Dr. Sarah (00:02):

Ever wonder what psychologists moms talk about when we get together, whether we’re consulting one another about a challenging case or one of our own kids, or just leaning on each other when parenting feels hard, because trust me, even when we do this for a living, it’s still hard. Joining me each week in these special Thursday shows are two of my closest friends, both moms, both psychologists, they’re the people I call when I need a sounding board. These are our unfiltered answers to your parenting questions. We’re letting you in on the conversations the three of us usually have behind closed doors. This is Securely Attached: Beyond the Sessions.

(00:41):

Hello. Welcome back. This is the Securely Attached podcast and we are answering listener questions on our Beyond the Sessions segment with Dr. Emily Upshur. Hello.

Dr. Emily (00:53):

So good to be here.

Dr. Sarah (00:55):

So we have a question from a parent of an 8-year-old. You ready?

Dr. Emily (01:02):

I’m ready. Let’s do it.

Dr. Sarah (01:03):

Okay. This parent writes in Hello. My 8-year-old has come up with every excuse in the book about why she can’t go to school. This starts the night before and continues into the morning with her ranging from crying to throwing a fit. When I make her go the first time it happened, I thought she was actually sick and let her stay home for the day. But I have made her go to school each time since then. Apart from just telling her she has to go, is there anything else I can do differently? So there isn’t a battle every single day.

Dr. Emily (01:35):

School refusal is the worst. It’s so hard.

Dr. Sarah (01:38):

It’s really tricky and I think there’s a range of Totally. It’s very common and I think there’s levels of intensity. Totally. It sounds like this is happening every single day, which is a lot. What would you say is, what’s the low range of typical and what’s the high range of like, Ooh, we’re really getting into a very serious school refusal issue.

Dr. Emily (02:02):

I mean, definitely the frequency, which what you’re talking about and what we always talk about is frequency and also intensity. So for me, oh, I have a belly ache and I don’t really feel like going to school, but oh fine, I’ll go. It has a little bit less hold. You as a parent can still send your kid off to school. You might be like, Ooh, I’m not sure. But it’s okay if you’re kid is even manifesting physical symptoms because they’re so anxious, like throwing up in the bathroom and you can’t wholeheartedly send them to school. And it’s really disruptive. It interrupts your ability to do your daily life, both your child’s as well as yours. That I think is one of the markers for me. Interrupting, being late or disrupting your daily routine is really…

Dr. Sarah (02:52):

On a regular basis on a way that is actually interrupting.

Dr. Emily (02:55):

Exactly. So once a month or maybe you can get through that, but if this takes on a little bit of a pattern or frequency that is really prohibitive to your daily routines, that’s a problem.

Dr. Sarah (03:09):

Yeah. I also think this parent sounds like they are, at least they’re having a battle every day, but it does sound like this parent is making their child go to school and sort of successfully doing so. I think that’s an important distinction.

(03:29):

School refusal still, I don’t want to go to school and I’m going to pitch a fit, and getting to school is a nightmare. But there’s a threshold too when it’s so bad that the parents are not, they’re not making their kid go to school or like you were saying, sometimes the somatic symptoms actually become so interruptive of the ability to go to school. They are getting actually sick. Because here’s the thing, when kids are really anxious, they actually can have, not psychosomatic, but actual physical symptoms. It’s not just in their head. They are truly experiencing pain in their stomach or because anxiety puts us into fight or flight, it activates our sympathetic arousal system. And the opposite of the sympathetic arousal is the parasympathetic arousal or rest digest. So if we are in an anxiety, if we are in a panicked state, we are actually moving our body out of rest digest, which means we are hitting the brakes really hard on our digestive system. So that actually can lead to stomach aches, nausea, vomiting, constipation or diarrhea or all kinds of issues. It can also lead to, you might see accidents happen more because of these, so this anxiety can actually create real true physical symptoms. It’s not faking it.

(05:00):

So I just want to name that can actually be a real, it can be confusing for parents, right? This mom was saying the first time I thought she really was sick and they might not actually be manifesting physical symptoms and they might just be complaining of them and make you think they’re sick and then you can work on that to discern what’s happening. But some kids are actually puking in the bathroom because they are so anxious. And then it’s really confusing for parents to know how much do I push?

Dr. Emily (05:26):

Yeah, no, I think that’s a really good point. And I also think this parent seems really attuned, which is really nice. I think she was savvy enough to say, wait, I thought you were sick, but maybe it’s not. And I do think trusting, we always advocate for trusting your gut as a parent, but I will also say it can be really hard to discern this and speaking to somebody else, a professional, your kid’s school counselor or a psychologist, somebody outside can be really helpful because it can be really hard to tell what’s going on and that collaborative nature, talking to the school and being like, what’s happening first period? Is there something where the first activity of the day or what’s happening in the drop off line? Just getting a little bit of information gathering can be really helpful because school refusal can be many things, but we often see school refusal being related to anxiety and worry. So sort of trying to understand what that picture is can be helpful in helping figure out some strategies for yourself and your child.

Dr. Sarah (06:30):

Yes, I would say the majority of school refusal cases are related to anxiety. I will add though that sometimes school refusal can be a sign of bullying. It can also be a sign of depression. I want to isolate and not engage anymore. So with an 8-year-old, well the 8-year-old, I’m less concerned about depression. I would definitely want to just make sure this is why checking in with the school and being collaborative in that to just find out are there any tricky variables? Yeah, tricky things going on with friends. What’s their mood when they get to school? If you have a kid who’s primarily anxious about school, that anticipatory anxiety can be really, really strong in the mornings at home. And then once they get to school and they get into their groove, they can, sometimes the anxiety dissipates and they can kind of engage. Often if it’s a bullying situation that’s not happening, they’re having challenges throughout the day or wanting to avoid certain classes or activities or things or people or being really isolated and going inward at school.

(07:45):

So I want to flag that because it doesn’t sound like that’s going on necessarily in this situation, but I always want to rule out something happening at school that’s making a child really uncomfortable and want to avoid school. Sometimes it can also be like school doesn’t feel good. It could be a sign that like, Hey, we might want to look at is there other academic challenges and stressors on the kid that they just want to avoid that piece. And that could also be anxiety is manifesting because of that. But I also always, I want to get curious about are there other academic challenges? Could there be a learning disability? Could there be learning difference or neurodiversity piece that’s making them feel like school just chronically doesn’t feel good? And so I’m wanting to increasingly want to avoid that. Sometimes that’s not the case and it’s just anxiety. I feel like there’s color to this that I just want to name the different rule outs that you’d want to kind of run through the checklist and gather some data on before you were like, it’s just anxiety, pure and simple, and then we’re going to treat the anxiety.

Dr. Emily (08:54):

Yeah, I love that. And I think you’re absolutely right. I think it can be such a range. I have a funny anecdote about my daughter who’s actually in third grade, there was a little bit of contagion anxiety. So one of the things which basically what that means is when you see when a child sees another child anxious or worried or having some concerns about school, your child who might not have generated that themselves might be like, oh wait, is there something wrong with going to school? I don’t know. Maybe I will miss you. Maybe I’m now thinking about how I’m missing you because that little girl is missing her. So there can be a little bit of that too, and I think that’s another, I just remember checking in with my school being and my teacher being like, oh, there’s a little bit of a blip right now coming back from break. Everybody who’s come back from break is having a little bit of trouble. They’re fine within, to your point, Sarah, they’re fine within five minutes, 10 minutes of class. But my daughter who had never really had any of that, I was like, what is going on? So I think having that curiosity, and that’s kind of a lower level, but it could range in any of those things, really important things that you just brought up as well.

Dr. Sarah (10:04):

And in addition to seeking out info from the school, you can certainly seek out info from your kid on this. I would just really recommend that those conversations are happening not in the morning when you are trying to get to school and they’re refusing to go. Totally. Those aren’t the times to be like, is there a problem with one of your teachers? Is there someone bugging you at school?

Dr. Emily (10:24):

That’s my favorite. I feel like I do that all the time. I’m like, what’s wrong?

Dr. Sarah (10:29):

Of course right now. But the most effective time is going to be at a time when you are initiating this conversation, not trying to convince them to do a behavior they’re trying not to do when they’re regulated, when you’re regulated and when you’re calming. I like to talk about the calm connected moments for my kids, our best kind of debrief, convos or my sloughy, I want to dig for info on what’s going on. Convos happen when we’re laying in bed, getting ready to go to sleep. That works for my kids. They are really receptive to reflective conversation in that moment probably because it helps them avoid having to go to bed and they’re like, how? And they’re also happy to talk now if it means I can stay up later with you.

Dr. Emily (11:13):

And they’re also, well, I think it’s the connected piece as well. And they’re littler, so it’s developmentally appropriate. My sweet spot is a car ride. I have a 14-year-old, so the sweet spot of nonchalant, not looking at each other, me driving, getting great intel really casually. You might have an older child who has school refusal that happens just as much. So I just wanted to put that out there as well.

Dr. Sarah (11:40):

Yes. Yeah, it’s not always going to be the same. You got to figure out what’s your kids’ receptive moments, when do they lean into your efforts to connect and sleuth a little bit.

Dr. Emily (11:53):

Yeah and they shift and change. So you have to just be attuned to that. Yeah.

Dr. Sarah (11:58):

But having a practice of having those kinds of, not the sleuthy conversations necessarily, but having reflective conversations with your kids on a very regular basis so that when you need to sleuth, they’re not like, what are you after here?

Dr. Emily (12:14):

I love that. That’s a really, really nice point. That’s a really good point. I like that.

Dr. Sarah (12:21):

Okay, so we’re just at a baseline. We’re checking all the pieces. We’re trying to get a clear picture. We’re going to check in with the school. We’re going to try to just capitalize on our already existing connection conversation times with our kids to s sleuth a little bit and probe gently with curiosity like, huh, I’ve noticed school’s been tough a lot lately. Is there something that’s not feeling so great? Maybe there’s a teacher that you’re having a tough time with or a subject that’s really frustrating or ask one question at a time. I’m just going to give you all the questions that I would ask, but don’t dump them all on them at once.

Dr. Emily (13:00):

And don’t be surprised if they’re like, you’re, that’s it. I really think that’s really important. I had a kid who was like, I don’t know where the bathroom is yet on my floor. And they only knew where the bathroom was on the first floor of the school, and it totally was. They couldn’t imagine having to ask a teacher or whatever. When we fix that problem, everything was much smoother. So it can be big, it can be small. I just always love to point that out.

Dr. Sarah (13:28):

So we really do need to figure out what’s driving the anxiety or the avoidance of school. That’s a big part of this because that’s going to help us figure out how to support them. Some of this is definitely building tolerance for anxiety, and we could talk a little bit about how we do that, but some of this is also going to be problem solving and it’s hard to solve problems if you don’t know the source of the problem. So that’s the first thing is we really do have to figure out, and we might have to get creative and it might be helpful to pull in the support of a therapist if we’re at a point where school refusal is getting interruptive of family life or even before it’s crossed that threshold, getting some help to be proactive in like, okay, what do I need to be asking? What are the questions that need to get answered so we can effectively problem solve? I feel like we’ve covered a good amount of that. Let’s talk a little bit now just about basic. We need to build our kids distress and anxiety tolerance so that we are not having battles and we are slowly getting them to be stretch and stretch and stretch so they can tolerate going to school or doing a thing that they have anxiety about and being able to cross this hurdle and kind come out the other side.

Dr. Emily (14:57):

I mean, I was going to say we can’t end this without going through sort of distress tolerance and this sort of really fundamental thing that you were saying around how much do we help or accommodate our children through these moments and how much of that is not really helping in the end. So I think that you and I talk about this all the time, but I think we think this is a really effective way to help a child build that tolerance to that discomfort that they can do things even when they’re hard. I can go to school even when I have a little bit of a belly ache, I’m going to be okay. I think that’s super important from the parent facing side of how to help build some of these resiliency, resiliency in your children.

Dr. Sarah (15:49):

And I mean, I don’t think we could do an anxiety episode without dropping space as a treatment modality because it really is just a really helpful tool. Space is a therapy, it’s an acronym. It stands for Supportive Parenting for Anxious Childhood Emotions. It was developed by Ellie Liebowitz at the Yale Child Study Center, and we’ll put a link in the show notes. He actually has been on the podcast and talked about space. We’ve done a bunch of episodes. I think just kind of using how do you actually space into practice in real life. We’ve answered other questions beyond the sessions segment, so we’ll link all those in the show notes, but short and dirty. Emily, why is space helpful?

Dr. Emily (16:36):

Well, I mean, I think when we as parents, if we think we suspect that our child is having school refusal, often based on anxiety, we’re apt to respond to their panic signals. I can’t go to school. I’m really sick. I have a belly. You’re like, oh my gosh, okay, you must be. So this parent was like, oh, okay. You must be sick. Okay, okay. You stay home. I don’t want you to go to school. And that is really a mis response. We’re responding appropriately as parents to a missed signal of anxiety from a child or a signal of anxiety from a child that we know is not really founded. There’s no danger. There’s nothing imminently bad happening. And so that we call an accommodation, oh, we’re accommodating our child by allowing them to stay home from school because we think they’re sick.

Dr. Sarah (17:27):

Or I would say specifically not the thinking they’re sick. It’s like if I know you’re not sick, but you are saying you’re too, if you just refusing to go to school and we’re like, well, okay, one more time. Basically what we’re saying is this anxiety that you have is something I have to either rescue you from or help you to avoid. And in implicit in that messaging, even though it’s not our intention is this is a dangerous feeling and you cannot handle this feeling. I don’t believe you can handle this feeling. I have to step in and save you from it.

Dr. Emily (18:00):

And by letting you not do it, I think it’s scary. That’s the message that you’re sending, the tacit implication.

Dr. Sarah (18:08):

You might be saying verbally, I don’t. You’re fine, you’re fine. But if you do accommodate the desire to avoid the anxious stimulus, in this case school, we are showing their body and their worry brain that okay, right, this is worth, my parents are helping me avoid this, so this fear is warranted. This fear is valid.

Dr. Emily (18:32):

And I think it’s really important to note that we’re saying really the end example, but these accommodations can start really small and then they can become pretty insidious or grow really big. So it could be like, well, can’t you just walk me to the school? Okay, I’ll walk you to the school. Well, can’t you just walk me into the classroom? You just stay for 10 minutes. So it builds, right? The more we accommodate, the more the child’s anxiety system says, I need you to help me right now. I need it. I need it. So in space, we work with parents on reducing appropriate accommodations, reducing accommodations appropriately I should say, so that you’re helping your child know that they can do these things. They have the capacity, they can tolerate that icky feeling and they can still do the thing even when it’s hard. And I think that’s a priceless thing. You’re taking your child whether they’re anxious or not, life is really about suffering often a lot of hardship. And the better you’re able at handling hardship, the less psychiatric problems you have, the less mood problems you have. You’re really giving your child a gift by helping them learn to tolerate distress.

Dr. Sarah (19:44):

And one thing you were saying is like, okay, yes, the accommodations can build over time. And all of a sudden now I’m like, oh my God, how did we get here where my kid is not going to school or we’re having just massive, I’m having to do jump through so many hoops to get my kid to actually get to school. So just like those things can start small and grow really big sometimes when they are big, we don’t just pull them. We work our way back down. Sometimes when we’re doing space and it’s a school refusal situation, the first thing we pull isn’t not going to school. Maybe it’s the parent, we’re going to try and go to school for one class.

Dr. Emily (20:26):

Or your parent not staying home with you if you refuse to go to school. There’s a lot of different ways.

Dr. Sarah (20:31):

There’s a lot of different ways that we can kind of push the system to have to stretch.

(20:35):

And that’s why it’s not like a cookie cutter thing. We really do look at all the accommodations that are being made. A lot of times when I’m working with families who have school refusal, I’m not starting with the school refusal because there’s other accommodations that are also happening that are maintaining the anxiety systems. And I might start with one of those because one, I have more control over pulling a behavior that I do. I don’t know. I’m trying to think of an example. I am going to, I’m going to walk you through your entire homework assignment and sit with you the whole time because you’re anxious about making mistakes and I’ll correct all of your answers for you because you get distressed if it’s not right. And I’m also not making you go to school, but making you go to school part, it’s harder to pull an accommodation that is the absence of a behavior.

(21:26):

It’s just a little harder because space is actually highly informed by something called nonviolent resistance, which is this idea of recognizing I have control over what I do and I do not have control over what someone else does. And so space kind of integrates that ideology by saying, we only look at parental accommodations that are involving parental behaviors that you have the control over starting or stopping yourself, and that when you start them or stop them, you allow space for your child to actually feel anxiety in an emotionally supportive way. We support them while they are feeling that anxiety, but we do not rescue them or accommodate them with our own behaviors in a way that turns off the anxiety. So in the situation where you’ve got school refusal, a lot of times it’s just, this is why school refusal is very tricky to treat even with space, which I do think is a helpful strategy, but we’re actually looking at something that we have.

(22:34):

It’s very hard to make an 8-year-old a little bit easier to make them go to school, but if you have a teenager, it’s very hard to physically make them go to school. And so I usually start with like, well, let’s first work on the anxiety piece and in other places of their life, helping them build their tolerance for anxiety. And then hoping that we can generalize that tolerance towards the school piece. And also then once we have more trust in the system, be able to actually create more boundaries and consequences and behavioral contingencies because we do have to control the child’s behavior a little bit when we’re talking about school refusal and space technically doesn’t look at behaviors that we are not making the child do or stop doing anything. That’s the whole point. We’re just going to change what we do. But I think with school refusal, you actually have to change the child. You have to have different demands for the kid.

Dr. Emily (23:33):

Yeah, totally.

Dr. Sarah (23:35):

So it’s like a space plus.

Dr. Emily (23:40):

I like it. Space plus.

Dr. Sarah (23:42):

Yeah. But I feel mean, fortunately it sounds like this parent is, I mean, I’m just trying to cover all the bases. For anyone listening, I know that this example is just one of probably millions that people can relate to, but if a parent is like, we’re having a battle every single day, I’d really look at what kinds of accommodations you might be doing related to getting to school, but also in other areas and try to figure out a way to start allowing your child to not rely on you to rescue them from anxiety in so many places by systematically one at a time, pulling or adjusting the amount that you’re rescuing them so that they can feel the feelings and still do the thing.

Dr. Emily (24:34):

I guess I would just say there is an approach to it. So I think if you’re feeling really overwhelmed and you’ve tried everything, the thing I love about space is there is a systematic approach, whether you do space or you do something else. If you’re feeling that way, really it is helpful to reach out and see what other support you can get.

Dr. Sarah (24:55):

Yeah. Ellie wrote a book too, so it’s like you can go, our practice has space groups. We do space one-on-one therapy. Lots of people offer this treatment. You can go to, I think space treatment.net is their website. But also, Ellie wrote a book, which is a great easy place to start. It’s called Breaking Free of Anxiety. I think it’s called Breaking Free of Childhood Anxiety and OCD. We’ll link that too, but that also walks you through a lot of this stuff. But when it comes to school refusal, just know it’s a little bit stickier, it’s a little bit more complex. And if it’s actually, it’s to the point where it’s getting in the way of functioning of the family, then I do really recommend going to someone who specializes in this because there’s more at stake if kids are not able to go to school. If their anxiety is so bad that they’re not able to go to school regularly, then that’s a lot for parents to figure out on their own, and you’re not alone. If that’s the case, this is something that is, it’s challenging to treat and it is definitely treatable.

Dr. Emily (25:56):

Yeah, definitely.

Dr. Sarah (25:58):

Well, thank you for writing this in. We just love your questions so much and please keep sending them and we will see you again next time.

Dr. Emily (26:06):

Bye.

Dr. Sarah (26:07):

Thank you so much for listening. As you can hear, parenting is not one size fits all. It’s nuanced and it’s complicated. So I really hope that this series where we’re answering your questions really helps you to cut through some of the noise and find out what works best for you and your unique child. If you have a burning parenting question, something you’re struggling to navigate or a topic you really want us to shed light on or share research about, we want to know, go to drsarahbren.com/question to send in anything that you want, Rebecca, Emily, and me to answer in Securely Attached: Beyond the Sessions. That’s drsarahbren.com/question. And check back for a brand new securely attached next Tuesday. And until then, don’t be a stranger.