School phobia affects 5 to 28% of children (boys and girls alike, more often between the age of 10-13 years) at some point during their education [1]. The symptoms consist of headaches, abdominal pain, nausea and vomiting, asthenia, excessive perspiration, muscle aches and bone pain, palpitations, dizziness, trembling or accelerated intestinal transit. The presentation commonly occurs just before going to the school or during school hours. The child repeatedly asks to leave the classroom and visit the school nurse. He or she may also exhibit psychiatrical symptoms like anxiety, avoidance coping, noncompliance, inflexibility or a tendency to defy authority. Temper tantrums may also start if his or her requests are not met. All these problems quickly disappear once the child is reassured that he or she can remain at home. School phobia may be a sign of a deeper psychiatrical abnormality, such as depression, pathologic anxiety or personality disorder [2].

Symptoms may happen gradually when it progressively becomes more difficult to convince the child to attend school or can take place abruptly, after a stressful event. Patients do not refuse to learn or do their homework, they only feel panic about going to school and fear may be so deep, some may cry throughout the previous night.

If the problem is not quickly addressed, it can lead to academic decline, school dropout, social isolation, and lack of success in the later stages of life, affecting the family life and causing economic problems.

Physical examination usually reveals no pathologic elements. However, an organic support for the child’s complaints may be suspected after clinical examination. Diseases to be looked out for include thyroid disorders, asthma, mitral valve prolapse, and gastrointestinal diseases, especially Crohn’s disease and dyspepsia.

If a somatic disease is suspected after clinical evaluation, thorough blood and imaging workup should be ordered. Complete blood cell count is needed in order to rule out anemia, a cause of abdominal pain. The same symptom can be caused by heavy metal intoxication, that also needs to be excluded. Thyroid and thyroid-stimulating hormones can be ordered if the clinical aspect suggests glandular pathology. Type I or II diabetes or decreased insulin tolerance are diagnosed using glycemia or urine glucose elimination.

If history or clinical evaluation point to an expansive intracranial process, computer tomography, magnetic resonance imaging or positron emission tomography are in order. If a cardiac problem is suspected, the first steps towards diagnosis are an electrocardiogram and echocardiography. A sleep disorder can also induce anxiety, therefore sleep studies may be useful [3].

If no physical cause for symptoms is found, causes of school refusal must be explored: fear of separation, fear that something may happen to his or her parents, avoiding teacher criticism, avoid being bullied [4], feeling unsafe in class [5] or the urge to pursue hobbies during school hours [6].

The clinician may apply the 'School Refusal Assessment Scale-Revised,' a useful instrument when trying to assess the cause of school phobia [7]. Other interview scales, such as 'Diagnostic Interview for Children and Adolescents-Revised,' 'Social Anxiety Scale for Children,' 'Multidimensional Anxiety Scale for Children or Child Behavior Checklist' also exist. Furthermore, observation of the whole family is indicated. The child should also be interviewed regarding suicidal ideation.

Treatment for school phobia often involves a combination of approaches. Cognitive-behavioral therapy (CBT) is commonly used to help the child manage anxiety and develop coping strategies. Family therapy may also be beneficial to address any underlying family dynamics contributing to the issue. In some cases, medication may be prescribed to manage severe anxiety symptoms. It's crucial to work closely with the school to create a supportive environment that encourages the child's return to school.

With appropriate intervention, the prognosis for children with school phobia is generally positive. Early identification and treatment can lead to significant improvements in the child's emotional well-being and school attendance. However, if left untreated, school phobia can lead to academic difficulties, social isolation, and the development of other mental health issues. Ongoing support and monitoring are essential to ensure long-term success.

The exact cause of school phobia is not fully understood, but it is believed to result from a combination of factors. These may include a predisposition to anxiety, stressful life events, or negative school experiences such as bullying. Family dynamics, such as overprotective parenting or parental anxiety, can also play a role. Each child's situation is unique, and multiple factors may contribute to the development of school phobia.

School phobia is relatively common, affecting approximately 1-5% of school-aged children. It can occur at any age but is most frequently seen in children aged 5-7 and 11-14, coinciding with key school transitions. Both boys and girls are affected, although some studies suggest it may be slightly more prevalent in boys. The condition can occur in any socioeconomic or cultural group.

The pathophysiology of school phobia involves the body's response to perceived threats. When a child experiences anxiety about school, the brain's fear center, the amygdala, becomes activated. This triggers the release of stress hormones like adrenaline, leading to physical symptoms such as increased heart rate and stomach discomfort. Over time, the brain may associate school with these unpleasant sensations, reinforcing the phobia.

Preventing school phobia involves fostering a positive school experience and addressing anxiety early. Encouraging open communication between children, parents, and teachers can help identify and resolve issues before they escalate. Teaching children coping skills for managing stress and anxiety can also be beneficial. Schools can play a role by creating a supportive and inclusive environment that minimizes stressors like bullying.

School phobia is a condition characterized by intense fear or anxiety about attending school. It presents with both emotional and physical symptoms and requires a comprehensive evaluation for diagnosis. Treatment typically involves therapy, family support, and collaboration with schools. With early intervention, the prognosis is generally positive, but ongoing support is crucial. Understanding the factors contributing to school phobia can aid in prevention and management.

If your child is experiencing school phobia, it's important to approach the situation with empathy and understanding. Encourage open discussions about their feelings and fears. Work closely with healthcare providers and school staff to develop a plan that supports your child's return to school. Remember, with the right support, children can overcome school phobia and thrive both academically and socially.

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