When the school desk presses

When the teacher called him an airhead in front of the whole class, Thomas had finally had enough. The eight-year-old ran straight home from class to his mum and vowed not to return to school. And so it came to pass. He never attended any of the usual educational institutions again - neither the village school nor a grammar school or even a university - and yet he became one of the most brilliant inventors of all time: Thomas Alva Edison (1847-1931).
Many children would be happy if their mothers took Mrs Edison as an example and simply accepted their refusal to go to school. However, the parents would not be doing them any favours by sending them away from school. Apart from the fact that home schooling is not even permitted in Germany and some Swiss cantons, a career from dishwasher to millionaire à la Edison remains a pipe dream - even in countries such as the USA or Austria, where schooling is compulsory instead of compulsory. In Switzerland, not everyone who wants to can teach their children at home. Each canton has different requirements. In the canton of Zurich, you have to be a qualified teacher, while in Ticino it is not allowed at all. In Bern, Aargau, Vaud and Appenzell Ausserrhoden, parents without a teaching qualification are also allowed to teach.

An estimated five to ten per cent of all children and young people in Germany suffer from general school anxiety. This corresponds to 600,000 to 1.2 million pupils. In Switzerland, according to a 2009 study, one in ten children do not want to go to school because they are afraid of the pressure to perform and bullying - and the trend is rising. Overall, more boys than girls are affected. The phenomenon is particularly common among children who move from kindergarten to primary school and later to secondary school. Not everyone copes easily with a new phase of life and new challenges.

Even children with above-average intelligence suffer from school anxiety.

Numerous studies on adolescent health from recent years agree that parents are only partially aware of their children's complaints and problems. In order to understand why a child does not want to go to school, it must first be clarified what exactly they are afraid of. Psychologists make a fundamental distinction between school anxiety, where the school itself is the trigger for the avoidance behaviour, and school phobia. In the latter case, the school itself only plays a subordinate role. Instead, the affected child fears leaving their most important attachment figure. Two thirds of children who suffer from separation anxiety stubbornly refuse to go to school. Unlike in the case of school anxiety or truancy, learning blocks, discipline problems or lack of concentration do not usually play a role. In practice, mixed forms are often found.
School phobia does not stop affected children from doing their homework, preparing their work and packing their satchels in the evening. However, they often turn back on the way to school because they perceive the separation from their primary carer as threatening. They can also develop psychosomatic complaints such as nausea, headaches or diarrhoea. As soon as they are back with mum or dad, the symptoms subside.

Too much care can be harmful

Children and adolescents with separation anxiety tend to be sensitive and anxious. They fear illness or death and often suffer from nightmares in which they are left alone. They appear shy and introverted when interacting with other children. At the same time, they can be extremely demanding or even aggressive towards their parents.

Panic separation anxiety is often a result of problematic family constellations or traumatic losses, for example due to parental divorce. However, too close an attachment to the carer can also prevent a child from becoming emotionally independent. Many children with school phobia were simply overprotected in their early years. In more than 80 per cent of cases, these are only children or first-borns, according to a study conducted by the University of Cologne in 2004. It is not uncommon for the mother to suffer from separation anxiety, which she then passes on to her son or daughter. Other children were expected to take on a lot of responsibility in the family at a very early age, causing them to worry about sick or stressed parents.

In order to get a budding school phobia under control, the child should go to school regularly again as soon as possible. This will teach them that nothing happens to mum when I'm not there - and nothing happens to me either. Parents need to understand that they are doing their children a favour in the long term if they send them to school despite feeling unwell. Their increased anxiety, on the other hand, makes it more difficult for children to overcome their own fear.

Various long-term studies from recent years, such as the study by Hellen Egger from Duke University in Durham, North Carolina, published in 2003, have shown that early treatment is not only important so that the child has the chance to do well at school. There is more to it: those who fail to overcome acute separation anxiety in childhood and adolescence are three times more likely to develop another mental illness as an adult, such as panic disorder or depression.

To prevent this from happening in the first place, however, parents should be consistent about school attendance from the outset - even if it is difficult. A very clingy child should be accompanied to school by friends rather than mum or dad. If a child only complains of a stomach ache or headache in the morning, school should not simply be cancelled.

What can parents of children with school anxiety do? Above all, remain consistent.

After the lesson, parents should discuss the issue again calmly at home so that the pupil learns that the pain was actually for no reason. Even if there were problems in the morning, the child deserves recognition if he or she has coped with the school day! Above all, however, it is important to take their strong need for closeness and security seriously and to check whether they are still dependent in other areas of life. If necessary, it may be advisable to involve a counsellor or school psychologist.

But what to do if a child simply cannot be persuaded to attend school? Advanced school phobia can only be cured through individual psychotherapy, usually in combination with family therapy. In very rare cases, drug treatment may also be necessary - for example, if a young person is not only suffering from separation from their carer, but also from severe depression. Antidepressants that affect the serotonin metabolism have proven to be effective in this case. Serotonin is a messenger substance in the brain that has a significant influence on mood. However, these drugs are not suitable for younger children in the vast majority of cases.

If the situation does not improve despite outpatient treatment, inpatient treatment may be considered in rare cases. This makes it possible to analyse the clinical picture even more comprehensively and to re-learn school attendance, initially in a hospital school. Various international studies report good prognoses for the further educational and professional careers of those affected. According to projections by Wolfgang Oelsner, Head of the Hospital School of Child and Adolescent Psychiatry at Cologne University Hospital, around three quarters of hospitalised children and adolescents overcome their fears permanently. Most importantly, however, the earlier the problem is recognised and treated, the better the chances of recovery.

«Don't be too busy!»

In contrast to phobia, school anxiety is specifically directed at what Erich Kästner (1899-1974) called the «children's barracks». The writer knew the fear of teaching from his own experience. He never forgot, he wrote, how queasy he felt when he himself sat in school for the first time, «in that grey, much too big anchor stone construction kit». With this confession, Kästner wanted to encourage new school cadets - because a certain amount of anxiety is normal: one in two children sometimes find everyday school situations threatening. Anxiety only becomes a problem when children can no longer control it.

«Don't be too diligent!», Kästner advises schoolchildren - and hits the nail on the head: because in most cases, school anxiety hides the fear of failure. It is not uncommon for over-ambitious parents who are determined to see their child at school to be to blame.
It's not just excessive demands that take the fun out of lessons. More and more children are suffering from anxiety about school, even though they have above-average intelligence. An overly strict upbringing, comparison with better siblings or even neglect and a lack of interest in academic success on the part of parents lead to a child feeling inferior and losing self-confidence. In addition to parental expectations and choosing the wrong type of school, various other factors can come into play here: a prolonged illness, a lack of praise, but also an unrecognised reading, spelling or arithmetic disability.

Sometimes children and young people have simply not learnt to prepare for exams effectively and in good time. They expect to fail exams in advance, worry about teachers' expectations and tend to make extremely pessimistic assumptions: «I'm not good enough.» - «The others can do everything better.» They are often not afraid of the actual exam situation, but of the threat of failure. The children and young people seem depressed, despondent and sometimes desperate. Nausea or diarrhoea on the day of a class test, sleep or concentration problems as well as social withdrawal, daydreaming and dawdling are typical signs.

According to a study by Gail A. Bernstein from the University of Minnesota, almost 30 per cent of children with school anxiety suffer not only from performance anxiety, but also from social anxiety. Shame, embarrassment and the worry of making a fool of themselves dominate the emotional world of these boys and girls. Because socially anxious children do not react appropriately to ridicule or physical violence, they are more often than average victims of bullying by classmates or teachers.

Because anxiety arises in the context of school, it must also be unlearned there. Parents are therefore not doing their distressed children any good if they write them an apology out of pity - in reality, however, most of them fail to do so with the consent of their father or mother. This supports the avoidance behaviour and reinforces the vicious circle. Affected parents need a lot of patience. The best way to help your child is to remain consistent without scolding. As with school phobia, praise and lots of encouragement are the best home remedies!

«When the homework is asked, I've got everything wrong again anyway.»

Morning fear monologue in the minds of affected children

Cognitive behavioural therapy is advisable for both acute learning blocks and test anxiety as well as social anxiety. This takes the pragmatic approach of helping the child to return to a regular school routine as quickly as possible. The therapist shows the pupil how to stop inappropriate behaviour: For example, he examines the frequency and intensity of the symptoms and the circumstances in which they occur. He identifies which physical reactions are triggered by the panic and tries to find out when they first occurred. Family, friends and teachers are involved in all of this. Parents usually need help to recognise whether they need to behave differently - for example in their role as a role model. If the mother can't stand an argument, the daughter also prefers to bury her head in the sand.

As soon as they get up or on the way to school, affected children and young people go through a kind of inner monologue that influences their emotional perception of reality: «When the homework is asked, I've got everything wrong again anyway.» Negative feelings and thoughts arise before the dreaded situation can even materialise. Corresponding schemata are stored in long-term memory and automatically activated whenever the keyword homework is mentioned, for example. The end of the story: the pupil already feels the fear of failure at home and develops psychosomatic pain in order to avoid having to go to school. If those affected become aware of this chain, they can learn to stop the spiral of thoughts.

Playfully overcoming fear

If a real confrontation with everyday school life is not (yet) possible, the therapist initially uses role play. He shows the young patient how to behave in a situation that is frightening for him in such a way that fear and panic do not arise in the first place. The child or young person practises an appropriate reaction in the game so that they can then fall back on it in reality.

Finally, systematic desensitisation means that the school environment is no longer perceived as threatening. Step by step, the pupil exposes himself to the feared situation. Initially, he stays at school for just one hour, later for two hours and then for a whole morning. The therapist tries to make him understand that everything actually went normally and that the feared failure, embarrassment or teasing did not materialise. It is important to deal with real problems such as gaps in knowledge or aggressive classmates, for example by providing extra tuition or talking to the bullies.
Teachers have a central role to play here: in most cases, only they can intervene - in cases of hardship together with social workers or school psychologists - if a child is being bullied by others. But beware: around 60 per cent of all children and young people avoid lessons because they have a strained relationship with their teacher. Many teachers are not even aware of this.
By the way: Teachers also suffer from something like «school anxiety»! Teachers are increasingly showing acute symptoms of exhaustion, exhaustion and resignation - they are suffering from burn-out syndrome. Teachers fear embarrassing themselves in front of the class, being ignored or laughed at. They are also burdened by pressure from parents who believe that their offspring has been cheated in terms of grades or in other ways.

Close co-operation between all parties involved helps pupils, parents and teachers to cope with everyday school life. If the fronts between the parties harden, everyone ultimately suffers.

«When the school bench presses». From «Brain and Mind». With the kind permission of Spektrum der Wissenschaft, Heidelberg, 2016

Case study: Little tyrants

His parents describe twelve-year-old M. as calm and courteous. However, if they ask for something he doesn't want, he reacts very aggressively. Shortly after the autumn holidays, he caught a cold and then had a stomach ache and headache every morning. He felt better at lunchtime and met up with friends. The doctors found no cause for the symptoms. The symptoms got worse and M. could no longer go to school. After several months without lessons, the boy was admitted to a paediatric psychiatric outpatient clinic with suspected school phobia. Therapy helped him and his parents to understand where the pain was coming from. After three months, he was able to return to seventh grade at his old secondary school.

What to do? Four tips for parents

Parents of children with school phobia should take the following points to heart:

1. Konsequent sein. Es schadet dem Kind, wenn Eltern mit in die Schule kommen. Besser, das Kind geht allein oder in Begleitung von Freunden.
2. Angemessen trösten! Klagt das Kind morgens über Beschwerden, sollten Eltern liebevoll darauf eingehen, aber nicht diskutieren, ob die Schule mal ausfallen kann. Das Kind muss wissen, dass es sich immer auch an einen vertrauenswürdigen Lehrer wenden kann.
3. Nicht belohnen!  Kommt der Schulbesuch einmal wirklich nicht in Frage, ist Bettruhe angesagt. Angenehme Tätigkeiten wie Fernsehen oder Lesen statt Unterricht sollten nicht erlaubt werden.
4. Loben! Auch wenn das Kind morgens geweint oder geklagt hat, bevor es in die Schule ging, verdient es nach seiner Rückkehr Ermutigung und Anerkennung.

Three forms of school refusal

In the case of school anxiety , the child tries to avoid situations or people that are directly
to do with school. In the case of school phobia , the child fears separation from their primary carer. Truancy is primarily a protest reaction on the part of the child or adolescent. Symptoms of the three variants often occur together.

Help for those affected

If parents suspect that their child suffers from school anxiety or school phobia, they should first contact their family doctor and class teacher. A discussion with a liaison teacher can help to find out whether the suspicion is justified. They can also put them in touch with suitable therapists. They can also contact the relevant school psychological counselling centre

About the author

Gerd Lehmkuhl is a psychologist and Head of Child and Adolescent Psychiatry at the University of Cologne. Rabea Rentschler is an editor at «Gehirn & Geist».