School phobia and school refusal
October 26, 2011, 12:00 pm
Dr. B. J. C. Perera
MBBS(Ceylon), DCH(Ceylon), DCH(England), MD(Paediatrics), FRCP(Edinburgh), FRCP(London), FRCPCH(United Kingdom), FSLCPaed, FCCP, FCGP(Sri Lanka) Consultant Paediatrician
KEY POINTS
* School phobia or school refusal is different from truancy.
* It is associated with considerable anxiety regarding schooling.
* There are many causes for school refusal.
* The reasons may be based in the school itself or at home.
* School refusal needs to be handled promptly but gently.
* School authorities need to be informed of the problem
* Professional help may be necessary in some cases.
School refusal is a term originally used in the United Kingdom to describe refusal to attend school as a consequence of emotional distress. School refusal differs from truancy in that children with school refusal feel anxiety or fear towards school whereas truant children generally have no feelings of fear towards school. Instead, truant children often feel angry and bored with school. The term school refusal was coined as a more general alternative to school phobia, which can be used to describe school refusal caused by separation anxiety as well. School phobias, known to professionals as school refusal is an extreme and complex form of anxiety about going to school but not the school itself as the name suggests. School phobia, school avoidance and school refusal are terms that describe an anxiety disorder in children who have an irrational and persistent fear of going to school. Their behaviour is different from children who are truant and express no apprehension about missing school. Children who have school avoidance want to be in close contact with their parent or caregiver whereas truants do not. School phobic children are often insecure, sensitive and do not know how to cope with their emotions. They appear anxious and may become physically ill at the thought of attending school.
Many children at some time in their school career are challenged by anxiety and fear about attending school. It has been estimated that approximately 1 to 5 per cent of school-aged children have had some form of school refusal. The rate is similar within both genders and there are no known socioeconomic differences. It is most common in the age group of 5 to 11 which is perhaps the most vulnerable age in view of their immaturity.
Children and adolescents with school refusal sometimes suffer from other problems such as mood disorders or clinical depression. The longer a child stays out of school the harder it is for them to go back and some believe that it is best to try to get the child back into school as quickly as possible. However, it may be hard to accomplish this as when forced, they are prone to temper tantrums, crying spells, psychosomatic or panic symptoms and threats of self-harm. These problems quickly fade if the child is allowed to stay at home.
Whereas some cases of school refusal can be resolved by gradual re-introduction to the school environment, some others may need to be treated with some form of psychodynamic or cognitive-behaviour therapy. Some families have sought alternative education for school refusers which has also proved to be effective. In extreme cases, some form of medication is sometimes prescribed but none of these have stood out prominently as solutions to the problem. A medical condition often mistaken for school refusal is delayed sleep phase syndrome (DSPS). That condition is a circadian rhythm sleep disorder which causes difficulty falling asleep at night and problems with waking up in the morning.
Going to school for the first time is a period of great anxiety for very young children. Many will be separated from their parents for the first time, or will be separated all day for the first time. This sudden change can make them anxious and they may suffer from separation anxiety. They are also probably unused to having the entire day organized for them and may be very tired by the end of the day. This leads to further stress and makes them feel very vulnerable. For older children who are not new to the school, who have had a long holiday break or have had time off because of illness, returning to school can be quite traumatic. They may no longer feel at home there. Their friendships might have changed. Their teacher and classroom might have changed. They may have got used to being at home and closely looked after by a parent. They feel insecure when all this attention is removed and suddenly they are under the scrutiny of their teachers again. Other children may have felt unwell on the school bus or in school and associate these places with further illness and symptoms of panic. They would want to avoid school in order to evade panicky symptoms and panic attacks fearing, for example, vomiting, fainting or having diarrhoea.
Factors that can cause reluctance to attend school can be divided into several categories. These categories have been developed based on studies in the United States. Some children may be affected by several factors at once. It may be possible that the child wants to avoid school-related issues and situations that cause unpleasant feelings in him, such as anxiety, depression or psychosomatic symptoms. The reluctance to attend school is one symptom that may sometimes indicate the presence of a larger issue, such as anxiety disorder, depression, sleep disorder, separation anxiety or panic disorder. It may also be that the child wants to avoid tests, presentations, group work, specific lessons or interaction with other children. The child in question may also want attention from outside the school from significant people such as parents or older acquaintances. It may also be that the child wants to do something more enjoyable outside of school such as practicing hobbies, playing computer games, watching movies, riding with friends or learning auto-didactically.
Possible triggers for school phobia include being bullied, starting school for the first time, moving to a new area and having to start at a new school, being off school for a long time through illness or because of a holiday, bereavement of a person or a pet, feeling threatened by the arrival of a new baby, having a traumatic experience such as being abused, problems at home such as a member of the family being very ill, marital rows, separation and divorce, violence in the home or any kind of abuse, not having good friends or any friends at all, being unpopular, being chosen last for teams and feeling a physical failure in game and feelings of academic failure.
When a child does not want to go to school, it is often assumed by school professionals that the reason lies at home. Perhaps the child is afraid to leave home out of an unrealistic belief he or she must stay behind to mind the boutique or to guard against some danger. The hypothesis is that the child feels unbearably anxious unless he or she stays home where the parents’ well-being may be confirmed. The child’s parents, on the other hand, may search for something in school that has intimidated their child. A school psychologist understands that school avoidance is probably the result of many factors and the child may be reacting to both home and school stressors.
Current thinking about school phobia suggests there are some children who refuse to attend school because of separation anxiety. These are mostly younger children who are less accustomed to being away from home. However, some may be trying to avoid uncomfortable feelings associated with school. They tend to be sensitive, overactive boys and girls who do not know how to deal with their emotions. They may fear being criticized or evaluated. A few are truly frightened by a particular activity such as riding the school bus or attending an assembly. Many of these children do attend school but with great discomfort. They tend to be highly anxious and lack the skills needed to handle social interactions. Perhaps they have had negative experiences in the past and are afraid something else will happen. Research indicates many children experience school events as stressful enough to produce such symptoms as withdrawal, aggression, moodiness or anxiety. Studies indicate many of these events to involve disciplinary methods which are punitive in nature and attack the child’s self esteem. A child’s behaviour may even resemble symptoms of post-traumatic stress disorder. In that condition, memories of a traumatic event continue to interfere with daily functioning, long after the actual event had taken place.
While severe stress responses may be unusual, any child who does not want to go to school is experiencing stress, and an important part of solving the problem is for the adults involved to assess what may have gone wrong. When a child seeks to avoid school, the parents are advised to quickly request consultation with both the classroom teacher and perhaps the school psychologist. If this is done, parents, teacher and psychologist may explore clues from both home and school to determine how the child’s needs are not being met. While most children are adaptive and resourceful and able to adjust to a certain amount of challenge, there are limits to adaptation. Children whose skills are weak in areas needed for school success may encounter demands beyond their abilities. Sensitive children who are highly in tune with others may encounter an experience which overloads their finely-tuned empathies. Whatever the cause, the parents need to see themselves as part of a professional team working to solve the problem.
But first of all, parents must bring the child to school. They will probably be strongly ambivalent about subjecting the child to what seems like a situation of unbearable stress. Children with anxieties about going to school may suffer a panic attack if forced which then makes them fear having another panic attack and there is an increasing spiral of worry with which parents often do not know how to deal. However, by working with the school authorities to find ways to modify school and home environments for the child’s benefit, some of the discomfort will be resolved. Sometimes simple interventions, such as a planned focus on the child’s positive behaviours or special time with an important person in the child’s life, may help the child to comfortably resume going to school. At school, short-term counselling, opportunities to engage in favourite activities or a chance to earn a privilege could be options. If necessary, the psychologist could also help find a therapist to work with both the child and the family.
The experience of joining with school personnel to successfully reintegrate a phobic child into the school will allow parents to learn what works and what doesn’t for their boy or girl. They will have an ally in the school psychologist, who will act as a liaison among the various people involved. If the child has other difficulties beyond school refusal, they will be addressed. Intervention will give the child a chance to benefit from the educational environment and to master academic tasks in a supportive and encouraging setting where the child may thrive.
Some children have a particular susceptibility to develop school phobia as a result of a medical condition. These disorders in clued Asperger Syndrome and Attention Deficit Hyperactivity Syndrome. They need to be dealt with differently to children without these. In fact relaxation techniques in these syndromes can make them more anxious.
The longer school phobia goes on, the harder it is to treat and early initiation of appropriate action is necessary. If a child is severely affected, it is better to ask for a referral to a professional as early as possible. Things a parent could do include getting help from your child’s school. Teachers need to be aware that there is a problem. It should be made quite clear to the child’s teachers that he or she is not just "playing up" but that the anxiety is very real and that the child is suffering from it.
At home, life should continue and the child should be encouraged to carry on as normal. But the child might want to stop going out, especially without the parents, even to parties that he or she was quite happy being left at before. Although parents need to deal sensitively with such children. It is also helpful to reassure the child and tell heim or her that the child would be fine once he or she has got over the part the child dreads. The child needs to be told, albeit ever so gently, that he or she has a private battle to fight every school day and that the child has to be brave enough to go to school under those difficult conditions. The parents n eed to keep to the same routine. They should make the child go to bed and get up at the same time every day, including weekends, so that he or she has some secure framework to live around.
The goal is to have the child return to school and attend class daily. In the best case scenario, the student’s confidence and enjoyment of school will increase when a plan is implemented and changes are made. However, if the school phobia is extreme, a therapist or psychiatrist’s assistance may be necessary.
The writer would appreciate feedback from the readers. Please e-mail him at bjcp@ymail.com
