Cognitive Behavioral Therapy for School Refusal

Cognitive Behavioral Therapy for School RefusalScott 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.

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.

Characteristics 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.


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).


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


Other associated problems (McShane, Walter, and Rey, 2001): Physical illness in parent Psychiatric illness in mother Psychiatric illness in father


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)


Common symptoms Somatic complaints: stomachaches, headaches, nausea, diarrhea,

vomiting, dizziness, rapid heart beat Panic attacks (or reports of “panic attacks”) Social anxiety Worry Phobias


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

Failure 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.

Assessment 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)

Assessment 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

Assessment 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

Assessment 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)

Assessment 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

Assessment 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)

Assessment 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

Assessment 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


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


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

Assessment 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

Consultation 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

Consultation 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?

Consultation 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

Functional 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.


4 subscales Negative Reinforcement:

Avoidance of Negative Affectivity Escape from Social Evaluation

Positive Reinforcement: Attention Getting Behavior Pursuit of Tangible Reinforcement


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.


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!)


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

Functional 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.

Treatment 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.

Treatment 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.

Treatment

Treatment 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!”

Treatment 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.

Treatment Social skills training

Body Language Eye contact Body posture Orientation of head and body Movement of limbs Facial expression

Voice quality Volume Tone


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.


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.


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


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.


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.


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.


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.

Treatment 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.

Treatment

Treatment

Treatment 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

Treatment 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.

Treatment 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.

Treatment 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.

Treatment 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.


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.


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.


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.”


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.

Treatment 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.


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.


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.)

Case 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


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.


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.


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.

Case 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


Bullied by peers in 8th 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.


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.


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.


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.


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.

Case 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


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.


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.


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.


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.

Case 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


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.


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.


Increased to 100% attendance. Questions about whereabouts lasted 1 day. Tutoring no longer necessary.


Rules around being illGo 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.

Case 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.

Case 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.

Accommodations 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.

Accommodations 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.

Treatment 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

Treatment 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.

Treatment 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.

Results 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

Results 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)

Documents

Cognitive Behavioral Therapy for School Refusal