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Question:

My daughter has been diagnosed with anxiety. She is 16. She is presently not attending school. She is able to go out with friends and sometimes go places with our family. She stays in bed until 1 or 2 in the afternoon. I feel her biological clock is messed up.

She had trouble leaving the house when she was 9, she did go to school only. Then again in 7th grade she stopped going to school at the end of the year and returned to school in January of 10th grade. She was great. She had a 3.8 average all of freshman year and she was weaned off prozac . Last Feb when she got onto 10 mg Prozac she couldn't go places, because she was anxious again. She tried to go to school but could not. As they increased the Prozac again, nothing worked and at 40 mg, she became manic.

Now she is on Effexor, and seems good but cannot get back to school. She has home instruction but there are days she won't get out of bed and doesn't know why. Some days she can't go, and I think it is because she didn't understand an assignment. Other days I think OCD thoughts keep her in bed.

How do we help with her biological clock? Should we use melatonin? Should she be reevaluated? She wants to go to school but doesn't know why she doesn't go.

Right now we need a therapist too her txpist is moving. Do you think she needs to go to a hospiatl for intensive therapy? She isn't suicidal , she does not use drugs or alcohol. This is a puzle and we need guidance. Thank you.

Answered by: Anne Marie Albano

From the description, this 16 year old girl is presenting with a long history of school refusal behavior (SRB). SRB is a serious behavioral condition that may accompany anxiety and mood disorders in children. In this case we read that the SRB started around age 9 in the form of difficulty separating from home, and occurred on and off until it finally took hold for the long term, and now at 16 she is home-tutored.

SRB results in academic decline (because home tutoring will not replace the depth and level of academic instruction found in a classroom), disruption in social and peer relationships, and increased dependency upon family members, among other things. The parent describes a problem with the adolescent’s “biological clock,” evidenced by sleeping until 1 or 2 pm, but what is not stated is what time she goes to bed and whether she has any regular and healthy sleep hygiene behaviors. It is difficult to say how much anxiety and depression are present, but the parent alludes to OCD thoughts. This teen has been resistant to various medication trials, and we are not clear what type of psychotherapy has been attempted. In this case, we would begin with a careful diagnostic evaluation and assessment of the motivating conditions underlying the school refusal. Is she (a) escaping from negative emotions such as OCD, panic or depression, (b) escaping social anxiety, (c) gaining much positive attention by staying home, and/or (d) having free or easy access to reinforcement that competes with school attendance, such as being able to sleep late, use the computer at all hours, etc.

Psychosocial treatment may begin with an intensive outpatient, cognitive behavioral program, along with intensive family behavioral management. If gains are not met in a reasonable time frame, then inpatient or residential treatment is indicated. It is essential for the CBT therapist and pharmacologist to work in tandem to track response and make adjustments to the pace and intensity of the treatments in an informed, evidence-based treatment plan. It is also essential for the parents to engage in the treatment now, as the window of opportunity is running out as the teen approaches the age of majority. SRB of this severity rarely remits on its own and leads to long-term disability.