School Refusal

I will admit to being an over indulgent parent (initial score of 75), however, after viewing your first week of sessions, I would like to know if you address my particular situation of an overly dramatic teenage girl who repeatedly "makes" herself too ill to attend high school? She cajoles, manipulates, and at a time of day when we all need to get to work, and have little time for such events. Nine times out of ten she wins. This characteristic needs to be modified in order to get her on a more goal-oriented track toward success in her career and future relationships.

Thank you for your e-book. It applies a logic system to solving this persuasive teenage dilemma in the US :)

Regards,

E.

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Hi E.,

Re: I would like to know if you address my particular situation of an overly dramatic teenage girl who repeatedly "makes" herself too ill to attend high school?

You’ll find a strategy to resolve this issue in Session #3. However, I would caution you to work the program as intended (one week at a time). If you leap to Session #3 without laying down the groundwork in Sessions #1 and #2, you will run the risk of failing with this program. Having said this, I’ll elaborate a bit regarding your daughter’s anxiety about school.

Parents can do several things to help their child who refuses to attend school:

· Firmly getting the child to school regularly and on time will help (see “When You Want Something From Your Kid” – Session #3). Not prolonging the goodbyes can help as well. Sometimes it works best if someone else can take the child to school after the parent or caregiver says goodbye at home.

· It truly helps to believe that the child will get over this problem; discuss this with the child (the parent or caregiver needs to convince himself or herself of this before trying to convince the child).

· Listening to the child's actual concerns and fears of going to school is important. Some of the reasons for refusing to attend school may include another child at school who is a bully, problems on the bus or carpool ride to school, or fears of inability to keep up with the other students in the classroom; these issues can be addressed if they are known. On the other hand, making too big a deal of school refusal may promote the child's behavior to continue.

· Supportive counseling is often made available at school in these circumstances so as to minimize reinforcement of school avoidant behaviors and to prevent secondary gain from school refusal and should be encouraged for any student who wishes to have it. If the child simply refuses to go to school, some parents have found that decreasing the reward for staying home helps, for example, do not allow video games or television, or find out what work is being done in the school and provide similar education at home, when possible. This is especially if the "illness" seems to disappear once the child is allowed to stay at home.

· The parent or caregiver should reassure the child that he or she will be there upon the child's return from school; this should be repeated over and over, if necessary. Let the child know that the parent or caregiver will be doing "boring stuff" at home during the school day. Always be on time to pick the child up from school if you provide transportation rather than a school bus.

· Whenever events occur that could tend to cause students to miss school (for example, traumatic events such as terrorism, school shootings, or other traumas) all attempts should be made to help students return promptly to school and to help them to feel safe at school.

In addition to parental intervention, teachers and school staff should help the student identify and recognize the triggers for school refusal.

Many children with school refusal have an earlier history of separation anxiety, social anxiety, or depression. Undiagnosed learning disabilities or reading disorders may also play a significant role in the development of school refusal.

Signs of a psychiatric disorder called separation anxiety disorder can include the following:

· Excessive reluctance to be alone at any time
· Excessive worry about losing a parent; excessive worry that a parent might be harmed
· Persistent refusal to go to sleep without a parent or other caretaker present
· Repeated complaints of physical symptoms whenever the child is about to leave a significant parental figure
· School refusal

These behaviors must begin before the child is aged 18 years, must last for 4 weeks or longer, and must cause serious problems with academic, social, or other functioning in order to be called a disorder.

Some commonly cited reasons for refusal to attend school include the following:

· A death in the family of a friend of the child
· A parent being ill
· Being bullied by another child
· Feeling lost (especially in a new school)
· Jealousy over a new brother or sister at home
· Moving from one house to another during the first years of elementary school
· Not getting along with a teacher or classmates
· Not having friends
· Parents separating, having marital problems, or having frequent arguments
· Parents worrying about the child in some way (e.g., poor health)

Helpful tools to confirm the diagnosis of an anxiety disorder and the level of impairment include the following:

· Children's Global Rating Scale
· The Child Behavior Checklist (CBCL)
· The Children's Manifest Anxiety Scale


I hope this helps,

Mark

Punishment or Discipline? What works best?

Hi S.,

== > I’ve responded throughout your email below:

Thank-you once again for your guidance Mark. As I read the letters from other parents, it is interesting that so many of the answers go back to the program although with variations. I did not realize until recently that all of these letters are available to read…including the ones that I send! I suggest that you email all of your on-line customers and give them the link to this part of the program at the onset. In my opinion, this would be a good resource and may reduce the amount of questions that you get.

== > Good idea! Thanks.

==> Join Online Parent Support

On that note!

I would appreciate your opinion on whether the following are “punishment” or “discipline” as I find the two are not as well defined as I need.

Scenario One: His car has been taken away indefinitely as he does not have a job to pay for the gas and insurance. We also tied this to his attendance at school. He will be done school this month so thought we should tie it to the job alone. Has not had car for 2 weeks. Punishment or Discipline?

== > Discipline.

We preferably take things away for no more than 7 days. He could earn money for gas by doing chores around the house. Also, try to make the discipline fit the “crime” (i.e., kid’s poor choice). I don’t see a good connection between “school attendance” and “lose of driving privileges” (maybe you have a good rationale though).

Whenever you are undecided about what to do, simply ask yourself “Will this foster the development of self-reliance in my child – or will it inhibit such development?” If it fosters self-reliance, you made a good decision. Thus, does withholding driving privileges foster or inhibit self-reliance? Answer: It inhibits it (other people have to drive him to wherever he needs to go).

Scenario Two: His cell phone was taken away as the bills were double the agreed to cost. We agree to pay for the phone (at the agreed to rate) until he is 18. He needs to do chores to pay us back for bill. Has not had cell phone for 2 weeks. Punishment or Discipline?

== > Discipline.

Punishment is what parents do when they are ‘pissed’ at their kid. Parents punish when they seek revenge (e.g., spank, slap, psychological disapproval, isolation from others, yelling, cussing, threatening, getting angry).

Discipline is the process of teaching a child the difference between acceptable and unacceptable behavior. Good discipline should be a positive force focusing on what a child is allowed to do. The goal of discipline is to help a child change impulsive, random behavior into controlled, purposeful behavior, and discipline should be reinforced with teaching, firmness, and reminders.

Do you think it is reasonable to give him his car to look for jobs and have him earn the gas required to do this?

== > Yes.

I want to ensure the discipline is relative to the crime in these cases as want him to learn from this.

Thanks

== > You are very welcome!

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I am really excited about this program...

Hi Mark,

Thanks so much for your responses. I am really excited about this program, and looking forward to all the changes we will be making! I ordered my husband the CDs since he is in his car a lot! I don't even remember the exact place that I found your program, but I do know it was late one night while I was, once again, searching online for articles on teen help. I found a link to your web site, and read about it over and over for a while before ordering it. We have been dealing with all sorts of therapy, etc since our son was 8, and I always thought I was going to find a specific answer, that something very specific was wrong with him, I even took him to a neurologist for a brain scan. We have never experienced anything like this in our family, and he is not from a broken or abusive home, me and his father have been married for 24 years, very stable, this all just started, it seems, out of the blue. Anyway, I am thrilled now to be working on this program and I will keep you posted.

Have a great day.

S.

ODD/ADHD/Anxiety

Thanks, Mark. Our son is 16. He has ODD, comorbid with ADHD, anxiety, and dsygraphia. He is not abusing drugs, holds a part-time job and plays varsity soccer and JV tennis at his high school. His poor grades are 100% due to opposition to the system, complete lack of organization, difficulty paying attention, and lack of ambition. With his high intelligence, everything and everyone is "stupid" to him. He can out-think and out-smart most people he encounters and gets a thrill out of doing so. He would never tolerate tutoring or any kind of support from us, not even a "checklist" of things to turn in tomorrow. I'm looking for information about what is known about people with a profile such as his as they move into adulthood. Is there any literature or studies on this topic? What does your first-hand experience tell you? I just can't imagine him in a healthly, long-term relationship, but hope that I'm very wrong about that.

We have already looked into alternative schooling a bit, but in his mind, they all mean effort of one sort or another and, to him, effort is pointless. If he's going to do something he doesn't enjoy all day, he may as well be making money, so goes his argument. In any case, I don't plan on spending any time convincing him he should be in school in the fall. But, if he really means it, we'll make sure the rules for staying in our home are clearly spelled out.

In addition to my nagging worry about his long-term prospects, I would welcome suggestions you may have about how other parents move through the grieving process of not having the child they thought they had. And, finally, what is your recommended route for treating his anxiety? I believe that this plays a big part in his defiant behavior, because he is afraid of confronting a whole host of situations. Were he able to do so, his grades would be better, his self-esteem would be better, and we would be less frustrated with him on a regular basis. I'm just not sure how to go about getting treatment for that.... Doesn't that usually start with counseling.... Something we're avoiding at present because we're implementing your program.

Thanks, as always,

C.

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Hi C.,

Re: Is there any literature or studies on this topic?

Yes:

1. Bardone AM, Moffitt TE, et al: (1998) Adult Physical Health Outcomes of Adolescent Girls with Conduct Disorder, Depression, and Anxiety. J Am Acad Child Adolesc Psychiatry 37(6):594-601.
2. Bird Her, et all (1993), Pattterns of Diagnostic comorbidity in a community sample of children aged 9 through 16 years. J Am Acad Child Adolesc Psychiatry 32:361-368.
3. Buitelaar JK (2000) Open-Label treatment with Risperidone of 26 Psychiatrically-Hospitalized Children ad Adolescents with Mixed Diagnoses and Aggressive Behavior. Journal of Child and Aadolescent Psychopharmacology 10 (1) 19-26.
4. Carlson, Caryn et al: Gender differences in children with ADHD, ODD, and Co-occurring ADHD&ODD identified in a School Population. J Am Acad Child Adolesc Psychiatry , 1997, 36(12):1706-1714.
5. Griffiths MD (1998) Dependence on Computer Games by Adolescents - Psychol Rep; 82(2): 475-80
6. Kavousssi RJ, Coccaro EF (1998) Divalproex Sodium for Impulsive Aggressive Behavior in Patients With Personality Disorder J Clin Psychiatry 59:766-680.
7. Kuhne M, et. al Impact of Comorbid Oppositional or Conduct Problems on Attention-Deficit Hyperactivity Disorder (1997) J Am Acad Child Adolesc Psychiatry 36(12);1715-1725.
8. Rachel G. Klein, PhD; Howard Abikoff, PhD, et. Al. (1997) Clinical Efficacy of Methylphenidate in Conduct Disorder With and Without Attention Deficit Hyperactivity Disorder Arch Gen Psychiatry.;54:1073-1080
9. Riggs PD, Mikulich LM, et. Al. (1997) Fluoxetine in Drug-Dependent Delinquents with Major Depression: An Open trial. Journal of Child and Adolescent Psychopharmacology 7: summer 87-95.
10. Singer MI, Slovak K, et al: (1998) Viewing Preferences, Symptoms of Psychological trauma, and Vioent Behaviors Among Children Who Watch Television. J Am Acad Child Adolesc Psychiatry 37(10): 1041-1048.
11. Harrell JS; Gansky SA; et al: (1997) Leisure Time Activities of Elementary School Children. Nurs Res Sep-Oct; 46(5): 246-53
12. .Wiegman O (1998) -Video Game Playing and its Relations with Aggressive and Prosocial Behaviour. Br J Soc Psychol Sep; 37 ( Pt 3):367-78
13. Behrman: Nelson Textbook of Pediatrics, 17th ed., Copyright © 2004 Elsevier p 663.
14. Croonenberg J, Joerg M et al: Risperidone in Children With Disruptive Behavior Disorders and Subaverage Intelligence: A 1-Year, Open-Label Study of 504 Patients J. Am. Acad. Child Adolese. Psychiatry, 2005;44(1):64-72
15. Disney ER, Elkins IJ, et al: Effects of ADHD, Conduct Disorder, and Gender on Substance use and Abuse in Adolescence. Am J Psychiatry 1999, 156:1515-1521.
16. Findling RL, Kusumakar V, Daneman D, Moshang T, De Smedt G, Binder C (2003), Prolactin levels during long-term risperidone treatment in children and adolescents. J Clin Psychiatry 64:1362–1369.
17. Findling RL, McNamara NK, et al: A Double-Blind Pilot Study of Risperidone in the Tretment of Conduct Disorder. J. Am. Child Adolesc. Psychiatry 2000, 39(4):509-16.
18. Kasen S, Cohen P, et al: Influence of Child and Adolescent Psychiatric Disorders on Young Adult Personality Disorder. Am J Psychiatry 1999, 156: 1529-1535.
19. Kuperman S, Schlosser SS, et al: Relationship of Child Psychopathology to Parental Alcoholism and Antisocial Personality Disorder. J Am Acad Child Adolesc Psychiatry 1999, 38(6):686-692.
20. Lavigne JV, Cicchetti c , et al: Oppositional Defiant Disorder With Onset in Preschool Years: Longitudinal Stability and Pathways to Other Disorders. J. Am. Child Adolesc. Psychiatry 2001, 40(12):1393-1400.
21. Renauld J, Birmaher B, et al: Suicide in Adolescents With Disruptive Disorders. J. Am. Child Adolesc. Psychiatry 1999, 38(7):846-851.
22. SCHUR SB Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY). Part I: A Review J Am Acad Child Adolesc Psychiatry - 2003 Feb; 42(2); 132-144
23. Speltz ML, McClelllan J, et al: Preschool Boys with Oppositional Defiant Disorder: Clinical Presentation and Diagnostic Change. J. Am. Child Adolesc. Psychiatry 1999, 38(7):838-845.
24. Helgeland MI, Kjelsberg E, et al: Continuities Between Emotional and Disruptive Behavior Disorders in Adolescence and Personality Disorders in Adulthood. Am J Psychiatry 2005; 162: 1941-1947.
25. Johnson JG, First MB, et al: Adverse Outcomes Associated with Personality Disorder Not Otherwise Specified in a Community Sample. Am J Psychaitry 2005; 162:1926-1932.
26. Paris J: Personality Disorders over time: Precursors, Course and Outcome. Journal of Personality Disorders, 17(6), 479-488, 2003.
27. Reyes M: A randomized, double-blind, placebo-controlled study of risperidone maintenance treatment in children and adolescents with disruptive behavior disorders. Am J Psychiatry - 01-MAR-2006; 163(3): 402-10
28. Steiner H Divalproex sodium for the treatment of conduct disorder: a randomized controlled clinical trial. J Clin Psychiatry - 01-OCT-2003; 64(10): 1183-91
29. Wakschlag LS Is prenatal smoking associated with a developmental pattern of conduct problems in young boys? J Am Acad Child Adolesc Psychiatry - 01-APR-2006; 45(4): 461-7

Re: What does your first-hand experience tell you?

The long-term outcome for ADHD/ODD teens can be that they develop a Personality Disorder, which is one of the "labels" psychiatry uses to describe people who have traits in their personality that cause them major problems. These are not things that come and go but last for decades. A person's personality starts to form as a teenager, and that is when we see personality disorders start to form. We have all met people with these types of problems. They fit into a few big categories that have lots of different names.

One group is people who are strange, different, and keep to themselves. This is called cluster A. Another group is people who are dramatic, have lots of mood problems, are forever getting into trouble, and whose lives are quite mixed up. This is called cluster B. They are often very difficult to get along with over the long run. Another group are people who are withdrawn, scared, and have to do things a certain way. This is called cluster C. When any of these problems screw up people's relationships, ability to work, get them in trouble with the law, or make them miserable, we call it a personality disorder.

Recent studies have shown that children who have certain psychiatric problems are much more likely to get personality disorders as adults. Children who have multiple psychiatric problems are even more at risk. Children who have ODD are about four times more likely to have a personality disorder when they grow up, that is about a 15% chance. If they already have some signs of personality disorder as a young teenager, they are 25 times as likely to have a personality disorder as adults. What this tells us is that the longer these problems go on in childhood and as teenagers, the more likely they are to lead to personality disorders as adults.

There are two types of Personality Disorder in Cluster B, which are especially associated with ODD/CD. These are Borderline Personality Disorder and Antisocial Personality Disorder.

Borderline Personality Disorder is called this because patients have many traits from different psychiatric disorders. They have very unstable moods, like bipolar disorder. They often have strange experiences, like people with schizophrenia. Their relationships with others are usually quite unstable. They often don't have much of a sense of who they really are or where they are going. They often cut themselves. Most of the people with this problem are female. If you have ODD/CD and are female, you have approximately a 15% chance of getting this.

Antisocial Personality Disorder is basically a continuation of Conduct Disorder. People with this problem continue to not respect the rights of others or their property. They continue to get in fights or worse. They often are stealing or cheating. Usually they are involved with the law. They have extremely high rates of substance abuse and high rates of suicide and other unnatural causes of death. This is primarily a male diagnosis. Almost 20% of teenagers with ODD/CD with have Antisocial Personality Disorder as a result.

If you have a personality disorder as a teenager, by the time you are a young adult, here are the chances that these bad things will happen to you:

1. Difficulties with interpersonal Relationships 20-30%
2. Ending up with other Psychiatric problems 35-40%
3. Having at least one of the above bad outcomes 70-80%
4. Having at least two of the above bad outcomes 50%
5. Make a suicide attempt- 6-10%
6. Not get as far in school as you should have been able to 25%
7. Serious assault on another 25-35%

Some personality disorders are much more likely to improve over time. After 15-25 years, only about 10% of adults who had Borderline Personality Disorder continue to have it. That means 90% got over it. Antisocial Personality disorder tends to improve, too. However, about 25% of people with Antisocial Personality Disorder die prematurely. Of those that do not die, most are better, but few have recovered completely.

Re: I would welcome suggestions you may have about how other parents move through the grieving process of not having the child they thought they had.

This is covered in the eBook (Session #1 – online version).

Re: …what is your recommended route for treating his anxiety?

Parents can help their teen in these ways:

• Continue to provide structure, stability, and predictability. Within reason, stick to the same rules, boundaries, roles, and routines.
• Encourage your teen to participate in activities normally enjoyed. Support involvement in positive and pro-social activities (e.g., sports, volunteer work, church).
• Encourage your teen to talk about what he or she is going through, and be willing to listen. Don't just jump to conclusions and give advice. Depending on the situation, your teen may not want advice -- just to be understood. Even if a problem seems small to you, it may be a major concern for your child. Minimizing a problem or saying "you'll get over it" is not helpful. It gives the message you don't understand or are not willing to listen.
• Model effective stress management and coping skills.
• Offer reassurance, encouragement, and support. Be willing to provide verbal or physical comfort, but don't be discouraged if your teen rejects your effort or is irritable. These are normal reactions to stress. Be patient and let your child know you're available if he or she needs you.

Teens can decrease stress with the following behaviors and techniques:

• Avoid excess caffeine intake, which can increase feelings of anxiety and agitation.
• Build a network of friends who help you cope in a positive way.
• Decrease negative self-talk. Challenge negative thoughts about yourself with alternative neutral or positive thoughts. "My life will never get better" can be transformed into "I may feel hopeless now, but my life will probably get better if I work at it and get some help."
• Develop assertiveness training skills. For example, state feelings in polite, firm, and not overly aggressive or passive ways ("I feel angry when you yell at me" "Please stop yelling").
• Don't use illegal drugs, alcohol and tobacco.
• Exercise and eat regularly.
• Learn practical and effective coping skills. For example, break a large task into smaller, more attainable tasks.
• Learn relaxation exercises (abdominal breathing and muscle relaxation techniques).
• Learn to feel good about doing a competent job rather than demanding perfection from yourself and others.
• Rehearse and practice situations, which cause stress. One example is taking a speech class, if talking in front of a class makes you anxious.
• Take a break from stressful situations. Activities like listening to music, talking to a friend, drawing, writing, or spending time with a pet can reduce stress.

Mark

re: "I cannot allow the violent behavior to continue..."

Mark, Well, M______'s final court date was set for this Thursday (we were told by the PO she was recommending release from probation). We have had some difficulties over the past 5 months he was in the intensive probation program, but we felt we were handling them well. M______ was even accepting our consequences better with less/minimal anger.

Or so we thought. We had a family graduation yesterday that M was told about at least a month ago. He was told to not schedule himself to work. His g'friend was invited. (The graduates sister was also planning on asking him to be an usher at her wedding in July so he knew it was important to be there). Well, he has 2 jobs. He was scheduled to work. His Dad (friend of the manager) arranged for M to have the day off. M needed the income to pay off his debts (he pays his own car insurance, overages on his phone, and now a "bad driver fee" from a recent speeding ticket. He also is in dept for gas money). His Dad and he agreed on a yard project for the equivalent hours/money. He was to perform the work Sunday before the graduation. He also has been told if he cannot pay his insurance/phone bill by the due date, he loses them until paid. He passed the due date, but was given until the end of the month.

M slept in until almost noon. Not motivated to start the yard project. Told he was not using the car until job was done (this would have settled the amount owed, but not gas debt or "bad driver" fee). He was "on call" at the other job. He has NEVER had to work on a "call in" day. He tells his Dad (I'm out) that he has to work. Dad says no your not. M insists. Dad says no car use. I come home and back up Dad. M starts to insist on taking the car. We still say no. He then proceeds to put his head (then foot/fist) through the drywall. There are now 9 holes in 4 different rooms in the house. 2 of these were repaired/painted less than 6 months ago from previous damage. Police called. PO called and left message (this was a Sunday). I called this job and let them know M would not be in to work there anymore. Police talked with M. He calmed down by the time they arrived. We (parents) chose to let PO/referee handle it (court already scheduled Thursday). He was told to give up phone (finally did) by us as he lost the privilege of using/having it due to behavior. 

 

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He was told to stay home, he said he was just going to cool off for 15-20 minutes (we were told by counselor and PO to let him do this when angry). Well, you guessed it, he met up with another boy we/courts have forbid him to see and he came home 2 1/2 hrs later (cannot prove he was with this boy, but only one on his phone call record). He was home by 7pm and curfew is 9:30. He/husband/I did not go to graduation. (Older and younger sons went). Took computer and PSP when gone. When he came home he was still doing things--dumped a whole pitcher of water on the floor (stating filling the dog's bowl but obviously doing on purpose), ripped up all my mail (bills) that were on the table ready to be mailed, started to rip up younger brothers "thank-you cards" from his birthday, eating/making mess in the bedroom, sleeping in younger brothers bed and wouldn't get out, etc. Was told his consequence would start when he began to follow the house rules.

Did go to school this am (I drove--don't feel I should but only 6 more days for this year and I don't want him to blow his grades [all A's and B's]).

He also stated this morning we would not see him until 9:30pm tonight when his curfew was when he was told to come straight home from school and call on the house phone (refused a ride home from me). Still awaiting the PO to call. Don't believe he will get off probation now (we don't want him to). He is in an intensive probation program. He feels that the court will not keep him as he is 17. We do not want him in our home any longer. We have tried your program, the intensive probation, a therapist, and it seemed like we were making progress and now this (we were feeling pretty good actually). We are in debt over this child and will take a few thousand dollars to fix our home, but are willing to shoulder more financially for a program for him as we don't think he can/should stay in our home.

I know that I'm venting, and sorry, but do you think he will be placed in a long-term program or will we have to allow him to stay? This began at 15 and now he's 17 and 4 mos. If he does stay, how do we work the program? I do not think he should have a cell phone, lap-top, or use of a car AT LEAST until his debts are paid (and now this includes house repair). We don't owe him these things and he certainly has not earned them. He can earn land line phone privileges and being able to go out. I cannot allow the violent behavior to continue. Other children in the home are being affected by this.

Any information/advice would be great.

Thanks.

J.

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Hi J.,

Just think how bad things might have been had you not used some of your new parenting strategies.

First of all – great job! You are really working the program. It’s tough – I know.

As I’m sure you know, your son needs to help pay for the damage.

Don’t worry about cell phones and laptops right now. Let’s step back and look at the bigger picture. In the bigger picture, (a) you need to have your son living elsewhere – soon, and (b) he needs to have the ability to live out in the real world. Thus, your mission at this point should be to begin making plans for his launch.

Mark

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