School phobia (also known as didaskaleinophobia or school refusal) is a type of anxiety disorder characterized by irrational fear of attending school. It usually affects sensitive and insecure children and causes physical symptoms which the child uses to prevent school exposure.
School phobia affects 5 to 28% of children (boys and girls alike, more often between the age of 10-13 years) at some point during their education . The symptoms consist of headaches, abdominal pain, nausea and vomiting, asthenia, excessive perspiration, muscle aches and bone pain, palpitations, dizziness, trembling or accelerated intestinal transit. The presentation commonly occurs just before going to the school or during school hours. The child repeatedly asks to leave the classroom and visit the school nurse. He or she may also exhibit psychiatrical symptoms like anxiety, avoidance coping, noncompliance, inflexibility or a tendency to defy authority. Temper tantrums may also start if his or her requests are not met. All these problems quickly disappear once the child is reassured that he or she can remain at home. School phobia may be a sign of a deeper psychiatrical abnormality, such as depression, pathologic anxiety or personality disorder .
Symptoms may happen gradually when it progressively becomes more difficult to convince the child to attend school or can take place abruptly, after a stressful event. Patients do not refuse to learn or do their homework, they only feel panic about going to school and fear may be so deep, some may cry throughout the previous night.
If the problem is not quickly addressed, it can lead to academic decline, school dropout, social isolation, and lack of success in the later stages of life, affecting the family life and causing economic problems.
Physical examination usually reveals no pathologic elements. However, an organic support for the child’s complaints may be suspected after clinical examination. Diseases to be looked out for include thyroid disorders, asthma, mitral valve prolapse, and gastrointestinal diseases, especially Crohn’s disease and dyspepsia.
BACKGROUND: Children and adolescents with school phobia sometimes complain of severe and persistent headaches that are diagnosed as chronic daily headache (CDH). [ncbi.nlm.nih.gov]
The most common symptoms that children experience are nausea, upset stomach, and headache. These complaints obviously mask the anxiety the child experiences, which tends to rise dramatically when the parent tries to get their child to go to school. [appliedlearningcenter.com]
The symptoms consist of headaches, abdominal pain, nausea and vomiting, asthenia, excessive perspiration, muscle aches and bone pain, palpitations, dizziness, trembling or accelerated intestinal transit. [symptoma.com]
If a somatic disease is suspected after clinical evaluation, thorough blood and imaging workup should be ordered. Complete blood cell count is needed in order to rule out anemia, a cause of abdominal pain. The same symptom can be caused by heavy metal intoxication, that also needs to be excluded. Thyroid and thyroid-stimulating hormones can be ordered if the clinical aspect suggests glandular pathology. Type I or II diabetes or decreased insulin tolerance are diagnosed using glycemia or urine glucose elimination.
If history or clinical evaluation point to an expansive intracranial process, computer tomography, magnetic resonance imaging or positron emission tomography are in order. If a cardiac problem is suspected, the first steps towards diagnosis are an electrocardiogram and echocardiography. A sleep disorder can also induce anxiety, therefore sleep studies may be useful .
If no physical cause for symptoms is found, causes of school refusal must be explored: fear of separation, fear that something may happen to his or her parents, avoiding teacher criticism, avoid being bullied , feeling unsafe in class  or the urge to pursue hobbies during school hours .
The clinician may apply the 'School Refusal Assessment Scale-Revised,' a useful instrument when trying to assess the cause of school phobia . Other interview scales, such as 'Diagnostic Interview for Children and Adolescents-Revised,' 'Social Anxiety Scale for Children,' 'Multidimensional Anxiety Scale for Children or Child Behavior Checklist' also exist. Furthermore, observation of the whole family is indicated. The child should also be interviewed regarding suicidal ideation.
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