School is an essential part of a child’s life. It is where children learn, make friends, develop new skills, and experience situations that contribute to their growth. But what happens when going to school itself becomes a source of fear and anxiety?This is when a different journey may begin, marked by morning tears, refusal to go to school, repeated complaints of stomachaches or headaches, or excessive attachment to parents.Some people may assume that a child refuses to go to school because of stubbornness or laziness. However, behind this refusal there may be a genuine fear that the child does not know how to express. The child may be afraid of being separated from their parents, being bullied, failing academically, or facing an embarrassing or uncomfortable situation. In some cases, a negative experience may cause the child to associate school with fear and anxiety.This pattern of intense fear associated with school is commonly referred to as school phobia. It is not simply a temporary desire to stay at home; if left unaddressed, it can affect a child’s school attendance, academic performance, social relationships, and self-confidence.Therefore, addressing school phobia begins with a simple but important question: What is frightening the child?Understanding the underlying cause is the first step toward helping the child, rather than relying solely on blame or forcing them to confront their fears without adequate support.At Dalili Medical, this article explores school phobia in children, including its main causes and symptoms, its potential impact on the child, and effective ways for families and schools to provide support and help reduce these fears.

1. What is school anxiety?

School anxiety is a feeling of fear, stress, or discomfort related to school, studying, exams, or relationships with teachers and classmates. It may affect a child’s behavior and academic performance.

2. Is school anxiety the same as school phobia?

No. School anxiety is a broader concept, while school phobia refers to an intense and persistent fear of going to school or staying there. It may cause a child to avoid or refuse to attend school.

3. What are the main causes of school anxiety?

School anxiety may result from fear of exams or failure, learning difficulties, bullying, or problems with classmates or teachers. It may also be associated with family-related stress, social anxiety, or fear of separation from parents.

4. How can I tell if my child is experiencing school anxiety?

A child may show several signs, such as crying before going to school, refusing to attend, repeatedly complaining of stomachaches or headaches, having difficulty sleeping, feeling tense, withdrawing socially, experiencing difficulty concentrating, or showing a decline in academic performance.

5. Can a child experience anxiety without talking about it?

Yes. A child may not always be able to express their feelings in words and may instead show anxiety through certain behaviors, such as avoiding school or homework, becoming irritable, remaining unusually quiet, becoming overly attached to their parents, or repeatedly complaining of physical symptoms.

6. Does school anxiety affect academic performance?

Yes, particularly when the anxiety is severe or persistent. It may lead to difficulties with concentration and memory, avoidance of classroom participation, difficulty performing during exams, and reduced motivation to learn, which may negatively affect academic performance.

7. Does stomach pain or a headache mean that the child is pretending to be sick?

Not necessarily. Anxiety can cause genuine physical symptoms, such as stomachaches or headaches. However, it is important not to assume that these symptoms are caused solely by anxiety, especially when they are severe or recurrent. Other possible medical causes should also be considered and evaluated.

8. How can parents help their child?

Parents can help by listening to their child and acknowledging their feelings without blame or criticism, trying to identify the source of the anxiety, establishing a regular sleep and study routine, and teaching simple relaxation and stress-management techniques. Parents can also encourage their child to gradually face situations that trigger anxiety while maintaining ongoing communication and cooperation with the school.

9. Should a child be forced to go to school?

When a child refuses to attend school, it is important to first understand the underlying reasons for the refusal. Forcing or punishing the child alone may not solve the problem, particularly if the child is experiencing bullying, severe fear, or a psychological or behavioral issue that requires professional support.

10. When does a child need professional help?

Professional help is recommended when anxiety is severe or persistent, causes frequent school absences or school refusal, leads to a noticeable decline in academic performance, disrupts sleep, causes recurrent physical symptoms, or significantly affects the child’s daily life, relationships, or usual activities.

11. Can school anxiety go away on its own over time?

Experiencing anxiety for a short period can be normal in certain situations, such as feeling nervous before an important exam. However, persistent or increasing anxiety may require appropriate support and intervention rather than simply waiting for it to go away on its own.

12. Can school anxiety be prevented?

The likelihood or severity of school anxiety may be reduced by providing a safe and supportive home environment, avoiding excessive pressure and constant comparisons, teaching children healthy ways to cope with stress, and paying attention to academic or social difficulties they may be experiencing. Early communication and ongoing cooperation with the school are also important when signs of anxiety begin to appear.

Causes of School Anxiety

The causes of school anxiety vary from one child to another. Anxiety may be related to academic, social, family, or psychological factors. Some of the most common causes include:

1. Fear of Exams and Grades

Some students may experience significant anxiety because they fear failing or receiving low grades. They may also believe that academic success is the primary measure of their personal worth.

Anxiety may also be associated with fear of forgetting information during an exam, pressure caused by frequent tests and homework, or comparing their grades with those of their classmates.

Example: A student may experience stomach pain or severe anxiety as an exam approaches.

2. Fear of Failure or Making Mistakes

Some students set extremely high standards for themselves and may feel that making mistakes is unacceptable. This can lead to behaviors and emotions such as:

• Excessive perfectionism.

• Fear of participating in class.

• Avoiding answering questions even when the student knows the correct answer.

• Constantly thinking about possible negative outcomes.

3. Problems with Classmates

Social relationships are an important part of a student’s school experience and can become a source of anxiety when the child experiences problems with classmates, such as:

• Bullying or teasing.

• Feelings of rejection or isolation.

• Conflicts with friends.

• Fear of speaking in front of others.

• Worry about not being accepted by the group.

4. Fear of Teachers or the School Environment

A student may experience anxiety because of certain experiences or situations at school, such as:

• Harsh or intimidating treatment by some teachers.

• Fear of punishment or being reprimanded in front of classmates.

• Feeling constantly monitored or evaluated.

• Experiencing embarrassing or negative situations in the classroom.

5. Family Pressure

School anxiety may increase when a child experiences family-related academic pressure, such as:

• Extremely high academic expectations.

• Constant criticism over grades.

• Being compared with siblings or classmates.

• Intense fear of the parents’ reaction to low grades.

• Family problems or tension that affect the child’s sense of safety and stability.

6. Learning or Concentration Difficulties

A student may experience recurring anxiety when they struggle with certain academic skills or subjects, such as:

• Reading or writing.

• Mathematics and arithmetic.

• Understanding certain school subjects.

• Maintaining concentration for extended periods.

• Managing time and completing homework.

In such cases, anxiety may not be the primary problem. Instead, it may develop as a result of repeated experiences in which the student finds schoolwork difficult or feels unable to keep up with academic demands.

7. Transitions or Major Changes

Anxiety may develop when a student experiences significant changes in their academic or personal life, such as:

• Moving to a new school.

• Transitioning to a more challenging academic stage.

• Changing teachers or classes.

• Moving to a new city or country.

• Being separated from friends or a familiar environment.

8. Fear of Separation from Parents

This type of anxiety is more common among younger children. Going to school may trigger fears about being separated from their parents. It may appear as:

• Crying when going to school.

• Becoming overly attached to their parents.

• Refusing to go to school.

• Worrying that something bad may happen to their parents while they are away.

9. Social Anxiety

Some students may experience intense anxiety in situations that require interaction with others or place attention on them, such as:

• Answering questions in front of the class.

• Speaking with the teacher.

• Giving an oral presentation in front of classmates.

• Eating in front of others.

• Making new friends.

10. Lack of Sleep and Fatigue

Not getting enough sleep, combined with academic pressure, can increase stress and anxiety. As a result, the student may become:

• More irritable and emotionally reactive.

• Less able to concentrate.

• More sensitive to school-related situations.

• More likely to experience fatigue and anxiety.

11. Previous Negative School Experiences

If a student has experienced something frightening or embarrassing at school, they may begin to anticipate that it will happen again. Examples include:

• Being teased or humiliated in front of classmates.

• Failing an important exam.

• Experiencing bullying.

• Being punished or reprimanded in front of others.

Such experiences may cause the child to associate school with fear and anxiety, which can affect their sense of safety and their willingness to attend school.

Symptoms of School Anxiety

The symptoms of school anxiety vary from one student to another. They may appear before going to school, while the child is at school, or even when simply thinking about school. These symptoms can be classified into emotional and psychological symptoms, physical symptoms, behavioral symptoms, academic and cognitive symptoms, as well as sleep-related symptoms.

1. Psychological and Emotional Symptoms

School anxiety may appear as a range of emotions and thoughts, including:

• Persistent feelings of fear or tension related to school.

• Excessive worrying about school-related matters and expecting negative things to happen.

• Fear of failure or not passing.

• Fear of exams or answering questions in front of teachers and classmates.

• Feeling unsafe or uncomfortable at school.

• Irritability and increased emotional sensitivity.

• Feelings of sadness or frequent crying.

• Low self-confidence and feeling incapable of succeeding.

• Difficulty relaxing and feeling that the mind is constantly occupied with worries.

2. Physical Symptoms

Anxiety can manifest through various physical symptoms, including:

• Rapid heartbeat.

• Increased sweating.

• Trembling of the body or hands.

• Headaches.

• Stomach pain or digestive problems.

• Nausea or feeling the urge to vomit.

• Dizziness or feeling unsteady.

• Shortness of breath or difficulty breathing.

• Muscle tension or tightness.

• Fatigue and exhaustion.

• Frequent need to use the bathroom.

3. Behavioral Symptoms

School anxiety may also lead to changes in a student’s behavior, such as:

• Trying to avoid going to school.

• Being repeatedly late for school.

• Frequently asking to go home.

• Crying or becoming overly attached to parents when going to school, particularly among younger children.

• Making excuses or finding reasons to avoid going to school.

• Avoiding participation in school activities.

• Avoiding answering questions or speaking in front of others.

• Withdrawing from classmates and social activities.

• Repeatedly asking to stay at home.

4. Academic and Cognitive Symptoms

Anxiety can affect a student’s ability to concentrate, learn, and perform academically. Common signs include:

• Difficulty concentrating and paying attention.

• Frequent forgetfulness.

• Difficulty understanding lessons due to preoccupation and anxiety.

• Declining academic performance.

• Difficulty completing homework.

• Hesitation to participate in class.

• Repeatedly thinking about mistakes and grades.

• Feeling unable to complete required tasks.

5. Sleep-Related Symptoms

School anxiety may also affect a student’s sleep pattern. Possible symptoms include:

• Difficulty falling asleep, especially before school days or exams.

• Frequent waking during the night.

• Waking up early while feeling tense or anxious.

• Occasional nightmares.

• Feeling tired and exhausted in the morning.

How Does a Child Express School Anxiety Without Talking About It?

Children are not always able to express their anxious feelings through words. Instead, anxiety may become noticeable through their everyday behavior and actions. A child may refuse to get up in the morning, take an unusually long time to get ready for school, or try different ways to avoid going to school.

The child may also experience recurring physical symptoms, such as headaches or stomachaches, even when there is no obvious medical cause. Some children may become more withdrawn or lose interest in playing and participating in activities they previously enjoyed.

Therefore, any sudden or persistent change in a child’s behavior deserves attention. It may be a sign of underlying feelings of anxiety or fear that require understanding and support rather than blame or punishment.

Anxiety-Related Behaviors in Children

The way children express anxiety varies depending on their personality, age, and circumstances. Some children may become extremely attached to their parents and refuse to be separated from them, even for short periods. Others may express anxiety through tantrums, frequent crying, or withdrawal from interactions with others.

Other behaviors may also appear, such as difficulty sleeping, waking during the night because of nightmares, or refusing to sleep alone. Some children may also engage in repetitive behaviors, such as nail biting, thumb sucking, or excessive movement, as responses to stress and emotional tension.

Observing these behaviors and understanding the situations in which they occur can help parents respond to their child’s anxiety in a calmer and more supportive way.

Sleep Problems in Children

Sleep disturbances can be among the signs that appear when a child is experiencing anxiety or stress. The child may have difficulty falling asleep, wake up several times during the night, or experience disturbing nightmares that cause them to wake up frightened or crying.

Some children may refuse to sleep alone or ask a parent to stay beside them throughout the night. Persistent sleep problems can affect a child’s mood, ability to concentrate, and academic performance. Therefore, it is important to monitor these difficulties, pay attention to their possible causes, and address them at an early stage.

School Avoidance

School avoidance may be one of the behaviors seen in some children who experience anxiety or face problems related to the school environment. A child may use various excuses to avoid going to school, such as complaining of feeling unwell or exaggerating certain physical symptoms.

School avoidance may also appear as extreme slowness when getting ready in the morning or repeatedly creating conflicts or problems before it is time to leave for school. These behaviors should not always be interpreted as stubbornness or laziness, as they may be the child’s way of expressing fear or a problem that they are unable to communicate in words.

The Impact of School Anxiety on Academic Performance and Psychological Development

School anxiety can affect a child in several areas, particularly when it is severe or persistent. Its effects are not limited to emotional well-being but may also extend to the child’s ability to learn, social relationships, and perception of themselves and their abilities.

First: The Impact of School Anxiety on Academic Performance

Difficulty concentrating and paying attention: Constantly worrying about fear, results, or mistakes may limit the child’s ability to focus on the teacher’s explanations and follow lessons.

Difficulty understanding and recalling information: Severe anxiety may make it harder for a child to process or recall information, particularly during exams and situations that require quick performance.

Poor exam performance: A child may know the correct answer but have difficulty remembering or expressing it because of stress and psychological pressure.

Avoiding studying and homework: The child may begin postponing homework or avoiding subjects they feel unable to master.

Frequent absences or lateness: When anxiety becomes associated with school itself, the child may try to avoid attending, which can result in missed lessons and accumulating learning gaps.

Reduced classroom participation: The child may hesitate to answer questions or ask them because of fear of making mistakes, being teased, or receiving criticism.

Reduced motivation to learn: If anxiety continues for a long time, the child may begin to view school as a source of pressure and stress rather than an environment for learning and development.

Second: The Impact of School Anxiety on Psychological Development

Lower self-confidence: The child may begin to believe that they are unable to succeed or that they are less capable than their classmates.

Increased fear of failure: The child may view mistakes as evidence of incompetence rather than as a normal part of the learning process.

Increased sensitivity to criticism: The child may be strongly affected by comments or guidance, even when they are minor or intended to be helpful.

Mood changes: Anxiety may be accompanied by sadness, tension, irritability, or increased anger.

Avoidance of social situations: The child may reduce interactions with classmates or avoid certain social activities because of fear of embarrassment or negative evaluation.

Reduced sense of safety and belonging: If school becomes consistently associated with fear and pressure, the child may feel uncomfortable or disconnected from the school environment.

Developing a negative self-image: Repeated experiences of failure or fear may contribute to negative thoughts about oneself, such as, “I can’t succeed” or “I always make mistakes.”

Treatment of School Anxiety with Medication

Medication is not the first treatment option for every child experiencing school anxiety. The choice of treatment depends on the cause and severity of the anxiety, the child’s age, and the extent to which symptoms affect school performance and daily life. Any decision to use medication should be made and monitored by a child and adolescent psychiatrist or another qualified healthcare professional who can properly assess the child’s condition.

1. Psychotherapy First in Many Cases

Cognitive behavioral therapy (CBT) is commonly used to treat anxiety disorders in children and adolescents. It can help children:

• Understand anxiety-related thoughts and fears and respond to them in more realistic ways.

• Develop skills for relaxation and managing anxious feelings.

• Gradually face anxiety-provoking school situations instead of continuing to avoid them.

• Manage fears related to exams, evaluation, or social interaction.

Psychotherapy alone may be appropriate for some mild to moderate cases. In more severe cases, or when improvement with psychotherapy is insufficient, a doctor may consider adding medication.

2. Selective Serotonin Reuptake Inhibitors (SSRIs)

In some cases of severe or persistent anxiety, a doctor may prescribe a medication from the selective serotonin reuptake inhibitor (SSRI) class, depending on the diagnosis, the child’s overall health, and age.

Medications that may be used for certain anxiety disorders in children and adolescents, depending on the individual case and medical assessment, include:

• Fluoxetine.

• Sertraline.

• Fluvoxamine in specific cases.

These medications do not work immediately. Improvement may take several weeks to become noticeable. The doctor determines the appropriate medication and dosage based on the child’s condition, age, and response to treatment.

3. The Importance of Medical Monitoring

When an SSRI is prescribed to a child or adolescent, regular medical follow-up is important, particularly during the early stages of treatment or after a dosage adjustment. Monitoring may include watching for changes such as:

• Increased anxiety or irritability.

• Changes in sleep or appetite.

• Noticeable changes in behavior or mood.

• Thoughts of self-harm or other concerning psychological changes.

Mentioning these possible effects does not mean that they will necessarily occur. Rather, it highlights the importance of medical monitoring and contacting the treating doctor if any unusual changes appear.

4. Medications That Should Not Be Used Without Medical Supervision

Children should not be given sedatives or anti-anxiety medications without a prescription or professional supervision, particularly benzodiazepines such as diazepam or alprazolam. These medications may cause drowsiness and dependence and are generally not the preferred option for long-term treatment of anxiety in children.

5. Does Every Child with School Anxiety Need Medication?

No. Not every child requires medication. In cases of mild anxiety, such as the usual nervousness before certain exams, study-management skills, relaxation techniques, family support, and psychological interventions may be appropriate and sufficient.

Exercises for Managing School Anxiety

Several simple exercises can be used to help children reduce stress and cope more effectively with anxiety-provoking school situations. Practicing these exercises does not necessarily mean that a child needs medication. They can be used alongside family support and psychotherapy when appropriate.

1. Deep Breathing Exercise

Deep breathing can help calm the body and reduce tension when a child feels anxious.

How to practice:

• Slowly inhale through the nose for about 4 seconds.

• Hold the breath for approximately 2 seconds.

• Slowly exhale through the mouth for 4–6 seconds.

• Repeat the exercise about 5 times.

It is preferable to practice this exercise at home first so that the child can use it comfortably before entering school or taking an exam.

2. Progressive Muscle Relaxation

This exercise can help reduce the physical tension associated with anxiety by briefly tightening different muscle groups and then relaxing them.

For example, the child can:

• Clench their hands and then relax them.

• Tighten their shoulders and then relax them.

• Tense the facial muscles and then relax them.

• Tighten the leg muscles and then relax them.

The exercise should be performed calmly while maintaining regular breathing.

3. “Talking Back to Anxiety” Exercise

This exercise helps children distinguish between anxiety-driven thoughts and actual facts.

For example, if the child says:

“I’m going to fail the exam.”

They can be guided toward a more realistic thought, such as:

“I feel scared, but I can study and do my best. I don’t have to perform perfectly.”

The goal is not to force the child to think positively in an artificial way, but to help them approach their thoughts in a more realistic and balanced manner.

4. Gradual Exposure Exercise

If a child avoids a particular school situation because of anxiety, the situation can be divided into small, gradual steps rather than confronting it all at once.

For example, if the child is afraid of speaking in front of the class, they could gradually:

• Talk with one of their parents.

• Speak in front of a sibling.

• Speak in front of a small group of people.

• Practice answering a question in front of the teacher.

• Give a short answer in class.

The child should ideally move to the next step when the previous one becomes more manageable, without forcing them to immediately face the most difficult situation.

5. Realistic Positive Visualization

The child can sit in a quiet place and imagine a school situation that causes anxiety, such as taking an exam. They can then visualize themselves handling the situation step by step:

• Entering the exam room calmly.

• Sitting in their seat.

• Taking a slow breath.

• Reading the questions one at a time.

• Starting with the questions they know how to answer.

This exercise allows the child to mentally practice coping with the situation rather than viewing it as a threat or as an experience they cannot handle.

6. The “5-4-3-2-1” Grounding Exercise

This exercise can be used when the child experiences a high level of anxiety. It helps redirect their attention toward their surroundings and the present moment.

Ask the child to focus on:

• 5 things they can see.

• 4 things they can touch.

• 3 things they can hear.

• 2 things they can smell.

• 1 thing they can taste, or alternatively, they can focus on their breathing.

This exercise can help shift attention away from anxious thoughts and toward the present moment.

7. Physical Activity

Physical activity can be an important part of a child’s daily routine. Examples include walking, running, cycling, playing, or participating in a sport appropriate for the child’s age and interests.

Regular physical activity can help improve mood and reduce stress in many children. It can also provide a healthy way of coping with everyday pressures.