As a child, you may have had a few days when you didn't particularly want to go to school, maybe to avoid a particular classmate or a big homework assignment you failed to complete. This type of reluctance is different from school phobia, a condition wherein a child has a fear of attending school. For these students, walking into a school can be a frightening feeling, and they might be overwhelmed by the school's size, the number of people in it, or feeling lost. This disorder was given its name in 1941 and may also be known as school refusal.

Students with school phobia experience severe emotional distress when they think about attending school. Many are simply afraid to be away from home and experience high levels of anxiety when they are away from parents and/or home. Other symptoms include depression, temper tantrums, and somatic (physical) symptoms.

School Refusal

Children with school phobia will try to persuade their parents to allow them to stay home. They may also experience headaches, stomach problems, or other somatic symptoms that seem real but are actually a result of the high levels of anxiety or the level of depression they have.

Children with school phobia may be confused with children who are often truant. However, students who are truant do not have anxiety about school, hide school absences from their parents, and demonstrate antisocial behaviors such as being delinquent or disruptive. Truant students also refuse to do homework. Children with school phobia are the opposite. They would go to school if they could but believe they cannot.

School absenteeism is a national problem; children are absent from school for a variety of reasons, one of which may be school phobia.

A phobia is actually a “fear of fear” because sufferers are not really frightened of any particular place, situation, object, or animal, although children tend to believe that there really is something to be afraid of.

School phobia or school refusal is a common childhood behavior problem that refers to a child’s refusal to attend school.

Unfortunately, today school phobia may be related to bullying at school or the internet.

Pathophysiology

Sufferers are really frightened of the feelings of fear that they experience with their “trigger” situation.

The beginning of a phobia usually follows periods of stress and often starts after a final trauma or after a first traumatic attack which appears to come out of the blue.

In the early stages of a phobia, sufferers feel frightened when in a particular place or situation, without knowing exactly why.

Whenever they go into the particular place or situation they experience an overwhelming feeling of impending disaster and feel a compulsive urge to escape from it.

Sufferers do not know why they are afraid but the feelings of fear that they experience are very real; these feelings start a spiral of fear and sufferers begin to think that they will get these awful feelings wherever they go.

As a result, the child with school phobia does not wish to attend school.

Statistics

Statistics on the frequency of school phobia vary a great deal.

The number of children who actively dislike school and avoid it whenever possible is probably about 5% of the school population.

Those who could be classed as school phobic would probably make up 1% of the school population or about 90, 000.

Well over half the numbers are boys and the peak onset is about 11 to 12 years of age.

Research indicates that the final peak age is about 14 years of age and may well be associated with depression.

Causes

Teachers and nurses can help detect school phobia by paying close attention to absence patterns.

Strong attachment. School phobic children may have a strong attachment to one parent, usually the mother.

Separation anxiety. School phobic children may feel fear separation from the parent, perhaps because of anxiety about losing her or him while away from home.

Problem at school. School phobia may be the child’s unconscious reaction to a seemingly overwhelming problem at school; the parent can unwittingly reinforce school phobia by permitting the child to stay home.

Clinical Manifestations

The symptoms are genuine and are caused by anxiety that may approach panic.

Vomiting. The child may display vomiting upon knowing that he will be going to school.

Headaches. Headaches may subside once the child is allowed to stay home.

Diarrhea. Diarrhea is also one of the symptoms of school phobia.

Abdominal pain or other pain. The patient may complain of pain in any part of the body just so he could skip school.

Low-grade fever. Even low-grade fever is manifested by the patient, all due to anxiety.

Assessment and Diagnostic Findings

Diagnosis is made on the basis of the following:

Family history. Any history of phobias or traumatic experiences contributes to the fear of going to school.

Physical symptoms. The absence of causes for physical symptoms may lead to the diagnosis of school phobia.

Psychological evaluation. Psychological evaluation varies with other findings and the age of the child but usually includes several assessments.

Behavioral checklist. A behavior checklist evaluates the child’s behavior at home and school.

Medical Management

Management includes a complete examination to rule out any organic cause for the symptoms.

School-family conferences. School-family conferences help the child return to school; those working with these children must recognize that they really do want to go to school but for whatever reason could not make themselves go.

Cognitive/behavior therapy. Cognitive/behavior therapy involves changing the way a sufferer behaves; as research would indicate that cognitive/ behavior therapy is more effective in the treatment of anxiety disorders in children than traditional psychotherapy as it helps the child to learn how to quell anxiety in phobias.

Family counseling. Family counseling can help parents to better understood and deal with the school phobic child by providing behavioral guidance and emotional support.

Systematic desensitization. This is a technique by which a child is gradually helped to modify his or her emotionally distressing reaction to school without experiencing distress.

Exposure therapy. This is a technique by which the child is exposed in a stepwise fashion to increasing intensity and duration of the emotionally distressing event coupled with encouragement to modify maladaptive and inappropriate cognitions gradually enough that the child becomes able to tolerate the previously distressing experience without distress.

Operant behavioral techniques. These involve reward for desired behaviors in order to increase their frequency.

Pharmacologic Therapy

Psychopharmacologic interventions may be required for underlying anxiety and phobia.

Serotonin reuptake inhibitors (SSRIs). SSRIs a such as fluoxetine (Prozac), may be useful for underlying depression.

Benzodiazepines. Drugs in this group work through enhancing the action of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA).

Nonselective beta blockers and alpha-2 receptor agonists. Beta-blockers are effective in managing the physical symptoms of anxiety that occur with school phobia; the alpha-2 agonists are used to manage anxiety.