Hello Mr. XXXXXXX
Welcome to Healthcare Magic and thanks for your query.

From your brief description, it appears that your son is having a 'school refusal' problem, for which the underlying cause may be separation anxiety. (In fact 80% of children with school refusal have separation anxiety as the underlying cause)

Now, separation anxiety is a part of a child's normal developmental process, usually starting at about 7 months of age; it is strongest between 10 and 18 months of age and gradually subsides by the age of 2 - 3 years. However, when there is persistence or development of separation anxiety beyond this age, it becomes a 'Separation Anxiety Disorder'.

From the information you have provided, I gather that your son has developed this problem only since 3 -4 months and also, it seems quite significant as he has not been going to school for the last 3 months. Such a sudden onset of severe separation anxiety and school refusal strongly suggests an underlying emotional distress or a recent onset stress.

So, the first important thing which needs to be done is a comprehensive evaluation, which will explore the possible reasons behind the school refusal / separation anxiety and can help determine what kind of treatment will be best. It is important to identify problems early and provide appropriate interventions to prevent further difficulties. The more prolonged is his absence from school, the more will be the later consequences on the child's social, emotional and educational development.

The next important thing to do is aim to put the child back in school as early as possible. This is because this behaviour can be reinforcing and the longer this is allowed, the more difficult it will be to get the child back to school.

Thirdly, it is also important to provide a sense of security for the child, both at home as well as at school, as this lack of security is often a cause fro separation anxiety. At the home environment, it is important to keep the child out of parental conflicts and family problems and there should be a co-ordinated and consistent approach in parenting / child care. You should also liaise with his school staff to ensure that his school environment is secure and comfortable.

Treatment predominantly involves psychological therapy / counselling. This will involve not only the child, but also the parents / other care-givers. For younger children, like your son, behavioural therapy is more appropriate. Behavioural therapy often involves a major role and effort form the parents and the most important thing is to be PATIENT AND CONSISTENT. In addition, if any underlying emotional / adjustment problems or depressive symptoms are identified, then they should be dealt with accordingly. Sometimes, medication may be required, especially if the symptoms are severe and disabling. Usually 'SSRI' medication or other anti-anxiety medication are used for short periods of time. A collaborative approach between the psychiatrist, parents and school staff yeilds the best results.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hello again...

I understand that this must be quite a distressful period for you and your family and your fears are justified. From the further information which you have provided, it is clearer that your child's underlying problem is a separation anxiety, which in turn is preventing him from going to school or being in any situation where he is separated from his primary 'attachment figure' (his mother). Such children often have a fear that something catastrophic may happen to the attachment figure or that they may be abandoned or lose their parents. So, whenever they are separated from them, they make desperate attempts which may even involve temper tantrums or aggressive outbursts.

You have mentioned that attempts by a therapist to explore any possible stressors were unsuccessful. This is because younger children of this age may not have the psychologically maturity or communicative ability to express their emotions. That is why for this age group, behavioural therapies are most effective. Now, behavioural therapy can be quite challenging and effort-taking, especially on the parents' side, but neverthless has to be undertaken with patience and consistence. Most behavioural therapies are based on the principle of 'de-sensitization' or 'exposure' where the child learns to overcome his fears after being exposed to the fearful situation which he has been avoiding. Initially, this is met with a lot of resistance from the child and this is where parents need to be careful not to give in to the child's fears but be consistent in their efforts. If not, the avoidance behaviour and the fear will only end up being more reinforced. On the other hand, whenever the child shows signs of independence, he should be praised and rewarded appropriately. It is important to take all these steps as early as possible, because the longer the child is absent from school the more difficult it becomes to return him.

As regards medication, like I had previously mentioned, they may be necessary in severe cases. SSRIs (a class of anti-depressant / anti-anxiety medication) are usually prescribed and these have proven to be effective and safe when used under the recomendation and supervision of a psychiatrist.

So, in summary, I would recommend the following:
- To consult a psychiatrist, preferably a child psychiatrist at the earliest.
- To apply and follow the behavioural techniques advised by your psychiatrist consistently (even it appears difficult initially).
- To return your child to school as early as possible (even if this may be by force or met with lots of resistance).
- To continually support and reassure your child and keep closely monitoring his progress in the near future .

Wish you all the best.

Kindly close the query if you are satisfied with the answer.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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