School phobia/school refusal

Definition The term school phobia was first used in 1941 to identify children who fail to attend school because attendance causes emotional distress and anxiety . In Great Britain and as of the early 2000s in the United States, the term school refusal is preferred.

Description School phobia is a complex syndrome that can be influenced by the child's temperament , the situation at school, and the family situation. Current thinking defines school phobia or school refusal as an anxiety disorder related to separation anxiety . Children refuse to attend school because doing so causes uncomfortable feelings, stress, anxiety, or panic. Many children develop physical symptoms, such as dizziness , stomachache, or headache , when they are made to go to school. School avoidance is a milder form of refusal to attend school. With school avoidance, the child usually tries to avoid a particular situation, such as taking a test or changing clothes for physical education, rather than avoiding the school environment altogether. School refusal usually develops after a child has been home from school for an illness or vacation. It may also follow a stressful family event, such as divorce , parental illness or injury, death of a relative, or a move to a new school. Usually refusal to attend school develops gradually, with children putting up increasingly intense resistance to going to school as time passes. Psychiatrists believe that in young children, the motivating factor often is a desire to stay with the parent or caregiver rather than to avoid an unpleasant situation at school. In older children, or if school refusal comes on suddenly, it may be related to avoiding a distressing situation at school such as bullying, teasing, severe teacher criticism, or it may follow a humiliating event such as throwing up in class. The longer a child stays out of school, the more difficult it is for that child to return. School refusal is not the same as truancy . Children who are school refusers suffer anxiety and physical symptoms when they go to school. They may have temper tantrums over going to school or become depressed. They may threaten to harm themselves if made to go to school. School refusers usually work to get their parent's permission to stay home. If allowed to stay home, they usually stay in the house or near the parent or caregiver. The child is willing to do make-up school work at home, so long as he or she does not have to go to school. Children who are truants are not anxious about school; they simply do not want to be there. They try to hide their absence from their parents and have no interest in make-up schoolwork or meeting academic expectations. Unlike school phobia, truancy often occurs with other antisocial behaviors such as shoplifting, lying , and drug and alcohol use.

Demographics Boys and girls refuse to attend school at the same rates. School phobia is highest in children ages five to seven and 11 to 14. These ages correspond with starting school, and transitioning through middle school or junior high school, both unusually stressful periods. Estimates suggest that about 4.5 percent of children ages 7 to 11 and 1.3 percent of children age 14 to 16 are school refusers. School phobia is an international problem, with an estimated rate of 2.4 percent of all school-age children worldwide refusing to attend classes. Children who are more likely to become school refusers share certain characteristics. These include: reluctance to stay in a room alone or fear of the dark

of the dark clinging attachment to parents or caregivers

excessive worry that something dreadful will happen at home while they are at school

difficulties sleeping or frequent nightmares about separation

about separation homesickness when away at places other than at school, or an excessive need to stay in touch with the parent or caregiver while away

Causes and symptoms There appears to be a genetic component to all anxiety disorders, including school phobia. Children whose parents have anxiety disorders have a higher rate of anxiety disorders than children whose parents do not have these disorders. School phobia is often associated with other anxiety disorders such as agoraphobia or other mental health disorders such as depression. Some experts theorize that another possible cause of school refusal is traumatic and prolonged separation from the primary caregiver in early childhood. Family functioning affects school refusal. Stressful events or a dysfunctional family can cause children to feel compelled to stay home. Young children are more likely to refuse to separate from their parent or caregiver because they fear something catastrophic will happen to the adult while they are at school. Older children may refuse to leave a parent who is ill or who has a substance abuse problem, in effect trying to cope for the parent. They may also be afraid of some specific aspect of school, such as riding the bus or eating in the cafeteria. It is not uncommon for middle and high school students to become school refusers because they are afraid of violence either at school or on the way to school, are afraid of failing academically, have been repeatedly bullied or humiliated at school, feel they have no friends at school, or are excluded. Children who refuse to attend school usually try to win a parent's permission to stay home, although some simply refuse to leave the house. Genuine physical symptoms are common and include dizziness, headaches, nausea , vomiting , diarrhea , shaking or trembling, fast heart rate, chest pains, and back, joint or stomach pains. These symptoms usually improve once the child is allowed to stay home. Behavioral symptoms include temper tantrums, crying, angry outbursts, and threats to hurt themselves ( self-mutilation ).

When to call the doctor Parents with a child who is avoiding or refusing school should call their pediatrician and arrange to have physical symptoms evaluated. If no reason for physical symptoms such as abdominal pain can be found, the pediatrician should make a referral to a child or adolescent psychiatrist who can evaluate the child for a range of behavioral problems including social phobia, depression, conduct disorder , and post-traumatic stress syndrome.

Diagnosis The most effective form of treatment is a combination of behavioral and cognitive therapy for an average period of six months. Behavioral therapy involves teaching both parents and children strategies for overcoming certain stressful behaviors such as separation and may involve desensitization by gradual exposure to the stressful event. Cognitive therapy teaches children to redirect their thoughts and actions into a more flexible and assertive pattern. Family therapy may also be used to help resolve family issues that may be affecting the child. Depending on the diagnosis, children may also be treated with drugs to help alleviate depression, panic and anxiety, or other mental health disorders. In October 2003 the United States Food and Drug Administration issued an advisory indicating that children being treated with selective serotonin re-uptake inhibitor antidepressants (SSRIs) for major depressive illness may be at higher risk for committing suicide . A similar warning was issued in the United Kingdom. Parents and physicians must weigh the benefits and risks of prescribing these medications for children on an individual basis.

Treatment Diagnosis is made on the basis of family history, the absence of causes for physical symptoms such as heart palpitations, vomiting, or dizziness, and the results of a battery of psychological tests . Psychological evaluation varies with other findings and the age of the child but usually includes several assessments for anxiety and a behavioral checklist that evaluates the child's behavior at home and school.

Prognosis The combination of cognitive and behavioral therapy appears to produce the most successful treatment results. In one study, more than 80 percent of children receiving this combination of therapies were attending school normally one year after treatment. Underlying conditions that might affect recovery from school phobia include Tourette syndrome , attention deficit disorder (ADD), depression, bipolar mental illness, panic disorder, or other anxiety disorders and phobias .

Prevention Little can be done to prevent school refusal. However, parents can give their children appropriate opportunities to separate from them during the toddler and preschool years by exposing them to activities such as preschool, playgroups, babysitters , and daycare. With older children, parents can step in to stop bullying behavior or remove their child from the bullying or humiliating situation as soon as it starts.

Parental concerns Many parents recognize that their child is genuinely distressed by attending school and unwittingly encourage school refusal by allowing their child to stay home. However, the longer the child is at home, the harder it is to return to school. Parents need to make the school aware of their child's difficulties and take a firm stand in working with the school to resolve any issues of safety or bullying that may be preventing their child from experiencing a full education. KEY TERMS Agoraphobia —Abnormal anxiety regarding public places or situations from which the person may wish to flee or in which he or she would be helpless in the event of a panic attack. Selective serotonin reuptake inhibitors (SSRIs) —A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, thus raising the levels of serotonin. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).

See also Separation anxiety .

Resources

BOOKS Davidson, Tish. School Conflict. New York: Scholastic, 2003.

ORGANIZATIONS American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016 3007. Web site: http://www.aacap.org.

WEB SITES Bernstein, Betinna E. "Anxiety Disorder: Separation Anxiety and School Refusal." eMedicine. Available online at http://www.emedicine.com/ped/topic2657.htm (accessed October 29, 2004). "'Facts for Families: Children Who Wont Go to School." American Academy of Child and Adolescent Psychiatry , July 2004. Available online at http://www.aacap.org/publications/factsfam/noschool.htm (accessed October 29, 2004). Fremont, Wanda P. "School Refusal in Children and Adolescents." American Family Physician (October 15, 2003). Available online at http://www.aafp.org/2-31015/1555.html

Tish Davidson A.M.