This month (January 2012) Consumer Reports posted an article on their website “Is fish oil right for you?”.  In this article the authors suggest that “Although the evidence isn’t overwhelming, the supplements may modestly …… improve the symptoms of ADHD ….. in children.”. Before we jump on the fish oil supplement bandwagon it is important to keep in mind that this finding is based on parent reports (survey data).  While such data can be useful it is important to remember that survey data lacks the scientific soundness of controlled research. Therefore, we should not assume that fish oil supplements are a magic bullet for the treatment of ADHD. In fact, Consumer Reports survey data on ADHD treatments found that 67% of parents who gave their children medication rated medication as “helping a lot.”  This is in stark contrast to parent ratings on fish oil supplements; only 12% of those who gave such supplements rated them as helping a lot. Finally, it is important to keep in mind that research has consistently shown that medication (primarily stimulant medication) based treatment helps 70-80% of children diagnosed with ADHD.

The date for the Center for Family change’s half day seminar “Financial Challenges and Ethical Practice” has been changed to March 6th 2012. All other registration information is correct.

What causes anger in teenagers is a complex topic; often problems with anger are caused by a combination of social, environmental, and internal factors. What is important to understand is that while many angry teenagers have the same symptoms, the causes are much different. In order to successfully help the teen that struggles with anger, I have found the secret lies with understanding the cause, or causes. Below is a list of different causes that can underlie anger in teens:

1) Difficulty coping with losses (divorce, death of a family member, loss of friendship/ romantic relationship)

2) Family conflict (conflict with a parent/ parents, sibling, addiction issues in a family member)

3) Peer causes (either peer conflict, or trying to follow norms of a negative peer group)

4) Difficulty managing academics (difficulty coping with stress and frustration of increased work load- can happen in school changes i.e. grade school to jr high, jr high to high school

5) Difficulty coping with emotions (sadness, uncertainty, self criticism, self doubt, hurt)

6) Negative, immature beliefs, cognitions, and values

7) Problems with physical health

Presence of chronic underling mental health issues (depression, anxiety, autistic spectrum disorders, behavioral disorders, or personality disorders)

This list is not meant to be a definitive one, but a starting point to look at the larger picture of the teen’s life situation, beyond the symptoms. Using creativity one can add many more causes to this list, as well as become aware that there can be more than one factor combining to create the problem. It is important to have an understanding of the time length of the anger problem; often-long term chronic anger can have different causes than anger that is more situational based. Also important are the questions: who, what, and where. (Who does the anger happen with, what triggers the anger, and where does the anger happen)

Thinking about the causes of the anger, allows us to enter the teen’s world and understand their viewpoint. This can be especially important in working with teenagers who are unable to articulate problems verbally, due to their developmental maturity. When we are able to look at how the symptoms of anger can have many different causes, this suggests the treatment approach that will best address the underlying cause. An important diagnostic skill is developing the ability to understand the teen’s situation and share empathy, regardless of the teen’s external behavior. Skillful use of empathy and compassion forms the cornerstone that successful treatment is built upon. Later articles in this series will address anger management treatment, cognitive therapy interventions, and understanding the etiology of the teen that has long term, chronic problems with anger and irritable mood.

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.