I recently received two children in my clinic. The parents of the first patient, who is a seven-year-old boy, said that their son felt nauseous and suffered from abdominal pain and vomiting as he dressed for school for several days. By mid day, he would be back to normal without any treatment. His physical examination was normal. On tactful interrogation he said he does not want to go to school as he is afraid of his teacher who beats him on a daily basis. The second patient was a seven- year-old girl who complained of abdominal pain in early morning hours before going to school, everyday. On physical examination she is appeared to be a healthy child. When asked if she was afraid of any thing or if any thing causes her to be anxious at that time, she said she is regularly bullied by senior students in the bus, so she tries to avoid going to school. School refusal is the inability to attend school on account of overwhelming anxiety, a condition that peaks in ages six and seven, ten and eleven years. The child could be unable to tolerate separation from a person who he or she is attached to and cannot go anywhere without that person. Another cause is anxiety, provoked by certain experiences in school – true phobia. The two forms of anxiety are sometimes intertwined. Children with this condition present with multiple vague somatic symptoms such as headache, abdominal pain and fatigue. Concerned parents take their kids to numerous child specialists and undergo elaborate medical evaluations and tests. Absence from school can be added to the sequence of symptoms mentioned above. Expression of somatic symptoms is used as a means of avoiding school and gaining attachment to parents. The children may have true phobia related to people in their schools or homework. When they are asked to go to school, these kids tend to become extremely anxious and incapacitated with escalating symptoms. There has to be a strong cooperation between parents and health-care providers. Such a relationship is built on trust, in order to convince parents to face this reality. Some parents are tyrannized by their defiant and clinging child. The treatment of children is aimed at gently promoting increased periods of separation. A perfect example would be encouraging children to go on overnight stays with their relatives or friends while arranging for an early return to school. School phobia is also seen in older children and adolescence, especially those who are stubborn and do not communicate with others often. Some of these adolescent have a depressive disorder or psychopathological condition. It is advisable to seek psychiatric consultation in such cases. The longer the child remains away from school the more difficult it will be for him to return. Treatment begins with an early, gradual return to school, while support is provided to the parents. Any existing underlying emotional disorders are treated simultaneously. Close liaison with teachers, school welfare officers and school psychologist is very helpful. Teachers in school should also know that such a condition exists, and it should be approached with support, sympathy and understanding. Every effort should be made to remove the cause of anxiety if it is in school or school related. The writer is a Pediatrician at My Care Medical Center with an M.B., B.S. DCH (Dublin) __
