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Some children
experience fear or panic when they think about
going to school in the morning. These children may
tell their parents that they feel nauseous or have
a headache, or may exaggerate minor physical
complaints as an excuse not to go to school. When
the child or adolescent exhibits a developmentally
inappropriate and excessive anxiety concerning
separation from their home or from those to whom
they are attached, they may be experiencing a
Separation Anxiety Disorder. Separation Anxiety
Disorder is characterized by the child exhibiting
three or more of the following for a period of more
than four weeks:
- recurrent
excessive distress when separation from home
or major attachment figures occurs or is
anticipated
- persistent and
excessive worry about losing, or about
possible harm befalling, major attachment
figures
- persistent and
excessive worry that an untoward event will
lead to separation from a major attachment
figure (e.g., getting lost or being
kidnapped)
- persistent
reluctance or refusal to go to school or
elsewhere because of fear of separation
- persistently
and excessively fearful or reluctant to be
alone or without major attachment figures at
home or without significant adults in other
settings
- persistent
reluctance or refusal to go to sleep without
being near a major attachment figure or to
sleep away from home
- repeated
nightmares involving the theme of separation
- repeated
complaints of physical symptoms (such as
headaches, stomachaches, nausea, or vomiting)
when separation from major attachment figures
occurs or is anticipated
As with Panic
Disorder, separation anxiety is most likely to
emerge during stressful times associated with major
transitions such as entering elementary school or
switching to middle school. It is also more likely
to occur following an extended amount of time with
the parent (such as being home for weeks on
vacation, a holiday break, or following a lengthy
time at home due to illness). In some cases,
separation anxiety may emerge following a major
trauma in the child's life, such as the death of a
family member or a move to a new neighborhood and
school. And as noted in the section on PANDAS, some
children or teenagers might have sudden-onset or
acute worsening of separation anxiety following an
infection, even a mild or short-lived one.
In addition to the
symptoms described above, children with an
unreasonable fear of school may
also:
- feel unsafe
staying in a room by themselves and
frequently go check to find their parent or
have a need to be able to see their parent
(e.g., a teenager in a shopping mall who
feels a lot of distress if they can't always
see their parent may be exhibiting a symptom
of separation anxiety)
- display
clinging behavior
- have
difficulty going to sleep
- have
nightmares about being separated from their
parent(s)
- have
exaggerated, unrealistic fears of animals,
monster, burglars
- fear being
alone in the dark, or
- have severe
tantrums when forced to go to school
Separation Anxiety
Disorder may be a precursor of other anxiety
disorders in adulthood, and early recognition and
treatment are important to prevent the development
of Panic Disorder and Agoraphobia.
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Separation Anxiety
Disorder can result in a child avoiding or refusing
to go to school, but the terms "Separation Anxiety
Disorder" and "School refusal" are not synonymous,
as the latter is not a formal diagnosis. That said,
children and teenagers who exhibit school refusal
often suffer from significant emotional distress,
most notably anxiety and depression. The most
common diagnoses associated with school refusal are
separation anxiety, social phobia, simple phobia,
panic disorder, post-traumatic stress disorder,
major depressive disorder, dysthymia, and
adjustment disorder. In one recent study looking at
school refusal vs. truancy, anxious school refusal
was associated with depression and separation
anxiety disorder, while pure truancy was associated
with oppositional defiant disorder, conduct
disorder, and depression. In those cases where both
anxious school refusal and truancy were exhibited,
almost 90% of cases had a psychiatric disorder,
with increased rates of emotional and behavior
disorders.
School avoidance or
school refusal may serve different functions in
different children or teenagers. For some children
or teens, it may be the avoidance of specific fears
or phobias triggered in the school setting (e.g.,
fear of school bathrooms due to contamination fears
associated with Obsessive-Compulsive Disorder, or
fear of test-taking). For other children or
teenagers, it may serve to help them avoid or
escape negative social situations (e.g., being
bullied by peers, or having a very critical
teacher). School avoidance or refusal can also
serve to (temporarily) reduce separation anxiety,
or to avoid settings that might be associated with
panic attacks, or to gain attention for any somatic
complaints (e.g., "Mommy, I can't go to school
because my tummy hurts!"). In one study of school
refusal, anxiety-related diagnoses were correlated
more with negatively reinforced school refusal
behavior (i.e., avoidance behavior), while
separation anxiety disorder was associated more
with attention-seeking behavior. Oppositional
defiant disorder and conduct disorder were
associated more with pursuit of tangible
reinforcement outside of school.
When school refusal
is anxiety-related, allowing the child to stay home
only worsens the symptoms over time, and getting
the child back into school as quickly as possible
is one of the factors that is associated with more
positive outcomes. To do that, however, requires a
multimodal approach that involves the student's
physician, a mental health professional, the
parents, the student, and the school team. The same
therapeutic modalities that are effective with
Panic Disorder and Obsessive-Compulsive Disorder
are also effective for school refusal, namely,
exposure-response prevention (a form of
cogntive-behavior therapy that may include
relaxation training, cognitive alterations, and a
graded hierarchy of steps towards the goal).
There is some
research that suggests that education support
therapy may be as effective as exposure therapy for
treating school refusal. Working with the school
psychologist, the student talks about their fears
and is educated in the differences between fear,
anxiety, and phobias. They learn to recognize the
physical symptoms that are associated with each of
these states and are given information to help them
overcome their fears about attending school. The
student is usually asked to keep a daily diary
where they record their fears, thoughts
(cognitions), strategies, and feelings about going
to school. The time of day that they arrived at
school is also recorded, and the record is reviewed
each morning with the school psychologist. Although
it might seem like a good idea to incorporate
positive reinforcement for school attendance, that
may backfire and merely increase the student's
stress levels and anxiety.
Parent training in
strategies to work with the child in the home is
also an important piece of any school-based plan to
deal with the student with school refusal.
Throughout this web
site, I have included reasonable
accommodations for different conditions, but when
it comes to school refusal, accommodating the child
by letting them stay home is generally
contraindicated, unless there are other issues.
Dr.
Rachel Klein of the NYU Child Study
Center has
provided some good tips to share with your
student's parents, including:
- Do not deny
the child's anxiety or worries, but
acknowledge them and reassure him/her. For
example: "I know you're worried I won't be
there to pick you up, but there's no reason
to worry. I'll be there."
- Try to find
ways to enable the child to go to school. For
example, a child is likely to feel reassured
if times are set for him or her to call the
mother from school. In extreme cases, mothers
may stay with the child in school, but for a
specified length of time which is gradually
reduced.
- It is most
important to tell the child exactly what s/he
is to expect. There should be no "tricks" or
surprises. For example, a child may be told
that he should try to stay in school for only
one hour, but after the hour he is encouraged
or asked to stay longer either by the school
or parent. This will backfire. The child will
eventually refuse future arrangements for
fear that they will be modified arbitrarily.
Part of being anxious is anxiety about the
unknown and the “what
if?”.
- Punishment
does not work, but kind, consistent, rational
pressure and encouragement do.
- Do not quiz
the child about why s/he feels scared. The
child often does not know why. By not being
able to provide an explanation, in addition
to being anxious, the child feels guilty
about not making sense of what is happening.
Better to acknowledge that the fears make no
sense and that the child has to fight
them.
- Be open to
hearing about how your child feels. However,
lengthy discussions about the child's
problems are not always helpful and can be
experienced as a burden by the child. The
focus must always be that you want to help
your child be free of worries and
fears.
- A child's
reluctance to go to school can be irritating
to parents. Expressing resentment and anger
is counterproductive. And you won't feel the
urge to do so if you adopt specific
strategies to assist your
child.
Other strategies
or tips for students with separation anxiety are
provided in another article
by Dr. Wagner
on this web site.
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