The Westport Day School: A Safe Place for Anxious Students - Mark Beitel, Ph.D.
Anxiety is one of the most vexing of all human problems, causing an incalculable amount of suffering for millions of people. Anxiety is an internal experience marked variously by tension, fear, and worry. Fear and anxiety can manifest similarly; however the former is a reaction to an identifiable external danger, whereas the latter may be an inappropriate or outmoded internal experience. Anxiety has cognitive (fears, worries, obsessions, compulsions), affective (tension, distress), and physiological symptoms (increased sweating, heart rate, etc.).
Anxiety, and associated disorders, appears in many forms (see Table 1 for a summary). The experience of anxiety can range from mild to severe. At the mild end, anxiety can actually have a facilitating effect on the performance of simple tasks (Yerkes & Dodson, 1908). At the severe end, however, anxiety can be quite disabling. Anxiety can be experienced in the neurotic range, with ego-dystonic symptoms experienced as intrusions and also in the psychotic range, with a deep sense of existential dread. Thought-disordered individuals often experience deep existential anxiety and suffering. The prevalence of anxiety disorders ranges from 8 to 9 percent of adolescents in the United States (Lewinshon, 1993).
Anxiety makes all of the challenges of growing up more difficult. Home life can be complicated by anxiety and the entire family can suffer along with the anxious child. School is another setting that is massively complicated by a child’s anxiety. Large, complex school systems can be insensitive to childhood anxiety. Anxious children are often quiet and inwardly turned; so they are easily ignored. The can be misunderstood and under-diagnosed. Anxious children often refuse to participate or under-participate in class because they are too afraid to speak. They are often unwilling to ask for help; and so they suffer in silence. Sadly, these children are often quite bright and motivated to learn; however, they are simply crippled by their anxiety. Consequently, they end up getting cheated out of living up to their academic potential.
Unfortunately, there are many anxiety triggers a regular education setting, including building size, student population, pace of instruction, separating from parents, and demands for social interaction. The anxious student can end up feeling very frightened and alone for much of the school day. A large body of scientific research indicates that significant anxiety has deleterious effects on all education-related psychological functions including sensation/perception, attention, cognition, learning, and memory (Eysenck, et al., 2007). This means that they have more difficulty paying attention, encoding information, problem-solving, and retrieving information, which makes education especially challenging. In other words, anxious learners cannot think as deeply or productively as they might be able to with less anxiety.
Some students become so anxious that they begin to avoid schoolwork and social interaction. At times, children with anxiety can begin to avoid school completely. Children in this category are considered school refusers. School refusal occurs in five percent of students and in equal rates across gender. Empirical research suggests that there are three types of school refusers: school phobic, separation-anxious, and generally anxious/depressed (King & Bernstein, 2001). However, a small percentage of school refusing students have no identifiable co-occurring mental or physical disorder.
In order to meet the educational needs of highly anxious students, we created the Westport Day School (WDS). WDS is an alternative educational setting designed specifically for students who suffer from significant anxiety. The WDS experience cultivates mindfulness, ethical sense, and wisdom in students by employing a model of education therapy and by focusing on the student-teacher relationship. The result is an exceptionally warm, welcoming, and calm academic setting for students who have had a difficult academic journey. Relational and motivational strategies to help fragile learners become fascinated by education. WDS is NOT a behavioral program and does not admit students with behavioral difficulties. Students at WDS receive weekly, individual social worker-delivered counseling designed to facilitate access to education at a high level. Students with difficulties that impact functioning outside of school are expected to have an external treatment team in place as intensive psychotherapy is not offered at WDS. Students do not participate in therapy groups, they do not share their stories with other students, and academic achievement is the focus of the school.
WDS targets student anxiety in a number of ways. For example, the class size is small, teachers are warm and supportive, and homework is modified as needed. We do not have bells, which can startle anxious students. Transition time between classes is limited. We focus on the quality of the student-teacher relationship and regard it as a primary vehicle for change. The relationship with the teacher allows the anxious student to take some appropriate academic and social risks with support. In larger settings, anxious students turn inward and stop participating in class. Our small class size (six students per class maximum) allows for teacher-facilitated social practice. We run a social-thinking curriculum continuously throughout the day; so students are able to practice healthy, safe social interaction. In this way, anxious students are able to come out of their shells and get the benefits of full academic participation.
Eysenck, M., et al. (2007). Anxiety and cognitive performance: Attentional control theory. Emotion, 7, 336-353.
King, N. J., & Bernstein, G. A. (2001). "School refusal in children and adolescents: A review of the past 10 years." Journal of the Academy of Child and Adolescent Psychiatry, 40, 197-205.
Lewinshon, P. M., Hops, H., Roberts, R. E., Steeley, J. R., & Andrews, J. A. (1993). Adolescent psychoapthology: Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 102, 133-144.
Yerkes R. M. & Dodson J. D. (1908). The relation of strength of stimulus to rapidity of habit formation. Journal of Comparative Neurology and Psychology, 18, 459–482.
School Refusal - Mark Beitel, Ph.D.
"Everyone has the right to education. Education shall be free... Educations shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental freedoms... Parents have a prior right to chose the kind of education that shall be given to their children" (United _Nations 1948). Access to education is a basic human right that is protected by US law. However, some children are unable or unwilling to avail themselves of their right to education. One subgroup of these children is referred to as "school refusers." School refusal has been defined as "child-motivated refusal to attend school or difficulties remaining in school for an entire day" (Kearney 1996). School refusal stands in contrast to truancy, which is more associated with conduct problems (Berg 1993). The estimates suggest that nearly five percent of school age children engage in refusal. It appears to be equally common in boys and girls (King 2001), though students with gender identity issues are at greater risk (Terada 2012).
Children who refuse school find themselves under a tremendous amount of stress, as do the parents and educators who work persistently to help them. As days turn into weeks, these children lose academic and social ground. School refusal is often, but not always, associated with internalizing disorders such as anxiety, depression, and somatization. King and Bernstein (2001) argued that there is evidence for three types of anxious school refusers: school phobic, separation-anxious, and generally anxious/depressed. Cognitive factors have been shown to play an important role in school refusal and its treatment. In a recent study (Maric 2012), school-refusing youth reported significantly higher levels of negative automatic thoughts than non-school-refusing peers. These thoughts had to do with perceived social threat and negative automatic thoughts concerning personal failure. The study also found higher rates of overgeneralization, a type of cognitive error associated with psychological distress. In addition, there is evidence to suggest that low self-efficacy plays a role in school refusal as well (Maric 2013). School refusers may have higher rates of learning and language disabilities than non-refusers as well (Naylor 1994). Interestingly, a small percentage of school refusing students have no identifiable co-occurring mental or physical disorder.
In order to help a child who is actively refusing school, we have to understand the meanings of, and motivations for and against, school attendance and refusal for the specific child. There are times when school refusal may be a healthy, self-protective response to an unhealthy or dangerous situation, particularly when serious, unaddressed bullying occurs. To help us understand the meaning of school refusal, (Kearney 2007) proposed a model based on the function of the behavior: (1) avoid school-based stimuli that provoke negative affectivity, (2) escape aversive social and/or evaluative situations, (3) pursue attention from significant others, and/or (4) pursue tangible reinforcers outside of school. This model has received research support and has informed empirically-based treatment of school refusal.
Successful intervention for school refusal takes a team approach. Often this team involves the pediatrician, a psychiatrist or psychiatric nurse practitioner, a clinical psychologist, and school personnel. The pediatrician and psychiatrist can be helpful in identifying medical issues that might be contributing to the situation. They also provide medication, if needed. The clinical psychologist provides scientifically supported psychotherapy (King 2000) to address the structural and functional issues related to school refusal. School personnel are critical to the implementation of the intervention and work as important members of the team. It is vital to ensure that every member of the professional team has experience in working with school refusing children.
The goal of any intervention for school refusal is to re-engage the child in learning. The typical goal is to return the child to their school setting by removing the obstacles to engagement. This might involve addressing bullying issues or providing appropriate support. Sometimes the damage has simply been too great or the system is unable/unwilling to change sufficiently. In these instances, placement in a therapeutic school setting is the most appropriate step. Therapeutic placements may involve an educational advocate, school placement professional, and/or an education attorney. Therapeutic placements can be short-term (90 days) or year-long. Matching the intellectual, academic, and social profile of the student to the therapeutic setting is critical to success. Placing a highly intelligent child with children who have intellectual deficiencies is not likely to work; neither is placing an internalizing student with externalizers.
It is important for parents to know that there is help available for the school refusing student. It begins with careful assessment of the meanings and motives of the refusal behavior, and contributing variables, and ends with an appropriate intervention that re-engages the student in learning. Creating the right team of professionals and encouraging healthy communication with the current school setting goes a long way toward restoring access to this most basic human right.
Berg, I., Butler, A., Franklin, J., Hayes, H., Lucas, C., & Sims, R. (1993). "DSM-III-R disorders, social factors and management of school attendance problems in the normal population." Journal of Child Psychology and Psychiatry 34: 1187-1203.
Kearney, C. A. (2007). "Forms and functions of school refusal behavior in youth: an empirical analysis of absenteeism severity." Journal of Child Psychology and Psychiatry 41: 53-61.
Kearney, C. A., & Silverman, W. K. (1996). "The evolution and reconciliation of taxonomic strategies for school refusal behavior." Clinical Psychology: Science and Practice 3: 339-354.
King, N. J., & Bernstein, G. A. (2001). "School refusal in children and adolescents: A review of the past 10 years." Journal of the Academy of Child and Adolescent Psychiatry 40: 197-205.
King, N. J., Tonge, B. J., Heyne, D., & Ollendick, T. H. (2000). "Research on the cognitive-behavioral treatment of school refusal: A review and recommendations." Clinical Psychology Review 4: 495-507.
Maric, M., Heyne, D. A., de Heus, P., van Widenfelt, B. M., & Westenberg, P. M. (2012). "The role of cognition in school refusal: An investigation of automatic thoughts and cognitive errors." Behavioural and Cognitive Psychotherapy 40: 255–269.
Maric, M., Heyne, D. A., MacKinnon, D. P., van Widenfelt, B. M., & Westenberg, P. M. (2013). "Cognitive mediation of cognitive-behavioural therapy outcomes for anxiety-based school refusal." Behavioural and Cognitive Psychotherapy 41: 549-564.
Naylor, M. W., Staskowski, M., Kenney, M. C., & King, C. A. (1994). "langauge disorders and learning disabilities in school-refusing adolescents." Journal of the American Academy of Child and Adolescent Psychiatry 38: 916-922.
Terada, S., Matsumoto, Y., Sato, T., Okabe, N., Kishimoto, Y., & Uchitomi, Y. (2012). "School refusal by patients with gender identity disorders." General Hospital Psychiatry 34: 299-303.
United_Nations (1948). ""Universal Declaration of Human Rights, Article 26" ": http://www.un.org/en/documents/udhr/ (Retrieved online: September 23, 2013).
Dr. Beitel maintains an active program of research on psychological mindedness and related constructs. He has published the following articles, on this topic, in peer-reviewed journals:
Beitel, M., Wald, L., Hutz, A., Green, D., Cecero, J.J., Kishon, R., & Barry, D. T. (2015). Humanistic experience and psychodynamic understanding: Empirical associations among facets of self-actualization and psychological mindedness. Person-Centered and Experiential Psychotherapies, 14, 137-148.
Beitel, M., Bogus, S., Hutz, A., Green, D., Cecero, J.J., & Barry, D. T. (2014). Stillness and motion: An empirical investigation of mindfulness and self-actualization. Person-Centered and Experiential Psychotherapies, 13, 187-202.
Beitel, M., Hutz, A. E., Hopper, K. M., Gunn, C., Cecero, J. J., & Barry, D. T. (2009). Do psychologically-minded clients expect more from counseling? Psychology and Psychotherapy: Theory, Research, and Practice, 82, 369-383.
Beitel, M., Ferrer, E., & Cecero, J. J. (2005). Psychological mindedness and awareness of self and others. Journal of Clinical Psychology, 61, 739-750.
Beitel, M., Ferrer, E., & Cecero, J. J. (2004). Psychological mindedness and cognitive style. Journal of Clinical Psychology, 60, 567-582.
Beitel, M., & Cecero, J. J. (2003). Predicting psychological mindedness from personality style and attachment security. Journal of Clinical Psychology, 59, 163-172.