SCHOOL PHOBIA*

ADELAIDE M. JOHNSON, M.D., EUGENE I. FALSTEIN, M.D.

S. A. SZUREK, M.D., and MARGARET SVENDSEN
Institutefor yuvenile Research, Chicago

Fo“ years psychiatrists have recognized that there is a type of emotional dis-
turbance in children, associated with great anxiety, that leads to serious ab-
sence from school. This is a deep-seated psychoneurotic disorder fairly sharply
differentiated from the more frequent and common delinquent variety of school
truancy. The syndrome, often referred to as “school phobia,” is recognizable by
the in ense terror associated with being a t school. The child may be absent for
-d
per1 s of weeks or months or years, unless treatment is instituted. The children,
on fleeing from school, usually go straight home to join the mother. Eventually
they refuse to leave the house. When the child is superficiallp questioned, he
cannot verbalize what he fears and the whole matter appears incomprehensible
to parents and teachers.Jtseems to us that this syndrome is not a clean-cut entity,
for one finds overlapping of the phobic tendencies with other neurotic patterns,
such as those of an hysterical or obsessive nature.
Although this type of problem is seen fairly frequently in any child guidance
clinic and can become very serious, there has been very little written about it.
I n 1932 Dr. Isra T. Broadwin‘ described this syndrome in his paper entitled,
A Contribution to the Study of Truancy. The title might suggest that it is only
another article on delinquent truancy but it does attempt to describe the psycho-
neurotic elements in this disorder.
There are all degrees of school phobia ranging from those that are abortive and
clear quickly, to those requiring intensive treatment. The severe school phobia
that is left untreated may develop into a seriously crippling condition. This is well
exemplified by a case of a woman of 31 who was analyzed by one of the writers,
(E.1.F). Her first acute anxiety began in the school room a t 13 and soon developed
into a severe school phobia which was untreated. This rapidly spread to include
phobias of many varieties from which the secondary gains were so great that after
18 years they constituted an insurmountable barrier to any very successful
analytic therapy.
Fairly intensive clinical experience with eight children treated a t the Institute
for Juvenile Research has resulted in a somewhat clearer insight into the dynamics
of school phobia as well as its therapy. The group studied includes an equal num-
ber of male and female children. The age range a t time of appearance of the
phobia was from 6 to 14 years of age. The symptoms had existed from 10days to
z years, one 8 year old boy never having gone to school. There was no consistent
determinant so far as ordinal position was concerned. Intelligence ranged from
low average to extremely superior-the majority of the children being in the
superior group. In the 8 cases studied the 4 boys were submissive and obedient
Presented at the 1941 meting.
Broadwin, Isra T. A Conhidwion to the Study d Truancy. Au. J. OUTHOPSYCHIATUY, 11.3.1932.
702
 ADELAIDE JOHNSON rt a/. 103

to their mothers, whereas the girls were aggressively defiant. All of these children
had a definite history pointing to the presence of considerable anxiety in their
early years, such as night terrors that were striking, promotion anxieties, earlier
short periods of phobid regarding school, severe temper tantrums, asthma and
eczema. The children came from homes of varied economic levels.
The outstanding common factors in initiation of the school phobia which seem
to be operating in all 8 cases are, first, an acute anxiety in the child, which condi-
tion may be caused by organic disease, or by some emotional conflict manifested
in hysterical, hypochondriacal, or compulsive symptoms precipitated by arrival
of a new sibling, promotion in school, etc. Second, and equally important, an in-
crease of anxiety in the morher due to some simultaneously operating threat to her
satisfactions, such as sudden economic deprivation, marital unhappiness, illness,
etc. Third, there seems always to be a strikingly poorly resolved early dependency
relationship of these children to their mothers..How these three cardinal factors
become interrelated in the production of the school phobia will be seen most
easily perhaps from study of a case summary and excerpts from others.
Summary of Case. Jack, age 9, the middle child in a family of three, developed
school phobia eight months before coming to the Institute. After a mild organic
illness associated with unnecessary trips to various medical clinics accompanied
by his over-solicitous mother, with two or three months of absence from school
the boy refused to return to school and developed hypochondriacal complaints,
temper tantrums, fears of storms, etc. Soon a full-blown school phobia was very
evident. Early in her clinic visits the boy’s mother said, “It made me sick to see
Jack so pale and anxious, angry and upset. Jack and I had such arguments about
his going to school and I became so sick and upset that last spring his father de-
cided it would be better for Jack not to go to school. Jack has always been so
lovable-always worried about my illnesses-more than the other two children.”
The mother stated that people in her community said the boy was “working her”
and she felt their view might be justified. Patient was described as “very cuddly,
always needing more love than the others.” The mother felt “he would have been
better off had she devoted all of her time to him.”
The child’s maternal grandmother had been in bed for years with an hysterical
disorder, and was growing increasingly demanding a t this time of her younger
daughter, the child’s mother. The latter suffered from many somatic neurotically
conditioned disorders that sent her to bed for days. She was a very dependent,
hostile woman and while in a resentful mood, used her illness as a way to punish
herself and her mother, to’enslave her husband and this boy. Unconsciously she
exploited the boy’s guilt regarding his resentments toward her in order to bind
him to herself. When treatment began a t the Institute regularly once a week, she
developed more severe disorders which a t first were used as an excuse for not
making the long trip. The family lived 250 miles from the clinic. She wrote, “I
know I’m impeding Jack’s progress by not coming in, for my husband can tell
you nothing.” Though the boy enjoyed his treatment hours from the start, his
mother early used every excuse to keep him home. Finally criticism from the
704 SCHOOL PHOBIA

school and community operated to increase the mother’s anxiety to the point
where she came to the clinic regularly. Very quickly she developed a dependent
transference to her psychiatrist (male) and subsequently seldom missed treatment
hours. The boy was treated in a playroom by a woman psychiatrist. In this situa-
tion he lived through in play activity and verbally his conflicts with the family as
brought out in relation to the therapist. Relationship interpretations were given
to the child as seemed necessary to the resolution of his conflicts.
In the five months of regular weekly treatment hours the patient worked
through a great deal of his ambivalence and rivalries toward both parents and
siblings. Especially was he concerned early with rage and guilt against the mother
becauy of her demands upon him for obedience and attention, and because of
her resentment of any independent strirings. After he had been in treatment for
some time he sent her a rather expensive present to cover both Mother’s Day
and her birthday. The mother complained bitterly to her therapist that Jack was
“No longer her dear little Jack who had always given her two separate presents
before.” There were periods of fearfulness, especially when his mother would be
very sick and, as these were worked through, patient brought o u t clearly a t times
his intense hateful wishes against her. As he asserted himself with the mother and
turned more to outside interests, the mother interpreted this behavior as a real
rejection. Often during treatment it was obvious that the boy felt very unhappy
regarding his absence from school, recognized the crippling to himself and felt
keenly the blow to his self-esteem when children became critical of him.
The mother discussed with her therapist her own unresolved dependence on
her mother, her sister, and the therapist. She discussed also her bulimia when left
alone, her longing for love, her feeling of inability to give it to her children, and
her competition with Jack for attention, e.g., she often complained that her head-
aches were worse than his. Her “pride was cut to the quick by Jack’s not going to
school” and she saw his refusal to go as defiance of her. This led to discussion of
her wish to dominate the boy as she was being dominated by her neurotic bed-
ridden mother. Early in the treatment she vacillated in her wish to have Jack
home, developed guilt as a result and tried to put the responsibility for forcing
him to go to school on Jack’s therapist. She also tried to prove that Jack’s thera-
pist was inadequate and exploited every opportunity to keep the boy near her.
As she worked through her own frustrated, dependent needs with her therapist
and felt indulged without criticism, she became much more giving with the
children and husband and demanded less appreciation and nursing care. She
became able to assert herself with her own mother, to sidestep the mother’s at-
tempts to make her guilty and to feel far better physically. After five orsix
months of treatment the boy returned to school and a year later a detailed letter
stated that there was no more trouble with the boy and that the mother was
feeling better than she had for years.
Dynamics. Consideration of the dynamics of this case with a few illustrative
excerpts from the others seemed to point to the following impressions.
Jack suffered some acute anxiety associated with organic illness which created
 ADELAIDE JOHNSON d a/. 70s

a tendency to regress to a greater dependency on the mother for the moment.

This is the first crucial step in the cycle to follow. The mother herselfhad been re-
cently more hostile and frustrated because of the increasing demands made by
her neurotic mother. This is an equally important factor in the genesis of the dis-
order.
Study of the early life situations of these mothers always shows an inadequately
resolved dependency relationship to their mothers with intense repressed resent-
ments. One recalls that Jack‘s mother felt she could never give him enough love-
that she should have been free to devote all her time to him as a little boy. This
with many other similar comments suggests strongly the dependency relationship
of Jack to his mother was never well resolved. What happens when Jack’s mother,
herself recently deprived and needing new satisfactions, begins to renew over-
indulgence to her child for the gratification it affords him and her? Though grati-
fied to some extent because of the child’s revived dependence on her, she feels
aroused within her a t the same time great resentment regarding granting to any-
one that which she was not given. Thus Jack’s mother reacted to his bid for re-
newed dependence with indulgence first and then with hostile envy. She clearly
indicated her envy and resentment by competing with him in the sphere of ill-
nesses, her headaches became worse, she felt that he should serve her refreshment
in bed, etc. She felt guilty regarding her resentment, however, and sensing his
rage a t her none too subtle frustrations and begrudging, she began to vacillate
in firmness in all situations. Furthermok, his rage aroused in her a recognition of
a mirror image of her own reaction to her mother’s dependent, infantile demands
and begrudgings, and this in turn led to even further guilt and vacillation in firm-
ness on her part. “When he looks so wild and angry and pale,” said the mother,
“I cannot stand it-it scares me and I give in. I can’t make him go to school.”
Occurring concommitantly is the ever-present conflict over the child’s efforts
a t independence. The mother of one boy said, “I can’t stand to see Bob such a
sissy. I want him to stand his own ground like other boys,” and a few minutes
later commented, “I told him to go to bed a t nine o’clock and a t nine-thirty he
walked into my bedroom fully dressed, hands in pockets and whistling-just
defying me-a mother should be considered an authority.”
In treatment Jack felt less dependent on his mother and gave her one gift to
cover Mother’s Day and a birthday which were one day apart. She was angry and
complained bitterly. On the one hand, tired and resentful of the child’s dependence
she urges him to stand on his own feet, but on the other, when he tries this, she
resents it as rejection and affront to her authority. In countless subtle ways these
mothers create intense guilt in the children for their independent strivings.
What does the child do in these various situations? Sensing his mother’s wish
to have him dependent again, he a t once exploits it. One girl utilized her asthma
attacks with the anxiety they aroused in her mother to exploit indulgence to a
great degree. One child early inveigled his mother into taking him to Florida to
rest, “He looked so sick and pale.” When the mother becomes angry regarding the
degree to which she is asked to give, the child is furious and more demanding. The
706 SCHOOL PHOBIA

same rage appears when the child’s attempts a t independence are thwarted.
AH these reactions lead the child to wish to punish the mother in various ways,
particularly through not going to school. Sooner or later all these mothers were
humiliated and miserable with the criticism leveled a t them regarding the child
from the community and relatives. As onemother put it, “It is like% knife
through my heart.‘’ Also the child punishes himself for his hostile rages in a
typically self-destructive way by falling behind in school and crippling himself
for life, if not treated. All of the children show fears and sensitiveness regarding
this. Frequently they will stay indoors all day and be seen on the streets only after
children are home from school. Furthermore, being home permits the child to re-
assure Mrnself and check up to be sure his hostile destructive wishes against the
parents, particularly the mother, do not ensue. One boy frequently said to his
mother with real venom, “You’re so old and haggard looking I doubt if you will
live long and I want to be with you.”
A fundamental step in this vicious circle is finally that of mutual restitution
which involves loving, giving, over-solicitousness regarding one another’s com-
forts with the need to be near each other. This constitutes the end and beginning
of the circle and they begin again with mutual indulgence of dependence and of
all that we now know follows this first step.
Very early in this chain of events there enters as a factor the school itself. When
the teacher, as a more consistent disciplinarian, frustrates the child, she arouses
his rage. Being less dependent on the teacher, who is a diluted form of the mother,
the child’s rage inhibited toward the mother can now find expression through
displacement, and the teacher in her milieu becomes the phobic object. To avoid
the teacher and school is now the defense against being placed in the situation in
which the overwhelming anxiety is aroused. Often a child early complains that
the teacher dislikes him.
It must be emphasized that in any clinic dealing with children we encounter
countless histories of abortive school phobias and all gradations of transient
anxieties with reference to going to school. These constitute the so-called “self-
cures” which were possibly brought about by sufficient shift in the balance of life
situations to offset anything more serious. A word should be said about the rela-
tion of this acute and deep anxiety which produces absence from school and the
common form of truancy where the child often absents himself from school and
dallies here and there about the neighborhood. He does not rush home as the
phobic children do. In the cases of phobia where the child hurries home, the re-
action seems to be part of a crystallized circle of mutually partially inhibited
rages and need to make restitution where dependence and guilt of child is far
greater with respect to the mother. In school phobias the mother is, in her vacil-
lating moments, more affectionate, and therefore guilt is greater in the child,
whereas in common truancy the child senses far less genuine love from the parent.
Treatment. Because of the vicious circle of guilt already indicated to be operat-
ing, it was believed that this circle could best be broken into by a therapy which
involved a collaborative dynamic approach to mother and child-treatment
 ADELAIDE JOHNSON d 01. 707

carried out by two therapists who co-incidentally attempted to relieve the guilt
and tension in both patients. The aim in each was to foster a positive dependent
transference in which each patient was permitted indulgence of his or her de-
pendent needs and a t the same time the expression of hostilities as lived out with
the therapist. The particular conflicts which led to the acute anxiety in both a t the
onset of the disorder, as well as the basic neurotic dependence problem, had to be
resolved. This led to ultimate release of tension and anxiety in both. Treatment
of the mother led to a calmer and more secure firmness in her attitude toward the
child. The child recognized in her a new firmness and this, plus his own treatment,
led to a resolution of the previous conflict. I t cannot be over-emphasized that the
mother needs and is given treatment as intensively as is the child, and by treat-
ment we do not mean advice.
Six children were treated in a playroom where their conflicts, reflected in be-
havior toward the therapist, were dynamically understood and interpreted to
them. One pre-adolescent and one adolescent child were treated in the usual
interview situation as were the mothers in each case. Of the eight children, seven
have returned to school and seem to be well along in their adjustment. One boy
is still in treatment and only in the past three months was it seen that nothing
fundamental could be accomplished unless his mother received regular treatment
by another psychiatrist for her neurotic role.
Early in our studies the mothers were frequently treated by the social worker
and the child by the psychiatrist, but it soon became clear that the most difficult
problem had been given to the social worker, and to treat mother and child a d e
quately in most instances two psychiatrists had to work collaboratively treating
mother and child equally intensively. The duration of regular once a week treat-
ment was from five months to over a year. In considering the factors operating
in effective treatment one must recognize not only the depth to which the-thera-
pists are able to go with both patients, but also those community attitudes which
are frequently vital to the mother and operative in bringing her to the clinic be-
fore she has developed any transference. Other factors are the relative secondary
gains of child and mother from the existent phobia, for if a t any time the balance
of secondary gain moves too much to one or the other, such an imbalance becomes
an asset in breaking into the vicious circle. The history of earlier neurotic episodes
in mother and child, length of time the phobia has existed, and especially present
life satisfactions of the mother, are important criteria of the prognosis. Treatment
of the child alone might be all that is necessary if the child is older (pre-adolescent,
and if he has not been ill too long). With younger children especially, a collabora-
tive type of treatment seems to us more efficacious because such a child is more
dependent upon the mother and the latter will not free the child without intensive
treatment herself. Such collaborative treatment by two psychiatrists has been
used by this clinic in treating a number of deeply crystallized intra-familial
neurotic disorders, but this is a matter for elaboration in a subsequent paper.
Little has been said of the role of the father and treatment of him, but in several
cases fathers have been seen many times. The impression has always been gained,
708 SCHOOL PHOBIA

however, that though he and his neurosis played into the mother’s difficulties and
led to greater disturbance and frustration in her, and thus indirectly to greater
conflict in the child, still, treatment of the mother with clarification of her feelings
about the father has seemed the more direct route to a resolution of the conflicts
for the child. Fortunately, from a practical point of view, the mother is freer to
come for treatment than would be the average father.
Discussion und Conclusion. Just how does this neurosis differentiate itself from
other childhood neuroses? The syndrome of school phobia does not seem to us to
be a qualitatively new and specific entity. It is a symptom developing under very
definite circumstances. First, it appears to us that there is present a history of a
poorly resolved dependency relationship between the child and its mother. With
4
this background, two specific factors now enter in to initiate the phobia. There
always occurs at the outset in the child some acute anxiety, produced either by
organic disease or some external situation which arouses conflict, and manifested
in hysterical or compulsive symptoms. Simultaneously the mother must be suf-
fering from some new threat to her security-marital unhappiness, economic dep-
rivation, or demands that she resents. Newly frustrated in her satisfactions, she
has need now to exploit the child’s acute anxiety and his wish for dependence.
On the basis of an early poorly resolved dependency relationship, both readily
regress to that earlier period of mutual satisfaction. Now the cycle begins which
soon results in the school phobia if the child is of school age, with the teacher, in
her milieu, made the phobic object.
DISCUSSION
B. MARKEY:*
OSCAR The term “school phobia” might well include the number-
less cases of pre-school anxiety which occur among children who are afraid.to
leave home for nursery school or kindergarten. The multiple symptoms of vegeta-
tive excitement which arise a t this time are too well known to be reported here.
Roughly, they constitute another aspect of the “morning sickness” complex.
I n these cases, “morning sickness,” unlike that which occurs not uncommonly in
pregnancy, is absent over the weekend. The authors limit themselves to a dis-
cussion of cases which develop long after school experience has begun. The under-
lying psychodynamics is essentially the same, but by now so well covered up that
the difficulty seems to develop suddenly and without apparent cause.
The report ofeight cases with successes in seven is a helpful contribution to this
important clinical problem. The number may be small but the paper ought to
stimulate renewed attention on the part of many students in the field so that a
reasonable amount of experience might soon be available through other published
papers. The smallness of the number is emphasized by the differences which a simi-
lar number of cases in my own experience reveals. It is interesting that all four
boys were regarded as of the submissive type and that all four girls were described
as aggressive. I n my series, six were girls and two boys. Both boys and two of the
girls might be regarded as essentially submissive. More aggressive cbaracterology
Cleveland, Ohio.
 ADELAIDE JOHNSON rt al. 709

was revealed in the other four girls. In one of the latter, there was considerable
evidence of masculine protest. By and large, the difficulties these children were
encountering in their general, as well as school, adjustment did not include mani-
fest social difficulty in their sex lives. Their problems in this regard were hardly
more significant than one might find in any other group of children who might
encounter difficulty in group adjustment.
The children in my group had all made seemingly satisfactory early adjust-
ments a t school. They had all gone willingly to kindergarten and had apparently
made no conscious effort to stop school until the beginning of the present disorder.
I t was not difficult, however, soon to bring to light evidence of early trouble in
their home relationships. As in the experiences which the authors report, all of
these children had found their greatest hazard in their relationship with their
mothers. It need not be implied, however, that their mothers were so strikingly
protective or controlling. It was only after some search that their relationship
with the sick child was found to be a determining factor. Anxiety, which the
authors have termed the common denominator in this syndrome, was always
pronounced by the time the child was brought in for study. It was not, however,
necessarily true that these mothers had previously suffered from cumulative
anxiety in their own adjustments and that this anxiety had burst into dramatic
form with the irritating development of the child’s school phobia. I have been
more impressed with a kind of pathology in the children themselves-a pathology
which might better fit the more orthodox psychiatric diagnostic charts.
In the case of two of the girls who appeared to be troubled by their school
relationships, it was revealed that this factor was simply on the surface of a be-
ginning cycloid disorder. Both girls were about to enter puberty; both were ac-
tively nubile, already presenting cause for anxiety to their mothers through their
beginning love affairs. They refused to return to school because they had suddenly
developed fears for their competency. They were in a vicious cycle of worry over
staying away from school and fear that their weaknesses might be exposed if they
returned. They were depressed, physiologically and psychologically inhibited,
and soon considerably reduced in psychomotor output. Almost without warning,
they tended to move rapidly into relative irritation and excitement. At such times
they gaily returned to school, quickly gained momentum and, in one of the cases,
achieved high academic success because of a basic intelligence superiority. One
showed a clear-cut manic-depressive pattern by the time she was 15. Her first
difficulty related to school phobia began before she was 13. The other child, nearly
14when she first retreated from school, has been under treatment for six months
without any clear-cut change.
Another significant case is that of a girl of 15 who falls in more with the schizoid
temperament. Here the anxiety was superficially tied up with the feeling that a
group had refused to accept her, a newcomer from another city. Her mother had
presented the same problem but had defended herself with the claim that the
child could not have known it. The authors’ suggestion that anxiety in the mother
is a fundamental part of the picture was well borne out in this situation. This girl
7x0 ScHoOL PHOBIA

responded reasonably quickly to treatment, though the mother presented what

appeared to be a typical resistance to treatment success. She consistently fought
the psychiatrist’s efforts to minimize the importance of the school attendance
factor. She built up grave complications for the child’s social adjustment, fre-
quently burst out with the complaint that the child might “never” be able to
return to school, that she needed to be forcibly faced with her reality, and so on.
This girl has returned to school and is making cautious, but definite, progress.
A second girl who had refused to go back to school until the age of 13, was soon
found to be a typically paranoid schizophrene. She had stubbornly refused to re-
turn to school after a brief vague illness on the grounds that she had fallen behind
and n e g e d private tutoring. Soon there followed a complicated series of circum-
stantial rationalizations. These were reinforced by the insistence that she could
work her problem out and needed no psychiatrist. Gradually symptoms of preen-
ing became noticeable. Bizarre changes in the coiffure, application of cosmetics
and dress were soon evident and some somatic delusions had become obvious. A
somewhat similar picture developed in the case of a boy of 1 2 who failed to go to
school following an accident to his father. H e rationalized that he needed to be
near his father a t all times to be sure of his safety. The boy refused to be separated
from his father for a moment and could not be reached for direct treatment.
Two girls, both somewhat aggressive, got considerable satisfaction out of
challenging the school system. It was a means of displacing resentment against
home authority. In the one case, a girl, emotionally confused by her psychosexual
experiences, was attempting to punish her mother who was anxious for school
successes. In the other case, the girl with a pathological rejection of boys and some
suggestion of recurrent homosexual panic, was attempting to punish her father
for his supposed mistreatment of her now dead mother.
In a word, it would appear that my experience tends to be somewhat less en-
couraging than that of the authors. T o begin with, treatment has been carried on
by one psychiatrist here, whereas the authors have been able to use two when
this seemed advisable. Their success in seven of eight cases may also be accounted
for on the basis of more classical psychoanalytic techniques. M y own discipline
tends to be somewhat more eclectic, though essentially emphasizing the psycho-
analytic methodology. Psychobiologic approach has been prominent in a t least
two of the cases. One of the girls had lost weight very rapidly and appeared to be
helped a great deal through nutritional improvement and emphasis on the im-
portance of a healthy body. In another, cooperation with an endocrinologist was
very helpful in separating out the factor of hormone disorders in the production of
cycloid reactions.
I would like to mention two other important points which have been helpful.
First of all, the school system has been highly cooperative. Wherever possible, the
administrators and teachers have reorganized their program to suit existing needs.
They have also reduced the authority of the attendance officer and have even
been willing to give permanent permission for exclusion. In fact, they may be too
ready to do this in some cases. In one case they might have allowed the child to
 ADELAIDE JOHNSON el 01. 7x1

retreat completely from the outside world by consenting to give her a permanent
exclusion permit. This would have precipitated a complete retreat from reality.
One other point has to do with the relatively common experience reported by
children who may produce symptoms as severe as these in one school, perhaps
because of difficulties in relationship with a given teacher or group, and then make
an apparently good adjustment in another school. Sometimes, also, children may
exhibit symptoms which may belie their true fear of school, yet be fundamentally
suffering from the same kind of school phobia. They may be getting themselves
into difficulty so as to force school authorities to punish them, perhaps even to
exclude them, when their basic desire may be to escape school altogether because
of a fundamental fear of the situation. Finally, my experience emphasizes the
belief that this syndrome is not fundamentally a sign of disorder in the school-
child relationship, but has its roots in a characterologic level long before the
beginning of school life.

Most children’s constitutions are either spoiled, or at least harmed, by cockering and
tenderness.
I would not have little children much tormented about punctilios or niceties of breed-
ing. Never trouble yourself about those faults in them, which you know age will cure.
J. LOCKE