http://www.nytimes.com/2006/08/29/health...RdusyIxLvEP/f9Q Personal Health Help for the Child Who Says No to School By JANE E. BRODY Published: August 29, 2006 James, a tall, bright, personable 12-year-old, had been successful socially, athletically and scholastically all through elementary school. But everything fell apart when he had to move on to a large centralized middle school. Never a morning person, James now had to get up at 6 a.m. instead of 7:30 to catch the bus. Once at school, he had trouble finding his way around and arrived late for many of his classes. Rather than asking for reasons, which included being bullied and hit by several older boys, his teachers simply gave him late marks and detention. Jamess grades plummeted, and his feelings about school crashed with them. He couldnt sleep at night. He started missing school a few days a week, then found himself unable to go at all. His parents were understanding and spoke to school authorities about his problems, but nothing anyone did seemed to make things better, not even disconnecting the television and computer to reduce the rewards of staying home. Beginning the Turnaround A psychological evaluation led to a diagnosis of a serious anxiety disorder set off by the abrupt change in school environment. Medication and 18 months at a therapeutic school, where James made steady progress, turned the situation around. He did not return to the public school that terrified him, but he is thriving in a small private school where he made the National Honor Roll. Refusal to go to school is not an uncommon problem; up to one-quarter of children do it at some point. While you might expect the problem to be severest when a child first enters school, it occurs most often and hits hardest at ages 10 to 13. At this age children typically leave the nurturing environment of elementary school and are thrust into the chaos of middle school and the confusion of dealing with so many teachers. Compound this with the hormonal upheaval. Many children suffer crises in self-confidence and self-image, often exacerbated by the fact that they go from being the oldest and most experienced students in the school to being the youngest and most inexperienced. Bullying, often perpetrated by young teens who are unsure of themselves, is one of the most common causes of this problem, called school refusal behavior. Children who are bullied or teased often become anxious about going to school, said Michelle Kees, a psychologist at the University of Michigan. And some of them may avoid school because it is too hard for them or perhaps because they have an undiagnosed learning disability, she added. Christopher A. Kearney, a psychologist at the University of Nevada, Las Vegas, offered guidance on dealing with the situation in the August issue of The Journal of Family Practice. He told of Nathan, a 13-year-old who, like James, had trouble adjusting to middle school. Though Nathan seemed fine on the weekends, during the school week he complained of headaches and stomachaches and told his parents he felt upset and nervous in school. He started going to school late, skipping classes and then skipping school altogether. Common symptoms of school refusal behavior may include aggressive behavior, clinging to a parent or other adult, defiance, excessive assurance-seeking behavior, refusal to get up or get ready for school, running away from school or home, or having temper tantrums and crying. Dr. Kearney described four circumstances that may prompt refusal to go to school: Often in combination with underlying anxiety and depression, the child may be distressed by teachers, students, the bus, the cafeteria, the classrooms and transitions between classes. The child may be trying to escape from distressing social situations or academic or athletic evaluations, including interacting with others or having to perform before others. The child may be seeking attention from parents by staying home or wanting to go to work with a parent. The child may find staying at home a rewarding experience that permits sleeping late, watching television, playing video games, or especially for teenagers engaging in delinquent behavior or substance abuse. Risking the Consequences Studies have shown that failing to deal with school refusal behavior can have serious consequences. In the short term, children who wont go to school decline academically, become alienated from friends and cause family conflicts and financial and legal problems. Had James not gone willingly to the therapeutic school, the courts would have forced him to attend a school for delinquent children. Common long-term problems listed by Dr. Kearney include dropping out of school, delinquent behaviors, economic deprivation, social isolation, marital problems and difficulty holding a job. Failing to receive the needed treatment can lead in later life to problems like anxiety disorder, depression or personality disorders. Young children just starting school or returning to school after summer vacation may fear leaving their family or environment. In most cases, the initial hesitancy disappears as the child becomes familiar with the school and its rules and makes new friends. But a child with severe separation anxiety who is paralyzed by the fear of leaving home needs professional help, which should include teaching the parents how to cope effectively with the problem. Discovering the Right Treatment Often, the problem can be minimized before school opens by doing a walk-through of the school and classroom with children and arranging outings or visits with others in the same class. Once school opens, some teachers may allow parents to stay in class with their children for part of the day for a few days. Dr. Kearney cautions that if a child has complaints like stomachaches, headaches or fatigue, as Nathan did, these should be checked out to be sure there is no underlying medical problem. After Nathans pediatrician determined that the boy suffered from no underlying physical problems, a psychological exam revealed a generalized anxiety disorder. He worried excessively about his social and academic performance at school, and he showed physical signs related to anxiety, Dr. Kearney wrote. If a psychological evaluation reveals a generalized anxiety disorder or depression, treatment is required, often with medication and professional counseling. Nathan was treated with a combination of sertraline (Zoloft) and anxiety management techniques, his parents received family therapy aimed at limiting the fun he had at home, and school staff members allowed him to gradually return to a full academic schedule. Cognitive behavioral therapy, which emphasizes patterns of thinking, is especially effective in such cases. For older children, techniques include relaxation training and breathing retraining to reduce the childs anxiety, establishing routines and consequences for not attending school, and developing a contract that increases incentives for going to school and disincentives for staying home.