I have been a therapist for 15 years working with families and adolescents in various clinical settings. During the last 10 years, I focused exclusively on helping families gather around loved ones to help them begin residential treatment. I was exclusively doing work with family systems to assist with getting anxious children (under 18) out of the home and into treatment.
Once disordered anxiety reaches a point where it meaningfully interrupts social and vocational function (school), it becomes challenging to make treatment gains while living at home. Ironically, a home setting becomes like a tar trap: the more time we spend at home (in retreat), the harder everything in the world beyond home begins to feel. It’s like going to outer space to escape the stress of gravity: it’s a nice vacation for a minute before we start to lose muscle mass and bone density, which makes returning to gravity that much harder. Before removing an adolescent from the home for a therapeutic intervention, it is important to put forth this information about anxiety to ensure the same perspective.
- Anxiety tends to snowball over time. It’s normally best to get right on it when it starts becoming an issue. Once it starts really interrupting life, the pile of incomplete projects, slipping grades, and missed experiences becomes its own feedback loop.
- The pandemic made anxiety worse for anyone who had a propensity towards it. As a culture, we are still digging out of this and will be for a long time. Having a clinical assessment to contextualize the client and family to understand where they fit in terms of anxiety can be helpful.
- With that said, we need a level of anxiety to ensure our survival. A lot of the messages in our culture/media tell us we are meant to be happy all the time, not anxious, and that everyone else, basically, is doing just that. This is rubbish and creates false expectations, stokes sadness, and even depression, and makes us feel anxious about being anxious. Normalize anxiety as the raw material that produces resilience.
- Medication can have its place in resetting the instrument that is our anxiety. We need anxiety to keep us safe, wise, and focused, after all. Medication, short-term or long-term, can give someone the experience of functional anxiety. And if this kind of medication (like an SSRI) is working really well, it will only alleviate 25-33% of one’s anxiety, maximum. This kind of medicine takes the edge off and lets us practice skills we have learned in therapy with an advantage and aids in the growth of resilience ).
With that context about anxiety, this list of considerations comes from countless conversations and family interventions with their adolescent or young adult child.
- School Refusal:
If your child is missing 20% or more of school days (1 day in 5), you have a clinical case of School Refusal [Berg I, 2002]. This can lead to a pantheon of experiences that, long term, may result in social, familial, and professional adjustment problems, major depression, suicidality, and other complications [Leduc et al., 2022]. However, school refusal is more complex than overall school attendance.
The idea of school refusal is an important starting point to gauge how impacted a teen is by their anxiety. The original idea is far more nuanced than days attended versus absences. There are also kids who will academically over-function because they have clinical anxiety, so class attendance and good grades are not solely reliable measures. We have to look at kids with a wide lens that spans academic, familial, social, self-care, and extracurricular dimensions. Success in one department does not cancel out problems in another, nor can adult over-function ultimately compensate for a child’s under-function. Residential treatment provides the best crucible to unlock lasting change in kids and their families that can then be carried by community-based mental health.
- School Refusal at School:
The teen is in school, but they are spending a significant amount of time sitting outside their counselor’s office or in the proverbial “Resource Room.” They are absent even though they are there. Parents may not be aware of or discount the significance. A school’s well-intended ‘never give up’ stance may fail to signal when it is time to do something clinically different. You as a parent need to advocate for more supports or different supports.
- Parental Over-Function:
Particularly if one parent is able to be at home, families can end up over-modifying their daily routine to compensate for a child’s anxious under-function. The job of being the at-home parent, over time, increasingly functions in place of the person suffering from the anxiety problem. A parent’s sense of worth becomes closely tied to their child’s ability to function in the world. The worse the anxiety becomes, the harder the parent works to compensate, which further reinforces anxiety in the child. It becomes an ironic feedback loop that obscures anxiety’s impact. [Lebowitz & Omer, 2013] Anxiety, when it takes on a life of its own, always affects a whole family. Everyone gets pulled into its energy. Some accommodate, some check out, some get angry, some join in the disorder, and sometimes we do each of these things. The solution to disordered anxiety, ultimately, involves everyone. It will have taken over aspects of the family’s life, changed perspectives, and revised the family’s vision of itself.
- Loss of Social Identity:
When teens start to withdraw from activities due to anxiety, their sense of self is eroded. Changes of interest are a natural part of growing up. Parents may have to adjust to who their kid actually is becoming versus who they were anticipated to be. However, when that reduction of engagement is a form of surrender when social identity and relationships are dropped for a type of retreat or lowest common denominator, then we have another form of refusal that needs to be considered to gauge our kids’ relative health.
Therapists, tutors, and other supports have their place. Over the arc of high school, the aim should generally be to teach rising adults how to internalize the support they need. The timed extinction of support varies from person to person, situation to situation. We must be careful not to create emotional and behavioral dependency. We should be working our way out of our jobs, or modifying what we provide to match and strengthen developing resilience and ability. If our kids can’t look after themselves by the end of high school, they will also not do so in college [Levine, 2008].
- A Scale to Understand When Outpatient Therapy is Effective:
The American Psychiatric Association says moderate anxiety problems should be functionally resolved by six months of outpatient Cognitive Behavioral Therapy (CBT) [Sauer-Zavala, et al. 2016]. Co-occurring conditions and increased severity will extend the duration of regular, methodical, motivated therapy. It can be hard to sustain these conditions for months at a time at home. Clearing away most of life’s noise to be able to focus on one thing with peers on the same journey is what residential therapy delivers. As a result, improvement gathers its own momentum more quickly and isolation is ended.
Be sure that resilience is growing. A mistake even therapists make is that therapy for anxiety is meant to make us less anxious. It doesn’t. Therapy helps us grow our resilience like an athlete grows muscle in a gym. As our resilience grows from the size of a Dixie cup to a 5-gallon bucket, the same tablespoon of anxiety loses its bitterness. We all have the capacity to grow our resilience to the strength we need to do the tasks appropriate to our development. And yes, once we have the required resilience, we don’t “feel” anxious, but it’s because our resilience changed, not the tasks of life.
- Substance Use:
When our kids are using substances to manage anxiety and they are still not functioning well, either because the refusal is still there or now there are other behavioral issues, they will benefit from being in a drug-free environment. If they take medication, other drugs will only confuse their prescription’s efficacy. If our kids don’t take medication but use other drugs in the meantime, they’re self-medicating, which can take on a life of its own.
About the Author
Richard Curtis is a Licensed Mental Health Counselor (LMHC), Love First Certified Clinical Interventionist (LFCCI), and former clinician with a Master’s in Counseling Psychology through Antioch University of New England. His clinical experience extends from teen and family PHP, psychiatric unit (adult and adolescent), Therapeutic Boarding School clinical counseling, and anxiety-focused interventions for admission to a Residential Treatment Center before going independent with Clinical Intervention in 2014. Raised in the United Kingdom and in boarding school before coming to the States for high school has provided him a lens of viewing culture from the outside and this has been helpful in understanding the range of other’s life experiences.
For more information, visit richardcurtisci.com or call 610.220.3098.
Berg, I. (2002). School Refusal Behavior in Youth: A Functional Approach to Assessment and Treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 41(6), 678–686.
- Leduc, C. P., et al. (2022). School Refusal in Adolescents: Prevalence, Risk Factors, and Comorbidity. Journal of Emotional and Behavioral Disorders, 30(1), 46–57.
- Lebowitz, E. R., & Omer, H. (2013). Treating Childhood and Adolescent Anxiety: A Guide for Caregivers. John Wiley & Sons.
- Levine, M. (2008). The Price of Privilege: How Parental Pressure and Material Advantage Are Creating a Generation of Disconnected and Unhappy Kids. Harper Collins.
- Sauer-Zavala, S., et al. (2016). The Role of Mindfulness in Cognitive Behavioral Therapy for Anxious Youth: A Randomized Controlled Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 55(4), 235–242.