While it is developmentally normal for younger children to be anxious about school this normal anxiety typically resolves quickly as the child adjusts to school. Moreover, most parents are able to provide the support needed to help their children overcome their initial anxiety. However, when anxiety about school causes a child significant distress intervention is often needed. This is particularly true for adolescents, who, from a developmental perspective, should have resolved normal fears about school.
To effectively intervene with problems of school refusal and school anxiety clinicians need to clearly understand what is underlying these problems. Children may fear and resist school for a variety of reasons. Some children may have undiagnosed anxiety disorders (OCD, a social phobia or panic disorder). Others may have experienced difficulties with peer relations or have been victims of bullying. In some instances, children who struggle academically may feel inadequate and resist school because they experience academics as humiliating. Additionally, significant family problems may leave a child or teen fearful about separating from their family. Finally, more serious psychological or psychiatric problems may be present and school anxiety/refusal may be one manifestation or corollary of these disorders. Thus, when treating children who are excessively anxious about school, professionals need to assess for the following:
- Presence of Anxiety Disorders
- Peer problems (particularly bullying)
- Academic difficulties
- Family conflicts and problems
- Presence of significant psychiatric/psychological problems
Additional factors that may complicate the assessment and treatment of school anxiety and school refusal are: somatic or medical symptoms, and maladaptive parental responses (these will be discussed later in the section on treatment). Children with school anxiety often experience stomach aches, headaches, and other somatic complaints that have been found to have no clear cut medical basis. These symptoms often appear in the evening (on nights before school) or on school mornings, but seem to lessen or disappear when there is no school. While some parents, and even some children, are quick to recognize the connection between their anxiety and physical symptoms, others focus on somatic symptoms, and need repeated feedback from medical professionals that there is not a serious physical illness present and that the child needs to attend school.
Treatment strategies vary significant depending on a variety of factors including: the age of the child, the child or teen’s motivation to attend school and engagement in therapy, the presence of other psychological problems and concerns, and the family’s response to the problem.
Treating younger children with school anxiety and school refusal
With younger children (those not yet in middle school) parental involvement in therapy is critical. First, younger children need support and reassurance to overcome their fears. Second, they often need firm limits to help them contain their anxiety and not give into fears. Third, parents, quite understandably, often react to anxious children in ways that inadvertently exacerbate or reinforce anxious behavior.
Younger children often benefit from the use of cognitive behavioral strategies that help them find more effective ways to reassure themselves (self-talk strategies) and calm themselves. They are also often receptive to cognitive interventions that help them recognize that their fears are groundless. Parents need to be enlisted to support the use of these strategies and to model adaptive coping. This is particularly important when parents are more anxious and more reactive to their children’s anxiety.
Firm limits are also important. Allowing anxious children to stay home from school does not help them be less anxious, as avoiding the source of anxiety only results in increasing avoidant behavior. Thus, parents often need support and encouragement to insist that their anxious child attend school. While accommodations can be made to help a child cope with their anxiety about attending school, not going to school is not a good option. Children who miss school often become increasingly resistant to attending as the avoidance lowers their anxiety and the idea of returning to school seems more daunting.
Parents often find it difficult to effectively respond to their child’s anxiety. Some may provide excessive amounts of reassurance (rather than pushing a child to learn how to reassure him or herself). Others may become impatient and frustrated (yelling at an anxious person has not been shown to lessen anxiety). Finally, those parents who struggle with problems with anxiety themselves may find their child’s anxiety particularly unnerving. Parents often need direction on how to firmly, but calmly respond to their anxious child. In addition, when parents disagree on how to respond, intervention is needed to help them find ways to take a more unified stance.
An example of a case recently seen in our practice involved a 9 year old boy was very anxious about going to school, particularly about taking the school bus. This boy frequently claimed to not feel well and not want to go to school, on school day mornings. His mother typically would walk him to the bus stop, wait with him, but if he balked about getting on the bus, the mother would often end up yelling at him. Not surprisingly this only resulted in the child becoming more upset (e.g., temper outbursts and running off). These bus stop scenes were happening at least twice a week when the family started therapy. The therapist was able to assist this child and his family by setting up a plan where the mother stayed calm, accepted that she could not make the child get on the bus, and would need to drive the child to school if he refused to get on the bus. The parent’s main objective was to remain calm, in order to help the child stay calm. Positive reinforcement (being picked up from school) was used to motivate the child to take the bus. Ideally, the therapist would have worked with the child on finding strategies to help reassure himself and calm himself. However, this boy was reactive to therapy, refusing to participate. Thus, the work with the parents was the key to helping this child significantly decrease his school anxiety and school refusal.
Treating older children and Adolescents
Working with older children (preteens) and teenagers is easier in some ways (teenagers can more effectively use CBT strategies) and harder in others (patterns of school avoidance, anxiety and refusal may be longstanding). A thorough assessment of what is contributing to the school anxiety is essential with these age groups. In our practice we have had cases where: undiagnosed learning problems accounted for much of the anxiety and resistance to attend school because this teenage boy felt very stressed about not being able to manage academically; bullying and threats from peers were to such a degree that one teenage girl literally did not feel safe in school; the presence of a major depressive episode resulted in a boy feeling unable to cope with school (focus on his work, respond to questions) and thus seek to avoid attending. Thus, careful assessment of the source or sources of school anxiety and refusal are critical.
In working with teenagers we have found that a combination of individual and family therapy is typically most effective. In individual sessions the therapist can work with the adolescent: educate the adolescent about anxiety, identify more effective coping strategies to manage and alleviate anxiety, and motivate the adolescent to work to overcome anxiety and attend school. In family sessions, the focus is often on helping parents provide more consistent and effective support and structure. In one case, involving a significantly depressed girl who was very anxious about being in school, her parents were able to arrange that she could visit the school social worker if needed and also would not be called on in class, by teachers. These interventions helped reduce the teenager’s resistance to going to school, reduced her anxiety in class so she was more able to focus on academics, and helped her feel more supported by her parents.
Coordinating with school personnel
Regardless of the age of the child, coordination with school personnel is critical so that all parties are “on the same page.” Not surprisingly children and adolescents not only will play parents against each other, but will do the same with parents and school staff. Thus, by working to improve communication between parents and school staff this type of problem can be eliminated. Often contact with school personnel can reassure anxious parents that school staff can and will be helpful to their child.
Conclusions
Working with school anxiety and refusal can be very challenging. Children and teenagers can, in more extreme instances, be very resistant to going to school. It may difficult, even impossible (initially), to engage some children and adolescents in therapy and establish that the goal of therapy is to return to school. In these instances more family focused treatment may be necessary, with the emphasis on how parents can more effectively respond to their defiant and anxious child.
Family work is essential, from our perspective. Even the best intentioned parents can inadvertently respond (out of their own frustration or anxiety) in ways that intensify and exacerbate problems, e.g., the frustrated parent who yells at the anxious child, or the anxious parent who does too much reassuring rather than pushing their child to work to reassure themselves. Moreover, most children and adolescents need parental support to help them overcome their anxiety. Finally, if there are significant family concerns, or if the child is struggling with more significant emotional involvement, family involvement is critical. When significant parental conflicts are present, it is incumbent on the therapist to identify and attempt to address these issues. When a child or teenager is struggling with major depression or other serious psychological problems, parents need to understand their child’s needs and how to best respond to them.
Presence of chronic underling mental health issues (depression, anxiety, autistic spectrum disorders, behavioral disorders, or personality disorders)
What makes us better?: A new study calls into question our understanding of change.
December 26th, 2010A recent study about a so called “honest placebo” has received a good deal of attention. This study is particularly intriguing because unlike other studies of placebo interventions the participants clearly knew they were being given a placebo, yet still benefited from receiving the placebo. This reseach makes us stop and question our understanding of what make us better, gives us relief from symptoms, and helps us change.
The study, led by Ted Kaptchuk at Harvard Medical School’s Osher Research Center and colleagues from Beth Israel Deaconess Medical Center (BIDMC) appeared on December 22 in PLoS ONE, an on-line journal, found that placebos worked nearly twice as well as no intervention in relieving irritable bowel syndrome (IBS) symptoms, despite the fact that patients in the control group receiving the placebo were clearly told they were receiving a placebo. The investigators stated that they went out of their way to be clear with patients that they were receiving sugar pills. The authors stated that, “Not only did we make it absolutely clear that these pills had no active ingredient and were made from inert substances, but we actually had ‘placebo’ printed on the bottle,” and further notied, “We told the patients that they didn’t have to even believe in the placebo effect. Just take the pills.” What is particularly startling about this study is that the placebo effect was quite powerful. The authors noted that those in the placebo group did as well as those who typically receive the most effective medications for IBS.
The investigators were cautious in interpreting their results, stressing that they only conducted one study, and that it was time limited, lasted for 3 weeks. Clearly their cautions are important: this is only one brief study, looking at one disorder. However, the study does raise intriguing questions about how and why people benefit from treatment. The authors hypothesized that possibly the ritual of taking medication may have accounted for the benefits of the placebo.
It is a short leap from this study to thinking about how and why mental health treatment, psychotherapy in particular, helps patients. There is a consistent body of research supporting the benefits of therapy, but there is no definitive answer or answers to how and why therapy works. In fact, there is an increasingly strident debate about what accounts for change: the specific strategies and methods associated with a given model, (Evidence Based Therapy) or the non-specific ingredients of therapy (empathy, hope, the client-therapist reliance). Advocates of Evidence Based Therapy assert that there is evidence that certain models and techniques are more effective, often Cognitive Behavioral Therapy. The American Psychological Association is a major proponent of evidenced based therapy and recently developed a website highlighting evidence based treatments http://www.div12.org/PsychologicalTreatments/disorders.html). On the other side, are a group of research (mostly psychologists as well) who argue that the claims of evidenced based therapy are greatly overblown and that the non-specific ingredients (primarily the therapeutic relationship) are what account for change (see for example the work of John Norcoss, Scott Miller and others; Miller’s website offers an accessible understanding of this view: http://www.scottdmiller.com/).
While one limited study clearly cannot resolve this debate it does force us to think more about how and why change/symptom relief occurs, and how/why different interventions work. In fact, the researchers note that previously it was assumed that placebos worked because people thought they were getting something that would help them. Their work clearly challenges our assumptions about how and why placebos work, further calling into question what accounts for change/symptom relief.
It is possible that rituals, in this study medical rituals (doing things that are associated with making one better), may be an ingredient in accounting for change/symptom relief. While there is far from definitive evidence to support this idea, this study reinforces the notion that we need to be more modest in our claims that we understand why and how change occurs. It also clearly suggests that we need to work to better understand what brings about change/symptom relief.
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