648 play an important role in the aetiology (see Table 2). Children with PRS are usually described as perfectionist, conscientious and high achievers. When such children are faced with stressful events that they feel they cannot con- trol, they enter into a state of learned helplessness. Previous child psychiatric problems may indicate a vulnerability to develop PRS when faced with stressful events, and parental psychiatric problems may affect the parents’ ability to support and protect their children. Enmeshed mother–child relationships are often seen (63%), but it is unclear whether they are primary or secondary to the child becoming ill. The aetiology of PRS in our case report remains unclear. Returning to Kate, the troubled relationship with the tea- cher can be considered a potential precipitating event, or a chronic stress factor, since he taught her for 2.5 consecu- tive years. Changing school only worsened the symptoms. This change, however, can be considered a supplementary stress factor. Physical or sexual abuse was explicitly denied. A precipitating viral infection could have been the trigger, since Kate’s complaints started with acute fatigue, a sore throat and a headache. Kate also seems to fulﬁl criteria 1 and 2 of Von Folsach and Montgomery [27]. She was known as a perfectionist and high-achieving girl and had a history of an episode of behavioural disturbances. No parental psychiatric problems were present. During the period of admission to our hos- pital, we did notice an enmeshed mother–child relation- ship, as well as helplessness and hopelessness in both mother and child, but these seemed to be secondary effects. Psychopathological consideration Refusal, which is considered one of the core symptoms of PRS, is deﬁned as a state in which one is unwilling to do something [28]. Withdrawal, another core symptom of PRS, can be deﬁned as a retreat from external reality [6] or a state of ceasing to participate in an activity or to be a member of a team or organization [28]. In clinical psy- chiatry, a third and related psychopathological state exists: regression. This is deﬁned as a return to a state of earlier development [6] or to earlier patterns of adaptation [21]. Refusal, withdrawal and regression have a resistance in common, a rejection of action [28], be it either active and/ or passive. Clinically, an increasingly pervasive negative attitude towards all the activities of daily life can be seen, which can occur in a gradual spectral way from refusal, the one pole, via withdrawal to regression, the other pole. We propose calling this spectrum the RWR (refusal–with- drawal–regression) spectrum. The three manifestations (refusal–withdrawal–regression) can ﬂuctuate in time due to the state of mind of the patient and the context. This state of mind is strongly inﬂuenced by the will and the patient’s faculty of judgement. Impaired judgement in 123 Eur Child Adolesc Psychiatry (2009) 18:645–651 children and adolescents is frequently linked to trauma, particularly chronic and severe trauma, but can also be due to a major psychiatric disorder. In adults, impaired judge- ment is most often due to a major psychiatric disorder, such as schizophrenia, an affective disorder or anorexia nervosa. This explains why these three clinically important mani- festations of the RWR spectrum are frequently met in the full age range of clinical psychiatry. With PRS, which is diagnosed only in children, refusal and withdrawal are more prominent. In adults, regression is more common. Diagnosis In the diagnostic process, a two-track multidisciplinary diagnostic approach by a paediatrician and a child psychia- trist, as also seen in our case report, is essential from the very beginning, as in the case of a disabling psychiatric disorder, a somatic cause must always be excluded. Regarding Kate, no organic cause of her complaints could be traced. Thompson and Nunn [24] were the ﬁrst to introduce diagnostic criteria for PRS (see Table 3). We suggest an adaptation of these criteria (see Table 4). In the past, PRS was often seen as related to eating disorders [5, 10, 14, 16, 22] and therefore ‘clear food refusal and weight loss’ was seen as a separate criterion. However, both the literature search and our case report show that refusal can be seen in different domains, including eating. In which domain the refusal is most prominent depends on the individual expression of PRS. We therefore suggest attaching crite- rion 1, ‘clear food refusal and weight loss’, to criterion 3, ‘partial or complete refusal in two or more domains’. To underline the severity and disabling character of PRS, we would also like to add an extra criterion: ‘The endangered state of the patient requires hospitalization’. Differential diagnosis Pervasive refusal syndrome has many forms of expression, resulting in symptom overlap with other psychiatric Table 3 Current diagnostic criteria for PRS [24] Diagnostic criteria for pervasive refusal syndrome 1. Clear food refusal and weight loss 2. Social withdrawal and school refusal 3. Partial or complete refusal in two or more of the following domains: mobilization, speech, attention to personal care 4. Active and angry resistance to acts of help and encouragement 5. No organic condition to account for the severity of the degree of symptoms 6. No other psychiatric disorder that could better account for the symptoms