School phobias hold many children back
by Bridget Murray
(September 1997)

As millions of school children head back to school this month, many eagerly await reuniting with friends and starting new academic challenges. But others bemoan leaving the comfort of home for the trials of school-a place where they might wear the wrong clothes or give the wrong answer in class. Some even refuse to go, throwing tantrums or complaining of stomachaches, headaches or nausea.

These children suffer from what's commonly known as school phobia, although many psychologists prefer calling it school refusal. Affecting between 5 percent and 10 percent of U.S. school children in its mildest form-and 1 percent of them in its severest form-the phobia can lead to serious problems with school absenteeism, psychologists say.

Chronic absence puts students at risk for psychological problems later in life, such as alcohol abuse and criminal behavior, as well as underemployment and even marital difficulties, says psychologist Christopher Kearney, PhD, a school refusal researcher at the University of Nevada, Las Vegas.

Broadly defined, school phobia is anxiety and fear related to being in school. In addition to throwing tantrums and feigning sickness, other typical school-refusal behaviors include panic attacks, crying, shyness, unhappiness, demands for parental attention, petulance and clinginess, psychologists report.

Most often the problems emerge after children have had long breaks from school, says Kearney. As their vacation dwindles to an end, some children dread the return to peers, teachers and homework. They may feel safer in the sanctity of home, where they feel loved by their parents instead of judged by their peers and teachers, psychologists say.

A closer look at the problem reveals that some children experience "generalized" anxiety about their abilities. They fear softball games, quizzes, science projects-anything that tests their mettle. Other children have distinct types of anxiety-related school refusal, says Kearney. One type stems from childhood anxiety about separating from mother and family. Another type-social phobia-involves worry over peer relations or public speaking. And simple phobias are fears about specific aspects of school, such as the wail of the fire-alarm or the walk down the hallway between classes. Several warning signs can alert teachers that a child is school phobic, says psychologist Robert Deluty, PhD, director of clinical training at the University of Maryland-Baltimore County. These include crying fits in class, withdrawn behavior and excessive time spent in the nurse's office. Teachers play a crucial role in flagging the problem and consulting parents and psychologists about treatment, notes Deluty. Overcoming the problem requires a team effort involving teachers, parents and psychologists, he says.

Separation anxiety

Separation anxiety typically affects young children. Those afflicted worry excessively when separated from their home and parents, often fearing for their life or their parents' lives, says Deluty. They worry that their parents will be kidnapped, attacked by monsters or killed in a car accident. To allay their worries, they cling to adults and demand constant attention.

Children with the problem experience such high levels of anxiety that their muscles tense up and their stomachs ache-they feel too ill to attend school but doctors find no evidence of physical illness, says Deluty.

Causes of separation anxiety are hard to pinpoint, but anxiety-prone children and depressive children with low self confidence are particularly susceptible, researchers say. The same is true of phobic children, they note. In many cases, parents unwittingly reinforce the problem by catering to their children's every whim, coddling and pampering them instead of encouraging them to think independently and solve their own problems, says Achenbach. Often the parent-in many cases the mother-becomes dependent on the child's company as well, Achenbach says.

In fact, mothers of anxious children often themselves have histories of school refusal, found psychologist Cynthia Last, PhD, director of the School Phobia program at Nova Southeastern University in Fort Lauderdale, Fla., in a study of 145 anxious children and adolescents. The study was published in 1990 in the Journal of the American Academy of Child and Adolescent Psychiatry (Vol. 29, No. 1, p. 31-35). Unhealthy cycles of dependency tend to run in families, she says.

Illustrating this phenomenon is the case of a 6-year-old school-phobic boy, treated by psychologist Larazo Garcia, PhD, of the Miami Psychological and Behavioral Center. The boy and his mother spent their days together "like one unit," says Garcia. The boy balked at attending school, and his mother, who was single and on welfare, didn't make him go.

Garcia used desensitization, a common anxiety treatment, to conquer the boy's fear of mother separation. He first introduced the boy to play with neighborhood children, then brought the boy to school and sat in class with him for 10 minutes.

On subsequent days he increased the time they spent together in school to gradually ease that child into a daily school routine. Noting that regular, extended separations from his mother hurt neither him nor her, the boy learned to spend his days at school. Anxious children typically spend too little time at school to realize that their parents are safe without them, Garcia notes. Garcia also involved the school's staff, a crucial aspect of treatment, says Kearney. Teachers and school nurses can encourage children to stay in class and urge them to check their anxiety by talking through it or using breathing exercises to calm their rapid breathing. Calling their parents should be the last resort, he says.

For their part, parents can more firmly set and enact rules about school attendance. Creating a regular morning routine prevents children from dwelling on anxiety and developing school-related aches and pains, says Kearney. Psychotherapy can also be used to help children face their fears, including the use of dolls to help them act out unrealistic fears about their parents getting injured or sick.

Social and simple phobias

Garcia's young patient also had an acute fear of interacting with peers and unknown adults, a form of social phobia. The child was extremely obese, which made him feel like a misfit.

"Some children are extremely fearful of being humiliated or embarrassed," says Last. "Peers' opinions are everything to them and children obsess over how others judge them."

In fact, most social phobias begin at around ages 11 or 12, a time when children tend to most viciously insult and pick on each other.

This cruelty, Last says, can seriously harm sensitive children. Particularly at-risk for developing peer-related phobias are children harassed for physical traits, such as obesity, skinniness or physical disabilities. Intellectual ability is also a source of heckling from peers: Some children suffer for their braininess while others get teased for their academic slowness, Last notes.

Adding to the problem of peer-related phobias is an increasingly hostile school environment, adds Cynthia Pilkington, PhD, a child and school psychologist at the Central Plains Clinic in Sioux Falls, S.D. Her patients experience aggression and name-calling at increasingly younger ages. "It used to be that nastiness was mostly in middle schools, but the teasing and taunting starts in kindergarten these days," says Pilkington.

Children with performance-related phobias may fear public speaking, tests or being questioned by teachers in class. Some develop unreasonable fears about their grades and academic performance, becoming so paralyzed with fear that they can't perform at all. Most of these children are perfectionists who fear earning a "B," Last says.

A number of treatments are available for the various phobias. As with separation anxiety, desensitization helps children grow accustomed to peers and eases them into the academic cycle of testing and grading. Some treatments focused on increasing competence are relatively straightforward, Deluty adds. For example, the child who fears public speaking will likely benefit from help giving speeches and the child who fears failing math class may simply need extra math tutoring, he says.

Also beneficial is coping-skills training that helps children avert or counter bullying remarks. The training teaches children to respond to insults with a firm voice and direct eye contact, instead of with violence or passive weeping, says Deluty. Teachers can also help by giving phobic students "a way to shine," says Pilkington. Such tasks as decorating a class bulletin board give anxious children a positive sense of identity, she says.

Drug treatments are also available to treat school phobia. Some psychiatrists have been using imipramine, which has antipanic and antidepressive effects. Thus far, though, studies of the drug's effects are inconclusive.

It's hard to tell what treatment works best because school phobia is an under-researched area, says Last. Behavioral therapy shows promise, but even those results are based largely on case studies, she says. However, notes Last, one thing is certain. With dogged cooperation from parents and school staff, most school phobias can be conquered.