8% (517) 6.1 (1.5, 25); p =.01 Child seen as sickly 2.1% (7) 0.4% (5) 0 0.8% (54) Single-parent household 44.0% (47) 45.9% (212) 41.7% (18) 21.8% (1530) 2.5 (1.4, 4.7); p =.004 2.8 (1.9, 4.0); p <.0001 Lives with a step-parent 15.9% (15) 16.2% (73) 12.2% (2) 13.2% (881) One parent an adoptive parent 2.2% (3) 8.4% (8) 4.7% (2) 3.6% (177) 3.4 (1.0, 12); p =.05 Parent(s) teenagers at child s birth 6.6% (10) 15.3% (79) 0.3% (5) 8.4% (572) 2.3 (1.2, 4.5); p =.01 Parent(s) without HS diploma 21.2% (39) 17.6% (124) 8.1% (11) 18.2% (1439) 0.2 (0.1, 0.7); p =.02 Parent(s) unemployed 15.1% (17) 12.0% (59) 41.7% (11) 9.0% (739) 4.6 (1.2, 17); p =.02 Lives in dangerous neighborhood 2.8% (7) 0.9% (8) 1.9% (2) 0.9% (77) Attends dangerous school 6.0% (7) 1.9% (12) 14.6% (4) 0.8% (70) 5.4 (1.5, 20); p =.01 9.9 (2.6, 38); p =.0008 Lax parental supervision 12.4% (18) 31.5% (167) 28.6% (16) 6.7% (599) 6.4 (3.9, 11.0); p <.0001 Trend 4.0 (0.9, 17); p =.06 Harsh disciplinary style 1.1% (4) 3.5% (17) 12.4% (2) 2.0% (132) Overprotective parenting style 0 1.6% (7) 2.8% (2) 0.8% (76) Child a scapegoat 2.6% (8) 5.3% (29) 2.9% (4) 2.2% (180) Violent/frequent arguments 1.9% (7) 2.5% (18) 23.8% (18) 1.7% (119) between parents 7.7 (1.7, 36); p =.009 Biological parent treated for 40.8% (51) 27.7% (146) 75.7% (19) 25.5% (1515) MH problem Trend 1.7 (0.9, 3.1); p =.08 6.2 (1.8, 22.0); p =.004 Nonbiological parent treated for 10.4% (10) 6.7% (28) 4.2% (3) 3.6% (273) MH problem 2.7 (1.1, 6.9); p =.04 Current maternal depression 13.5% (22) 11.9% (63) 13.6% (5) 5.5% (459) Biological parent treated for substance abuse 10.5% (20) 8.4% (59) 24.3% (11) 6.9% (634) Nonbiological parent treated for substance abuse 5.4% (6) 1.5% (7) 1.9% (2) 2.0% (189) Biological parent history of criminal conviction(s) 30.0% (46) 18.7% (122) 57.2% (14) 20.1% (1593) Nonbiological parent history of criminal conviction(s) 10.5% (10) 2.5% (18) 4.7% (3) 4.4% (401) Note: Values are weighted percentages (unweighted n); bold values also present odds ratios (confidence interval) and p values where p.10. HS = high school; MH = mental health. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003 803

EGGER ET AL. impoverished home (as observed by the interviewer), to live in a single-parent household, to have at least one adoptive parent, to have been born to teenage parents, and to have lax parental supervision. The most striking finding for the mixed school refusers was that three quarters had a biological parent who had been treated for mental health problems. Half lived in poverty; 41.3% had moved multiple times. The mixed school refusers were also more likely to have a parent without a high school diploma or an unemployed parent. Like the pure anxious school refusers, they were nearly 10 times more likely than non school refusers to attend a dangerous school. Like the pure truants, they were more likely to have lax parental supervision. DISCUSSION The prevalence, age, and gender characteristics of anxious school refusal and truancy were consistent with previous studies (Granell de Aldaz et al., 1984; King and Bernstein, 2001; Stickney and Miltenberger, 1998). Use of agnostic definitions of school refusal based on descriptions of the behavior rather than assumptions about etiology or associated psychopathology led to three main findings: (1) All three types of school refusal were significantly associated with psychiatric disorders. (2) We identified a subgroup of school refusers noted in two smaller community studies (Berg et al., 1993; Bools et al., 1990): mixed school refusers with both anxious school refusal and truancy. A startling 88% of mixed school refusers had at least one DSM-IV disorder and 75% had a biological parent who had been treated for mental illness, clearly suggesting that any level of mixed school refusal should be seen as a red flag alerting providers to a high risk of childhood psychopathology. (3) By separating school-refusing behavior from psychopathology, we found an overlap between emotional and behavioral disorders in all three types of school refusal. Like the community studies of Bools et al. (1990) and Berg et al. (1993), we found that school refusal was strongly associated with, but not synonymous with, psychiatric disorders. In our study three quarters of the children with pure anxious school refusal and pure truancy did not meet criteria for any psychiatric disorders. The rates of psychopathology found by Bools et al. and Berg et al. were higher than ours (50% in both studies), most likely because their study populations had severe manifestations of school refusal (e.g., children remanded to court for nonattendance or who had missed more than 40% of a term), while the children in our study had fairly mild school refusal (Berg et al., 1993; Bools et al., 1990). Nonetheless, we also did find a strong association between even these mild presentations of school refusal and psychiatric disorders. The rate of psychiatric disorders was three times greater for children with pure anxious school refusal or pure truancy than children without attendance problems. Our pure anxious school refusers were most similar to the anxious school refusers/school phobics identified in clinical studies. Like Kearney and Silverman (1996), we found that a wide range of psychopathology was associated with anxious school refusal, yet much of the apparent heterogeneity was due to the comorbidity of psychiatric disorders (Angold et al., 1999), not a primary relationship with anxious school refusal. When we accounted for the effects of comorbidity, children with pure anxious school refusal were specifically at increased risk for SAD and depression, with the relative risk of depression greater than for SAD, despite the fact that anxious school refusal is a symptom of SAD. The apparent association with simple and social phobias was actually mediated by the association between pure anxious school refusal and depression, not an independent relationship with anxious school refusal. These data also demonstrate that the association between depression and anxious school refusal was specific to school refusal, not simply the comorbidity between anxiety disorders and depression, a distinction that has been argued in the literature (Last and Strauss, 1990). These data also do not support the subtyping of anxious school refusers by types of anxiety disorder as proposed in the clinical literature (King and Bernstein, 2001). Similarly, the association between truancy and depression was not due to comorbidity between CD and depression, but was rather an independent relationship. Retrospective studies have shown links between childhood truancy and depression (Robins and Robertson, 1996). Further research into the longitudinal course of depressed versus nondepressed truants might provide insights into the interaction between antisocial behaviors, behavioral disorders, and depression. Truancy, a symptom of CD, was, as expected, strongly associated with CD. Yet the presence of CD did not distinguish truants from either pure anxious school refusers or mixed refusers. Links between anxious school refusal and noncompliance, tantrums, and aggression have been previously noted (Bernstein and Garfinkel, 1986; Cooper, 1966, 1986; Hersov, 1960b; Kearney and Silverman, 1996; 804 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003

SCHOOL REFUSAL COMMUNITY STUDY McShane et al., 2001; Smith, 1970), but few studies have found that behavioral disorders were associated with anxious school refusal. Most clinical studies of anxious school refusal have either used a definition of anxious school refusal that excluded children with CD or have used CD or truancy as study exclusion criteria. An exception is Bernstein and Garfinkel s (1986) study in which 23% (n = 6) of very severe anxious school refusers met criteria for CD. The nonsignificant trend linking pure anxious school refusal with CD and the strong association between mixed school refusal and CD suggest that refusal to go to school, whatever the underlying relationship with anxiety or fears, may have antisocial, oppositional aspects. These data highlight the importance of not using CD or behavioral symptoms as exclusion criteria for anxious school refusal. Assessments of anxious school refusers need to include behavioral symptoms and disorders so that treatments/interventions can target the full range of psychopathology. The mixed refusers were more severely affected than pure anxious school refusers and pure truants across multiple domains: the frequency of both types of schoolrefusing behavior was greater; their rate of overall psychopathology and the range of disorders was also greater; they had more nightmares and night terrors; and they experienced significantly higher rates of stressors. Their high rate of CD distinguished them from the pure anxious school refusers, while the associations with SAD and panic disorder, as well as with fears and worries, distinguished them from the pure truants. In a review of childhood anxiety disorders, Pine and Grun (1999) distinguished between unconditioned fear anxiety symptoms (i.e., panic, SAD, separation fears) and conditioned fear symptoms (i.e., specific or social phobia, social or performance anxiety), suggesting that separate, although related, neural pathways may underlie these two types of fear. The mixed school refusers had increased rates of panic and SAD symptoms (conditioned fear symptoms) but did not have increased rates of phobias or performance or social anxiety, while the pure anxious school refusers had a mixture of unconditioned and conditioned fear symptoms. The truants, on the other hand, did not have increased rates of anxiety disorders or either type of fears. We also found that having a biological parent treated for a mental health problem was significantly associated with both anxious school refusal and mixed school refusal but not truancy. These data suggest that there may be differences in the biological roots of the anxiety component of anxious school refusal and/or differences in how biological susceptibility interacts with social, psychological, or other biological risk factors to produce the subtypes of anxious school refusal. Symptoms Associated With School Refusal Hersov (1960a) found that disturbed sleep was one of the presenting symptoms of anxious school refusal, and Schmitt (1971) noted that anxious school refusers often presented to the pediatrician with insomnia or fatigue. We did find that separation-type (i.e., refusal to sleep alone) and depression-type (i.e., insomnia, fatigue) sleep disturbances were associated with anxious school refusal and depression-type sleep symptoms with truancy. Nightmares and night terrors were strongly associated with mixed school refusal, while there was a trend toward an association with pure anxious school refusal. We also found support for the association between anxious school refusal and somatic complaints (Bernstein et al., 1997). A triad of school refusal, sleep difficulties, and somatic complaints might alert pediatricians or family physicians to the presence of associated psychiatric disorders. Beyond Separation Fears Pilkington and Piersel (1991) have argued that the separation anxiety theory (and, we would add, a phobic theory) of anxious school refusal has failed to take into account the external variables that may be causing anxious school refusal. While our data support the association between separation fears and pure anxious school refusal, the prevalence of separation fears remained remarkably low considering the hypothesis that the school refusal arises from separation anxiety. Fear of school was the most common fear of pure anxious school refusers (35.5%) and mixed school refusers (54%). Children s fears of school might arise from external adverse experiences, rather than purely from internal conflicts. Their resistance to going to school or leaving home may not be excessive or unreasonable (i.e., phobic), but rather an appropriate response to real events. Recent research has supported the idea that school environment and peer effects contribute to behavior problems and school absences (Berg, 1992; Maughan, 2001). While we did not have information about the specific content of the children s school fears, we did have hints about the possible sources of their fear of school: pure anxious school refusers and mixed school refusers felt they attended a dangerous school more often than children without anxious school J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:7, JULY 2003 805

EGGER ET AL. refusal. A third were bullied and/or teased by peers. They had difficulty making and keeping friends. Conversely, the pure truants, who were not afraid of school, did not have difficulty making friends (although their relationships were more conflictual), were not bullied or teased, and were not more likely to feel their school was dangerous. Our data also supported previous findings that problematic family and social environments are associated with school refusal (Berg et al., 1993; Bernstein and Borchardt, 1996; Bernstein et al., 1990, 1999; Bools et al., 1990; Place et al., 2000). In particular, the mixed school refusers experienced multiple family stressors: half lived in poverty, 40% had an unemployed parent, 40% had moved more than four times in last 5 years, a third had inadequate parental supervision, a quarter witnessed violent and frequent arguments between parents, and as noted previously, three quarters had a parent who had been treated for a mental illness. Their worries about what might happen at home while they were at school, like their school fears, may have arisen from real experiences, and thus be conditioned, not unconditioned fears. Limitations A significant limitation of this study was the lack of specific data on the frequency, context, and function of the school-refusing behavior. Our characterization of the three groups of school refusers would have been strengthened by data from school administrators and teachers and the court system on school attendance, school and/or legal responses to absences, and classroom behavior. In the future, use of an assessment such as the School Refusal Assessment Scale (Kearney and Silverman, 1990, 1993) in a population-based study would help us to understand better not only the specific content of school-refusing behavior but also the functions these behaviors serve for the child and his/her family. Data on cognitive functioning with a specific focus on mental retardation, academic achievement, and learning disabilities would also have enabled us to examine how academic functioning and ability shapes children s aversion to school. Another limitation was that the sample was selected from school rolls, so our population might exclude children whose anxious school refusal or truancy was so severe that they dropped out of school. Thus our findings might underestimate the association with psychopathology. Clinical Implications These data should help parents, educators, and pediatricians recognize the importance of evaluating children with school attendance problems for psychiatric disorders. Even mild anxious school refusal and/or truancy warrants screening for psychopathology. There is good clinical evidence that anxious school refusal, particularly when coupled with an affective disorder, can be effectively treated with CBT or other behavioral interventions (Blagg and Yule, 1998; King et al., 1998; Last et al., 1998), although it is worth noting that the majority of children in these treatment trials met criteria for at least one anxiety disorder. The role of pharmacotherapy to treat anxious school refusal remains equivocal, although support for the use of selective serotonin reuptake inhibitors with anxiety disorders and depression in children points to their potential efficacy with anxious school refusers and truants (King and Bernstein, 2001). School-based interventions to decrease bullying in schools, improve school safety, as well as to teach social skills training to children who have difficulty making and maintaining peer relationships might also reduce a child s risk. 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