School Refusal & OCDSchool Refusal & OCD

Done by: Hisham Al-HammadiDone by: Hisham Al-Hammadi

School RefusalSchool Refusal

Refusal to go to or to stay in school, without any Refusal to go to or to stay in school, without any attempts to conceal.attempts to conceal.

Often associated with anxiety.Often associated with anxiety. Sometimes called school phobia.Sometimes called school phobia.

Prevalence:Prevalence: Around 3% in children with a psychiatric disorder.Around 3% in children with a psychiatric disorder. Around 5% among referrals to CPCAround 5% among referrals to CPC Both sexes are equally affected.Both sexes are equally affected. The incidence peak during three periods of school life:The incidence peak during three periods of school life:

Age 5 and 6.Age 5 and 6. Age 11 and 12.Age 11 and 12. Age 14 to 16.Age 14 to 16.

Clinical picture:Clinical picture:

High level of anxietyHigh level of anxiety Onset is usually gradual, or may be acuteOnset is usually gradual, or may be acute Physical symptoms like: headache, nausea, abdominal Physical symptoms like: headache, nausea, abdominal

pain and palpitations.pain and palpitations. The symptoms are usually school day linkedThe symptoms are usually school day linked The child is usually a good student and of average The child is usually a good student and of average

scholastic ability.scholastic ability.

Differential diagnosis:Differential diagnosis: TruancyTruancy Depressive disorderDepressive disorder Conduct disorderConduct disorder Physical illnessPhysical illness

Aetiology:Aetiology:

Individual factors: withdrawalIndividual factors: withdrawal separation anxietyseparation anxiety family factorsfamily factors factors specific to schoolfactors specific to school psychiatric disorders: depression, phobic psychiatric disorders: depression, phobic

anxiety or other psychiatric conditions.anxiety or other psychiatric conditions.

Management:Management:

recognition and differentiation from other causes of recognition and differentiation from other causes of school non-attendance.school non-attendance.

attempt should be made for an early return to school.attempt should be made for an early return to school.

Outcome:Outcome: most mild and acute cases resolve rapidly without any further most mild and acute cases resolve rapidly without any further

problems.problems. Younger children with a stable family background have the best Younger children with a stable family background have the best

prognosis.prognosis. About a third of clinic cases are able to continue their education About a third of clinic cases are able to continue their education

but will have emotional and social difficulties including but will have emotional and social difficulties including relationship problem in adult life and some develop agoraphobia.relationship problem in adult life and some develop agoraphobia.

One third have poor outcome with serious implications on their One third have poor outcome with serious implications on their education.education.

Obsessive compulsive disorder:Obsessive compulsive disorder: These disorders are characterized by obsessions such as thoughts. These disorders are characterized by obsessions such as thoughts.

Ideas or images that are repetitive, intrusive and persistent.Ideas or images that are repetitive, intrusive and persistent. Recognized by the person as unreasonable, silly or stupid, but Recognized by the person as unreasonable, silly or stupid, but

attempts made to resist this are usually associated with increase in attempts made to resist this are usually associated with increase in anxiety.anxiety.

Compulsions have a similar quality and include repetitive rituals, Compulsions have a similar quality and include repetitive rituals, checking, washing, cleaning, counting etc that are carried out to checking, washing, cleaning, counting etc that are carried out to neutralize or prevent discomfort or anxiety.neutralize or prevent discomfort or anxiety.

Are recognized as senseless or excessive, and are often associated Are recognized as senseless or excessive, and are often associated with marked distress or impairment in functioning.with marked distress or impairment in functioning.

Prevalence:Prevalence: Is around 0.3 to 1%.Is around 0.3 to 1%. Most cases of adult OCS have an onset in childhoodMost cases of adult OCS have an onset in childhood OCD may be secondary to other disorders such as anxiety, OCD may be secondary to other disorders such as anxiety,

depression, schizophrenia.depression, schizophrenia. Complications include interference with school achievement and Complications include interference with school achievement and

peer relations, and physical sequelae such as dermatitis due to peer relations, and physical sequelae such as dermatitis due to repeated washing rituals.repeated washing rituals.

Aetiology:Aetiology:

Genetic factorsGenetic factors Psychodynamic theoryPsychodynamic theory Learning theoryLearning theory Biochemical theoriesBiochemical theories Organic brain disordersOrganic brain disorders

Treatment:Treatment:

Behavioral techniques and family involvementBehavioral techniques and family involvement Antidepressant drugsAntidepressant drugs Serotonin reuptake inhibitorsSerotonin reuptake inhibitors

Outcome:Outcome: Symptoms persist into adult life in about a third Symptoms persist into adult life in about a third

of cases.of cases. A first attack of mild obssessional symptoms A first attack of mild obssessional symptoms

have a good outcome, but chronic severe and have a good outcome, but chronic severe and intractable cases are difficult to treat and have a intractable cases are difficult to treat and have a poor prognosispoor prognosis