School refusal is characterized by refusal to attend or remain in school without attempts to conceal, and is often associated with anxiety. It affects around 3-5% of children, peaking between ages 5-6, 11-12, and 14-16. Symptoms include high anxiety, physical symptoms, and school-linked distress. Differential diagnoses include truancy, depression, and conduct disorder. Management involves early return to school, with most mild cases resolving rapidly. One third have poor long-term outcomes affecting education and relationships. Obsessive compulsive disorder is characterized by intrusive thoughts and repetitive rituals to relieve anxiety, affecting around 0.3-1% and often persisting into adulthood.

1. School Refusal & OCDSchool Refusal & OCD
Done by: Hisham Al-HammadiDone by: Hisham Al-Hammadi

2. School RefusalSchool Refusal
 Refusal to go to or to stay in school, without anyRefusal 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.

3. 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, abdominalPhysical 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 averageThe 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

4. Aetiology:Aetiology:

Individual factors: withdrawalIndividual factors: withdrawal

separation anxietyseparation anxiety

family factorsfamily factors

factors specific to schoolfactors specific to school

psychiatric disorders: depression, phobicpsychiatric disorders: depression, phobic
anxiety or other psychiatric conditions.anxiety or other psychiatric conditions.

5. Management:Management:
 recognition and differentiation from other causes ofrecognition 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 furthermost mild and acute cases resolve rapidly without any further
problems.problems.

Younger children with a stable family background have the bestYounger children with a stable family background have the best
prognosis.prognosis.

About a third of clinic cases are able to continue their educationAbout a third of clinic cases are able to continue their education
but will have emotional and social difficulties includingbut 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 theirOne third have poor outcome with serious implications on their
education.education.

6. 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, butRecognized by the person as unreasonable, silly or stupid, but
attempts made to resist this are usually associated with increase inattempts 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 tochecking, 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 associatedAre 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 andComplications include interference with school achievement and
peer relations, and physical sequelae such as dermatitis due topeer relations, and physical sequelae such as dermatitis due to
repeated washing rituals.repeated washing rituals.

7. Aetiology:Aetiology:
 Genetic factorsGenetic factors
 Psychodynamic theoryPsychodynamic theory
 Learning theoryLearning theory
 Biochemical theoriesBiochemical theories
 Organic brain disordersOrganic brain disorders

8. 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 thirdSymptoms persist into adult life in about a third
of cases.of cases.
 A first attack of mild obssessional symptomsA first attack of mild obssessional symptoms
have a good outcome, but chronic severe andhave a good outcome, but chronic severe and
intractable cases are difficult to treat and have aintractable cases are difficult to treat and have a
poor prognosispoor prognosis