Cognitive Behavioral Therapy for School Refusal

1. Cognitive Behavioral Therapy for School Refusal Scott Hannan, Ph.D.

2. 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.

3. 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.

4. Characteristics 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).

5. Characteristics 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

6. Characteristics of School Refusal • Other associated problems (McShane, Walter, and Rey, 2001): • Physical illness in parent • Psychiatric illness in mother • Psychiatric illness in father

7. 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)

8. Characteristics 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

9. Characteristics 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

10. 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.

11. 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)

12. 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

13. 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

14. 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: 9ratings (Very Much Below Average to Very Much Above Average) • Ages 8-19 • Scale 0 (never true) – 3 (often true)

15. 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

16. 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)

17. 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

18. 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

19. Assessment 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

20. Assessment 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

21. 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

22. 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

23. 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?

24. 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

25. 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.

26. Functional 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

27. Functional 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.

28. Functional 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!)

29. Functional 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

30. 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.

31. 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.

32. 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.

33. Treatment

34. 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!”

35. 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.

36. Treatment • Social skills training • Body Language • Eye contact • Body posture • Orientation of head and body • Movement of limbs • Facial expression • Voice quality • Volume • Tone

37. Treatment • 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.

38. Treatment • 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.

39. Treatment • 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

40. Treatment • 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.

41. Treatment • 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.

42. Treatment • 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.

43. Treatment • 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.

44. 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.

45. Treatment

46. Treatment

47. 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

48. 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.

49. 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.

50. 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.