Scott Hannan, Ph.D.. Definition of School Refusal . Problem with school attendance as manifested by:. Complete school absence.. Receiving tutoring through the school system.. No current educational plan.. ID: 671107
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Cognitive Behavioral Therapy for School Refusal
Scott Hannan, Ph.D.
Slide2Definition of School Refusal
Problem with school attendance as manifested by:
Complete school absence.
Receiving tutoring through the school system.
No current educational plan.
Excessive school absences.
Sporadic attendance.
Difficulty after vacations or on a particular day.
Partial day attendance.
Frequently leaving class (may spend time in guidance, nurse, etc.)
Leaving school early.
Entering school late.
Slide3Characteristics of School Refusal
School refusal was traditionally broken into anxiety based school refusal and behavior based (opposition/defiance/low motivation) school refusal (=truancy).
Occurs in 1-5% of school age children (King et al., 1995; Kearney and Roblek, 1997).
Increase in school refusal behavior at points of transition.
Entering elementary school and ages 10 – 13 are prime times.
Slide4Characteristics of School Refusal
Occurs equally in males and females, although some estimates indicate that school refusal driven by oppositional behavior occurs more often in males (Egger, Costello, and Angold, 2003).
Occurs equally among race and income levels (Kearney and Bates, 2005).
Slide5Characteristics of School Refusal
Can take up to 2 years for these children to receive treatment.
20%-40% may take longer to receive treatment (Bernstein,
Svingen
, &
Garfinkel
, 1990;
McShane
, Walter, and
Rey, 2001).
Common problems associated with onset (
McShane
, Walter, and Rey, 2001):
Conflict at home
Conflict with peers (14% were related to bullying)
Academic difficulty
Family separation
Changing schools/moving
Physical illness
Slide6
Characteristics of School Refusal
Other associated problems (
McShane
, Walter, and Rey, 2001):
Physical illness in parent
Psychiatric illness in mother
Psychiatric illness in father
Slide7
Characteristics of School Refusal
Wide variety of associated diagnoses:
Separation Anxiety Disorder most frequent
Generalized Anxiety Disorder
Specific Phobia
Social Phobia
Oppositional Defiant Disorder
Major Depressive Disorder
ADHD
Also common to have no diagnosis
Associated problems
Academic problems, social isolation, family conflict, financial consequences, legal issues (Kearney, 2006)
Slide8Characteristics of School Refusal
Common symptoms
Somatic complaints: stomachaches, headaches, nausea, diarrhea, vomiting, dizziness, rapid heart beat
Panic attacks (or reports of “panic attacks”)
Social anxiety
Worry
Phobias
Slide9Characteristics of School Refusal
Common behaviors
Trips to nurse/guidance
Tearfulness
Refusal to get out of bed
Tantrums
Oppositional behavior
Lying
Damaging property
Aggressive
Escape (school, car)
Reassurance seeking
Slide10Failure to return to school
Valles and Oddy (1984)
When family discord is part of the problem:
If family discord is not addressed, school refusal continues and family problems continue into adulthood.
Failure to return to school is associated with increase in legal problems.
Failure to return to school associated with higher rates of anxiety and depression.
Slide11Assessment of School Refusal
Diagnostic evaluation
Anxiety Disorders Interview Schedule for Children for DSM-IV (ADIS-IV; Silverman and Albano, 2004)
Child version: ADIS-IV: C
Parent version: ADIS-IV: P
Structured clinical interview
Provides examples of behavior one would expect to see in these diagnoses along with prompts to rate the level of fear (0 – 8) (8 = Very, very much)
Slide12Assessment of School Refusal
ADIS-IV
Structured clinical interview
School Refusal
Separation Anxiety Disorder
Social Phobia
Specific Phobia
Panic Disorder
PTSD
OCD
ADHD
Generalized Anxiety Disorder
Affective Disorders
Externalizing Disorders
Somatoform Disorders
Slide13Assessment of School Refusal
Conners-March Developmental Questionnaire (Conners and March, 1994)
Parent completed questionnaire
Problem Description
Treatment history (medication, psychotherapy)
Motor development
Family information
Temperament
Birth history
Medical and psychiatric history
School performance/behavior
Slide14Assessment of School Refusal
Multi-dimensional Anxiety Scale for Children (MASC; March, 1997).
39 item self report measure
Scales and Subscales
Physical Symptoms (Tense, Somatic)
Harm Avoidance (Perfectionism, Anxious Coping)
Social Anxiety (Fear of humiliation, Performance fears)
Separation/Panic
Total Anxiety
Anxiety Disorders Index
Inconsistency Index
T-scores: 9
ratings (Very Much Below Average to Very Much Above Average)
Ages 8-19
Scale 0 (never true) – 3 (often true)
Slide15Assessment of School Refusal
Children’s Depression Inventory-2 (Kovacs, 2010)
28 item measure
Ages 7-17
Forms: Child, parent, teacher
Reponses 0-2 (2 indicating more depressive symptoms)
Questions relate to mood, interpersonal problems, anhedonia, self-esteem, item on suicide, ineffectiveness
Slide16Assessment of School Refusal
School Refusal Assessment Scale-Revised (SRAS-R; Kearney, 2002)
Revision of School Refusal Assessment Scale (Kearney and Silverman, 1993)
Child and parent versions
24 items: 4 subscales (6 questions for each subscale)
Used to assess 4 main functional components of school refusal
Avoidance of negative affect (Negative reinforcement)
Escape from social evaluation (Negative reinforcement)
Attention getting behavior (Positive reinforcement)
Pursuit of tangible reinforcement (Positive reinforcement)
Slide17Assessment of School Refusal
School Refusal Assessment Scale-Revised (SRAS-R; Kearney, 2002)
Scoring:
Mean of all items in the subscale for child and parent(s)
Mean subscale items for child/parent(s)
Rank order the subscales.
Highest score is considered to be the primary reason for school refusal
Scores within 0.50 points of one another are
considered equivalent
Slide18Assessment of School Refusal
Achenbach System of Empirically Based Assessment: School Age Children (Achenbach and Rescorla, 2001):
Child Behavior Checklist (CBCL): Ages 6-18
Teacher Report Form (TRF): Ages 6-18
Youth Self Report (YSR): Ages 11-18
Slide19Assessment of School Refusal
Achenbach System of Empirically Based Assessment: School Age Children (Achenbach and
Rescorla
, 2001):
Syndrome Scales
Anxious/Depressed
Withdrawn/Depressed
Somatic Complaints
Social Problems
Thought Problems
Attention Problems
Rule-Breaking Behavior
Aggressive Behavior
Slide20Assessment of School Refusal
Achenbach System of Empirically Based Assessment: School Age Children (Achenbach and
Rescorla
, 2001):
DSM-oriented Scales
Affective Problems
Anxiety Problems
Somatic Problems
Attention Deficit/Hyperactivity Problems
Oppositional Defiant Problems
Conduct Problems
Slide21Assessment of School Refusal
Social Anxiety Scale for Children (LaGreca and Stone, 1993)
22 items
5 point Scale (1=Not at all – 5 = All of the time)
Child scale
Parent scale
Subscales
Fear of Negative Evaluation
Social Avoidance and Distress for New Situations
General Social Avoidance and Distress
Slide22Consultation and School Refusal
Consultation is essential to treating school refusal behavior
School personnel
MD: Pediatrician, Psychiatrist, Other specialist
Does the child have any medical limitations that impact their ability to function at school?
Child and/or family may present with physical complaints that they believe impact their ability to function at school. Verification will be essential to treatment planning and working toward school accommodations.
Current medication regimen
Other mental health providers
Slide23Consultation and School Refusal
Family history and school refusal
Child’s history with school refusal
Acute problem: What are issues surrounding acute problem?
Chronic problem: When does the problem typically arise?
Family history with school refusal
Parental history
Sibling history
Are their current siblings refusing school?
Are their siblings who have dropped out of school?
Slide24Consultation and School Refusal
Home environment
Who is at home all day?
Current family problems
Divorce
Parental illness
Sibling illness
Other family member illness
What happens when child is home alone?
What’s been tried to get the child into school?
School
Parents
Slide25Functional Assessment
Using the School Refusal Assessment Scale-Revised
Breaks school refusal into 2 basic issues
Negative Reinforcement: Increase in a behavior due to removal of aversive stimuli.
Child complains of stomach pains
gets out of class.
Child refuses to get out of car stays home from school.
Positive Reinforcement: Increase in a behavior due to the onset of a rewarding stimuli.
Child complains of stomach pains stays home and plays video games.
Child refuses to get out of car parents/school personnel pleading with child.
Slide26Functional Assessment
Using the School Refusal Assessment Scale-Revised
4 subscales
Negative Reinforcement:
Avoidance of Negative Affectivity
Escape from Social Evaluation
Positive Reinforcement:
Attention Getting Behavior
Pursuit of Tangible Reinforcement
Slide27Functional Assessment
Using the School Refusal Assessment Scale-Revised
Utilize the scores on the SRAS-R along with data gathered through clinical interview and consultation to determine the function of school refusal behavior
Avoidance of negative affectivity
Children that avoid school due to negative emotions: School evokes anxiety (panic, separation fears, phobias, etc.) or depressed mood. This negative emotion may manifest itself at school or at home (night, mornings, weekends, vacations)
Escape from social evaluation
Children that avoid school due to social fears/performance fears.
Slide28Functional Assessment
Using the School Refusal Assessment Scale-Revised
Attention getting behavior
Children whose school refusal behavior leads to increased attention from adults:
Increased attention from school staff (nurse, guidance counselor, school psychologist, teacher, etc.)
Increased attention from parents.
Spend time with parents at home.
Parents pleading with child.
Parents arguing with child (Even negative attention can be reinforcing!)
Slide29Functional Assessment
Using the School Refusal Assessment Scale-Revised
Pursuit of tangible reinforcement
Children whose school refusal behavior is reinforced by positive stimuli
Video games during school hours
Going out with friends after school (when they have not attended)
Home with siblings
Watching television during school hours
Drug use
Time with peers that are also truant
Slide30Functional Assessment
Typically you will find more than one function may be related to school refusal behavior.
Example: Child experiencing panic attacks gets put on home bound tutoring. He spends most of his day watching television and then gets tutored at home for two hours.
Negative reinforcement: Reduces panic attacks by not going to school.
Positive reinforcement: Gets all his work done in 2 hours. Spends rest of time watching television.
Slide31Treatment
Psycho-education
Family, child, and school personnel need to be made aware of what is maintaining school avoidant behavior.
Cognitive therapy
Must be made developmentally appropriate.
Elementary school
Identify the connection between thoughts and feelings
Find a way they can connect to challenging their thoughts.
Detective Thinking: Use the example of Scooby Doo.
Coping self statements.
Identify with a superhero/favorite star/character to beat their anxiety
Use parents as a resource to help them challenge their thoughts.
Slide32Treatment
Cognitive therapy
Middle School through High School
Learn to make the connection between thoughts, feelings, behavior, environment, and physical sensations.
All emotions are healthy. We are trying to lower the intensity of emotions. Important to normalize their emotions.
Slide33Treatment
Slide34Treatment
Cognitive Therapy
Catastrophizing
Make problems into catastrophes
Example: Boy asks girl out. She says “No.”
“I’m such an idiot. Everyone will laugh at me! No one will ever want to go out with me. I’ll have to switch schools!”
Reality: He’ll get to school the next day. Her friends will laugh when he walks by. His friends will make fun of him. After lunch, no one will care.
Fortune telling/Mind reading
Predicting bad things will happen. “If I don’t know the answer, my teacher will be mad at me.”
Predicting we know what others are thinking. “They all think I’m crazy!”
Slide35Treatment
Cognitive Therapy
Devise a rational thought:
What does the evidence tell us?
What would I tell a friend with a similar problem?
Emphasize that changing the thought is only part of the work that needs to be done. If it just required a new thought, they’d have done it already. They’ve probably already tried.
Need to pair a change in thinking with a change in behavior.
Slide36Treatment
Social skills training
Body Language
Eye contact
Body posture
Orientation of head and body
Movement of limbs
Facial expression
Voice quality
Volume
Tone
Slide37Treatment
Social skills training
Having a conversation. Start by making them feel normal.
“I want to teach you social skills. It’s obvious that you have social skills, but a lot of people have a hard time using them when they are nervous. We have to practice in here, so you have an easier time when you are nervous.”
Use examples:
Baseball players practice in a batting cage.
Musicians practice scales.
Actors practice their lines.
Slide38Treatment
Social skills training
Having a conversation.
Introduction:
Introduce yourself if you don’t know the person.
Say hello and the person’s name if you do know them.
Ask a general question.
Ask a specific question.
Middle
Ask questions. Remember people like to talk about themselves.
Reflect back what they have said.
Show an interest in what they’ve said.
Don’t try to control the conversation.
Slide39Treatment
Social skills training
Having a conversation.
End
Make a transition
Notice social cues someone needs to go.
Recognize your own need to go (but don’t jump out of the conversation prematurely)
Set up a meeting for another time.
Formal
Informal
Slide40Treatment
Social skills training
Having a conversation.
Things to remember
Not all conversations will go well.
You cannot and are not expected to control the entire conversation.
Look for clues in your environment for what to talk about:
Mondays: Ask about the weekend.
What’s going on?: Assembly? Test? After school?
T-shirt someone is wearing.
Book someone is reading.
Topic previously discussed: Movie, music, etc.
Slide41Treatment
Social skills training
Returning to school: WHERE HAVE YOU BEEN?!
Big issue on kids minds.
Practice an answer.
Short and concise.
Transition to a new topic.
“I’ve been out sick. It’s nothing major. The doctors say I’m fine now. What’s been going on since I’ve been out?”
Stick to your simple answer and questions die down in about a day and a half. Generally question is most prevalent that first morning.
Biggest problem is when you avoid the question or school personnel tell other children not to ask. It will become gossip and lead to rumors.
Slide42Treatment
Social skills training
Dealing with bullying.
Practice assertiveness.
Utilize body language skills.
Assertiveness is not aggressive.
Concise and to the point.
Explain what you need.
“You need to give me my books back.”
Use planned ignoring when appropriate.
Get help when needed.
Utilize cognitive restructuring. You didn’t tattle. You gave them an opportunity to stop. You have the right to be left alone. They continued to push and they chose to have to talk to a teacher/parent/etc.
Slide43Treatment
Social skills training
Making friends
Join clubs
Talk to peers in class
Repetition is key.
Patience. Takes time to make friends.
Watch out for those that are stuck on internet friendships.
Slide44Treatment
Exposure therapy
Create an exposure hierarchy. List of situations that bring on anxiety. Situations you can practice in session and the child can practice on their own.
Approximately 15 items.
Rate on a scale of 1-10 (10 = Extremely scary).
Try to get 5 mild items (1-3), 5 moderate items (4-7), 5 high items (8-10).
Start with the lowest level items. Build skill and understanding of how exposures work.
Slide45Treatment
Slide46Treatment
Slide47Treatment
Exposure hierarchy example:
Ask someone directions 2
Saying hello to a teacher 3
Conversation with unknown adult 4
Asking someone to borrow a pen 5
Conversation with unknown peer 7
Answering a question wrong 7
Dropping my books 9
Giving a speech in front of the class 10
Slide48Treatment
Exposure
Practice without safety behaviors/distractions
A safety behavior is what someone does to feel less vulnerable.
Example: I’ll go into class if I can sit right by the door, in case I need to leave really quickly.
As you do the exposure check on their anxiety levels and what they are thinking.
Give them time to habituate.
Repetition is the key.
By pairing a change in thought while confronting the situation, the child will learn that the event is not that bad or that they are capable of handling the event.
Slide49Treatment
Problem solving
Problem orientation
Normal part of life.
Opportunity to make things better.
Identify the problem.
Who, what, where, when, how?
Brainstorm ideas.
Allow the child to come up with all ideas.
Bad ideas can lead to good ideas if we let them go through the process of brainstorming.
Slide50Treatment
Problem solving
Narrow down ideas
What are the long term and short term consequences?
What has happened when I’ve tried this before?
Is it safe?
Is it fair?
What makes me think this will work?
Make a choice.
Evaluate outcome.
If it doesn’t work, try another solution.
Slide51Treatment
Behavior Management
What are current behavior management strategies?
Set up routines:
Bedtime
Wake up time
Home work time
Leaving house for school. How do they get to school?
Set up boundaries:
When home from school, no electronics.
When you have not gone to school: No time with friends, no electronics.
Slide52Treatment
Behavior Management
Set up boundaries
No in the moment negotiations.
Parents must be in agreement. No splitting.
Move away from arguing, yelling, negotiating, giving up in frustration. This strengthens school refusal behavior. Parent winds up chasing after the child. Let the consequences work for themselves.
Slide53Treatment
Behavior Management
Positive reinforcement
Getting to school each day for a week leads to a sleepover with friend.
Negative reinforcement
Homework completion before dinner leads to no cleaning up after dinner.
Response cost: Removal of positive stimulus on the onset of undesired behavior.
Refusal to go to school leads to losing phone for the evening.
Punishment: Introducing a negative stimulus on the onset of an undesired behavior.
School refusal leads to extra chores on the weekend.
Slide54Treatment
Behavior Management
Create a written contract.
If possible, start with positive or negative reinforcement.
Teach parents to be consistent, reliable, and firm.
Short concise commands vs. lengthy explanations.
No questions. Make commands
Define desirable behavior.
Define consequences.
Tell child what you need to see vs. what you don’t want to see.
“You need to start your homework.” vs. “Stop fooling around with your brother.”
Slide55Treatment
Behavior Management
No sarcastic comments.
Parents have final say.
Example. Bedtime plan: Bedtime is 9:30 PM. Child is given to 9:45 PM to be in bed (15 minute cushion). If child is in bed at 9:46 PM (according to parent clock), consequences are put in place. Even if child argues that their watch said 9:44 PM, it does not matter. Parent is ultimate authority. Liken it to an umpire/referee.
Slide56Treatment
Test Anxiety
Hadapp, Glanzmann, and Laux (1995)
Worry has a negative relationship to achievement.
Emotion has a positive relationship to achievement
Suggests that the anxiety one feels may push one to prepare for a test, but excessive worry will interfere with studying or recall during a test.
Suggests cognitive therapy for intervention.
Slide57Treatment
Test Anxiety
Examine evidence
How do they generally do on tests?
How do they prepare for tests?
Studying
Listening in class
Homework
What resources do they have when they are struggling.
Slide58Treatment
Test Anxiety
Exposure
In order to reduce worry, one needs to challenge the thought through behavioral challenges.
For excessive studying: Reduce amount of time spent studying.
May require limits set by parents.
Time worriers: Practice taking tests in session. Timed and un-timed. Do an assessment on how they do un-timed. How long do they take? (Don’t let them know you’re timing them.)
Slide59Case examples
Avoidance of Negative Affect
16 year old male.
Diagnosis: Panic Disorder with Agoraphobia
SRAS:
Avoidance of Negative Affect 5.17
Escape from Social Evaluation 4
Attention Getting Behaviors 4.83
Pursuit of Tangible Reinforcement 2
Slide60Case examples
Avoidance of Negative Affect
Treatment plan
Exposure
Crowded places (mall, bookstore)
Interoceptive exposures: Spinning in a chair (dizziness), hyperventilating (short of breath, tightness in chest, light headed).
Cognitive restructuring
Aimed to reduce catastrophic thinking.
“I’ll have a panic attack and everyone will see it and think I’m crazy.”
Discussed difference between anxiety and escape behavior. Others most likely wouldn’t notice his anxiety, but they do notice when he hides in the back of the car screaming at his mother.
Slide61Case examples
Avoidance of Negative Affect
Treatment plan
Behavior problems
When he was home from school, he spent time with his parents.
No established wake up times (for patient or parents).
Went to movies with parents.
Infantile behavior. Curling up in fetal position, crying.
Behavior management
Set up routines for wake up times.
No movies, TV, computer, video games during school hours.
Behavior plan. Earned time to go paintballing with friends when he achieved 90% attendance over 2 weeks.
Consequences from school. Patient had been given accommodations on absences. Patient held to no more than 18 unexcused days or would need to repeat year.
Slide62Case examples
Avoidance of Negative Affect
Reduction in panic attacks.
Parents struggled to follow through with behavior plans.
They wouldn’t keep track properly, make exceptions.
Wouldn’t follow through.
School retention increased compliance.
Slide63Case examples
Escape from Social Evaluation
15 year old male.
Diagnosis: Social Phobia
SRAS:
Avoidance of Negative Affect 3.83
Escape from Social Evaluation 5.33
Attention Getting Behaviors 2.33
Pursuit of Tangible Reinforcement 4.83
Slide64Case examples
Escape from Social Evaluation
Bullied by peers in 8
th
grade.
3 siblings. 2 at home.
1 experiencing psychiatric problems.
1 avoiding school due to past bullying.
Neither one in school during the day.
Parents had little skill is setting boundaries for their children.
All children followed rules at home, but they could not set rules around school compliance.
Slide65Case examples
Escape from Social Evaluation
Social skills training.
Exposure: social exposures.
Virtual reality: Making class presentation.
Started by just seeing self in front of class.
Role plays with multiple people in session.
Practice explaining where he’d been.
Parent behavior management.
No electronics during day.
No time with siblings.
Reward: Going to school would lead to video game he wanted.
Slide66Case examples
Escape from Social Evaluation
Cognitive restructuring.
Challenged belief that others don’t like him.
Past friendships.
Current friendships.
Reality of what would happen in class if he made a mistake.
Assertiveness training.
Role played in session.
Slide67Case examples
Escape from Social Evaluation
Behavior management.
At time of school reintroduction
Plan for 1 class at a time.
Reduced schedule.
Child refused. Brothers didn’t go, why him.
Father was angry at the school, who threatened truancy.
Further psycho-education on problems on school refusal.
Child informed of involvement of courts/DCF if he did not comply.
Started to attend.
Slide68Case examples
Escape from Social Evaluation
Returned to school for partial day.
Completed core requirements.
Noted feeling of pride in returning to school.
More comfortable around peers.
Still struggled to make friends, but made some efforts to talk to peers. Talked to lab partner consistently.
No bullying.
Slide69Case examples
Attention Getting Behavior
17
year old
female
.
Diagnosis: Panic Disorder with Agoraphobia
SRAS:
Avoidance of Negative Affect
4.83
Escape from Social Evaluation
1.83
Attention Getting Behaviors
5.16
Pursuit of Tangible Reinforcement 2
Slide70Case examples
Attention Getting Behavior
Rapport building.
She thought most people did not get her and came in with very little trust.
Spent first session talking about television shows.
Identified self as different than peers. Took pride in negative reaction from others.
Discussed conflict with mother.
Father not involved in life.
Grandfather (with whom she was close) passed away early in her life.
She emotionally supported mother after death of grandfather.
Helps take care of youngest sibling.
Slide71Case examples
Attention Getting Behavior
Rapport building.
Felt as if no one took care of her and she was not going to let anyone do so now.
Exposure therapy:
Straw breathing (shortness of breath, dizziness)
Hyperventilating (tightness in chest, light headed, dry mouth)
Staring wall (de-realization)
Walk through tunnels at hospital.
School exposures. Walking around school at start of school year.
Post office.
Slide72Case examples
Attention Getting Behavior
Cognitive restructuring
Challenging belief that she “has to” do things alone.
Challenging belief that others can’t help her.
Behavior management
Reduction in arguments.
No pleading to go into school.
Drop her off. If she doesn’t go, she has consequences at home (no computer, no reading)
Reward. 4 out of 5 days of attendance
$10 iTunes gift card.
Increased expectation to earn gift card.
Transitioned to unwritten intermittent reinforcement.
Slide73Case examples
Attention Getting Behavior
School accommodations.
School entered her into new therapeutic setting in school.
Began transition to regular education classes.
Given pass to talk to guidance counselor.
Reduction in panic attacks.
100% attendance.
Reduced fighting with mother.
Mother felt increased ability to discipline.
Slide74Case examples
Pursuit of Tangible Reinforcement
13
year old male.
Diagnosis:
None
SRAS:
Avoidance of Negative Affect
3
Escape from Social Evaluation
1.6
Attention Getting Behaviors
4.5
Pursuit of Tangible Reinforcement
5.33
Slide75Case examples
Pursuit of Tangible Reinforcement
Physical complaints
Stomachaches in morning
Headaches
Missed school due to illness.
Home tutoring 2 hours per day.
Spent time with friends after school and on weekends.
Watched TV all day
Refused to come out of room when grandfather watched him.
Slide76Case examples
Pursuit of Tangible Reinforcement
Rapport building
Used virtual reality as a way to get his interest. Fear of heights.
Behavior management.
Removal of all electronics.
Eliminate time with friends.
He would just read instead. Parents did not want to limit books.
Threatened with court referral.
End to tutoring.
Practiced what to say to peers.
Slide77Case examples
Pursuit of Tangible Reinforcement
Increased to 100% attendance.
Questions about whereabouts lasted 1 day.
Tutoring no longer necessary.
Slide78Case examples
Pursuit of Tangible Reinforcement
Rules around being ill
Go to school when fever/vomiting have ceased for 20 hours.
Parents have final say on going to school.
Sinus infections/ear infections are not reasons to stay home.
Headaches are not a reason to stay home.
Went to home on first day of going to school.
Did not like the attention. Went easily to school.
Sent him to school when he had strep throat. Did not find out until after school.
He used it against parents.
Turned around on him. His behavior has lowered trust in his judgment.
Slide79Case examples
Complications
Case where patient vomited in school due to anxiety.
School adjusted rules to allow him to stay in school when vomiting.
Suicidal threats.
Patient whose SRAS indicated Attention Getting Behavior, made threats to harm self when school attendance was proposed.
Parents took it seriously.
No discussions.
Took patient to hospital at threats.
No time with friends while she was suicidal.
Slide80Case examples
Complications
Family and student not invested in treatment.
There by court order.
Agreement with school.
Stay firm with family. Cancel treatment and report follow up.
Family needs to understand seriousness of school refusal.
Child resisting all behavior plans/parents struggling with behavior plans.
Find out local laws
Truancy
Child Protective Services
Get parents to
commit
to filing with courts or family with service needs.
Slide81Accommodations
Accommodations to increase school attendance.
Alter school schedule.
What classes are needed.
Start later in day or end early in day.
Set up a point person with whom parents/student discusses problems.
Passes
Passes with limits: Example: 5 passes a week for 10 minutes
Makes child think about when they really need it.
Less likely to use multiple passes on Monday.
Slide82Accommodations
Make up work
Work with school to identify the necessary assignments
Tutoring/extra help
Keep contact with school to assess make up work.
Are teachers following plan.
Find point person to help advocate for student with teachers.
Slide83Treatment structure
Session frequency/duration
Tolin, et. al (2009)
15 sessions over 3 weeks.
2 hours per session
75% returned to school
Other schedules
Weekly
Twice weekly
Slide84Treatment structure
Where
In office
At school
Dealing with privacy
Other locations that bring on anxiety
At child’s home
Mornings before school. Work with parents.
Slide85Treatment structure
Timing of transition
Take an assessment of the child and their ability to transition.
In general a moderate pace is most effective. Increase time in school over 2-3 weeks.
Drawing it out much longer can lead to problems.
Each transition (increase in schedule) can be taxing. You run the risk of prolonging this process and reinforcing anxiety over school.
Run into vacations, which tend to bring up avoidance.
Some students may choose to make a big leap to avoid questions from peers. Assess their readiness.
Slide86Results
CBT is effective in transitioning children back to school
Heyne, et al. (2011):
Increase in school attendance.
Decrease in anxiety
King, et al. (1998).
4 week CBT
Increase in school attendance
Improvements in self reports of anxiety and depression
Improvements in ratings by parents and clinicians
King, et al. (2001)
Follow up on 4 week program.
18% showed attendance problems.
3-5 year follow up: 84% rate of attendance
Slide87Results
CBT is effective in transitioning children back to school
Heyne, et al. (2002)
Parental involvement associated with increased school attendance.
Parental involvement associated with fewer internalizing problems.
Case Studies: Show improvement in school attendance.
Tolin et al. (2009)
*75% improvement, but relapses. 75% completed school in other formats
Kearney (2002)
Kearney (2001)
Slide88Today's Top Docs
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