Twelve-year old Amy’s best friend was “happy slapped” recently in a shopping centre. Rumour has it the Year 11 culprits have Amy in their sights next.

She is refusing to leave the house. Eight-year-old Neil has always been disruptive and underachieved. Since his father was sent to prison and his mother became depressed, he frequently misses school. On days when he comes in, he gets stomach-ache after assembly and stays in the medical room until lunchtime. Isabelle, 6, was an imaginative, confident child until the birth of her twin brothers coincided with the maternity leave of her class teacher. Now she screams every day at the school gate, insisting her new teacher is fierce and nobody likes her any more.

CONTESTED UNCERTAINTIES

Which of these children has school phobia? All of them? Any of them? At its most extreme, school phobia is an evidently irrational fear of school, resulting in emotional and physical symptoms: clinginess, tantrums, panic, fear of individual teachers, pupils, situations or lessons - the school bus and PE are common triggers - unexplained headaches, stomach-aches, exhaustion, nausea, vomiting andor diarrhoea.

But in the real world, things are rarely so clear cut. Is Amy’s fear of her friend’s attackers irrational? It may be dangerous to assume so. Does Neil’s anger and shame stem from his own failure (attracting the label “disaffected” and later “truant” rather than “school phobic”), or from those of his parents? When does a reaction to normal stresses - new baby in the house, new teacher - cross the line into abnormality, as Isabelle’s seems to have done?

The very term “school phobia” is contested in Britain, though not in America, with “school refusal” preferred by some. Its prevalence is unknown, because most local authorities do not disaggregate school phobic children when they count all their non-attenders. It is thought to be rare, though most secondary schools will contain more than one child whose absences - they may not be every day, but crucially they will increase over time - are the result of fear.

Children’s anxiety is likely to get out of hand when starting primary school at five; at 11, on transfer to secondary school, and, probably due to the social and emotional pressures of adolescence, at 14. Girls and boys appear to be affected equally; only and youngest children, and those with Asperger syndrome and attention deficit hyperactivity disorder, are more at risk.

CAUSE: SCHOOL OR HOME?

With so much uncertainty, it seems hardly surprising that the causes of school refusal are also unclear. Stories in the media imply no confusion:

“My child was bullied, therefore he has school phobia” is the recurrent line. Something bad has happened at school, hence school is what the child fears.

But fears are complex things, and most bullied children do not develop school phobia, points out Ruth Loshak, co-ordinator of the Red Balloon Learner Centre in Cambridge, a “safe place” in a city centre house which teaches up to 12 teenagers, all victims of bullying, most of whom have refused to return to school.

“On the whole, I would say these are fundamentally anxious or insecure children,” she says. “All children are subject to bullying of some sort and most shrug their shoulders and deal with it; their family supports them, talks it through and manages it. If you look at our families, in almost every case there’d be reasons why they can’t do that. But it wouldn’t be true in every case.”

Schools can be scary places for children, particularly new schools, larger than anywhere the child has experienced previously. Some schools are rigidly authoritarian, or chaotic. But not every child in them is paralysed at the thought of going through the gates. “Almost always there is some difficulty or anxiety in the family, either overt or less conscious,” says Anne Casimir, senior educational therapist at the Caspari Foundation, in London, which supports children with emotional difficulties. “So the child feels more vulnerable when they go to school.”

BLAMED OR REJECTED

All kinds of things can unsettle a family, from the arrival of a new baby to parental illness, bereavement, marital break-up, or the threat of violence: a child may fear one parent is only safe from the other when he or she is home to protect a mother or father. Any of these may result in a child feeling unsafe anywhere but home. They may also result in the child’s parent(s), if not actually encouraging them to stay at home, then at least not feeling able to insist they attend school. Understandably, schools sometimes then feel that the parents are colluding in the child’s absence.

They may also feel rejected, says Anne Casimir.

Most teachers aim to make their classrooms attractive and welcoming: it is disturbing to discover that the very thought of them makes a child physically sick. While understanding the importance of family factors, schools have to be very wary of letting these tensions shift them into blaming the parents, says Dr Felicity Fletcher-Campbell, senior researcher at the National Foundation for Educational Research and collaborator on one of the very few reports on school phobia in recent years (see below).

“There’s a lot of blaming. You hear people say the parents are mollycoddling the child, or ‘with a home like that, what do you expect?’

Obviously, causes are important, but it’s useful to focus on dealing with the situation.”

Marianna Csotis, former secondary physics teacher and author, whose daughter experienced school phobia, agrees: “Blaming isn’t helpful even if there is cause for concern about the home. Parents don’t deliberately stress their children out.”

WORKING IN PARTNERSHIP

Instead, experts agree, everyone dealing with a phobic child needs to work in partnership. An individual class teacher must not be left to shoulder the burden, particularly in primary schools. The child, teacher and family need pastoral support. Educational psychologists andor the education welfare service should be involved. Schools should seek advice from the primary mental health worker for their patch in the local Child and Adolescent Mental Health Service (CAMHS), says Lee Miller, who runs Young Minds training courses for schools and local authorities.

Above all, parents should be part of any discussions about what the child’s fears are focused on, and what can be done to keep the child coming to school, or get them back in as quickly as possible. “Someone needs to act as home-school liaison, perhaps a learning mentor,” says Anne Casimir.

“Someone who can explain the school’s point of view to the parents, and the parents’ point of view to the school. It’s important it should work both ways.”

Everyone needs to work in unison. What degree of firmness will adults express to the child? What will happen when the child refuses to go to school? What will happen if the child has a stomach-ache, or is sick? Parents need to know that they will not deliver a child claiming to be ill only to be rung up and told to take their sick child home again. But they also need to know the school will take basic healthcare precautions - using a forehead thermometer, for example - to ensure the child is not physically unwell.

EARLY INTERVENTION

Experience of school phobia suggests that early intervention is so crucial that CAMHS are actually more likely to intervene at the start of a case than once it has become chronic and entrenched, says Lee Miller. As soon as schools suspect that anxiety is preventing a child’s attendance, either through absence patterns or from the child’s behaviour, they should contact parents and discuss what the child’s fears are and how the child can be supported.

That may include temporary removal of whatever is making the child anxious: a short-term release from PE, for example, or a change of lesson grouping.

It may include finding activities a child enjoys, additional praise and reassurance in the classroom, part-time attendance, or allowing the child to start school slightly late or finish early, to avoid the corridor crush.

Children may need permission to go to the toilet; they will need a safe adult, perhaps a learning mentor or head of year, to turn to when they feel insecure. They may want a sympathetic teacher to meet them at school, or see them onto the bus at the end of the day.

If bullying or intimidation are issues, senior staff will need to demonstrate that they are taking the child’s and parents’ fears seriously, even if all the right policies are in place. Other children may help here, says Felicity Fletcher-Campbell: “This needs to be brought out into the open. Sometimes other children in the class are good at knowing what helps one of their peers.”

In primary school, circle time can be a good setting; in secondary schools a discreet discussion with a few of the child’s friends may work better.

“The teacher should explain that the child has a problem coming to school and has been very brave to come,” says Marianna Csotis. “They should show pleasure when the child comes to school, and acknowledge the child’s effort in getting there. And they should never make negative remarks like ‘Oh, so you decided to come in today’.”

PANIC ATTACKS

None of these measures is going to work in every case, and schools need to recognise when a child’s anxiety has become uncontrollable, possibly resulting in a panic attack. In this situation, the child’s instinctive “fight or flight” adrenaline rush comes into play quite uncontrollably: any suggestion that they are malingering, or can “snap out of it”, is misguided.

The child may breathe rapidly or feel unable to breathe, they may experience faintness or dizziness, sweating, a racing heart, flushes, ringing in the ears, tingling or numbness in the hands and feet, nausea, a need to go to the toilet, an unidentified terror. Having one panic attack will increase a child’s fear that others will follow, and he or she is likely to become even more anxious and avoid the situation in which the first attack occurred.

During an attack a child needs to be reassured that this is not their fault, that they have done nothing wrong, that no one is angry with them.

They need to be kept in as warm, quiet and safe a place as possible.

Children who have regular panic attacks can be helped with relaxation techniques, counselling or cognitive behaviour therapy, generally with a referral from a GP.

PREVENTATIVE MEASURES

Once a child is established in a pattern of panic and school absence, it can be intractable. “Our children simply say ‘I won’t go to school’,” says Ruth Loshak. Those children who do make it back, either into their original school, a new school, or a support unit, may also relapse.

Yet so much can be done to prevent school phobia, says Lee Miller, simply by hawk-like attention to children’s attendance patterns and intervention at any sign of anxiety.

Often what these children need to prevent their fears getting out of hand is more of what all children need, say experts: lots of praise and encouragement, anti-bullying measures which can be relied on, kindly and supportive adults, a sense that school is a safe place to be.

Whereas, once school has got tangled up with the child’s internal fears - imagine facing your own private terrors every time you get up in the morning - then, says Felicity Fletcher-Campbell, school, family and child all have a mountain to climb: “Successful schools see this as a continuum; they look for strategies which make all children feel comfortable. They see that these children aren’t that different. Something has just gone askew in their lives.”

TRAINING AND RESOURCES

School Phobia, Panic Attacks and Anxiety in Children, by Marianna Csoti, (Jessica Kingsley, pound;16.99)

School Phobia and School Refusal: research into causes and remedies, by Tamsin Archer, Caroline Filmer-Sankey and Felicity Fletcher-Campbell, pound;8, from NfER Publications Unit. Tel: 01753 637002.

www.youngminds.org.uk

www.phobics-awareness.org

www.rcpsych.ac.uk