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Treatment Approaches to Addressing School Anxiety, Refusal and Avoidance.    .pdf version click here
What to do When Your Child is Afraid or Does Not Want to Go to School.
Dr. Cummings treats childhood and adolescent anxiety disordersby Colleen Cummings, Ph.D.,   Clinical Psychology Associates of North Central Florida 
With the start of a new school year, parents can certainly expect to see some increased anxiety, worries, and fears in their children.  With school come many changes, such as a new teacher, new classmates, tests, homework, and afterschool sports and activities. Parents often ask: how can I tell when it is too much? And, What can I do about it?
 
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2121 NW 40th Terrace Ste. B, Gainesville FL 32605                                         352-336-2888   
 
When should I seek help for my child with anxiety?
Anxiety disorders are, not surprisingly, among the most common psychological disorders to affect school-age children (Costello et al., 2003), affecting around 3 to 24% of youth (Cartwright-Hatton et al., 2006). To a certain extent, anxiety is normal; we all feel anxious from time to time. In fact, researchers have concluded that a little bit of anxiety is a good thing. If we never felt anxious, we probably wouldn’t study for a test, plan for the future, or flee from danger. However, anxiety becomes a problem when (1) it causes us significant amounts of distress, (2) it is well out of proportion to the circumstances, and (3) it causes us problems in our daily life.
In order to meet the level of a disorder, we should ask ourselves if the anxiety is more than a normative response to a stressor, and if it is interfering with normal functioning. For instance, with the start of the school year, parents may notice that their child appears to be worrying about teachers, friends, etc., may have some difficulty sleeping the night before school, and may look to parents for reassurance about a number of topics. A child may even cry or appear clingy during the first week of school. These types of behaviors, if brief in duration, are generally within the normal range for younger children.
 
When anxious behaviors persist for several weeks, cause problems for the child, or raise the concern of school professionals, it may be time to seek the help of a child psychologist. Unfortunately, once these symptoms become persistent and repetitively disruptive, these “clinical” levels of anxiety usually will not just go away, and can lead to future problems like depression or substance abuse.
 
What does treatment for school anxiety look like?
Fortunately, both talk therapy and pharmacotherapy have been shown to be effective in a number of studies with children (e.g., Walkup et al., 2008).  We focus on the type of therapy with the highest evidence-base for anxiety disorders: cognitive behavior therapy (CBT). CBT for anxiety focuses on modifying thoughts and behaviors that contribute to and worsen symptoms.  Typically, CBT is a short-term treatment (e.g., 16 to 20 sessions) that can be delivered in a variety of formats, such as individually or in a group, one-on-one with your child or with the whole family.
 
A child and adolescent psychologist may taper treatment to meet the child or adolescent’s needs; for instance, parents may be very much involved in the treatment of a young child, whereas group treatment, when available, may be more appropriate for an adolescent with social anxiety. CBT for anxious youth often includes psychoeducation, skill-building, behavioral exposure, and relapse prevention (Kendall & Hedtke, 2006). Additionally, parenting techniques and social skills training may be integrated as needed. Skill-building may include relaxation techniques, problem-solving skills, and cognitive restructuring (i.e., identifying and modifying anxious thoughts). Exposure tasks include helping the child face his/her fears, often in a gradual fashion, to help the child practice his/her new skills to cope with anxiety, and to learn that the situation was not as scary as s/he may have thought that it would be.
 
Tips for Parenting an Anxious Child
Having an anxious child can be very stressful! In addition to finding appropriate treatment for their child, there are a few things that parents can do to help at home. First, parents can normalize their child’s experience of anxiety. They can talk to their child about things that make them feel worried; as long as they also talk about how they managed the anxiety. For example: “The other day, I had to give a big presentation at work. I was really nervous that I would mess up. I took some deep breaths and reminded myself that all I could do was my best. Even though I made a few mistakes, no one really noticed and I felt proud of myself afterwards.”  In this way, parents can be a model of good coping for their child.
Second, parents can encourage their child to face his/her fears whenever possible. It is completely natural for parents to want to protect their child, but it’s important to remember that experiencing anxiety is not inherently harmful. Rather, it can be helpful in teaching a child that the worst didn’t happen, and even if it did, s/he was able to handle it. Finally, when parents do see their child coping effectively with his/her anxiety by trying something scary, they can remember to praise him/her. We all deserve to be rewarded for being brave.  
It will come as no surprise that children and adolescents will pay more attention to what parents do, how they act, and the emotional tone parents convey.  Just as modeling good coping techniques assists in establishing a sense that anxieties are something that can be confidently managed, parents can inadvertently magnify children’s anxieties if parents have untreated or poorly managed anxiety disorders, or tend to convey negative or worrisome actions, emotions or statements about school, outcomes, or the future in general.  Prior to treatment, a psychologist will assess family and other factors to ensure an approach that will give the child or adolescent the best chance for success.
What is School Refusal? – School Refusal Defined:
School refusal is defined as “child-motivated refusal to attend school and/or difficulties remaining in classes for an entire day” (Kearney & Albano, 2007). It can include children who are completely absent from school for periods of time, skip particular classes or leave early, are chronically late to school, and/or demonstrate intense behaviors such as tantrums, crying, begging, or clinging to try to get out of going to school. Overall, school refusal is more than just school jitters and affects 2-5% of children at any time. School refusal most commonly occurs during periods of transition; for instance, beginning at a new school. While children who refuse school are often of average or above average intelligence, school refusal is associated with child and family stress, declining academic performance, financial expense, social alienation, and many other problems.
Given the impairment and often legal consequences resulting from poor school attendance, families are encouraged to seek treatment relatively quickly as problems persist. CBT for school refusal often includes collaborating with the family and school professionals such as teachers or principals. It is important for professionals to determine the function of the school refusal behavior. Children can avoid school for anxiety-related reasons (e.g., social or separation anxiety problems) or behavioral difficulties. Treatment will then be targeted towards the specific function(s) of the school refusal behavior, and often includes psychoeducation and skill-building, a hierarchy that gradually increases school attendance, and positive reinforcement.

Resources for School Anxiety, School Avoidance and School Refusal:
 
Websites:
·       The Child Anxiety Network: www.childanxiety.net
·       New York University Child Study Center:www.aboutourkids.org
·       Anxiety Disorders Association of America: www.adaa.org
·       The Center for Mental Health Services: www.mentalhealth.org
 
 
Related Articles from our CPANCF.COM Website:
·       Common Childhood Fears 
 

Books for Parents:
·       Monsters Under the Bed and Other Childhood Fears: Helping your Child Overcome Anxieties, Fears, and Phobias. Garber, Garber, & Spizman
·       Straight Talk about Psychiatric Medications for Kids.  Wilens.
·       Good Friends are Hard to Find: Help your Child Find, Make, and Keep Friends.  Frankel & Wetmore.
·       Helping Your Anxious Child. Ron Rapee
·       Freeing Your Child from Anxiety. Tamar Chansky
Books for Children:
·        First Day Jitters. Danneberg.
·        Wemberly Worried.  Henkes.
·        Scary Night Visitors: A Story for Children with Bedtime Fears.  Marcus, Marcus, & Jesche.
·        I Don’t Know Why…I Guess I’m Shy: A Story About Taming Imaginary Fears.  Cain & Smith-Moore.
·        Into the Great Forest: A Story for Children Away from Parents for the First Time.  Marcus, Marcus, & Jesche.
·        Night Light: A Story for Children Afraid of the Dark.  Dutro & Boyle.
·        Cat’s Got Your Tongue?  A Story for Children Afraid to Speak.  Schaefer & Friedman.
·        Up and Down the Worry Hill.  Wagner. (OCD)
·        Kissing Doorknobs.  Hesser (OCD for young adults)
References
Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and
development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60, 837-844. doi:10.1001/archpsyc.60.8.837
Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected
population: Prevalence of anxiety disorders in pre-adolescent children. Clinical Psychology Review, 26, 817-833. doi:10.1016/j.cpr.2005.12.002
Kearney, C. A., & Albano, A. M. (2007). When children refuse school: A cognitive-behavioral therapy approach (2nd ed.). New York, NY: Oxford University Press.
Kendall, P. C., & Hedtke, K. (2006a). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore, PA: Workbook Publishing.
 
About the Author:
 
Dr. Colleen Cummings completed her doctorate in clinical psychology with a specialty in child psychology from The Ohio State University.  She completed her American Psychological Association-accredited internship training in clinical child psychology at the Children's National Medical Center in Washington, D.C. and postdoctoral research and clinical work at the Temple University Child and Adolescent Anxiety Disorders Clinic in Philadelphia, Pennsylvania.  She is an expert in evidence-based treatment for childhood and adolescent anxiety disorders, incorporating cognitive-behavioral techniques in her therapy. 
 
Dr. Cummings practiced as a licensed psychologist in the State of Pennsylvania since 2011 before becoming a licensed psychologist in Florida.  Update 11/24/14: Colleen Cummings, Ph.D. now practices as a licensed psychologist in Rockville, Maryland. Her practice website link is: http://www.alvordbaker.com/.
 
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