By Christmas of Year 9, Cassie's daughter Linda* had developed a paralysing fear of school that prevented her from attending any lessons. "She'd be shaking, frozen, like a rabbit in the headlights," says Cassie. "She lost her ability to speak to anyone outside the immediate family or go anywhere and do anything. She even developed a fear of the fear - she'd be so frightened that she'd freeze up, so that she couldn't contemplate going to school."
Far from this being the result of having long-running problems with school, Linda was a pupil who had been in the gifted and talented set of her year group and was assessed at the age of eight as having the literacy age of a 13-year-old.
"The school didn't have a clue how to deal with it," says Cassie, who believes that the teachers put their grades and position in the league table ahead of her daughter's needs.
By contrast, Linda's small primary school had provided a supportive enough environment for her to flourish, but the larger, more academic grammar school proved more stressful. A series of sick days (that could have been caused by stress) made her worry about coming back and a verbal attack from a classmate in Year 9 was the final straw that made it physically impossible for her to attend. Eventually Cassie had to leave her own job to teach Linda at home and bring her to the few classes she could attend.
Children have always had fears about school, whether it's fear of leaving their parents or fear emerging from peer relationships. The term school phobia was coined in 1941 by Adelaide M. Johnson and her colleagues but the loose definition still made it difficult to differentiate between truants and school phobics and pin down specific symptoms.
It is one of those terms that sounds too simplistic to be taken seriously - a "condition" any teenager would love to have. After all, who wouldn't want a legitimate excuse not to go to school? In a debate about school phobia on a TES web forum, one poster, voicing the concerns of many teachers, wrote: "Are you saying you don't believe that educational culture now requires us to invent syndromes and conditions to explain away problems and things that require effort, and blame, to resolve?. I worry what will happen if we continue to make excuses for this avoidance of responsibility."
According to the most recent Government figures, however, one in 10 children and young people from the ages of five to 16 suffer from some kind of mental health problem and school phobia is included within this group.
Exact figures for the reason pupils become non-attenders are difficult to determine, but pupils diagnosed as school phobic make up a proportion of the 38,000 long-term absent and the 340,000 pupils at risk of persistent absenteeism.
"Very often there's an underlying anxiety order that drives it," says Dr Sam Cartwright Hatton, a child psychologist who specialises in anxiety disorders. "There tend to be certain peaks where children are more susceptible - in the transition from primary to secondary school or a time of family trauma or divorce."
The causes of school phobia are as individual as the pupil and as a result, each sufferer requires different care. "The perceived wisdom is that you've got to get them back (to school) as soon as possible," says Dr Cartwright Hatton.
But she prefers not to take such a hard line. "In some circumstances, I actually feel that does more harm than good and until that child has some coping strategies, to deal with what's through that door, it feels unfair with me," she says. Establishing the root cause is essential: "If you haven't worked out what's causing it, no matter how hard you try to treat it, you won't."
It doesn't help that there isn't a clear definition of school phobia and it isn't registered in the Diagnostic and Statistical Manual of Mental Disorders no. 4 (DSM-IV), which catalogues all psychiatric disorders and is known as the psychiatrists' bible. A 2004 report from the National Foundation for Educational Research found that a couple of different terms were used by local authorities and schools to describe such pupils, including pupils with acute anxiety about attending school; pupils who cannot face school; and pupils who persistently refuse to attend. It's also known as school refusal, particularly in the US, which suggests that pupils' attitude, rather than their mental health, is the problem.
Sufferers and their parents, however, blame the current high-stakes education system for heightening their symptoms. The emphasis on testing at so many levels puts on enormous pressure, even for those who are academically able, while the transition from primary to a larger secondary school is also acknowledged as a cause of anxiety. In the past, these pupils may not have had this external pressure but even if problems did arise, they were more likely to be seen as a phase that they'd grow out of.
In today's "therapy culture", where the Government is ploughing millions into training therapists, and where helplines have reported a surge in calls since the onset of the recession, classifying this childhood anxiety as an illness is a natural next step.
Frank Furedi, Professor of sociology at the University of Kent and author of Therapy Culture: Cultivating Vulnerability in an Uncertain Age, argues that the collection of school phobia symptoms have been grouped together, as an almost arbitrary construction. "The way that I read the situation is that for some time, education has been dominated less by a narrative of hope, than of fear," he says. "There have always been anxieties about kids' education, but now it's the fear of exams, the fear of bullying or the fear of pressure, that have been a dominant background to the way that children are regarded in school."
According to Professor Furedi, recognising school phobia as a medical term is part of a wider tendency to medicalise problems that are difficult to attribute to a specific cause. "The normal fears and anxieties that we all have as children from time to time, intensify, as children are now given permission to see that in a much more stabilised form," he says. "I would argue that one of the consequences of this will actually be to expand the problem."
He draws a comparison with the huge rise in diagnosis of attention deficit disorder - a similar example of parents and teachers latching on to a tangible means of deciphering and dealing with their child's problems. An illness with a name and a cure is often preferable to having to address any wider sociological or psychological problems that have to be dealt with closer to home, he says.
For school phobics, it's the same. Sufferers may find it easier to deal with something specific and seek specific treatment, rather than manage a range of complex anxiety issues that are difficult to deal with and emerge in seemingly irrational circumstances.
Dr Cartwright Hatton agrees that the term school phobia isn't necessarily helpful. "A lot of psychiatric problems, generally speaking, are a problem with life aren't they?" she says. "Especially with children, it's a problem with what's going on around you. If something's got a label, there's a tendency to treat it in one way. Like if you have diabetes, you take insulin, but if you have school phobia, there could be 50 different treatments."
Linda was never diagnosed with school phobia and although she spent years out of school and eventually moved to a smaller, less intimidating school for a year to try to cope, she doesn't identify with the term.
"I think its just part of a larger phobia about interacting with people," she says. "I think I always had a bit of that and I've always been shy but the school exacerbated the problem."
But why then has school phobia become part of psychologists' vernacular? And if the term has been contrived, how does that explain the severe symptoms? General anxiety problems that often have a debilitating impact on sufferers are on the rise among children as well as adults. Experts who have worked with sufferers argue that the term school phobia is just something that local authorities, schools and often parents have found useful in an educational context. "People call things how they see them," says Dr Cartwright Hatton. "I don't see a child who's refusing to go to school, because I'm not a teacher: I see a child who's got an anxiety disorder."
Looking back at her time at school, 20-year-old Isobel does think that it would have helped if there was more awareness of what she was going through. "A lot of people have anxiety specifically related to school, and I certainly did, and to have that term available would be really helpful," she says.
She recognises that there are potential problems if children are misdiagnosed or if their problems are misinterpreted. "Pupils could be branded as having a phobia of school when it's something relatively simple that can be sorted out quite quickly," she acknowledges. But at the same time, Isobel is all too aware of misdiagnosis from the other side. "There might be children branded as either not paying attention, or not keeping up with the work, when actually, it's a school phobia and it's really important that schools recognise that."
Like Linda, Isobel's experience of school phobia comes from a number of different things. Her problems started at the age of nine, when her parents were going through a divorce. "When I was at school, I felt so trapped," she says, looking back on her time at primary school. "I'd always sit with my legs to the side so that I could get up and leave as quickly as possible. Constantly, throughout the lesson I'd be trying to calm myself down. It was like a shot of adrenaline."
Her symptoms improved for a couple of years but then became overwhelming during Year 10 at secondary school when she had glandular fever and then became afraid of coming back. She missed a whole year of school, but was finally able to return after working with a cognitive behavioural therapist.
There are a wide range of things that can cause school phobia, but one common experience of sufferers and their carers is confronting the negative attitudes of teachers. Linda's German teacher told her that she wasn't getting special treatment, and would ask the whole class to read aloud individually as she waited with rising fear for her turn, which was always last. Isobel's head of year suggested coming in for one class on a Monday, two on a Tuesday, and by the end of the week, being in for a full day. Considering that her fear was about being confined or restricted, her teacher's proposition wasn't a solution.
Marianna Csoti's daughter developed school phobia at the age of nine and she has since written a book for parents, carers and teachers, entitled School Phobia, Panic Attacks and Anxiety in Children. "My daughter's teachers and headteacher were very unsympathetic and many parents have emailed me over the years with shocking tales of how unkind their children's teachers are," says Ms Csoti.
"Any progress that a child has made can be undone in a moment. For example, after one child had managed to attend sports day with her mother - which for her was a huge feat - her teacher said something like: `You should be taking part. It's no good being lazy'."
Ms Csoti pinpoints a range of factors that brought on her daughter's phobia. The family had just moved to a 12th-century building that had an over-sensitive fire alarm that regularly went off. Three people her daughter knew had died within a short period of time and then another, after her problems had started. She was often sent home from the new school when her anxiety was interpreted by teachers as illness and this in turn perpetuated her own concern about her health.
"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," says Ms Csoti. "She vomited in the mornings before school - and often on arrival at school."
These anxieties came to the fore when she dropped her daughter off at the school gates. "The only compulsory activity children have is going to school, so if they're afraid of leaving their mother, then it shows at the forced parting point which is when they must go to school," she says. "It's the way stress in children manifests itself."
School phobia may be a disease of the times and symptomatic of a culture where everyday concerns are medicalised and treated with therapy. Teachers may feel like they are being asked to mollycoddle sensitive pupils and that being overly protective isn't going to help them in the long run. Some pupils may just be shy or nervous with parents who are excessively sensitive. But that doesn't devalue the experience of pupils with these kinds of problems, which can lead to serious repercussions if they are not dealt with compassionately.
* Names have been changed. Source: `School Phobia, Panic Attacks and Anxiety in Children' by Marianna Csoti
Dealing with school phobia
- Lower your expectations. This isn't favouritism; it is recognising that they have just as much a disability as children with more obvious problems.
- Acknowledge the effort it takes for a school phobic child to attend school, and the distress it causes in the family. Show pleasure that they have managed to come to school.
- Comfort a primary school phobic child. If the child is very young, they may appreciate being met at the gate or in the class the moment they come in, as this will be the highest stress point of their day.
- Give a special contact person (a mentor) for a secondary school phobic child. This may be the form teacher, head of year or special needs teacher.
- Punish the child because they do not conform to the behaviour of others in the class.
- Make a joke at the expense of the child. They will feel humiliated and the joke may well be continued in the schoolyard.
- Ignore the child's hand if it is raised for the very first time: they need to be rewarded for taking such a positive step.
- Force the child to take part in sports day or go on school trips and don't make them feel bad about not attending on those days.