Nicole is a 9-year-old Caucasian female who lives with her mother. Nicole’s father has never lived with the family and has not been in contact for many years. Nicole is a fourth-grade student at an urban elementary school and her mother works as an assistant at a veterinary hospital. Nicole and her mother moved to the city within the past year.
Presenting Problem: For the past several weeks, Nicole has increasingly refused to attend school. Initially, Nicole claimed illness in order to stay home, but lately has been tearfully refusing to go to school because she “wants to stay home” and is “scared to go back” to her classroom. Her mother has been forced to take time off from work, and occasionally enlists neighbors to stay with Nicole when she has to work. School officials are insisting that Nicole return to school immediately or begin a program of home tutoring.
Biological Factors: Nicole has always been an anxious child who had difficulty with separation and new experiences. While her mother is unaware of any family history of anxiety disorders, she claims that Nicole has seemed “edgy” and “fearful” from “day one.” Nicole’s diet is significant for her lack of appetite—excessive consumption of caffeine-rich cola beverages (approximately 6 cans per day)—and she also complains of sleep difficulties.
Psychological Factors: Nicole is deeply attached to her mother who works full time. Her mother finds it challenging to parent such a needy child. Nicole is beset by ongoing anxiety, particularly in response to separation experiences such as going to school and sleepovers at friends’ homes. She has numerous strengths, such as her high intellect, loving nature, and artistic skill. She has poor self-esteem, and is riddled with feelings of inadequacy.
Social Factors: Nicole lives and attends school in an urban environment. Having moved to the city only recently, Nicole and her mother feel relatively isolated and feel tentative in a big city with significant crime and hustle-bustle. Nicole’s relatives all live in distant cities, and her mother’s work demands have limited their ability to make social or community connections.
Biopsychosocial Formulation and Plan: Nicole, who may or may not have a biological tendency toward anxiety, is certainly not benefiting from the high levels of caffeine she is consuming. Caffeine may be contributing to some degree to her sleeplessness, low appetite, and possibly even her anxiety. Most prominent, however, appears to be Nicole’s sense of isolation in a new and intimidating environment and her necessary dependence on her single, full-time working mother. By staying home from school, Nicole (perhaps unconsciously) succeeds in securing her mother’s presence, or at least the attention of a neighbor. Nicole’s school refusal may be inadvertently reinforced by the companionship and attention of her mother and neighbors, as well as by relief from the more challenging aspects of getting to school on public transportation and contending with school demands. The lack of a secure social support network appears to be enhancing her dependency on her mother and generating fearfulness and school refusal.
Treatment should progress in a number of ways. First, a behavioral program should be instituted whereby shaping is utilized to gradually reinforce Nicole’s reentry to school. For example, Nicole’s mother could spend the first hour of her school day during her first week back at school, then only the first 30 minutes, then merely accompany her to school, and so forth. Nicole’s successes could be reinforced by special time with her mother, enjoyable experiences with friends, or other desirable incentives. This behavioral plan should be augmented by some supportive psychotherapy to help Nicole express her fears and dependency needs, both verbally and through nonverbal means such as play and drawing. Efforts should also be encouraged for the family to extend their social network, and consultation could be provided to determine available resources and strategies. Nicole’s participation in activities (such as group art projects), which can enhance her sense of esteem and competence, would also be beneficial. Finally, all caffeine should be eliminated from Nicole’s diet