Abdominal pain, disturbing thoughts, social fear, and anxiety over failure: For some children, emotional challenges and anxiety can transform everyday situations – such as meeting friends, leaving the house, or returning to school – into a source of real distress. At Schneider, a unique program was developed designed to assist children and adolescents dealing with avoidance and emotional difficulties, including school anxiety and avoidance of the educational setting, through group activity that included art, emotional regulation skills, social games, and encounters with dogs.
Within the category of students who do not attend school regularly, there are students defined as school refusers. This is a diverse group that includes students who are unwilling to attend school alongside students who demonstrate significant signs of anxiety when required to attend the educational setting.
School refusal can manifest in a wide range of symptoms. Sometimes it involves physical and emotional restlessness, and at times negative self–thoughts or the fear that something bad will happen at school. Children may complain of abdominal pain, nausea, difficulty breathing, embarrassment, social fear, fear of aggression from others, fear of getting "stuck" in front of tasks or in front of the class, a feeling that they are being judged by those around them, or a sense of loneliness.
"Sometimes those around them interpret the avoidance as a lack of desire to go to school, but in many cases it is a real difficulty," explains Tzipi Hershkovitz, a social worker in the Mental Health Department at Schneider Children's Medical Center. "Children can experience very great distress surrounding attendance at school, to the point of physical symptoms such as abdominal pain, difficulty breathing, or a feeling that something bad is about to happen. It is important to understand that they do not choose to feel this way, which is why they need tailored support rather than criticism."
The reasons for avoidance are also varied. For some children, it is the fear that they will not meet academic requirements, while for others it is the fear of bullying or the fear of disappointing their parents. Due to the complex and individual nature of these problems, it is difficult to establish a single clear definition for school fear or school refusal, and accordingly, it is also difficult to estimate the extent of the phenomenon. Therefore, close cooperation is required between the education system, the family, and professionals in order to provide each student with the response appropriate to their needs. The treatment is adapted to the reasons that led to the difficulty. Following a professional evaluation, support frameworks are built for the children and their families aimed at assisting in a return to functioning and to the educational framework.
In cases of school anxiety, children experience real distress surrounding attendance at school. In contrast, school refusal is often perceived as avoidance of attending the framework for any reason, although overlap sometimes exists between the conditions. When the source of anxiety is identified, a combination of supportive parental authority can be offered alongside the creation of a safe, consistent, and gradual environment that will assist the child in returning to school. Simultaneously, emotional therapy can be provided that helps in understanding the anxiety, learning emotional regulation techniques, and experiencing gradual exposure to situations that evoke difficulty and avoidance. In certain cases, educational or emotional support is also provided within the school framework, and occasionally medication is required to reduce the intensity of the anxiety.
In contrast, in cases of school refusal, a broader intervention is sometimes required that includes entities in the community and the education system, alongside the construction of an organized plan for returning to the framework or finding a suitable alternative framework. In these cases as well, it is important to identify the emotional and psychological factors that may contribute to the development and persistence of the phenomenon.
"Once the source of avoidance is identified, an intervention plan tailored to the child and family can be built," says Dr. Ella Yaniv, a psychiatrist and director of the Crisis Intervention Center in the Mental Health Department at Schneider Children's Medical Center. "The goal is to help the child develop a sense of capability, acquire tools for anxiety regulation, and gradually return to the educational setting. The earlier the intervention takes place, the greater the chance of preventing worsening of the avoidance and impairment of functioning."
'The connection with animals allows children to open up'
Against the backdrop of these challenges, Schneider Children's Medical Center developed a unique program spanning two weeks for children and adolescents dealing with school avoidance and emotional difficulties that made it hard for them to attend the educational framework on a regular basis. The program's objective was to allow participants to re–experience a group framework prior to the start of the school year, in a safe, containing environment tailored to their needs.
For two weeks, the children arrived for five two–hour sessions a day and participated in a variety of activities designed to gradually prepare them for the return to school. The program included art workshops, DBT groups for developing emotional regulation skills and coping with stress, social games, and group meetings with therapy dogs that regularly visit the hospital as part of the Patient Service and Experience Unit. All of these were intended to help the children cope with their fears, practice integrating into a peer group, and strengthen their sense of capability ahead of the return to school.
"The idea was to create a sort of dress rehearsal for the children ahead of the opening of the school year," Dr. Yaniv explains. "For the children, the mere act of coming to the framework, meeting a group of their peers, and experiencing joint activity are significant steps. The non–judgmental and safe environment allowed them to re–engage in social connections and accumulate experiences of success." Despite the initial anxiety with which some participants arrived at the program, many managed to create new social connections, participate in group activities, and gradually experience situations they had previously avoided. For them, meeting other children experiencing similar difficulties provided a sense of belonging and understanding.
This is not the only framework in which a therapeutic process can be undergone in a group. At Schneider, there are several groups comprising patients and care professionals that serve as a therapeutic framework where patients can talk freely with their peers in an environment with care professionals who assist in mediation. There, acceptance and support from children dealing with similar challenges are facilitated, fostering a sense of belonging and reducing the feeling of standing out that often characterizes children dealing with emotional difficulties. In the group, participants can share and help others alongside the presence of care professionals who maintain the discussion as health–promoting and therapeutic.
One of the prominent components of the program was the meeting with Keren Matry – a medical dog trainer – and the therapy dogs Teddy and Yuli. Through the joint activity, the children learned to communicate, express feelings, develop self–confidence, and participate more actively in what was happening around them. "The connection with animals allows children to open up, build trust, and feel safe even when words do not come yet," says Hershkovitz. "For some of them, it was a pleasant and non–threatening way to integrate into the group, connect with other children, and face the fears accompanying them ahead of the return to school."
According to the professionals at Schneider, one of the most significant things for children dealing with school anxiety is the realization that they are not alone. "When a child meets peers who experience difficulties similar to their own, they understand they are not abnormal and that help is obtainable," Hershkovitz concludes. "The ability to talk about fears, practice new skills, and experience small successes in a safe environment is often the first step on the path back to school, to routine, and to a sense of self–confidence."