James Wallace, MD, explains the various negative effects associated with school avoidance and how primary health care providers, along with parents, can catch early signs of social and separation anxiety.
James Wallace, MD, associate professor, Department of Psychiatry and Pediatrics, University of Rochester Medical Center, Child and Adolescent Psychiatry Faculty Trainer,
This interview is part 2 of a 2-part series discussing school avoidance with James Wallace, MD.
Interview transcript (edited for clarity):
Contemporary Pediatrics:
Hi, and thank you so much for visiting Contemporary Pediatrics. I'm editor, Joshua Fitch.
James Wallace, MD:
I'm Jim Wallace. I'm a child and adolescent psychiatrist at the University of Rochester, and also a faculty of the REACH Institute.
Contemporary Pediatrics:
Today we're going to talk about school avoidance. How can a pediatrician play a role in this? Is it better the younger the child is? Let's talk about that preteen to early teenager who is probably right in the thick of this problem and missing days of school as a result of it.
Wallace:
Well, pediatricians can play several roles. We do a lot of training at the REACH Institute to try to help them learn how to do more mental health interventions, but part of it is to try to recognize things early patterns early, recognizing a child who has an anxious temperament, maybe anxiety runs in a family, you've worked with siblings, and maybe even took care of the parents, so you know that they're vulnerable. They maybe have some early signs, like separation anxiety when they're little and maybe physical signs, stomachache, headache, all that kind of stuff. So, all those put someone at risk to, you know, start to escalate those feelings and part of that for a lot of kids, is to put the brakes on social exposure, and that means going school. The other thing is, families vary a lot in their ability to get kids to do non-preferred activities, right? It takes some strength in parents and some resolve and consistency. And not all families are totally healthy, right? Parents have their own issues, the pandemic threw a lot of people off, there are certainly high-risk populations, who have a hard time of doing the heavy lifting of getting a reluctant child to go to school, and it's really hard to do. The other thing we worry about when you start not going to school is that there are other spirals that start. So if you don't go to school, then you tend to lose your sleep hygiene. You don't go to sleep, you don't wake up on time, you sleep in, you nap during the day. So that gets broken, you don't socially engage, so you don't have that circle of friends that you're building, and so that tends to spiral out of control. So all these things tend to go wrong, if you don't have the structure of the school day to work from so it's a big concern. Like you said, Josh, I think it's really helpful to start the younger, the better. To even start setting limits, and dealing with kids being emotionally reactive, when they're little toddlers and gett parents comfortable with that so they can actively parent and tolerate the distress that kids have when you set limits and give structure to their lives. This is going to be so critical later. One of the challenges with not doing that is that if you accommodate kids and their distress and their anxiety, then their impairment gets keeps getting bigger and bigger and bigger. So, if they don't attend school, downstream, there are a lot of problems, right? So, things like failure to launch, right. So, you have now your young adult, who can't go to a job interview, who can't go out there and learn how to drive who can't think about independent living skills like cooking and shopping and things like that, because they're still so tangled up in their social anxiety that they never worked through that during their childhood in their adolescence. So that's a big problem. There's evidence that people who miss a lot of school chronically growing up, have trouble sustaining relationships, have trouble sustaining employment, have trouble following through with a lot of things and end up in very difficult situations and poverty and still in their parents' homes. Failure to launch becomes a very big issue for a lot of these kids.
Contemporary Pediatrics:
Is there any data, for example, for when a parent says, "my child has had a problem with school avoidance in the past, and has kind of gotten on the right track," and maybe the positive effects that that turnaround has had? Can you speak to that at all?
Wallace:
One of the things that we can do, and I think it's very heartening to say "listen, even the worst anxious child who misses school who has somatic symptoms, who is having panic episodes, who's really kind of a mess, can better." Usually to make that work, it requires a very collaborative approach. So obviously, you have to do a lot of psychoeducation with the parents about their role. You have to work with schools with their role and how can they kind of make sure that child has support there and they don't have to go home in order to feel that they get some support. Also, pediatricians are now getting better and better, through programs like REACH training, at making psychiatric diagnoses. So, if the child has an anxiety disorder, and needs treatment, then if you recognize that and initiate part of the treatment and refer for the other parts of the treatment, that makes a huge difference. We have evidence that if you treat an anxiety disorder, you can get over 80% of kids in remission. It's so much better that they don't have an impairment, but that usually requires the pediatrician can often initiate a medication, and also certain kinds of evidence-based psychotherapies really help families get better. Cognitive behavioral therapy is one of those where they teach kids coping skills and how to have fewer negative thoughts, and then they have to work on exposing themselves to the things that make them uncomfortable, building their mental muscles until they can take on the stressors of normal life. It doesn't have to be an excessive stress for an anxious child. So even though when you have unmanaged anxiety and school avoidance, it can be a disaster, if you manage it, you can really turn things around, even with a teenager, it’s not like you have to intervene when someone's 6, or 7 or 8 [years]. I've worked with some very challenging kids who are late in high school, and they can still, really rally. If you can decrease their anxiety and give them some skills, and get the parents to nudge them a little bit forward, they can often get themselves together. I've treated a lot of kids who go to college and struggle, and then come home and do some work, build some strength, do some gradual exposure work, and then they can go back to college and be successful. It's not something to give up hope on. There's a lot of hope. But again, recognizing it early is helpful when the problem is smaller, when kids are more kind of amenable to coaching by parents, and not quite as reluctant to do that. But then getting them to the right people, either a well-trained primary care doctor who's had some training so they know how to make a diagnosis and treat anxiety, major depression, things like that, or get into mental health professionals who can do that and therapists who know how to do this sort of structured therapy to get kids stronger and more successful.
This interview is part 2 of a 2-part series discussing school avoidance with James Wallace, MD.
