anxiety in adolescents in relation to school refusal

J . child Psychol. Psychiat., Vol. 5, 1964, pp. 59 to 73. Pergamon Press Ltd. Printed in Great Britain.

ANXIETY IN ADOLESCENTS IN RELATION TO SCHOOLREFUSAL

LYDIA JACKSON

IN THE years before the last war children were referred to child guidance clinicsmuch more frequently on account of truanting than because they refused to attendschool. In recent years, however, refusal to attend school has become so relativelycommon that educational authorities, as well as child guidance clinics, had to give itspecial attention. Several papers were recently published (Talbot (1957), Hersov(1960), Davidson (1961) et al.) in which the term 'school phobia' was accepted asa suitable term to describe this condition.

In the majority of studies, it was the family situation, not the school as such, whichprovided the investigators with their most relevant material. Hersov (1960) foundthat only 8 of his 50 school refusers had unusually elderly parents, while others hadan ovei-indulgent mother and an inadequate father. McGlashan (1962) found that22 of a group of 44 children had one parent missing for various reasons, and 7 wereactually bereaved. In another 6 cases there seemed to be a connection between theonset of symptoms and the death of an important member of the family, other thanone of the parents. Davidson (1961) and Talbot (1957) mention death in the familyas one of the principal factors associated with refusal to go to school.

Early separation from the mother was mentioned as a significant factor byMcGlashan (1962): 18 of her 44 cases suffered separation under the age of 4 y;of 30 cases examined by Davidson (1961) 11 had experienced separation under theage of 5. On the other hand Hersov (1960) notes that only 4 out of his group of 50school refusers had suffered separation under the age of 5, and that early separationexperience was significantly more common (23 out of 50) among the children whotruanted from school. The child's position in the family is not included among therelevant factors by McGlashan (1962) and is not mentioned by Davidson (1961),but Hersov (1960) found that 18 out of his group of 50 were youngest in the familyand 14 were only children. Change of school appears to be a very common pre-cipitating factor in school refusal, and abdominal pain and sickness a frequentlyrecurring symptom.

The general impression is that school refusers form a varied gfoup, or rather acollection of sub-groups, which include different types of personality with differingfamily backgrounds and different past histories. The particular sub-group which Ifelt was worth examining in greater detail consisted of four adolescent girls, three ofwhom refused school at the age of 11, at the time of changing from the primary to thesecondary school, while the fourth did so at the age of 12, in her second year at thesecondary school. This seems to be the peak age for school refusing.

I chose these cases for reporting from a dozen or more similar cases because, inaddition to refusing school, they had several other symptoms in common, as well asremarkably similar developmental histories and family backgrounds. In all 4

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60 LYDIA JACKSON

families the parents were middle-aged or elderly, conventional lower middle-classpeople, in fairly comfortable circumstances, apparently well-adj usted to each otherand past the stage of sexual love. In one the marriage was childless, the girl wasadopted at 3 mth and remained an only child. In the other three cases the girl wasthe youngest by as many as five to nine years with one or two elder siblings. In all4 cases she was over-protected, over-indulged and kept rather young by parents whoviewed the approach of adolescence in their daughter with undisguised alarm. Threeof the 4 girls were of superior intelligence (I.Q.s from 133 to 144); the fourth had anI.Q^. of just over 100. In 2 of the 4 cases there was a history of previous resistance toattending school at the age of 5 to 6; one child had to be dragged screaming toschool, the other refused to go after an upset during the school dinner, but waspersuaded to return. The remaining two showed no such resistance; they seemed toenjoy their primary school. The breakdown occurred about the time of the change-over to the senior school. They then showed every sign of panic and terror, wereimpervious to persuasion and reassurance, and apparently unable to overcome theirfear of school. Yet, if they managed to get there, they appeared to enjoy it and,though tense, were able to attend, and do school work. It seemed that the schoolwas much more terrifying in prospect than in actual fact. As one 'near' schoolrefuser, a boy, had put it with an unconscious humour: "You see, I like school, butI don't like going . . .".

The school refuser's anxiety about going to school has often been described as'separation anxiety'. It seems that the term here is used in its meaning of a fearresponse to an immediate situation, and not in the sense in which Edelston (1943)and Bowlby (1951) had used it when they linked the later psycho-neurotic conditionof some of their patients with an experience of separation from the mother in infancyor early childhood. In the 4 cases reported and in several others, there had been nosuch experience, unless it could be assumed in the case of the adopted girl that shehad suffered the trauma of separation when transferred at 3 m of age from herfoster-mother to her mother by adoption. This is an unlikely source of later anxiety.

The symptoms which this group shares with many other school refusers are thosethat accompany their anxiety, or through which their anxiety expresses itself,namely feelings of sickness, of revulsion from food, of vomiting when food is takenand of violent headaches. These attacks occurred always on school-mornings, hardlyever during the week-ends or holidays, and of course prevented the sufferers fromgoing to school.

CASE HISTORIES(1) Elizabeth was 12 :3 when she began treatment. She is now 13:9 and still in treatment. She is a

school resister rather than refuser, but nearly became a refuser just prior to referral. Elizabeth is agirl of considerable charm, well-developed for her age, dark, pretty, demure, with a quiet manner anda gentle voice. She is the youngest of 4 children; until recently she knew only 1 of her siblings, hersister Mary, 2^ y her senior. The two elder children do not live in England, and she had never metthem at the time of starting treatment. Elizabeth was adopted at 3 m of age, after her mother diedat her birth, by a paternal uncle and his wife who were childless. During the first 3 m of her lifeshe was looked after by the nuns for whom her mother used to work. She was bottle-fed until 11mof age; clean and dry at 14 m; talked at 1 y and was said to have been a happy and contentedbaby. She had had only the usual childish illnesses, during which she stayed at home.

ANXIETY IN ADOLESCENTS IN RELATION TO SCHOOL REFUSAL 61

The adoptive parents' marriage although childless, appeared satisfactory. The uncle is a huge,easy-going, good-natured Irishman. The personality ofthe aunt, a Londoner, is very different; asmall, rather tense woman with a squint, who combines high standards of behaviour with stronginferiority feelings; is clearly afraid of sex; is fond, yet very critical of Elizabeth, expecting her to bea good little girl, owing respect and obedience to her adoptive parents. She is inclined to think herhusband is spoiling Elizabeth; is jealous of the growing girl and guilty about this, as well as aboutElizabeth's breakdown. *

The onset of symptoms in this case was precipitated by an incident on Guy Fawkes' night.Elizabeth was in the garden with some neighbours letting off fireworks. A spark set alight a fireworkshe was holding in her hand. A neighbour shouted to her to throw it down, but she was so frightenedthat she ran to the house still clutching it, and it burned her hand. The burn was slight, but Elizabethwas so shaken that she was allowed to stay at home for 2 weeks. Her family doctor then decided sheshould go back to school. A week later she was brought to the doctor "in a sorry state", complainingof attacks of depression which came on up to five times a day, the longest period without attack beinga day. She stated she felt them coming on, and felt very sad and tired; also that she was becoming'silly' at school, and unable to work or understand what she was being told. She wept copiously attimes because she felt so sad. When seen by the family doctor she "looked frightened and tense as ifwaiting for a calamity". He referred her to the clinic because her mother found that she used hersymptoms to evade going to school.

During her interviews the mother reported a change in Elizabeth's personality well before theburning incident. She had been told of her adoption at the age of 4, "as soon as she could under-stand", and was a happy, obedient child until the age of about 11 y. She became rebellious andmoody, began to say to mother: "I don't have to do as you tell me"; resented her desires being frus-trated, demanded teen-age clothes, such as winkle-pickers and jeans. Her mother ascribed some ofthis to the infiuence of her sister Mary, a rather sophisticated and self-assertive youngster, whomElizabeth had begun to meet more often (as she lived not far away).

Elizabeth started her menstrual periods soon after her 11th birthday but the mother found itextremely difficult to discuss the facts of life with her. She explained her own childlessness by tellingElizabeth that God gave children or withheld them at His will. Elizabeth had a period of insomniasome months previously, and her mother had taken her into her own bed; the insomnia became athing ofthe past, but Elizabeth refused to move out ofthe parental bedroom. She took special noticeof all alarming news in the papers and worried about milk being contaminated by nuclear fall-out,then about smallpox and polio injections.

In treatment with me Elizabeth was, at first, very shy, polite, faintly intrigued and very inarticu-late in conversation, adding 'you know' and 'like' to every phrase. She would say: 'I 'was feelingtired-like, you know", and soon became very involved and repetitive if she tried to explain or relateanything. When I tried her out with my Test of Family Attitudes (1952), she found no difficulty inproducing coherent and well-turned-out stories. The theme of sadness and loneliness recurred inseveral stories, but when this was brought into discussion Elizabeth denied that she felt sad or lonely.For a few weeks her symptoms seemed to be in abeyance. The school, too, was 'all right', she said.She spoke of her resistance to going to school as a thing ofthe past. "Then" she used to feel so sadat school that she would start weeping in class. The teacher did not seem to understand. She hadsaid something to the effect that Elizabeth was "not as nice as she pretended to be". Her best friendseemed to have no use for her and preferred the company of another girl. "I felt I was no good."

During the next couple of months we went over the topics which could be assumed to be ofparticular interest to her and which she was not able to discuss freely with her mother; her adoption,what her life might have been if her parents had not died so early, and the facts of conception andchildbirth. She was looking forward to meeting her brother, aged 19, for the first time during thecoming holiday. She was feeling much brighter, but still could not eat a proper breakfast before goingto school.

She then began to talk about the "slow feeling" which came over her usually in the mornings,but sometimes at dinner time in school. She looked at food with disgust, could not eat it, felt sad andwanted to cry. Her description of this condition was often contradictory: it was a "slow feeling", an•"empty feeling", and once she said it was a feeling of "being full". The effect, however, was always

*Henceforth uncle and aunt will be referred to as "father" and mother".

62 LYDIA JACKSON

the same: she could not take food. Sometimes she said she felt dry and very thirsty; she had to drinka lot. At one time her mother reported that Elizabeth was drinking gallons of milk. She was quitealarmed: "It can't be good for her!"

Elizabeth was free from these attacks of "empty feeling" and crying during the holidays andweekends, then suddenly she had an attack one week-end when her sister Mary was staying withthem. This girl had left school and was working in an office in London. From subsequent conversa-tions it emerged that Elizabeth was very mixed in her feelings towards this sister. Refiecting hermother's view, she criticized Mary for being too sophisticated and opinionated; she pitied her for theharsher upbringing she had experienced with her own adoptive mother (who was widowed and alsoan aunt); yet she envied her for having many friends and a greater freedom in associating with them;and she was jealous of the attention Mary received from her own parents when staying with them.She was quite explicit about this: comparing her own inability to eat breakfast and Mary eating alarge one, she said: "You can be as dainty and fussy as you like and yet you don't get better treatedthan girls who are cheeky and rude". . .

Meanwhile her mother reported that Elizabeth was asserting herself much more at home. Oncewhen the mother was unwell, Elizabeth "told ofT" her devoted father for expecting her to find histie for him; on another occasion she actually slapped his face for not paying attention to her demandthat he should look at her new shoes. On the other hand, she also sat on their laps and told them she"liked being loved", and liked resting on the bed while her mother fondled her. Later followed aaincrease in awkwardness and unhelpfulness, a more open expression of hostility towards the parents,especially the mother, and a corresponding improvement in school work (from 20th to 12th place)and in relationships with her classmates.

At present, at the age of 13 : 9 she is not yet free from some of her symptoms, but no longer projectsher conflicts on to the school. She brings up a great deal of material for discussion, which refiectsanxiety about being 'different' from other girls, and is able to discuss it freely, with insight andeloquence contrasting with her former inarticulateness. She is alternately demanding and helpful athome.

(2) Jennifer was a girl of 11 : 3 when first seen. Her only brother was 20 and living at home. Shewon a place at a grammar school, sampled it, and after a couple of days would not return; wastransferred to a secondary modern school, screamed and made a scene when taken there; was offereda vacancy at another grammar school and had an interview with the headmistress, but when thelatter was about to take her to her class, Jennifer dug her toes in and would not come. Her I.Q.. was144.

She was a pretty girl with auburn hair and brown eyes, small-boned and slender, who spoke in afaint little voice. Her parents were in their late forties and devoted to one another; the father a veryreligious, warm-hearted man; the mother a perfect housewife with a tremendous sense of duty towardsthe family, and no interests outside her home. She was anxious under her apparent placidity.

Pregnancy was normal; Jennifer was bottle-fed from the start; development was early and normal,there were no serious illnesses and no separations except at 7 y when the child spent a week at a farmwith a friend. She resisted school when she started at 5 y, had to be forced to go, but then settleddown.

Her refusal to go to school at 11 y was accompanied by disturbed nights, violent headaches,screaming, sickness and vomiting. She was sick on a number of occasions before coming to the clinic.This she resented, especially at the start of treatment, and after breaks for holidays. When first seen,she had been sleeping in her mother's bed in her parents' bedroom from the time she was born. Onlysome months later was she given a separate room. The father's libido seemed to be fully employedin voluntary services to his church, the mother's in her houshold duties. She said about her marriage:"We are just boy and girl together . . . " Her attitude towards sex could be illustrated by two examples.When she was lent Human Growth (Beck 1950) to make it easier for her to discuss the subject withJennifer, she read it to her but stopped at the section concerned with intercourse, saying: "Now youknow quite enough to be getting on with". And when later the book was read to the end by Jenniferherself, her mother said to her: "That's right: now you can forget all about it".

Jennifer began treatment when she was 11:3, and came to see me twice a week over a period of15 m, 95 times in all. She resented it from start to finish, at certain periods less intensely than atothers. At the start she said to her mother: "I don't want to play silly games: I can play them at


home". And whenever periodically it appeared as if she might agree to attend school, she would say:"It's silly my going to the clinic if I am going to school".

After a time she seemed to enjoy her sessions and would talk easily, sometimes humorously and in asophisticated manner, about anything except her symptoms and the school. If either were mentionedshe at once dropped her eyes and grew completely mute; sometimes she looked a martyr and on thepoint of bursting into tears. She was able to express hostility by this resistance, also by showing greatpleasure in beating me in games, or hitting me hard with the ball in the game of 'he', but she wouldnot confirm or refute any interpretation of her symptoms or behaviour, nor would she help in anyway in the exploration of her fears regarding school. Other things emerged, however, from someremarks she made in conversation. Thus she said about a small boy in a story: "Everyone treated himas a grown-up which he liked very much". She drew a picture of her family in which her fatheroccupied the most important place; she described games and fights with boys in her primary schoolwith an obvious pleasure; she half-admitted that she would be happier in a large co-educationalschool than in a grammar school for girls; she criticized her mother by saying: "Mummy dustseverything about 5 times; she dusts all the time". Towards the end of treatment, in some desperation,I thought of a device in the form of a comic strip telling the story of her two aspects, Jennifer Whiteand Jennifer Black, and involving her in making up some of the things these two said and did. Shewas very resistive to this as well, but on occasions invented an incident in which teachers got veryhurt by the children, Jennifer being one of them.

At home the conflict between Jennifer and her parents, especially her mother, intensified astreatment continued. Her mother stated: "She hates being told to do anything; she is very argu-mentative". "She looks at you in a very evil way when she disagrees with you." When Jenniferignored her mother's requests and her father reminded her of it, she "looks as if she could kill usboth". Sometimes she gives the mother 'killing' looks and smiles at father and brother. She won'tanswer her parents when they talk about school to her, she puts on a 'vacant stare'. The mother said:"You could shake her".

At first Jennifer avoided going out of the house altogether: she hated neighbours and friendsremarking on her being out of school. She stayed out the whole of the autumn term, but attendedSunday school with a friend and took part in preparations for a Christmas bazaar. Early in Januaryshe went for an interview with the headmistress of a girls' grammar school, who was prepared toaccept her. Jennifer was very sick before, but calm and self-possessed during the interview. The head-mistress then offered to take her to her class, which Jennifer had not expected. She panicked andabsolutely refused to come. She would not go to school on the following day and was sick before herinterview at the clinic. She stayed out of school for the next two terms, attending for treatment twicea week, but continued attending the Sunday school where she was put in charge of the toddlers andproved to be very good with them.

In June of the same year she had an interview with the headmaster of another (mixed) school,with a view to attending it the following September (by which time she would have been out ofschool for a whole year and 11 m in treatment). She liked this large, comprehensive school, butwhen the time came to start her first term there, she was again very sick and refused to go.

Both parents meanwhile were suffering from nervous strain; the mother especially was unable tosleep and seemed on the verge of a nervous breakdown. Neither parent, however, would take a holi-day, or leave Jennifer with her grandmother. Another 3^ m passed before Jennifer finally managedto get to school at the beginning of the second term. The parents tried to take her there, but she wouldnot go, so they brought her to the clinic. I was not there, but her father and a psychiatrist got her,screaming, into a car and drove her to school. She went in with a friend, seemingly calm, but was outalmost immediately and returned home. A day or two later, a good-looking young school-mastercalled at the house and persuaded her to return. She went, and has never looked back since. She wassick most mornings, however, for some weeks before going to school, and her mother had to take her,and often also to meet her as she came out. Since she was back in school, her parents preferred hernot to continue treatment and Jennifer herself was very much against continuing. The P.S.W.,however, maintained contact with the parents, and I saw Jennifer twice since she stopped attendingfor treatment; at the age of 12:10 and of 14 : 2. She is now 16^; she has done very well at school andhad had no relapses as far as school refusing is concerned.

She remains ambivalent towards her parents, "loving and hateful" at the same time. The deter-

64 LYDIA JACKSON

mined side of her character and her undeveloped feeling life found expression in violent infatuationswith boys, all of whom found her too possessive and broke off the relationship. Her last affair wasparticularly violent: Jennifer threatened suicide and attempted to strike the boy with a carving knife.She gives no help at home, is untidy, hoards things. Her mother showed deep resentment at this.

The latest information on Jennifer is that she is determined to leave school without attemptingto pass "A" level examinations (she passed some at "O" level), has decided to become a solicitor bybeing articled to one, and wants to leave home. This is adolescent self-assertion with a vengeance inone who seemed so mild and timid a few years ago.

(3) Diana was not quite 11 y old when she started treatment with me as a private patient, onceweekly. She was the younger by eleven years of two children, both girls. Her sister was married andlived away from home. Diana had not been tested for an I.Q,. but she was intellectually superior as hersubsequent success in school showed. Her parents were elderly middle-class people; the father had abusiness in a large village near London; the mother had no other duties except looking after the houseand the family.

Diana was breast-fed for 9 m and was "a good baby". Her mother, in speaking abouther, used this wonderfully expressive but somewhat sinister phrase "We didn't know we had her".She was toilet trained by 18 m. Being a war baby, when she was 9 m old her mother took heraway from the vicinity of London to a friend's house in the country where they stayed for 10 m.Diana had a toileting relapse there which apparently lasted only a few days, but the way her motherspoke of it was indicative of her standards. She said that Diana "used to go behind the sofa and do itthere. It was dreadful!" and Diana herself was "very distressed". The friend with whom they stayed"adored" Diana.

When Diana was 4^, she was playing in their own garden, and suddenly the barrage guns openedup with a roar. She Red to the house, screaming, and would not go outside for a fortnight. The mothertook her away again to stay with friends, and Diana had measles there rather badly.

After three months they returned home, and at 5 y Diana began attending a nursery school at aneighbouring convent. She seemed to enjoy it and wanted to go, though her mother thought shewas a bit frightened of the nuns' habits. Soon, however, there was trouble: a nun had reproved herfor not finishing her lunch, and next day Diana refused to go back. She said she was afraid that thesame nun, who was not her regular supervisor, would be in charge of her table. She was persuadedto go and settled down when she found the offending nun was not there. At 5J y Diana had scarletfever and was away in hospital for 3-4 weeks; the mother visited regularly and the child, according toher, liked the hospital and had wanted to go.

She was nearly 6 y old when she started attending her primary school, a private one and, soonafter starting, she had whooping cough.

She herself described her feelings about the school to me in a very precise way: "I didn't like it atfirst, I liked it a lot the second term and the third. After that I didn't like it at all. . . . " She did not,however, refuse school until she was nearly 11, and her refusal was precipitated by the followingincident. The geography teacher told Diana to take a book home to finish some work she did notcomplete in class. When she brought it back on the following morning, she was severely reprimandedby her form mistress for having taken the book, and when she tried to justify herself by referring tothe other teacher, she was scolded. When she was pressed to go back Diana made a frightful scene,weeping and saying that she was frightened. The parents said that when she gets into this state, sheis sick, goes off her food and loses weight. They made it clear that Diana was not a physical coward: sheclimbs trees, goes on high swings and on roundabouts in fair grounds which, the mother remarked,would make her sick, but she became anxious and agitated whenever she was faced with a new situa-tion or with making a decision, such as whether to go to church or not.

I saw her first in May when she had been already away from school since the previous September.The parents first consulted the family doctor. He said: "I believe your young lady is playing you up".The neighbours advised thrashing. One morning, when Diana would not get up, her father went upand smacked her "on the bottom". She "just screamed". He ordered her to dress herself, which shedid with many tears, but while he was getting the car ready to take her to school, she dashed upstairsand locked herself in the attic. This was the orily occasion on which she was beaten. "But", the motherremarked: "when you have a child like that it's quite an effort to keep your hands off her."

Before she came to me she was seen (I am not sure how often) by a young male psychiatrist over


a period of 3-4 m. He told the parents that he "could not make her out", and about a week beforeI saw her, he advised them to take her to school by force, if necessary. This resulted in a frightfulscene which had completely exhausted the parents and Diana, but failed, in its purpose. The psy-chiatrist, when told of this, remarked that "he had been prepared for this" and advised the parentsto persevere, but they felt unequal to the task. It was after this that they decided to seek help else-where.

They were in fact very anxious and bewildered parents, simple and kindly, who reminded me of apair of cart horses who had produced a thoroughbred colt. But this impression may have been super-ficial. The father told me that Diana "took after him" in her tendency to react to worry with gastricupsets. Mother's eyes often filled with tears while she talked of Diana's condition.

It was clear from their description that Diana's anxiety and refusal to attend school made theirprivate world revolve round her, and that she completely dominated them through her symptoms.

She was doing well at school (they showed me her school reports): her behaviour had been alwaysgood; her marks showed steady progress, and "special remarks" contained nothing special.

The parents said Diana had always been shy with adults, but easily made friends with children; atpresent she played with the neighbours' little boy, aged 8. She also joined children at playtime at alittle nursery school not far from her home, but took great care to stay away at the hours when therewas any danger for her of being enticed into lessons.

Diana was a tall, slender girl, with grey eyes and long plaits of reddish hair. She was obviouslyvery shy, and would not look at me, but she was not inhibited in her play. At once she made use ofsand and water and of all small dolls and animals she could find. She had a kind of brittle vitalityabout her, an effervescent eagerness which, one felt, could be shattered by a touch. Her enormousfamily of dolls went on holidays and did all kinds of dangerous things; they fell off rocks and theirboats overturned; the children kept falling into "a great hole" which they did not know was there,and the older members of the party were very slow and inept in rescuing them. I remarked on thefear some children had of falling down the lavatory and suggested that she felt she would "go downthe drain" if she did not return to school quite soon. I also added that she probably felt her parentsand the rest of us were pretty ineffective in helping her with her problems. She promptly escaped tothe other side of the room.

That the school situation was in her thoughts most of the time was evident from her insistenceon giving names to all the dolls and their pet animals; all these had to be written down, and everytime she came, this list had to be read out, like a school register, and the presence of each creaturechecked on it. Later in treatment she "tested" me by asking me the names and ages of all the dolls inan obsessional, ritualistic manner.

A couple of months after the beginning of treatment she was able to tell me what had happenedto stop her going to school, much as her mother had told me: the incident with the book. She said,"The form mistress was furious. It wasn't my fault." When I suggested that this clash might have beendue to rivalry between the two teachers, Diana immediately confirmed this and described an incidentwhen the geography teacher mended a torn book from the class library, and the form mistress, whowas in charge of the library, showed extreme annoyance, tore the cover off, etc. She also told meabout the nun at the convent school: "When you didn't like something at dinner and asked to begiven a little, she would give you a lot and make you eat it up".

While she was telling me this, she held an inflatable rubber toy (fish or duck) in her hand andwas squeezing it hard, making its eyes pop, and thrusting it at me. I said: "That's what you wouldlike to do to those teachers, wouldn't you?" She laughed guiltily and said: "No".

The parents found her self-confidence was increasing: Diana went to Girl Guides and to Sundayschool, often on her own, without waiting for a friend to call on her, but she still had sudden panicsabout minor things, and demanded that her mother should decide for her. In shops she made themother ask for things, but if she did not like something, she refused to accept it. She "knows what shewants and wouldn't be put upon". The mother was aware of a firm core in Diana's personality andof her considerable drive. She remarked on Diana's self-consciousness about undressing in anyone'spresence: she would not take her blouse off in a dress shop. The mother herself admitted to being self-conscious in that way. Edith, the elder girl, was rather the reverse. Edith and Diana used to bathtogether. Mother always locks herself in the bathroom.

After she had been coming to me for 3 m and had been away from school for nearly a year.

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I found a young girl who was prepared to coach Diana in school subjects at her home. Her motherand I prepared her for this and she seemed to be accepting it. She was, however, very agitated beforeher first lesson, and in tears afterwards, because she was given some sums to do for the next day. Shethen found she was able to do them, quickly and without help, but before her next lesson she began tolook preoccupied again, felt sick and wanted to go to bed. The mother gently insisted on her facingthe situation and Diana went downstairs with her books to meet the tutor, and was soon heard chattingquite happily to her.

These attacks of anxiety with sickness, refusal to eat breakfast and refusal to get up on the morningsof the lessons continued for some weeks.

In treatment she began to assert herself more openly: she would start mixing paints in preparationfor painting, after she had been told it was time to go; she would wash paint-brushes in the water tray;she slapped wet sand with a spade so hard that it flew all over the room; once, as she was hammering,she saw that I was blinking, so she waved the mallet right in front of my eyes to see if I would closethem, or blink faster. When I told her I did not have something she was asking for, she remarked:"You ought to have!" Allowed to choose bits of material for her dolls' clothes, she grabbed most ofthese. I asked whether her mother had any bits. Diana replied: "Yes, but she keeps saying she mightneed them. She's been saying it for years!"

Plans were being made for her to go in January to a secondary modern school near her home,where her parents knew one ofthe teachers. Diana knew of this, and she had one of her sharp attacksof anxiety with a gastric upset on the occasion of going to church with the Guides. She was afraid shemight be told to go to the altar and do something in view of the whole congregation. She cried aboutthis, saying "I did so want to go!" In the afternoon she recovered sufficiently to join the Guides'parade. The parents were frightfully worked up about this, and both went to watch the parade, tomake sure she was all right. The father told me afterwards that he used to be just like Diana in anysituation requiring a public performance, and so was his sister.

Diana was able to tell me of her interview with the headmaster of the school, and of a teacher ofwhom everyone was afraid; the girls had told her that "he wouldn't let them breathe". On the daybefore she was due to start, I asked her: "Will you get to school tomorrow?" She just whispered,"I don't know".

She had an attack of sickness the evening before, but she did go that morning. On the followingmorning her mother rang me up to say she was refusing again. I suggested she should "press her ascalmly and gently as possible", and a few days later I heard that she went and was settling down. WhenI saw mother and daughter a week later, the mother reported that things were "far better than any-thing they had expected". Diana was even beginning to eat her breakfast. The teacher, friend oftheparents, who had watched her, unobserved, in her class, told them that she seemed perfectly happy,but Diana told her parents afterwards: "I felt ever so sick!"

After only 3 m in school Diana sat for the 11 + examinations, passed them with flying coloursand got a place in a good grammar school. During her period at the secondary school I saw herfortnightly, but soon difficulties arose: the school authorities did not think she needed treatment, andthe children apparently njade 'nasty' remarks about it. Diana's mother, with tears in her eyes, toldme that she "did not want Diana to feel different". The treatment stopped when she entered thegrammar school. By that time the mother was well aware that underneath her shyness and liabilityto panic, Diana had a stubborn and strong-willed personality. She referred to her as "a determinedlittle madam", who "wouldn't stay away one night with her cousins when we asked her to, but wasready to do so when she expected to go swimming with one of them".

She described her in terms of perfectionism: "She wants things just so", and in games with otherchildren insists on fairness to the point of meticulousness; she was a bad loser; in games alwayswanted to be first to choose; was intolerant of frustration, such as a change of plans for an outing andsuch like. The father, on the other hand, sounded as if he could not bear letting Diana fight herown battles.

I kept in touch with the family over the years. Diana stood the course at the grammar school andpassed her G.C.E. in eight subjects. But when she was 18 y her mother wrote to ask advice abouther because she was having attacks of depression, weeping and gastric upsets whenever she was facedwith some new challenge, a responsible task at school, or anything requiring a fresh decision. Shegave as an example an incident when a young man they knew called to ask her to go to the cinema with


him. She refused, then cried because she had wanted to go. The parents felt she was rather isolatedand not really happy. Her headmistress had "great things planned for her", but this only increasedher anxiety. Diana herself wanted to do medical research.

The next time I heard from Diana herself was in 1961, at the age of 22. She wrote to say that shegot married 6 m ago; that after failing "A" level in Physics and Chemistry, she decided, to give upthe idea of going to a university and took an office job which she liked. She got engaged during thattime and was saving money to get married. At the time of writing, her husband was still training to bea draughtsman, and she had obtained another post, dealing with the costing and manufacturing ofdrugs, which she found very satisfactory. They were planning to start a family in 2 or 3 y. She con-cluded her letter with this sentence: "I knew at one time I felt I would never have the courage to goto work and get married; but the work you began, my husband finished when I met him, and nowI am very happy".

(4) Veronica was referred to the clinic by her headmistress and the Care Committee at the age ofII : 1, in her last year at the primary school because she was, in the words of the school report,"showing signs of continuous and increased nervous strain and consequent ill health". She had beenabsent from school 105 times during the previous year and stayed away 6 times during the first monthof the current autumn term. Despite these absences she was doing well in school subjects and wasdescribed by her headmistress as "very earnest and hard-working—too much so!" She was said to be"always extremely well-behaved, friendly and over-anxious to please". She was friendly also to otherchildren and mixed well with them.

Veronica was the youngest of 3 children with 2 brothers aged 16 and 20. Her parents were bothjust under 50; she was their favourite child, who had always been easy, and had "never given themany trouble". The boys, on the other hand, were unsatisfactory: they were described as inconsiderateand selfish; the younger had been before the Juvenile Court.

Pregnancy and delivery were normal; Veronica was breast-fed for about 4 m, then the bottlewas added. She was a good, happy baby; talked early and understood easily. She was always veryactive. She had gastroenteritis at 5 y and was very ill for 2 weeks. There were no separations until 6 ywhen she had pneumonia and was an in-patient for 10 days. Mother visited every day and Veronicacried a great deal and was very disturbed at the separation from her. Her mother said that Veronicawas very attached to her and had the closest relationship with her of the whole family. She had sleptin the parents' bedroom until she was 10. The father was a commercial artist, workingvery hard, and was said to be "a worrier". The mother did a domestic job to help with the finances ofthe family. She had a lot of migraine headaches, was often extremely tired and disturbed by frequentquarrels with the boys. Like Veronica she suffered from attacks of sickness. Veronica was very keenon ballet dancing and showed considerable promise. Her mother always went to dancing classeswith her.

Her mother could not give a definite date for the onset of symptoms. She said Veronica wouldnot eat breakfast and was sick before going to schopl. After having sat for her 11-}- examinationsshe was sent to the seaside on a recuperative holiday, on the school doctor's advice. She was unhappythere and wrote to her mother every day. She feared arithmetic lessons; she also said she feared leavingher mother because she might die in her absence.

Veronica was 1 1 : 5 when she started treatment. She had returned to school after the recuperativeholiday, but later in the year contracted a heavy cold, stayed away from school for two weeks, andthen could not bring herself to go back. She was striking to look at with her pale-golden complexion,very dark eyes and long heavy plaits of blonde hair, a child out of a fairy-tale. She held herself veryerect and looked one straight in the eye, but with a slight frown of anxiety or mistrust. Her wholeexpression changed, however, when she smiled: she looked enchanting then. She showed whatappeared to be a grudge against life in her first interview: spoke of having "two flipping brothers athome"; said she "hated students" taking them for lessons at school instead of regular teachers.

The following week her mother showed us a statement written down by Veronica, illustratingwhat she felt about the school: "School—the prison; hall—the gathering place; headmistress—prisongovernor; form-mistress—cell-warder; another teacher—assistant governor; all the people at school—warders; the music teacher (whom alone she liked)—a comforter; L.C.C.—the Magistrates".That morning Veronica cried in bed, trembled and said she felt a lump in her chest and that she kept

68 LYDIA JACKSON

getting a pain in her stomach. A couple of weeks later, she told her mother: "I'd rather commit suicidethan go to school".

When soon afterwards I spoke to her of possible alternatives, such as a boarding school, shedeclared that if she were sent against her will, she would just do nothing; "They can't make me, andI'd run away". She was outspoken, even fierce at times, yet in discussion she made it clear that"answering back" was in her opinion the most serious kind of misbehaviour. Her form-mistress, shesaid, could be "horrible". She said of another teacher: "She has so many ideas that she doesn't giveus time to work them out".

When she was told that she had done very well in her 11 + examination, she did not quite believethis, and told her mother: "If I've passed, I'll go back to school, if I haven't, I won't go back".Discussing alternatives (grammar or comprehensive) with me, she said: "All schools are the same tome". Early in May she was still saying that she would never return to her primary school, it was"horrible", she "could not face it". A fortnight later, after 3 m attendance at the clinic, she wentback and continued going until the end of term, although she was often sick in the morning. Hermother brought her to the clinic only twice after that, once in May and once in August, just beforeshe began her first term at a girls' grammar school. Before the summer holidays she had asked mewhether she could stop coming for treatment when she began school. In this her mother supportedher. Veronica thought she would be happy at her new school "as long as they don't grumble at you,and don't keep on at you for something you hadn't done that you couldn't do".

In September her mother reported that Veronica "loved school". She was apprehensive at first,could not eat breakfast, then settled down. She felt that at this school she was treated more like agrown-up responsible person. But her naother felt she was still a child: she liked sitting on mother'sknee for a cuddle. The mother sounded as if she enjoyed it too.

Early in October of the same year, the mother rang up in distress to say that Veronica was againrefusing school after staying at home part of the week with a bad cold. She told her mother that shecould not go: "I'm scared".

The true reason was her anger at the headmistress who refused permission for Veronica to stayaway for an extra ten days at the end of school holidays, in order to take part in a pantomime at aprovincial art festival. Veronica was chosen from a group of several girls who applied for the partand was very keen to go. She was brought to see me in October. When I discussed the situation withher and pointed out that she had liked her school, Veronica replied: "I didn't know they were goingto be so mean". She resisted coming back to the clinic, saying: "I don't like going to that dingy oldplace. Going there didn't make me go back to school last time. I just don't like school."

After we got in touch with the school and discussed the matter, the headmistress decided to giveVeronica leave to take part in the pantomime, and she returned to school, but was sick every morningbefore going. During the subsequent 8 m she attended the clinic 19 times and showed that shefeared and disliked losing in games; she would say, "Oh dear!" whenever the game went againsther; would never grant me a doubtful point; was openly delighted when she won (which she usuallydid). When on one occasion I claimed a "go" I thought I had missed, she grudgingly let me have twoin succession, then said: "I am sure you have had all your goes!" But this was about as far as herhostility to me went; she grumbled to her mother but was never rude or unpleasant to me. Everything,however, conspired to make her attendance at the clinic difficult. Her dental appointments weremany, and often coincided with her appointment at the clinic, then she strained her leg dancing,then she had a cold. The whole year during which this mother and child attended the clinic, waspunctuated with the mother's headaches and the girl's colds, dental treatment and leg injuries.Veronica did not cooperate in dental treatment either: once she bit the dentist and ran out; on anotheroccasion she would not let the dentist do anything to her teeth. After a longer than usual Easter breakand a heavy cold, she was again sick before re-st?.rting school. She told me: "I want to be the best ineverything". She had been made a captain of her class and spoke to me scornfully of her class-mateswho "talk all the time". She said her telling them not to "made no difference". About the dentist shesaid she did not mind her teeth being extracted but she would not go back there because they were"horrible people". "I don't like being forced."

In May she again strained her leg and had to have physiotherapy; then she had earache. Earlyin June she returned to school; told me with a smile that she had felt "rather peculiar" before goingback but was "all right now". At the end of the term she refused to go again because she feared she


might be called upon to speak in front of the assembly in her capacity of form president. Her form-mistress called on her, explained that she would not have to speak, and Veronica went back with her.She obtained honours in 6 out of 7 subjects at the end of the year, but was worried because she didnot get them in all 7 subjects. She won a medal for long jump (12 ft 9 in.).

After returning to school the following September, Veronica was determined not to come backto the clinic despite the headmistress' wish that she should continue. Veronica would not accept eventhe late afternoon appointment. Her mother came alone in October with a bad headache. She reportedthat Veronica was losing her good manners, that she answered back rudely and never said "please"or "thank you". She was refusing to take her own dog out in the mornings, but spent a lot of time withher friend Christine playing records. She was rather annoyed with her mother for going to the clinic.

Six months later we heard from the mother that Veronica was doing well at school but had givenup dancing after her brother's wedding in March. She just asked a rhetorical question: "Do I haveto go?" and stopped going.

A year and two months after she had attended for treatment for the last time at the age of 12 : 9,her mother rang up to say that Veronica had not been to school for a month. As before, it was aftera heavy cold; she suffered from headaches and eye-strain and was ordered spectacles. She would notget up in the mornings and said she did not feel well. She told her mother she was "bored" at school.She was brought to see me in October: she was now 14:2 , and she told me that she was "fed up withschool". Her resentment against all adults, against authority, as such, attached itself to most trivialmatters. She resented the fact that the girls were not allowed to have club meetings in their new hall:it was too precious. "They are afraid we will damage it." She explained her sudden withdrawal fromdancing by saying that the dancing instructress gave all her attention to the little girls in her schooland took no trouble with the older ones, of whom there were only a few left. "I didn't see how I couldpass my second grade in that way." Why did she not try another dancing school?" I asked. "Oh,because I have been accustomed to that one."

She admitted to fearing every new situation; if she tries to go to school, she "gets all worked upinside", she said; feels sick at the thought of going; if she got there, she would feel sick all day. Shesaid: "I like learning but I don't like school". When at school she feels "caged in". In discussingher relationship with her parents she said of her father: "Whenever I ask him something he alwayssays: 'Ask your mother'." I spoke of her parents' considerate treatment of her in this predicament; shereplied: "I suppose that's the trouble. I have always had my own way." But "mother won't let mego anywhere; perhaps because I am the youngest and the only girl".

The mother was able for the first time to express resentment towards Veronica: "If I had herchances with her brains and at the school she is at!" She wondered if she "ever knew her". She wa-,difficult and remote with the whole of the family; played her records or her transistor all day; or"just sits about and won't stir". The mother said to her: "You are afraid to move . . . " to whichVeronica replied: "Yes, I am".

She made all the preparations for going to school after the Christmas holiday, washed her hair,copied a lot of lessons into her books, but when the moment came she did not go. By then she hadbeen out of school for 6 weeks. Nor would she come to the clinic to see me. However, I maintainedcontact with her headmistress, a very tolerant person, who agreed with me that applying any kind ofpressure to get Veronica to go would not work, but on my suggestion she arranged that Veronica'sbest friend would call regularly at her house and keep her informed of what was happening at school.So Veronica planned to return on a Monday and told her mother to wake her up quite early and,if she would not get up, to pull ofTher bed-clothes and drag her out of bed. On the important morning,Veronica would not get up but the friend called at 8 o'clock and, by joint efforts, she and the mothermanaged to get her out of bed. On the following day she went more or less readily. By that time shehad been out of school for the best part of 3 m. I telephoned the school last time in May 1963.The headmistress reported that Veronica, now 14:6 , was doing very well in school subjects and wastalking of going to a university. The headmistress however felt that she still needed to keep in touchwith the therapist, but Veronica would not attend the clinic for treatment.

D I S C U S S I O N

It is perhaps worthwhile re-emphasizing the points of similarity between thesefour cases: their parents were over the age of 50 or approaching that age; the mother

70 LYDIA JACKSON

menopausal, the father usually several years older than his wife. The child, theyoungest in the family, was separated from her older siblings by as many as 11 yin one case, and by 9 and 5 y respectively in two other cases. The adopted girl was ina position of an only child, though she knew she was the youngest of four. The relation-ship of the parents to each other in all these marriages was one of loyal partnership,with some evidence of real devotion to one another and the minimum of disagree-ment. On the other hand, there seemed to be very little or no sex life left over fromwhatever there was before. The father, though not ineffective as a bread-winner,was certainly not effective as the head of the family, and was not the dominant partnerin the marriage. The mother, in all 4 cases, was a very good housewife, extremelyconscientious and a perfectionist. In all 4 cases the mother showed that she feared,and preferred to deny, any indication that instinctual drives were active in her child:none was able to tell the girl about the "facts of life" and asked for it to be done bythe therapist.

There was more than a touch of neuroticism in all these mothers: Veronica'smother suffered from frequent severe headaches; she was also sick when anxious andfound it very difficult to assert herself. Diana said about her mother: "Mummycan't look over the edge of a cliff". Jennifer's mother suffered from severe insomniaand was on the verge of a nervous breakdown, while Jennifer dithered whether togo or not to go to school; Elizabeth's mother had abdominal pains and other com-plaints while EHzabeth was difficult. Nor were the fathers free from symptoms:Jennifer's father's religious fervour was certainly over-intense; Diana's father hadgastric upsets when nervous, and said that he used to be just as nervous of any publicperformance as his daughter was; Elizabeth's natural father had a nervous break-down; Veronica's was said to be over-conscientious and "a worrier".

There are also indications that these mothers certainly experienced hostility andanger towards their awkward offspring, but held it under rigid control. The violentheadaches of Veronica's mother were most likely a substitute for anger as well as apunishment for her own hostile feelings; it was she who said: "People think I amplacid, but I'm not underneath". Diana's mother said of her: "When you have achild like that, it's quite an effort to keep your hands off her". Jennifer's mothertaunted and nagged her quite a lot about not going to school; she said: "You couldshake her", and her remarks about the "killing looks" Jennifer gave her parentscould very well be a projection of her hostility towards the child. Of the 4 mothers,the adoptive one spoke most frankly of her anger when Elizabeth was awkward.

In two of the mothers their fear and repudiation of instinctual drives was rootedin their own childhood: Jennifer's mother had been terrified of her own father'srages; Veronica's mother was fostered by a stranger after her father had deserted,and could not forgive her own mother for having parted with her in infancy. Shewas so quiet as a child that "nobody knew I was there".

The girls' personalities were similar in several respects. All four had been "verygood babies". Veronica's mother could not remember her ever having had a tantrumwhen she was a toddler; Diana's mother said of her: "We didn't know we had her";Elizabeth, as a baby, was "contented and placid"; Jennifer was no trouble at all.They achieved bladder and bowel control at an early age, 18 and 14 m were


mentioned, so it appears as if the mothers had been methodical in training them,despite their protestations that it had been easy.

The children themselves assimilated maternal standards at a very early age. All4 were described by their parents as having been "very good little girls" almost tothe very monlent of their breakdown; and all 4 seemed "quite happy", at least partof the time in their primary schools.

Whatever the psychological mechanism involved, be it imitation, unconsciousassimilation of patterns of behaviour, identification or inherited predisposition (thelatter of course does not apply to the adopted girl), there could be no doubt that allthese four girls were perfectionists, like their mothers; that they set themselves impos-sibly high standards, and that falling below these standards, or even making amistake, was to them an equivalent of "naughtiness". Three of the 4 were alsodetermined characters with a strong will of their own, the fourth, the adopted girl,only a little less so. Their symptoms could perhaps be examined from the followingangle.

Accepting as broadly correct the observation that instinctual drives are intensifiedin puberty and adolescence and that many of the traumas and conflicts of earlychildhood are then re-activated and re-lived, what conflicts might these girls berevealing in their symptoms, in the sickness, the vomiting, the refusal of food, the"empty" feeling and the fear of school, as well as their extraordinary stubbornnesswhen they are being pressed? In terms of psychoanalytic theories these conflictswould belong to the oral phase of development and to the subsequent anal phase,these two phases being telescoped and re-lived on the infantile and the adolescentlevel simultaneously.

It is significant that these girls were "very good babies"; their mothers, too, were"very good" mothers, and in those early years conflicts between them had beenavoided. The absence of temper tantrums at the toddler stage suggests excessive fearof damaging the mother and a thorough inhibition of self-assertive drive when it islikely to be most urgent. It may be a matter for discussion whether it is easier for achild to emancipate itself from a good or from an unsatisfactory mother: physicalseparation between a young child and his mother seems to have a particularlydevastating eflect in cases where the relationship was a bad one. Be that as it may,the fact is that these girls, 3 of them highly intelligent and successful in their studies,had reached a stage of physical and intellectual development when the need toseparate from the mother and to establish themselves as true persons was becomingpowerful and conscious. Emotionally they were immature; their mothers still likedthem to be "little girls", and they sat on their mothers' and fathers' knees and liked acuddle. They also liked getting into the parental bed; three of them shared theparents' bedroom frona their infancy up to the age of 10 or 11; one had always sleptin the mother's bed. Their curiosity about the marital relationship, the conceptionof children, the differences between the sexes was over-stimulated by this proximity,yet the parents were unable and unwilling to satisfy it. The normal adolescentrebellion against authority was made particularly difficult for these girls because theparents were so indulgent; and the hostility they felt at inevitable minor frustrationsclearly aroused excessive guilt feelings, and a fear of punishment which was moreintense, the less defined this punishment was in their fantasies. The transition to the

72 LYDIA JACKSON

Oedipal (Electra) phase seemed to be blocked by the exceptionally close tie with themother. That these girls attempted at times to take over the wife's role with theirfathers was especially evident in Jennifer, who made her father and her brother toethe line when she was left in charge for a couple of days, and in Elizabeth who repri-manded her adoptive father for making excessive demands on his wife (asking her tofind his necktie) and once slapped his face because he refused to look at her new shoeswhen she wanted him to. It does seem, therefore, that one aspect of these girls'resistance or downright refusal to attend school was an open attempt to assertthemselves as persons in their own right, to stand up to their parents and parent-figufes, such as teachers and other representatives of authority. It was an act ofcourage and defiance rather than of cowardice.

Their other symptoms, on the other hand: the rejection of food., the inability toeat before school and vomiting, could be seen as due to infantile conflict, i.e., asrejection of the bad aspect of the mother, whose food might poison them in punish-ment for their hostility towards her. Feeling sick and vomiting, a natural expressionof disgust, is the very act of rejection, getting rid of the poisons, or of the 'bad' stuffin oneself, one's hostihty. The opposite side of this conflict is the excessive craving forfood which two of these girls showed: Jennifer often literally stuffed herself with foodand made herself sick by over-eating; Elizabeth drank pints of milk when the moodwas upon her. She also showed jealousy of her sister—Mary—on the oral level,hence her reference to Mary's appetite. The characteristic conflict of the anal phase,ambivalence towards the mother, stubbornness and defiant self-assertion, failed tomake their appearance in these girls at the toddler stage; and they still hardly daredshow it to their mothers as adolescents, hence the school as the source of authority,with teachers as "bad mother" figures, became the natural object on which to projecttheir hostihty and fear. Two of the four girls strongly resisted treatment, seeing theclinic as an ally of the school. Because their fears were really a regression to a muchearher phase of development, they were nameless: the girls could neither describenor define them, and they readily confirmed their irrational character. The schoolas such had nothing to do with it, except that it was a place where they could make amistake, which to them was equivalent to "being bad"; where they could be blamed,could have their angry feelings aroused to the point of losing control and doing theunimaginable, dreadful things which in their unconscious they had wished andfeared doing to their mothers. Veronica showed how dangerous she felt her hostilityto be when she said that she felt "caged" when in school, while Elizabeth's guilt onaccount of her hostility could well have been the cause of exaggerated reactions toher burn.

SUMMARYFour cases of school refusing were examined with a view to clarifying the etiology

of a particular sub-group of school refusers whom the author had treated. Thematerial obtained in treatment and in interviews with the mothers indicated astrongly ambivalent mother-daughter relationship in which mutual hostility hadbeen deeply repressed and was being projected by the girl on to the school, whereasher infantile conflict was expressed in the rejection of food and greed for food. Thegirls responded to treatment directed at uncovering their hostility and allowing


them to work through it in their relationship with the therapist. The family psycho-pathology in these cases was so closely woven into the pattern of mother-daughterrelationship, that it did not prove possible to modify it to any considerable extent.However, the mothers, and to some extent the fathers, were helped to tolerate acertain amount of hostility from their adolescent children and to guard againstputting too many obstacles in their way towards emancipation.

Acknowledgments—Acknowledgments are due to the psychiatric social workers, thelate Miss C. N. Fairbairn and Miss Phyllis Winterbottom for the material supphedin their careful histories and notes on the interviews with the mothers of Elizabeth,Jennifer and Veronica; also to the clerical staff of the Unit for their help in typing themanuscript.

REFERENCESBECK L . F . (1950) Human Growth. The Camelot Press, London.BOWLBY J. (1951) Child Care and the Growth of Love. Penguin Books Ltd., London.DAVIDSON S. (1961) School Phobia as a Manifestation of Family Disturbance. J . Child PsychoL

1, 270-287.EDELSTON H . (1943) Separation Anxiety in Young Children: A Study of Hospital Cases. Genetic

PsychoL Mono. 28, 3-95.HERSOV L . A . (1960) Persistent Non-Attendance at School. J . Child PsychoL 1, 130-136.HERSOV L . A . (1960) Refusal to Go to School. J . Child PsychoL 1, 137-145.JACKSON L . (1952) A Test of Family Attitudes. Methuen & Co. Ltd., London.MCGLASHAN A . (1962) School Refusal. A Review of 44 Cases with Special Reference to Treatment

in a 'Day Hospital'. (Personal Communication.)TALBOT M . (1957) Panic in School Phobia: A Study of Five Cases. Amer.J. OrthopsychiaL 27, 286-295.

anxiety in adolescents in relation to school refusal

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