With her friendly smile, firm handshake, and stylishly oversize glasses, it's hard to imagine Eva Haydu, 17, not fitting in, let alone feeling unbearably sad.
Yet not long ago, that was so. She didn't want to go to school. She gave up running track; she was too stressed, too easily tired. She was taken to a hospital because she felt like hurting herself.
Some people at Gateway Regional High School "didn't understand how it feels to have anxiety," the junior said. "I was depressed."
But then the Westville girl learned about Transitions Academy, a small program in Cherry Hill that works with young people such as Haydu. Finally her problem was given a name:
More than a year later, with counseling and help, Haydu feels quite differently - about others, about herself, and about the place she calls school.
"Now I feel it's my favorite place," she said. "It feels like home."
Haydu, some might say, is one of the fortunate ones.
For many children, school refusal can be a disorder that is misunderstood and can easily go undiagnosed, leading to loss of valuable learning, isolation, and family turmoil as well as social and emotional problems.
The Anxiety and Depression Association of America defines it as the disorder of a child who refuses to go to school on a regular basis or has trouble staying in school.
Physical symptoms can include headaches, stomachaches, and nausea. The condition is often accompanied by anxiety disorders and depression. Tantrums, fear of separation, and defiance commonly occur as well.
Starting school, moving, and other stressful events can trigger the onset. So can bullying, fear of failure or abandonment, concern about a parent, and other factors. It commonly takes place between the ages of 5 and 6 and 10 and 11, as well as times of transition, such as entering middle school or high school.
Often a sign of a deeper problem, anxiety-based school refusal affects 2 to 5 percent of school-age children, according to the association.
Christopher Kearney, director of the Child School Refusal and Anxiety Disorders Clinic of the University of Nevada, Las Vegas, said school-related anxiety is likely on the rise. He said some form of school refusal behavior holds true for 25 to 35 percent of all children.
And it is not merely a U.S. phenomenon. Kearney said in recent years he had received inquiries from people in dozens of countries.
Lynne Siqueland, a clinical psychologist with the Children Center for OCD and Anxiety in Plymouth Meeting, said it was important to try to get the child back to school as soon as possible. If a child is out for a while, gradual return may be necessary.
The issue of absenteeism among America's children has been receiving attention of late. My Brother's Keeper, an initiative by the Obama administration to reach out to at-risk youth, has bolstering attendance as a significant focus.
In addition, the U.S. Department of Education's Office of Civil Rights is expected to soon release new data on how many students miss 15 days or more of school per year. Educators often consider students who are absent 10 percent or more of the time to be chronically absent.
School refusal, however, differs from simple truancy. In school refusal, parents are often aware of the absence, and the children will often choose to stay home, where they feel safe. A truant child often will not. Truant children do not want to go to school, but they usually will not exhibit the distress a school-refusing child will.
Barbara Donahue, director of First Children Services, which includes the Transitions Academy, said she became aware of school refusal about a dozen years ago while working as a special-education child study team leader, encountering children who were very difficult to get back to school
Since starting Transitions Academy about 11 years ago, she said, they have worked with about 90 children. About 58 percent returned to district schools, about 22 percent graduated from the academy, and the rest went to alternative programs. Quite a few have gone on to college.
The students' tuition is paid by their home districts, Donahue said. At Transitions, classes are small; currently there are about a dozen students in high school and six in middle school. Techniques such as cognitive-behavioral therapy and mindfulness are used.
Homeschooling is generally frowned upon for these students; they need the socialization, Donahue said. "They need to start facing their fears so they can do more," she said.
Collin Horn, 16, of Sewell, said that he left Washington Township High School in part because the workload there was too much for him - up to 3 a.m. or worse - given his ADHD.
But Horn, the son of a dentist and a nurse, said he had problems earlier, too.
"I was just an outcast [in middle school]," he said. "I never fit in with everyone."
His twin sister, he said, is doing fine at Township. Transitions for him feels a better fit.
"The learning here is structured, organized," he said.
He likes that there are fewer students. "I feel upbeat and relaxed," he said, compared with before - "stressed out and frantic."
He has ambitions for the future - to be an Army Ranger or auto technician. And he has friends, including Eva Haydu. They go on dates to the park, he said.
Haydu, who emigrated from Romania with her family about 10 years ago, said that even at Transitions she was "super anxious" at first.
But before long, Haydu, who would like to study psychology or graphic arts, was won over by the kindness shown to her and the friends she made, enough to make her want to be in school.
"What I guess helped me the most was the people around me, people I loved, and not caring what was going on around me," she said. "Caring about myself. And smiling. You can save someone's life with a smile."