school phobia: implications for school health educators

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This article was downloaded by: [North Dakota State University] On: 30 October 2014, At: 18:08 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK American Journal of Health Education Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhe20 School Phobia: Implications for School Health Educators Anna Torrens Salemi a & Kelli McCormack Brown b a Dept. of Community and Family Health , College of Public Health, University of South Florida , 13201 Bruce B. Downs Blvd., MDC 56, Tampa , FL , 33612 E-mail: b Dept. of Community and Family Health , College of Public Health, University of South FL Published online: 20 Dec 2013. To cite this article: Anna Torrens Salemi & Kelli McCormack Brown (2003) School Phobia: Implications for School Health Educators, American Journal of Health Education, 34:4, 199-205, DOI: 10.1080/19325037.2003.10761864 To link to this article: http://dx.doi.org/10.1080/19325037.2003.10761864 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

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Page 1: School Phobia: Implications for School Health Educators

This article was downloaded by: [North Dakota State University]On: 30 October 2014, At: 18:08Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

American Journal of Health EducationPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/ujhe20

School Phobia: Implications for School Health EducatorsAnna Torrens Salemi a & Kelli McCormack Brown ba Dept. of Community and Family Health , College of Public Health, University of SouthFlorida , 13201 Bruce B. Downs Blvd., MDC 56, Tampa , FL , 33612 E-mail:b Dept. of Community and Family Health , College of Public Health, University of South FLPublished online: 20 Dec 2013.

To cite this article: Anna Torrens Salemi & Kelli McCormack Brown (2003) School Phobia: Implications for School HealthEducators, American Journal of Health Education, 34:4, 199-205, DOI: 10.1080/19325037.2003.10761864

To link to this article: http://dx.doi.org/10.1080/19325037.2003.10761864

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of theContent.

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Page 2: School Phobia: Implications for School Health Educators

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School Phobia: Implications for School Health Educators

Anna Torrens Salemi and Kelli McCormack Brown

ABSTRACT

This review addresses school phobia, a problem of growing concern among educators. Clear definitions of school phobia have emerged only recently, but differential diagnosis between school phobia and related disorders remains controversial. The public health implications of school phobia are significant. Various school personnel may play key roles in the identification of school phobia. Theoretical explanations of school phobia address the questions regarding whether the phobia is stimulated by something in the school setting, phobia is actually of the school, or is merely a component of the school. The pathology of school phobia can be severe. School health educators need to recognize its symptoms and the profile of those at risk to engage in early intervention. The prevalence of school phobia varies depending on the source. Strategies for early intervention are comprehensive and coordinated and can be integrated into existing frameworks such as the coordinated school health program. Future directions include addressing school phobia from an ecological perspective.

School phobia was first described in 1932 by Broadwin as "consistent absence from school... without a comprehensible reason" (Broadwin, 1932, p.254). "School phobia" is a term frequently used, but often misunderstood (Kearney, Eisen & Silverman, 1995). Literature on school pho­bia grew out of diverse fields such as psychology, nursing, social work, and pediatrics, all having one common de­nominator: contact with children. The lit­erature reflects the nature of school phobia and its identification within a school. A number of different personnel within a school, from the bus driver to the princi­pal, could assist in identifying a student with school phobia. It is important for health educators to be aware both of this diversity within the literature and the complex na­ture of school phobia.

The outcome of school phobia appears

simple, yet is quite serious; the student re­fuses to attend school. Given that school is 5 days a week, school phobia becomes a daily issue. Problems associated with school phobia are considerable, leading to poten­tially adverse consequences (Hsia, 1984; Jenni, 1997; King & Bernstein, 2001; Want, 1983). It is important to recognize that school attendance is mandated by law. Schools act in loco parentis, assuming the obligations and responsibilities of pre­paring students to become productive members of society. Society has expecta­tions for students to complete their educa­tion, which amounts to the equivalence of a full-time job for 13 years. School phobia is an issue that requires quick resolve to avoid dismal results.

In this review we summarize the current literature about this disorder. First, the controversy regarding the complicated

definition of school phobia is explored, be­cause an understanding of this controversy is of critical importance. Second, the sig­nificance of school phobia as a public health issue is addressed. In addition, a summary of the prevalence rates is included. Third, we review existing theoretical explanations concerning school phobia and their rela­tionship to the school setting. We then describe the pathology of school phobia,

Anna Torrens Salemi, BA., MPH, CHES, is a Doctoral Student in the Dept. of Community and Family Health, College of Public Health, University of South Florida. 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL 33612. kmbrown@hsc. usfedu. Kelli McCormack Brown, PhD, CHES, PASHA is an associate professor, Dept. of Community and Family Health, College of Public Health, University of South FL

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providing a profile of a typical child/ado­lescent. We discuss the implications of school phobia for early intervention includ­ing some strategies and how they can be incorporated into a coordinated school health program ( CSHP). We conclude with suggestions for future directions regarding strategies and research.

DEFINING SCHOOL PHOBIA Of all of the "internalized" disorders

among youth, the one most subject to con­troversy is school phobia (Kearney et al., 1995). The reason for this controversy is, in part, due to some confusion about the descriptive terms and definitions used by various researchers. In 1941 "school pho­bia" was developed as a phrase to describe an "over-dependent mother-child" rela­tionship (Murray, 1998a, p.l). Over time "school phobia" evolved into an umbrella term that covered virtually everything dealing with school absenteeism. School phobia, school refusal, school avoidance, and separation anxiety are terms used in­terchangeably to report on this phenom­enon. Yet the literature suggests that each separate term possesses inherent character­istics that demand differentiation.

School phobia further evokes contro­versy because not all students who refuse to attend school are phobics; some may just not want to attend and should more prop­erly be labeled as truant. More confusion over the terms results because the fourth edition Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) does not dif­ferentiate among these events (Murray, 1998b). The terms are referenced under the headings of social phobia, separation anxi­ety, and conduct disorder (Murray, 1998b ). Thus, each counselor/psychologist has his or her own way of defining the problems and a consensus has not been reached about the nature of the problems. The issue has been labeled "anxiety-based school refusal" as well as "anxiety-based" and "nonanxiety based school refusal" (Murray, 1998b ). Other counselors/psychologists refute both of these definitions, instead designating school refusal as symptomatic of more

complex issues, such as social phobias (Murray, 1998b). For the purposes of this review, focusing on relevant information for school health educators, school phobia is defined as "anxiety and fear related to be­ing in school" (Murray, 1998b ).

Several studies distinguish between the meaning of separation anxiety and school phobia. Separation anxiety is the term of choice whenever a disproportionate amount of anxiety is associated with a child separated from his or her care giver (i.e., mother) (Lee & Miltenberger, 1996). Often the child fears harm coming to his or her guardian while they are separated. In con­trast, school phobia is not tied exclusively to such separation. The key factors that dif­ferentiate school phobia and separation anxiety are the "significance of the attach­ment figure" (i.e., mother), and the "speci­ficity of the anxiety/phobia" (e.g., fearing embarrassment) (Lee & Miltenberger, 1996). School phobia, which can strike at any time during a child's matriculation through school, can result from varying causes, such as an extended illness, geo­graphic relocation or new school, death in the family, trauma at school, or a threat to the child's security (APA Experts, 1997; Jenni, 1997).

PUBLIC HEALTH IMPLICATIONS Negative outcomes associated with

school phobia include poor academic per­formance, family and peer relationship problems, and poor social and educational development (Last & Strauss, 1990; Want, 1983 ). Long-term effects of untreated or poorly treated cases leave the child further behind developmentally and at risk for school failure and involuntary drop-out (Hsia, 1984; Jenni, 1997). From these out­comes, the detrimental public health impli­cations can be derived.

The two goals of Healthy People (HP) 2010 are to (I) improve quality of life and (2) eliminate health disparities (U.S. De­partment of Health and Human Services [US-DHHS], 2000). One of the indicators of quality of life is sound physical and men­tal health (US-DHHS, 2000). Many aspects

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of health are affected by school phobia, in­cluding those in the physical, mental, so­cial, and emotional domains. Ranging from the somatic effects of the phobia on the stu­dent to the stress experienced by all parties involved, having school phobia can greatly impact a child's quality of life. Furthermore, if the situation is not resolved, the effects on long-term quality of life could prove devastating. The lack of education or a poor experience within the student's matricula­tion can reverberate throughout life. The second goal of HP 20 I 0 seeks to eliminate health disparities, which may be partially attributed to issues such as lack of educa­tion (US-DHHS, 2000).

Education has been cited as a factor in a longer, healthier life (US-DHHS, 2000). Such a phenomenon is attributed to many factors that are related to having an educa­tion, such as literacy and the ability to at­tain employment. Higher levels of educa­tion also increase the possibility of obtaining and interpreting health-related information required to develop positive health behaviors (US-DHHS, 2000). Again, the underlying problems that can arise from an unresolved case of school phobia are dis­cernible. The impact of school phobia may be detrimental, thus prevalence must be considered as well.

PREVALENCE OF SCHOOL PHOBIA An accurate analysis of the prevalence

of school phobia depends on how it is be­ing defined. Because the definition is not consistently used, the reported incidence rates vary. Second, Berry ( 1993) notes a lack of investigations into the incidence of school phobia (Berry, 199 3). Therefore, we hypothesize that the estimates may not be accurate due to the variation in definition and the dearth of available studies.

Most studies estimate the proportion of students with school phobia in the United States to be 1-8% of the school-age popu­lation (Berry, 1993; Ceria, 1997; Lee & Miltenberger, 1996). Last and Strauss ( 1990) refer to school phobia as a "relatively wide­spread disturbance," with a prevalence rate among the general population of school-age

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children at I o/o and among clinically re­ferred children between 3 to 8o/o (Last & Strauss, I990, p.3I ). Jenni (!997) puts the prevalence rate into perspective by estimat­ing that if a person were to walk into a middle school, he or she would find be­tween one and five students with the prob­lem (Jenni, I997).

From a comparative perspective, Jenni (!997) points out that school phobia is more prevalent in highly competitive soci­eties such as Japan, where it is estimated to occur in 3I to 52% of middle school stu­dents (Jenni, I997). Although in the United States the numbers are not as high as Japan's, even an estimate of I o/o is sufficient to demand more attention.

THEORETICAL EXPLANATIONS FOR SCHOOL PHOBIA

Two theoretical explanations have been used to better understand the cause of school phobia. Kearney et al. (!995) poses these explanations as the questions "Is school phobia actually a phobia?" and "Is school phobia actually a fear of school?" The first question can be addressed by concep­tualizing school phobia within the catego­ries of social and specific phobias. Accord­ing to DSM-IV, social phobias are characterized by a fear and avoidance of social situations in which the individual may become embarrassed (American Psy­chiatric Association, I994). Specific phobia can be defined as "fear of some object or situation that incites excessive, irrational, specific and avoidant behavior-provoking nature"(Kearney et al., I995, p.70). School phobia, depending on the surrounding fac­tors, may warrant a diagnosis of social pho­bia or specific phobia. Unfortunately, there is a lack of studies in this area preventing an analysis determining the levels of fear invoked in such students (Kearney et a!., 1995). Rather, studies have predominantly centered around diagnosis, anxiety scales, and case studies.

The second question, "Is school phobia actually a fear of school?" threatens tradi­tional school phobia explanations that typically center around the institution of

school as the stimulus of fear. The school itself represents a variety of components (students, teachers, cafeteria, etc.), so that, once a diagnosis of school phobia is made, the stimulus of the phobia may still remain unknown (Kearney eta!., 1995). It could be possible that school phobia is related to tactile items within the school. For example, a student may have a fear of entering the cafeteria or the library. On the other hand, other individuals may suffer general social fears that manifest in school (Kearney et al., 1995). The complexities of the stimuli present difficulties when a counselor or other school professional tries to determine appropriate plans of action. For example, if the counselor is trying to use desensiti­zation techniques, yet is unaware of the exact source of fear, the efforts may be too nonspecific to be effective (Kearney et a!., 1995). Certainly, these theoretical questions are significant and complex enough to justify the availability of applicable infor­mation for school health educators, coun­selors, psychologists, teachers, and other school personnel.

PATHOLOGY OF SCHOOL PHOBIA School phobia can be triggered by a

variety of stimuli, such as an embarrassing situation, confrontation with a bully, a dis­agreement with a teacher, or some other traumatic event (Kohn, 1999; Mayo Clinic, 1999). However, to understand the pathol­ogy of school phobia, it is necessary to ex­amine the onset of the phobia. Researchers agree about the general times of onset-at the beginning of formal education, at the transition to middle school or junior high, or at the end of compulsory education (Berry, 1993). School phobia may begin with a stimulus, followed by a course of events, though each case is unique. After the stimulus event occurs, the primary caregiver may hear complaints of stomach aches. The child may feel dizziness, nausea, and fever­ishness (Berry, 1993). The parent subse­quently may permit him or her to stay home. By allowing the child to stay home, however, the parent unknowingly enables the school phobia behavior (University of

Pittsburg, 1990). As the starting hour of school passes, the child's symptoms may begin to subside. The symptoms often in­tensify on Sunday evenings, Monday morn­ings, and following a vacation (Berry, 1993). This pattern may continue each day de­pending on the severity of the case.

School phobia has been categorized into a myriad of subtypes and categories. For a detailed history of the development of these subtypes, the reader is referred to Kearney's text School Refusal Behavior in Youth (Kearney, 2001). Generally, school phobia is divided into two categories: an acute onset (Type I, acute) and a more se­vere, persistent case (Type II, chronic) (Kearney, 2001 ; Pilkington & Piersal, 1991 ). Students with acute school phobia are absent anywhere from 2 weeks to 1 year of school (Kearney, 2001). The acute con­dition is more easily resolved and is usually related to a type of separation anxiety. Moreover, the severe form (Type II, chronic) occurs less frequently but, if not properly resolved, can have detrimental short- and long-term consequences if not properly re­solved (Last & Strauss, 1990; Pilkington & Piersal, 1991.) The severe form is likely to intensify with stronger physical ailments and more adamant refusals to attend school. Students with chronic school phobia are absent for longer than 1 year of school (Kearney, 2001).

Jenni ( 1997) carefully describes the type of panic experienced by students with severe cases of school phobia: "There is a sense of the body being out of one's con­trol. Those afflicted may experience faint­ness, heart palpitations, shortness of breath, dizziness, nausea, loss of control, the des­perate need to escape, and a sense of im­pending doom that includes the belief that one is about to die or go insane" (p.211 ).

The more severe cases generally occur during adolescence and include the previ­ously described panic attack (Jenni, 1997). One of the hallmark behaviors, according to Pilkington and Piersel (1991), is failure to remain in school despite pressure or threats of punishments from parents, teachers, and school administrators. Most

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Page 5: School Phobia: Implications for School Health Educators

professionals who have dealt with cases of school phobia agree that if untreated, the phobic condition can have a permanent and adverse effect on the youth's social and emo­tional development (Want, 1983). Likewise, untreated school phobia has the potential to affect school performance, academic achievement, and learning.

PROFILE OF A CHILD WITH SCHOOL PHOBIA

Schools have commonly viewed and placed students who are absent from school because of school phobia in the same cat­egory as truant students, yet it is important to differentiate the two. The signs of school phobia are not difficult to discern, yet without knowing the profile of vulnerable students, school personnel can easily miss them (Kohn, 1999). Knowledgeable school personnel are key for early identification of youth with school phobia to enable prompt treatment. It cannot be assumed that school phobia will go away on its own or that a parent or pediatrician will iden­tify it (Want, 1983).

Want ( 1983) describes five common characteristics of students with school pho­bia: anxiety, willfulness, dependency, de­pression, and unrealistic self-image (Want, 1983). Anxiety is the most distinguishing feature of a child with school phobia. Will­fulness (the manipulation of authority fig­ures) is not as common, whereas depen­dency (reliance on a parent for support and protection) is readily seen. Depression can arise from school phobia and may be situ­ational. An unrealistic self-image is com­mon in adolescents with school phobia and is indicative of a "hypersensitivity to threats to self-image" (Want, 1983).Although these characteristics may be observed in truant students, they occur more frequently among students with school phobia.

Until the onset of the disorder, students are generally average to excellent students who enjoy school and rarely pose a behav­ioral problem in class (Jenni, 1997). Youth who later develop school phobia may seem "hypervigilant, with an overactive danger alarm" (Jenni, 1997, p.209). Jenni (1997)

suggests three coexisting conditions that are central to the onset of panic disorders such as school phobia: (a) a genetic predisposi­tion to anxiety, (b) a threatening loss event, and (c) an internal physical experience that appears catastrophic to the individual (Jenni, 1997).

Another theory on the profile of stu­dents with school phobia hypothesizes that the child will have at least one parent who is highly anxious ( Cerio, 1997). This propo­sition is consistent with Jenni's theory of being predisposed genetically to anxiety (Jenni, 1997). Such information about the parent is pertinent in gaining a better un­derstanding of the child. The chosen treat­ment method should contain a child-fam­ily component (Cerio, 1997). When one parent is highly anxious but not included in the treatment, he or she could potentially reinforce the phobic behavior, inadvertently enabling and preventing a prompt return to a normal setting.

Lee and Miltenberger ( 1996) refer to the typical child with school phobia as being "from a higher socio-economic back­ground, male and having post-pubertal onset of symptoms" (p.475). It is generally agreed that students with school phobia excel academically prior to absenteeism, as they may be achievement-oriented students who set high standards for themselves, and who may pressure themselves and fear im­perfection (Kearney, 2001; University of Pittsburg, 1990). It seems ironic that these students develop such strong aversions to school. As an example, in competitive soci­eties such as Japan school phobia has in­creased over the last two decades. It has be­come such an issue in Japan that the United Nations Committee on the Rights of the Child stated in its concluding observations, Article 43, that the State of Japan should "take further steps to combat excessive stress and school phobia" (United Nations Com­mittee on the Rights of the Child, 1999, p.4).

IMPLICATIONS FOR SCHOOL HEALTH EDUCATORS

Youth spend more time in school than anywhere else outside the home. This pre-

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sents a compelling reason why early inter­vention efforts for school phobia should be implemented. School personnel should be knowledgeable and provide stress-free school environments conducive to allowing students to feel comfortable in and con­nected to their school setting. School per­sonnel must be able to identify students with school phobia early to minimize the trauma that can result, including peripheral impact on learning and academic achieve­ment (Want, 1983) . School personnel should develop guidelines for identifying students with school phobia, which should decrease the number of students in school who are inappropriately categorized as tru­ant. Prevention programs for school pho­bia are nonexistent, and treatment facilities are limited. Prevention techniques usually focus on preventing a relapse of the behav­ior, not the initial onset (Kearney, 2001). Emphasis on early intervention provides the best option for successful resolution of school phobia.

The long-term outcomes of school pho­bia are typically poor if not properly ad­dressed. Most of the research has been con­ducted only in clinical settings, therefore the usefulness of such data is limited (Jenni, 1997). Early studies revealed poor outcomes, such as continued absenteeism and mental disorder (Jenni, 1997). Studies conducted on outpatient treatment proved more suc­cessful (Jenni, 1997). School phobia did not predict mental disorders in adulthood, except a slight prediction for agoraphobia (lenni, 1997). The current literature does not reveal any relationships with gang­activity, suicide, or other risk behaviors among youth with school phobia.

Within school systems health educators need definitive approaches for managing school phobia. School health personnel should be educated so that they under­stand that students with school phobia are not willfully avoiding school (lenni, 1997). Sensitivity toward the student and his or her situation is necessary to avoid nega­tive relationships.

Jenni ( 1997) and Want ( 1983) offer dif­ferent steps to build strong strategies within

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Page 6: School Phobia: Implications for School Health Educators

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schools for resolving school phobia. Want (1983) outlines a 1 0-step strategy that is comprehensive and involves a school inter­vention team, family involvement, therapy, and the development of an individualiz­ed plan for the student (Table 1). This

approach is practical, refrains from the use of a psychoanalytical intervention, and is compatible with the CSHP, utilizing a simi­lar component structure.

school, the family, and the child. This model emphasizes "depathologizing" school pho­bia and emphasizing the manageability of the phobia. Such an effort maintains that school is the best location for treatment and that patience is required (Jenni, 1997). The

Jenni's ( 1997) suggestions also focus on a collaborative model that involves the

Table 1. Existing Strategies and Early Intervention Within Coordinated School Health Program (CSHPJ

CSHP Component & Suggested Integration

Health Education • Curriculum includes a focus on emotional. mental. and social health • School phobia introduced within existing relevant programs such as bullying prevention, peer mediation. or stress management

School Health Services • Provide access to health care services • Treatment of physical ailments related to school phobia within school setting-student does not have to leave school

Counseling, Psychological, and Social Services • Provides assessment and services • Assist in identification of students with school phobia • Coordinate treatment of student

Healthy School Environment • Promote school connectedness • Provide safe. friendly, and healthy environment at school

Family and Community Involvement • Key to successful treatment of school phobia by providing reinforcement through a comprehensive approach • Resources and support available to students, family, and school personnel • Network with community resources such as coalitions that direct people to resources available. Likewise. raise aware­ness within these coalitions regarding school phobia.

Existing Strategies & Suggestions

• Have child keep track of progress (Jenni, 1999) • Increase awareness of school phobia among staff through in-service training

• Limit student complaints {Want. 1983)

• Organize a school team-include parents. teachers. administrators, and student {Want I 983) • Assess family configuration {Want 1983) • Develop a plan {Want 1983) • Arrange student transportation to school {Want I 983) • Select a team member to provide limited counseling for students/parents {Want I 983)

• Allow students to maintain contact with their friends­students are typically humiliated by this phobia {Jenni, I 999) • Make child aware of scheduled changes; relapse occurs easily {Jenni, I 999)

Parents • Parents must play a role in resolving problem {Jenni, I 999) • Parents must keep positive outlook {Jenni. I 999) • Involve parents in everything {Want I 983) • Encourage parents to seek counseling/therapy for selves and child {Want, I 983)

Teachers • Keep teachers informed and explain that there may be a temporary suspension of focus on students academic progress (Jenni. I 999) • Prepare teachers for students return {Want, I 983) • Do not allow home schooling! {Want I 983)

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main goal of both strategies is the prompt return to school of the child with school phobia (Jenni, 1997; Want, 1983).Allowing the child to miss school days only reinforces the school phobia behavior.

The emphasis of both strategies is a "team -oriented approach" that includes not only the student, parents, and counselors, but also the administrators and teachers (Table 1) (Jenni, 1997; Want, 1983). Any strategies implemented in schools must be flexible, comprehensive, and coordinated. Integration of such strategies into a CSHP seems a positive next step providing the necessary framework for early intervention. Although it may prove difficult to address school phobia from every component of the CSHP, it is worthwhile to consider struc­turing interventions within the framework.

Within the eight components of the CSHP, the following can work collabor­atively to address school phobia: health education, health services, counseling, psychological services, social services, healthy school environment, and family in­volvement (Table 1) (Allensworth & Kolbe, 1987) . Health education emphasizes a planned curriculum that addresses the physical, mental, emotional, and social aspects of health. Within this component, early intervention of school phobia could be addressed within existing programs

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for students. These may include bully­ing prevention, peer mediation, and stress management.

School health services would involve treating the physical ailments that arise in serious cases of school phobia. As opposed to sending the student home, which is det­rimental to the student, students who get a "stomach ache" due to school phobia can be seen at the school clinic. Due to the col­laborative nature of the CSHP, health ser­vices would be aware of the student's prob­lem, thus allowing care without sending him or her home (Tyson, 1999).

Counseling and psychological and social services are central to proper identification and treatment of the child with school pho­bia (Allensworth & Kolbe, 1987). Services could be provided to students in school, and social service staff could coordinate outside treatment if necessary. All the elements im­portant to successful treatment of the child with school phobia would be communi­cated through the CSHP model, enabling continuous monitoring. An example is through the component of promoting a healthy school environment. The school must be a physically healthy and safe place for learning (Resnicow & Allensworth, 1996). Based on the nature of school pho­bia, it can prove difficult to identify the stimulus of the phobia (e.g., a bully);

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therefore, communication among all school personnel is necessary in targeting such behaviors and providing early intervention (Resnicow & Allensworth, 1996).

Finally, a key component to resolving school phobia within the CSHP model is family and community involvement. It is critical that family members are involved in all steps of caring for a child with school phobia. Issues of transportation, therapy, and parental support are essential to over­coming the phobia. Resources must be available to allow students, school person­nel, and family members the necessary sup­port for sufficient and prompt care (Tyson, 1999). Table 2 provides a detailed list of available resources for students, school per­sonnel, and parents.

FUTURE DIRECTIONS In conclusion, intervention programs

can be instrumental in the treatment of stu­dents with school phobia. To date, the re­search conducted is predominantly inter­vention based as opposed to prevention focused. Although many highly publicized teen problems (e.g., teen pregnancy, sub­stance abuse) have a myriad of prevention programs in place, programs focused on preventing school phobia do not exist. Such a lack is understandable due to the individu­alistic nature of school phobia. Feasible

Table 2. Available Resources on School Phobia !t ;r ·~ .... ·!J,,

Resources Availability

When Children Refuse School. Graywind Publications Inc. . The Psychological Corp .. 2000. A Cognitive Behavioral Therapy Approach ISBN: 0-12784-468-6 (Parent Workbook). 2000. By Christopher A. Kearney & Anne Marie Albano.

When Kids Say No to School: Helping Children at Risk Harold Shaw Publishers. ISBN: 0-87788-406-4 of Failure, Refusal, or Dropping Out fl998). By Elaine K. McEwan.

The Identification and Treatment of School Phobia. The National Association of School Psychologists. ISBN: 0-932955-f1993) . By Leslie Zeldin Paige. 08-8; Publication no. 6503

The Child Anxiety Network (offers a list of centers. http://www. childanxiety. net/Directory _of _providers. htm clinics. and professionals)

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Page 8: School Phobia: Implications for School Health Educators

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strategies include early identification and intervention. Within the literature on

school phobia, emphasis is placed on involv­ing many team members in working on a resolve to the student's phobia. While en­

couraging this coordinated approach, the literature still suggests this process functions

as a microcosm. Students do not attend school in a mi­

crocosm. Students comprise one compo­nent within this complex and dynamic sys­tem we refer to as school. Schools are composed of multiple parts, within com­

munities, which mesh together creating an individual school climate. In light of this,

we suggest that strategies for managing

school phobia move beyond the microcosm of the school. An ecological perspective to managing school phobia entails not just the student, family, and school personnel, but it moves beyond that, taking into account peer relationships, teacher-student rela­

tionships, school climate, school connect­edness, and community factors.

Incorporating existing strategies into frameworks such as the CSHP is one ex­ample of how we can start to move forward

with an ecological approach. School phobia research must move in

new directions in the future. New research reveals the impact that outside factors have on students and their success in school. Obtaining education is likewise an impor­tant factor in living a healthy and produc­tive life. Issues such as bullying, violence, school connectedness, and community all play roles in how a student experiences school. Furthermore, relationships among students and school personnel should be examined in light of school phobia. Al­though most of the research has focused on family dynamics, there is a lack of fo cus on school dynamics, especially between stu­dents and staff. Future research on school phobia should take these factors into

consideration and explore associations among these factors.

REFERENCES Allensworth, D. D., & Kolbe, L. J. ( 1987). The

comprehensive school health program: Explor­ing an expanded concept. Journal of School

Health, 57, 409-412.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Dis­

orders (4th ed.). Washington, DC: American

Psychiatric Association. APA Experts. (1997). Psychologists offer

back to school tips to parents: resiliency, the "first day," school phobias and homework. Re­

trieved October 1998 from ericps.ed. uiuc.edu/

npin/pnews/pnew897f.html Berry, G. L. (1993). The school phobic child

and the counselor: identifying, understanding, and helping. Education, 114, 37-45.

Broadwin, I. T. ( 1932). A contribution to the

study of truancy. American Journal of Orthop­

sychiatry, 2, 253-259. Cerio, /. ( 1997). School phobia: a family sys­

tems approach. Elementary School Guidance &

Counseling, 31 , 180-191. Hsia, H. ( 1984 ). Structural and strategic ap­

proach to school phobia/school refusal. Psychol­

ogy in the Schools, 21, 360-367. lenni, C. B. ( 1997). School phobia: how

home-school collaboration can tame this fright­ful dragon. School Counselor, 44, 206-217.

Kearney, C. A. (2001). School refusal behav­

ior in youth. Washington, DC: American Psycho­

logical Association. Kearney, C. A., Eisen, A. R., & Silverman, W.

K. (1995). The legend and myth of school pho­bia. School Psychology Quarterly, 10, 65-85.

King, N.J., & Bernstein, G. A. (200 I). School refusal in children and adolescents: A review

of the past ten years. Journal of the American

Academy of Child and Adolescent Psychiatry,40,

197-205. Kohn, M. F. (1999). School phobia. Parents

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Last, C. G., & Strauss, C. C. (1990) . School refusal in anxiety-disordered children and ado­

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Child and Adolescent Psychiatry, 29, 31-36. Lee, M. I., & Miltenberger, R. G. (1996).

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Mayo Clinic. (1999) . School Avoidance. Re­trieved October 29, 1999, from http:/ I

www. ma yo h ea I th . o rg/ m ayo/9609 I h tm/ school_p.htm

Murray B. (1998a). School phobias hold

many children back. APA Monitor. Retrieved October 29, 1999, from http:/ /www.apa.org/

monitor/sep97 I define.html

Murray B. (1998b). How do psychologists define "school phobia? APA Monitor. Retrieved October 29, 1999, from http:/ /www.apa.org/ monitor/sep97 /define.html

Pilkington, C. L., & Piersal, W. C. (1991 ).

School phobia: A critical analysis of the separa­tion anxiety theory and the alternative

conceptualization. Psychology in the Schools, 28,

290-303. Resnicow, K., & Allensworth, D. (1996) .

Conducting a comprehensive school health pro­gram. Journal of School Health, 66, 59-63.

Tyson, H. ( 1999). A load off teachers' back.

Phi Delta Kappan, 80, K1-K8. United Nations Committee of the Rights of

the Child. (1999). DRAFT Concluding obser­vations of the Committee on the Rights of the Child: Japan. Retrieved on October 29, 1999, from http://www.un.gov

University of Pittsburgh. (1990). The only thing they have to fear is school itself. Growth

and Development, 1, 1-2. U.S. Department of Health and Human Ser­

vices. Healthy People 2010 (2nd ed.) . Washing­

ton, DC: U.S. Government Printing Office, No­vember 2000.

Want,/. H. (1983) . School based interven­

tion strategies for school phobia: a ten step "common sense" approach. Pointer, 27, 27-32.

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