Separation anxiety disorder (SAD) is a relatively common disorder in children and adolescents and panic disorder (PD) is a relatively common disorder in adults. Investigators have suggested that SAD and PD may be related in several ways:
- The symptoms that children with SAD exhibit when separated from their parents look much like symptoms of panic in adults.
- Children with SAD are more likely to develop PD as adults than children with other anxiety disorders.
- The offspring of parents with PD have more than a threefold increased risk of SAD, suggesting a strong familial relationship between SAD and PD.
- The majority of children with prepubertal onset of PD also manifest symptoms of SAD.
Thus, SAD and PD may represent different clinical manifestations of the same underlying disorder; both groups of children often refuse to go to school because they fear separation from their caretakers. Most clinicians recognize that the longer a school-refusing child is out of school, the more difficult it is to get him or her back. Therefore, treatment always focuses on returning the child to school as soon as possible. School refusal, however, can be due to many other factors (peer rejection, learning difficulties, substance abuse) which the clinician will wish to consider when designing a treatment plan for school-refusers. I offer several guidelines for returning anxious children to school as soon as possible.
Mobilize parents, teachers and school administrators. Ask those involved in the child’s care to support the child’s return to school as soon as possible. Solicit their support before returning the child to school. Many a plan to return a child to school has gone awry by an overanxious parent or teacher who could not tolerate the child’s tears, or an administrator who was too harried to set aside the time necessary to accommodate the child’s return to the classroom. Have all adults (parents, teachers, administrators, staff) agree to a target date by which the child is to return to the classroom. A concrete and agreed upon return to school date prevents delays that can result from misunderstandings or disagreements among those involved.
Plan a graduated return to school. Work out a plan that returns the child to the classroom in steps. Consider place (classroom or hallway), length of time in place (10 minutes or 1 hour), and situation (quiet and alone or noisy and crowded) when planning the steps. Ask the child to rate his or her level of distress for each situation in order to build an exposure ladder or hierarchy. For example, Karen, a bright but anxious 7-year old, agreed to a plan where she would walk with her mother into the school and stand in the hallway outside her class room for 10 minutes while her mother waited in the car. Karen rated this a 5 (out of 10). Next, Karen stood in the hall while her mother drove away and returned in 10 minutes. Karen rated this a 6.
Identify a safe place in school for the child. Once the child is in school, locate a safe place in the school that the child understands he or she can go to when feeling overly anxious or distressed. For example, Jill, who had many symptoms of panic and feared she would vomit, agreed to return to her classroom one hour before class was dismissed so that she could walk home from school with her friends. She also agreed that if she became too uncomfortable in the classroom, she would go to the library, where she felt more comfortable and wait until school was dismissed. Gradually, Jill expanded the time in her classroom and eventually ate lunch with her friends. Only once did she have to go the library to wait out her anxiety.
Make out-of-school time neutral or unpleasant. Many parents make the mistake of rewarding the child, indirectly, for remaining out of school. Often, parents have little choice in such matters. When a child misses school, parents must take off time from work to be with the child, take the child to work, or leave the child at home. This added one-on-one contact with the parent, however, can decrease the likelihood that the child will want to return to school. Identify which parent is the least reinforcing and ask him or her to pick up the child when he or she wishes to leave school. Instruct the parent in how to coach the child to stay in school, if possible, and how to be minimally reinforcing (not punitive) when taking the child home. In addition, work with parents to structure the child’s time outside of school so that it is as similar to class time as possible. During the time the child would be in the classroom, they are to study. If they finish their studies, they are to do other tasks around the house (washing the dishes, mowing the lawn). They have their lunch recesses at the same time and for the same length as when in school. George, who had been out of school for one month by the time he saw a therapist, did not like the changes his parents made in his routine at home — even though the parents were a bit pleased. Their home had never been cleaner! In spite of these changes, George remained reluctant to commit to a plan to return to his classroom. Only when George found that his recesses were boring because there were no other kids to play with did he take steps toward returning to school.