INCLUDING SCHOOL PHOBIA (SCHOOL REFUSAL)
Young children have more fears and phobias than adults, and experience
the emotion of them more intensely. Such fears may start and stop for little
apparent reason as the child develops. When the child loves something one
day and fears it the next, this is more likely to be due to changes in the
child than the result of some traumatic episode.
Novelty, unpredictability and sudden changes can also induce fear in children,
and illness might ‘put them back’, reviving old fears that they had put behind
them at an earlier age. Adults also teach children to fear certain things
before the child has even come across them, through their words or actions.
Children may also ‘pick up’ the fears of adults in their family.
There is little evidence to suggest that children who are particularly timid,
over-dependent, subject to tantrums and mood swings, or with poor appetite,
are more likely to be phobic. And children who have phobias at an early age
usually develop into normal adults.
WHAT EXACTLY IS A PHOBIA?
Anxiety is a human trait and most individuals will have experience of it.
Anxiety helps with vigilance, learning and general performance but in excess,
it starts to work against us as extreme self-focus and apprehension reduces
this attention and performance. Anxiety at the minor symptom level
is familiar to virtually all of us and from Anxiety Care’s experience, this
often seems to weigh against an acute sufferer seeking help; or, perhaps,
for an adult taking a child’s anxiety seriously. Embarrassment and
shame at an ‘over reaction’, perhaps aggravated by the particular blending
of emotions (such as anger, shame, guilt or sadness mixing with a dominating
fear) that make up their ‘personal anxiety’ keeps the problem hidden and
prevents this person, particularly if he or she is in their teens, from understanding
that this response doesn’t mean they are weak, soft or immature.
It is often not understood that anxiety can follow a continuum from mild
to acute that leaves some people with ‘liveable’ responses but others deeply
disabled. With most phobias, the vast majority of young people will
be at, or close to, the mild end of the line where the problem is, at most,
irritating, but in no way affects their everyday lives. This can work against
the severe phobic as people experiencing a similar fear at a low level very
easily come to believe that the acute sufferer is weak or ‘over reacting’.
Severe anxiety releases adrenaline and other chemicals into our blood, and
these speed up our heart-beat, sharpen our senses and heighten our physical
powers. These changes prepare us for what is called ‘flight or fight’- either
to fight for our lives, or to run for them. A phobia is a disorder in which
the body reacts in exactly the same way, and we experience the same feelings
of anxiety and fear – but in situations where there is absolutely no need
for ‘flight or fight’. The part of the mind that controls anxiety
has, to all intents and purposes, lost all sense of proportion, and screams
`danger!’ when the situation is not threatening in any rational way.
No matter how harmless the feared creature may be, for a severely phobic
person the fear reaction is every bit as real as if the cause was a major
threat. People with phobias usually realise all too well that their reaction
is irrational, but this makes no difference to its effect.
WHAT DO CHILDREN FEAR?
The objects and situations that children fear vary a good deal. When very
young children show fear it can be hard to judge exactly what is causing
it, and many parents underestimate the number of things that frighten their
children. In one study of ‘just-fours’, parents reported that two-thirds
of children had recurrent fears, and other research points to a typical pattern
and there are some fears such as as snakes, spiders and heights that seem
common to us as a species. Parents should always be aware that some intense
fears are quite a natural developmental stage and will ease naturally.
The following is a general list of normal fears:
Age 2-4: fear of animals, loud noises, being left alone, inconsistent discipline,
toilet training, bath, bedtime, monsters and ghosts, bed wetting, disabled
people, death and injury.
Age 4-6: fear of darkness and imaginary creatures. Also animals, bedtime,
monsters and ghosts. Other fears, such as of strangers seem to be persistent.
‘Stranger fear’ would probably be called ‘shyness’, while fear of snakes
tends not to decrease much, if at all, during this period. Children at this
age may also fear loss of a parent, death, injury and divorce.
Beyond these ages, irrational fears tend to decline rapidly, though there
may be further peaks to do with other situations, e.g. age 9-11: fear of
school; fear of blood and injury.
Older children tend to worry more about death and related topics such as
nuclear war. Up to age 11 boys and girls tend to be equally represented in
the ‘fear tables’; after 11 years boys lose their fears more rapidly than
It has been suggested by some research that children between the ages of
three and six; sometimes confuse reality, dreams and fantasy. This concept
has been challenged in recent years, so it is not safe to believe that everything
that the child of this age fears is just something they will grow out of.
Young children may also sometimes believe that inanimate or non-living objects
have lifelike qualities. They may too have inaccurate concepts of size relationships
(monsters that can come up through plug-hole for example). They may also
lack an accurate understanding of cause and effect and often perceive themselves
as helpless and powerless, without effective means to control what is happening
8 year-olds will probably have fragments of earlier fears but additional
ones will tend to be more rationally based and will possibly include fear
being late for school, social rejection, criticism, new situations, adoption,
burglars, personal danger and war.
9 and 10 year-olds are also likely to fear divorce, personal danger and war
and these three are very likely to continue as fear problems into the mid
teens. This age group might also fear blood and injury.
11 and 12 year-olds might fear animals, kidnapping, being alone in the dark
and injections. Marks states that beyond this age boys lose their fears
more readily than girls.
13 year-olds seem to fear heights as well as the three mentioned above.
14-16 year-olds will tend to have a wide range of rational or almost rational
fears which might include: injury, kidnapping, being alone in the dark, injections,
heights, terrorism, plane or car crashes, sexual relations, drug use, public
speaking, school performance, crowds, gossip and divorce.
These childhood fears are not that different from those of adults.
The most common adult fears are: public speaking, making mistakes, failure,
disapproval, rejection, angry people, being alone, darkness, dentists, injections,
hospitals, taking tests, open wounds and blood, police, dogs, spiders and
As will be noted from the above, many childhood problems wax and wane as
a normal part of development and a sensitivity in a certain area might be
aggravated by a current problem so that this particular child temporarily
‘falls back’ into an earlier level of fear when faced with a trauma or severe
family or school problems.
WHAT ARE THE SYMPTOMS OF PHOBIA?
In adults, phobias produce all the unpleasant physical symptoms of
* heart palpitations
* feeling sick
* chest pains
* difficulty breathing
* ‘jelly legs’
* feeling ‘unreal’
* intense sweating
* feeling faint
* dry throat
* restricted or ‘fuzzy’ vision or hearing.
In severe cases, people may feel certain that they are about to die, go mad,
or lose control of themselves and injure someone, or do something disgusting
and humiliating. Most of all they feel an overpowering urge to ‘escape’ from
the situation they are in. Children are more likely to cry, shout or scream,
or simply run away when confronted by the things they fear, though they may
also be sick or go rigid. Paleness, perspiration and trembling are also signs
of severe anxiety.
The level of symptoms that children with phobias experience varies a great
deal, from very mild anxiety to very severe panic and terror. A mild degree
of nervousness in particular situations is not usually a problem, but it
is only a matter of degree, and at the other end of the scale there are children
who have full-scale panic attacks when in the dreaded situation, and soon
refuse to enter it altogether because of the terror that grips them at such
Phobias aren’t just severe anxiety: the anxiety is turned into a phobia by
avoidance. In the early stages of a phobia the child’s parents sometimes
try to tackle his or her fears head on by forcing him or her to enter the
feared situation. If this works, the phobia can be overcome. If it
doesn’t, this is only likely to strengthen the fears and make the child want
to avoid the phobic situation even more. It also risks destroying the child’s
confidence in its parents.
Avoidance is attractive because it brings a reduction of the tension; thus
it rapidly becomes a habit. As with adults, avoiding the situations that
make them feel frightened makes children more sensitive to those situations,
and ‘conditions’ them to fear them even more.
This is why phobias can be such a big problem. Because we tend to avoid the
things we fear, the fear can worsen very rapidly. To recover, we need to
put that process into reverse, but the fear reaction is virtually automatic,
and very difficult to control. It is a reaction inherited from our early
history as a species, when we needed some instinctive protection to balance
out our curiosity and tendency to flirt with danger. Fortunately, humans
learn quickly and can train themselves to respond positively to threats,
and not to react with terror to things which prove, with experience, to be
IT CAN’T JUST BE ANXIETY, CAN IT?
A child with severe phobic symptoms has an anxiety condition. This
is much worse than just being nervous or ‘a bit of a worrier’. Anxiety at
this level can be as disabling as many physical diseases. However, because
it seems unreasonable for someone to react so strongly to such ordinary situations,
many parents may suspect a more ‘logical’ explanation – perhaps a serious
physical or mental illness. Then the child may become a frequent visitor
to the doctor’s surgery and undergo a long series of medical tests, all of
which draw a blank.
It often comes as a great relief to parents when they learn that the problem
is not a brain tumour, psychosis etc., and that the nasty and frightening
symptoms are in fact caused by anxiety. However, there is always the remote
possibility that the child also has a medical condition, and this is one
reason why we always recommend parents of phobic children to keep in touch
with their GP.
HOW CAN CHILDREN’S FEARS BE TREATED?
The first thing to be considered is whether or not the phobia impacts strongly
on the child’s life. If it does not interfere with day-to-day functioning
then it might be worth considering allowing nature to take its course.
If there is a level of handicap or severe distress, then treatment is indicated.
Persistent fears in children can be treated in much the same way as they
are in adults; that is by desensitisation through being exposed to the feared
situation. However, as children’s fears are often volatile and transitory
the child’s previous record with fears should be considered before launching
into an elaborate treatment programme. As already said, most fears will cease
to be a problem without any need for treatment, and there is always the risk
of teaching the child a new way of getting attention if every expression
of fear brings a dramatic response from a parent. (Of course, if a child
feels the need to use ‘fears’ as a way to be noticed, this might indicate
different kinds of problem within the family.)
Nobody with a phobia responds to punishment or obtains the slightest improvement
from being ‘talked out of it’. Children in particular seem to respond best
to being helped to increase their skill and competence, and being encouraged
to take part in activities that will involve the thing they fear. With young
children especially, practical activities that involve exposure could also
be turned into a game, since most children respond better to play than to
work. With a fear of bees, for instance:
first the bee is shown in a sealed bottle, some distance away
then it is brought closer; then closer (the child can be rewarded with a
small treat for every shoe’s length closer he or she is prepared to approach
the bottle – or allows the bottle to approach, if that is less stressful).
eventually the child can be helped to touch the bottle, with a grand prize
other exposure ‘steps’ could include walking in the garden (accompanied at
first) when bees are about, with an escape route clearly established to build
if the parent is feeling brave, further exposure could be undertaken by ‘modelling’,
i.e. doing the feared thing and showing the child in practice that there
is no need to be afraid. In the case of a bee this might involve letting
the bee alight on their clothing, with the child safely distant.
In extreme cases of phobia in children a therapist might use relaxation,
videos and ‘fantasy exposure’ (helping the child to face the dreaded situation
in his or her imagination) before attempting live exposure work.
Most children do not want to upset their parents and may be resistant to
talking about the intensity of their feelings. If this is the case,
one technique suggested by Anxiety Care is to ask the child what he or she
thinks a close friend would be feeling in this situation. This doesn’t
work, of course, if the friend is perceived to be tough, but if the child
can be helped to explore this cared-for person’s possible responses in similar
situations, where he or she was afraid, this can establish the level of fear
that the phobic child accepts as ‘normal’. Parents can sometimes be
horrified at the fear levels uncovered in this way and it is important that
an over reaction that involves shame and feelings of worthlessness as a parent
do not become involved. If it does, this will only cloud the issue
and unbalance the necessary socialising and discipline that the child needs
in the rest of his or her daily life.
When the child resists support, it can become very difficult. Where
very negative thinking is involved, the parent can try to help by gently
challenging the child’s thought processes. This is described in ‘Poor
Thinking’ on this site. Obviously a heavy challenge is rarely likely
to work with a very young child and the parent needs to work out the best
way to approach the problem: in some way helping the child to look at his
or her thoughts and beliefs in a way that is challenging, not threatening.
If the child refuses all help then the parent could usefully talk to a doctor
or therapist without the child being present in order to learn ways to apply
help at such time that the child is willing to accept it.
Sometimes depression occurs alongside a severe phobia. The problem
here is that depression undermines: it takes away the will to try to overcome
the phobia and may even make the sufferer feel that he or she is helpless
against it. Where depression is suspected the GP must become involved.
If the depression is mild or moderate, the child will probably receive help
focused on the anxiety with concurrent support for the depression. If the
depression is judged to be severe, the focus will be on treating the depression.
Drugs are rarely the first treatment of choice for young children.
In the developing brain the neurotransmitting system seems to be particularly
sensitive to medication so it is unlikely that a doctor would suggest medication
early on in treatment for a very young child. If it is considered,
the dosages would have to be very carefully monitored.
SCHOOL PHOBIA (SCHOOL REFUSING)
The number of children who dislike school and avoid it whenever possible
is probably more than 5% of the school-age population, but less than 1% could
genuinely be called ‘school phobic’. School phobia, also called ‘school refusal’
is commoner among boys, and the peak onset in Britain is at the age of 11-12
years. This is perhaps not surprising, since this is the age when most children
move from primary to secondary school, and therefore experience great changes
in their lives.
There are also smaller peaks at the age of 5-7 years old, where separation
from the mother may be a primary cause (See the article on separation anxiety
on this site); and at 14, where it is more likely to be associated with a
psychiatric disorder such as depression.
Some older adolescents and young adults may experience fears of college or
work that resemble school phobia; most of these will have been school refusers
Sometimes school refusing begins suddenly, for instance after a prolonged
absence from school due to illness; following an abrupt change of school
or class; after school holidays – or even after a weekend. However, the actual
event immediately before school refusal is unlikely to be the sole cause
of the problem, though it might have been the last straw on top of a lot
of other things. These additional situations could include family problems;
difficulties at school; anxiety about puberty; other sexual matters;
general difficulty with social situations; anxiety about being separated
from the parents (mainly the mother); bereavement; or depression.
However, most cases of school refusal seem to develop slowly. Reluctance
to attend gradually increases, with visible signs of anxiety that grow more
obvious as the child is pressured to go. Sometimes the child will deny that
he or she is afraid, but signs such as paleness, trembling and frequent urination
may be very obvious to the parent. Typically the child will complain of bodily
pains, stomach trouble or nausea in the early morning. These problems usually
cease abruptly if the child is allowed to stay at home, and re-appear when
he or she is once again pressured to go to school.
Some children will simply refuse to go to school, offering no reason. Others
might complain of bullying, or of being unable to get on with teachers or
do the school work. Some may express fears about undressing in front of other
children, or of making a spectacle of themselves by fainting, vomiting or
losing control of their bowels. Less often they may mention fears of something
happening to one or both of their parents while they are at school, or simply
of feeling `unsafe’ when far from home.
Children deal with their fear of attending school in many ways. Some may
go through the morning ritual almost normally, but are then unable to leave
the house, or turn back before reaching school. Others may flatly refuse
to get out of bed, or lock themselves in somewhere, or run off until they
feel it is safe to return home. Some will gladly put up with punishment as
the price of not going, and many will promise (and mean it at the time) to
go ‘this afternoon’ or ‘tomorrow’ if they are only allowed to stay at home
now. Some children have been known to threaten, or even attempt, suicide
when they felt totally trapped by the situation.
PHOBIA OR TRUANCY?
School phobia is sometimes confused with truancy – even by teachers and educational
workers. However, truants do not usually express or display such high levels
of anxiety, and nor do they flatly refuse to attend school. It is just that
there are other things they would rather be doing. They are more likely to
pretend to set off for school, and then disappear on the way, or during the
day, returning home at the normal time, so that parents are often the last
to find out what is happening. Truants also tend to become involved in other
delinquent behaviour. They may also come from disadvantaged areas and
homes where there is not enough discipline, caring, or simple parental interest.
Their school work is likely to be rather poor and they will probably show
little interest in what the school thinks of them.
This is in sharp contrast to the typical school refuser, who comes from a
stable home with both parents present and caring (if sometimes over-protective)
and who is often described as “always such a good boy/girl – never any trouble
before this”. Typical refusers may also be sensitive to the point of timidity,
being unduly wounded by adverse comments from teachers, and have unrealistically
high goals for themselves; they may then become excessively upset at their
TREATMENT FOR SCHOOL REFUSAL
Anxiety Care receives many letters and phone calls from parents of school
refusers. Besides the anxiety and confusion, many share a feeling of guilt.
They have been told, or have read, that it is “all their fault” for making
a “mummy’s boy (or girl)” out of the child. In our culture, that usually
means ‘wimpish’ and ‘inadequate’. Parental reactions can then be deep shame
or anger and a closing of family ranks. None of this is conducive to helping
the child out of the problem.
Although ‘separation anxiety’ (difficulty in leaving mother) can be a major
factor in school refusal for 5 to 7 year-olds, it is not necessarily significant
for older children. ‘Real’ fears of such things as being bullied, PE and
games, unfriendly teachers, the size of the school, and other personal and
family difficulties, might be the dominant factors. Several cases brought
to Anxiety Care have been triggered (or ‘last-strawed’) by a death in the
family. Sometimes it was not a close relative, or even a human being that
died; but for an 11 or 12 year-old this may have been the first time that
the finality of death came home to them; and this can be a shock. Even if
the experience wasn’t particularly traumatic, it is never safe to assume
that children will deal with such a loss as an adult would.
Children may also react to loss of friends through moving to a new school
or area in the same way that they would to a bereavement. A good therapist
would not jump to conclusions about reasons, but would make a systematic
investigation of all the possible factors – child, family and school.
PROFESSIONAL THERAPY FOR SCHOOL REFUSING
Parents cannot afford to allow school refusal to be ignored or treated in
a haphazard and ineffectual manner. The law requires a child to be educated,
and most parents are not able to pick and choose where this takes place.
If children do not go to school, parents may be taken to court, and there
is even the (very slight) risk of the child being taken into care. Nobody
wants this to happen, so professional help is usually readily available,
and it is vital for parents to make the best use of it.
Most current treatments for school refusing are carried out around the home
and the school by clinical child psychologists. They will involve helping
the child to deal with anxiety symptoms in the situation where they developed,
while getting the child back to school as quickly as possible. Inpatient
treatment compares poorly with this kind of ‘live’ support, though a small
minority of children do fare better away from home.
Some parents may be tempted to take their child out of the school system
altogether, but research shows that temporary home tuition is not a useful
road to recovery, and works against the child’s early return to school. Permanent
withdrawal, even if some children do better academically, and feel more content
outside the school system, has some dangers. The child with low social skills
may not learn how to relate to the peer group, which can become a major problem.
The child may also never resolve the underlying problems that generated,
or were part of, the school phobia.
They may thus become prime candidates for a similar anxiety disorder later
in life when faced with going to college, or to work. They may also be so
handicapped by lack of the social and ‘peer’ learning gained at school that
character traits such as timidity, over-sensitivity, and the tendency to
have unrealistic expectations of themselves and others, may become a permanent
barrier between the young adult and the rest of the world.
The problem with setting a goal of ‘the child returning to school as quickly
as possible’ is deciding how soon to aim for. The therapist’s personal beliefs
and the extent of the child’s anxiety will be the main factors here.
However, whether the period is short or long, all therapists will have a
series of priorities. They will:
work at establishing a good, trusting relationship with the child and the
clarify the situations that actually create anxiety
desensitise the child to these situations by getting the child to imagine
the dreaded events, with relaxation techniques, and simply by talking about
lastly, they will help the child to confront the situations ‘live’.
THERAPISTS AND PARENTS
Therapists are well aware that they need the full support of the child’s
family, and that there can be much confusion, anger, guilt and plain misconception
to work through before therapy proper can begin. They would spend time with
the parents, trying to assess how much bearing their behaviour and reactions
have on the school refusal problem.
They would probably meet with the parents alone, so that other problems which
could be affecting the child might be resolved without the child being drawn
into them (or feeling to blame for them). They would also talk through worries
such as parents feeling cruel and guilty about forcing the child to go to
school. Where parents are uneasy about seeming to criticise teachers, or
staff feel threatened or irritated by the idea that their school is a ‘dreaded
place’, they would also act as go-between.
The therapist would also help the parents find the best ways to deal with:
the child’s tantrums, complaints about illness, refusal to talk about the
problem (or insistence on doing so)
redressing the balance if the child had begun to dominate the family through
ways to avoid escalating threats and/or polarising into ‘protecting mother’
and ‘threatening father’ that can be so damaging in the families of school
Towards the end of the treatment, with the child ready to attend school,
the therapist would also discuss the best times to return, such as after
a weekend or a holiday, rather than in midweek, which might arouse more comment
from other children. And they would work out, perhaps using role play, the
responses the child might use to those making fun of his or her absence.
After the child has returned to school, they would go on to help the parents
recognise danger points in the future, and encourage them to use the ‘management’
techniques they have learned.
Live exposure to the dreaded situation is part of overcoming all phobias.
However, simply dragging a child to school would not be appropriate in most
cases. While school may be the focus of fear, most school refusers get to
that point via a number of ‘stressor’ situations working together.
So before the journey to school is attempted, the various fears already mentioned
have to be faced. Nevertheless, the journey to school has to be undertaken
sooner or later, and this can be a very dramatic time, when the parents’
anxiety is almost as high as the child’s. Parent and therapist have to be
clear how to deal with this. A good therapist will have explained that all
‘exposure work’ is built round the child’s actual anxiety level, not what
it should be or could be. This will ease parents’ fears of the child experiencing
a total collapse or breakdown. A strategy would be worked out in advance
for certain situations, for example:
with a young child, the parents would not linger within sight of the classroom,
fuelling the child’s anxiety as well as their own
if the child was to be physically restrained from escaping, the parents wouldn’t
let the child think that a little more hysteria might bring them leaping
to the defence
there would be a planned response if the child should run home.
It is extraordinarily hard for parents to stand by while their children suffer,
even when they know it is necessary and temporary. Therapists work closely
with parents, and they understand how important it is for the family to be
able to support the child as he or she gradually comes to terms with school
The basic reference works on which we have drawn are:
Fears, Phobias and Rituals by Professor I M Marks, published by Oxford University Press (1987), and
Handbook of Parent Training: Parents as Co-Therapists for Children’s Behaviour Problems (C.E. Schaeffer (Ed.)) Section 111, Chapter 3;
Prof. W. Yule, Ph.D, New York;