Anxious school refusal: these warning signs that should alert parents

Behind what was once called school phobia lies a more complex reality: anxious school refusal. A disorder on the rise sharply among adolescents, often revealing deep suffering. How can you spot it? And most importantly, how can you help your child? We have answers with paediatric psychiatrist Marcelline Renaud-Yang and neuropsychologist Daniela Lima Dias. MonacoSanté keeps you informed.

A genuine struggle, not a whim

It is an intense and uncontrollable fear that prevents going to school. In France, nearly 5% of adolescents are affected, a figure rising sharply since the health crisis. Contrary to popular belief, these young people do not refuse school out of opposition. They want to go but cannot. "The adolescent is overwhelmed by emotional distress that manifests itself in the form of excessive fear and significant somatic symptoms", describes paediatric psychiatrist Marcelline Renaud-Yang, who works at the Plati Centre. While the term school phobia appeared in 1941, with the generalisation of compulsory schooling, it was progressively abandoned by the medical sphere in the 1960s in favour of anxious school refusal (ASR), considered more encompassing. On the physical level, young people report palpitations, cold sweats, headaches, a knot in their stomach or sleep disturbances. This state leads to increasingly marked absenteeism "not at all concealed from parents". On the psychological level, both experts are clear: ASR is a manifestation, or even a consequence, of one or more underlying anxiety disorders. "Overnight, the child goes from academic success to a total inability to attend class. Parents then look for a single cause", summarises the specialist. Yet the reality is far more complex. One should not confuse ASR with school dropout either. "In the first case, it is a matter of intense emotional distress with anxiety manifestations and functional signs linked to school confrontation. Conversely, in school dropout, the adolescent gradually abandons their studies without necessarily experiencing anxiety: motivation disappears, meaning fades and other objectives take over", explains neuropsychologist Daniela Lima Dias.

Key ages to watch out for

Are there more vulnerable profiles? Are certain periods of life more conducive to this? "We clearly observe two age peaks that require particular vigilance. First around 11-12 years old, when transitioning from primary to secondary school. Then between 14 and 16 years old, in year 9, 10, or 11. These periods correspond to peaks in the appearance of anxiety disorders in general", indicates the paediatric psychiatrist. These pivotal moments coincide with increased awareness of social and school pressures, while puberty amplifies vulnerabilities. "Adaptation capacities are then put to the test", adds Daniela Lima Dias. ASR often results from a combination of environmental, family and individual factors: low self-esteem, social pressure (through social networks in particular), increased school demands (Middle School Diploma Level, Parcoursup, Baccalaureate), but also difficult family circumstances (separation, illness, tensions, overprotection). Identifying what lies behind the symptoms is essential, as the stakes are high. "Approximately 50% of these young people risk developing depression. And 30% a psychiatric condition, such as generalised anxiety disorder or personality disorder, bipolar disorder, etc.", warns Dr Renaud-Yang.

A therapeutic framework linking family, care and school

Faced with this fragility, the objective is to gradually restore the young person's capacities, provided intervention occurs before complete breakdown. "When they arrive for consultation, parents have already tried everything: threats, enticement, total understanding, or, conversely, rejection. Most of the time, they have exhausted their resources", notes the paediatric psychiatrist. Many have tried various approaches such as sophrology, meditation, or acupuncture. This delay could complicate the situation: "At an advanced stage, it becomes very difficult to bring a withdrawn adolescent to consultation. Even the implementation of care can be hindered". To make the care pathway more visible and accessible, a screening and management protocol is being rolled out in collaboration with the Department of Education, Youth and Sport (DENJS) and the Medical Inspectorate for Schools. "There must be a genuine partnership between the healthcare sector, schools, the family and the young person. Without this, nothing works", insists Dr Renaud-Yang. From the next school year, initial screening in secondary schools in the Principality could allow, with parental consent, referral to the Medical Psychology Service (Plati Centre). "We are committed to receiving young people quickly for a thorough assessment, using questionnaires and assessment scales. The objective is to identify underlying anxiety disorders, those affecting learning that are hidden or relational, or even possible depressive complications", clarify the specialists. This scheme will also include a monitoring unit for at-risk profiles.

Therapy: the key to returning to school

"We must seek to eliminate or address the hidden disorders. And it is this work that allows, gradually, to deconstruct ASR", clarifies the neuropsychologist. Care must be integrated. It is only through these efforts that the adolescent will return to class cognitive behavioural therapy (CBT) is today the most effective approach. "It involves reflection on causes and false beliefs. But also work on progressive exposure consisting of gradually approaching the school, and creating reassurance zones to overcome each step", explains Dr Renaud-Yang. Beyond individual therapy, the protocol also provides for group therapy and work on parental support. Finally, it is sometimes necessary to introduce medication. This care pathway also goes through specific adjustments. Behind ASR, there is above all an adolescent in distress who needs to be understood, supported and cared for. "In life, we are faced with many difficult events. It is a hurdle that must be overcome together, so that the young person and their family are no longer isolated. They must see a healthcare professional and should not hesitate to reach out to the school", concludes the paediatric psychiatrist.

Dr Renaud Yang & Dr Lima Dias