Symposium on Behavioral Pediatrics

School Phobia Philip R. Nader, MD.,* Dorothy Bullock, AC8W,** and Bill Caldwell, Ph.D. t

As the child began to look less and less in mother's direction and to enter tentatively into the nursery school program, mother was noted to move from a peripheral position in order to occupy a seat closer to her child. The umbilical cord evidently pulled at both ends. When the morning for return to school arrived, the patient responded with customary complaints of nausea and abdominal pain. Mother reported that after a few incoherent attempts to insist that his son must go, his father broke into tears, shouting: "My God, I can't do it," and tore off to the bathroom to vomit.

The above vignettes2 illustrate the dynamics often found in cases of school phobia, also called school refusal. The importance of more complex family interaction1 , 6, 10 has also been emphasized. School refusal is not an uncommon syndrome,3 nor is it confined to a specific population or socioeconomic group. Early recognition makes management easier, and can prevent the development of more serious problems, yet little has been written to help the physician gain skills in handling all aspects of school refusal.

DETECTION School refusal has been characterized as the "great imitator."8 While the presenting problem may be clearly physiological, reactions of the patient and others to the illness may lead to a school refusal pattern. At other times the child with school refusal may be brought to the physician with more obvious psychosomatic complaints. In still other instances, the initial parental complaint may be that the child is refusing to go to school. Since the presentation is variable, the physician must be aware of factors considered high risk for school refusal. From the School Health Programs and Child Development Division, Departments of Pediatrics and Psychiatry, University of Texas Medical Branch, Galveston "'Associate Professor of Pediatrics and Psychiatry; Director, School Health Programs, and Co-Director, Child Development Division '''''Associate in Pediatric Social Work and Director of Social Work, Child Development Division t Associate Professor of Pediatrics and Psychiatry; Co-Director, Child Development Division

Pediatric Clinics of North America- Vol. 22, No.3, August 1975

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The "delicate" child, the chronically ill child and the special child (for example, the child of older parents) is susceptible to later school refusal. When a child has experienced difficulties early, such as premature birth, traumatic delivery, or frequent illnesses in infancy, parents may understandably become overly concerned and protective. Likewise, children who. develop chronic illnesses may be so treated that a cycle of overprotection and indulgence develops. Parental illness, hospitalization, or marital strife may also precipitate a school refusal crisis. The child feels a responsibility to be at home to "make sure" nothing happens. Having followed some children since infancy, the physician can be alert for school refusal symptoms in children of families who have been unable, for various reasons, to separate themselves from the growing child. These parents may never have left a preschool child in a strange environment, for example. Accurate school attendance data may not be initially apparent, since mother may not realize that the child misses an unusual amount of school ("After all, you wouldn't want me to send him to school when he's sick, would you?"). A commonly seen absence-symptom pattern may be useful in detecting school refusal: (1) Increasing numbers and episodes of illness-related absence over a given period of time; (2) more absences in the fall than in the spring; (3) great reluctance to return to school after holidays; and (4) absence or scarcity of physical symptoms on weekends and during the summer. Some children's anxiety level may be high enough to produce persistent complaints on Sunday afternoon in anticipation of a return to school on Monday. When a pediatrician encounters the child who is not attending school, he must first consider three possible explanations: (1) the child may be so organically ill that he cannot attend school; (2) the child's behavior may be part of a severe emotional problem; or (3) there may be reality factors which appropriately would cause the child to fear going to school. Miller7 urges the physician to accomplish a "somatic" work-up rapidly. A complicating iatrogenic factor can be added by physician insecurity and indecision. A thorough history and physical examination with simple laboratory tests such as a CBC may be all that is required. Even if the physician is quite sure the presenting symptoms are most compatible with school refusal, he should not omit the examination, since it reassures both parents and child. Additional negative laboratory tests do not "convince" parents, but only reinforce their worries about the possible presence of a serious physical problem. Bizarre behavior that indicates loss of contact witI! reality, marked withdrawal, or behavior that is destructive to the child or to others are not characteristic of a child with uncomplicated school refusal. Should these be present, further investigation and possible referral may be indicated. Situations that might cause a child to be realistically afraid of attending school include continual failure at school, bullies who coerce a child to pay tribute in money or favors, sexual activities forced upon the child, and constant embarrassment because of home conditions (father in prison, mother entertaining countless men at home, alcoholic parents

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who fight). Attributing school nonattendance solely to such factors requires caution, however. While they may be significant, they may not be a sufficient explanation for school refusal. 4

CONFIRMATION Faced with the indicators noted above, the physician proceeds with three important confirmatory steps. Having already seen the mother and child together, he first sees the child alone. He will note the ease or difficulty with which this can be accomplished and the resulting anxiety it produces in either mother or child. Second, he observes the family interaction patterns. This will be accomplished by a family or parental conference with both father and mother present, or at a family conference which includes the significant family members (mother, grandmother, etc.). A third diagnostic step will include gathering information directly from the child's school.

Approach to the Patient It is essential for the pediatrician to talk with the child. This helps him understand the child's perception and to compare it with informa.tion secured from the mother. The child is generally found to be verbal and bright, and "likes school." It should be clear that the pediatrician believes the child is experiencing the physical discomforts about which he complains. Valuable information can be secured from a child by phrasing questions in the first and third person: "Jim, it must be hard for someone to go to school when he is feeling sick." "I remember when I went to school I often wondered what was happening at home." If this brings no response then the pediatrician might add, "1 wonder if you ever think of what's happening at home when you are in school?'; With some children direct questions will secure vital information: "Tell me, Rodney, what really gives you a hard time at school?" "Barry, do you ever worry about what might happen to mother or daddy?"

Tasks in talking with the child during this phase include: (1) securing information about the current episode of school absence; the child's recollection of past attendance patterns and attitudes toward school are also relevant; (2) reassuring the child that his physical complaints are not imaginary or mere lies; and (3) reassuring the child that some things can be done about the problems, but that the child must do his part to help work things out.

Approach to the Family Specific information about family relationships is required. Reviewing the early morning routine often gives clues which confirm a school refusal pattern: "Mrs. Young, it would help me get a better understanding of Julie's problems if you will tell me about the faInily routine in the mornings. First, who gets Julie up?"

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"Oh, I always get her up; she's so hard to wake up and sometimes she seems scared when she first wakes up." "I see, and then what happens?" "Well, I usually talk to her for a minute or SO; you know she is still bothered by those headaches and says she gets tired every afternoon. I've noticed she comes in from school just exhausted. Sometimes I have her lie down and rest for a few minutes when she comes in." "All right, and after she wakes up what does she do?" "Usually she gets up and dresses herself, but sometimes if I see she isn't feeling well I may give her a little help. She seems to like that and since I'm not with her all day I don't think it hurts anything."

Such a conversation begins to clearly point out the dependency relationship existing between mother and child. Missing school is not seen as unusual or symptomatic. Mothers seem unconcerned when reporting dependency-promoting activities such as helping mother, watching TV, or "just playing around the house." Listen for two clinical indicators in the language of a family. One is a certain "illness orientation" or "organicity." Frequent somatic references ("gives me a headache," "makes me sick") are coupled with much family discussion surrounding health concerns ("We'll go for a picnic if mother feels OK. Johnny's awfully angry today, he must be sick."). Another indicator is the use of the word "we" by the mother when referring to her child (how are "we" doing). The diagnosis of school phobia should not be considered confirmed until there has been an interview with the father. This can be accomplished by interviewing the parents together. In such an interview, an understanding of family communication patterns should emerge: How do family members communicate? Who primarily exercises control in the home? Does the patient tend to align with one parent almost to the exclusion of the other? How do the parents describe the child's problems? Do the parents differ significantly in their attitudes and behaviors toward the child, his problems and other family concerns? What stresses are evident in the family? Three general interaction patterns are commonly seen. Both parents may be overly concerned and solicitous of the child, and unsure of how to handle the child's illnesses and complaints. This often results in the child showing manipulative behavior. In a second pattern, one parent, usually the mother, is very protective and concerned and the other parent disagrees completely on the treatment of the child. Each undermines the other, and the child takes advantage of the disagreements. Thirdly, the mother may be overly involved with the child, talking for him and caring for his every need, while the father appears rather "absent" in the family. When the father does respond to questions, it is often blandly, intellectually, and with little indication of emotional involvement. History will show that as mother and father grow more distant, the mother and child become more enmeshed. The child may even take sides with the mother against the distant father. This emotional attachment may be displayed dramatically in an interview situation by the mother and child sitting closely beside one another, often maintaining physical contact, while the father remains distant and apart. Clarification of the severity and causes of these patterns will help

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plan treatment efforts. The observed pattern may result from a simple lack of child-rearing information, from informed parents who lack parenting skills or from more severe marital problems. Approach to the School Confirmatory information from the school will include (1) actual number of days missed compared to the number of days school was in session (for both current and previous school years); (2) illnesses occurring at school and what action was taken; (3) any indication that mother has been overly concerned about child's health or safety (notes or phone calls); (4) the child's ability and achievement scores on tests; (5) the child's day-to-day functional level as indicated by grades and teacher observation; (6) observations of school behavior, including relationships to other students and to teachers; and (7) any indication of "reality factors" which could cause the child to fear going to school.

TREATMENT Predictors of success include: age (first grade through junior high school), short duration (several months or less), and at least one cooperative parent who seems to realize that there is other than a physical cause for the problem. Predictors of more difficult cases include adolescent or high school age, longer duration (several months or more), older siblings who manifested school refusal, and parents who attribute the problem to the school itself or to a physical illness. Treatment outcome is measured against both an immediate shortterm goal, returning to school, and long-term goals such as an improved self-concept and more positive peer interaction, and improved family communications and child-rearing approaches. One of the best predictors of successful long-term treatment, as well as a reinforcement of the diagnosis, is whether the child responds to the prescribed treatment plan of immediate return to school. Approach to the Patient The child must receive from the physician, either alone or with the family present, this friendly, reassuring message: "I know it is hard, but you can get back to school." As the child becomes aware of the power the doctor influences over his parents in enforcing a return to school, the physician can expect that a charming, "cute" patient may be changed to a scowling manipulative and petulant child, clinging to mother in the waiting room. "Jim, you know you are supposed to be in school. I know it must be scary sometimes, but everyone is just a little afraid of going to school at some time. I know you are worried about your mother (father, grandmother), but she wants you to go to school. You said you really like school, so all of us are going to work with you in getting you back to school. I have talked with your mother and dad and they both know that you really have had headaches (stomach aches), but still you need to be in school. We have all decided that it will be all right to go to school even when you have a headache."

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The pediatrician must make it clear that all adults involved understand the child's feelings and physical symptoms, and that all have agreed that the child is to return to school. There must be no wavering on the latter point. No attempt should be made to reason with the child about why he should go to school or to entice him with stories of how much fun school is. Approach to the Family School refusal is always a family problem. Successful treatment depends on the family accepting the explanation given by the pediatrician and working cooperatively with him and with the school to effect changes in family patterns. The pediatrician should make it quite clear that he considers school refusal a family problem, but that he blames neither the parents nor the child. The physician can show how parents set the tone for family conversations and thereby focus the family's attention on health rather than illness behavior: "Going to school is the job of children, just as work is for adults." It will be necessary to deal again with parental doubts. Mother may say, "But he really looks so pale and sickly, 1 just can't bring myself to force him." "I know he wants to go to school, but he just sits there with his head in his arms until 1 say, 'You just don't look like you can go to school.'" Then the physician can ask, "What do you think that means to him when you say that?" or, "What do you suppose would happen if you didn't mention not going to school?" The response indicates the degree to which the parents understand the situation. The physician may need to reiterate his awareness that the child has had physical symptoms: "Yes, I know that he has been breathing quickly and says his heart is pounding. That is part of school refusal. I have examined him thoroughly and there is nothing physically seriously wrong. I think you will find that once he is back in school and things are going smoothly again, these physical complaints will gradually stop."

There must be no compromise with the decision to return the child to school: "There is absolutely no physical reason for him not going to school. He's healthy, he's smart, he's just like other children his age and he needs to be in school with them."

It may be less difficult for the child to go to school than it is for the parent to let him go to school. Recognition of this difficulty will be useful: "Of course, I can understand how frightening it is to see him go off to school, especially with all the trouble he's had. You certainly have had some rough times."

It is imperative that the parents be brought together in their approach to the child. Parents need to discuss with the physician how they will get the child back to school. The physician should ask the parents to come up with a plan which is appropriate. The degree of communication and cooperation will predict how quickly the problem can be resolved.

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If the parents are widely divergent in their approach to child rearing and schooling and are unable to acknowledge or discuss these differences, referral for marital counseling or family therapy should be considered. If, on the other hand, the parents can discuss their differences, the physician can facilitate their attempts to work together in solving the problems that resulted in school refusal. The physician must keep the discussion focused on the family's approach to handling the school refusal, and not allow it to bog down in a lengthy discourse about education in general, or the peculiarities of the child's teacher, or how much fun the family had on vacation last summer when there were no problems. He should limit the interview to no longer than 40 to 45 minutes or an hour. It is important to avoid overemphasizing and reinforcing physical complaints. Parents need to be instructed not to inquire about Johnny's state of health. In turn, the physician needs to be wary of prescribing medication, as it may only serve to reinforce the sick role behavior. One child known to the authors was on 10 pills every other day, including steroids for allergic symptoms and an anticonvulsant drug for headaches thought to represent migraine. When the vicious cycle involving sick role behavior was interrupted, both medications were successfully tapered and discontinued without subsequent difficulty or increased symptomatology. . Emerging independence can be further supported by having the parents discuss making and enforcing family rules. It is imperative that the physician not usurp the parental role by supplying too many answers and too much advice. This would only reinforce their problem of being ineffective parents. Instead, he should urge them to begin their family discussions there in the interview situation. This allows the physician to help them identify their task, remain on the subject, avoid bringing the child into their discussion as a partisan, and rely on themselves to formulate answers.

Approach to the School A visit to a school emphasizes the significant part the school will play in a cooperative plan for treatment of school refusal. A visit can be exceedingly productive and is worth the physician's time. Since it is intimately related to the treatment, parents generally will not object to being charged for the time required. At this meeting, which can easily be held before school (8:00 to 8:30), the presence of the principal and the child's teacher is essential. If there is a nurse or guidance counselor it is advisable that they also be present. The physician can first ascertain the school's view of the problem and how they have tried to deal with it. School personnel may have variable degrees of sophistication about school phobia. It may be extremely difficult for a school to ignore the physical complaints of a child. It is an exceptional nurse, teacher or principal who can hold to a firm limit in the face of a child covered with vomitus. The physician can reassure the school that there is no physical problem that is not recognized and being taken care of. Once the child is successful in returning to school there will likely be no problem of the

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child again leaving the school. In fact, children with school phobia have been known to require being taken to school in the morning, but manage to walk home for lunch, returning for the afternoon session. The child's manipulative behavior in school requires firm, kind limit setting by school personnel. The physician can support the school in this approach. Continued communication between the physician, school staff and the family is mandatory. School personnel can be much more effective than when no communication exists. The nurse, because of her identified role in the school, may not be in the best position to see the child, as this may only reinforce a sickness role. If she does playa counseling role for the child, it should be by appointment for brief periods and not on call for "emergencies." Often a teacher or counselor can be helpful in recognizing the child's worries, providing a regularly scheduled supportive relationship for the child. During the school visit, other contributing factors to the school refusal can be discussed: achievement below abilities; adolescent shyness regarding showers; upcoming examinations which may unduly stress a child who has been absent; oral recitation for a painfully shy child. Plans to cope with each of these problems can be made at this time. Plans also need to be made to increase his outside activities as well as classroom participation. The physician should be open to school personnel's opinions and suggestions, but he should retain decision-making regarding the treatment program. Well-meaning counselors may suggest referralto psychiatric or mental health centers, bypassing the source of primary health care. Should approaches with the family fail to return the child to school, schools have legal options and court action open to them. At times, school officials may need encouragement and support from the physician to initiate such action in these instances.

FOLLOW-UP If treatment has been successful, consistent school attendance and gradual decrease of somatic complaints will be noted, accompanied by an improved self-image, improved peer relationships and increased independence for the child. Marital problems will decrease and improved parental communication and mutual support will be evident.

Patient Follow-Up As attempts are made to normalize the child's school and home situation, the degree of anxiety or somatic symptoms may initially increase, but should decrease within several weeks. The more seriously disturbed the child, the more frequently one notes the emergence of other fears: nightmares, feelings of guilt, shame, worthlessness, depression or freefloating anxiety. Sometimes in an older patient this progresses to unwillingness to even leave home. If such occurs, the physician will consider referral.

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Family Follow-Up The number and frequency of parent counseling sessions will be determined by the family's success in achieving both short-term and longterm goals. The physician and family need to be sure that both know where they are in this process. Parents also need to understand the contract they are worKing under. Often it is helpful to agree upon a definite number of family or parent counseling sessions and then to re-evaluate the goals with the family before proceeding. This process may entail reassessment and re-evaluation of the previously determined long-term goals. Indicators can be identified during counseling sessions that portend difficulties which may require referral. One example is overly helpless parents who state blind dependence on the advice of the physician but seem completely unable to follow through. This may be a pitfall for the physician generally accustomed to an authoritarian manner of dealing with patients. Another pitfall is a tendency to support one parent at the expense of the other, such as asking the father to take over the mother's role in getting the child to school "since obviously your wife can't." It would be better to say: "How do you both feel you might work together to help him get to school in the morning?" School Follow-Up By maintaining communication with the school, one can document the outcome measures of initial treatment (for example, decrease in nurse visits, somatic complaints and absenteeism). This will also permit surveillance for a supportive school environment which should result in increased participation in school life beyond just being "present." School personnel may change jobs and have many demands pressed upon them. One needs to keep old and new personnel current with the situation. Children with school refusal may have difficulty in adjusting to new environments in the future. If transfer to another school is anticipated, a visit or special orientation may be useful "anticipatory guidance." REFERRAL Most preadolescent school refusal cases will not require referral. A decision to refer will be reached by considering both patient and family characteristics. Referral should be neither taken as the first action after school refusal has been diagnosed nor considered only as a last resort. Whether a referral is made depends upon several factors. One is the skill and competence of the primary physician. He need not study psychotherapy extensively in order to work with a family; he will, however, read articles, attend meetings and participate in workshops9 as he becomes more involved in parental counseling. Another factor is setting aside the time required to deal with such problems. This factor often reflects the first, since the time is often made available once a physician feels competent to handle such problems. A third factor is the availabil-

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ity (geographic and financial) of referral sources; a fourth, the willingness of the family to go elsewhere for help; and finally, and not the least important, the effectiveness and skills of the therapist to whom the family is referred. In the adolescent patient, one almost always finds more severe psychological problems. Schizoid behavior, guilt or depression may be prominent symptoms. The primary physician may still be the best one to manage such a child and his family, particularly if he can rely on a psychiatrist's guidance and support. Referral for marital counseling is often a logical outcome of brief parental counseling around a case of school refusal. If the parents are found to exhibit extreme differences in their child-rearing approaches, attempts to engage the two in working out their divergent approaches may only bring bitter accusations from one against the other, blaming, and other nonproductive activity. The physician should attempt to underscore the fact that "obviously, both of you have different ways" of viewing the situation. He avoids taking sides and neutralizes the fight by stating that their problem now is to come to still another approach that the two can agree on. If they still are unable to work together or if they make repeated attempts to get the physician to take sides, it is likely that the couple will need more long-term counseling. Another indication of need for further help is the mother who is intensively involved with the child and the father who is aloof and uninvolved with his wife. As the above suggestions are attempted with such a family, the mother will become extremely defensive and cling to the child even more. The father generally will be more intellectual or attempt to state that he has "been right all along." He will not attempt to interact with his wife, and he may even remain completely silent. In such extreme cases, the couple may never have had a positive relationship, and the mother may have turned to the child from the time he was first born. This situation will require extensive help and referral is indicated.

Referral Resources Almost every community with more than 30,000 people has a family service agency. Increasing numbers of community mental health centers are being established in rural areas as well as urban areas. School personnel and pastors may also be of help. Nursing roles are expanding and school nurse practitioners may have additional skills in handling such problems. School psychologists and social workers will also have had training in dealing with school refusal. For severe and persistent situations, the pediatrician will find psychiatric social workers, clinical psychologists, and psychiatrists skilled"in working with families. In some areas professional family counselors, family therapists, and marital counselors are appropriate resources. Knowledge of the availability of community resources needs to be coupled with a knowledge of these agencies' effectiveness and the likelihood of accepting for therapy certain "types" of cases, or "kinds" of patients. Attention to minor details such as talking specifically to the psychiatrist or director of outpatient services may facilitate the referral

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process. Pediatricians who see numbers of patients requiring child psychiatrist services report more success in reaching the private child psychiatrist if one calls 5 minutes before the hour. In rare cases, where there is no other alternative, and where every other means of treatment has been tried, the physician has an obligation to consider hospitalization in order to separate the child from the home. This may be especially important in an area where referral resources are extremely distant or with an adolescent who is depressed or suicidal.

Making a Referral Stick Referral should almost never be made on an initial visit for school refusal unless it is clear that suicide or other serious calamity might occur. Even though a relatively major family or personal psychological problem is revealed to the physician in the course of parent counseling, an immediate suggestion of a referral implies that the family is "so bad" you cannot see them again. The physician may need to allow a family to take several sessions in "getting ready" for referral. Therapists have expressed surprise when referred patients have had such preparation: "They were so ready to work on the problems." When referral is indicated, the primary physician is responsible for preparing the family for referral and preparing the therapist to whom the referral is made. If a referral is made after the pediatrician has worked with the family for several sessions and no progress is noted, he may then be frank with the family and explain their need for extended help. The family's acceptance of a referral for counseling will depend upon the relationship the physician has been able to build. If he has been able to be supportive to each member even in the midst of confrontation, he probably has gained their confidence. When making the referral, he needs to continue to avoid taking sides. If the parents have intense differences of opinion, he might say: "The two of you have quite different ways of viewing this situation. It is going to take a while to come to a common approach. I have the name of someone who will be able to work with you regularly for a while to get this worked out." In the case of the family that becomes defensive when referral is suggested, even more attention is needed to the referral process. Much support is demanded, especially for the one adult most involved with the child. This person will be the most threatened by a referral. By not implying guilt, but again indicating that "everyone is interested in the child's happiness and adjustment" and that all the family members are "needed to work on this, and it will take some time," the physician can facilitate the referral. It is always important to explicitly state the belief that the referral will "help things get better." The name and telephone number of the referral source should be on hand. The physician will indicate that the parents should contact the counselor immediately and state that the physician "will help out" by letting the counselor know to expect the call. Once referred, it is mandatory for the primary physician to keep in

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contact with the agency or doctor to whom the family was referred. A follow-up telephone call should be made to insure that the family actually began meeting with the counselor. In addition, the physician should request the counselor to contact him should the family not continue in his care. Someone must remain in contact with the family until the child is regularly back in school.

SUMMARY Pediatricians and other primary care providers are in an ideal position to prevent, to diagnose and to treat children with school refusal. Detection requires recognition of high risk situations, and delineation of possible reality factors or environmental hazards. The physician will find school refusal associated with perceived or actual physical illness, debility, or vulnerability, family stresses including illnesses and marital problems, over-protective mother-child interaction patterns, and previous difficulties in achieving mother-child independence and separation. Confirming the diagnosis depends on interview with family members. Positive indicators are dysfunctional patterns of family communication, parental emphasis on illness, and manipulative behavior on the part of the child. Data from the school on absenteeism need to be supplemented by the school's observations of individual achievement and ability measures, grades, and teacher observations of peer and adult interaction. . Treatment techniques center around returning the child· to school by involving the child, the family, and the school in this process. Specific counseling techniques and principles aim to recognize each individual's feelings and to stress the active role of the parents in solving problems together. Follow-up is based upon assessment of clearly understood short-term and long-term goals. Referral should be rare, and should not be undertaken before proper evaluation has been completed. Making a referral "stick" depends greatly upon the degree of rapport and trust which has been established with the family. In most school refusal cases, management by the pediatrician or primary physician can be a rewarding, stimulating experience which provides a high degree of parent and physician satisfaction.

REFERENCES 1. Davidson, S.: School phobia as a manifestation of family disturbance: Its structure and treatment. J. Child. Psychol., 1 :270, 1960. 2. Eisenberg, L.: School phobia: A study in the communication of anxiety. Amer. J. Psychiat., 114:712,1958. 3. Eisenberg, L.: School phobia. PEDIAT. CLIN. N. AMER., 5:645, 1958. 4. Hersov, L.: School refusal. Brit. Med. J., 3:102,1972. 5. Loofl', D. H.: Acute school phobia. In Feelings and Their Medical Significance. Vol. 15, No.3, May-June, 1973. (Ross Timesaver, published by Ross Laboratories, Columbus, Ohio.)

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6. Malmquist, C. P.: School phobia, a problem in family neurosis. J. Amer. Acad. Child Psychiatry, 4:293, 1965. 7. Miller, D. L.: School phobia: Diagnosis, emotional genesis, and management. New York State J. Med., 72:1160, 1972. 8. Schmitt, B.: School phobia- The great imitator: A pediatrician's viewpoint. Pediatrics, 48:433 (1971). 9. Sumpter, E., and Friedman, S. B.: Workshop dealing with emotional problems: One method of preventing the "dissatisfied pediatrician syndrome." Clin. Pediat., 7:149, 1968. 10. Takagi, R.: The family structure of school phobias. Acta Paedopsychiatrica, 39:131-146, 1973. School Health Programs University of Texas Medical Branch 1202 Market Galveston, Texas 77550

School phobia.

Pediatricians and other primary care providers are in an ideal position to prevent, to diagnose and to treat children with school refusal. Detection r...
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