Children who refuse to go to school have been widely studied, with most researchers dividing them into two groups: those who skip school because of fear or anxiety and those who skip school because of a lack of interest. Other researchers have argued that in order to accurately study the association between school refusal and psychiatric disorders, assumptions about associated psychopathology must be left behind. As such, the authors utilized a descriptive, rather than etiological, definition of school refusal in order to study the associations of school refusal with DSM-IV psychiatric disorder and specific fears. Data from eight annual waves of the on-going, longitudinal Great Smoky Mountain Study (GSMS) were analyzed, which included structured interviews with 9- to 16-year-olds and their parents. Data were analyzed using SAS PROC GENMOD, with robust variance estimates and sampling weights. Results indicated that anxious school refusal was associated with depression and separation anxiety disorder. Truancy was associated with oppositional defiant disorder, conduct disorder, and depression. Of the children who exhibited characteristics of both anxious school refusal and truancy, 88.2 percent had increased rates of both emotional and behavior disorders. The authors concluded that anxious school refusal and truancy are distinct, but not mutually exclusive, and are significantly associated with psychiatric disorders and adverse experiences at home and school. Treatment approaches should be examined for those children exhibiting both anxious school refusal and truancy. Tables, references