The Great Masquerader

Anxiety and School Refusal

By: Ryan Ruth Conway, PsyD

Everyone experiences anxiety at some point in life. It is a normal, adaptive human emotion that helps us prepare for important events and optimizes performance – think upcoming tests, ballet recitals, sports playoff games – and alerts us to danger in situations that threaten our safety. However, some individuals experience anxiety so intensely and so frequently that it becomes impairing, hindering their daily functioning. In fact, according to the National Institute of Mental Health (NIMH), it is the most common mental health disorder in the United States among adults and children. In my work with children and teens, I have seen anxiety become such a powerful force that it gets in the way of having sleepovers at friend’s houses, limits social engagement, results in marked physical discomfort, impairs concentration in class, and even contributes to flat out refusal of school.

Anxiety is an inward focused feeling, meaning that we experience it internally. As a result, it is often unrecognizable to parents and teachers and can go easily undetected for a long time until it becomes a problem. Children might be ashamed to talk about it, try to push it away to avoid distress or be limited in their ability to fully articulate what is happening. Behaviorally, anxiety causes a fight-flight-freeze reaction. It leads to acting out and aggressive behaviors (i.e., “fight”) as well as running away and escaping (i.e., “flight”). Anxiety can also be an underlying source of noncompliance, disguised as unwillingness to engage and shutting down in overwhelming situations (i.e., “freeze”).

In a recent New York Times Magazine article (see link below), writer Benoit Denizet-Lewis takes a closer look at the increasing prevalence of adolescent anxiety as well as a residential program, Mountain Valley Treatment Center, that provides services for more severe cases. In an information age, many teens, parents, educators and mental health professionals are citing social media as partly to blame for the uptick in anxiety. The constant comparing to peers through social media is problematic in that it makes teens feel like they aren’t good enough, which can greatly impact their self-esteem. In my clinical work I see an overreliance on smartphones due to the reinforcing function they serve – whether it be a text back to hang out or a “like” on an Instagram post – and I will often work with youth on self-reinforcement and finding alternatives that are intrinsically rewarding to them.

Many of the students interviewed for the New York Times Magazine article who attended Mountain Valley had histories of significant difficulty attending their regular school due severe anxiety and/or depression, a presentation known as school refusal. School refusing behaviors exist on a spectrum, from the mild (e.g., missing gym class every now and then due to fears of changing in front of classmates) to the more severe (e.g., missing entire weeks of school due to persistent worries about having panic attacks). Early intervention is key. The longer the child or adolescent is out of school, the more pressure they feel about “catching up” academically. The more they feel like they are falling behind, the more depressed and anxious they become. The more upset and stressed they are, the more difficult it is to get back to school. And the cycle continues.

Understanding this cycle, NESCA offers a special program for youth who refuse school because of emotional distress, called Back to School (BTS). In this program, clinicians use a comprehensive evidence-based treatment approach and work closely with parents and school faculty to figure out the most effective plan that will help the student reenter school.

• Given the importance of catching school refusal early, here are some warning signs to look out for:

• Test-taking anxiety

• Peer bullying

• Ongoing visits to the nurse despite no apparent signs of illness

• Frequent requests to phone or go home during the school day

• Somatic complaints without a medical explanation (e.g., stomachaches, headaches, etc.)

• Absences on significant days (e.g., tests, speeches)

• Sleep problems or resistance to leave bed in the morning

• Changes in mood – anxiety, irritability, sadness 

If you have any questions about the BTS Program or NESCA’s therapy program in general, please contact Dr. Ryan Ruth Conway at rconway@nesca-newton.com or 617-658-9831. Dr. Conway will additionally be speaking at several workshops this fall on the subject of School Anxiety, School Phobia, and School Refusal. Information regarding upcoming NESCA events can be found on our web site at http://www.nesca-newton.com/events.html.

Article: 

Denizet-Lewis, B. (2017). Why Are More American Teenagers Than Ever Suffering From Severe Anxiety? The New York Times Magazine. Retrieved from https://www.nytimes.com/2017/10/11/magazine/why-are-more-american-teenagers-than-ever-suffering-from-severe-anxiety.html.

About the Author:

Dr. Ryan Ruth Conway is a licensed clinical psychologist who specializes in Cognitive Behavioral Therapy (CBT), behavioral interventions, and other evidence-based treatments for children, adolescents and young adults who struggle with mood and anxiety disorders as well as behavioral challenges. She also has extensive experience conducting parent training with caregivers of children who present with disruptive behaviors and Attention-Deficit/Hyperactivity Disorder. Dr. Conway has been trained in a variety of evidence-based treatments, including Parent-Child Interaction Therapy (PCIT), Dialectical Behavior Therapy (DBT), and Exposure with Response Prevention (ERP). Dr. Conway conducts individual and group therapy at NESCA utilizing an individualized approach and tailoring treatments to meet each client’s unique needs and goals. Dr. Conway has a passion for working collaboratively with families and other professionals. She is available for school consultations and provides a collaborative approach for students who engage in school refusal. 

Catch Them When They're Good!

A Positive Parenting Tool

By: Ryan Ruth Conway, PsyD

If your child’s go-to response to your requests is typically “no,” then keep reading…

Children who tend to disobey rules, become easily agitated, experience temper outbursts and argue with authority figures are known to display a pattern of behaviors called disruptive behaviors. These behaviors can cause significant family turmoil and become quite challenging for schools to manage. Children who have trouble regulating their emotions and behaviors may be pinned as “the bad kids.” This is unhelpful, because it does not explain what exactly is underlying the acting out. This type of reputation can also impact a child’s self-esteem, resulting in feelings of inadequacy and self-doubt. Disruptive behaviors could be masking other issues that are not obvious to teachers and parents. Consider the possibility that the kindergarten student who shuts down and refuses to engage in class is not oppositional, but instead experiencing anxiety about being away from his mother or father. Maybe the second grader obtains his parents’ attention most often at home when she lashes out. In trying to control disruptive behaviors, children get a lot of attention from adults for what they are doing wrong, often times unintentionally.  

One of the hallmarks in teaching caregivers how to effectively manage these kinds of behaviors is positive parenting, which comes from a behavior therapy approach. Among positive parenting techniques is “catching them when they’re good,” which shifts the focus away from what is problematic and towards the appropriate behaviors parents want to see continue. With this technique, parents become more mindful about the behaviors they attend to, and seek out opportunities to let their child know when he or she is on the mark. It feels good for both the giver and the receiver, and can bring you closer to your child!

Positive feedback is a powerful tool at any age. For children, it comes in many forms – a sticker for helping to set the dinner table, a praise statement (“I’m so pleased that you are using gentle hands with your brother”), even a hug! As your child starts to recognize that you are giving more attention to appropriate behaviors, they will similarly shift from negative actions (e.g., sassing off, whining, crying, etc.) to positive ones.

Behavioral parent training empowers caregivers by teaching them specific skills to not only manage their children’s behavior at home, but also to improve communication, build warmth within the parent-child relationship and create a calmer household. The Society of Clinical Child and Adolescent Psychology (SCCAP), a group dedicated to disseminating information about evidence-based therapies for youth mental health problems, sites behavior therapy (individual parent and groups of parents with or without child participation) as the most efficacious treatment for disruptive behaviors in children. The SCCAP website, www.effectivechildtherapy.org, was recently updated and is a helpful resource for parents seeking information and guidance about treatment for children and teens.

NESCA is excited to be offering a new group for parents and children ages 7-10 who exhibit disruptive behaviors and/or ADHD symptoms. This group will have separate parent and child sections – with opportunities for combined parent-child sessions – and utilize both behavioral and cognitive-behavioral techniques. For additional information, visit http://www.nesca-newton.com/events.html.

Or visit our previous article about behavioral parent training and the research backing this approach: http://www.nesca-news.com/2017/04/parent-training-programs-101.html. 

About the Author:

Dr. Ryan Ruth Conway is a licensed clinical psychologist who specializes in Cognitive Behavioral Therapy (CBT), behavioral interventions, and other evidence-based treatments for children, adolescents and young adults who struggle with mood and anxiety disorders as well as behavioral challenges. She also has extensive experience conducting parent training with caregivers of children who present with disruptive behaviors and Attention-Deficit/Hyperactivity Disorder. Dr. Conway has been trained in a variety of evidence-based treatments, including Parent-Child Interaction Therapy (PCIT), Dialectical Behavior Therapy (DBT), and Exposure with Response Prevention (ERP). Dr. Conway conducts individual and group therapy at NESCA utilizing an individualized approach and tailoring treatments to meet each client’s unique needs and goals. Dr. Conway has a passion for working collaboratively with families and other professionals. She is available for school consultations and provides a collaborative approach for students who engage in school refusal.