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 [1]. 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 [2].

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.

• Disability

  Our programs and services are available to children who have attention deficit hyperactivity disorder (ADHD), autism spectrum disorder, anxiety and mood disorders, tics and Tourette disorder, learning disabilities, stress and trauma, and early childhood [aboutourkids.org]

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  She's seeking a civil rights attorney to file a suit against the school board for discriminating against her disabled daughter. Meanwhile, the tutors have stopped coming, and the fines are mounting — topping $11,000 this spring. [npr.org]

• Enuresis

  […] anxiety disorder 22.4% Generalized anxiety disorder 10.5% Oppositional defiant disorder 8.4% Major depression 4.9% Specific phobia 4.2% Social anxiety disorder 3.5% Conduct disorder 2.8% Attention deficit/hyperactivity disorder 1.4% Panic disorder 1.4% Enuresis [mdedge.com]

• Diarrhea

  Symptoms of school phobia in children Physiological symptoms: sweating of the hands and body, muscle tension high vomiting, Diarrhea, changes in feeding and in sleep habits. [earlychildhoodeducationwebsites.blogspot.com]

  Common physical symptoms include headaches, stomachaches, nausea, or diarrhea. But tantrums, inflexibility, separation anxiety, avoidance, and defiance may show up, too. [adaa.org]

  Reasons to remain home might include not just complaints of discomfort but recognizable symptoms: a temperature greater than 101 degrees, vomiting, diarrhea, a rash, a hacking cough, an earache or a toothache. [healthychildren.org]

  Your child may have a panic attack with sweating, dizziness, racing heart, vomiting, diarrhea, or shaking. School phobia may get in the way of your child's normal activities. [drugs.com]

• Recurrent Abdominal Pain

  […] and illness (notably cancer, Crohn’s disease, dyspepsia, hemophilia, chronic fatigue syndrome) Nausea and vomiting Diabetes Palpitations and perspiration Dysmenorrhea Recurrent abdominal pain or other pain Head louse infestation Shaking or trembling [mdedge.com]

• Palpitations

  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]

  Dizziness, heart palpitations, dry mouth, excessive sweating, breathlessness, nausea, and full blown panic attack are few other symptoms of Didaskaleinophobia. [fearof.net]

  Moreover, your child may complain of dizziness, headaches, stomachaches, body aches, heart palpitations, nausea, diarrhea, shakiness and vomiting when it is time to go to school. [doctornicki.com]

  In addition, physical/somatic symptoms (especially frequent in older children and adolescents), such as dizziness, lightheadedness, nausea, stomachache, cramps, vomiting, muscle aches, or palpitations, may be present and problematic, causing the child [emedicine.medscape.com]

• Sweating

  The symptoms typically include extreme anxiety, dread and anything associated with panic such as shortness of breath, rapid breathing, irregular heartbeat, sweating, excessive sweating, nausea, dry mouth, nausea, inability to articulate words or sentences [common-phobias.com]

  Symptoms of school phobia in children Physiological symptoms: sweating of the hands and body, muscle tension high vomiting, Diarrhea, changes in feeding and in sleep habits. [earlychildhoodeducationwebsites.blogspot.com]

  When it's almost time for school, a child may sweat, sometimes profusely, shake, or have a high pulse rate, while in anger, fear, or despair. [phobia.wikia.com]

  Dizziness, heart palpitations, dry mouth, excessive sweating, breathlessness, nausea, and full blown panic attack are few other symptoms of Didaskaleinophobia. [fearof.net]

• Behavior Disorder

  Michiel Westenberg, School refusal and anxiety in adolescence: Non-randomized trial of a developmentally sensitive cognitive behavioral therapy, Journal of Anxiety Disorders, 25, 7, (870), (2011). [doi.org]

  Abstract We address issues pertaining to problematic school absenteeism, a pressing social dilemma that is a substantial correlate of behavior disorders in youth and linked to later problems in adulthood. [dx.doi.org]

  "contingency management, self control, and education support in the treatment of childhood phobic disorders: a randomized clinical trial." journal of consulting and clinical psychology 67:675–687. wicks-nelson, r., and israel, a. c. (1997). behavior disorders [encyclopedia.com]

• Compulsive Disorder

  That said, social anxiety is commonly co-morbid with other anxiety symptomatology; especially Obsessive-Compulsive Personality Disorder, which includes perfectionism and Obsessive-Compulsive Disorder. [social-anxiety.com]

  It could be that fear of germs or contamination makes the child afraid of school and the condition to be addressed is actually Obsessive Compulsive Disorder. [brandonuteachertools.net]

  Morgan Smith, for example, has been diagnosed with obsessive-compulsive disorder, and she has always been tormented by fears. [greatschools.org]

  […] study] Fluvoxamine (Luvox) and sertraline (Zoloft) have been approved for the treatment of obsessive compulsive disorder in children. [aafp.org]

• Aggressive Behavior

  Bullying is unwanted aggressive behavior among school-aged children involving a real or perceived power imbalance that is repeated or has the potential to be repeated over time. [emedicinehealth.com]

• Headache

  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]

  But with the child who is school phobic, parents become worried because these children are convincing about having a headache or a stomachache. [valueoptions.com]

• Dizziness

  Many children develop physical symptoms, such as dizziness, stomachache, or headache, when they are made to go to school. School avoidance is a milder form of refusal to attend school. [healthofchildren.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]

  […] school phobia include: Refusal to attend school Creating reasons why not to go to school Missing a lot of school Frequent complaints about not feeling well with vague or non-specific complaints Complaints of chronic physical symptoms (e.g. headaches, dizziness [vrphobia.eu]

  Gellner: A child with school phobia stays home from school and is missing a lot of school days because of vague physical symptoms, usually the type people get when they're upset or worried such as stomach aches, headaches, nausea, tiredness or dizziness [healthcare.utah.edu]

  Dizziness, heart palpitations, dry mouth, excessive sweating, breathlessness, nausea, and full blown panic attack are few other symptoms of Didaskaleinophobia. [fearof.net]

• Seizure

  Her seizures were actually panic attacks. [mlive.com]

  The physical symptoms are nothing short of harrowing: hyperventilating, chest pains, dry mouth, shaking, crying, dizziness, nausea, and seizures. [elearnmag.acm.org]

  Anti-Convulsant (kun-vull-sunt): This medicine is usually given to control seizures. But, it may also be used to lessen violent behavior, aggression, or irritability. This medicine may also help control your child's mood swings. [drugs.com]

• Stroke

  For a while Josef coped by going to his uncle’s store after school where he helped out, which gave him a sense of purpose, but his uncle had a stroke a few months ago and the store has been closed since. [anxietybc.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 [3].

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 [4], feeling unsafe in class [5] or the urge to pursue hobbies during school hours [6].

The clinician may apply the 'School Refusal Assessment Scale-Revised,' a useful instrument when trying to assess the cause of school phobia [7]. 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.

Kelly, School phobia: A review of theory and treatment, Psychology in the Schools, 10, 1, (33-42), (2006). [doi.org]

Young, School Phobia: A Discussion of Aetiology, Treatment and Evaluation, Psychological Reports, 39, 3, (783), (1976). Eugene W. Kelly, School phobia: A review of theory and treatment, Psychology in the Schools, 10, 1, (33-42), (2006). [dx.doi.org]

PHARMACOLOGIC TREATMENT Pharmacologic treatment of school refusal should be used in conjunction with behavioral or psychotherapeutic interventions, not as the sole intervention. [aafp.org]

The prognosis is relatively good in preadolescent children and relatively poor in older children. [ncbi.nlm.nih.gov]

Fremont listed the following options: Educational-support therapy Cognitive-behavioral therapy Parent-teacher interventions A combination of therapy and medication Intensive psychotherapy Bernstein reported a positive prognosis for school-phobic children [aspeneducation.crchealth.com]

Once school refusal becomes significant enough to be termed a disorder and has begun to go on for several weeks, the prognosis is still excellent with treatment. [emedicinehealth.com]

The authors discuss the etiological significance of the almost universal parental pathology and family malfunction for both groups of children. [ncbi.nlm.nih.gov]

[…] also found that full-term and very preterm infants (VPT) had changes in the amygdala: positive correlations with subcortical and limbic structures and negative correlations with cortical regions, although magnitudes were decreased in VPT infants. [11] Etiology [emedicine.medscape.com]

Numerous reviews have focused on the etiology, prevalence, assessment, and treatment of school refusal, and a number of these have focused specifically on treatment outcomes. [doi.org]

Most epidemiological studies have come from mental health literature. These study findings, extrapolated from referrals to clinics, suggest that school refusal occurs in approximately five per cent of all school-age children (Last & Strauss, 1990). [senmagazine.co.uk]

Epidemiology Approximately 1 to 5 percent of all school-aged children have school refusal. 3 The rate is similar between boys and girls. 4, 5 Although school refusal occurs at all ages, it is more common in children five, six, 10, and 11 years of age. [aafp.org]

[…] school attendance, underscoring the long-term nature of school refusal, thus a chronic care approach to school refusal is needed even through combined treatment – augmentation of cognitive behavior therapy (CBT) with fluoxetine improved outcomes. [9] Pathophysiology [emedicine.medscape.com]

School phobia can often be prevented by proper anticipatory guidance regarding independence during well child exams. Received January 25, 1971. Accepted May 8, 1971. [pediatrics.aappublications.org]

Prevention Little can be done to prevent school refusal. [healthofchildren.com]

It usually affects sensitive and insecure children and causes physical symptoms which the child uses to prevent school exposure. [symptoma.com]

The behavior is differentiated from parents who deliberately withdraw their child from school and from youths with significant exigent circumstances such as homelessness that prevent adequate school attendance. [doi.org]

Address family violence prevention. [emedicine.medscape.com]

1. Kearney CA, Silverman WK. The evolution and reconciliation of taxonomic strategies for school refusal behavior. Clin Psychol: Sci Prac. 1996;3:339-354.
2. Kearney CA. Bridging the gap among professionals who address youth with school absenteeism: overview and suggestions for consensus. Prof Psychol Res Prac. 2003;34:57-65.
3. Mindell J, Leichman E, DuMond C, et al. Sleep and Social-Emotional Development in Infants and Toddlers. J Clin Child Adolesc Psychol. 2017;46(2):236-246.
4. Glew G, Fan M, Katon W, et al. Bullying, psychosocial adjustment, and academic performance in elementary school. Arch Pediatr Adolesc Med. 2005;159:1026-1031.
5. Swahn M, Bossarte R. The associations between victimization, feeling unsafe, and asthma episodes among US high-school students. Am J Public Health. 2006;96:802-804.
6. King N, Heyne D, Tonge B, et al. School refusal: categorical diagnoses, functional analysis and treatment planning. Clin Psychol Psychother. 2001;8:352-360.
7. Kearney CA. Identifying the function of school refusal behavior: a revision of the School Refusal Assessment Scale. J Psychopathol Behav Assess 2002;24:235-245.