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Please note that Anxiety Care does not currently provide services for those under the age of 18, however we do offer support for parents/guardians/etc.
CHILDRENS FEARS & PHOBIAS
INCLUDING SCHOOL PHOBIA (SCHOOL REFUSAL)Young children have more fears and phobias than adults, and experience the emotion of them more intensely. Such fears may start and stop for little apparent reason as the child develops. When the child loves something one day and fears it the next, this is more likely to be due to changes in the child than the result of some traumatic episode.
Novelty, unpredictability and sudden changes can also induce fear in children, and illness might 'put them back', reviving old fears that they had put behind them at an earlier age. Adults also teach children to fear certain things before the child has even come across them, through their words or actions. Children may also 'pick up' the fears of adults in their family.
There is little evidence to suggest that children who are particularly timid, over-dependent, subject to tantrums and mood swings, or with poor appetite, are more likely to be phobic. And children who have phobias at an early age usually develop into normal adults.
WHAT EXACTLY IS A PHOBIA?
Anxiety is a human trait and most individuals will have experience of it. Anxiety helps with vigilance, learning and general performance but in excess, it starts to work against us as extreme self-focus and apprehension reduces this attention and performance. Anxiety at the minor symptom level is familiar to virtually all of us and from Anxiety Care's experience, this often seems to weigh against an acute sufferer seeking help; or, perhaps, for an adult taking a child’s anxiety seriously. Embarrassment and shame at an 'over reaction', perhaps aggravated by the particular blending of emotions (such as anger, shame, guilt or sadness mixing with a dominating fear) that make up their 'personal anxiety' keeps the problem hidden and prevents this person, particularly if he or she is in their teens, from understanding that this response doesn't mean they are weak, soft or immature.
It is often not understood that anxiety can follow a continuum from mild to acute that leaves some people with 'liveable' responses but others deeply disabled. With most phobias, the vast majority of young people will be at, or close to, the mild end of the line where the problem is, at most, irritating, but in no way affects their everyday lives. This can work against the severe phobic as people experiencing a similar fear at a low level very easily come to believe that the acute sufferer is weak or ‘over reacting’.
Severe anxiety releases adrenaline and other chemicals into our blood, and these speed up our heart-beat, sharpen our senses and heighten our physical powers. These changes prepare us for what is called 'flight or fight'- either to fight for our lives, or to run for them. A phobia is a disorder in which the body reacts in exactly the same way, and we experience the same feelings of anxiety and fear - but in situations where there is absolutely no need for 'flight or fight'. The part of the mind that controls anxiety has, to all intents and purposes, lost all sense of proportion, and screams `danger!' when the situation is not threatening in any rational way. No matter how harmless the feared creature may be, for a severely phobic person the fear reaction is every bit as real as if the cause was a major threat. People with phobias usually realise all too well that their reaction is irrational, but this makes no difference to its effect.
WHAT DO CHILDREN FEAR?
The objects and situations that children fear vary a good deal. When very young children show fear it can be hard to judge exactly what is causing it, and many parents underestimate the number of things that frighten their children. In one study of 'just-fours', parents reported that two-thirds of children had recurrent fears, and other research points to a typical pattern and there are some fears such as as snakes, spiders and heights that seem common to us as a species. Parents should always be aware that some intense fears are quite a natural developmental stage and will ease naturally. The following is a general list of normal fears:
Age 2-4: fear of animals, loud noises, being left alone, inconsistent discipline, toilet training, bath, bedtime, monsters and ghosts, bed wetting, disabled people, death and injury.
Age 4-6: fear of darkness and imaginary creatures. Also animals, bedtime, monsters and ghosts. Other fears, such as of strangers seem to be persistent. 'Stranger fear' would probably be called 'shyness', while fear of snakes tends not to decrease much, if at all, during this period. Children at this age may also fear loss of a parent, death, injury and divorce.
Beyond these ages, irrational fears tend to decline rapidly, though there may be further peaks to do with other situations, e.g. age 9-11: fear of school; fear of blood and injury.
Older children tend to worry more about death and related topics such as nuclear war. Up to age 11 boys and girls tend to be equally represented in the 'fear tables'; after 11 years boys lose their fears more rapidly than girls.
It has been suggested by some research that children between the ages of three and six; sometimes confuse reality, dreams and fantasy. This concept has been challenged in recent years, so it is not safe to believe that everything that the child of this age fears is just something they will grow out of. Young children may also sometimes believe that inanimate or non-living objects have lifelike qualities. They may too have inaccurate concepts of size relationships (monsters that can come up through plug-hole for example). They may also lack an accurate understanding of cause and effect and often perceive themselves as helpless and powerless, without effective means to control what is happening to them.
8 year-olds will probably have fragments of earlier fears but additional ones will tend to be more rationally based and will possibly include fear being late for school, social rejection, criticism, new situations, adoption, burglars, personal danger and war.
9 and 10 year-olds are also likely to fear divorce, personal danger and war and these three are very likely to continue as fear problems into the mid teens. This age group might also fear blood and injury.
11 and 12 year-olds might fear animals, kidnapping, being alone in the dark and injections. Marks states that beyond this age boys lose their fears more readily than girls.
13 year-olds seem to fear heights as well as the three mentioned above.
14-16 year-olds will tend to have a wide range of rational or almost rational fears which might include: injury, kidnapping, being alone in the dark, injections, heights, terrorism, plane or car crashes, sexual relations, drug use, public speaking, school performance, crowds, gossip and divorce.
These childhood fears are not that different from those of adults. The most common adult fears are: public speaking, making mistakes, failure, disapproval, rejection, angry people, being alone, darkness, dentists, injections, hospitals, taking tests, open wounds and blood, police, dogs, spiders and deformed people.
As will be noted from the above, many childhood problems wax and wane as a normal part of development and a sensitivity in a certain area might be aggravated by a current problem so that this particular child temporarily ‘falls back’ into an earlier level of fear when faced with a trauma or severe family or school problems.
WHAT ARE THE SYMPTOMS OF PHOBIA?
In adults, phobias produce all the unpleasant physical symptoms of 'normal' fear:
* heart palpitations
* feeling sick
* chest pains
* difficulty breathing
* 'jelly legs'
* feeling 'unreal'
* intense sweating
* feeling faint
* dry throat
* restricted or 'fuzzy' vision or hearing.
In severe cases, people may feel certain that they are about to die, go mad, or lose control of themselves and injure someone, or do something disgusting and humiliating. Most of all they feel an overpowering urge to 'escape' from the situation they are in. Children are more likely to cry, shout or scream, or simply run away when confronted by the things they fear, though they may also be sick or go rigid. Paleness, perspiration and trembling are also signs of severe anxiety.
The level of symptoms that children with phobias experience varies a great deal, from very mild anxiety to very severe panic and terror. A mild degree of nervousness in particular situations is not usually a problem, but it is only a matter of degree, and at the other end of the scale there are children who have full-scale panic attacks when in the dreaded situation, and soon refuse to enter it altogether because of the terror that grips them at such times.
Phobias aren't just severe anxiety: the anxiety is turned into a phobia by avoidance. In the early stages of a phobia the child's parents sometimes try to tackle his or her fears head on by forcing him or her to enter the feared situation. If this works, the phobia can be overcome. If it doesn't, this is only likely to strengthen the fears and make the child want to avoid the phobic situation even more. It also risks destroying the child's confidence in its parents.
Avoidance is attractive because it brings a reduction of the tension; thus it rapidly becomes a habit. As with adults, avoiding the situations that make them feel frightened makes children more sensitive to those situations, and 'conditions' them to fear them even more.
This is why phobias can be such a big problem. Because we tend to avoid the things we fear, the fear can worsen very rapidly. To recover, we need to put that process into reverse, but the fear reaction is virtually automatic, and very difficult to control. It is a reaction inherited from our early history as a species, when we needed some instinctive protection to balance out our curiosity and tendency to flirt with danger. Fortunately, humans learn quickly and can train themselves to respond positively to threats, and not to react with terror to things which prove, with experience, to be harmless.
IT CAN'T JUST BE ANXIETY, CAN IT?
A child with severe phobic symptoms has an anxiety condition. This is much worse than just being nervous or 'a bit of a worrier'. Anxiety at this level can be as disabling as many physical diseases. However, because it seems unreasonable for someone to react so strongly to such ordinary situations, many parents may suspect a more 'logical' explanation - perhaps a serious physical or mental illness. Then the child may become a frequent visitor to the doctor's surgery and undergo a long series of medical tests, all of which draw a blank.
It often comes as a great relief to parents when they learn that the problem is not a brain tumour, psychosis etc., and that the nasty and frightening symptoms are in fact caused by anxiety. However, there is always the remote possibility that the child also has a medical condition, and this is one reason why we always recommend parents of phobic children to keep in touch with their GP.
HOW CAN CHILDREN'S FEARS BE TREATED?
The first thing to be considered is whether or not the phobia impacts strongly on the child’s life. If it does not interfere with day-to-day functioning then it might be worth considering allowing nature to take its course. If there is a level of handicap or severe distress, then treatment is indicated.
Persistent fears in children can be treated in much the same way as they are in adults; that is by desensitisation through being exposed to the feared situation. However, as children's fears are often volatile and transitory the child's previous record with fears should be considered before launching into an elaborate treatment programme. As already said, most fears will cease to be a problem without any need for treatment, and there is always the risk of teaching the child a new way of getting attention if every expression of fear brings a dramatic response from a parent. (Of course, if a child feels the need to use 'fears' as a way to be noticed, this might indicate different kinds of problem within the family.)
Nobody with a phobia responds to punishment or obtains the slightest improvement from being 'talked out of it'. Children in particular seem to respond best to being helped to increase their skill and competence, and being encouraged to take part in activities that will involve the thing they fear. With young children especially, practical activities that involve exposure could also be turned into a game, since most children respond better to play than to work. With a fear of bees, for instance:
first the bee is shown in a sealed bottle, some distance away
then it is brought closer; then closer (the child can be rewarded with a small treat for every shoe's length closer he or she is prepared to approach the bottle - or allows the bottle to approach, if that is less stressful).
eventually the child can be helped to touch the bottle, with a grand prize for this.
other exposure 'steps' could include walking in the garden (accompanied at first) when bees are about, with an escape route clearly established to build confidence.
if the parent is feeling brave, further exposure could be undertaken by 'modelling', i.e. doing the feared thing and showing the child in practice that there is no need to be afraid. In the case of a bee this might involve letting the bee alight on their clothing, with the child safely distant.
In extreme cases of phobia in children a therapist might use relaxation, videos and 'fantasy exposure' (helping the child to face the dreaded situation in his or her imagination) before attempting live exposure work.
Most children do not want to upset their parents and may be resistant to talking about the intensity of their feelings. If this is the case, one technique suggested by Anxiety Care is to ask the child what he or she thinks a close friend would be feeling in this situation. This doesn’t work, of course, if the friend is perceived to be tough, but if the child can be helped to explore this cared-for person’s possible responses in similar situations, where he or she was afraid, this can establish the level of fear that the phobic child accepts as ‘normal’. Parents can sometimes be horrified at the fear levels uncovered in this way and it is important that an over reaction that involves shame and feelings of worthlessness as a parent do not become involved. If it does, this will only cloud the issue and unbalance the necessary socialising and discipline that the child needs in the rest of his or her daily life.
When the child resists support, it can become very difficult. Where very negative thinking is involved, the parent can try to help by gently challenging the child’s thought processes. This is described in ‘Poor Thinking’ on this site. Obviously a heavy challenge is rarely likely to work with a very young child and the parent needs to work out the best way to approach the problem: in some way helping the child to look at his or her thoughts and beliefs in a way that is challenging, not threatening. If the child refuses all help then the parent could usefully talk to a doctor or therapist without the child being present in order to learn ways to apply help at such time that the child is willing to accept it.
Sometimes depression occurs alongside a severe phobia. The problem here is that depression undermines: it takes away the will to try to overcome the phobia and may even make the sufferer feel that he or she is helpless against it. Where depression is suspected the GP must become involved. If the depression is mild or moderate, the child will probably receive help focused on the anxiety with concurrent support for the depression. If the depression is judged to be severe, the focus will be on treating the depression.
Drugs are rarely the first treatment of choice for young children. In the developing brain the neurotransmitting system seems to be particularly sensitive to medication so it is unlikely that a doctor would suggest medication early on in treatment for a very young child. If it is considered, the dosages would have to be very carefully monitored.
SCHOOL PHOBIA (SCHOOL REFUSING)
The number of children who dislike school and avoid it whenever possible is probably more than 5% of the school-age population, but less than 1% could genuinely be called 'school phobic'. School phobia, also called 'school refusal' is commoner among boys, and the peak onset in Britain is at the age of 11-12 years. This is perhaps not surprising, since this is the age when most children move from primary to secondary school, and therefore experience great changes in their lives.
There are also smaller peaks at the age of 5-7 years old, where separation from the mother may be a primary cause (See the article on separation anxiety on this site); and at 14, where it is more likely to be associated with a psychiatric disorder such as depression.
Some older adolescents and young adults may experience fears of college or work that resemble school phobia; most of these will have been school refusers when children.
Sometimes school refusing begins suddenly, for instance after a prolonged absence from school due to illness; following an abrupt change of school or class; after school holidays - or even after a weekend. However, the actual event immediately before school refusal is unlikely to be the sole cause of the problem, though it might have been the last straw on top of a lot of other things. These additional situations could include family problems; difficulties at school; anxiety about puberty; other sexual matters; general difficulty with social situations; anxiety about being separated from the parents (mainly the mother); bereavement; or depression.
However, most cases of school refusal seem to develop slowly. Reluctance to attend gradually increases, with visible signs of anxiety that grow more obvious as the child is pressured to go. Sometimes the child will deny that he or she is afraid, but signs such as paleness, trembling and frequent urination may be very obvious to the parent. Typically the child will complain of bodily pains, stomach trouble or nausea in the early morning. These problems usually cease abruptly if the child is allowed to stay at home, and re-appear when he or she is once again pressured to go to school.
Some children will simply refuse to go to school, offering no reason. Others might complain of bullying, or of being unable to get on with teachers or do the school work. Some may express fears about undressing in front of other children, or of making a spectacle of themselves by fainting, vomiting or losing control of their bowels. Less often they may mention fears of something happening to one or both of their parents while they are at school, or simply of feeling `unsafe' when far from home.
Children deal with their fear of attending school in many ways. Some may go through the morning ritual almost normally, but are then unable to leave the house, or turn back before reaching school. Others may flatly refuse to get out of bed, or lock themselves in somewhere, or run off until they feel it is safe to return home. Some will gladly put up with punishment as the price of not going, and many will promise (and mean it at the time) to go 'this afternoon' or 'tomorrow' if they are only allowed to stay at home now. Some children have been known to threaten, or even attempt, suicide when they felt totally trapped by the situation.
PHOBIA OR TRUANCY?
School phobia is sometimes confused with truancy - even by teachers and educational workers. However, truants do not usually express or display such high levels of anxiety, and nor do they flatly refuse to attend school. It is just that there are other things they would rather be doing. They are more likely to pretend to set off for school, and then disappear on the way, or during the day, returning home at the normal time, so that parents are often the last to find out what is happening. Truants also tend to become involved in other delinquent behaviour. They may also come from disadvantaged areas and homes where there is not enough discipline, caring, or simple parental interest. Their school work is likely to be rather poor and they will probably show little interest in what the school thinks of them.
This is in sharp contrast to the typical school refuser, who comes from a stable home with both parents present and caring (if sometimes over-protective) and who is often described as "always such a good boy/girl - never any trouble before this". Typical refusers may also be sensitive to the point of timidity, being unduly wounded by adverse comments from teachers, and have unrealistically high goals for themselves; they may then become excessively upset at their perceived failures.
TREATMENT FOR SCHOOL REFUSAL
Anxiety Care receives many letters and phone calls from parents of school refusers. Besides the anxiety and confusion, many share a feeling of guilt. They have been told, or have read, that it is "all their fault" for making a "mummy's boy (or girl)" out of the child. In our culture, that usually means 'wimpish' and 'inadequate'. Parental reactions can then be deep shame or anger and a closing of family ranks. None of this is conducive to helping the child out of the problem.
Although 'separation anxiety' (difficulty in leaving mother) can be a major factor in school refusal for 5 to 7 year-olds, it is not necessarily significant for older children. 'Real' fears of such things as being bullied, PE and games, unfriendly teachers, the size of the school, and other personal and family difficulties, might be the dominant factors. Several cases brought to Anxiety Care have been triggered (or 'last-strawed') by a death in the family. Sometimes it was not a close relative, or even a human being that died; but for an 11 or 12 year-old this may have been the first time that the finality of death came home to them; and this can be a shock. Even if the experience wasn't particularly traumatic, it is never safe to assume that children will deal with such a loss as an adult would.
Children may also react to loss of friends through moving to a new school or area in the same way that they would to a bereavement. A good therapist would not jump to conclusions about reasons, but would make a systematic investigation of all the possible factors - child, family and school.
PROFESSIONAL THERAPY FOR SCHOOL REFUSING
Parents cannot afford to allow school refusal to be ignored or treated in a haphazard and ineffectual manner. The law requires a child to be educated, and most parents are not able to pick and choose where this takes place. If children do not go to school, parents may be taken to court, and there is even the (very slight) risk of the child being taken into care. Nobody wants this to happen, so professional help is usually readily available, and it is vital for parents to make the best use of it.
Most current treatments for school refusing are carried out around the home and the school by clinical child psychologists. They will involve helping the child to deal with anxiety symptoms in the situation where they developed, while getting the child back to school as quickly as possible. Inpatient treatment compares poorly with this kind of 'live' support, though a small minority of children do fare better away from home.
Some parents may be tempted to take their child out of the school system altogether, but research shows that temporary home tuition is not a useful road to recovery, and works against the child's early return to school. Permanent withdrawal, even if some children do better academically, and feel more content outside the school system, has some dangers. The child with low social skills may not learn how to relate to the peer group, which can become a major problem. The child may also never resolve the underlying problems that generated, or were part of, the school phobia.
They may thus become prime candidates for a similar anxiety disorder later in life when faced with going to college, or to work. They may also be so handicapped by lack of the social and 'peer' learning gained at school that character traits such as timidity, over-sensitivity, and the tendency to have unrealistic expectations of themselves and others, may become a permanent barrier between the young adult and the rest of the world.
The problem with setting a goal of 'the child returning to school as quickly as possible' is deciding how soon to aim for. The therapist's personal beliefs and the extent of the child's anxiety will be the main factors here. However, whether the period is short or long, all therapists will have a series of priorities. They will:
work at establishing a good, trusting relationship with the child and the family
clarify the situations that actually create anxiety
desensitise the child to these situations by getting the child to imagine the dreaded events, with relaxation techniques, and simply by talking about it
lastly, they will help the child to confront the situations 'live'.
THERAPISTS AND PARENTS
Therapists are well aware that they need the full support of the child's family, and that there can be much confusion, anger, guilt and plain misconception to work through before therapy proper can begin. They would spend time with the parents, trying to assess how much bearing their behaviour and reactions have on the school refusal problem.
They would probably meet with the parents alone, so that other problems which could be affecting the child might be resolved without the child being drawn into them (or feeling to blame for them). They would also talk through worries such as parents feeling cruel and guilty about forcing the child to go to school. Where parents are uneasy about seeming to criticise teachers, or staff feel threatened or irritated by the idea that their school is a 'dreaded place', they would also act as go-between.
The therapist would also help the parents find the best ways to deal with:
the child's tantrums, complaints about illness, refusal to talk about the problem (or insistence on doing so)
redressing the balance if the child had begun to dominate the family through the phobia
ways to avoid escalating threats and/or polarising into 'protecting mother' and 'threatening father' that can be so damaging in the families of school refusers.
Towards the end of the treatment, with the child ready to attend school, the therapist would also discuss the best times to return, such as after a weekend or a holiday, rather than in midweek, which might arouse more comment from other children. And they would work out, perhaps using role play, the responses the child might use to those making fun of his or her absence. After the child has returned to school, they would go on to help the parents recognise danger points in the future, and encourage them to use the 'management' techniques they have learned.
Live exposure to the dreaded situation is part of overcoming all phobias. However, simply dragging a child to school would not be appropriate in most cases. While school may be the focus of fear, most school refusers get to that point via a number of 'stressor' situations working together. So before the journey to school is attempted, the various fears already mentioned have to be faced. Nevertheless, the journey to school has to be undertaken sooner or later, and this can be a very dramatic time, when the parents' anxiety is almost as high as the child's. Parent and therapist have to be clear how to deal with this. A good therapist will have explained that all 'exposure work' is built round the child's actual anxiety level, not what it should be or could be. This will ease parents' fears of the child experiencing a total collapse or breakdown. A strategy would be worked out in advance for certain situations, for example:
with a young child, the parents would not linger within sight of the classroom, fuelling the child's anxiety as well as their own
if the child was to be physically restrained from escaping, the parents wouldn't let the child think that a little more hysteria might bring them leaping to the defence
there would be a planned response if the child should run home.
It is extraordinarily hard for parents to stand by while their children suffer, even when they know it is necessary and temporary. Therapists work closely with parents, and they understand how important it is for the family to be able to support the child as he or she gradually comes to terms with school life.
The basic reference works on which we have drawn are:
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