AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), separation anxiety is a fairly common anxiety disorder that consists of excessive anxiety beyond that expected for the child's developmental level related to separation or impending separation from the attachment figure (eg, primary caretaker, close family member) occurring in children younger than 18 years and lasting for at least 4 weeks.¹

Features include clinically significant symptoms of anxiety (ie, severe distress or impairment of function), unrealistic worries about the safety of loved ones, reluctance to fall asleep without being near the primary attachment figure, excessive distress (eg, tantrums) when separation is imminent, nightmares with separation-related themes, and homesickness (ie, desire to return home or make contact with the caregiver when the child is separated). In addition, physical/somatic symptoms (especially frequent in older children and adolescents), such as dizziness, lightheadedness, nausea, stomachache, cramps, vomiting, muscle aches, or palpitations, may be present and problematic, causing the child and family to seek medical treatment because of impaired ability to attend school or meet social responsibilities.

Pathophysiology

Separation anxiety is developmentally normal in infants and toddlers until approximately age 3-4 years, when mild distress and clinging behavior occur when children are separated from their primary caregivers or attachment figures (eg, being left in a daycare setting). Research results regarding hormonal influences during pregnancy and the neonatal period suggest that maternal endocrine activation during pregnancy (eg, exposure to adrenocorticotropic hormone [ACTH], dexamethasone, or conditions that cause their release) and/or early separation or loss (eg, the neonate not being raised by the original primary caregiver) may result in lower cortisol levels overall and may correlate later in development with clinically significant symptoms of anxiety, learned helplessness, and depression.

Some children may be more vulnerable to separation anxiety based on their temperament (ie, level of anxiety dealing with new situations) or based on environmental stresses such as the death of a close relative or an interactive pattern with an over-protective, needy, or depressed parent. Transient developmental fears (eg, fear of the dark) are generally normal and do not interfere with normal functioning or result in long-term developmental difficulty; however, studies show a subgroup of children who do not meet the criteria for diagnosis of an anxiety disorder but who may have substantial impairment later in life. Studies of children who, in first grade, present with significant symptoms of anxiety (enough to cause clinically significant impairment in social and academic functioning) reflect a correlation with significant impairment in reading and math achievement 5-6 years later.

Frequency

United States

The prevalence ranges from 1.3% in teenagers aged 14-16 years to 4.1-4.7% in children aged 7-11 years. In 1987, Burke et al reported that 5% of school-aged children are identified as school refusers.² In 2005, the Centers for Disease Control prioritized identifying why students do not graduate high school. As many as 40% of students who do not graduate high school have a diagnosable mental health disorder; up to half of those individuals may have anxiety disorders such as posttraumatic stress disorder (PTSD) and school phobia.

International

In 1990, Bowen et al reported a 2.4% overall prevalence rate.³

Mortality/Morbidity

Extremely rare instances of mortality occur in severe separation anxiety. In "mothering to death" cases in the United Kingdom, the primary caregiver of an initially physically healthy child (generally an only child) interacted with the child in such a way that the child was perceived and behaved as physically ill and helpless; as adults, these children functioned as dependent and feeble individuals. In one such case in the United Kingdom, the child became disabled and died.⁴ This example is reflective of unchanging dysfunctional parent-child interaction at home. This example is reflective of unchanging dysfunctional parent-child interaction at home.

• Mortality generally results from associated major depression that may lead to suicide.
• Long-term follow-up studies of children successfully treated for school refusal because of separation anxiety reveal some children with continued impairment of social functioning (ie, social and affective constriction) despite having returned to school; this may reflect the long-term impairment and morbidity and unchanging dysfunctional parent-child interaction at home.

Race

No specific differences in prevalence rates are noted for specific racial or cultural groups; however, somewhat increased incidence has been reported among families of lower socioeconomic status as well as single parent families.

Sex

The prevalence is approximately equal between males and females. In 1984, Granell de Aldaz et al reported that the prevalence of school refusal was equal for boys and girls.⁵

Age

Mean onset of separation anxiety disorder is at age 7.5 years. Mean onset of school refusal is at age 10.3 years.

• Separation anxiety disorder is most frequent among younger children. One study lists prevalence rates for children aged 7-11 years at 4.1%; the same study lists prevalence rates for children aged 12-14 years at 3.9% and a prevalence rate of 1.3% for adolescents aged 14-16 years.
• Separation anxiety disorder manifests slightly differently in different age groups. Children younger than 8 years tend to present with unrealistic worry about harm to their parents or attachment figures and school refusal. Children aged 9-12 years tend to present with excessive distress at times of separation (eg, sleepaway camp, overnight school trips). Adolescents aged 12-16 years more commonly present with school refusal and somatic problems involving autonomic symptoms, such as headaches, dizziness, lightheadedness, sweatiness, or GI or musculoskeletal symptoms (eg, stomachache, nausea, cramps, vomiting, muscle or body aches such as back pain or muscle tension).

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

History must be obtained from multiple informants, including the patient, parents or caregivers, and other pertinent persons such as teachers and coaches. Screen for features of depression (eg, anhedonia, insomnia, feelings of worthlessness) and ask the child directly about symptoms. The onset and development of symptoms as well as their context helps to establish the diagnosis of anxiety disorder. Noting whether anxiety is stimulus-specific, spontaneous, or anticipatory; if the symptoms result in avoidant behavior (ie, degree of constriction of daily life) that is clinically significant and disabling; and whether social and familial reinforcers of symptoms are present is helpful.

Pertinent educational, developmental, and family or social history should be obtained, including any family history of anxiety disorders and history of separations and losses, school attendance, academic functioning, presence of environmental stressors, and degree of involvement with peer group and social competence.

• Family history is extremely helpful in elucidating precipitating factors and should be obtained in a therapeutic manner so that the family feels the interviewer understands the emotional stress and is responsive to it.
• Separation anxiety disorder generally manifests with clinically significant symptoms of anxiety such as unrealistic and recurrent worries about harm of loved ones, especially when separated or faced with threatened separation from the primary attachment figure, along with severe distress and impairment in functioning. Severe distress and impairment in functioning may be indicated by the following signs:
• • Reluctance to fall asleep without being near the primary attachment figure
  • Excessive distress (eg, tantrums) when separation is imminent
  • Nightmares about separation-related themes
  • Homesickness (ie, a desire to return home or make contact with the primary caregiver when separated)
  • Frequent physical or somatic symptoms such as abdominal pain and palpitations
• The family frequently reinforces separation anxiety symptoms. For example, when the family experiences a major life stress or illness and the child expresses mild refusal to leave the primary caregiver (who may be anxious, distressed, or depressed), the child is not firmly encouraged to appropriately separate and instead is rewarded either overtly or covertly not to separate (ie, when the child who refuses to leave is given extra attention or when the child who refuses to attend school is excused by the parent). In these instances, the parent does not clearly give the child the task of developing strategies to adapt to the separation.
• Separation anxiety is often the precursor to school refusal, which occurs in approximately three fourths of children who present with separation anxiety disorder.
• Boys and girls do not significantly differ in symptom presentation.
• In general, younger children may be referred more often because older children usually present with somatic symptoms, which may not be as clearly correlated with situations of imminent or actual separation from attachment figures.

Physical

Generally, somatic symptoms, such as palpitations or abdominal pain, have no clear physical origin. However, a careful physical examination with appropriate blood work is recommended to rule out physical causes, including occult serologic streptococcal infection; hyperthyroidism; hypothyroidism; mitral valve prolapse; asthma; or GI infection, inflammation, bleeding, or ulceration.

• When approaching the child and family, reassure both the child and family that somatic symptoms are indicators of a problem that is serious and requires attention. Psychological interventions should proceed simultaneously with medical evaluations.
• To help prevent secondary gain, encourage the child and family to live as normal a life as possible (despite the symptoms) to prevent worsening impairment of functioning. This includes returning to school immediately if school refusal is an issue.
• To help prevent secondary complications, do not be overzealous in the workup for a physical etiology of the somatic problems; however, do be prudent.

Causes

Studies show that children of adults with anxiety disorders have higher rates of anxiety disorders. Experts have postulated that early and traumatic separation from the attachment figure (as well as a family history of anxiety disorders or depression in first-degree relatives) may increase the likelihood of the child and, later on, the adolescent or adult developing separation anxiety disorder, school phobia, and depressive-spectrum disorders. Examples of early and traumatic separation include a prolonged stay away from the primary caregiver during the neonatal period, later sudden hospitalization, and early loss of attachments because of death or divorce. Hormonal changes (eg, exposure prenatally to increased levels of ACTH), which may result from stress, may also increase the likelihood of these disorders.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Posttraumatic stress disorder
Specific phobias
Inappropriate academic placement
Avoidance of school because of fear of violence (eg, gang-related violence) or teasing
Truancy
Conduct disorder
Substance abuse or dependence
Depression (Note that depressed or anxious children are commonly teased.)
Grief reaction
Brain tumor (if associated with vision or coordination impairment)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Consider the following tests to rule out possible conditions only when clinically pertinent and age relevant.
• • Triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone (TSH) - To rule out thyroid abnormalities
  • Two-hour postprandial glucose - To rule out type I or type II diabetes mellitus
  • Titers (especially with a history that includes fever, rash, or sore throat with incomplete or no treatment [with antibiotics] and history of acute change in personality or anxiety or obsessive features) - For antistreptococcal antibodies (ASO titer), Babesia (to rule out babesiosis), Lyme disease, and rickettsial illness (eg, Rocky Mountain spotted fever)
• Blood level of lead and other heavy metals such as mercury - To rule out lead or heavy metal poisoning (abdominal pain)
• CBC count, hematocrit (Hct) level, hemoglobin (Hgb) concentration - To rule out the presence of anemia, for example, as a cause of abdominal pain
• Drug screen of urine for drugs of abuse - To rule out stimulant or steroid abuse

Imaging Studies

• If other information suggests brain tumor or seizure disorder, perform appropriate imaging studies (eg, MRI, CT scanning, positron emission tomography [PET] scanning).
• Obtain an echocardiogram with functional examination to rule out mitral valve prolapse or other structural cardiac abnormalities (eg, regurgitation).

Other Tests

• Functional behavioral assessment should include specific observations of the child's symptoms and behaviors; note frequency, intensity, location, and proximity to caregiver.
• Family assessment is often extremely helpful. Family therapy can reveal whether intergenerational factors maintain or worsen symptoms as well as improve dysfunctional patterns of family communication and interaction. In the family assessment, the style of relatedness of the family should be described; enmeshed versus disengaged family stressors, including losses (especially if proximate to the start of symptoms), and family history of anxiety, alcoholism, somatoform, or mood disorders should be noted.
• Family history of school refusal (especially in mothers) is also helpful because it may correlate with separation anxiety disorders in the child.
• History of prominent anxiety symptoms in either the child or parents in certain situations (eg, preanesthesia, perianesthesia) may correlate with phobic or anxious symptoms in the child at a different time (ie, postanesthesia).
• Perform a structured or semistructured interview to determine whether a risk of suicidal ideation is present.
• Structured or semistructured interview scales are extremely helpful in confirming the clinical diagnosis and should be administered by clinically experienced personnel (eg, child and adolescent psychiatrists, developmental and behavioral pediatricians, clinical psychologists, social workers). The following are examples of structured or semistructured interview scales to assess anxiety disorders in children and adolescents:
• • Schedule for Affective Disorders and Schizophrenia for School-Age Children–Epidemiologic Version-5 (K-SADS-E5)
  • Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL)
  • Diagnostic Interview for Children and Adolescents Revised (DICA-R)
  • National Institute of Mental Health Diagnostic Interview Schedule for Children (DISC)
  • Anxiety Disorders Interview Schedule for Children (ADIS)
  • The Hamilton Anxiety Rating Scale
  • The Anxiety Rating Scale for Children (Revised)
  • Multidimensional Anxiety Scale for Children (MASC)
  • Revised Children's Manifest Anxiety Scale
  • Visual Analogue Scale for Anxiety (Revised)
  • Interview Schedule for Anxiety Disorders for DSM-IV (Child Version)
  • Social Anxiety Scale for Children (Revised)
  • Child Behavior Checklist

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

The goal of treatment is to facilitate the child returning to normal developmental functioning. The child with separation anxiety needs to be able to tolerate normal separation from caregivers without distress or impairment of functioning. The child or adolescent with concomitant school refusal should consistently attend school without subjective experiencing of distress. Placing the child on homebound instruction is contraindicated.

The multidimensional model of treatment includes the following approaches:

• Cognitive-behavioral therapy is associated with the shortest duration of treatment (mean 6 mo) and best outcome, with some studies showing 83% of children attending school at 1-year follow-up. Cognitive therapy attempts to restructure the child's thoughts and actions into a more assertive and adaptive framework. Also included are systematic desensitization and exposure and operant behavioral techniques to facilitate successful separation of the child from the parent as well as a rapid return to typical life such as attendance of school close to 100% of the time. Identification and recognition (including being able to articulate the feeling) of somatic symptoms related to anxiety as well as the creation of a new functional response to deal with symptoms are central to successful behavior change. Modeling, role-playing, relaxation techniques, and reward systems for behavior change are examples of cognitive-behavioral therapies.
• Pharmacologic therapy should be used along with other therapies in an adjunctive manner when the level of functional impairment is moderate to severe to prevent further loss of function and to facilitate or hasten positive outcomes of behavioral interventions.
• • Before and during a trial of fluoxetine (Prozac), the only selective serotonin reuptake inhibitor (SSRI) approved by the US Food and Drug Administration (FDA) for use in those younger than 18 years, the clinician must closely monitor the patient for new-onset self-harm or suicidal behavior or ideation.
  • Recent placebo-controlled studies by the FDA have shown that the risk of self-harm and potentially suicidal behavior is 1.5-3.2 times greater with paroxetine or venlafaxine and other serotonin-norepinephrine reuptake inhibitors (SNRIs), except for fluoxetine, sertraline, and citalopram, than with placebo. The FDA requires a black box warning because of this increased risk.
  • Although initial studies had shown improved response to paroxetine (Paxil), this medication should be used only in those older than 18 years (for adjunctive pharmacologic treatment) and with caution because it must be dosed twice daily to prevent withdrawal symptoms that seem to be associated with increased risk of new-onset suicidality or self-harm.
• In the psychodynamic approach, a child-oriented and trained mental health professional usually delineates the psychologic rationale (whether conscious or unconscious) for the child's symptoms and behaviors. Individual psychodynamic therapy (play used as the modality for younger or nonverbal children) at least twice a week results in the best outcome (>70% improvement). More frequent treatment of 3-4 times per week for 6 months helps the child or adolescent work through feelings and reactions to the upsetting situations and encourages the child or adolescent to behave in a different manner.
• Family therapy includes obtaining history of family members for psychosomatic symptoms, anxiety disorders (eg, agoraphobia), depression, and alcoholism as well as facilitating communication to change dysfunctional patterns within the family. These patterns may serve to maintain the child feeling unable to separate from attachment figures (eg, loyalty conflicts). These family actions may cause the family to unwittingly encourage the child in the ill role.
• Social therapy includes gathering history regarding other factors that may have an impact on or explain the child's behavior. Determine if the child is refusing school for nonseparation issues, such as avoiding the school bully or gang, hiding academic problems (ie, developing abdominal pain on test day only), or refusing school because of anticipation of school failure. These symptoms usually reflect other factors that contribute to the child not wishing to attend school, such as learning disorders or inappropriate school placement.

Consultations

Consultation with child and adolescent psychiatrists or behavioral/developmental pediatric specialists is helpful to coordinate treatment efforts and reduce unnecessary medical procedures. This helps in gathering a complete history, including information from the parents, teachers, school staff, and peers.

Many specific structured and semistructured scales for anxiety disorders are used by mental health professionals (see Other Tests). They include the MASC from Duke University, the Screen for Child Anxiety Related Emotional Disorders (SCARED) from the Western Psychiatric Institute and Clinic, the Separation Anxiety Test from the University of Washington, and the DICA. The specific anxiety scales are not diagnostic but can be helpful for measuring response to therapeutic interventions such as medications and cognitive-behavioral therapy.

Diet

No diet has been proven helpful. No vitamin supplements have been proven helpful, although vitamin B-6 and magnesium seem to have been given to children with a multiplicity of behavioral disorders without benefit and potential harm (nerve impairment, intestinal difficulties).

Activity

No restrictions on activity apply.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medication treatment has proven effective as adjunctive treatment along with cognitive-behavioral therapy for both separation anxiety and school refusal and may hasten return to normal activities. Medication as the only treatment should not be used initially as treatment for separation anxiety disorder.

Neuroleptics (ie, antipsychotic agents) are contraindicated in separation anxiety disorder. Cases of children with Tourette syndrome have been reported in which separation anxiety disorder develops after initiation of haloperidol or pimozide or other neuroleptic medication. Associated weight gain with neuroleptics, particularly olanzapine, may increase later risk for potentially life-threatening cardiovascular disease due to persistent elevation of serum cholesterol and triglycerides, either because of the direct effect of the neuroleptic or secondarily because of the effects of weight gain on turnover of cholesterol and related compounds within the body.

Drug Category: Antidepressant agents

Historically, tricyclic antidepressants (TCAs) such as imipramine have been used for years in children as treatment of enuresis. However, concerns have arisen regarding their safety in these patients because cases of sudden cardiac death have occurred despite monitoring of serum blood levels and ECGs. Furthermore, other adverse effects have been noted, including hypotension, dry mouth, and glaucoma.

TCAs, such as imipramine (Tofranil), are not recommended for the first-line treatment of separation anxiety disorder and school refusal; however, the FDA has approved these medications for pediatric use as long as the substantial risk of mortality and morbidity in overdose is carefully monitored.

In the past, SSRIs have been recommended for first-line pharmacologic treatment of separation anxiety disorder because of efficacy; however, except for fluoxetine (Prozac), the FDA has not approved most selective serotonin reuptake inhibitors (SSRIs) for use in children younger than 12 years. Safety concerns because of complications (eg, increased risk of suicidal ideation or plan or disinhibition with aggression) preclude their current use in children and adolescents unless the patient's response is closely monitored (weekly basis for at least the first month) or unless the patient has had a past history of good response to SSRIs or SNRIs.

Prozac (fluoxetine) is currently the only SSRI approved for use in children and adolescents and at this time is only approved for the treatment of depression or obsessive-compulsive disorder. SSRIs have proven unparalleled relative safety in overdose and few cardiac or anticholinergic adverse effects. Efficacy studies of medication use for separation anxiety have shown promising results with respect to SSRIs and symptom remission; however, practitioners are advised against prescribing SSRIs, specifically paroxetine or venlafaxine, in children and adolescents.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of depressive illness. After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.⁶ This is the largest study to date to address this issue.

Currently, evidence does not associate obsessive-compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.

Children at high risk for pediatric bipolar mood disorder (ie, positive first-degree family history for bipolar disorder or alcoholism along with history of aggression, impulsivity, and/or sleep disturbances related to initiation or maintenance of sleep) should be administered SSRIs with caution because hypomania or frank mania or psychosis along with behavioral disinhibition may result.

Drug Category: Anxiolytic agents

These agents reduce anticipatory and acute situational anxiety, as well as reduce muscle tension symptoms. Reduce symptoms in panic disorder. They are not first-line treatment in children or adolescents because of concerns regarding drug dependence, withdrawal symptoms, and tolerance.

Drug Category: Antihistamines

No controlled studies are available to evaluate efficacy in separation anxiety disorder; however, possible adverse effects include a decrease in sleep latency and in mid sleep awakenings.

Drug Category: Beta-adrenergic blocking agents

These block the physiological symptoms of anxiety and inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Weekly individual and family behavioral therapy, including cognitive-behavioral methods, is recommended to practice overcoming resistance to normal separation as well as to practice communicating differently as a family.
• Play therapy can be extremely helpful, especially for children who have had to undergo medical procedures or surgery.

Deterrence/Prevention

• Psychoeducation with the family so that the child is rewarded for developmentally appropriate actions and does not receive secondary gain from the symptoms of school refusal or separation anxiety disorder
• Preparation of children before medical or surgical procedures to help them feel less helpless in the situation

Complications

• Truancy
• Major depression
• Substance abuse or dependence

Prognosis

• The prognosis is good with early detection and treatment involving the family of the child.

Patient Education

• Note that prevention of separation anxiety and school refusal begins with professional recognition of excessive attachment disorder and dynamics. Such prevention begins during yearly checkups in the pediatrics office, with discussions of healthy separation techniques. Educate families regarding healthy ways to deal with the inevitable stresses that occur in families with children and healthy ways to deal with sibling rivalry.
• Recommend support for parents who may also have concurrent mental health or substance abuse issues. Address family violence prevention. Address any parental issues related to a sense of loss or feeling of abandonment or loneliness once the child or adolescent returns to a normal level of functioning and no longer requires the intense level of interaction with the parent or parents.
• For excellent patient education resources, visit eMedicine's Anxiety Center and Mental Health and Behavior. Also, see eMedicine's patient education articles Anxiety, Panic Attacks, Hyperventilation, and School Refusal.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Medically necessary homebound school instruction is not recommended in this situation because it may prolong the child's symptoms and increase the severity of symptoms because of secondary gain increases. The child must return to school as quickly as is medically and socially possible.
• Return to other normal duties should be recommended gradually to prevent the child and family from intensifying anxiety and prematurely dropping out of treatment. School attendance, however, is not negotiable.
• Prevention of school anxiety and refusal includes the following activities:
  • Trials of brief separations between parent and child before the first day of school
  • Visitation to a new school or classroom before classes start
  • Positive preparation for the first day of school
    • Procurement of school supplies
    • Arrangement of suitable familiar transportation arrangements to get to school
    • The possibility of setting up, in advance, phone time to call home to prevent undue anxiety

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Nov 27, 2007