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1.1 Background

1.2 Justification of Study

1.3 Objective of Study

1.4 Significance of Study

1.5 Conceptual framework

1.6 Research Question

1.7 Operational definition


2.1 Introduction

2.2 Review of literature


3.1 Research Design

3.2 Research setting and population

3.3 Sampling

3.4 Instrumentation

3.5 Data collection procedure

3.6 Data analysis procedure

1.1 Background
The term school phobia was first used in 1941 to identify children who fail to attend school
because attendance causes emotional distress and anxiety. In Great Britain and as of the early
2000s in the United States, the term school refusal is preferred. ((“School Phobia/School
Refusal - symptoms, average, Definition, Description, Demographics, Causes and symptoms,
Diagnosis,” n.d.).

School refusal behaviour refers to the child’s refusal to go to school and/or persistent
difficulty to remain in class for the entire school day, which manifest in children and
adolescents from 5-17 years of age.(Inglés, Gonzálvez-Maciá, García-Fernández, Vicent, &
Martínez-Monteagudo, 2015).

School refusal is not truancy , but a serious behavioural problem that can have detrimental
consequences. Empirical treatment involves a collaborative approach of cognitive and
behavioural therapies involving the child, parents and school.(“School refusal: identification
and management of a paediatric challenge | Australian Medical Student Journal,” n.d.)

School phobia or school refusal is an emotional disorder of the children who are afraid to leave
the parents, especially mother and prefer to reamin at home and refuse to go to school
absolutely.(Wong DL ,Hockenberry MJ.Wong’s Nursing Care of Infants and children.7th
ed.USA) .

School refusal is generally thought to encompass difficulties attending or staying in school and is
associated with extreme emotional distress. The child stays home with their parents’s knowledge
, despite the parents having made a reasonable attempt to encourage the child to attend school.
(“School refusal: identification and management of a paediatric challenge | Australian Medical
Student Journal,” n.d.)

School refusal is defined as a child’s inability to continue school for reasons, such as anxiety and
depression. The prevalence of school refusal has been reported to be approximately 1% in
school-age children and 5 % in Child psychiatry samples. It’s prevalence is similar in boys and
girls. (Burke AE, Silverman WK,1987).

Boys and girls refuse to attend school at the same rates. School phobia is highest in children ages
5-7 and 11-14. These ages corresponds with starting school, and transitioning through middle
school or junior- high school, both unusually stressful periods.(“School Phobia/School Refusal -
symptoms, average, Definition, Description, Demographics, Causes and symptoms, Diagnosis,”

Anxiety disorders are the most common psychiatric diagnosis in school going children
worldwide, with an estimated overall prevalence rate of 8%. An Indian study reported the
incidence of childhood psychiatric disorders as 18/1000/year.(Bakhla et al., 2013).

A prospective observational community based survey was done in South Korean First graders
where participants were 277 children, aged 6-7 years. Out of them 248 children responded to the
follow-up survey , 7.66% of children met the criteria for school refusal behavior during the 3
months after entering primary school.(Park et al., 2015).

A study was conducted in 5 elementary schools of Takaoka city in Japan where study population
was 2,057 children.out of them1,698 respondents were relevant for this study and 32.2% children
had the feeling of avoiding the school(Akimoto, Sekine, Yamada, & Tatsuse, 2017).

School phobia is an international problem with an estimated rate of 2.4% of all school age
children (Moirangthem,2013).

School phobia is a serious disorder affecting upto 5% of elementary & middle school children
1.2 Justification of Study

Study conducted on Banglore 2006 to know the outcome of children with school phobia
revealed that 29 children (87.9%) have school phobia and other 63.6% are disorder of
depression. The study concluded that children with school phobia are to be investigated and
proper care should be given by the parents (, Johnson.JH, 2001).

Upto 60% of students at secondary schools in Germany report having avoided school for several
hour or even a whole day over the course of their schooling.(Knollmann, Knoll, Reissner,
Metzelaars, & Hebebrand, 2010).

More than ¼ of all youth will engage in some degree of school refusal during their schooling
years, ranging from complaints and threats to avoid school, to missing school for months or even
years at a time. School refusal peaks at several points of development including with entry into
kindergarten, between ages 7-9 and again with entry into middle or high school (admin, 2015).

A prospective community survey was conducted in adolescents, where school phobia was noted
in 4.8% of adolescents. Panic disorder, Social anxiety disorder and Seperation anxiety disorder
were significantly related to school phobia.(Nair et al., 2013).

School refusal is not a formal psychiatric diagnosis. However children with school refusal may
suffer from significant emotional distress, especially anxiety and depression. It leads to some
consequences such as poor educational attainment, reduced employement prospects,social
isolation/ relationship problems (Fremont WP,2003).

Estimates suggest that about 4.5% of children ages 7-11 and 1.3% of children ages 14-16 are
school refusers. School phobia is an international problem, with an estimated rate of 2.4% of all
school-age children worldwide refusing to attend classes.(“School Phobia/School Refusal -
symptoms, average, Definition, Description, Demographics, Causes and symptoms, Diagnosis,”

Approximately 1-5% of all school aged children will demonstrate school refusal behaviour at
some point. One study showed that a high prevalence of adolescents with school refusal and co-
morbid depression also experienced learning difficulties, which may have been a causal factor in
their school refusal.(“School refusal: identification and management of a paediatric challenge |
Australian Medical Student Journal,” n.d.)
Severe and prolonged school refusal jeopardises the young person’s social, emotional and
academic development and may be associated with mental health problem in adulthood.(Heyne,
King, Tonge, & Cooper, 2001).

A study conducted in Banglore, India evaluated 33 subjects (8-16) years presented with school
refusal to a Tertiary Child and Adolescent Psychiatric Service. 29 subjects(87.9%) had a
psychiatric diagnosis at baseline. Depressive disorder (63.6%) was commonest followed by
Specific phobias (30.3%). Psychiatric morbidity is high in clinic population of children with
school refusal especially mood disorders(Prabhuswamy, Srinath, Girimaji, & Seshadri, 2007) .

As the problem is increasing in global context, we need to make all parents aware of this issue as
a serious problem. Most of the parents have neglected this and they think their child is
misbehaving but actually the child needs help from their parents.

1.3 Objectives of Study

*To determine the prevalance of school phobia among students of class 8 of Sunrise English
School .

*To know the factors afftecting school phobia among students of class 8 of Sunrise English
School .

1.4 Significance of Study

This research helps to find out the factors affecting school phobia.

This research will be helpful to other researcher to take this study as a reference and compare
the fact of present and past.

The findings of the study might be helpful to concerned authorities by knowing the factors
affecting school phobia.



Students of class 8 of Sun – Development of tools Prevalence of school phobia

rise-english-school among students of class 8 of
Content validity and reliability of tools
Associated factors for school
Modification of tools phobia among students of
class 8 of Sun-rise –english -

Fig: Conceptual framework on prevalence and factors affecting school phobia

1.6 Research Question

• What is the prevalence of school phobia in selected students ?

• What are the factors for school phobia in selected students?

1.7 Operational Definition

Prevalence of school phobia: in this study, prevalence of school phobia refers to dislike to go to
school or difficulty in staying at school for a whole day.

Factors for school phobia: in this study factors associated with school phobia are socio-
demographic factors, parental factors, school factors, economic factors, family environment
factors, educational status of parents.


According to a research done in South Korea -the participants were 277 children, aged 6–7 years,
who were expected to enter primary school in 2 months. The parents were surveyed about the
child‫׳‬s history of SAS(sepration anxiety symptom) and their behavior. The children were
questioned about anxiety symptoms. The children were surveyed about whether school refusal
behavior developed or not after they entered primary school . Among the 248 children who
responded to the follow-up survey, 7.66% of children met the criteria for school refusal behavior
during the 3 months after entering school. We found no significant differences in the occurrence
of school refusal behavior according to the children‫׳‬s SAS history. Familial risk factors for
school refusal behavior included low parental educational level and a working mother. School
refusal behavior by first graders cannot be fully explained by the expression of SAS and could be
implicated in a more complex psychopathology.(Park et al.,2015).

In a cross sectional study done in India , all students of class 8 were assessed using the Spence
anxiety scale. The sample consisted of 146( 55% male and 45% female) with a mean age of 12.7
years. A total of 16(11%) students scored above cutoff for high anxiety, the mean scores across
gender shows that female students scored significantly higher in total and all sub types of
anxiety. Most of the students perceived their parents “Democratic” and other two authoritarian
and permissive type of parenting weer almost equal. There was significantly higher anxiety
among the students who perceived their parents as authoritarian.(Bakhla et al., 2013).

A study was conducted on virtual reality exposure treatment for school phobia, on 33 school
phobic student at Spain. The result of the study reveals that an estimated of 2-5% of school aged
children are having frequent problem of school phobia.(Glefand & Feldman,2010).

A questionnaire survey was conducted in July 2014 and 1,936 students responded. Out of those who
responded , data from 1,698 respondents were relevant for this study. The questionnaire included question
on lifestyle factors, health status,and the social and family environments. Logistic regression analysis was
analysis was performed to evaluate whether the feeling of school avoiding school, as the dependent
variable, is associated with the independent variables such as social and family environment factors and
lifestyle factors. The odds ratios (OR) and their 95% confidence intervals (95% CI) were calculated. The
percentage of children who had the feelings of avoiding school was 32.2% in the study sample. This study
showed that feeling of school avoidance was significantly correlated with several lifestyle factors. School
health activities aiming at establishing desirable lifestyle for children could reduce the number of children
who have the feeling of school avoidance (Akimoto et al., 2017).
A study was conducted in Bangalore, India where 33 subjects(8-16 years) were evaluated in a Child and
Adolescent Psychiatric service. 33 children with school refusal who met the inclusion criteria were
evaluated in this study. The study revealed that 29 subjects (87.9%) had a psychiatric diagnosis at
baseline. 6 subjects had school phobia as the only diagnosis at baseline. 3 of them did not have the
diagnosis at follow-up. Out of 29 who received a psychiatric diagnosis, 21 children (63.7%) had more
than one diagnosis, 8 (24.2%) had more than two diagnosis and 2(6.1%) had four diagnosis. Learning
disorder was present in 5 subjects with two of them having no other psychiatric diagnosis. Psychosocial
factors influencing school refusal was found in 29 of subjects(87.9%). The main factors were parental
overindulgence (45.5%) , intrafamilial communication difficulties (39.4%) and parental over
protection(33.3%)(Prabhuswamy et al., 2007).


3.1 Research Design:

A cross sectional descriptive research design will be used to find out the prevalence of school
phobia among children.

3.2.1 Research population:

Students of class 8 of Sun Rise English School.

3.2.2 Setting:

Sun Rise English School, Krishnapur-6, Chitwan.

3.3 Sample:

A Probability randomized sampling technique will be used in this study where structured
questionaries will be set on the basis of study objective.

Inclusive criteria:

Only those students of class 8 of Sun rise English school.

Exclusive criteria:
Students of class 8 who are not well and are absent in the class.

3.4 Instrumentation:

A self administered questionnaire will be developed to collect information in this study. .

Questions will be based on objectives with simple and understandable language. The instrument
will be divided into two parts:

1st part of the instrument consisted questionnaire interview related to socio demographic

2nd part consisted questionnaire interview related to prevalence and associated factor of school

The content validity of the instrument will be maintained by developing instrument on the basis
of literature review and following the research advisor.

For the reliability and feasibility of the instrument , test retest method will be appiled .

3.5 Data collection procedure

Formal approval will be taken from concerned authority of NPI-NSH College for data collection.
Then permission for study will be taken from the study area, Sun rise English school . Verbal
and written informed consent will be taken from the respondents to ensure the right of the
respondent for voluntary participation in this study. Anonymity will be maintained by giving
serial number instead of name of participants. Confidentiality will be maintained by not
disclosing the information given by the participants to others and using their information only
for study purpose.

The questionnaire will be developed in English and translated in local Nepali language and then
provided to the students. Respondents will be allowed to terminate their participation at any time
during the period of data collection. Respondents will not be influenced by any means to
participate in the survey. A well developed questionnaire will be provided to students of class 8
of Sun rise English school for 20 minutes.

3.6 Data Analysis Procedure

All the collected data will be checked, edited and organized daily for the completeness and
accuracy. Coded data will be entered and analysed using statistical method. For the descriptive
analysis frequency, percentage ,mean ,range and standard deviation was used. After analysis of
data,the findings were presented in the form of table.