School is often the setting where anxiety becomes a crisis. Going to school, staying at school or functioning in school can become huge problems. Getting a child back in school and functioning becomes THE family focus. In this post I am going to try to detail the process I would usually recommend and provide a case study to illustrate it. I hope this post will be general enough to fit most situations but specific enough to offer concrete practical direction.
To keep this “relatively” brief and applicable, I am going to make some assumptions.
- Your child is in primary school, approx. ages 5 – 11. Getting an older child back to school often has some additional complications that I won’t cover in this post. You can adapt this to any fear in any age but know there can be other factors needing attention in different ways than how to treat anxiety.
- You have an understanding of exposure and response prevention and are willing to do this with your child. If not, here is a post about it.
- The reason for the school problem is anxiety and not something else.
- You are willing and able to put the time, patience and willingness to see this through. If you have a therapist who will oversee this with you that is great. That is not always an option so you may have to do it.
- You are able to arrange for ongoing education in some form while going through this.
I am going to describe the steps in theory and then illustrate the steps with an actual case. I changed the name and some detail in order to protect the privacy of my young patient. We will call her Karyn.
Close the back door
First of all, take any ongoing option of staying home off the table. If your child thinks there is an option to stay home they will attach to that with a molecular bond. Sometimes it is important to make home less comfortable to help with motivation. This might involve chores and/or removing media access for example. If you have to do something like homeschool because of anxiety, then you have to do it. (I’m not referring to homeschool in principle at all, only when it is a result of anxiety.) The bottom line is that you have to educate your child and in some cases this might be what has to happen. At some point you may need or want your child to get back to school and these steps would apply. When possible, it is always better to face anxiety then avoid it.
Karyn: Some background. When I started to see her she was in a small private school that allowed the family a lot of flexibility in working with her anxiety. They had tried public school without success. Of course, not every school setting will have this flexibility so you may have to become a strong advocate for you child in order to arrange for a process of returning. I discuss that some in this post. This was as far as they would go and staying home or homeschool was not an option.
Determine the kind of anxiety
I like to ask, “How does your anxiety show up?” “What kinds of problems does it cause?” It can be helpful to externalize it so that you child can think of it as a character they have to battle. It might help for them to give it a name. Here is a brief explanation. Take our test about your child’s symptoms. It has a good sample of common symptoms. Make a list of all the symptoms you can think of. It doesn’t have to be perfect and you don’t need certainty regarding a diagnosis.
Karyn: Here were some representative symptoms: Frequently avoids going or staying in school. Almost always went in late. On first day of school the previous year she took off running when the principal tried to walk her in the front door. She was afraid of getting sick, particularly throwing up. The only way she would stay in school is if her dad was on the campus and she had a mobile phone with her. She avoids being apart from one parent or the other. She reported that she would flush (face would turn red), sweat, curl up, rock, felt stomachaches, and hyperventilated. It appeared to me that she was struggling with separation anxiety and emetophobia.
Make a list of triggers
A trigger is anything that produces anxiety. So think of the symptoms and consider what could be the trigger(s)? Just doing this with your child will probably cause anxiety. It wouldn’t be a surprise if your child resists talking about it, particularly in detail. I am sorry about the tension that will probably cause you but this is actually helpful because you know that thinking about it is a trigger. Put it on the list. Here is a good way to ask questions to get the info you need. “When you got anxious did you have a picture or words in your mind?” Have your child think of any time he remembers feeling anxious. Have him think about every time he noticed the feeling or symptoms. It might be getting dressed in the morning, going to the bus or car, driving to school, seeing the parking lot, walking in, etc. You will probably have to prompt his memory. It will help if you give the context. For example, if you know he was anxious at school narrow it down to the specific class or subject. Was there anyone present? Was it at the beginning, etc.? You want the triggers that hardly count all the way to the big stuff. You want to know a) what was in the environment? ex. Classroom, smell of cafeteria, test, etc. b) what was he feeling in his body – not things like sad, happy, rather things like stomachache, dizzy, jumpy. c) If the fear came true what would happen? I would panic, fail the test, miss my mom, etc.
Karyn: Here were some of her triggers: Any situation without easy and inconspicuous escape. Any feeling of stomach discomfort. Public eating. Going into school building. Anyone who seemed to have any symptoms of being sick. Thinking about vomit. Talking about vomit. Anyone else talking about vomit. Being more than a few minutes away from a parent. No way to immediately call parent. Thought of vomiting in class. Fear of making a scene. Possible contaminants that could give her flu. Getting ready for school. Leaving car to go inside.
Make list of safety behaviors
How does your child try to make things safer or less scary? If the action or thought reduces the anxiety then it is a safety behavior. The main thing anyone with anxiety will try is to just avoid it altogether. That is not always possible so people resort to secondary avoidances. For example if someone is afraid of catching the flu then having zero contact with the flu virus would be the primary avoidance. Since that is nearly impossible then a secondary avoidance would be to wash and clean anything that has been in public. If your child is afraid of being separated from you then having you in sight would be a primary avoidance. If that isn’t possible then having a way to get hold of you by phone or text would be secondary. Here is a post about this. Write these down as well.
Karen: Asking for reassurance, “Do you think I am sick?” “Will you promise to answer right away?” “Will you promise to get me right away?” Dad at school. Having a parent along on field trips. Go with mom if she travels overnight. Insist mom or dad come to all appointments with doctor, dentist or psychologist (that was me). Skipped breakfast and lunch so wouldn’t have anything to throw up. Keeping phone with her. Using sanitizer to clean. Avoiding if any hint of sickness and stay home if someone at school is sick. Staying home at any hint of stomachache. Scan for stomachache first thing upon waking up. Sitting by door or exit in any meeting like class or church service. Avoiding public meetings like youth group. Turning down overnight events. Avoid parties that parent couldn’t attend or be nearby.
Organize the triggers into steps, easy to hard
At this point you should have a list of symptoms, what triggers the symptoms and the attempts to reduce anxiety or make it safe. Have your child imagine if he were to face the triggers would they be a mild, medium and high challenge? If he couldn’t do the safety behavior would that change how hard it would be? Don’t worry too much about fitting them into the category. This is just a rough organization. Some will probably change anyway.
Karyn: Since there were two different areas of anxiety for her we decided to work on the emetophobia first. Having success at the beginning is very important so I like to start with something imaginary. I will explain that in more detail shortly. I essentially followed this outline. (By the way, our emetophobia supplement to Turnaround should be available by the end of this month. As I write it is March, 2016.) So things like talking and thinking about getting sick were easy to medium challenges. Being around sick people and eliminating cleaning safety behaviors were a higher challenge. It was virtually impossible to completely separate the separation anxiety from the fear of getting sick so I eventually blended them together. For separation anxiety thinking about being apart was easiest. Medium challenge was going into school sooner. Dad leaving sooner from school was medium to difficult. Not having cell phone access was high challenge. Staying home while mom goes out of town was high as well. I am not going to give the complete list since this post is getting really long as it is. Hopefully you get the idea.
Motivation is crucial
This whole process will be a disaster if your child goes bonkers when you want them to do this. This is where you have to use your parent super powers. Kids love stories. You will need to come up with some stories that explain how this works so that your child will be willing to move forward. One reason I love working with kids is that they are more likely to do what you tell them. Of course, it is easier for me the psychologist to get kids to do stuff than it is for parents. This was just as true at my house when my kids were younger. Here is a story I use that kids get for the most part. Feel free to modify it or use your own. Think of something that you kid was anxious about first and now they can do it without fear like learning to ride a bicycle or skateboard. I think we do a bang up job with this in the Turnaround program. We explain how all this works in a way that will make sense to your child. Your child doesn’t have to be excited to do this, just willing. One friend was talking about getting his grown kids to come to visit and he said he had no problem with using bribes. He said tongue-in-cheek but it is about using rewards. When something is this hard then personally I wouldn’t hesitate to add in a reward system. I bought a bunch of gemstones (at least that is what the seller said) on eBay and I use those. Rewards can backfire as well so do a little research on ways to make this work. Coupon systems seem to be very effective.
Develop and begin the steps
You will be mostly done with this when you organize the triggers. However, here is when you will need to be creative. Don’t worry if you aren’t creative, it won’t be hard to make your child anxious. The art is creating some anxiety but not so much that you have a war on your hands. So our goal is to figure out a way for each of these triggers to create fear when we are ready for it. For some triggers this is obvious but it is harder with others. For example, let’s say the trigger is thinking about getting in trouble with the teacher. Well, you can’t call up the teacher and get her to pretend your child is in trouble. Well, at least most people can’t pull that off…. If your child is afraid of this they are likely trying to NOT get in trouble. So this fear is mostly something they imagine will happen. So here is where you get creative. If you can’t arrange it in real life, your child can imagine it. There are 4 ways to create anxiety triggering exposures. 1) imaginal, 2) virtual, 3) analogical/similar, 4) situational. Usually the degree of fear follows the order I listed the types of exposures. However, you can always rearrange them.
Karyn: Here are examples of each type of exposure and specific things we did to trigger some anxiety. The process is exposure, or triggering the fear, and removing safety behaviors. I don’t always note which is which in my description.
Imaginal: I started by saying words associated with throwing up, then put them in short sentences and then wrote out some vignettes. These are worse case. Don’t put anything in them that would make it easier. By the time I used vignettes about vomiting with Karyn I added separation elements into them. Here is a brief example. “I am at school and the kid next to me says he is sick. Then he gags, doubles over and pukes in the floor. I freak out and feel sick. I pull out my cell phone to call my dad and the phone is dead. The teacher says I have to stay in my seat. I am feeling like I might vomit. My dad can’t help me.” Read the emetophobia posts I listed before to see exactly how to do this including how long, who does what, when you know to stop, etc.
Virtual: There are lots of pictures and videos of vomit on the internet. More than you can imagine. Once you start noticing there are vomit scenes in television shows and movies aplenty. I had Karyn make a movie of walking into her school. If you can make a video of walking through school or the scary situations that would be great. Obviously you would need the appropriate approvals.
Analog/similar: I didn’t have to do this much with Karyn. The previous exposures created the stomach discomfort, curling up, rocking sensations, etc. However, if your child has social anxiety then you might practice how to talk to someone or go somewhere to watch how people handle certain things. They could give a speech to family members, for example, if that is a trigger. Maybe reading out loud is a trigger and they can do that for you. For some kids they might be afraid of getting hot, dizzy or choking. You can create situations to evoke these feelings. Here is a video using the Sesame Street character Grover explaining this. These are called interoceptive exposures.
Situational. These are the real life exposures. Examples can be to drive past the school, drive and park in front, sit there for longer and longer, walk up to the building, walk in, stay for longer and longer period of time, step by step. If there is a step where your child gets stuck then try writing a vignette for the next step. For your child it might be the bus, might be certain classes, teachers, kids. For Karyn, she gradually went into school sooner. We timed it. She was about an hour late to start and we shaved it in 15 minute increments. If she had a bad day and took a step back we just started from there and kept going. I had her watch videos of people vomiting in the car on the way to school. Additionally, we started dropping off safety behaviors. Her Dad gradually left school sooner. She started to bring lunch to school. Then she would eat a bite. Gradually she added to that. She stopped wiping down her desk with sanitizer and then stopped taking hand sanitizer. I think she had several dispensers with her at any given time to start. We eliminated them one by one. The family sat in places harder to get out of in church. Eventually she spent the night at home with dad when mom went overnight to see her mother.
In summary, here are the steps:
First, we created imaginal exposures. Words, sentences, stories
Second, we found and created virtual exposures. Pictures, audio, movies
Third, we created steps of facing her fear in real life.
It’s a process, not an event
We started treatment in January. By May and she was going into school right away and her dad was leaving in less than 30 minutes. She reported she wasn’t worried about throwing up. Over the summer she went to school for various functions and maintained her gains. She had a reason for this but we would have created something if she didn’t have a reason. One of my favorite moments was when she came in to celebrate having a friend spend the night. The friend got sick and puked all over her room. I mean all over. Want to know what was cool? She helped her dad clean it up. A few weeks later she got sick, twice. No fear. Next school year she was a bit anxious to start but didn’t give into the fear and was fine within a couple weeks. Her dad doesn’t stay at all. Last I heard she was able to go on some field trips without either parent.
There is no way to know how long a process like this will take. Be prepared for it to take longer than you expect. There are two periods where people are very tempted to give up. The first is the beginning. The first exposures are often the hardest because your child will be changing direction. Avoiding reduces anxiety but reinforces the problem. The feelings you will be evoking are the very ones your child has been committed to eliminating. It might be a while before you see the anxiety come down significantly. It will probably freak you out to see your child get anxious and that you are doing it on purpose. It might be worse than you expect. Keep going. Remember, your child is not in any danger. Their fear is WRONG. They will be able to tolerate the fear. The second period is when things are better enough that it isn’t wrecking everyone’s life. It is good enough. The process is a big pain and this is when people take a “holiday.” Unfortunately, if you do this then you leave the possibility of a relapse on the table. You might have one anyway but chances go up if you quit before facing all the triggers.
I hope this is helpful and I would appreciate feedback for anyone who tries to put this into practice. If you put your story in as a reply it might help other parents.