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The pediatric management of school phobia
T H E P E D I A T R I C 3/[ANAGEMENT OF SCHOOL P H O B I A LEON EISENBERG, M.D., BALTIMORE, ~V~D. T IS the purpose of this presentation to outline the psychiatric principles u n d e r l y i n g effective pediatric m a n a g e m e n t of the child with school phobia and to indicate the results t h a t m a y be anticipated from a psychologically i n f o r m e d approach to diagnosis and treatment. School phobia comes to the attention of the pediatrician early a f t e r its onset and p r o m p t diagnosis and judicious t r e a t m e n t can have a decisive impact on its f u r t h e r course. It lends itself to the r e a d y delineation of psychodynamic issues in the genesis of neurotic disorders in childhood. I t is a m a t t e r of some u r g e n c y t h a t the pediatrician sharpen his psychological skills. The therapeutic advances of the past two decades have produced m a j o r shifts in the p a t t e r n o f pediatric practice with behavior problems becoming an ever more imp o r t a n t focus of the " n e w " pediatrics. 1 lKoreover, if there is to be any f r u i t f u l consequence of the concept of preventive mental h y ~ e n e , it must find expression within the framework of pediatric practice in view of the pediatrician's strategic role in well-child care. The psychiatrist is, and of necessity will remain, the eonsnltant whose aid is sought a f t e r
I
l~rom the Johns Hopkins University School of Medicine and the Johns Hopkins Hospital Presented at the Ninth International Congress of Paediatrics, Montreal, Canada, July 23, 1959, in S e c t i o n I V : "Psychiatry in Pediatric Clinics,"
b r e a k d o w n has occurred. His contribution to prevention, both p r i m a r y and secondary, will depend u p o n his success in communicating to his pediatric colleagues such useful information as m a y be employed appropriately in office and clinic practiceY -4 THE PROBLEM
The child with school phobia has a dread of attending school, a dread which has no a p p a r e n t justification in his school experience. E v e n in the instances in which an unpleasant school encounter m a y be related to the precipitation of the syndrome, the experience is likely to have been one to which other children have been exposed with, at most, only t e m p o r a r y distress. Moreover, efforts to change teacher, class, or school r e g u l a r l y prove ineffectual in relieving the symptoms. The fear of school m a y not be at all overt. The presenting complMnt may consist of any one of a wide v a r i e t y of somatic symptoms, whose distinguishing features a~'e their early morning onset, p r o m p t subsidence as school attendance is avoided, and singular absence on holidays. The ehild with school phobia is not, let me make it d e a r , a truant. The t r u a n t dislikes school, has usually been an indifferent seholar, and starts out as if to go to class, only to spend the day roaming the streets. He is 758
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likely to compound his felony by ingenious devices to conceal his failure to attend. The child with school phobia, on the contrary, is almost always a good student, is f r e q u e n t l y a model of d e p o r t m e n t and has vocational goals for which schooling is required.* R a t h e r t h a n concealing his difficulty in school attendance f r o m his parents, he alarms them with his dismay and turns to them f o r solace. Most often, he will refuse to leave his home during school hours for fear his disability will become k n o w n to the neighbors. How, then, are we to u n d e r s t a n d this paradoxical behavior.~ The answer becomes a p p a r e n t when we extend our observation to the family as well as the child. A s t u d y of the behavior of mothers of such children in a specialized n u r s e r y school revealed in striking fashion t h a t the mothers clung to their children even more desperately t h a n the children to them. 6 They h o v e r e d in constant attendance, i n t r u d e d themselves on various pretexts into the children's play, resisted the teachers' efforts to ease them out of the playroom, and offered f r e q u e n t and uncalled for " r e a s s u r a n c e " to the children. It was not uncommon to note a child happily engaged with his group, r a t h e r unconcerned when m o t h e r announced that she was about to leave, until her unnecessarily prolonged and tearful good-byes let him know he was expected to cry. Once she left, he could usually be induced to d r y his tears and re-enter the group activity. His mother, during the same period, * I n a s u r v e y o f 41 c h i l d r e n w i t h s c h o o l phobia, we found that none were defective, l e s s t h a n o n e t e n t h w e r e o f dull n o r m a l intelligen,ce, a n d h a l f w e r e in t h e b r i g h t to s u p e r i o r r a n g e o,f i n t e l l i g e n c e . ~
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was observed b y the social w o r k e r to be pacing about f r e t f u l l y in the waiting room, unable to be convinced that he would survive her absence. Clearly, then, the basic issue is not going to the school, but leaving mother. We are dealing, not so much with a phobia, as with a n x i e t y about separationJ -9 This is most readily evident from direct observation in the n u r s e r y school but can be confirmed for older children by taking note of mother-child interaction iu the clinic waiting room and b y detailed questioning about family behavior during the separation process2 This defines the crucial therapeutic task: to enable child and family to liberate themselves from excessively close ties that stifle emotional growth. But before we consider t r e a t m e n t procedures, let us first ask ourselves w h y this r a t h e r remarkable behavior exists. A f t e r all, the m o t h e r has summoned the physician because she is distressed by her child's inability to leave her for school. How are we to believe that she is causing him to remain at home? I t should no longer surprise us to discover t h a t eon.trary motivations can exist at one and the same time within both mother and child. Recognition and understanding of this ambivalence are necessary if we are to be of assistance in correcting the problems it produces. The mother, on the one hand, wishes her child to develop normally, to attend school, and to overcome his fears. O n the other, she needs his close a t t a c h m e n t to her. She mistakes his clinging for a demonstration of love. ~She, too, is afraid, just as he is afraid, that some u n n a m e d catastrophe is impending. She calls in the physician because she recognizes
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t h a t her child's b e h a v i o r is a b n o r m a l - - b u t also because she is becoming resentful of the demands f o r her cons t a n t presence. The child's s y m p t o m s are comprehensible as his response to his mothe r ' s a m b i v a l e n t motivations. She m a y offer verbal r e a s s u r a n c e t h a t there is n o t h i n g to f e a r b u t does so in a t r e m u l o u s voice t h a t conveys her own anxiety. She " i n s i s t s " he leave for school b u t does so in an unconvincing m a n n e r ; her indecisive movements and her q u a v e r i n g voice m a k e it clear that, really, he need not. I t e r anxious questions about h o w he feels offer him the clue t h a t if he but complain of being" ill, he witl not h a v e to face the d r e a d e d s e p a r a t i o n f r o m mother. W h y do these m o t h e r s - - o r , in some instances, f a t h e r s - - n e e d t h e i r child r e n so closely tied to t h e m ? The pathogenesis of s y m p t o m f o r m a t i o n m a y be r a t h e r stereotyped, as a l r e a d y indicated, but the u n d e r l y i n g causes are as complex and i n t r i g u i n g as the h u m a n situation itself. The reasons will v a r y for each ease and can be elicited only b y s y m p a t h e t i c and pereeptive inquiry. I can b u t allude, in oversimplified fashion, to a few representative ease i l h s t r a t i o n s : B a r b a r a was b o r n late in a childless m a r r i a g e , a f t e r five p r e c e d i n g miscarriages. She w a s all h e r m o t h e r h a d so Iong sought and all she was likely ever to have. H e r m o t h e r ' s coddling and constant caution a b o u t her s a f e t y created in B a r b a r a a morbid p r e o c c u p a t i o n with ilIness and injury. Sheila became her m o t h e r ' s " s p e c i a l " child w h e n she was b o r n shortly a f t e r the m a t e r n a l g r a n d m o t h e r ' s sudden death. I t was h e r b u r d e n to filI an a c h i n g void. The symbiosis
OF P E D I A T R I C S
between mother and Sheila was idyllic until mother took her first vaeation away from her daughter. Sheila could not be gotten to school while her mother was away. A delay at the airport in the arrival of the plane bringing mother home sent the child into a panic. Once mother arrived, Sheila clang to her avidly, fearing for her safety, and retaliating for being abandoned. Mother was immobilized by her guilt at having left her daughter. i~{rs. L. resented Allan's presence; his arrival had sealed the eompaet of a bitterly disappointing marriage. I{er anger toward him was ineompatible w i t h her conscious ideals of motherhood. As a visible b a d g e of her love, she s u r r o u n d e d him w i t h a suffocating eloud of overproteetion. H e r fears f o r his s a f e t y were the projections of her own hostile impulses. H e r frenzied a t t e n t i o n created in Allan an insatiable appetite f o r p r o o f of her devotion; his d e m a n d s drove her to a n g r y o u t b u r s t s which frightened both of t h e m b y t h e i r enormity. Allan could not t r u s t h e r out of his sight f o r f e a r she m i g h t not r e t u r n ; he punished her b y d e m a n d i n g complete subservience to his whims. iVir. R. relived t h r o u g h P e t e r the unresolved issues of his t r o u b l e d childhood. He t r i e d to experience vicariously, b y p r o v i d i n g it to his son, the ideM f a t h e r i n g he so avidly c r a v e d and h a d n e v e r received. So close were the bonds t h a t w h e n P e t e r complained of nausea, his f a t h e r vomited. P e t e r had learned a d r o i t l y to m a n i p u l a t e his f a t h e r b y simulating illness to avoid u n p l e a s a n t responsibilities. Philip had become the sole source of satisfaction in his m o t h e r ' s e m p t y marriage. Seduced b y her constant hovering, he h a d a b a n d o n e d a n y interests outside the home. As he app r o a c h e d adolescence, he became acutely anxious at the first dim perception of the erotic elements in their love relationship.
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I V [ A N A G E M E N T OF S C H O O L P t t O B I A
Examples could be multiplied. B u t perhaps the few cited will serve to illustrate the range and complexity of the h u m a n issues involved. More detailed case studies r e p o r t e d in the literature should be consulted to supp]ement these necessarily abbreviated vignettes2 -~ TREATMENT
I t cannot be emphasized too strongly t h a t t r e a t m e n t begins with a searching diagnostic evaluation. A careful history and a t h o r o u g h physical examination will in most instances suffice to indicate to the physician t h a t he is dealing with a school phobia; in some cases, however, special diagnostic procedures will be necessary before organic p a t h o l o g y can be exeludedP Once he has established to his own satisfaction that the symptoms are those of school phobia, the pediatrician must seek to identify the m a j o r issues in family life that have given rise to the symptoms, if he is to develop a plan to i n t e r r u p t the pathological cycles and to support the healthy trends in parents and child. This need not require a psychiatrist in most instances. The pediatrician usually has some prior knowledge of the family; he has a considerable asset in the positive expectations the family bring to him as the physician who has t r e a t e d other illnesses successfully. A sensitive and interested inquiry, based on familiarity with the issues likely to be found, will lead to the identification of the central conflicts. *Positive , evidence of psychopathology does not rule out the p o s s i b i l i t y of a conc u r r e n t o r g a n i c lesion. To take a recent example, an obviously d i s t u r b e d child w i t h recurrent abdominal pain was referred for psychiatric treatment; pediatric workup and subsequent operation revealed hydronephros i s s e c o n d a r y to u r e t e r M o b s t r u c t i o n .
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With diagnosis established, the central focus in m a n a g e m e n t is p r o m p t return to school. This may seem at first glance a hazardous und e r t a k i n g with a child who displays panic at the prospect of r e t u r n i n g to school. The physician, no less than the family, ntay f e a r the precipitation of an acute breakdown. In fact, however, this does not occur with adequate support to child and family. The reasons for this therapeutic emphasis and its success require discussion. To begin with, the longer the absence f r o m school, the more complicated is the process of return. Added to the child's initial fears are now somewhat realistic concerns about the amount of school w o r k he has missed, the possibly u n f r i e n d l y reception by his schoolmates and the embarrassment at faeing his teacher. Moreover, he has learned to luxuriate in the e x t r a attention and solicitude his symptoms bring (the secondary gain), tie has been denied normal growth-promoting experiences at school and instead has remained in the v e r y situation which had produced his difficulty in the first instance. The fact that the adults a r o u n d him are sufficiently Marmed to agree that he is unable to leave home serves to convince the child that his fears are real. It is as though all conspire to avoid facing the actual source of the symptoms by accepting their displacement on to school. In addition, failure to insist on p r o m p t r e t u r n feeds neurotic patterns within the family itself. Mother continues to get such gratification as is provided her b y the child's clinging. I f the physician compounds the
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p r o b l e m b y r e c o m m e n d i n g a home teacher, then motivation f o r change will h a v e been considerably diminished. Once the child has a home teacher and can continue his academic progress, there is less pressure within the f a m i l y to alter a situation which has become r a t h e r comfortable. Indeed, the few failures we have experienced with e l e m e n t a r y sehool children t~ave been in those instances where u n i n f o r m e d physicians have provided medical certification for the child to remain at home. W h e n the records of a group of such children were examined several years ago in the Baltimore school system, it was found t h a t all of them had been at home for at least one year and several for as long. as 3 years at the time the survey was undertaken, la It is a co~h~mn-sense rule in dealing with fears that the sooner the individual can be p e r s u a d e d to expose
himself to the situation in which his f e a r developed, the more readily does he overcome the f e a r itself. One recalls the baseball p l a y e r who is inserted it~ the lineup i m m e d i a t e l y a f t e r he has r e c o v e r e d f r o m being' hit by a pitched ball, lest he become " b a l l s h y , " or the recolnmendation t h a t a person who has been in a driving accident t a k e the wheel as soon as he can in order not to allow a deepseated reluctance to drive to develop. This principle holds in the ease of a child with school phobia. Insisting t h a t he r e t u r n to school means to the child t h a t the physician believes him capable of returning. This provides the only effective reassurance. Before developing a specific p l a n for r e t u r n to school, one m u s t t a k e
OF P E D I A T R I C S
into aeeount the s e v e r i t y a n d duration of the syndrome. W i t h an ineipient or m e r e l y t h r e a t e n e d school phobia, firm guidance of the p a r e n t s on the necessity of r e g u l a r attendance will usually suffice to a b o r t developmetlt of a full picture. F o r a child who has r e m a i n e d out of school f o r some time, a realistic p r o g r a m m u s t be geared to the p r o b l e m he provides at school and to the strength his p a r e n t s are able to muster. The physician should communicate with the school social w o r k e r or principal. Obviously, if one is to call for forceful r e t u r n of the child to school, as m a y be necessary in some instances, the school m u s t be p r e p a r e d to follow t h r o u g h in r e t a i n i n g the child in class. I n deMing with the school, it is imp o r t a n t at the outset to establish a collaborative relationship. The teacher m a y be apprehensive t h a t the physician regards her as responsible for the child's diffleuity. She m a y feel a sense o3 guilt that she has somehow failed tile child or m a y be a n g r y t h a t he did not find her classroom sufficiently inviting to remain. I f the physician states his u n d e r s t a n d i n g of the dynamics og school phobia as a home rather than a school problem, he immediately puts school personnel at ease. W h a t the school is able to do wilI depend upon the skill and experience of t h e teacher. A new or insecure teacher, who m a y be v e r y r e l u c t a n t to receive a crying child in her classroom, should not have this b u r d e n t h r u s t u p o n her. I f one feels t h a t the ehifld is not r e a d y for i n d e p e n d e n t r e t u r n to school but should have his m o t h e r in a t t e n d a n c e for a period of adjustment, t h e n one m u s t h a v e a teaeher
EISENBERG:
M A N A G E M E N T OF S C H 0 0 I J P H O B I A
who will not find the presence of the m o t h e r in her classroom t h r e a t e n i n g to her. All of these issues should be discussed f r a n k l y with the principal or social w o r k e r and a specific p l a n for the p a r t i c u l a r ease developed. W e have not hesitated, in those instances when we felt no progress was being made by the p a r e n t s t o w a r d ret u r n i n g the child to school, to recomm e n d to the school t h a t the mat%er be b r o u g h t to the a t t e n t i o n of the Juvenile Court. I t is not t h a t we would r e c o m m e n d t h a t a child with school phobia be c o m m i t t e d to a training" school; it is r a t h e r that, for some families, it is necessary to invoke the a u t h o r i t y of the court to indicate forcefully t h a t school attendanee is compulsory. I n ahnost every instance in which we have resorted to the use of the court, the child has been b r o u g h t b y the p a r e n t s to school before the court hearing was held. The mode b y which a child is to be r e t u r n e d to school will then v a r y with o n e ' s estimate of the s e v e r i t y of the p r o b l e m and the a t t i t u d e of the parents and the school personnel. Possible w a y s of m a n a g i n g the situation v a r y f r o m simple insistence u p o n ret u r n for incipient eases to such techniques as: h a v i n g the m o t h e r r e m a i n with the child in the classroom for the first few days of r e t u r n with a schedule developed f o r her g r a d u a l w i t h d r a w a l ; h a v i n g the child r e m a i n in the p r i n c i p a l ' s or eounselor's office until he is able to a t t e n d Mass activi t y ; and h a v i n g the child visit his t e a c h e r a f t e r class is dismissed in o r d e r to get his homework. I should like to reiterate our finding t h a t placing a ehild on home teaching is a
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g r a v e e r r o r in the t r e a t m e n t of school phobia. As I(lein s pointed out, it is essential t h a t the child enter the school building itself. This their becomes the bridge to full attendance. The p / a n should be discussed fully with the child. He should be told t h a t the physician considers him able to r e t u r n and t h a t r e t u r n is obligatory. School attendance has been set b y civil a u t h o r i t y to which the physiMan m u s t defer as well as the child. The child m a y be given some choice as to the schedule by which his ret u r n is to be effectuated but he has no choice as to w h e t h e r he is to return. At the same time, discussion with the p a r e n t s should focus on their b e h a v i o r during the period it, which the child's r e t u r n is being discussed and carried out. They should be helped to recognize t h a t t h e i r own anxieties will be c o m m u n i c a t e d to the child if they themselves are not convinced of the correctness of the positiott t h e y are taking. This concept ear~ be made more m e a n i n g f u l by citing examples of their b e h a v i o r in the office and at home. A m o m e n t ' s reflection will serve to m a k e it clear that the general m e t h o d described is most easily applied to the y o u n g child whose physical beh a v i o r can be controlled b y his parents. The p r o b l e m is of an order of m a g n i t u d e several times g r e a t e r it~ the adolescent child. I t should h a r d l y need emphasis t h a t the m a n a g e m e n t of school phobia is not a m a t t e r of a single consultation. The physician m u s t be available to child and f a m i l y at r e g u l a r intervals in order to provide the supp o r t necessary during the trying' period of r e a d j u s t m e n t .
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RESULTS
F o r the purpose of this paper, all of the cases registered in our clinic between 1952 and the present have been summarized. To these cases have been added 10 seen at a specialized n u r s e r y school and an additional 10 seen in consultation elsewhere. As shown in Table I, of the 67 children, 48 were successfully r e turned to s c h o o l TABLE
I.
THEI{APEUTIC
I~ESULTS
AGE
(YEARS)
SUCCESS
FAILURE
TOTAL
Less t h a n :~1 11 and older
39 9
5 14
44 23
Total
48
19
67
A sharp distinction is evident, however, between the 44 children who were less t h a n 11 years of age at the time the diagnosis was made and the 23 who were 11 years of age and older. R o u g h l y speaking, this is the division between the elementary school and j u n i o r and senior high school levels. Of the elementary school age group, 39 or 90 per cent were successfully r e t u r n e d to school. This figure, however, underestimates the percentage of success that should be obtained. Of the 5 failures, 3 occurred in children who were certified by physicians in the c o m m u n i t y as unable to attend school, thus rendering f u r t h e r help ineffectual. I n contrast, of the 23 children of j u n i o r high school age, only 9 or 45 per cent had been successfully ret u r n e d to school at the time the survey was undertaken. A m o n g the 14 failures, there were 4 children who were schizophrenic. Seven came from families t h a t were grossly decompen-
OF P E D I A T R I C S
sated, "multiple problem" families. These children were repeating patterns of defeat and inadequacy that had been evidenced repeatedly by either one or both parents. The sharp contrast in results between the elementary and the high school age groups indicates t h a t the adolescent with school phobia is not a suitable problem for pediatric management but requires referral to a psychiatric clinic. This is evident not only from the s t u d y of clinical results but from review of the patients themselves. These children were far more disturbed t h a n the y o u n g e r group, who were reacting to c u r r e n t family situations. I n the adolescents, the symptoms reflected a severe disturbance of psychological structure resalting from years of exposure to a distorted family environment. 17 W e might then revise our diagnostic and therapeutic appraisM with these findings in mind. School phobia is a syndrome but not a disease in itself. It is a symptomatic manifestation of an emotional disturbance which m a y vary from a situational reaction to a severe character neurosis or even a psychosis. 11, 13, 14, 17 F o r the severely disturbed adolescent, extensive p s y c h o t h e r a p e u t i c w o r k is required if a successful result is to be obtained,. I t m a y be a r g u e d that psychiatric or pediatric first aid for the element a r y school child m i g h t result in disappearance of the symptoms but leave the basic pathological problem untouched. I f this, be true, one would anticipate a recurrence of the school phobia or a substitution of other psychiatric symptoms. I n o r d e r to assess
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this question, we obtained follow-up i n f o r m a t i o n on all cases seen at o u r clinic between the y e a r s 1952 and 19572 There w e r e no eases Iost to the study. The a v e r a g e duration of the follow-up period was 3 y e a r s a n d v a r i e d f r o m 15 m o n t h s to 6 years. Table I I presents our findings. TABLE II. OUTC01V[EoP 41 CASES OF SC~mOL PHOBIA FOLLOWED FOI~ AN AVERAGE PERIOD 0~ 3 YEARS AGE ( YEAItS)
ATTENDING UNABLETO TOTAL SCH00L ATTEND REGULARLY REGULAt~LY
Less than 11 11 and older
24 5
3 9
27 14
Total
29
12
45
As can be seen, the results are essentially the smue as those obtained at the time t r e a t m e n t was t e r m i n a t e d . The 29 successful cases were w i t h o u t m a j o r difficulties as j u d g e d b y reports f r o m t h e i r p a r e n t s and schools. Three of the children exhibited some academic difficulties; 2 of these h a d I.Q.'s in the 85-90 range. Three others h a d become aggressive r a t h e r t h a n f e a r f u l or w i t h d r a w n . W e cannot say w h a t these p a t i e n t s will be like 10 or 15 y e a r s f r o m the p r e s e n t but at least over the follow-up period the results a p p e a r to be enduring. There has been no indication of sympt o m substitution of m a g n i t u d e sufficient to suggest t h a t the t h e r a p e u t i c emphasis had been incorrect. These resuits become u n d e r s t a n d a ble w h e n we recognize how m a j o r an accomplishment it is to enable a child a f r a i d of school to r e t u r n a n d overcome his difficulty. H i s pathological dependence on his p a r e n t s has been diminished. His p a r e n t s h a v e b e e n
765
enabled to p e r m i t h i m to resume a more n o r m a l life as t h e y h a v e t u r n e d to a more g r a t i f y i n g relationship w i t h him. He has h a d the opport u n i t y of i n t e r a c t i o n with his peer group. I n essence, w h a t has been aceomplished is t h a t his g r o w t h potentim has been allowed to flower. Is this not the v e r y process b y which most normal children, all of w h o m have difficulties to overcome in the course of life, move on to g r e a t e r m a t u r a tion? The striving f o r health, given a r e a s o n a b l y challenging environ~ ment, is a potent t h e r a p e u t i c factor in the h a n d s of the p h y s i c i a n skilled in its guidance. l~EFERENCES 1. May, C. I).: Can the New Pediatrics Be Practiced? (Editorial)~ Pediatrics 23: 253, 1959. (Discussed in L e t t e r s to the Editor, Ibid. 23: 1005, 1959.) 2. Kanner, L., and Eisenberg, L.: Childhood Problems in Igelation to the Farofly, P e d i a t r i c s 20: 155, 1957. 3. Eisenberg, L.: The Parent-Child Rela. ship and the Physician, A. N . A. J. Dis. Children 91: 153, 1956. 4. Eisenberg, L.: Progress in Neuropsyehiatry, J. PEDIAT. 5.1: 331, 1957. 5. Rodxdguez, A., Rodriguez, M., and Risen berg~ L.: The Outcome of School Phobia, Am. J. Psyehiat. In Press. 6. Eisenberg, L. : School Phobia: A Study in the Communication of Anxiety, Am. J. Psyehiat. 114: 712, 1958. 7. Johnson, A. 1VL, et al.: School Phobia, Am. J. Orthopsychiat. 11: 702, 1941. 8. Klein, E.: The Reluctance to. Go to School. In Freud, A., I-~artmann, H., and Kris, E , editors: Psychoanalytic Study of the Child, New York, 1945, I n t e r n a t i o n a l Universities Press, I n c , vol. 1, p. 263. 9. Eisenberg, L.: School Phobia: Diagnosis, Genesis and Clinical Management, Pediat. Clin. N o r t h America, pp. 645666, 1958. 10. Estes, K. R., Haylett~ C. H., and J o h n son, A. 3/[.: Separation Anxiety, Am. J. Psychotherap. 10: 682, 1956. 11. Coolidge, J. C., et al.: School Phobia: Neurotic Crisis or Way of Life, Am. J. Orthopsychiat. 27: 296, 1957. 12. Suttenfi~ld, V.: School Phobia: A Study of Five Cases, Am. J. Orthopsychiat. 24: 368, 1954.
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13. Talbott, IV[.: Panic and School Phobia~ Am. J. Orthopsychiat. 27: 286~ ]957. 14. Waldfogel, S.: Family Relations in the I)eve]opment of School Phobia~ Am. J. Orthopsychiat. 27: 754, 1957. 15. Glaser, I~i.: Problems in School Attendance, P e d i a t r i c s 23: 371~ 1959.
16. Hardy, J.B.: Personal Communication. 17. Coolidge, J. C., et al.: School Phobia in Adolescence--Ai~Vianifestation of a Severe Character ]Disturbance. Presented at the American Orthopsychiatric Associationt San Francisco~ April, 1959.
I
l~rom the Johns Hopkins University School of Medicine and the Johns Hopkins Hospital Presented at the Ninth International Congress of Paediatrics, Montreal, Canada, July 23, 1959, in S e c t i o n I V : "Psychiatry in Pediatric Clinics,"
b r e a k d o w n has occurred. His contribution to prevention, both p r i m a r y and secondary, will depend u p o n his success in communicating to his pediatric colleagues such useful information as m a y be employed appropriately in office and clinic practiceY -4 THE PROBLEM
The child with school phobia has a dread of attending school, a dread which has no a p p a r e n t justification in his school experience. E v e n in the instances in which an unpleasant school encounter m a y be related to the precipitation of the syndrome, the experience is likely to have been one to which other children have been exposed with, at most, only t e m p o r a r y distress. Moreover, efforts to change teacher, class, or school r e g u l a r l y prove ineffectual in relieving the symptoms. The fear of school m a y not be at all overt. The presenting complMnt may consist of any one of a wide v a r i e t y of somatic symptoms, whose distinguishing features a~'e their early morning onset, p r o m p t subsidence as school attendance is avoided, and singular absence on holidays. The ehild with school phobia is not, let me make it d e a r , a truant. The t r u a n t dislikes school, has usually been an indifferent seholar, and starts out as if to go to class, only to spend the day roaming the streets. He is 758
EISENBERG:
MANAGEMENT
likely to compound his felony by ingenious devices to conceal his failure to attend. The child with school phobia, on the contrary, is almost always a good student, is f r e q u e n t l y a model of d e p o r t m e n t and has vocational goals for which schooling is required.* R a t h e r t h a n concealing his difficulty in school attendance f r o m his parents, he alarms them with his dismay and turns to them f o r solace. Most often, he will refuse to leave his home during school hours for fear his disability will become k n o w n to the neighbors. How, then, are we to u n d e r s t a n d this paradoxical behavior.~ The answer becomes a p p a r e n t when we extend our observation to the family as well as the child. A s t u d y of the behavior of mothers of such children in a specialized n u r s e r y school revealed in striking fashion t h a t the mothers clung to their children even more desperately t h a n the children to them. 6 They h o v e r e d in constant attendance, i n t r u d e d themselves on various pretexts into the children's play, resisted the teachers' efforts to ease them out of the playroom, and offered f r e q u e n t and uncalled for " r e a s s u r a n c e " to the children. It was not uncommon to note a child happily engaged with his group, r a t h e r unconcerned when m o t h e r announced that she was about to leave, until her unnecessarily prolonged and tearful good-byes let him know he was expected to cry. Once she left, he could usually be induced to d r y his tears and re-enter the group activity. His mother, during the same period, * I n a s u r v e y o f 41 c h i l d r e n w i t h s c h o o l phobia, we found that none were defective, l e s s t h a n o n e t e n t h w e r e o f dull n o r m a l intelligen,ce, a n d h a l f w e r e in t h e b r i g h t to s u p e r i o r r a n g e o,f i n t e l l i g e n c e . ~
OF S C H O O L P H O B I A
759
was observed b y the social w o r k e r to be pacing about f r e t f u l l y in the waiting room, unable to be convinced that he would survive her absence. Clearly, then, the basic issue is not going to the school, but leaving mother. We are dealing, not so much with a phobia, as with a n x i e t y about separationJ -9 This is most readily evident from direct observation in the n u r s e r y school but can be confirmed for older children by taking note of mother-child interaction iu the clinic waiting room and b y detailed questioning about family behavior during the separation process2 This defines the crucial therapeutic task: to enable child and family to liberate themselves from excessively close ties that stifle emotional growth. But before we consider t r e a t m e n t procedures, let us first ask ourselves w h y this r a t h e r remarkable behavior exists. A f t e r all, the m o t h e r has summoned the physician because she is distressed by her child's inability to leave her for school. How are we to believe that she is causing him to remain at home? I t should no longer surprise us to discover t h a t eon.trary motivations can exist at one and the same time within both mother and child. Recognition and understanding of this ambivalence are necessary if we are to be of assistance in correcting the problems it produces. The mother, on the one hand, wishes her child to develop normally, to attend school, and to overcome his fears. O n the other, she needs his close a t t a c h m e n t to her. She mistakes his clinging for a demonstration of love. ~She, too, is afraid, just as he is afraid, that some u n n a m e d catastrophe is impending. She calls in the physician because she recognizes
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t h a t her child's b e h a v i o r is a b n o r m a l - - b u t also because she is becoming resentful of the demands f o r her cons t a n t presence. The child's s y m p t o m s are comprehensible as his response to his mothe r ' s a m b i v a l e n t motivations. She m a y offer verbal r e a s s u r a n c e t h a t there is n o t h i n g to f e a r b u t does so in a t r e m u l o u s voice t h a t conveys her own anxiety. She " i n s i s t s " he leave for school b u t does so in an unconvincing m a n n e r ; her indecisive movements and her q u a v e r i n g voice m a k e it clear that, really, he need not. I t e r anxious questions about h o w he feels offer him the clue t h a t if he but complain of being" ill, he witl not h a v e to face the d r e a d e d s e p a r a t i o n f r o m mother. W h y do these m o t h e r s - - o r , in some instances, f a t h e r s - - n e e d t h e i r child r e n so closely tied to t h e m ? The pathogenesis of s y m p t o m f o r m a t i o n m a y be r a t h e r stereotyped, as a l r e a d y indicated, but the u n d e r l y i n g causes are as complex and i n t r i g u i n g as the h u m a n situation itself. The reasons will v a r y for each ease and can be elicited only b y s y m p a t h e t i c and pereeptive inquiry. I can b u t allude, in oversimplified fashion, to a few representative ease i l h s t r a t i o n s : B a r b a r a was b o r n late in a childless m a r r i a g e , a f t e r five p r e c e d i n g miscarriages. She w a s all h e r m o t h e r h a d so Iong sought and all she was likely ever to have. H e r m o t h e r ' s coddling and constant caution a b o u t her s a f e t y created in B a r b a r a a morbid p r e o c c u p a t i o n with ilIness and injury. Sheila became her m o t h e r ' s " s p e c i a l " child w h e n she was b o r n shortly a f t e r the m a t e r n a l g r a n d m o t h e r ' s sudden death. I t was h e r b u r d e n to filI an a c h i n g void. The symbiosis
OF P E D I A T R I C S
between mother and Sheila was idyllic until mother took her first vaeation away from her daughter. Sheila could not be gotten to school while her mother was away. A delay at the airport in the arrival of the plane bringing mother home sent the child into a panic. Once mother arrived, Sheila clang to her avidly, fearing for her safety, and retaliating for being abandoned. Mother was immobilized by her guilt at having left her daughter. i~{rs. L. resented Allan's presence; his arrival had sealed the eompaet of a bitterly disappointing marriage. I{er anger toward him was ineompatible w i t h her conscious ideals of motherhood. As a visible b a d g e of her love, she s u r r o u n d e d him w i t h a suffocating eloud of overproteetion. H e r fears f o r his s a f e t y were the projections of her own hostile impulses. H e r frenzied a t t e n t i o n created in Allan an insatiable appetite f o r p r o o f of her devotion; his d e m a n d s drove her to a n g r y o u t b u r s t s which frightened both of t h e m b y t h e i r enormity. Allan could not t r u s t h e r out of his sight f o r f e a r she m i g h t not r e t u r n ; he punished her b y d e m a n d i n g complete subservience to his whims. iVir. R. relived t h r o u g h P e t e r the unresolved issues of his t r o u b l e d childhood. He t r i e d to experience vicariously, b y p r o v i d i n g it to his son, the ideM f a t h e r i n g he so avidly c r a v e d and h a d n e v e r received. So close were the bonds t h a t w h e n P e t e r complained of nausea, his f a t h e r vomited. P e t e r had learned a d r o i t l y to m a n i p u l a t e his f a t h e r b y simulating illness to avoid u n p l e a s a n t responsibilities. Philip had become the sole source of satisfaction in his m o t h e r ' s e m p t y marriage. Seduced b y her constant hovering, he h a d a b a n d o n e d a n y interests outside the home. As he app r o a c h e d adolescence, he became acutely anxious at the first dim perception of the erotic elements in their love relationship.
EISENBEtgG:
I V [ A N A G E M E N T OF S C H O O L P t t O B I A
Examples could be multiplied. B u t perhaps the few cited will serve to illustrate the range and complexity of the h u m a n issues involved. More detailed case studies r e p o r t e d in the literature should be consulted to supp]ement these necessarily abbreviated vignettes2 -~ TREATMENT
I t cannot be emphasized too strongly t h a t t r e a t m e n t begins with a searching diagnostic evaluation. A careful history and a t h o r o u g h physical examination will in most instances suffice to indicate to the physician t h a t he is dealing with a school phobia; in some cases, however, special diagnostic procedures will be necessary before organic p a t h o l o g y can be exeludedP Once he has established to his own satisfaction that the symptoms are those of school phobia, the pediatrician must seek to identify the m a j o r issues in family life that have given rise to the symptoms, if he is to develop a plan to i n t e r r u p t the pathological cycles and to support the healthy trends in parents and child. This need not require a psychiatrist in most instances. The pediatrician usually has some prior knowledge of the family; he has a considerable asset in the positive expectations the family bring to him as the physician who has t r e a t e d other illnesses successfully. A sensitive and interested inquiry, based on familiarity with the issues likely to be found, will lead to the identification of the central conflicts. *Positive , evidence of psychopathology does not rule out the p o s s i b i l i t y of a conc u r r e n t o r g a n i c lesion. To take a recent example, an obviously d i s t u r b e d child w i t h recurrent abdominal pain was referred for psychiatric treatment; pediatric workup and subsequent operation revealed hydronephros i s s e c o n d a r y to u r e t e r M o b s t r u c t i o n .
761
With diagnosis established, the central focus in m a n a g e m e n t is p r o m p t return to school. This may seem at first glance a hazardous und e r t a k i n g with a child who displays panic at the prospect of r e t u r n i n g to school. The physician, no less than the family, ntay f e a r the precipitation of an acute breakdown. In fact, however, this does not occur with adequate support to child and family. The reasons for this therapeutic emphasis and its success require discussion. To begin with, the longer the absence f r o m school, the more complicated is the process of return. Added to the child's initial fears are now somewhat realistic concerns about the amount of school w o r k he has missed, the possibly u n f r i e n d l y reception by his schoolmates and the embarrassment at faeing his teacher. Moreover, he has learned to luxuriate in the e x t r a attention and solicitude his symptoms bring (the secondary gain), tie has been denied normal growth-promoting experiences at school and instead has remained in the v e r y situation which had produced his difficulty in the first instance. The fact that the adults a r o u n d him are sufficiently Marmed to agree that he is unable to leave home serves to convince the child that his fears are real. It is as though all conspire to avoid facing the actual source of the symptoms by accepting their displacement on to school. In addition, failure to insist on p r o m p t r e t u r n feeds neurotic patterns within the family itself. Mother continues to get such gratification as is provided her b y the child's clinging. I f the physician compounds the
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p r o b l e m b y r e c o m m e n d i n g a home teacher, then motivation f o r change will h a v e been considerably diminished. Once the child has a home teacher and can continue his academic progress, there is less pressure within the f a m i l y to alter a situation which has become r a t h e r comfortable. Indeed, the few failures we have experienced with e l e m e n t a r y sehool children t~ave been in those instances where u n i n f o r m e d physicians have provided medical certification for the child to remain at home. W h e n the records of a group of such children were examined several years ago in the Baltimore school system, it was found t h a t all of them had been at home for at least one year and several for as long. as 3 years at the time the survey was undertaken, la It is a co~h~mn-sense rule in dealing with fears that the sooner the individual can be p e r s u a d e d to expose
himself to the situation in which his f e a r developed, the more readily does he overcome the f e a r itself. One recalls the baseball p l a y e r who is inserted it~ the lineup i m m e d i a t e l y a f t e r he has r e c o v e r e d f r o m being' hit by a pitched ball, lest he become " b a l l s h y , " or the recolnmendation t h a t a person who has been in a driving accident t a k e the wheel as soon as he can in order not to allow a deepseated reluctance to drive to develop. This principle holds in the ease of a child with school phobia. Insisting t h a t he r e t u r n to school means to the child t h a t the physician believes him capable of returning. This provides the only effective reassurance. Before developing a specific p l a n for r e t u r n to school, one m u s t t a k e
OF P E D I A T R I C S
into aeeount the s e v e r i t y a n d duration of the syndrome. W i t h an ineipient or m e r e l y t h r e a t e n e d school phobia, firm guidance of the p a r e n t s on the necessity of r e g u l a r attendance will usually suffice to a b o r t developmetlt of a full picture. F o r a child who has r e m a i n e d out of school f o r some time, a realistic p r o g r a m m u s t be geared to the p r o b l e m he provides at school and to the strength his p a r e n t s are able to muster. The physician should communicate with the school social w o r k e r or principal. Obviously, if one is to call for forceful r e t u r n of the child to school, as m a y be necessary in some instances, the school m u s t be p r e p a r e d to follow t h r o u g h in r e t a i n i n g the child in class. I n deMing with the school, it is imp o r t a n t at the outset to establish a collaborative relationship. The teacher m a y be apprehensive t h a t the physician regards her as responsible for the child's diffleuity. She m a y feel a sense o3 guilt that she has somehow failed tile child or m a y be a n g r y t h a t he did not find her classroom sufficiently inviting to remain. I f the physician states his u n d e r s t a n d i n g of the dynamics og school phobia as a home rather than a school problem, he immediately puts school personnel at ease. W h a t the school is able to do wilI depend upon the skill and experience of t h e teacher. A new or insecure teacher, who m a y be v e r y r e l u c t a n t to receive a crying child in her classroom, should not have this b u r d e n t h r u s t u p o n her. I f one feels t h a t the ehifld is not r e a d y for i n d e p e n d e n t r e t u r n to school but should have his m o t h e r in a t t e n d a n c e for a period of adjustment, t h e n one m u s t h a v e a teaeher
EISENBERG:
M A N A G E M E N T OF S C H 0 0 I J P H O B I A
who will not find the presence of the m o t h e r in her classroom t h r e a t e n i n g to her. All of these issues should be discussed f r a n k l y with the principal or social w o r k e r and a specific p l a n for the p a r t i c u l a r ease developed. W e have not hesitated, in those instances when we felt no progress was being made by the p a r e n t s t o w a r d ret u r n i n g the child to school, to recomm e n d to the school t h a t the mat%er be b r o u g h t to the a t t e n t i o n of the Juvenile Court. I t is not t h a t we would r e c o m m e n d t h a t a child with school phobia be c o m m i t t e d to a training" school; it is r a t h e r that, for some families, it is necessary to invoke the a u t h o r i t y of the court to indicate forcefully t h a t school attendanee is compulsory. I n ahnost every instance in which we have resorted to the use of the court, the child has been b r o u g h t b y the p a r e n t s to school before the court hearing was held. The mode b y which a child is to be r e t u r n e d to school will then v a r y with o n e ' s estimate of the s e v e r i t y of the p r o b l e m and the a t t i t u d e of the parents and the school personnel. Possible w a y s of m a n a g i n g the situation v a r y f r o m simple insistence u p o n ret u r n for incipient eases to such techniques as: h a v i n g the m o t h e r r e m a i n with the child in the classroom for the first few days of r e t u r n with a schedule developed f o r her g r a d u a l w i t h d r a w a l ; h a v i n g the child r e m a i n in the p r i n c i p a l ' s or eounselor's office until he is able to a t t e n d Mass activi t y ; and h a v i n g the child visit his t e a c h e r a f t e r class is dismissed in o r d e r to get his homework. I should like to reiterate our finding t h a t placing a ehild on home teaching is a
763
g r a v e e r r o r in the t r e a t m e n t of school phobia. As I(lein s pointed out, it is essential t h a t the child enter the school building itself. This their becomes the bridge to full attendance. The p / a n should be discussed fully with the child. He should be told t h a t the physician considers him able to r e t u r n and t h a t r e t u r n is obligatory. School attendance has been set b y civil a u t h o r i t y to which the physiMan m u s t defer as well as the child. The child m a y be given some choice as to the schedule by which his ret u r n is to be effectuated but he has no choice as to w h e t h e r he is to return. At the same time, discussion with the p a r e n t s should focus on their b e h a v i o r during the period it, which the child's r e t u r n is being discussed and carried out. They should be helped to recognize t h a t t h e i r own anxieties will be c o m m u n i c a t e d to the child if they themselves are not convinced of the correctness of the positiott t h e y are taking. This concept ear~ be made more m e a n i n g f u l by citing examples of their b e h a v i o r in the office and at home. A m o m e n t ' s reflection will serve to m a k e it clear that the general m e t h o d described is most easily applied to the y o u n g child whose physical beh a v i o r can be controlled b y his parents. The p r o b l e m is of an order of m a g n i t u d e several times g r e a t e r it~ the adolescent child. I t should h a r d l y need emphasis t h a t the m a n a g e m e n t of school phobia is not a m a t t e r of a single consultation. The physician m u s t be available to child and f a m i l y at r e g u l a r intervals in order to provide the supp o r t necessary during the trying' period of r e a d j u s t m e n t .
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RESULTS
F o r the purpose of this paper, all of the cases registered in our clinic between 1952 and the present have been summarized. To these cases have been added 10 seen at a specialized n u r s e r y school and an additional 10 seen in consultation elsewhere. As shown in Table I, of the 67 children, 48 were successfully r e turned to s c h o o l TABLE
I.
THEI{APEUTIC
I~ESULTS
AGE
(YEARS)
SUCCESS
FAILURE
TOTAL
Less t h a n :~1 11 and older
39 9
5 14
44 23
Total
48
19
67
A sharp distinction is evident, however, between the 44 children who were less t h a n 11 years of age at the time the diagnosis was made and the 23 who were 11 years of age and older. R o u g h l y speaking, this is the division between the elementary school and j u n i o r and senior high school levels. Of the elementary school age group, 39 or 90 per cent were successfully r e t u r n e d to school. This figure, however, underestimates the percentage of success that should be obtained. Of the 5 failures, 3 occurred in children who were certified by physicians in the c o m m u n i t y as unable to attend school, thus rendering f u r t h e r help ineffectual. I n contrast, of the 23 children of j u n i o r high school age, only 9 or 45 per cent had been successfully ret u r n e d to school at the time the survey was undertaken. A m o n g the 14 failures, there were 4 children who were schizophrenic. Seven came from families t h a t were grossly decompen-
OF P E D I A T R I C S
sated, "multiple problem" families. These children were repeating patterns of defeat and inadequacy that had been evidenced repeatedly by either one or both parents. The sharp contrast in results between the elementary and the high school age groups indicates t h a t the adolescent with school phobia is not a suitable problem for pediatric management but requires referral to a psychiatric clinic. This is evident not only from the s t u d y of clinical results but from review of the patients themselves. These children were far more disturbed t h a n the y o u n g e r group, who were reacting to c u r r e n t family situations. I n the adolescents, the symptoms reflected a severe disturbance of psychological structure resalting from years of exposure to a distorted family environment. 17 W e might then revise our diagnostic and therapeutic appraisM with these findings in mind. School phobia is a syndrome but not a disease in itself. It is a symptomatic manifestation of an emotional disturbance which m a y vary from a situational reaction to a severe character neurosis or even a psychosis. 11, 13, 14, 17 F o r the severely disturbed adolescent, extensive p s y c h o t h e r a p e u t i c w o r k is required if a successful result is to be obtained,. I t m a y be a r g u e d that psychiatric or pediatric first aid for the element a r y school child m i g h t result in disappearance of the symptoms but leave the basic pathological problem untouched. I f this, be true, one would anticipate a recurrence of the school phobia or a substitution of other psychiatric symptoms. I n o r d e r to assess
EISENBERG:
MANAGEMENT OF SCHOOL PHOBIA
this question, we obtained follow-up i n f o r m a t i o n on all cases seen at o u r clinic between the y e a r s 1952 and 19572 There w e r e no eases Iost to the study. The a v e r a g e duration of the follow-up period was 3 y e a r s a n d v a r i e d f r o m 15 m o n t h s to 6 years. Table I I presents our findings. TABLE II. OUTC01V[EoP 41 CASES OF SC~mOL PHOBIA FOLLOWED FOI~ AN AVERAGE PERIOD 0~ 3 YEARS AGE ( YEAItS)
ATTENDING UNABLETO TOTAL SCH00L ATTEND REGULARLY REGULAt~LY
Less than 11 11 and older
24 5
3 9
27 14
Total
29
12
45
As can be seen, the results are essentially the smue as those obtained at the time t r e a t m e n t was t e r m i n a t e d . The 29 successful cases were w i t h o u t m a j o r difficulties as j u d g e d b y reports f r o m t h e i r p a r e n t s and schools. Three of the children exhibited some academic difficulties; 2 of these h a d I.Q.'s in the 85-90 range. Three others h a d become aggressive r a t h e r t h a n f e a r f u l or w i t h d r a w n . W e cannot say w h a t these p a t i e n t s will be like 10 or 15 y e a r s f r o m the p r e s e n t but at least over the follow-up period the results a p p e a r to be enduring. There has been no indication of sympt o m substitution of m a g n i t u d e sufficient to suggest t h a t the t h e r a p e u t i c emphasis had been incorrect. These resuits become u n d e r s t a n d a ble w h e n we recognize how m a j o r an accomplishment it is to enable a child a f r a i d of school to r e t u r n a n d overcome his difficulty. H i s pathological dependence on his p a r e n t s has been diminished. His p a r e n t s h a v e b e e n
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enabled to p e r m i t h i m to resume a more n o r m a l life as t h e y h a v e t u r n e d to a more g r a t i f y i n g relationship w i t h him. He has h a d the opport u n i t y of i n t e r a c t i o n with his peer group. I n essence, w h a t has been aceomplished is t h a t his g r o w t h potentim has been allowed to flower. Is this not the v e r y process b y which most normal children, all of w h o m have difficulties to overcome in the course of life, move on to g r e a t e r m a t u r a tion? The striving f o r health, given a r e a s o n a b l y challenging environ~ ment, is a potent t h e r a p e u t i c factor in the h a n d s of the p h y s i c i a n skilled in its guidance. l~EFERENCES 1. May, C. I).: Can the New Pediatrics Be Practiced? (Editorial)~ Pediatrics 23: 253, 1959. (Discussed in L e t t e r s to the Editor, Ibid. 23: 1005, 1959.) 2. Kanner, L., and Eisenberg, L.: Childhood Problems in Igelation to the Farofly, P e d i a t r i c s 20: 155, 1957. 3. Eisenberg, L.: The Parent-Child Rela. ship and the Physician, A. N . A. J. Dis. Children 91: 153, 1956. 4. Eisenberg, L.: Progress in Neuropsyehiatry, J. PEDIAT. 5.1: 331, 1957. 5. Rodxdguez, A., Rodriguez, M., and Risen berg~ L.: The Outcome of School Phobia, Am. J. Psyehiat. In Press. 6. Eisenberg, L. : School Phobia: A Study in the Communication of Anxiety, Am. J. Psyehiat. 114: 712, 1958. 7. Johnson, A. 1VL, et al.: School Phobia, Am. J. Orthopsychiat. 11: 702, 1941. 8. Klein, E.: The Reluctance to. Go to School. In Freud, A., I-~artmann, H., and Kris, E , editors: Psychoanalytic Study of the Child, New York, 1945, I n t e r n a t i o n a l Universities Press, I n c , vol. 1, p. 263. 9. Eisenberg, L.: School Phobia: Diagnosis, Genesis and Clinical Management, Pediat. Clin. N o r t h America, pp. 645666, 1958. 10. Estes, K. R., Haylett~ C. H., and J o h n son, A. 3/[.: Separation Anxiety, Am. J. Psychotherap. 10: 682, 1956. 11. Coolidge, J. C., et al.: School Phobia: Neurotic Crisis or Way of Life, Am. J. Orthopsychiat. 27: 296, 1957. 12. Suttenfi~ld, V.: School Phobia: A Study of Five Cases, Am. J. Orthopsychiat. 24: 368, 1954.
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13. Talbott, IV[.: Panic and School Phobia~ Am. J. Orthopsychiat. 27: 286~ ]957. 14. Waldfogel, S.: Family Relations in the I)eve]opment of School Phobia~ Am. J. Orthopsychiat. 27: 754, 1957. 15. Glaser, I~i.: Problems in School Attendance, P e d i a t r i c s 23: 371~ 1959.
16. Hardy, J.B.: Personal Communication. 17. Coolidge, J. C., et al.: School Phobia in Adolescence--Ai~Vianifestation of a Severe Character ]Disturbance. Presented at the American Orthopsychiatric Associationt San Francisco~ April, 1959.