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School Phobia
Q.
I am a school nurse at the intermediate school level and every year we have several students who are put on homebound status because of school phobia.
Recently, a school in a nearby school district has started a new approach hereby instead of sending a teacher to the home to instruct the child, they require the student to come to the school after regular class hours to one room that is set off from the busy after school activities for their instruction.
The district believes it is a healthier approach for the student. Do you believe it is better to have the child stay away from school or to have the child come to the building for their instructions while dealing with school phobia?
A.
I believe that keeping the child away from school only reinforces the school phobia, and would not encourage a program of that sort. But first, let's back up a minute. What is called "school phobia" is not really a phobia about schools. It is usually a form of either Separation Anxiety Disorder or Social Phobia.
In Separation Anxiety Disorder, the anxiety is usually limited to situations in which the child is separated from the parents. Social phobia (SP) involves anxiety about being judged, evaluated, criticized, or humiliated by others, usually in some type of performance situation; for example, giving a speech before a group. A child with severe, generalized SP may be anxious even when with others in the home setting, unlike the child with Separation Anxiety Disorder. So--it is important to ensure that the child with so-called school phobia gets a thorough diagnostic evaluation by a child psychologist or psychiatrist.
A good review of cognitive-behavioral therapy (CBT) for social phobia is provided by Huppert et al (Curr Psychiatry Rep. 2003 Aug;5(4):289-96.). CBT emphasizes ways of desensitizing the person to the feared situation, including the use of "in vivo exposure". This means exposing the person directly to the feared situation. Sometimes this needs to be approached more gradually, or by means of imaginative techniques, rather than direct exposure. In the case of children with SP, family education and therapy can also be of help, by teaching parents how to avoid reinforcing social phobic behaviors. But keeping the child away from school seems to me a self-defeating way of managing SP in the long-term. Serotonergic antidepressants of the Prozac type may also be very helpful in dealing with SP, and should be considered as part of the overall treatment approach if CBT alone fails.
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January 2004
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