School Phobia Pediatric Nursing Care Management

School phobia, also called school refusal, is severe anxiety or fear around attending school that drives persistent refusal to go. It grows out of separation anxiety, social difficulty, or academic stress, and it can stall a child's emotional and educational development. The nursing job is to recognize the anxiety behind the physical complaints, rule out organic causes, and support a structured return to school.

What is School Phobia?

School absenteeism is a national problem, and school phobia is one reason kids stay home. The phobia is really a "fear of fear": sufferers are not frightened of a specific place, situation, object, or animal, though children believe there is something real to fear. School refusal is a common childhood behavior problem, a child's refusal to attend school, and today it may stem from bullying at school or online.

Pathophysiology

Sufferers are frightened of the feelings of fear they get with their trigger situation. A phobia usually follows periods of stress and often starts after a final trauma or a first traumatic attack that seems to come out of nowhere. Early on, the child feels frightened in a particular place or situation without knowing why, with an overwhelming sense of impending disaster and a compulsive urge to escape. The feelings are real, and they start a spiral: the child begins to believe these awful feelings will follow them everywhere. The result is refusal to attend school.

Statistics

Frequency estimates vary widely. About 5% of the school population actively dislikes school and avoids it when possible. Those who would be classed as school phobic make up roughly 1% of the school population, about 90,000. Well over half are boys, and peak onset is about 11 to 12 years of age. The final peak age is about 14 years and may be associated with depression.

Causes

Teachers and nurses can help catch school phobia by watching absence patterns. School-phobic children may have a strong attachment to one parent, usually the mother, and may fear separation, perhaps from anxiety about losing that parent while away from home. School phobia can also be an unconscious reaction to a seemingly overwhelming problem at school, which a parent can unwittingly reinforce by letting the child stay home.

Clinical Manifestations

Symptoms are genuine and driven by anxiety that can approach panic: vomiting on learning school is coming, headaches that subside once the child is allowed to stay home, diarrhea, abdominal or other pain timed to skip school, and even low-grade fever, all from anxiety.

Assessment and Diagnostic Findings

Diagnosis rests on family history (any phobias or traumatic experiences feeding the fear), physical symptoms (the absence of a physical cause points to school phobia), psychological evaluation (varies with findings and the child's age, usually several assessments), and a behavioral checklist evaluating the child's behavior at home and school.

Medical Management

Start with a complete exam to rule out any organic cause. School-family conferences help the child return; recognize that these children genuinely want to go but cannot make themselves. Cognitive/behavior therapy changes how the child behaves and is more effective than traditional psychotherapy for childhood anxiety disorders, teaching the child to quell anxiety. Family counseling helps parents understand and handle the child with behavioral guidance and emotional support. Systematic desensitization gradually modifies the child's distressing reaction to school without provoking distress. Exposure therapy steps up the intensity and duration of the distressing event while encouraging the child to modify maladaptive cognitions, building tolerance. Operant behavioral techniques reward desired behaviors to increase their frequency.

Pharmacologic Therapy

Medication may be needed for underlying anxiety and phobia. SSRIs such as fluoxetine (Prozac) may help underlying depression. Benzodiazepines work by enhancing the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Nonselective beta-blockers manage the physical symptoms of anxiety, and alpha-2 receptor agonists are used to manage anxiety.

Nursing Management

The nurse's role is to be a firm, active listener who can steady the child's behavior.

Nursing Assessment

Assessment distinguishes the underlying problems and names any episode that surfaces during care. Assess for culture-bound anxiety states. Assess the child's level of anxiety; Hildegard E. Peplau described 4 levels: mild, moderate, severe, and panic. Assess how cultural beliefs, norms, and values shape the child's view of the stressful situation. Assess physical reactions to anxiety.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are: fear related to an unfriendly environment or threatening people; anxiety related to a threat in the environment; and impaired social interaction related to self-concept disturbance and fear of the school environment.

Nursing Care Planning and Goals

The child will show reduced fear and anxiety: verbalizing feeling less anxious, keeping a usual sleep pattern, relaxed facial expression and body movements, stable vital signs, usual perceptual ability and interactions, identification of strategies to reduce anxiety, and increased external focus.

Nursing Interventions

A welcoming, safe environment comes first, along with recognizing anxiety triggers and practicing relaxation. Orient the child to environment, equipment, and routines. Familiarize the child with new experiences or people to build awareness and lower anxiety. Accept the child's defenses; do not dare, argue, or debate, so the child feels secure. Help the child identify precipitants of anxiety that may guide interventions. Let the child talk about anxious feelings and examine anxiety-provoking situations. Help the child build anxiety-reducing skills. Educate child and family about the symptoms of anxiety. Instruct on appropriate use of anti-anxiety medications.

Evaluation

The plan succeeds when the child verbalizes feeling less anxious, keeps a usual sleep pattern, shows relaxed facial expression and body movements, holds stable vital signs, returns to usual perceptual ability and interactions, identifies strategies to reduce anxiety, and shows increased external focus.

Documentation Guidelines

Document the level of anxiety and precipitating or aggravating factors; description of feelings expressed and displayed; awareness and ability to recognize and express feelings; the treatment plan; the teaching plan; responses to interventions, teaching, and actions; progress toward outcomes; modifications to the plan; and referrals and followup plan.