Chapter- 11

Social Anxiety Disorder in Schools: The Example of Paruresis

Steven Soifer* and Wendi Albert
University Of Memphis, Memphis, TN 38152, United States

Keywords: Anxiety, Cognitive behavior therapy, Parcopresis, Paruresis, Psychogenic urinary retention, Shy bladder syndrome, Social anxiety disorder, Social phobia.

INTRODUCTION

Social anxiety disorder is one of the most commonly occurring mental health issues in

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^* Corresponding author Steven Soifer: University Of Memphis, Memphis, TN 38152, United States; Tel: 901-67–2615; Email: sdsoifer@memphis.edu

Raymond J. Waller (Ed.)
All rights reserved-© 2016 Bentham Science Publishers

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youth (March & Albano, 1998), with prevalence rates of 8% (Miller, Gold, Laye-Gindhu, Martinez, Yu, & Waechtler, 2011; Neil & Christensen, 2008). However, epidemiological studies in the United States found that only 5.4% of those with social phobia sought treatment (Lipsitz & Schneier, 2000). This chapter includes a review of the literature on social anxiety disorder and social phobia disorder in children, including a discussion of the implementation of evidence-based interventions to treat anxiety disorders in school settings. A detailed description of the diagnostic criteria for social anxiety disorder, barriers to treatment, and a rationale for increasing purposeful mental health programming in schools are also discussed.

The DSM-IV-TR and DSM-V use the terms “social phobia” and “social anxiety disorder” interchangeably to describe clinical impairments due to the overwhelming feeling of fear, and therefore, both terms were used in reviewing the literature. Following this literature review, we will examine a specific social phobia – paruresis or shy bladder syndrome – among children and adolescents, the environmental considerations and influences of the school for children with paruresis, encouraging the reader to reflect deeply on the functional impairment that paruresis – a condition defined by such situational specificity (attempting to urinate in the presence of other people), can have on quality of life.

Literature Search Strategy

This literature review consists of systematic reviews, meta-analyses, other evaluations of the literature, experimental and quasi-experimental designs, and case studies with children and adolescents as participants, reported in the English language, and published in peer-reviewed journals. Keyword terms included: social phobia, social anxiety, anxiety disorder, anxiety, intervention, treatment, assessment, school*, classroom, youth, children, adolescent, cognitive behavioral, and CBT. Searches were conducted from 1977 to 2014 on the following databases: ERIC, ScienceDirect, PsycInfo, Education Full Text, Social Work Abstracts, SAGE, Project Muse, JSTOR, Wiley, and Social Sciences Abstracts. Unpublished literature was not included in the review.

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Social Anxiety Disorder/Social Phobia Disorder: Overview

According to the American Psychiatric Association (2000), as cited by Kearney (2005), social anxiety disorder is defined as a “severe, irrational fear and avoidance of social interactions and/or situations that involve performance before others, evaluation by others, and possible negative consequences such as embarrassment” (p. 2). The key factors in diagnosing social anxiety disorder as a clinical syndrome are the degree to which the fear inhibits everyday functioning and the extent to which the individual is distressed by having the fear (Lipsitz & Schneier, 2000).

The diagnostic criteria for social anxiety disorder are different in children than in adults in that the anxiety must occur in peer settings and not just during interactions with adults (Spence, Donovan, & Brechman-Touissant, 2000). These authors described how the fear or anxiety may be expressed by children in crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. According to Hudson and Rapee (2000), as cited by George (2008), social anxiety usually appears after 8 years of age, when individuals have developed the ability to anticipate negative evaluations from others and they begin to experience associated feelings of self-consciousness. This age of onset is not firm, however, and earlier onset can occur. Social anxiety disorder may manifest as school phobia, which is a common, and conspicuous display of anxiety in schools in which children experience severe anxiety regarding the idea of attending school and therefore may leave early or refuse to attend completely (Hudson, & Rapee, 2006).

Symptoms and Risk Factors

Socially anxious children and adolescents exhibit various symptomology that involves fear of negative personal evaluation and avoidance of social situations. Symptoms inhibit, among other outcomes, academic success, and eventually can even result in increasing long-term health risks. The tasks of adjustment and school functioning are immeasurably more difficult for anxious youth and can be manifest or be exhibited through:

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• truancy,
• repeating grades, and
• decreased likelihood of graduating

compared to students without an anxiety disorder (Mychailyszyn, Mendez, & Kendall, 2010; Lipsitz & Schneier, 2000).

Biedel, Turner, and Morris (2000) found that younger children with excessive social anxiety might exhibit oppositional and school-refusal behaviors, while adolescents tend to report more alcohol and substance abuse. Children with excessive social anxiety have chronically elevated heart rate levels (Kramer, Seefeldt, Heinrichs, Tuschen-Caffier, Schmitz, Wolf, & Blechert, 2012) and are at a greater risk for suffering from higher levels of dysphoria, depression, and other mood disturbances (Biedel et al., 2000). Biedel and colleagues (1999), as cited by Kearney (2005), reported that 60% of youth with social phobia had concurrent mental health diagnoses. Of the described population, 30% had a comorbid diagnosis of:

• generalized anxiety disorder,
• ADHD, or
• a simple (specific) phobia (such as paruresis).

Risks associated with anxiety in children often include:

• emotional difficulties,
• parental anxiety,
• difficult family circumstances,
• interpersonal problems,
• traumatic and stressful life events, and
• school problems (Tomb & Hunter, 2004). Obstacles to Treatment

Although few children and adolescents seek treatment for anxiety disorders, evidence suggests that social anxiety disorder in children is not necessarily a

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transient problem from which young people will recover without some form of treatment (Spence et al., 2000). Unfortunately, there are a significant number of potential barriers families may face in seeking treatment, examples of which may include:

• cost,
• time constraints,
• availability of qualified therapists, commitment, and
• logistical challenges (Essau, Conradt, Sasagawa, & Ollendick, 2012).

Further, adolescents may be hesitant to pursue mental health services due to concern of being labeled “abnormal” (Fisher, Masia-Warner, & Klein, 2004; Masia-Warner et al., 2011). Some research suggests that income status may not determine whether or not a family seeks treatment for the youth. For example, a study of 36 students with social anxiety disorder conducted by Masia-Warner, Fisher, Shrout, Rathor, and Klein (2007), revealed that only 11.1% of adolescents had ever sought treatment, despite all study participants being from a middle-class background.

School-Based Services

In order to facilitate access for children needing services, school-based programs have been suggested by many and are, of course, a theme of this text. School-based programs, whether part of the formal, universal school curriculum or as after-school activities and services, may decrease many of the difficulties families face in seeking treatment in the community, including:

• time,
• location, and
• transportation challenges (Neil & Christensen, 2009).

A school-based intervention would be particularly apropos for effectively treating anxiety disorders because school, among the most prominent means of social engagement for most children, is often where social anxiety manifests (Mennuti, Freeman, & Christner, 2006; Fisher, Masia-Warner, & Klein, 2004). In addition,

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schools are uniquely situated to utilize a systems approach that involves:

• peers,
• family members,
• school staff, and
• community members,

which could positively influence treatment outcomes (Mennuti et al., 2006). For example, natural peer interaction provides an opportunity for children with social phobias to practice social exposure and skills, as well as to benefit from peer modeling (King, Heyne, & Ollendick, 2005). On the other hand, there may be some pitfalls related to school-based treatment services such as, for example, stigma and labeling (Dadds & Spence 1997).

Assessment

Currently, there are some assessment tools available possessing clinical utility which, utilized in conjunction with clinical interviews, are helpful in identifying youth with elevated anxiety symptoms. For social anxiety symptoms, Mennuti et al. (2006) noted that the Social Phobia and Anxiety Inventory for Children (SPAI-C) and the Spence Children’s Anxiety Scale are useful as screening tools. Other assessment tools include the:

• Behavior Assessment System for Children (BASC-2),
• Child Behavior Checklist (CBCL),
• Conner’s Comprehensive Behavior Rating Scale (CCBRS), and
• Beck Anxiety Inventory for Youth (McLoone et al., 2006).

According to Deputy and DeVitis (1996), teachers can play an integral role in identifying social anxiety disorders among children by:

• gathering data,
• providing feedback on students’ reactions to stressors, and
• contributing behavioral observational information concerning student’s current psychological status.

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Offering a dissenting caveat, McLoone et al. (2006) contended that behaviors associated with excessive anxiety might not be readily identified by teachers, whose attention may be more likely oriented to externalizing behaviors. Best practice involves, however, including teacher reports used in conjunction with other sources of data including assessment instruments such as those listed above.

Interventions

Even though most children and adolescents in schools do not suffer from anxiety disorders, all students may benefit from school-wide programs that reduce stress and anxiety and promote mental health. Such programs, when designed to be flexible for example, accommodating school calendars and working around student schedules produce the most benefit. An example of an intervention designed to be a universal program promoting the mental health of students is the FRIENDS program.

The FRIENDS program, which has been endorsed by the World Health Organization, utilizes a cognitive-behavioral, school-based curriculum demonstrated to have numerous mental health benefits, in addition to preventing and treating anxiety disorders (Essau et al., 2012). It was designed to be used with elementary, middle school, and early high school students. It incorporates peer support and modeling and includes programming for circumventing negative stigmatization (McLoone et al., 2006). The effectiveness of the FRIENDs approach is supported by several outcome studies. For example, in a study conducted by Lowry-Webster, Barrett, and Dadds (2001), 75% of the children who were classified as at-risk for developing an anxiety disorder in the intervention group were no longer considered at-risk at post-intervention.

Coping Cat has also been utilized to educate children and adolescents on how to identify, regulate, and cope with anxiety symptoms. With this intervention, students develop their own plans for gradual exposure to people, places, and

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things they fear employing cognitive-behavioral techniques (Tomb & Hunter, 2004). Leaders use social reinforcement to encourage and reward the students, and the students, in turn, are encouraged to reinforce their own successful coping skills. A modified version of Coping Cat, the Coping Koala program, also has studies suggesting its efficacy in reducing anxiety symptoms in children.

For some students, a more intensive, targeted intervention may be necessary to curb anxiety and improve student success. For example, Skills for Academic and Social Success (SASS) was developed as a cognitive-behavioral school-based intervention for adolescents in high school with a social anxiety disorder (Fisher et al., 2004). Components of SASS include:

• psychoeducation,
• realistic thinking strategies,
• social skills training,
• exposure exercises, and
• a focus on relapse prevention (Masia-Warner et al., 2011).

Miller et al. (2011) modified the (SASS) program, incorporating the flexibility discussed above to positive effect. In order to work within the school’s schedule, sessions were reduced from 12 to 10, with session duration lasting one hour as opposed to forty-five minutes. Paired t-tests revealed significant differences from pre- and post-assessment on both self-report measures of symptoms of anxiety, t (23) = 4.20, p<.001, and anxious avoidance, t (23) =2.81, p=.01. Masia-Warner et al. (2007) likewise reported improvement of participants after SASS implementation. Following a 12-week attention-controlled trial, 59% of their study’s intervention group no longer met the criteria for social anxiety disorder. An advantage of the SASS program is that it coalesces the participation of teachers, parents, and peers of socially anxious youth, to provide psychoeducation on social anxiety, such that all those involved can derive benefits (Fisher et al., 2004). A final  example,  the  Cool  Kids  program,  is  an  anxiety  treatment  program

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administered to small groups of children who are either at high risk or are already manifesting symptoms of excessive anxiety using techniques including:

• psychoeducation,
• cognitive restructuring,
• graduated exposure, and
• assertiveness skills training

to reduce anxious symptoms (McLoone et al., 2006).

Therapeutic Components of Intervention

In terms of effectively reducing the anxious thoughts and feelings children and adolescents may manifest, cognitive behavioral treatments have the most empirical support. For example, Neil and Christensen (2009) conducted a systematic review of 27 randomized controlled trials describing 20 individual programs, school-based prevention, and early intervention programs for anxiety. Cognitive-behavioral therapy (CBT) techniques were components of the majority (78%) of the programs reviewed with positive effects. CBT has substantiating evidence that it reduces anxiety via delivery modalities including:

• group interventions,
• parental involvement, and
• early intervention for children with mild to moderate symptoms (Bernstein, Layne, Egan, & Tennison, 2005).

Therapeutic elements fundamental to CBT programs used to treat anxiety disorders include cognitive restructuring and graduated exposure. McLoone et al. (2006) described cognitive restructuring as teaching children to identify their anxiety-producing thoughts, researching evidence of the accuracy of those thoughts, and using this evidence to challenge and replace maladaptive thoughts. This cognitive technique can be modified based on age and cognitive abilities (Spence et al., 2000). Graduated exposure involves breaking down an anxiety-provoking situation into less threatening steps that a child can master incrementally, conceptually like progressing up the steps of the ladder (McLoone et al., 2006).

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It is best to incorporate parental/caregiver involvement so that the treatment strategies can be practiced and reinforced at home. While intervention for mental health conditions is often thought of as an individual and therapist endeavor, social anxiety is a phenomenon that is amenable to group intervention- group intervention may be preferable. Biedel, Turner, and Morris (2000), for example, argued that a group format is more useful and effective for the treatment of anxiety disorders than individual therapy because the group setting creates more opportunities for social exposure tasks as well as providing a means of peer modeling and support (King et al., 2005).

Summary

Although the majority of children with mental health challenges do not receive the services they need, among those who do, schools are well positioned to be the primary medium of service provision. School-based interventions are appropriate for effectively treating anxiety disorders in children and adolescents because:

• often the anxiety is manifested in school settings and around school issues,
• school service provision reduces many barriers families face in seeking treatment, and
• school can provide an affordable, accessible, and manageable locus of intervention.

Although few universal programs have been thoroughly investigated, intensive programs exist that reduce symptoms of students with functionally impairing social anxiety. CBT, like other best practice interventions, typically involves multiple components and is tailored to:

• individual needs,
• preferences,
• treatment goals, and
• cognitive abilities.

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CBT interventions, emphasizing learning and skill acquisition, are a natural fit for a school environment and have the most empirical support. However, the problem of excessive, functionally impairing anxiety has yet to be resolved for all people or all conditions.

Paruresis: The “Secret” Social Phobia

Paruresis, or shy bladder syndrome, is one form of social anxiety disorder that children and adolescents can suffer from but which is rarely recognized and is, in fact, largely unknown. The best estimate available of the number of people in the US who suffer from this social phobia is 22 million, or about 7 percent of the population (Kessler, Stein, & Berglund, 1997). Based on US census data, this would mean of those between the ages of 5-21, there are about 5 million potential sufferers (http://quickfacts.census.gov/qfd/states/00000.html) in this largely school-aged group.

It is possible that the number could be higher. There is anecdotal information that one-half of public school children avoid using the school bathroom (http://projectclean.us/). The reasons, of course, are more complex than just undiagnosed paruresis, as other factors such as germ phobias and school bullying in the bathrooms no doubt account for some of this avoidance. Nevertheless, clearly, a substantial percentage is explained by paruresis, and there is little awareness by teachers and school officials of the problem.

Before undertaking a discussion of treatment strategy, it is necessary to give the reader a clearer understanding of what paruresis is and the environmental context of the disorder (Soifer et al., 2001). This is important since a significant number of cases of paruresis in younger sufferers appear to be caused by environmental variables related to school restrooms and restroom use procedures. While education practice has responded to much that has been learned about teaching children over decades of practice, inquiry, and investigation, at least one domain in the school environment bears striking similarity across decades–little has changed within the school restroom environment since one of the authors (Soifer) was a public school student in the 1960s.

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What is Paruresis?

Paruresis, also referred to as shy bladder or shy bladder syndrome, is a DSM V social phobia under the category 300.23 and involves “fear [of] and avoid[ing] urinating in public restrooms when other individuals are present” (APA, 2013, p. 203). It affects men, women, and children in equal numbers, based on the limited data available (Stein, Torgund, & Walker, 2000). Descriptively, for those with paruresis, being in a public restroom when others are present is an anxiety-inducing situation. All anxiety disorders involve physiological responses, and paruresis is no exception.

In persons with paruresis, part of the physiological response is that the bladder neck muscle “freezes up” or spasms. The person with paruresis, as a result, cannot urinate regardless of the desire or attempt to do so. This inhibitory response is not volitional (which is a common myth), and the person cannot urinate, regardless of the urgency of the need, for a period of minutes to hours to even days, depending on the person and the situation. In rare cases, psychogenic urinary retention is the result. The inability to urinate may result in the need to be catheterized, as would be the case if the sufferer had a physical blockage present in the urinary tract. In addition to learning history and environmental influences, there is most likely a genetic component associated with this disorder, as is the case with many mental health issues (Soifer et al., 2001).

While the typical age of onset for social phobia is around puberty and many cases of paruresis fit this pattern the onset can be significantly earlier. The youngest age of onset, based on personal clinical practice experience (Soifer) is three, and the latest incidence of initial symptomology involves individuals over seventy. Some people with paruresis have a co-morbid anxiety disorder, but at least 75% of one online sample did not (Hammelstein & Soifer, 2005). There is a dearth of data on incidence for children, except for a survey done online of children with

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selective mutism. In this sample, one-half of responding parents said their child also suffered from shy bladder syndrome (http://www.selectivemutismcenter.org/ aboutus/whatisselectivemutism).

Finally, it should be noted that there is a bowel equivalent to paruresis, which is called shy bowel syndrome or paraparesis. This condition usually does not tend to present a problem of the same significance in the school setting, since children could have a bowel movement before school and/or when they got home after school (Chalabi, 2008).

Literature on Paruresis and Children

There is little written on the topic of paruresis, and virtually none of the existing data has focused on the school setting, especially from a treatment point of view. This lack of research tests the bounds of imagination since school is the setting most likely associated with negative effects for children and adolescents for social phobias. Prevalence rates for college students have been studied, though findings range widely. Malouff and Lanyon (1985) concluded from a college questionnaire that 7% of the responding population suffered from paruresis. Williams and Degenhardt (1954), who coined the term paruresis, surveyed college students and found that 14% suffered from the disorder. Rees and Leach (1975) reported prevalence rates for paruresis of 25-50% among male college students (n=190) and 20-25% among female college students (n=113).

Finally, Gruper and Shupe (1982) reported a correlation between body shyness and paruresis and reported that almost one-third of their sample of 90 male college students had a significant degree of urinary hesitancy around others. Some case study results are available. Khan (1971) treated a 9-year-old boy with severe urinary retention, reporting positive short-term effects. Glasgow (1975) treated a 21-year-old male college student, and after some trial and error, helped him with the problem using fluid loading and prolonged exposure. Stams, Martin, and Tan (1982) treated an 8-year-old boy with paruresis successfully using drug therapy and positive reinforcement in the form of money. Nicolau, Toro, and Prado (1991) treated a 13-year-old girl using CBT combined with family therapy.

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Caffaratti et al. (1993) discussed the treatment of a young girl and erroneously noted that the disorder is uncommon in adults and even less common among children. Bosio, Mazzuchelli, and Sandri (1996) discussed how a 3-year-old boy with urinary retention was treated by a team of professionals, though the treatment of 5 years duration, an excessive amount of time was reported. Jaspers (1998) successfully treated a 16-year-old male using CBT, reporting that medications held little hope for people with this problem. Finally, Kroll, Martynski, and Jankowski (1998) treated a 14-year-old girl with psychogenic urinary retention using a combination of pharmacological and medical techniques. While these chronicles offer preliminary conceptual assistance for clinicians, their value is tempered by the inherent methodological weaknesses of case study reports.

Assessment and Diagnosis

Although there are now assessment tools for assistance with diagnosing paruresis, these tools, with few exceptions, are developed for use with adults (Deacon et al., 2012; Gibbs, 2004; Hammelstein & Pietrowsky, 2005; Soifer, 2010; Soifer et al., 2001). For example, the Liebowitz Social Anxiety Scale (Heimberg et al., 1999) includes the item “urinating in a public bathroom,” rated on a 4-point Likert scale for both fear and avoidance (low to high).

One scale mentioned in the literature – Spence Children’s Anxiety Scale (SCAS) – contains an indicator about shy bladder: “I feel afraid if I have to use public toilets or bathrooms” (Essau, Muris, & Ederer, 2002).

In addition, an assessment tool for adolescents, the Kutcher Generalized Social Anxiety Disorder Scale for Adolescents (K-GSADS-A), uses a 4-point Likert scale with response options ranging from never to severe: “Using a public toilet facility or urinating (sic) in public” (Brooks & Kutcher, 2004). These are among the few options available for the assessment of children with paruresis at the time of writing.

Treatment Protocol

The following described treatment protocol was formulated by one of the authors (Soifer) and has been adopted by a small number of other therapists. For adults,

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treatment for paruresis is relatively straightforward, defined, and substantiated by a small body of supporting evidence. The treatment protocol for children was developed from clinical practice beginning with a 9-year-old boy with autism and a 13-year-old girl, and was adapted from work with numerous adults.

The basic treatment protocol involves between 8-12 individual sessions using CBT techniques. This includes in vivo gradual desensitization or exposure, cognitive techniques such as decatastrophizing, and some elements now associated with Acceptance and Commitment Therapy (ACT). Not uncommonly, some form of adjunct drug therapy is used, either with Selective Serotonin Reuptake Inhibitors (SSRIs), benzodiazepines, or both (Soifer, Himle, & Walsh, 2010). Service delivery occurs in weekend workshops involving a group of people suffering from paruresis (usually 5-20, mostly adult men). The time devoted to talk therapy in the group setting is roughly equivalent to an average of 10 typical therapy sessions for those who seek individual treatment. Applied practice is done throughout the duration of the weekend (Soifer, 2013).

Overall results for both the individual and group treatment have been excellent, though these results were collected in the absence of experimental controls. In one descriptive study (Soifer, Himle, & Walsh, 2010), data from 101 participants in shy bladder weekend workshops collected between 1997-2003 showed significant improvement for many of the participants following the workshop. Benefits were maintained at a one-year follow-up.

Working with children, in particular, those in elementary and middle schools presents some singular challenges. The first problem is how to know whether a child has paruresis. There is a pervasive lack of awareness concerning this issue among the lay public that likewise affects many professionals. In fact, it may be the least recognized social phobia in childhood. Moreover, many people are hesitant to discuss psychosocial concerns, and clinical experience suggests that people are often especially reluctant to discuss paruresis.

Once a child has been diagnosed with paruresis, several things must happen. Among the top priorities is that school officials need to be notified, and some accommodations for the child must be provided. In fact, failure to provide a

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a student with accommodations may place the school at risk of a lawsuit under the new Americans with Disabilities Act as Amended (ADA), though to date, we are unaware of such a lawsuit having been brought under either the old ADA or the new ADA against a public (or private) school. Next, a treatment plan must be developed. Ideally, this plan will have at least two components. The first is treatment in the home environment, which should be relatively easy to implement (it is not recommended to do treatment in an office setting). The second component, when feasible, occurs in the school setting and is much more challenging to implement.

Great creativity and flexibility are needed in the treatment of children with paruresis. While it might seem intuitively uncomplicated to work on this issue, years of clinical experience suggests otherwise. Anecdotally, most clients have pursued multiple avenues of assistance and express exasperation with every single previous provider seen, either in the medical or mental health fields. As an example of poor advice clients have received, several have reported being told to “drink until you pee.” Not only is it bad advice, but in the case of someone with severe paruresis, following this advice can actually make the problem worse. In such cases, this recommendation can place a sufferer at risk of hospitalization for medical intervention such as catheterization.

The in-home treatment protocol for children consists of first developing a behavioral hierarchy that catalogs the child’s difficulty in using the bathroom at home. While it is possible that he or she has no difficulties at home, it is highly unlikely. The hierarchy should be developed to consider environmental factors such as:

• ambient noise (bathroom fan on/off or TV on high or low in the background);
• whether the bathroom door is locked, just closed, or open; and
• whether the interventionist is paying attention to the client or something/someone else (listening to see if the client is going or not, reading the paper, talking on a cellphone).

Intervention begins at home and continues until the child is able to urinate with

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the therapist outside a potentially open bathroom door in the home. When this has been accomplished it is time to implement phase 2 of the treatment plan – in the school itself. The first phase of treatment in the home typically takes 4-8 sessions, depending on the severity of the paruresis.

The school treatment plan, as mentioned before, is often more challenging. First, the therapist is going to need to secure full cooperation and participation from school personnel, though such initiatives may be met with significant resistance. Second, even with cooperation, the school must demonstrate flexibility in allowing the therapist to work with the child, which may involve difficult logistical arrangements, such as:

• being in the school when it is empty (before or after school hours),
• absolute commitment to protecting the privacy of the child, and
• providing reasonable accommodations for the child during the day (for example, using the teachers’ bathroom for privacy purposes and alerting teachers to this fact).

The child with paruresis is going to need virtually no one around (except the therapist, of course) to practice using the bathroom(s) in school. Otherwise, the school protocol is similar to the home protocol; that is, consideration of the key environmental factors causing the problem (proximity, visual and/or auditory cues, someone waiting) and working along the behavioral hierarchy through in vivo graduated exposure methods until anxiety reduction occurs. For example, the therapist might start down the hallway from the bathroom, placing him/herself there, and asking the client to go into the bathroom.

The first step in desensitization may be simply entering the bathroom itself. Then, after doing this, s/he might try urinating in the stall, then (if the client is male) at a urinal when the therapist is outside the restroom, and continue progression through the hierarchy. This all presupposes the client has done fluid-loading, that is, maintained hydration so that the physical need to urinate occurs. The ultimate goal may be somewhat variable, but a reasonable treatment goal to consider:

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• if the student is a girl, the therapist will want to get to the point where she is in the next stall, outside/or the occupied stall door, talking with the client (e.g. asking the client if she is done because the therapist needs to use the toilet);
• if the student is a boy, and there are urinals present in the bathroom, the goal might be for the therapist to be standing at a urinal adjacent to the client (also talking to the client as he relieves himself).

It typically takes an additional 4-8 sessions to get to this point, depending, again on the severity of the paruresis. In addition, as this therapy is occurring, the student should be practicing during the week during school hours, beginning presumably in the teachers’ bathroom and then proceeding to use the school public bathroom, following the behavioral hierarchy constructed for this purpose. School officials will need to make such accommodations as giving the student a hall pass to use the public bathroom whenever s/he needs to.

Environmental Considerations

Anecdotal reports from children and adolescents suggest that the origin of a significant number of cases of paruresis is in school, and a majority involve bullying in the school bathroom. Typically, such bullying manifests as verbal abuse from peers. Some, however, involved children exposed to physical abuse situations – such as an attempt by peers to open or even break down a stall door (if there were stall doors) to shoving or trying to shove a boy into a urinal while he is trying to urinate. Due to the current paucity of data, it is impossible to determine how many children begin school with paruresis and how many begin school and develop paruresis. Supervision of school restrooms could assist with problems such as bullying, but, ironically, could exacerbate the suffering of a student with paruresis from other causal mechanisms.

The reader may question what responsibility the school should have in the therapeutic needs of a student with paruresis. At least part of the answer to that question might begin with the effects of paruresis on school behavior and engagement so common that they could be presumed, including:

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• in advanced paruresis, children aggressively avoid going to school (this can be misconstrued as school phobia, especially if the child has told no one about the problem),
• being late to classes (so s/he can use bathrooms when few, if any, are in them),
• behavior problems in the classroom (to be “expelled” from the class so s/he can actually use the bathroom under pretense), and retaining urine all day, which is detrimental to school performance can result in serious physical outcomes.

Finally, it should be remembered that paruresis in many children appears to occur as a consequence of adverse events that occurred in school restrooms.

CONCLUSION

The inclusion of a discussion of paruresis may seem somewhat esoteric. It certainly involves a clinical phenomenon about which little empirical information was conveyed to the reader when there are innumerable mental health conditions about which much information could be disseminated. However, this example was included with intent, because it may serve as the best example of how a situationally specific mental health condition can have global effects on functioning and quality of life.

Paruresis, a term with which few people are likely familiar, involves an anxiety disorder occurring from the attempt to urinate when others are present, resulting in the inability to urinate, even if the need and desire are present. It is very common for school programming to regiment access to the restroom as a scheduled, group activity. Many schools likewise restrict access to restrooms at other times. The reader is encouraged to consider the effect that the inability to void urine for the entire day would have on a child in school, as well as the effect this inability would have on the student’s capacity to concentrate, for example, on abstract mathematical concepts. Once evident, there is no reason to presume the problem will either be mitigated or disappear over time unless effective intervention occurs.

Paruresis restricts what, for most people, takes but a few minutes and often

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carries little import for the typical day, thus making the restricted need to toilet the focus of the sufferers’ day. A student with shy bladder experiences a significant amount of suffering, both physical and emotional, though the limited evidence available in addition to clinical experience suggests that this suffering is highly unlikely to be communicated to others for several reasons, not the least of which is embarrassment. The suffering that occurs is not due to the ill intent of school personnel. However, if you will pause to reflect for a moment, consider the divergent outcomes that could occur for a student suffering from paruresis in a school functioning under a regimentation to follow directives or else approach to human development, in contrast to a school committed to the promotion of health mental and physical of the people in that school community. The level of suffering experienced by our imagined student with paruresis is likely to be dramatically different.

CONFLICT OF INTEREST

The authors confirm that they have no conflict of interest to declare for this publication.

ACKNOWLEDGEMENTS

Declared none.

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