It is very common for children to refuse to go to school, but when does this behaviour indicate a possible mental health problem or when is it a social problem?
If a child has been missing from school and out in the community rather than at home, this is classically labelled as truanting. Often parents or carers are unaware of their child’s nonattendance, until alerted by the school or other authorities. Even when the family have been made aware of this problem, sometimes they are still unable to get their child to change their ways. This type of behaviour can sometimes be the first indicator of a need for more parental or family support and assistance. The longer and more frequently the truanting has been going on for, the higher the chance that the child may have been exposed to criminal activities, sexual exploitation or substance misuse and the involvement of Social Services may be necessary. There is also a high risk of the child experiencing mental health difficulties as a result of traumatic or neglectful experiences, or from substance misuse.
When a child refuses to leave the house go to school and parents or carers feel unable to persuade them otherwise, this behaviour is classically labelled as “School Phobia”. This type of behaviour usually indicates a high likelihood that the child, and sometimes also the carer, may be suffering from an Emotional or Anxiety Disorder. Children sometimes have physical symptoms or mood or anxiety symptoms. The child may have underlying anxieties and be trying to avoid facing their fears. The fears can feel huge and incapacitating and can present as panic symptoms if confronted.
The child may have developed a fear of the school itself, a fear of travelling to school, or a fear of being separated from their carer. Sometimes this type of anxiety can be triggered by past experiences such as being bullied, but sometimes the fear doesn’t appear to have an obvious rational trigger. Sometimes these children also have developmental disorders such as learning difficulties or autism that have made them more sensitive or vulnerable. Commonly the carers may also have physical or mental health difficulties themselves. The child can feel anxious about their carer’s welfare. Some children may also be functioning as their parent’s carer and feel a strong sense of duty to remain at home with them. Again, there may be a need for the involvement of Social Services.
How common is School Phobia?
Minor issues with odd days off are very common, but most carers are able to respond appropriately before difficulties become chronic and entrenched.
It most commonly occurs at times of school transition, such as age 5 when children are first setting in to primary school, or at age 11 or 14/15 when starting at secondary school.
It effects boys and girls in equal numbers and from all social classes.
It also commonly occurs following a period of authorised absence, e.g. for illness.
Children are typically viewed as “good”, quiet or conforming rather than wilfully troublemaking. They are also often academically above average. Some are also previously outgoing with many friends.
Sometimes the school may not be a “good fit” for the child and they may be feeling chronic stress. Typically, this may be due to high academic pressure and a perfectionistic personality, or else feeling unable to meet academic expectations due to learning difficulties. Sometimes the school may just feel too big, crowded and noisy. There may be bullies and sometimes there may be an identified overly strict or “scary” teacher.
Sometimes there are family issues that also need resolving. Carers may be struggling to remain consistent, calm and firm when needed. This is most commonly due to either their own mental health difficulties or a lack of much needed support and help from others.
What is the best way to manage School Phobia?
Once any physical problems or school-based problems have been ruled out, then it is important to act as soon as possible to try and get the child back into school as quickly as possible. Reassurance and parenting support may then be enough.
However, if the absence has been prolonged and the child is showing a high degree of anxiety then a gradual reintroduction may be needed. A part-time attendance, with an aim for a gradual stepwise increase in hours until consistent full time attendance can be achieved, is usually the most successful approach. There also needs to be regular review of progress by all professionals involved.
Chronic cases may need additional therapeutic help from Mental Health Professionals who can offer both Individual and family based sessions.
Try to avoid offering home tuition as this will decrease motivation to leave the house. If attempts to reintegrate into mainstream classes prove unsuccessful, consider a referral to an onsite Special Needs classroom or another smaller teaching unit with a lower pupil number and a higher staff ratio.
What is the prognosis?
Generally good! Mild and acute cases usually resolve rapidly. The prognosis tends to be better for younger children and those with a stable and supportive home background.
Two thirds of children presenting with School Phobia will grow up to become “normal” healthy adults with no serious or ongoing mental health difficulties.
One third, however will have ongoing mental health problems such as anxiety disorders, “work refusal” and agoraphobia.
Dr Sarah Taylor is a Psychiatrist with Psychiatry UK – you can view her profile here.