Therapy for OCD/School Refusal

[mama2alex]

We've been through two therapists so far and neither helped with his school refusal/anxiety. So many here have reported such great results from therapy, so maybe I'm picking the wrong therapists. Lately he's been saying that he's afraid he'll doing something wrong at school, like hit someone or swear (and be suspended for it), and that's why he sometimes can't get in - so I believe the root cause is OCD. What exactly should the therapist be doing to help him get back there consistently? I have the name of someone local who's supposed to be very good, but I want to know what to look for so we don't waste more time and money on this. I was considering USF Rothman Center, but I am now too ill to travel, so I'd like to try one more local therapist.

 

If anyone can give me specifics on how it works, I'd appreciate it. The last person we saw said she had worked with school refusal and would do ERP, but then she did things like fill out forms, play a board game about feelings with us and ask DS what we do when he's not in school and whether he's allowed to watch tv or see friends. It felt like a waste of time so we only went 5 times.

[MomWithOCDSon]

In our experience, school refusal is one of those OCD things that feeds off itself. So in the end, it's about breaking the cycle.

 

While I do think you need a different/better/more hands-on therapist, one of the things that Dr. Storch and all the therapists at USF are very strong about (I've heard them speak on it, in a panel, and they've authored a paper, as well)is that the entire family has to get behind the theme that the OCD cannot be accommodated. That by giving in to the child's OCD needs/demands (like school refusal), you are inadvertently validating the child's OCD fears, giving him the message that he has good reasons for fearing school and that you, on some level, share them. Think of it as "tough love" in the extreme,sometimes. Here's an abstract for one of the papers (I have a full copy of it that was handed out at a conference, that I can email to you if you like):

 

Storch - Family Accommodation and OCD

 

So a therapist can help, and the good ones will even get involved on site at the school, work with the staff if necessary, etc. But it will be equally important that you and the rest of the family line up with the therapist, as well, and basically speak with one voice.

 

Here's what we did. DS had school refusal before we started PANDAS treatment, and then even once we started treatment and he began to feel better, the mere thought of returning to school sent him into a tailspin. Our therapist at the time did not go to the school site, but he would've if we'd needed him to; fortunately, we had an IEP case manager at the school who was up to the task and helped us execute a plan, along with our therapist off-site and in sessions with us and DS, the school psychologist and the social worker.

 

DS started to go back to school, one class at a time. We started with his easiest class -- his resource class period -- which happened to be in the middle of the day. We dropped him off and picked him up, and he went straight to the classroom. He used this 50-minute period for a couple of weeks to meet with each of his teachers, ask them questions about some of the work he'd done at home during homebound, get help with anything he'd had trouble with, etc. Once he'd been doing that one class for a couple of weeks and his case manager could see that he was settling in and feeling less anxious during that hour, we added the next class, the one after the resource class. And so he attended those two classes for a couple of weeks while he got re-acclimated and rebuilt his confidence that he could handle being in the classroom, navigating the halls, doing the work, etc. We kept up that program, adding one class back to his schedule at a time until he was going from the middle of the day through the rest of the school day. Then we began to work backwards, adding one class at a time before his resource period, until he was back in school for the full day.

 

It definitely helped that, for the first few weeks, he came to and left school essentially on his own, without having to navigate the chaos of crowded hallways and lockers when all the kids were coming and going. Even once he got to attending on a full schedule again, we arranged for him to use doors in and out that were not designated for the masses, and he was allowed to enter the building 15 minutes before the first bell rang so that he could go to his locker and get his things (and himself) together without having to deal with the crowds and the noise.

 

We also had a "back-up" plan ready in the event he got overwhelmed and needed a break from class at some point. His case manager was his point person, so he would head to see him first; if he was unavailable for whatever reason, his next go-to was the school social worker, with whom he was building a good relationship. The third option was his Gifted Education teacher, who volunteered and who was wonderful with him, so he always felt safe and accepted, however he was feeling at the time.

 

The staged plan was demanding for us because of the drop-up/pick-up demands, especially for the first several weeks, but it allowed DS a chance to get his "sea legs" under him again, to remember that he could be successful at school and engaged while he was there . . . . that it wasn't all fears and tears. It also helped us with our "tough love" responsibilities: school was non-negotiable, but initially, it was only for that one period each day. And then it was two periods each day, and so on. So we had to be hard-butts and insist he make it for the agreed-upon time, but it helped take the sting out that we weren't insisting that he just jump into the deep end right off the bat, without having a chance to get accommodated to the temperature of the water.

 

In the event you don't have any major support at the school itself (like a case manager or invested teacher), then I would look for a therapist who is prepared to roll up their sleeves and go on-site, walk your child through what his return might be like, spend some time working with the school staff to devise the "back-up" options, etc. so that your child -- once he gets in the school --- can stay there, successfully -- rather than having to go to the office and call to have you come pick him up.

 

I hope some of that helps. There are certainly other ways to go about it, too, and they probably vary by the child's age and maturity level.

[dcmom]

Hi Mama-

 

Just wanted to chime in here, as we went through this

 

My school- loving, smart, motivated daughter had a pandas exacerbation in 5th grade. The ocd was horrible, and she ended up on homebound instruction for two marking periods.

 

We also worked with a couple of local psychs. Yes- mostly a LONG warm up period- talk about it, talk about it. Not only was that a waste of time, but it was detrimental to her self esteem (IMHO). We were basically trying the ease into school approach that Nancy detailed. One class a day, working up. She was great- she tried to be compliant. But she would come out of school white as a ghost. She spent the entire class in fear, ocd thoughts, etc. No learning was taking place. She could go- but was miserable.

 

We eventually (wish we did it sooner) went to USF. We learned so much about dealing with ocd, and about putting our family back together. We learned she needed to face her fear directly. Her fear was not school itself, but was a fear of vomiting in class, and being embarrassed (sounds somewhat similar to your son). So, she had to say vomit, see photos of vomit, watch videos of people vomiting, say the word vomit to strangers (USF is a hospital setting), tell strangers stories of her vomiting in class, pretend to vomit in front of strangers, etc.

 

Well it worked! She did not need to be eased into class after this- she was totally fine. She was over the fear.

 

So my thought is, you need the therapists to address the underlying fear- fear of doing something bad. And he needs to simulate doing this (in baby steps) over and over. It does not need to be done at school, but some kind of environment outside the home (I would think).

 

We have found that our local psychs in DC and in NJ just weren't willing or able to really dig in, get their hands dirty, and be tough enough to get this done. All of our local psychs wanted to develop a "relationship" with the child, whereas our psych at USF told me, if your child really likes their ERP therapist- then you probably are with the wrong therapists. My kids did not love him- but I think now, they really appreciate what he did for them- that no one else could.

 

Feel free to pm me.

 

Eileen

[Ebersolk]

You need to make sure that any therapist is doing ERP. My daughter also went through school refusal. What you are describing above, sounds like "bad thought" ocd which my daughter has. My daughter used to think she would put up her middle finger (she was in third grade so it had no rational basis) and she was afraid she would swear. She also would think she would cheat on a test or that if she bumped into someone at school she did it on purpose or that she wanted to hurt herself.

 

ERP deals with "exposing" them to their fears. So we worked up to actually having her put up her middle finger and to curse (sounds crazy right?). With the cheating, we would say maybe you did cheat on that test. or So what if she did. The ocd always wants to be 100% sure so we would say maybe you did, maybe you didn't.

 

I learned you can't start at the top of thing they are the most afraid of (like putting them in school all day), but start out slow (like one class as described above- or if just making it into the parking lot or the door works and each day do a little bit more).

 

We went through 2 psychiatrists and it was not until our 4th therapist, that we got the right one. I have heard great things about USF.

[smartyjones]

So my thought is, you need the therapists to address the underlying fear- fear of doing something bad. And he needs to simulate doing this (in baby steps) over and over. It does not need to be done at school, but some kind of environment outside the home (I would think).

 

We have found that our local psychs in DC and in NJ just weren't willing or able to really dig in, get their hands dirty, and be tough enough to get this done. All of our local psychs wanted to develop a "relationship" with the child, whereas our psych at USF told me, if your child really likes their ERP therapist- then you probably are with the wrong therapists.

 

 

mama -- so sorry you are in the middle of this - as impossible as it seems now - you can and will get to the other side of this. i highlighted dcmom's points b/c although we had a different slant than her child (i think my ds had more real fears mixed in with the unfounded ones) (of course, dcmom, no intent to offend, would you say that's correct also?) and we worked with it differently, i believe these points she makes are absolutely key.

 

for my ds, pandas hit at age 4.5 in the fall of his second half-day preschool year -- so quite early in his school career. that year and the following were back and forth as he enjoyed school again when he had 100% remission with the first abx and had fears and troubles again when he relapsed off abx. the next year, we were attempting to move in a bad economy and ended up homeschooling the entrie year. last year, was disastrous with an utter lack of compassion and understanding from the staff (with what i believe were civil right violations) that ended him in home teaching from nov - end of year and both of us with PTSD. we have a great psych who is frantastic with anxiety who thought he'd likely be better off out of the school system b/c they couldn't seem to understand him (as they were trying to send him to reform school with no evals and an un-acted upon 504) , would treat him as if he were bad and over time,he'd come to believe them. we have another psych who was previously a school psych and thought we'd be able to find people to help. so -- here we were this year with a spot in a great new charter school. and with ds in a good state of health - a pandas diagnosis, an anxiety diagnosis, a twice-exceptional diagnosis - pretty healthy but with a definite attitude of school refusal.

 

ds had a mixture of unfounded and correctly founded fears. i think a large part of it was that he was anxious that something would happen that he wouldn't be able to handle and that was why he clung to me. again, sounds like your son b/c he had fears and b/c he had had actual things happen. last year, we worked with the psych discussing how to 'handle what he hated." that was good groundwork, but the real change comes when he is able to actually handle it. he began the school year with one hour and increased by 45 minutes -- the school psych wanted 1 hour, he wanted .5 hour, so they compromised. lunch was also an issue, so they worked some different plans about easing into to cafeteria. he was in full day by the mid/end of sept. the school pysch was very good in allowing him some leeway to feel confident and in having an opinion, but very strong in where she was drawing the line. in the end, i think that's the key and unfortunately, a lot of psychs aren't adept in doing that -- or aren't spending enough time to do it -- it's hard in a 45/60 min appt.

 

ds now has an adult (teaching student) that meets him at the front door to walk to class. we'd lean on this in the am as one of his 'people to help problem solve'. so, when ds would throw up the issues, i'd say, 'that's a good thing to talk to mr. x about'. ds also had others set up as his problem solvers, so we could problem-solve at home that he could discuss that with one of them. he needed this b/c he was worried of these things -- sounds like your son -- if you could set up someone/somewhere he could go when he felt things getting out of control and that he would swear or throw. it may be that he never will, but knowning that he has an action to do if it does can be helpful in working the 'what if' of anxiety.

 

my ds is still young, 3rd grade, and has missed much of the formative aspect of norms and rules of the past few years of school so this is helpful b/c he's kind of emotionally/socially a 1st grader in a 3rd grade world, so there are some accomodations to allow him to catch up. he's responding really well with that and increasing in independence.

 

after thanksgiving break, he was refusing to go -- made it into the lobby but no further - wanted to stay home and read christmas book like he had on the weekend, yada, yada, yada. principal got involved and was excellent -- agreeing, 'yes, i didn't want to get out of bed and come today either - and look, here we are and here is where we belong today.' it was rough, but after i left, she said he breathed of sigh of resignation and went down to class.

 

 

the last few days of this break, we heard, 'i'm not going back to school.' i said since i knew it was hard to return after a fun break, we had pancakes in the am - he got one sticker on his challenge chart for cooperating at home and one for going into school with nice manners. this is now motivational to him -- in the past,he was too involved and/or too in exacerbation for that to work. the clincher was an extra 10 minutes to play the new lego batman wii. yeah, it's a lot of bribes but it is very difficult for him to do and one psych framed it to me that it was a reward for practicing something difficult. he jumped out of the car and ran into school. the focus was on the extra time, not the anxiety of what he couldn't do.

 

for us, we needed the helpful staff of the school to be on board and work intensively with us at times. we didn't have that last year and it was disastrous. that proactive intervention has made all the difference this year. without it, we may have had to do something like USF. i imagine there ds would have uncovered fears such as trouble with writing, getting in trouble, not having his concern understood by teachers that may have helped shuttle him into class like dcmom's dd. so - we reached a similar end, b/c he encountered those as the day went on - but would not have been able to without the supportive staff of the school. no way that would have happened with just me and our private psychs (even though i think they are good). and last year's debacle was partly due to that the school yielded to my expertise and i ended up in the school acting as his aide which wasn't helping his independence or ability to see he could handle what came up there.

 

have your read Ross Greene's book Lost at School. it's kind of a sequel to Explosive Child and deals specifically with school. i've found it very helpful.

 

for us, this is kind of the long version of success. i'm encouraged and hopeful we are all doing well. if we relapsed(not in pandas, but in school refusal) and weren't seeing progress with the school team, i think i'd seriously consider USF.

Edited January 3, 2013 by smartyjones

[dcmom]

Hey smarty-

 

I take no offense You are a brilliant mom and a great forum friend!

 

HOWEVER don't take offense, but I am going to pick apart what you said- just for an academic/ philosophical discussion. I think there is really not a difference between ocd's unfounded and "founded" fears. A fear is a fear. To someone with ocd, they do not see a difference- and the reality of therapy is not to establish that your fear is unfounded- because actually many of these fears could happen. My dd could very possible vomit in class, mama's son could blurt a curse out, etc. We cannot guarantee either of them that these things won't happen. BUT- the point is to make sure they KNOW that whatever happens (worst fear), they can handle it. Once that is learned- it doesn't matter if the fear happens- they handle it.

 

I am not sure I totally understand your son't situation- so I am not necessarily speaking to this- but just speaking more generally- it doesn't matter whether the fear is an alien abduction at school, or the fear is an F at school- if the person has this fear they are equally as scary, even though we can see the difference.

 

So I am very carefully for minimal accommodations to get them into school- I am a firm believer that they need to be aware that these are accommodations, and they need to have some sort of time frame.

 

My philosophy is that if all the other kids can do it (whatever "it" is)- so can mine. No (more) kid gloves here. Kinda turning back the clock to some old fashioned parenting- but with some modern conversation thrown in.

 

BTW- did anyone see parental guidance? Very funny movie!

[MomWithOCDSon]

BUT- the point is to make sure they KNOW that whatever happens (worst fear), they can handle it. Once that is learned- it doesn't matter if the fear happens- they handle it.

 

 

Yes! There was a speaker at this year's IOCDF conference who used the exact same phraseology: "You can handle it." As he pointed out, telling a person with OCD that "everything will be okay," or "you'll be fine" is like setting them and yourself up for perceived disappointment and/or failure. Because what's "fine" and/or "okay" for them is frequently for the world to spin on its axis in the opposite direction to accommodate their fears. And when that doesn't happen, they feel misled, lied to, or as though they've failed somehow, and your assurances lose all credibility.

 

So we're pretty careful now to tell our DS that he can handle it. It may not be "perfect" or "easy" or to his liking, but he can handle it!

[mama2alex]

Thanks to all of you for your well-thought-out and detailed responses! I am going to have to read through them a couple more times as I have brain fog at the moment - just one more challenge to make this all even more fun. I actually had already decided - and communicated to ds - that after the break, he will have to get in every day or start to lose "things." Mostly this will consist of the things he's most into right now - Xbox, tv, computer, etc. I told him that I know he can do it and its my job to push him. My instincts were telling me it was time to push him hard, as gentle prodding, rewards and nice therapists have failed us miserably. Also, after he was home for 7 weeks with Epstein Barr, he got back to school for 2 or 3 hours a day for two weeks straight. He had one day when he panicked, but he got in later in the day. So I was already thinking along the lines of starting out with 2 or 3 hours per day and working up, and our assistant vice principal had actually suggested this as well.

 

There are a number of things in your posts that I will use as we try this. I am definitely going to switch to "You can handle it." That's brilliant. And he has someone he can go to when things get rough at school, but she's often not at her desk, so we need backups. The school is incredibly supportive, so we'll be able to get whatever support we need. I think I'm going to print out all your responses and keep them with me. One wrinkle that's occurred in the last few days is that the LLMD started him on different abx and he's obviously herxing. He didn't want to leave the house this morning and said he feels out of control. He actually hit a friend the day before yesterday, and pushed someone in anger today, which is out of character. Because of this, I may start with even less time at school, but I'm not sure yet. Any additional thoughts on this balance are welcome.

 

Thanks again for all your support!

[pandakid11]

What do you do when your kid starts shaking and cannot walk when approaching school? He doesn't even know what the fear is? We are trying one class but cannot even do that. This is awful.

 

Thanks Tim

[MomWithOCDSon]

What do you do when your kid starts shaking and cannot walk when approaching school? He doesn't even know what the fear is? We are trying one class but cannot even do that. This is awful.

 

Thanks Tim

 

I know it's hard and I don't want to sound heartless, but would it be possible to take him to the school and leave him there for a class period, even if he is shaking and collapsing to some extent? Maybe he can't actually attend a "class," but is there a school psychologist or social worker, or a resource classroom, maybe, where he could go and just get acclimated to being back in the building, sitting in a chair or desk, without you there to "protect" him?

 

Assuming he's getting adequate medical care for the condition, the next hurdle is getting past that huge fear of being back at school, on "his own," without the safety of home and/or family. Again, if he's responding well otherwise to the medical interventions, the resurgence of these behaviors upon trying to return to school, whether unconscious or subconscious, are no longer solely medical manifestations, and his brain is trying to "protect" him from the anxiety returning to school induces. But the only way to get past that is, quite literally, to get past it. Unfortunately, every time he tries and "fails" (returns home), his fear is being supported. But even though that first hour back may be awful, and the next day only slightly less so, over the course of a few days, he will begin to regain his confidence at being able to "handle" being back in that environment.

 

Really, it's just exposure response prevention (ERP) therapy to sort of an extreme level. He's going to have to be exposed to going back into the school, to having those behaviors return, but then being encouraged, required, to stay there, in a safe place, until he achieves the monumental goal of having the behaviors reduce substantially or leave altogether.

 

JMHO. All the best to you!

[Dedee]

Everyone here is so super smart. I am so proud of the expert knowledge on this board. We have been to USF twice and most of what we learned has been echoed in this thread. There should be a paypal account or something. Seriously....... This is very difficult topic and I have cried and worried so much over this very issue with my daughter many hours in the past. I just want to say that at the time of my daughter's school refusal we had not yet been to USF and we did the best we could at the time. There were many many days that it took both my husband and myself to get my daughter into school. I would have to drive while my husband held my daughter down in the back seat (so she wouldn't attack me). When we got to school the principal would meet us in the parking lot. We had to get her out of the car (legalities) and the principal (very understanding lady)would carry my daughter into school kicking and screaming the entire time. Once in school the principal and the school nurse would keep her in the nurses area, many times physically restraining her, until she calmed down. Sometimes this would be an hour or more. Once calm, she would go into the class room. These were horrible times for us. It was terrible to leave our daughter screaming and begging us not to leave her. She had terrible seperation anxiety. But I had noticed that the more I accomidated her the more resistant she was to going the next time. We were lucky to have an understanding principal and teacher. I'm not sure if they really understood the whole PANDAS thing, but they did understand that she needed to go to school and accomodating her fear wasn't helping. They were actually very kind to her and believed her fears were real which helped us.

 

All this to say, that I completely understand your anguish as I am sure so many others do. It's so hard to find a good ERP therapist. We tried a couple of times after coming back from USF but just never found any who really compared.

 

I am sorry you are feeling so bad yourself. That must make it very difficult to deal with everything. Hope you feel better soon. Best wishes to your family.

 

Dedee

[dcmom]

I have been away since my last post, but wanted to follow up.....

 

I am not necessarily for forcing a child to school without the proper tools.

 

In other words- at USF we really did not use any negative reinforcement to fight ocd- mostly positive.

 

We spent our time prior to usf trying to force my dd to school. She was mostly compliant. But when she wouldn't go, we did have consequences. Unfortunately none of that addressed her fear. Her fear was vomiting at school, and just being at school was not helping, well, because she was not vomiting there. So she was constantly worried about it (putting it mildly). She went on like this for months, miserable, trying so hard to comply, but being really scared. At USF they did ERP for the vomit fear, and that was it- it was all over.

 

So in my opinion- you need to find the specific fear at school, and address that directly, asap, and then work back into school.

 

I don't know how to do this without usf Your child needs to tell you what they are afraid of. They won't want to tell you, they will lie to you, but you need to get it out of them. Sometimes my kids will write it down- it is easier than saying it. Once you have the fear- you can work on that. You can work concurrently with them to get them back into school.

 

IMHO if school refusal has gone on for longer than two weeks, I would make every effort to get to USF. If you cannot, I would contact Dr Eric Storch at USF and ask him if he has any recommendations for more local therapy programs. (for example there is one closer to me at UPENN, but it is costly).

 

I am ALL for tough love. But sending them into a situation without the tools they need, and punishing them if they do not succeed (without the proper tools) is not going to help. I hope I am not sounding harsh- but we did just that, and it definitely is not a self esteem booster- if we had went to USF sooner, we would have saved a lot of heartache for the whole family.

[mama2alex]

I appreciate all input and suggestions, even if it is harsh. That's ok. There's no way around it.

 

School started again this morning, and it was a huge flop. We got into the school and to his locker, but he freaked out, started crying, said that losing Xbox was too much pressure, he couldn't do it, he was going to have a terrible life, etc. When he started saying he wanted to die and threatening to hit me, I cut him off and said it was time to either go in to class or leave. We left.

 

He only needed to get in for 3 hours - and once he started freaking out I said I would pick him up after 2 - but he couldn't do it. Afterward, he said he actually felt relieved because now he didn't have the loss of the Xbox priveleges "hanging over him" now. Weird.

 

His current fear of going to school is that he will do something wrong (like hit someone) or say something wrong (swear, yell at someone). That's all he's told me, but there is likely more. I don't know how to do ERP on something like this, and haven't yet found a local therapist to guide us through it. Last year he was afraid of his teacher and getting in trouble, as well as one boy who he said was picking on him (that boy left the school and so did the teacher). The year before, it seemed to be more separation anxiety. It just keeps morphing, and I really feel that if we can get him in consistently, even if its just partial days, that will be the exposure we need. I think its the missed days that are hurting us. So I'm going to continue to push, and take away priveleges (one a week, max). I know it sounds mean, but I really think its the right thing for him right now, and I'm not positioning it as punishment or doing it in a harsh way, just very matter-of-fact - "If you can't go in every day in a given week, you lose a privelege. It's my job to push you, and I do it because I love you." He gets it - after he calmed down today, he used the phrase "tough love," and I said "exactly." Also, if he loses all his computer, tv, xbox, etc priveleges and still won't go, that tells me something. And it will probably motivate him to participate in his own recovery - like actually telling us everything that's bothering him, or actually talking to a therapist instead of burying his head in my lap.

 

In the meantime, we are talking about saying "I can do it" instead of yelling "I can't!" He really likes the show "Biggest Loser" and I am watching with him and making comparisons between their situation and his. How hard they have to work and how the woman who just quit the show repeatedly said "I can't." We're talking about focusing on just right now, or just today, instead of getting overwhelmed by the thought of going to school every day for the next 100 some days.

 

I can see that we will most likely need USF to get through this, but I just can't travel right now - I'm in too much pain and too tired. I'm going to set it up for summer and hope that I'm well enough by then. We are also going to have to move out of our house due to mold toxicity. Things are looking a little daunting right now.

 

Thank you all for your suggestions, comments and for sharing your experiences. Your support is getting me through this.

[dcmom]

mama- you are doing your best in an impossible situation. I don't think you are being mean. I just make my suggestions because we were in your exact position We pushed, we got her to school, we offered rewards and did some consequences. She said the same thing your son said- the rewards were so much pressure.

 

What does he fear will happen if he does something wrong? This sounds very similar to my dd. She was afraid of vomiting (and the embarrassment it would cause) he is afraid of doing something in class also. I think he needs to go through scenarios of him DOING these things, to see that whatever comes, he can deal. You should be able to find someone local (if you can pay $$$) to do this with him.

 

Call Dr Eric Storch for advice. Call the IOCDF for recommendations. INTERVIEW the psych on the phone. Tell them your son clearly needs immediate ERP- he needs to work through doing these things in a class type situation. Find out exactly what steps they will take, and if they will jump into it immediately, in the first session or two.

 

I hate to see you lose the rest of the school year

[philamom]

Is it mostly a fear he will get in trouble, or is he an episode where he may actually swear or hit a child? The reason I ask, if he is just dealing with the fear and won't actually hit someone, you could try role playing the situation at home. Have him pretend to swear at a child, then pretend the teacher has a lttle talk with him, then he apologizes to the child, so forth, until the end result is that it will be fine. Show him how the teacher will still like him. Keep it light and add some minor humor (not at hurting another child of course). Maybe work up to him getting sent to the principal's office with the end result being the prinipal nicely talking with him how to resolve the situation. IDK - thinking outloud.

 

You know we are in a similar situation with the school refusal - more in line with dcmom's previous situation (vomiting). Punishments do nothing for us- when push comes to shove the fear is too great. And then for my daughter, she becomes depressed. Huge rewards are also detrimental since it is so much pressure that she cant take on. I reward small tasks with small things. Is there any part of the school day that he enjoys?

 

Sorry you are not feeling well!