We have studied 29 school phobic youngsters (14 boys and 15 girls), of mean age 12 years 10 months (S.D. = 14.7 months) shortly before admission to an adolescent psychiatric in-patient unit. The diagnosis was made when there was severe difficulty in attending school, severe emotional upset at the prospect of having to go to school, staying home during school hours with the parents' knowledge and absence of significant anti-social disorders. Information was gathered from the patient and one parent, usually mother. Most youngsters had completely refused to go to school (23) and the remainder went occasionally with great reluctance; this seemed to depend on the attitudes of parents, school and medical agencies. Psychoses, gross physical illness, truancy, and neurotic disturbances other than school phobia resulting in absence from school were excluded. The cases were classified, reliably, into 19 ‘acute’ (11 boys, 8 girk) and 10 ‘chronic’ (3 boys, 7 girls) school phobics. This was done on the criterion of previous severe reluctance to attend school: at least 3 years of trouble-free attendance led to a classification as ‘acute’, the remainder were ‘chronic’. The mean age of the acutes (13 years 1 month) was significantly higher (P<0.001) than that of the chronics (12 years 3 months). In the acutes, the school phobia had been present 5 months (S.D. =3.5 months) on average in the boys, and 1 year 5 months (S.D. = 16.5 months) on average in the girls; which was a significant difference (P<0.02). The mean time between onset of symptoms and complete refusal was 3.5 months [boys-2 months (S.D. = 2 months) girls-6 months (S.D. = 9 months)]. The following features did not show significant differences between the acutes and chronics; social class of the patient's father (the typical social class was 5a on the Hall and Jones Scale of Occupational Prestige for Males), the mean age of mother when the child was bom, the number of only or youngest children in the family, birth complications, the number of severe illnesses, accidents and operations added to separations from mother in the first decade, missing some school without the parents' knowledge, suicidal gestures, the occurrence of symptoms on transfer to secondary school, somatic symptoms, frank mental illness in parents and I.Q. (W.I.S.C. total score); 4 acute cases had symptoms coming on following a bereavement.

SYNOPSISInterviews were conducted with parents of 100 children taken to a ‘School attendance committee’, because of persistent failture to attend School. Clinical assessmen t of the attendance problem was carried out so that children were categorized as ‘School refusers’ (N = 24), ‘truants’ (N =53), ‘both refusers and truants’ (N =9), or as ‘neither’ (N =14). Any ICD-9 psychiatirc disorder was separately identified. Cluster analysis of information collected in a standard way indicated that there was a group of children with the features of ‘School refusal’ who often had genralized neurotic disorders as well and who were mostly girls, another group with the feature of ‘truancy’ all of whom had conduct disorders who were mainly boys, and a third cluster of childrsen who were usually ‘truants’ but less often psychiatrically disturbed. The study provided evidence for the existence of School refusal with and without generalized neurotic disturbance in a non-clinical population.

Severe school attendance problems, which once commanded a great deal of attention in child and adolescent psychiatry, have fallen from favour and are increasingly viewed as varieties of social impairment which may accompany disorders such as anxiety disturbances in the case of school refusal and conduct disturbances in the case of truancy. It is argued that this relegation of school attendance difficulties may have gone too far. As presenting complaints, albeit sometimes masked by apparent physical illness, they still have much to recommend them as indicators of a wide variety of present and future problems: educational, social, family, legal, medical, and, last but not least, psychiatric. Prevalence, features, causative factors, outcome, and management are discussed. Particular attention is paid to DSM and ICD classification. Gaps in present knowledge are indicated.

Eighty 13-15-year-old children who failed to attend one of four schools for more than 40% of a term, without good reason, were studied. A systematic schedule (C.A.P.A.) was used in interviewing parents and children. Twenty-five had DSM-III-R Disruptive Behaviour Disorders and 15 had Anxiety/Mood Disorders. Truancy was associated with the former and school refusal with the latter but both often occurred without any Disorder. Fourteen children had neither school refusal nor truancy. Compared to controls, poor attenders came from materially disadvantaged homes. School refusal with anxiety disorders rarely received psychiatric treatment. Non-disturbed absentees were not usually dealt with appropriately.