School Phobia

December 20, 2011

In early August you performed a school physical on Eric -- a robust 5-year-old about to start kindergarten. Both Eric and his mom appeared excited about the prospect of his starting school.

On his first day of school, Eric's mom called saying that Eric had a sore throat and because of this was unable to attend school. She asked you to see him. You did and his throat culture was negative for Strep and his CBC was normal. You advised her to let Eric stay home for a day or two and then send him to school.

A few days later Eric’s mom called to report that Eric now had an upset stomach. She again asked you to see Eric because he was too sick to attend school. You did - - and again his exam was normal.

This process was repeated a number of times during the next few weeks and Eric attended school for only 2 days.

Eric is in the first stage of a school phobia, which can occur at any age. The symptoms may vary, but the underlying reason for them is a fear of leaving home. School phobia constitutes a psychiatric emergency. The longer the child does not attend school, the more difficult it is to engage him or her in regular school attendance.

Immediate action is essential. Ideally, if your time, commitments, and the organization of your office allow, you will need to meet with the child’s parents and the child to explore elements of the home situation, details about the child’s health, and the nature of the school environment-any of which might contribute to his anxiety. Topics for discussion during this meeting include:

-- The parent’s relationship
-- If the parents are divorced, with which parent does the child live?
-- If there is a joint custody arrangement, how does it work?
-- If only one parent is involved in the child’s care, who cares for the child when the parent is not  home?
-- Is anyone at home seriously ill or does anyone suffer from a psychiatric disorder?
-- Are other family members not living in the home seriously ill?
-- What is the family’s current economic situation?
-- Has the child a prior history of separation anxiety?
-- What is the makeup and structure of the classroom and school?

If, on the basis of information obtained during this meeting, you discover an anxiety-provoking situation, a set of interventions needs to be developed to reduce the child’s fears. The physician then needs to aid the parents in developing a plan to help the child attend school.

For example, if one of the grandparents is ill and the parents are preoccupied with the relative’s care, the primary care physician can work with them to develop a strategy that addresses how the illness affects the home life, the child, and any siblings. Clarifying the impact that a family crisis may have on a child may be the first step toward reducing tension in the home.

Working with the parents to understand and develop strategies to address the crisis may help change dynamics in the home. If this change occurs, the physician can now work with the parents to establish routines and support to help the child go to school.

When the interventions proposed do not work or the primary care physician does not have time to accomplish these goals, the child and family will need a referral to a children’s mental health professional.