When an asthma inhaler becomes part of a child’s anxiety cycle

A case study shows how mapping the factors that maintain anxiety can reveal unexpected treatment targets, from inhaler use to family responses and school avoidance.

A clinical formulation can do more than catalogue symptoms: it can help explain why a problem persists and where treatment might have the greatest effect. In a session on science-informed case conceptualisation, Bryce McLeod set out a five-step approach that used a single example of social anxiety in an adolescent girl to show how clinicians can move from description to a working explanation of what is maintaining distress.

That distinction matters because a diagnosis tells a clinician what a young person is experiencing, while a formulation asks what set the problem in motion and what keeps it going. In the model McLeod described, each part of the formulation is treated as a testable hypothesis. If a suspected maintaining factor is targeted and nothing changes, the clinician revisits the map and adjusts course. That approach is closely aligned with the broader CBT 5 Ps framework, which separates presenting, predisposing, precipitating, perpetuating and protective factors, and with the wider view in clinical literature that formulation should connect assessment with treatment planning.

In McLeod’s case example, the girl had started avoiding peers at school and her attendance was slipping. She also had asthma and was reaching for her reliever inhaler repeatedly during the school day, especially when she felt her body responding in front of other people. The assessment suggested anxiety sensitivity, meaning she was closely monitoring bodily sensations and interpreting them as signs that something was wrong. Because reliever inhalers can themselves raise heart rate, the treatment that was meant to ease symptoms may also have been feeding them. In effect, a medical tool had become part of the anxiety cycle.

The formulation also brought the family into view. The girl’s mother described some anxiety of her own, and when her daughter became distressed, staying home seemed to relieve both of them in the short term. That is one reason formulation is often more useful than a symptom checklist: it can show how well-intentioned responses from parents or carers may accidentally preserve a child’s difficulties. The challenge, as McLeod noted, is to discuss those ideas carefully, using language drawn from the family’s own account rather than a blunt technical explanation that can sound blaming.

Treatment followed the formulation. McLeod used cognitive behavioural therapy with exposure, matching the intervention to the mechanisms he believed were keeping the problem alive. Psychoeducation helped the girl understand how inhaler use could intensify physical sensations, while exposure work deliberately brought on those sensations in a safe setting so she could learn they were tolerable. For the mother, the work combined support around school refusal with help managing her own anxiety. The formulation also guided measurement: the girl brought her inhaler to sessions so use could be tracked, and she recorded how often she spent time with peers at school. Over time, peer contact increased and inhaler use moved closer to what her asthma alone would predict.

The example also raises a wider clinical question: when a coping strategy has a protective purpose as well as a potential cost, how should clinicians help families distinguish between the two? McLeod’s answer was to keep the formulation collaborative, concrete and open to revision, and to ground it in the behaviours that matter in everyday life. That is the practical promise of case conceptualisation: not a neat theory for its own sake, but a way of turning assessment into a treatment plan that can be tested, refined and explained to families in language they can recognise.