August 29, 2006
Personal Health
Help for the Child Who Says No to School
By JANE E. BRODY, NY Times

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James, a tall, bright, personable 12-year-old, had been successful socially, athletically and scholastically all through elementary school.

But everything fell apart when he had to move on to a large centralized middle school. Never a morning person, James now had to get up at 6 a.m. instead of 7:30 to catch the bus. Once at school, he had trouble finding his way around and arrived late for many of his classes. Rather than asking for reasons, which included being bullied and hit by several older boys, his teachers simply gave him late marks and detention.

James’s grades plummeted, and his feelings about school crashed with them. He couldn’t sleep at night. He started missing school a few days a week, then found himself unable to go at all. His parents were understanding and spoke to school authorities about his problems, but nothing anyone did seemed to make things better, not even disconnecting the television and computer to reduce the “rewards” of staying home.

Beginning the Turnaround

A psychological evaluation led to a diagnosis of a serious anxiety disorder set off by the abrupt change in school environment. Medication and 18 months at a therapeutic school, where James made steady progress, turned the situation around.

He did not return to the public school that terrified him, but he is thriving in a small private school where he made the National Honor Roll. Refusal to go to school is not an uncommon problem; up to one-quarter of children do it at some point. While you might expect the problem to be severest when a child first enters school, it occurs most often and hits hardest at ages 10 to 13.

At this age children typically leave the nurturing environment of elementary school and are thrust into the chaos of middle school and the confusion of dealing with so many teachers.

Compound this with the hormonal upheaval. Many children suffer crises in self-confidence and self-image, often exacerbated by the fact that they go from being the oldest and most experienced students in the school to being the youngest and most inexperienced.

Bullying, often perpetrated by young teens who are unsure of themselves, is one of the most common causes of this problem, called school refusal behavior. “Children who are bullied or teased often become anxious about going to school,” said Michelle Kees, a psychologist at the University of Michigan. And some of them may avoid school because it is too hard for them or perhaps because they have an undiagnosed learning disability, she added.

Christopher A. Kearney, a psychologist at the University of Nevada, Las Vegas, offered guidance on dealing with the situation in the August issue of The Journal of Family Practice. He told of Nathan, a 13-year-old who, like James, had trouble adjusting to middle school.

Though Nathan seemed fine on the weekends, during the school week he complained of headaches and stomachaches and told his parents he felt upset and nervous in school. He started going to school late, skipping classes and then skipping school altogether.

Common symptoms of school refusal behavior may include aggressive behavior, clinging to a parent or other adult, defiance, excessive assurance-seeking behavior, refusal to get up or get ready for school, running away from school or home, or having temper tantrums and crying.

Dr. Kearney described four circumstances that may prompt refusal to go to school:

Often in combination with underlying anxiety and depression, the child may be distressed by teachers, students, the bus, the cafeteria, the classrooms and transitions between classes.

The child may be trying to escape from distressing social situations or academic or athletic evaluations, including interacting with others or having to perform before others.

The child may be seeking attention from parents by staying home or wanting to go to work with a parent.

The child may find staying at home a rewarding experience that permits sleeping late, watching television, playing video games, or — especially for teenagers — engaging in delinquent behavior or substance abuse.

Risking the Consequences

Studies have shown that failing to deal with school refusal behavior can have serious consequences. In the short term, children who won’t go to school decline academically, become alienated from friends and cause family conflicts and financial and legal problems. Had James not gone willingly to the therapeutic school, the courts would have forced him to attend a school for delinquent children.

Common long-term problems listed by Dr. Kearney include dropping out of school, delinquent behaviors, economic deprivation, social isolation, marital problems and difficulty holding a job. Failing to receive the needed treatment can lead in later life to problems like anxiety disorder, depression or personality disorders.

Young children just starting school or returning to school after summer vacation may fear leaving their family or environment. In most cases, the initial hesitancy disappears as the child becomes familiar with the school and its rules and makes new friends. But a child with severe separation anxiety who is paralyzed by the fear of leaving home needs professional help, which should include teaching the parents how to cope effectively with the problem.

Discovering the Right Treatment

Often, the problem can be minimized before school opens by doing a walk-through of the school and classroom with children and arranging outings or visits with others in the same class. Once school opens, some teachers may allow parents to stay in class with their children for part of the day for a few days.

Dr. Kearney cautions that if a child has complaints like stomachaches, headaches or fatigue, as Nathan did, these should be checked out to be sure there is no underlying medical problem.

After Nathan’s pediatrician determined that the boy suffered from no underlying physical problems, a psychological exam revealed a generalized anxiety disorder. “He worried excessively about his social and academic performance at school,” and he showed physical signs related to anxiety, Dr. Kearney wrote.

If a psychological evaluation reveals a generalized anxiety disorder or depression, treatment is required, often with medication and professional counseling. Nathan was treated with a combination of sertraline (Zoloft) and anxiety management techniques, his parents received family therapy aimed at limiting the fun he had at home, and school staff members allowed him to gradually return to a full academic schedule.

Cognitive behavioral therapy, which emphasizes patterns of thinking, is especially effective in such cases.

For older children, techniques include relaxation training and breathing retraining to reduce the child’s anxiety, establishing routines and consequences for not attending school, and developing a contract that increases incentives for going to school and disincentives for staying home.

Childhood Disorders
"Part of being a parent is educating yourself about your child's health and well-being. The information below can help you learn more about the types of mental illnesses that children may experience as they grow and develop."

Corabell Arps, MD Child and Adolescent Psychiatrist at The Acadia Hospital
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Childhood is often thought of as being one of the happiest times in a person's life. A time where a carefree attitude and a worry-less life provide the environment in which a child grows and develops. For many children, however, this isn't always the case.

Research shows that 12 million American children suffer from some type of mental illness. It also shows that fewer than one in five receive the treatment they need to recover from their illness. When we think about topics such as depression or anxiety, we don't normally think of them as including young people. Most adults don't consider that emotional problems may effect a child, too. The reality is that children today deal with emotional issues and stress, the same as adults. Understandably, they often have a more difficult time handling and overcoming painful emotions and situations.

What types of illnesses effect children? Remarkably, children deal with some of the same types of disorders that adults do.

Depression, once thought of as strictly an "adult" illness, affects 3 to 6 million children in America. Depression in children has many of the same symptoms as it does in adults: sadness, helplessness, fatigue and low self-esteem. Recognizing depression in children, however, is sometimes difficult. One of the problems often encountered is the inability of a child to accurately express how he or she feels. A young child may not understand the concept of "helplessness" and therefore cannot explain it to an adult. This appears to be a major reason why so many children who suffer from depression go untreated. For those who do receive the needed treatment, therapy is essential. Therapy treatment teaches a child to express feelings and learn to adapt to and cope with environmental stresses.

Attention-deficit disorder (ADD) affects from 3 to 10 percent of all children in America. This condition is sometimes referred to as hyperactivity, minimal brain dysfunction, minimal brain damage and hyperkinetic syndrome. ADD is a child's inability to concentrate, learn and maintain a normal level of activity. With the disorder, a child usually requires close and constant supervision, is excessively active, and has difficulty finishing any activity requiring concentration. The disorder often appears before the age of seven and is more prominent in boys than in girls. Treatment for the child with ADD can include medication, psychotherapy, or a combination of both. Between 70 and 80 percent of children who suffer from ADD respond to treatment and learn to better control his or her own behavior.

Nearly all children have certain fears at different stages of their development. Fear of monsters, the bogeyman or strangers are certainly not uncommon. Normally, a child merely outgrows these fears. Sometimes, though, fears may persist and develop, interfering with a child's normal schedule. These fears may be simple phobias; fear of certain people, places or things, and may subside without any type of treatment. More often than not, children with childhood phobias do not receive treatment for their fears. It is important to consider, however, that treatment may be required if the fear persists or accelerates. Treatment for childhood phobias is comparable to that of adult phobias. The child is treated with behavioral therapy in which they are exposed to the feared object and must learn to overcome their anxieties and manage their fears. The phobia generally disappears or decreases so that it no longer interferes with the child's daily activities.

Being separated from a parent may be a traumatic time for a child, especially if he or she is not old enough to understand the circumstances of the separation. It is usually overcome when the child's attention is diverted or he or she adapt to the surroundings. For some children, the anxiety of being away from a parent or loved one is too overwhelming to comprehend, and causes severe emotional stress. Separation anxiety disorder is diagnosed when a child develops a severe anxiety, almost to the point of panic, when he or she is separated from a parent or loved one. This anxiety is so intense that it interferes greatly with the everyday activities of the child. Separation anxiety disorder may cause a child to feel faint, be nauseated, or develop headaches. Children suffering from separation anxiety disorder are often afraid to visit or sleep at a friend's house, go to school, or even leave the house unless accompanied by a parent. Therapy and medication are two methods of treatment which usually allow the child to overcome or cope with the separation.

By far the most common single group of psychiatric illnesses in American children is conduct disorders. Many people confuse a child with a conduct disorder with simply being rebellious or being a juvenile delinquent. Nothing could be farther from the truth. Studies suggest that a child with a conduct disorder often has underlying problems that have not been diagnosed. The disorder may result from a child's attempt to cope with his or her hostile environment or from a chemical imbalance in a child's biological structure. Research does indicate that children that have parents who suffer from the same problems are more vulnerable to develop a conduct disorder. Conduct disorders do not go away without proper intervention and appropriate treatment. Treatment is generally geared toward making the child realize and understand the effects of their behavior. For children suffering from an attention deficit disorder or depression in addition to the conduct disorder, medication may be required.

Not all children who are a bit unruly, who don't listen or who don't pay attention suffer from a disorder mentioned here. Being a child today is no easy task, and each child has his or her individual way of dealing with situations. Parenting today presents its challenges, too. It is important for a parent not to overlook a potential problem. Situations, especially prolonged or recurring, may indicate that there is more present than meets the eye.

Often, a child needs to discuss the problems or issues he or she is coping with as much as an adult does. CAPS: Children and Adolescents with Problems is a support group offered at The Acadia Hospital for individuals aged 12 to 18. This group is not designed to provide therapy or a solution to a child's problems. Rather, this group provides support, encouragement and feedback on issues facing children and their parents today. Group meetings are every Friday at 7 PM.

Making your child's life completely happy and carefree isn't always a realistic thought. Especially since the pressures and issues facing today's child are different from those that you faced as a child. Not every child has one of the childhood disorders mentioned, but it would not be accurate to say that they don't exist. Perhaps the acknowledgement, understanding and treatment of these childhood disorders will help make the growing process of every child an easier one.

To learn more about childhood mental health, check out our Healthy Living Library for links to additional resources on the world wide web.

Anxiety Disorders: Treatment Works