ABSTRACT
School Phobia is a phobic attitude toward and avoidance of school. Most commonly occurs when a child is first introduced to school (age 4 or 5) and early adolescence.
This disorder is best considered as a symptom. It is caused by a variety of conditions, including: a) Separation anxiety suffered by the child; b) Extreme separation anxiety suffered by the parent; c) Malingering; d) A legitimate cause of fear to the child at the school.
Treatment: a) Elimination of legitimate causes of fear and getting the child back to school as soon as possible in order to avoid reinforcement of school avoidance; b) Psychotherapy to treat the underlying disorder; c) Psychiatric hospitalization for extreme cases.
The aim of this case study was to describe and analyze the process of assessment, treatment and interventions of a 10-year old school phobic child, Matt. Matt is a student with average intelligence and a significant discrepancy (1.5 standard deviation) between Verbal and Performance scores (WISC-III); an age equivalent score of 7-0 to 7-5 on the Bender Gestalt Test; and a 5th percentile on the Draw-A-Person test. His educational profile indicates the following Grade Equivalent scores on the Woodcock-Johnson-Revised Test: Letter-Word Identification: 6.7; Passage Comprehension: 6.9; Calculation: 4.5; Applied Problems: 3.3; Dictation: 3.1; Writing Samples: 1.7; Science; 9.2; Social Studies: 6.6; Humanities: 4.8; Broad Reading - 6.7; Broad Math - 3.9; Broad Written Language - 2.1; Broad Knowledge - 6.6. Matt's obtained a mental age equivalent score of 7.9 on the Detroit Test of Visual Motor Integration.
A careful assessment and coordination of a multidisciplinary intervention plan was the corner stone for the school reintegration of the phobic child within the first two months of the new school year, after being out of school for more than nine months.
Furthermore, the involvement of the immediate and extended family members in the assessment, treatment planning and intervention phases was crucial for the social and educational re-integration of this school phobic student.
INTRODUCTION
" Every morning I think the whole neighborhood knows when Tim and I arrive at school - His screams can been heard for blocks around, I'm sure. I have to peel his fingers off my arms and force him into his third grade classroom. I'm in tears myself by the time I leave. What could be so terrifying about third grade?"
Martin & Greenwood (1995) Going to school is usually an exciting and enjoyable experience for young children. However, for some two to eight percent of the school population (Clarizio & McCoy, 1976; Martin & Greenwood, 1995) it brings fear and panic. This is a legitimate cause for concern for parents, school officials and educators in general. The potential long-term effects are serious for a child who has persistent fears in going back to school and does not receive the professional assistance that the complexities of his/her condition require. The child may develop serious educational or social problems if away from school and friends for an extended period of time.
School phobia can be defined as an exaggerated, often illogical fear of attending school. Fear of separating from home and/or some situation in school may be operating. However, school phobia must be differentiated from nonattendance due to other causes, such as truancy, boredom, or fear of academic failure. According to Ajuriaguerra (n. d.), the child with school phobia really wants to go school and has educational ambition while the "malingering" child does not like to go to school and prefers wondering on the streets.
The multiple somatic symptoms associated with this disorder such as nausea, stomachaches, numbness and dizziness disappear once school has been avoided.
One specificity of this condition, is that the children prone to school phobia are often overly dependent and resentful toward their parents, and their fear and anxiety may be displaced to school. In many cases, the mother may inadvertently reinforce "staying home", and, simultaneously, going to school may represent "loss of mother".
CASE INFORMATION
This case involved a ten year old boy, Matt, 4th grader who attended a parochial school in a regular basis with no previous problems until Christmas of his fourth year of schooling. He started experiencing some separating anxiety from his mother in the Christmas Holidays in which he found it increasingly difficult to be with other kids, especially when mother was around. Beginning in February, however, Matt began experiencing waves of severe tearfulness, anxiety, and a state of immense fear upon being separated from his mother. Matt is put on psychotropic medication for his anxiety and fear (Xanax, paxil and clonodin) and gets individual and family counseling twice a week until mid-September. According to records, his clinical treatment included training in muscle relaxation, diaphramic breathing, and guided fantasy to impact his anxiety; In addition, direct talk, cognitive reframing, and play therapy techniques to address some of the sequelae of this condition were attempted.
However, Matt could not win over his fears when September came and he was hospitalized due to suicidal behavior and ideation. Thus, severe school avoidance struggles kept him at home from February to October. Matt's medical problems worked as interfering factors on this case of school phobia: he suffers from asthma, which requires inhalers and has a severe milk allergy.
The clinical opinions of out of school professionals involved voiced that going back to a regular, public school environment would not the best choice for Matt: "I strongly believe that more intense interventions are needed to impact positively on his condition than those that normally work for other children in his situation. (He) has responded very well to a locked inpatient setting and is making positive strides" (from records, outpatient clinical therapist, October). According to this outpatient clinical therapist the best choice for Matt would be a Hospital school program. It was at this point that our school district got involved in doing their own assessment and work on coordinating a plan to get Matt back in school.
CASE DEVELOPMENT AND TREATMENT
Matt was observed and assessed at the hospital by our multidisciplinary team and, based on our findings, we concluded that our public school district could gather the appropriate resources to get Matt and his family re-integrated into a daily social and educational environment.
The following phases were involved in the assessment and treatment:
1st Phase: Assessment and intervention plan (End of September-October).
Based on our assessment and discussion of results at the multidisciplinary team meeting, a treatment plan was developed, coordinated and signed by all educators involved.
Some of the points stressed on the plan were the following:
a) Matt was expected to attend school everyday and mother/family made the commitment to bring him to the school; b) Development of a strategic plan and specific procedures to deal with expected eventual crisis at school with the following chain of responsible agents: Classroom teacher, psychologist, school nurse and finally Matt's mother/family.
Furthermore, an important meeting with Matt, his family and new teacher to talk about goals and plan took place. Classroom teacher and psychologist kept daily logs to reflect on interventions, to measure Matt's progress and to present as evidence to his family.
2nd Phase: Going back to School (October).
Although my school one of the largest in the district for Matt (school with a thousand children), it was chosen because had a full time school psychologist and a good team of professionals motivated in doing their best to offer the possibility of success to Matt and his family. The multidisciplinary team decided to, initially, place Matt in a more restrictive school environment, a mild/moderate special education classroom with the goal of placing him in a regular classroom as soon as possible. After the first week of school for Matt, rewards and withholding of privileges were introduced in Matt's plan as he was arriving late at school.
3rd Phase: Transference to regular 5th grade classroom (November).
With one month of school, in the special education classroom, Matt was transferred to a regular 5th classroom and the plan was adapted to reflect the transition.
The following points were carefully stressed: a) Matt was acquainted with a classmate with whom he had co-joint counseling sessions once a week; b) Matt was able to visit his previous special education class at the end of each day with his new teacher's permission; c) A "good bye party" from his special education class was held at end of first full week in the regular 5th grade class.
4th Phase. Follow up (December-May).
Matt was in a regular classroom and was going out for reading/writing and math his two areas of academic weakness. He continued to be monitored by school nurse and school psychologist. The frequent weekly sessions were reduced to once a week and intervention plan was modified to reflect his progress. During this phase, a special attention was placed on coming holidays and vacations to control potential relapses. The coordination and communication with "out of school" professionals (clinical therapist, psychiatrist, and pediatrician) continued to be honored.
IMPLICATIONS FOR SCHOOL EDUCATORS
The application of an eclectic intervention including family system strategic and structural approaches and behavioral based techniques are crucial for the success of a full re-integration of the school phobic child. The family needs to be involved in the solution process and the other members of the school community must also be involved as 'important participants' in the process. It is very importance that the " public school" remains active in and concerned in relation to the school phobic student and his family as soon as the child is identified as school phobic.
CONCLUSION
The aim of this case study was to describe and analyze the process of assessment and treatment of intervention of a 10-year old school phobic child who did not respond to out of school interventions, including psychiatric hospitalization.
This case involved a ten-year-old boy, 4th grader who attended a parochial school in a regular basis with no previous problems until Christmas of his fourth year of schooling. He started experiencing some separating anxiety from his mother in the Christmas Holidays in which he found it increasingly difficult to be with other kids, especially when mother was around. Persistent severe school avoidance struggles kept him at home from February to October.
As "out of school" long term interventions were unsuccessful, our public school district was involved and developed a plan to get Matt re-integrated into the social and educational daily activities.
Crucial components of our intervention plan included:
· Frequent availability of psychologist to Matt, teachers and
family.
· Collaboration and regular communication with school nurse,
teachers, and out of school providers.
· Rewarding Matt for school
attendance and withholding privileges for nonattendance (at home and at
school).
· Channeling of resources to get a rapid return to school
and a full day attendance.
· Systematic planning efforts and
coordination of a motivated and available multidisciplinary school team.
A quick return to school which meant the transition from the hospital setting to school environment was crucial for this success but required collaboration of multidisciplinary team members, closed and extended family members, educators and mental health care providers. Also, a flexible behavioral contract among student, psychologist, teacher and mother was instrumental in managing Matt's anxiety and facilitating his school attendance.
In conclusion, a careful and multidisciplinary assessment, the coordination of a multidisciplinary team and the availability and motivation of public school educators were the essential factors for the school reintegration of this phobic child within the first two months of his new school year.
Furthermore, the involvement of the immediate and extended family members in the assessment, treatment planning and intervention phases was crucial for the continuing social and educational integration of this school phobic student.
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