Extract of School Phobia, Panic Attacks and Anxiety in Children

Contents

INTRODUCTION
CHAPTER ONE: SCHOOL PHOBIA
CHAPTER TWO: ANXIETY DISORDERS
CHAPTER THREE: BULLYING
CHAPTER FOUR: SEPARATION ANXIETY
CHAPTER FIVE: SOCIAL PHOBIA
CHAPTER SIX: POSITIVELY DEALING WITH THE CHILD'S ANXIETIES
CHAPTER SEVEN: WHEN THE CHILD IS SEVERELY AFFECTED BY ANXIETY AND RELATED PROBLEMS
CHAPTER EIGHT: FIRST STEPS IN RECOVERY: LETTING GO
CHAPTER NINE: WHAT TO DO IF THE CHILD REGRESSES
POEM: THE ANXIOUS CHILD
FURTHER RESOURCES
USEFUL CONTACTS
INDEX

Introduction

No official statistics are available for children suffering from school phobia in the UK. However, according to Anxiety Care (see Useful Contacts), the number of children who dislike school and avoid it whenever possible, is probably more than 5 per cent of the school age population, but less than 1 per cent could be genuinely called school phobic. The Royal College of Psychiatrists suggest that between 5 and 10 per cent of children and young people have anxiety problems bad enough to affect their ability to live a normal life.

This book gives information and advice to parents and carers of, and professionals working with, children aged 5 to 16 that suffer from anxiety disorders, especially separation anxiety and social phobia that are part of school phobia (see Chapter Two). Chapter One includes photocopiable pages for professionals, and parents and carers, to give to teachers to help them understand the anxieties some children have about school.

Occasionally, a child that has suffered from school phobia in primary school has it recur in secondary school, often in a different form. This book helps helps parents, carers and professionals help children of any age recover from school phobia, guard against recurrence, and guard against it starting with a younger sibling, and has many practical tips.

My interest in writing this book is largely personal. My own daughter suffered severely from school phobia, starting just before her sixth birthday and coming though about nine months later. She suffered most of the symptoms mentioned in the book and became a sickly child from lack of food and constant stress. Her ability to function outside the confines of her home became extremely limited and her fears affected her whole life, which affected ours. During the extremes of her suffering, she attended school only part time on health grounds.

I found out that most of the people I turned to for help did not know how to give it. Some were unwilling to even try. As one who likes to problem-solve, I worked hard at finding my own solutions and had these confirmed by the child and adolescent psychiatrist to whom my daughter was referred after persistent requests. The practical advice given in the book has come from my own experiences with my daughter.

It was only when I heard of other children suffering from school phobia that I realised it was a more common problem than I'd thought and I wanted to share what I had learnt with others to limit the damage to all involved, but most particularly to the children vulnerable in their distress.

The reasons for school phobia to play a part in any child's life are varied but the theme that is common to all is stress that the child is unable to handle. The quickest way through is to remove the stress, allowing the child to relearn that the things he or she now perceives as dangerous are completely safe. If this is not possible, the child must be helped to deal with the stress and understand why he or she has such fears and learn to keep them under control.

The stresses in my own daughter's life that led to school phobia were: We had moved to a twelfth century castle to be houseparents to students that lived in that part of the college. The building was noisy with wind; doors banging; voices echoing in corridors; flag pole wire banging against the pole; the college rescue services' call-out siren (which was an old World War II siren sited above my daughter's bedroom); fire alarms (there was a beeper in my daughter's bedroom) and door bells on both floors of our accommodation (one of which was fixed to my daughter's bedroom door). Drizzle, fog, flies, wind blowing in particles and detector faults continually set off the over-sensitive fire alarms. Consequently, my daughter became very afraid of fire; alarms; of being burnt; of going to sleep and of being left alone. My daughter heard students' footsteps coming up the stone stairs and was afraid someone would come into her room. (Strangers had wondered into our flat more than once to look around having ignored all the private signs at the gates.) Consequently, my daughter became very afraid of strangers coming in, being burgled and again, of going to sleep and of being left alone. Her bedroom had great shadows from the various arches and doorways and this made her afraid of things lurking in the dark. She had a bad bout of croup and vomited before and during her journey to hospital in the ambulance. She developed a fear of being sick, of being ill and of dying. There were three deaths she knew of before her trouble started and another, a friend of her father's, later in the year. This increased her fear of illness and dying. For some time she had an undetected urine infection that made her need to frequently visit the toilet. She worried about needing to go when there wasn't a toilet. For a year after her infection had cleared up she continued to go to the toilet with great frequency, especially when she was anxious. (This was the last symptom of her anxiety to go.) She stepped in dog mess one morning before getting onto the school bus and it made her feel sick. She connected vomiting in the ambulance with being sick on the school bus and was afraid to travel on the bus again. She was sent home from school three times as soon as she arrived because teachers thought she was ill, but she was just anxious. This increased her concern for her health, not believing me when I told her she was fine.
The combined effect of these events made my daughter anxious about leaving home and not being in the same room as either my husband or myself when at home, needing to follow us everywhere.

Nine months later she was a different child, having 90 per cent recovered. It helped that the student house in the castle closed and we were moved to be houseparents to students that lived adjacent to our new family house, but she had started to recover six months before. The move had just speeded up her recovery. She did briefly regress three years later but all was resolved within three weeks and this prompted me to write Chapter Nine.

Just because a child is shy or anxious about some things or situations, it is important not to label her whole character as such. There can be many facets to a child. For example, my daughter remains a shy child with new adults but is outgoing with friends and people she knows well. She developed an early taste for scary theme park rides on which many of her friends could not contemplate going. There are other glimpses of a determined and fun-loving personality that we try to build on, trying not be over-protective and encouraging her to be continually challenged so that she is moving forward, but without pressurising her. We show our expectation that she will be fine. If she expresses a desire to do something, and it is within our power to agree (without there being concrete reasons to disagree), she is encouraged to go for it.

Author's note
Although professionals use the term school refusal, and sometimes school avoidance, throughout this book this condition has been referred to as school phobia. This is to avoid confusing truancy with an anxiety problem, and because many parents and carers think of a child as having school phobia, discuss the problem with others using this term and in using it, the underlying fear the child has is immediately understood.

A chapter has been included on general information about anxiety as school phobia is a result of extreme anxiety in children and is a complex disorder. Many anxiety disorders coexist or are linked in some way.

Because anxiety is such a big problem for children with Asperger Syndrome, and many children with it experience a high degree of school phobia, information that is specific to understanding and helping these children through their particular fears has also been included. Children with Asperger Syndrome need to be handled differently to children without the syndrome as, for example, desensitisation (graduated exposure) may cause further distress in an Asperger child yet can help a child without the syndrome.

However, it is accepted that children with AD(H)D, Attention Deficit (Hyperactivity) Disorder, and other conditions such as learning disabilities are also more prone to anxiety and anxiety disorders. Part of this may be because of having to deal with their condition, often in an environment where the people around them do not understand their difficulties or because they have not had their condition diagnosed and so are not on the road to help. Some children do not neatly fit in to any one category as many have more than one condition so professionals may be reluctant to make any firm diagnosis at all which means the child cannot be statemented with special educational needs. Or professionals may be reluctant to look further after applying one label to a child, which can also mean that the child does not get appropriate help. Part of the difficulty in diagnosis is that children with, for example, AD(H)D have symptoms that overlap with the symptoms of other conditions including Asperger Syndrome. Like children with Asperger Syndrome, children with AD(H)D can have problems with social skills, making friends and clumsiness, so some of the advice given to adults dealing with anxiety in children with Asperger Syndrome is also applicable to AD(H)D children (such as helping with improving the child's social skills).

Whatever the reason for a child's anxiety, this book will help adults involved with the child understand the havoc anxiety can wreak and the distress it causes the sufferer, so that they are more tolerant and can assist the child in coping with his or her anxieties.

Chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME), in children is often confused with anxiety or school phobia and parents and carers of children with CFS have often been accused of enabling them to truant by professionals that do not understand the condition or cannot make a diagnosis of what is wrong with the child. Because of this, children with CFS have also been mentioned.

To avoid the continual use of he/she in this book, 'she' has been used to encompass both sexes except in sections that refer to autistic spectrum disorders as this difficulty mainly occurs in boys. And to avoid the continual use of parent/carer, the word parent has been used to mean any adult who is in the position of being the main carer for the child. This person may be her natural birth parent, her adoptive or foster parent, an adult that looks after children in care or another relative such as a grandparent. When the word parents is used, this may mean either a couple or one person that has responsibility for the child.

All the web addresses listed in this book were checked prior to publishing. As time goes on, the list will become inaccurate although the addresses for organisations are not likely to change.

Chapter One: School Phobia (first part only)

School phobia is not a true 'phobia'. It is far more complex and can include a range of disorders including separation anxiety, agoraphobia and social phobia, although the anxiety is centred around the school environment. In reality, the school phobic child is usually afraid of leaving the secure home environment, and the safe presence of the main carers.

A young child suffering from separation anxiety may get the same symptoms when being left at a friend's home as being left at school. A child suffering from agoraphobia may get the same symptoms in a cinema as on the school bus. And another child, suffering from social phobia, might suffer the same symptoms when asked to read aloud in a place of worship, for example, so it is not only the school that causes these distressing symptoms.

However, since these symptoms of distress occur so regularly around the school environment and it is not always clear what is causing the child's turmoil, and the child may be so severely affected that she cannot attend school, the general term is conveniently called school phobia. Some professionals prefer to call this school refusal or school avoidance but, again, confusion can come about if people think that this includes truants who experience no anxiety about school and who feel no guilt or anxiety for not having attended.

Is the child truanting?
School phobia is an umbrella term for children who do not want to go to school because of anxiety; and their anxiety keeps them at home. This is contrasted with truanting children who intentionally do not go to school and who usually do not stay at home (and truanting older adolescents often show anti-social behaviour, such as being involved in criminal activities).1 Other children may simply prefer to be at home playing, finding it more interesting than being in school and so try to get their parents' permission to be at home, but also do not experience fear.

School phobic children who do not attend school because their symptoms are so severe are not truants because they have a specific anxiety about school and they remain at home with their parents' knowledge and, perhaps, presence. These children are children with special needs and should be dealt with in a sensitive and caring way as they are likely to be very sensitive and timid, feeling afraid of being perceived as failures2.

The types of school phobia
There are two types of school phobia3. The first is related to separation anxiety (see Chapter Four) and is generally found in children up to age 8 (although older children can suffer from this too: the longer separation anxiety continues, the more difficult it is to treat). The younger child is less likely to have learnt to feel confident and to be independent away from her parents. The onset of separation anxiety is usually sudden in children who have had it naturally subside after the age of three1 although it can start from the age of 6-8 months and continue thereafter.

The second type predominantly affects children above age 8 and revolves around the social aspects of the school and can be considered to be social phobia (see Chapter Five). The onset of this is gradual and can start from increased self-awareness around the time of puberty4.

Sometimes, travelling to school is the problem; the child may suffer from agoraphobia (see Chapter Two). However, this is usually an extension of other anxiety problems the child has and so it would probably also be present in a child who has separation anxiety. (The child may want her parents to drive her to school, fearing that something embarrassing might happen on the bus or train and not feeling secure unless with someone to look after her should she feel panicky. This was the case with my daughter who feared being sick on the school bus relating it to the times she'd been sick in the ambulance and when she felt sick on the school bus after stepping in dog mess.)

Three age groups that have peaks in school phobia 
There are three peaks for school phobia: The first is at age 5 to 7, and is related to separation anxiety. The second predominates at age 11 to 12, due to the anxieties associated with changing from a primary to a secondary school and is linked to social phobia. The third is at age 14 to 16 and is linked to social phobia and other psychiatric disorders such as depression and other phobias.
There may be another small peak due to separation anxiety when children have a change in school building when they move from infants to juniors, or from first to middle schools at ages 7 to 8. Fears children have when starting or changing school usually develop in the early months of the first term, typically September to November in the Northern Hemisphere. Separation anxiety can be exacerbated by a return to school after school holidays.

Indicators of susceptibility in children
There are certain family characteristics1 that indicate whether a child is likely to be more susceptible to suffering an anxiety disorder such as school phobia. Indicators are:

Another close family member suffers from an emotional or anxiety related problem.
The child has been over-protected and is therefore often more dependent on her parents, fearful of going it alone. (This is possibly the case with an only child.)
The child has a very anxious mother, and the mother's anxiety is transmitted to the child, making her feel that she also has cause to worry. (The child can also 'model' her mother, and behave in the same way that her mother does, worrying about the same sort of things in the same sort of way.)
The child may have a father that plays little part in her upbringing or he may be absent altogether.
The youngest child in a family is often the most vulnerable to anxiety disorders because she is considered to always be the 'baby' of the family and is treated as such. Also, when parents know they will have no more children, they sometimes want to keep the youngest very close to them and, albeit unconsciously, dependent.
The child has a chronic illness and has needed to be very dependent on her parents and has not had the confidence to know she is fit and strong and able to cope with what life throws at her.
The child is often well behaved and academically able.
School phobia can develop as the result of depression1, which makes the child feel she can't possibly cope with the pressures and challenges of school or as the result of an escalation of a number of fears and stressors (as with my daughter).

The symptoms of school phobia
Whatever anxiety disorder or disorders the child is suffering from, she can experience anxiety symptoms including: crying diarrhoea feeling faint a frequent need to urinate headaches hyperventilation nausea and vomiting a rapid heart beat shaking stomach aches.
School phobic children feel very unwell when having to go to school. The symptoms disappear once the 'threat' of going to school is lifted. For example, once a child has convinced a parent that she is really ill this time and the parent gives the child the benefit of the doubt, the child relaxes and the symptoms fade. However, they return as soon as the 'threat' is reintroduced.

How Does School Phobia Start?
Going to school for the first time is a period of great anxiety for very young children. Many will be separated from their parents for the first time, or will be separated all day for the first time. This sudden change can make them anxious and they may suffer from separation anxiety. They are also probably unused to having the entire day organised for them and may be very tired by the end of the day, causing further stress and making them feel very vulnerable.

For older children who are not new to the school, who have had a long summer break or have had time off because of illness, returning to school can be quite traumatic. They may no longer feel at home there. Their friendships might have changed. Their teacher and classroom might have changed. They may have got used to being at home and closely looked after by a parent, suddenly feeling insecure when all this attention is removed; and suddenly they are under the scrutiny of their teachers again.

Other children may have felt unwell on the school bus or in school and associate these places with further illness and symptoms of panic, and so want to avoid them in order to avoid panicky symptoms and panic attacks fearing, for example, vomiting, fainting or having diarrhoea.

Other children may have experienced stressful events.

Possible triggers for school phobia (collected from literature mentioned at the end of the chapter) include: Being bullied. Starting school for the first time. Moving to a new area and having to start at a new school and make new friends or just changing schools. Being off school for a long time through illness or because of a holiday. Bereavement (of a person or pet). Feeling threatened by the arrival of a new baby. Having a traumatic experience such as being abused, being raped, having witnessed a tragic event. Problems at home such as a member of the family being very ill. Problems at home such as marital rows, separation and divorce. Violence in the home or any kind of abuse; of the child or of another parent. Not having good friends (or any friends at all). Being unpopular, being chosen last for teams and feeling a physical failure (in games and gymnastics). Feeling an academic failure. Fearing panic attacks when travelling to school or while in school.
(Please note that depression has not been included here as a cause of school phobia as in the points above the underlying reasons that might have caused it have been covered.)

Point 1 is looked at in Chapter Three.
Points 2-10 can be related to separation anxiety, where the child feels insecure away from her parents or fears that something may happen either to herself or to a parent during the period of separation and are looked at more closely in Chapter Four.
Points 11-13 are concerned with social performance and are looked at more closely in Chapter Five.
Point 14 is concerned with agoraphobia and panic disorder and is looked at further in this chapter and in Chapters Two and Seven (where help for specific and general fears is given).

Please note that the above points are not intended to cast blame on the child's parents. However, if a child's fears are to be addressed it often helps for the root cause or causes to be identified and in doing this, steps can be taken to help the child. It is understood that every home has its problems (including mine). In being aware of what they are and the effect they are having allows parents to look objectively on the situation to see what they can do to help the child. The main concern has to be for the child, whatever her reason for stress.

Risks of untreated school phobia
If the school phobia is so severe that the child stops going to school, her education and social development may suffer. Since school phobia in older children tends to be centred around social phobia, this withdrawal from the social aspects of school can compound the difficulties the child already has. Also, parents have the problem of finding alternative ways of educating the child (see Home education in Chapter Seven).

Temporary home tuition may make it harder for the child to return to school (however, children with autistic spectrum disorders may hugely benefit from a long break and may even fare better out of the school system if they do not respond well to the school environment, particularly in their teens when they may also be suffering from obsessive compulsive disorders and depression)5. However, there are special schools that specifically cater for children with autistic spectrum disorders (see below).

Although permanent removal from mainstream education may make the child happier, professionals are concerned that if a child's underlying fears have never been addressed and dealt with, the child may store up problems for the future. For example, the child may fear leaving home to go to college or work, the previously unresolved fears holding her back, making her very dependent on family support. The lack of social contact may also have a detrimental affect, making it hard for her to make friends in a new environment and be socially on the same wavelength as the majority. And, if the child is already very shy or over-sensitive, she is more likely to remain so.

Once the child's anxieties interfere with her everyday life, parents should seek help from a professional such as a child and adolescent mental health professional; for example a child psychologist or psychiatrist.

Special schools for children with autistic spectrum disorders
Children with autistic spectrum disorders that attend special schools catering especially for them may have fewer of the problems such children face in mainstream schools because the environment is adapted to suit their particular needs.

Jayne Birch, Headteacher of Springhallow (Ealing, London), a special school for children with autistic spectrum disorders, says: 'I do think specialist education is often the best place to assist anxious pupils with autistic spectrum disorders (ASD). I often visit pupils with ASD who are placed in mainstream schools and they find the whole experience stressful, confusing and scary. Our older pupils who have been with us since they were small are not overly anxious and none have developed obsessive compulsive disorders. The pupils who cause us most concern in these areas are those who have come from/been excluded from mainstream schools as older pupils. They are often distressed and take a long time to build relationships. They often have high anxiety levels.

'Our environment is ordered and structured, calm and quiet, even when pupils and staff move around the school. Lunchtimes and assemblies too have a routine and are well staffed. Our teaching styles are designed to assist the pupils in managing their anxiety: we break things into small manageable tasks. Much anxiety is caused by pupils not knowing what is going to happen next, needing to control their environment and often not being able to, and wanting reassurance and confidence boosters. We also teach our pupils (from a very early age) how to calm themselves and how to ask for help. Calmness is the key to managing and working with pupils with ASD and most of our pupils do not need breaks because of anxiety.'