Prevalence of psychiatric comorbidity and associated sociodemographic factors in children and adolescents with school refusal

Seda Aybüke Ozsagir; Elif Abanoz; Beyza Karatas Bozok; Oya Gulesen Kapan; Nazmiye İnce; Ayla Uzun Cicek

doi:10.17944/interdiscip.1803809

Prevalence of psychiatric comorbidity and associated sociodemographic factors in children and adolescents with school refusal

Abstract

Objective: To examine the sociodemographic and clinical characteristics of children with school refusal, identify accompanying psychopathologies, and investigate the relationship between comorbid psychopathologies and the severity of school refusal and demographic features. Method: The study included 52 children and adolescents aged 7-16 who presented to a child and adolescent psychiatry clinic between November 2023 and November 2024 with reluctance to attend school and a diagnosis of school refusal. The researcher administered a questionnaire to participants that included sociodemographic data and questions related to school refusal. Children were asked to complete a school refusal rating scale. Semi-structured psychiatric interviews were conducted with children and their families to identify psychopathologies accompanying school refusal in children. Results: Of the cases, 48.1% were male, and 51.9% were female. The mean age was 12.31±2.73 years. At the time of referral to the outpatient clinic, more than two-thirds of the children had never attended school. More than two-thirds of the cases were accompanied by at least one psychopathology, and this rate was significantly higher in males. The most common comorbid psychopathologies were generalized anxiety disorder, major depression, and separation anxiety disorder. In the younger age group, somatic complaints were statistically significantly more frequent, and separation anxiety disorder was more commonly comorbid. No significant relationships were found between school refusal rating scale scores and demographic data, clinical characteristics, or comorbid psychopathology. Conclusion: School refusal is one of the child psychiatric emergencies that causes serious academic, social, and psychological problems in children and adolescents in the short and long term. Furthermore, the presence of accompanying psychopathology further worsens the prognosis. Therefore, understanding the demographic and clinical factors in these children, examining their relationship with comorbidity, and addressing these factors in clinical practice will positively influence intervention processes and prognosis.

Keywords

Ethical Statement

Ethical permission was obtained from the Sivas Cumhuriyet University, Medical Faculty Clinical / Human Research Ethics Committee for this study with date 19.10.2023 and number 2023-10/26, and Helsinki Declaration rules were followed to conduct this study.

References

Ingul JM, Havik T, Heyne D. Emerging school refusal: A school-based framework for identifying early signs and risk factors. Cogn Behav Pract 2019;26(1):46–62. https://doi.org/10.1016/j.cbpra.2018.03.005
Heyne D, Gren-Landell M, Melvin G, Gentle-Genitty C. Differentiation between school attendance problems: why and how? Cogn Behav Pract 2019;26:8–34. https:// doi. org/ 10. 1016/j. cbpra. 2018. 03. 006
Leduc K, Tougas AM, Robert V, Boulanger C. School Refusal in Youth: A Systematic Review of Ecological Factors. Child Psychiatry Hum Dev 2024 Aug;55(4):1044-1062. doi: 10.1007/s10578-022-01469-7.
Suveg C, Aschenbrand SG, Kendall PC. Separation anxiety disorder, panic disorder, and school refusal. Child Adolesc Psychiatr Clin N Am 2005;14(4):773-95, ix. doi: 10.1016/j.chc.2005.05.005.
Heyne D, Brouwer-Borghuis M. Signposts for School Refusal Interventions, Based on the Views of Stakeholders. Contin Educ 2022;3(1):25-40. doi: 10.5334/cie.42.
Garfi J. Overcoming School Refusal: A practical guide for teachers, counsellors, caseworkers and parents. Australian Academic Press, 2018.
Hanna GL, Fischer DJ, Fluent TE. Separation anxiety disorder and school refusal in children and adolescents. Pediatr Rev 1 Febbraio 2006;27(2):56–63. https://doi.org/10.1542/pir.27-2-56.
Kearney CA. Functional impairment guidelines for school attendance problems in youth: Recommendations for caseness in the modern Era. Professional Psychology-Research and Practice 2022;53(3):295–303. https://doi.org/10.1037/ pro0000453

Allen CW, Diamond-Myrsten S, Rollins LK. School Absenteeism in Children and Adolescents. Am Fam Physician 2018;98(12):738-44.
Di Vincenzo C, Pontillo M, Bellantoni D, Di Luzio M, Lala MR, Villa M, Demaria F, Vicari S. School refusal behavior in children and adolescents: a five-year narrative review of clinical significance and psychopathological profiles. Ital J Pediatr 2024;50(1):107. doi: 10.1186/s13052-024-01667-0.
Black LI, Zablotsky B. Chronic School Absenteeism Among Children With Selected Developmental Disabilities: National Health Interview Survey, 2014-2016. Natl Health Stat Report 2018;(118):1-7.
Mcshane G, Walter G, Rey JM. Functional Outcome of Adolescents with ‘School Refusal. Clinical Child Psychology and Psychiatry 2004;9(1):53-60. doi:10.1177/1359104504039172
Haight C, Kearney CA, Hendron M, Schafer R. Confirmatory Analyses of the School Refusal Assessment Scale-Revised: Replication and Extension to a Truancy Sample. JPsychopathol Behav 2011;33(2), 196-204. doi: 10.1007/s10862-011-9218-9
Seçer İ. The Adaptation Of School Refusal Assessment Scale into Turkish: Relıability And Validity Studies. PJS 2014b;30(6):1197-1202.
Kaufman J, Birmaher B, Brent D, et al: Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 1997;36:980. https://doi.org/10.1097/00004583-199707000-00021
Gokler B, Unal F, Pehlivanturk B, et al: Schedule for affective disorders and schizophrenia for school age children present and lifetime version: validity and reliability of the Turkish version. Turk J Child Adolesc Ment Health 2004;11:109.
Benoit L, Chan Sock Peng E, Flouriot J, DiGiovanni M, Bonifas N, Rouquette A, Martin A, Falissard B. Trajectories of school refusal: sequence analysis using retrospective parent reports. Eur Child Adolesc Psychiatry 2024 Nov;33(11):3849-59. doi: 10.1007/s00787-024-02419-5.
Kardaş Ö, Kardaş B, Bildik T. Gençlerde okul reddi davranışı: buzdağının görünen ucu. Türkiye Klinikleri Child Psychiatry-Special Topics 2018;4(2), 159-67.
Kearney CA. Forms and Functions of School Refusal Behavior in Youth: An Empirical Analysis of Absenteeism Severity. Journal of Child Psychology and Psychiatry 2007;48(1):53-61. doi: 10.1111/j.1469-7610.2006.01634.x.
Kearney CA, Beasley JF. The Clinical Treatment of School Refusal Behavior: A Survey of Referral and Practice Characteristics. Psychology in the Schools 1994; 31(2):128-32. https://doi.org/10.1002/1520-6807(199404)31:2
Li A, Yang DD, Beauquesne A, Moro MR, Falissard B, Benoit L. Somatic symptoms in school refusal: a qualitative study among children, adolescents, and their parents during the COVID-19 pandemic. Eur Child Adolesc Psychiatr 2024 Jul;33(7):2243-51. doi: 10.1007/s00787-023-02313-6.
Bernstein GA, Massie ED, Thuras PD, Perwien AR, Borchardt CM, Crosby RD. Somatic Symptoms in Anxious- Depressed School Refusers. J Am Acad Child Adolesc Psychiatry 1997;36:661–8. https://doi.org/10.1097/00004583-199705000-00017
Li A, Guessoum SB, Ibrahim N, Lefèvre H, Moro MR, Benoit L. A Systematic Review of Somatic Symptoms in School Refusal. Psychosom Med 2021;83(7):715-23. doi: 10.1097/PSY.0000000000000956.
Eroglu M, Mentese Babayigit T, Bilgen Ulgar S, Ozturk Polat E, Erguven Demirtas M et al. School Refusal and Determinants: Parental Psychopathology, Family Functioning, Attachment and Temperament. Psychology in the Schools 2025; 62:853–863 853 of 975 https://doi.org/10.1002/pits.23359.
Nayak A, Sangoi B, Nachane H. School Refusal Behavior in Indian Children: Analysis of Clinical Profile, Psychopathology and Development of a Best-Fit Risk Assessment Model. Indian J Pediatr 2018;85(12):1073-8. doi: 10.1007/s12098-018-2631-2.
Inglés CJ, Gonzálvez-Maciá C, García-Fernández JM, Vicent M, Martínez- Monteagudo M C. Current Status of Research On School Refusal. Eur J Educ Psychol 2015;8(1):37-52 https://doi.org/10.1016/j.ejeps.2015.10.005
Aslan, M. 8-14 yaş grubu öğrencilerde anksiyete duyarlılığı ile okul reddi arasındaki ilişkinin incelenmesi,(Yayımlanmamış Yüksek Lisans Tezi). Çağ Üniversitesi, Sosyal Bilimler Enstitüsü: Mersin, 2018.
Holzer L, Halfon O. The school refusal. Arch Pediatr 2006;13:1252-8. https://doi.org/10.1016/j.arcped.2006.05.010
Bahalı K, Tahiroğlu AY. Okul reddi: Klinik özellikler, tanı ve tedavi. Psikiyatride Güncel Yaklaşımlar 2010;2(3), 362-83.
Prabhuswamy M, Srinath S, Girimaji S, Seshadri S. Outcome of children with school refusal. Indian J Pediatr 2007;74:375–9. https://doi.org/10.1007/s12098-007-0063-5
Egger HL, Costello JE, Angold A. School refusal and psychiatric disorders: a community study. J Am Acad Child Adolesc Psychiatry 2003;42:797–807. https://doi.org/10.1097/01.CHI.0000046865.56865.79
Last CG, Strauss CC. School Refusal in Anxiety-Disordered Children and Adolescents Journal of the American Academy of Child & Adolescent Psychiatry 1990;29(1):31-5. https://doi.org/10.1097/00004583-199001000-00006
Fernández-Sogorb A, Inglés CJ, Sanmartín R, Gonzálvez C, Vicent M, García-Fernández YJM. Validation of the Visual Analogue Scale for Anxiety-Revised and school refusal across anxiety profiles. Int J Clin Health Psychol 2018;18(3):264-72. doi: 10.1016/j.ijchp.2018.07.002.
Gonzálvez C, Inglés CJ, Fernández-Sogorb A, Sanmartín R, Vicent M, García-Fernández JM. Profiles derived from the school refusal assessment scale-revised and its relationship to anxiety. Educational Psychology 2018a;40(6):1–14. https://doi.org/10.1080/01443410.2018.1530734
Fremont WP. School refusal in children and adolescents. Am Fa. Physician 2003; 68(8):1555-60.
Buitelaar JK, Van Andel H, Duyx JH, Van Strien DC. Depressive and Anxiety Disorders in Adolescence: A Follow-Up Of Adolescents With School Refusal. Acta Paedopsychiatrica: International Journal of Child & Adolescent Psychiatry 1994;56(4):249-53.

Details

Primary Language

English

Subjects

Child and Adolescent Psychiatry

Journal Section

Research Article

Authors

Seda Aybüke Ozsagir ^*
0000-0003-4793-0662
Türkiye

Elif Abanoz
0000-0002-9214-4735
Türkiye

Beyza Karatas Bozok
0000-0003-4205-5360
Türkiye

Oya Gulesen Kapan
0000-0002-9012-1126
Türkiye

Nazmiye İnce
0000-0002-4874-5269
Türkiye

Ayla Uzun Cicek
0000-0003-2274-3457
Türkiye

Publication Date

April 16, 2026

Submission Date

October 14, 2025

Acceptance Date

December 22, 2025

Published in Issue

Year 2026 Volume: 17 Number: 57

DOI

https://doi.org/10.17944/interdiscip.1803809

IZ

https://izlik.org/JA85AC83JH

Cite

RIS / Bibtex

APA

Ozsagir, S. A., Abanoz, E., Karatas Bozok, B., Gulesen Kapan, O., İnce, N., & Uzun Cicek, A. (2026). Prevalence of psychiatric comorbidity and associated sociodemographic factors in children and adolescents with school refusal. Interdisciplinary Medical Journal, 17(57), 25-33. https://doi.org/10.17944/interdiscip.1803809

AMA

1.Ozsagir SA, Abanoz E, Karatas Bozok B, Gulesen Kapan O, İnce N, Uzun Cicek A. Prevalence of psychiatric comorbidity and associated sociodemographic factors in children and adolescents with school refusal. Interdiscip Med J. 2026;17(57):25-33. doi:10.17944/interdiscip.1803809

Chicago

Ozsagir, Seda Aybüke, Elif Abanoz, Beyza Karatas Bozok, Oya Gulesen Kapan, Nazmiye İnce, and Ayla Uzun Cicek. 2026. “Prevalence of Psychiatric Comorbidity and Associated Sociodemographic Factors in Children and Adolescents With School Refusal”. Interdisciplinary Medical Journal 17 (57): 25-33. https://doi.org/10.17944/interdiscip.1803809.

EndNote

Ozsagir SA, Abanoz E, Karatas Bozok B, Gulesen Kapan O, İnce N, Uzun Cicek A (April 1, 2026) Prevalence of psychiatric comorbidity and associated sociodemographic factors in children and adolescents with school refusal. Interdisciplinary Medical Journal 17 57 25–33.

IEEE

[1]S. A. Ozsagir, E. Abanoz, B. Karatas Bozok, O. Gulesen Kapan, N. İnce, and A. Uzun Cicek, “Prevalence of psychiatric comorbidity and associated sociodemographic factors in children and adolescents with school refusal”, Interdiscip Med J, vol. 17, no. 57, pp. 25–33, Apr. 2026, doi: 10.17944/interdiscip.1803809.

ISNAD

Ozsagir, Seda Aybüke - Abanoz, Elif - Karatas Bozok, Beyza - Gulesen Kapan, Oya - İnce, Nazmiye - Uzun Cicek, Ayla. “Prevalence of Psychiatric Comorbidity and Associated Sociodemographic Factors in Children and Adolescents With School Refusal”. Interdisciplinary Medical Journal 17/57 (April 1, 2026): 25-33. https://doi.org/10.17944/interdiscip.1803809.

JAMA

1.Ozsagir SA, Abanoz E, Karatas Bozok B, Gulesen Kapan O, İnce N, Uzun Cicek A. Prevalence of psychiatric comorbidity and associated sociodemographic factors in children and adolescents with school refusal. Interdiscip Med J. 2026;17:25–33.

MLA

Ozsagir, Seda Aybüke, et al. “Prevalence of Psychiatric Comorbidity and Associated Sociodemographic Factors in Children and Adolescents With School Refusal”. Interdisciplinary Medical Journal, vol. 17, no. 57, Apr. 2026, pp. 25-33, doi:10.17944/interdiscip.1803809.

Vancouver

1.Seda Aybüke Ozsagir, Elif Abanoz, Beyza Karatas Bozok, Oya Gulesen Kapan, Nazmiye İnce, Ayla Uzun Cicek. Prevalence of psychiatric comorbidity and associated sociodemographic factors in children and adolescents with school refusal. Interdiscip Med J. 2026 Apr. 1;17(57):25-33. doi:10.17944/interdiscip.1803809