Case Study

Case Study

Bridget is a 13-year-old girl in the                                  

7th grade. Her parents report that she

has recently begun refusing school, due

to fear that she will vomit in front of

her peers while in class. Her parents

explain that she experienced significant

separation anxiety when she began kindergarten.

After several weeks of crying

and clinging at drop-off time, she was

eventually able to attend school regularly.

Since that age, Bridget has had

frequent complaints of stomachaches

and fear of attending school. Although

she missed more school than the average

child, she had been able to keep up

with her work.

More recently, however, Bridget has

missed several weeks of school. Her parents

report responding in a variety of ways:

reasoning with her that it is unlikely she

will vomit; offering rewards or special treats

for promised school attendance; threatening

to take her to school in her pajamas;

text messaging by cell phone with Bridget

throughout the day; and picking her up

whenever she feels nervous or sick.

Bridget’s parents report that she has

always been a strong-willed and stubborn

child. Bridget’s mother reports that

as the oldest, Bridget has always been

her father’s “baby.” She states that he

often threatens Bridget when she does

not attend school but then is the first to

“give in” to Bridget’s cajoling when she

asks for a return of privileges they have

revoked.

Bridget’s parents are concerned that

she is becoming increasingly isolated

from peers and fear that she will become

depressed or suicidal. As a result, they have

allowed her unlimited access to time with

friends, despite poor school attendance.

They are reluctant to restrict privileges or

enjoyable activities while Bridget is out

of school for fear that this will negatively

impact her mood. Bridget’s mother reports

that her own mother has severe anxiety

and has encouraged Bridget’s parents to

be more understanding of the intense discomfort

Bridget is experiencing.

 At present,Bridget’s parents are holding her out

of school so that she will meet the required

number of absences to qualify for a tutor

to help her with her schoolwork.

For Bridget’s family, psychoeducation

was the first step in helping her family

make steps toward helping her attend

school. After learning that anxiety was not

dangerous or harmful to her and that anxiety

would remit over time, they were more

comfortable setting firm limits with her

regarding school attendance. Through imaginal

exposure (visualizing school scenarios

in detail) in the office and learning relaxation

techniques, Bridget became more

willing to attend school. The family learned

cognitive behavioral techniques together,

and Bridget’s parents began emphasizing

that becoming sick at school was not in

itself a catastrophic event.

In addition to learning techniques for

coping with feeling ill, such as breathing

and using self-statements (reminders made

to oneself about how to cope or relax),

Bridget talked through how she would cope

if she did vomit at school. When Bridget

complained of feeling sick before school,

her parents were able to remind her to

use her coping strategies and emphasized

that she would feel better over time. They

stopped responding to her text messages

during the day and worked with the school

nurse to send Bridget back to class when

feeling ill.

Family therapy sessions focused on

helping members feel secure in their

relationships and accept negative feeling

states, such as anxiety and anger, as tolerable

parts of every family’s experience.

Today Bridget attends school regularly

with some periods of anxiety that she and

her family are able to manage. Her family

has continued family therapy because

they have found it helpful in addressing

other issues.

✦ ✦ ✦

C. Sloan Alday, Ph.D., is an Assistant Clinical Professor

in the Department of Psychiatry and Human

Behavior at the Warren Alpert Medical School of

Brown University. She is a psychologist on the

Adolescent Inpatient Unit and in Outpatient Services

at Bradley Hospital.

References:

Thienemann M, Moore P, Tompkins K: A Parent-

Only Group Intervention for Children with Anxiety

Disorders: Pilot Study. JAACAP 2006; 45(1): 37–46.

Cartwright-Hatton S, Murray J: Cognitive Therapy

with Children and Families: Treating Internalizing

Disorders. Behavioural and Cognitive Psychotherapy.

Published online by Cambridge University

Press,

Oct 2008. doi:10.1017/S1352465808004840.