to the editor: I enjoyed the article “School Refusal in Children and Adolescents,”¹ by Dr. Fremont in the October 15, 2003 issue of American Family Physician. School refusal is an important issue, and I would like to add a few observations and recommendations.

In my practice, I have noticed more and more cases of school refusal. In my experience as a family physician and as a parent of a child with this condition, I think that the anxiety and depression described by Dr. Fremont¹ often is more related to school than the problems at home or endogenous psychologic issues.

Statistics from the U.S. Department of Education suggest that up to 40 percent of children in the United States do not read at their current grade level.^2–4 Most of these children are of normal intelligence. These difficulties often are not identified for several years, by which time issues such as behavior problems, severe academic problems, or school phobia have become more problematic. When kids cannot read at their grade level, their academic and/or behavior performances deteriorate. Often, the cause of these problems is not properly identified as reading and learning problems and these kids are labeled as having behavioral or psychologic issues.

Budgets at the federal, state, and local levels are being stretched. In my experience, early evaluation and intervention of reading and learning problems are seriously delayed and often are not identified until major behavioral or emotional issues become the dominant focus for the child. Schools do not have the money, resources, or staff to properly evaluate many of these children.

Although Dr. Fremont¹ suggests psychoeducational and other educational evaluations, it was my impression that the major focus of the article suggested that the origin of school phobia is a primary psychologic problem. I disagree. In dealing with many children who have school phobia, I can think of few who did not have a primary learning or reading deficit that had not been properly evaluated or addressed as the primary cause of their school phobia.

Certainly, concomitant psychologic and home issues are significant contributing factors, but I would urge the author and other clinicians who see children with school phobia to consider reading or learning issues first. The psychologic issues that physicians identify and diagnose may be secondary. Unless reading and learning issues are addressed, any other therapy is doomed to failure.

editor’s note: This letter was sent to the authors of “School Refusal in Children and Adolescents,” who declined to reply.