School Phobia

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Phobias are becoming a common manifestation in people for all ages; experiencing a phobia could almost rob you of a normal, functional life.

Description


School absenteeism is a national problem; children are absent from school for a variety of reasons, one of which may be school phobia.

  • A phobia is actually a “fear of fear” because sufferers are not really frightened of any particular place, situation, object, or animal, although children tend to believe that there really is something to be afraid of.
  • School phobia or school refusal is a common childhood behavior problem that refers to a child’s refusal to attend school.
  • Unfortunately, today school phobia may be related to bullying at school or the internet.

Pathophysiology


Sufferers are really frightened of the feelings of fear that they experience with their “trigger” situation.

  • The beginning of a phobia usually follows periods of stress and often starts after a final trauma or after a first traumatic attack which appears to come out of the blue.
  • In the early stages of a phobia, sufferers feel frightened when in a particular place or situation, without knowing exactly why.
  • Whenever they go into the particular place or situation they experience an overwhelming feeling of impending disaster and feel a compulsive urge to escape from it.
  • Sufferers do not know why they are afraid but the feelings of fear that they experience are very real; these feelings start a spiral of fear and sufferers begin to think that they will get these awful feelings wherever they go.
  • As a result, the child with school phobia does not wish to attend school.

Statistics


Statistics on the frequency of school phobia vary a great deal.

  • The number of children who actively dislike school and avoid it whenever possible is probably about 5% of the school population.
  • Those who could be classed as school phobic would probably make up 1% of the school population or about 90, 000.
  • Well over half the numbers are boys and the peak onset is about 11 to 12 years of age.
  • Research indicates that the final peak age is about 14 years of age and may well be associated with depression.

Causes


Teachers and nurses can help detect school phobia by paying close attention to absence patterns.

  • Strong attachment. School phobic children may have a strong attachment to one parent, usually the mother.
  • Separation anxiety. School phobic children may feel fear separation from the parent, perhaps because of anxiety about losing her or him while away from home.
  • Problem at school. School phobia may be the child’s unconscious reaction to a seemingly overwhelming problem at school; the parent can unwittingly reinforce school phobia by permitting the child to stay home.

Clinical Manifestations


The symptoms are genuine and are caused by anxiety that may approach panic.

  • Vomiting. The child may display vomiting upon knowing that he will be going to school.
  • Headaches. Headaches may subside once the child is allowed to stay home.
  • Diarrhea. Diarrhea is also one of the symptoms of school phobia.
  • Abdominal pain or other pain. The patient may complain of pain in any part of the body just so he could skip school.
  • Low-grade fever. Even low-grade fever is manifested by the patient, all due to anxiety.

Assessment and Diagnostic Findings


Diagnosis is made on the basis of the following:

  • Family history. Any history of phobias or traumatic experiences contributes to the fear of going to school.
  • Physical symptoms. The absence of causes for physical symptoms may lead to the diagnosis of school phobia.
  • Psychological evaluation. Psychological evaluation varies with other findings and the age of the child but usually includes several assessments.
  • Behavioral checklist. A behavior checklist evaluates the child’s behavior at home and school.

Medical Management


Management includes a complete examination to rule out any organic cause for the symptoms.

  • School-family conferences. School-family conferences help the child return to school; those working with these children must recognize that they really do want to go to school but for whatever reason could not make themselves go.
  • Cognitive/behavior therapy. Cognitive/behavior therapy involves changing the way a sufferer behaves; as research would indicate that cognitive/ behavior therapy is more effective in the treatment of anxiety disorders in children than traditional psychotherapy as it helps the child to learn how to quell anxiety in phobias.
  • Family counseling. Family counseling can help parents to better understood and deal with the school phobic child by providing behavioral guidance and emotional support.
  • Systematic desensitization. This is a technique by which a child is gradually helped to modify his or her emotionally distressing reaction to school without experiencing distress.
  • Exposure therapy. This is a technique by which the child is exposed in a stepwise fashion to increasing intensity and duration of the emotionally distressing event coupled with encouragement to modify maladaptive and inappropriate cognitions gradually enough that the child becomes able to tolerate the previously distressing experience without distress.
  • Operant behavioral techniques. These involve reward for desired behaviors in order to increase their frequency.

Pharmacologic Therapy

Psychopharmacologic interventions may be required for underlying anxiety and phobia.

  • Serotonin reuptake inhibitors (SSRIs). SSRIs asuch as fluoxetine (Prozac), may be useful for underlying depression.
  • Benzodiazepines. Drugs in this group work through enhancing the action of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA).
  • Nonselective beta blockers and alpha-2 receptor agonists. Beta-blockers are effective in managing the physical symptoms of anxiety that occur with school phobia; the alpha-2 agonists are used to manage anxiety.

Nursing Management


The role that the nurses hold in caring for patients with school phobia should be that of a firm, active listeners to control the behavior.

Nursing Assessment

Assessment is required in order to distinguish possible problems that may have lead to anxiety as well as name any episode that may happen during nursing care.

  • Culture. Assess for the presence of culture-bound anxiety states.
  • Level of anxiety. Assess the patient’s level of anxiety; Hildegard E. Peplau described 4 levels of anxiety: mild, moderate, severe, and panic.
  • Perception of a situation. Assess for the influence of cultural beliefs, norms, and values on the patient’s perspective of a stressful situation.
  • Physical reactions. Assess physical reactions to anxiety.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

  • Fear related to unfriendly environment or threatening people around.
  • Anxiety related to threat in the environment.
  • Impaired social interaction related to self-concept disturbance and fear of the school environment.

Nursing Care Planning and Goals

The client will experience a reduction in fear and anxiety as evidenced by:

  • Verbalization of feeling less anxious.
  • Usual sleep pattern.
  • Relaxed facial expression and body movements.
  • Stable vital signs.
  • Usual perceptual ability and interactions with others.
  • Identification of strategies to reduce anxiety.
  • Demonstration of increased external focus.

Nursing Interventions

Offering a welcoming and safe environment is the first and most important step, as well as recognizing triggers for the anxiety and practice of relaxation techniques.

  • Orientation. Orient client to environment, equipment, and routines.
  • Familiarization. Familiarize patient with new experiences or people as needed to provide awareness and decrease anxiety.
  • Acceptance. Accept patient’s defenses; do not dare, argue, or debate so that the patient may feel secure and protected enough.
  • Determine factors to anxiety. Help patient determine precipitants of anxiety that may indicate interventions.
  • Allow verbalization of anxiety. Allow patient to talk about anxious feelings and examine anxiety-provoking situations.
  • Develop skills to avoid anxiety. Assist the patient in developing anxiety-reducing skills to provide a variety of ways to manage anxiety.
  • Education. Educate patient and family about the symptoms of anxiety.
  • Medication instruction. Instruct the patient in the appropriate use of anti-anxiety medications.

Evaluation

A successful care plan is evidenced by:

  • Verbalized feeling less anxious.
  • Usual sleep pattern.
  • Relaxed facial expression and body movements.
  • Stable vital signs.
  • Usual perceptual ability and interactions with others.
  • Identified of strategies to reduce anxiety.
  • Demonstrated of increased external focus.

Documentation Guidelines

Documentation for a patient with school phobia includes:

  • Level of anxiety and precipitation/aggravating factors.
  • Description of feelings (expressed and displayed).
  • Awareness and ability to recognize and express feelings.
  • Treatment plan.
  • Teaching plan.
  • Client’s response to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcomes.
  • Modifications to plan of care.
  • Referrals and follow-up plan.

Practice Quiz: School Phobia


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1. The psychiatric nurse uses cognitive-behavioral techniques when working with a client who experiences panic attacks. Which of the following techniques are common to this theoretical framework? Select all that apply.

A. Administering anti-anxiety medication as prescribed.
B. Encouraging the client to restructure thoughts.
C. Helping the client to use controlled relaxation breathing.
D. Helping the client examine evidence of stressors.
E. Questioning the client about early childhood relationships.
F. Teaching the client about anxiety and panic.

1. Answer: B, C, D, F. Encouraging the client to restructure thoughts, helping the client to use controlled relaxation breathing, helping the client examine evidence of stressors, teaching the client about anxiety and panic.

  • B, C, D, F: These are all appropriate techniques based on the framework of cognitive-behavioral therapy.
  • A: Teaching administration of medications to the patient is not part of the cognitive-behavioral therapy.
  • E: Questioning is not a strategy involved with cognitive-behavioral therapy.

2. Marty is pacing and complains of racing thoughts. Nurse Lally asks the client if something upsetting happened, and Marty’s response is vague and not focused on the question. Nurse Lally assess Marty’s level of anxiety as:

A. Mild.
B. Moderate.
C. Severe.
D. Panic.

2. Answer: C. Severe.

  • C: When the client has difficulty focusing and exhibits excessive motor activity, the level of anxiety is severe.
  • A: Mild anxiety is characterized by increased alertness and problem-solving ability.
  • B: Moderate anxiety is characterized by the ability to focus on central concerns but the inability to problem-solve without assistance.
  • D: Panic level of anxiety is characterized by complete inability to focus and reduced perceptions.

3. Nurse Martha is teaching her students about anxiety medications; she explains that benzodiazepines affect which brain chemical?

A. Acetylcholine.
B. Gamma-aminobutyric acid (GABA).
C. Norepinephrine.
D. Serotonin.

3. Answer: B. Gamma-aminobutyric acid (GABA)

  • B: Antianxiety medications stimulate the neurotransmitter GABA, which is a chemical associated with relaxation.
  • A, C, D: The other options are not affected by benzodiazepines.

4. School phobia is usually treated by:

A. Returning the child to the school immediately with family support.
B. Calmly explaining why attendance in school is necessary.
C. Allowing the child to enter the school before the other children.
D. Allowing the parent to accompany the child in the classroom.

4. Answer: A. Returning the child to the school immediately with family support.

  • A: Exposure to the feared situation can help in overcoming anxiety.
  • B: This will not help in relieving the anxiety due separation from a significant other.
  • C: Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable.
  • D: This will not help the child overcome the fear.

5. Which is the desired outcome in conducting desensitization:

A. The client verbalize his fears about the situation
B. The client will voluntarily attend group therapy in the social hall.
C. The client will socialize with others willingly
D. The client will be able to overcome his disabling fear.

5. Answer: D. The client will be able to overcome his disabling fear.

  • D: The client will overcome his disabling fear by gradual exposure to the feared object.
  • A, B, and C: These options are not the desired outcome of desensitization.

See Also


Related topics to this study guide:

Further Reading


Recommended resources and books for pediatric nursing:
  1. PedsNotes: Nurse's Clinical Pocket Guide (Nurse's Clinical Pocket Guides)
  2. Pediatric Nursing Made Incredibly Easy
  3. Wong's Essentials of Pediatric Nursing
  4. Pediatric Nursing: The Critical Components of Nursing Care
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