REFUSING TO ATTEND SCHOOL DUE TO ANXIETY
Ben is a 12 year old boy who lives at home with his mother and older sister. At the time of referral Ben had been refusing to attend his mainstream secondary school for 11 weeks and had lost any previous roles, habits and routines associated with a school routine.
Reason for Referral
Ben was referred for an occupational therapy assessment by his mother due to concerns regarding his high levels of anxiety and non attendance at school. He had been assessed by the CAMH’s service but not offered ongoing intervention.
Occupational Therapy Assessment
An initial assessment was completed at the family home in December 2013. The assessment was person centred and utilised a number of occupational therapy models and strategies focusing on Ben’s current functional capacity and occupational performance in the context of attending school. The assessment involved individual time with Ben as well as an informal interview with his mother.
At the assessment it was identified that Ben appeared anxious to do well and ‘do the right thing’, presenting with low self esteem and confidence and very high expectations of both himself and others. He described feeling too anxious to attend school although his description of anxiety symptoms was inconsistent. The transition from a small local primary school, and a teacher whose teaching style suited Ben’s learning style, to a large secondary school (where the teaching style is more traditional) had a significant impact upon his confidence and self-esteem. It was evident that he felt more anxious and vulnerable when he was unable to control his environment and those within it, therefore he had developed avoidance behaviours to ensure that he did not fail. He appeared to be enjoying the relaxed time and lack of structure/routine at home and would therefore find the reinstatement of any structure difficult.
Remaining absent from school (with no structure to his day and no school work to complete) would clearly have a long term detrimental effect upon Ben’s functional capacity, mood and overall well being.
Occupational Therapy Treatment Plan
It was identified that Ben required the development of a consistent and collaborative programme which taught and prompted him to implement strategies to self regulate and functionally organise himself in order to enable him to fully integrate back into secondary school education.
Ben was offered an occupational therapy programme consisting of 12 weekly sessions, each session lasting for two hours which focussed on:-
- Working collaboratively with Ben, his mother and the school with the long term objective of enabling him to return to full time education;
- Liaising with Ben’s secondary school to establish a graded plan for him to return to school including the allocation of a pupil mentor to support his integration;
- Working with Ben and his mother to develop and implement a daily routine which differentiated between school and non-school days, reinstating roles and habits such as ensuring homework was undertaken at scheduled intervals throughout the week in order to provide the essential foundation upon which to build life blocks and strategies;
- Developing emotional coping strategies to enable Ben to tolerate his emotions and regain a sense of control over his feelings, thoughts and emotions;
- Integrating the principles of the Alert Programme into the school and home-based programme. A person's nervous system must be in an optimal state of arousal in order to attend, concentrate and perform tasks in a manner suitable to the situational demands. Strategies need to be implemented to assist Ben to develop the ability to self regulate, attain, maintain and change arousal appropriately for a task or situation. (When difficulties in self regulation occur, the individual will have trouble changing the degree of alertness they feel which in turn will compromise optimal functioning.) The optimum state for learning is alert, attentive and focused;
- Teaching Ben strategies to help him remember and organise himself (e.g. use of diaries and lists) in all aspects of daily living;
- Working with Ben’s mother to ensure the implementation of a consistent, collaborative approach at home;
- Incorporating a functional skills programme in order to assist Ben to develop his confidence, self esteem and positive coping strategies.
As a result of occupational therapy input Ben was able to:-
- Gradually re-engage in school in a manageable sustainable way building up to regular school attendance towards the end of the programme;
- Recognise a reduction in the physical sensations, thoughts and emotions associated with anxiety;
- Identify and regularly engage in activities which will help improve his confidence and self esteem;
- Increase the amount of physical and structured activity in his day, which positively impacted on his emotional health and wellbeing;
- Develop a bed time routine which encouraged Ben to sleep in his own bed and get adequate sleep in order to be school ready;
- Utilise skills underpinned by the principles of the Alert Programme to help him attend to, concentrate on and perform tasks;
- Implement strategies to enable him to develop the ability to self regulate, attain, maintain and change arousal appropriately for a task or situation in a manner suitable to the situational demands. These strategies included taking regular exercise (using the trampoline), drinking water regularly and using alerting activities throughout the day such as pushing down walls, pushing up from the chair and square breathing;
- Develop strategies to help him break down tasks and activities and approach tasks in a graded manageable way, enabling him to feel a sense of control in situations;
- Understand the impact his environment has on attention and learning and minimise distractions wherever possible;
- Utilise strategies to help him maintain focus such as a fidget ball or refocusing attention to one task at a time.