Child and Adolescent Psychiatry Consulting

Interventions at Home

At home, as well as at school, providing a sympathetic and tolerant environment and making some adaptations may be helpful to aid a child or adolescent with separation anxiety disorder.

• Learn about the disorder and how it is experienced by the child This empathy and understanding may have a powerful and helpful effect.
• Listen to the child’s feelings . Isolation can foster low self-esteem and depression in children with separation anxiety disorder.
• Keep calm when a child is upset about separating . If a child sees a parent is able to remain calm, the child can model the parent’s attitude.
• Gently reassure the child that he or she survived the last separation
• Consider the most challenging times of separation, such as going to school, or getting ready for bed.  If a child tolerates separation from one parent more easily than from the other parent, arrange school drop-off, bedtime, and other transitions to be handled where possible by the parent from whom it is easier to separate.
• Talk about enjoyable activities that the child can anticipate at school or wherever the child is going,
• Help the child understand when and how they can contact the parent
• Firmly, consistently, and caringly set limits. (“I know you’d like Mommy to bring you to bed, and I know this is hard for you. Mommy said good night and she’ll see you first thing in the morning, and you’ll make breakfast together. You’ve got her picture beside you to remind you that she’s thinking about you. Good night now.”)
• Practice relaxation techniques . to empower children and adolescents to develop mastery over symptoms and improve a sense of control over their body.
• The best treatment for children with school refusal and separation anxiety is to attend school . Even if a shorter school day is necessary initially, children’s symptoms are more likely to decrease when they discover that they can survive the separation.
• Support the child’s participation in activities . Helping the child or adolescent to get through the separation fears and to engage in activities will encourage continued participation in healthy activities.
• Praise the child’s efforts. Young people often feel that they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised.

Interventions at School

By encouraging the child to have input in developing interventions, the strategies implemented  will be more likely to succeed, and they will nurture the child’s problem solving abilities.

Examples of interventions at school may include:

Accommodations

• Allow flexible scheduling

1. Allow the child to arrive later than peers, and to “check in” on arrival with a trusted contact.
2. If the child is avoiding school, identify sources of anxiety, and quickly address the problem, while returning the child to school as soon as possible—even if they are only able to attend for a few hours at first.

• Provide a desirable activity or responsibility for the student upon entering school
  • Before school begins, allow the student to feed fish, clean boards, play with peers, or discuss music/sports with another student who shares interests. Give the student in-school responsibilities such as in-school “messenger” to increase involvement in the school environment.

• Reward desired behaviors

1. Ask the parent to send short notes for the child to read as a reward for staying in school, and provide them at appropriate intervals.
2. For each successful school attendance, reward the student with 10 minutes of free play with a child chosen by the teacher.
3. Praise each positive step the child makes toward alleviating their fears of separation and school avoidance

• Provide times during the school day for the student to communicate with his or her family:
  • Allow the student to read a short sentence onto the parents’ cell phone or voicemail, or allow the child to send an email or text message.

Instruction in Coping Techniques

• Relaxation/Visualization: Have the student use relaxation techniques to diminish anxiety associated with being at school. Once this skill is developed, then have the student to visualize him/herself successfully participating in the school day
  • Teach the student how to relax his/her body (“tense your fingers, count to five, and then relax; then do the same with your neck, legs, toes, etc”) and use mental imagery (“imagine resting on the most comfortable pillow; the sound of a pleasant ceiling fan. Then while in a relaxed state, ask the student to visualize what a perfect day in school would look, feel, smell, and sound like and record his/her ideas in a personal journal.

• Help the student increase daily participation in class through reinforcement of academic, family, and social successes; focus on the parts that worked if the student doesn’t make it through the entire day
  • Focus on minutes the student stayed in class, or worked on academic tasks. Provide a reward once the student gets to one hour, for example, with a ticket to eat lunch with a desired peer, time to read a chosen book or listen to preferred music.

• Provide school-to-home and home-to-school transitional objects, and understand that transitions may be difficult. Remember that the child’s behavioral issues are likely related to the separation anxiety, and not because they are oppositional or defiant
  • Have the student take home a classroom object (favorite school book, arts and crafts activity, game) to serve as “transitional object” (familiar object that makes the child feel safer, more comfortable) between school and home. Have in-school a box filled with favorite home toys and objects to use at designated times throughout the school day.

• Help the student cope with anxiety by using problem-solving and thought-stopping in response to negative cognitive thoughts
  • Have the student develop positive self-coping statements based on fears of separating from parents. Self-coping statements include “I can be brave”, “I can do this”, “My parents will not leave me”, “I am not in danger”, “In five minutes I’ll be able to go play, eat lunch, see my best friend, or look at my favorite book”.

• Provide the student with competing responses to negative thoughts or behaviors
  • The student says “I’m afraid I’ll miss my parents and start crying in class.” Ask the student: “if you start to feel sad, what can you do before you start to cry? Can you read something that makes you laugh? Can you distract yourself by doodling?”

Behavioral Interventions

• Ask the child and parent to practice separations at home
  • Have the student practice being separated in the home from the parent for a certain number of trials and time intervals per day. Start with small time intervals with the parent out of the child’s sight but close enough to be heard. Expand time and space intervals as the child becomes more successful. Replicate at school what the child has in his/her room when the parent is elsewhere (familiar book, comfortable pillow, sounds of adults talking).

• Identify a staff person to meet the student on arrival at school or at a class
  • Designate a specific aide, teacher, school staff person to meet the student at the curb at a specific time; identify a fallback person if the designee is absent/unavailabl

• Identify a “safe place” or “free pass”

1. Allow the child to leave class by going to an identified location to reduce anxiety during stressful periods. Developing guidelines for appropriate use of the safe place will help both the student and staff. this should include that the location is not particularly rewarding by having fun activities (video games, tv, food) or people (school staffpersons who talk with and attend to the child extensively)
2. Some students may feel empowered if they are first encouraged to try a relaxation technique or other de-escalation attempt prior to leaving the class.

• If the student is frequently unable to get to school on time, create a plan for immediate return to school whenever feasible
  • Plan ahead of time how the student can get to or return to school if he/she misses the bus or a parent. Try to identify several options for getting the student to school (ride with a parent on the way to work, ride with a different carpool, or take the middle school bus with a sibling)

• Identify other adults the student can contact if a parent is gone or unavailable
  • Designate (during a calm time) student-preferred office staff person, aide, or coach who can help if a parent is late, or can help to minimize the child’s efforts to contact the parent during the academic day.