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As a clinical psychologist that provides both psychotherapy to pre-teens and adolescents as well as court-custody evaluations for high-conflict families, I have become aware of a deceivingly prevalent but under-discussed problem - students who fall into a pattern of refusing or avoiding school.
What follows is a basic treatment plan template, I commonly propose for such crisis-situations.
Step 1: Determine the function or “source” of the school anxiety-avoidance.
Assessment of the “why” is a critical first step. For instance, when a student stops attending school, there are many possible (sometimes multiple) causes. Perhaps the student has developed an intense fear of being embarrassed or negatively perceived by teachers/peers, or fears being blindsided by a panic attack at the most inopportune time? Performance anxiety in the classroom or bullying anxiety in the hallways are some of the many additional sources of stress that might escalate into a school avoidance or refusal problem.
This task of soliciting from the student a clear and pointed explanation for school anxiety-avoidance is easier said than done. If the parent(s), teacher(s), or a mental heather staff member (e.g. guidance counselor or school psychologist) is unable to solicit this key clinical information, then an individual or family therapist should be obtained to conduct a more formal and elaborate evaluation.
Step 2: Craft a Personally-Tailored Plan of Cognitive and Behavioral Interventions
A student’s anxious-avoidant pattern is driven by cognitive, physiological, and behavioral content.
Maladaptive thoughts patterns like catastrophizing (e.g. “I’m going to fail the test today”) and mindreading (e.g. “My teacher and peers will think I’m stupid”) are common thoughts that underlie academic and social anxiety. Such thoughts immediately trigger physiological symptoms (e.g. rapid heartrate and hyperventilating) that fuel further self-defeating interpretations and behavioral choices (e.g. “Now that I’m trembling with anxiety, today is definitely not going to go well!”).
Hence, the treatment plan must include cognitive, behavioral, and physiological strategies that are fitted to the student’s individual vulnerabilities, strengths and preferences.
Step 2a: Cognitive Interventions
Anxious and self-destructive thought patterns must be targeted, reality-checked, and reframed. I have often said to the student paralyzed by performance anxiety, “If you studied for the test, you might surprise yourself and do well. But if you avoid trying altogether, then you’ll definitely fail and dig a deeper hole.”
Other strategies that promote emotional distance from distressing thoughts can help, such as cognitive defusion. I often instruct students to tell themselves (during high-anxiety episodes), “I’m having a negative thought right now. A thought is just a thought. It is not a fact or a reality.” I also promote mantras of mindful thinking - “I’m going to imagine putting this distressing thought on a leaf and watch it float down the stream (and out of mind).”
In more serious cases, this cognitive restructuring process requires myriad solutions and skills-training. For instance, basic reality-testing strategies involve saying to the anxious-avoidant student, “Is there any good evidence that supports your assumption that your teachers and peers perceive you negatively?” If no good evidence emerges, then the assumption can be dismissed as unfounded - problem solved! If, however, the student highlights some clear and compelling information to support this nasty self-hypothesis of social rejection then it becomes important to troubleshoot the student’s socially counterproductive and off-putting behaviors.
Step 2b: Behavioral Interventions
The anxious-avoidant student must learn to intervene on a physiological level to manage the arousal inherent in anxiety. This involves learnign two core skills - relaxation (e.g. deep breathing) and distraction (e.g. mindful focus on external stimuli). Just as we go to the gym or play sports to exercise our bodily muscles, we can also exercise our minds by practicing with discipline taking deep, slow breaths, or going for mindful walks and keeping focus locked on external (e.g. trees, sky, birds) versus internal (e.g. pounding heart, sweating) sensations. Skillful breathing and distraction are critical tools for working through emerging high-anxiety states.
The other key piece to behavioral treatment is the notion of “safe exposure” - it is the notion that school participation is a requirement for healthy living. Therefore, any discomfort that gets in the way of consistent and meaningful school participation must be willingly tolerated.
A heightened degree of prescheduled daily structure can be paired with this basic mantra.
Busyness is one of the best weapons against anxiety, so the anxious-avoidant student should be assisted in designing a morning routine of predictable and consistent structure (e.g. brush teeth, get dressed, eat breakfast, check school bag, play a computer game in moderation, depart house for school, etc.).
Step 3: Coordination of Care
The treatment plan in Step 2 is, in theory, a collaboration between student and therapist.
But in order for the treatment plan to be maximally effective, it must be understood and agreed upon by the student’s parents and school as well. Continuity of care is critical, as the student may need emotional support and healthy pressure, on a daily and micromanaging basis, until a pattern of approach-oriented, anxiety-reducing habits is cemented.
The school may need to support the treatment plan in ways that are superficial (e.g. making a staff member available to receive the anxious-avoidant student at the front door) and complex (e.g. constructing an IEP that temporarily or mildly promotes flexibility, compassion, and accommodation for poor punctuality and work submissions).
Step 4: Always Assess for Deeper Sources of Anxiety
Often the source of school anxiety-avoidance can be something simple, straightforward and isolated (e.g. a demanding teacher or aggressive peer), but sometimes the nature of escalating anxiety-avoidance may stem from a more complex “cry for help,” related to matters that are external (e.g. parental divorce) or internal (e.g. sexual identity changes). Such information would, of course, be critical for updating and enhancing a successful treatment plan.
