School Refusal Labels for children who have trouble

School Refusal

Labels for children who have trouble with school attendance Truant School phobic School Refusing: a term used to describe a child-motivated refusal to attend school or to remain in school all day

Some Reasons for Refusal • To escape uncomfortable peer interactions – Break up with boyfriend/girlfriend – Bullying – Not “fitting in”/ self esteem issues • Body image issues • Gender dysphoria

Some Reasons for Refusal • To avoid uncomfortable academic situations – Test taking – Oral presentations – Learning issues

Some Reasons for Refusal • To receive attention from significant others outside of school – Parents – Peers • Fear that something will happen to a parent after he/she is in school

Statistics • 28% of school aged children in America refuse school at some point during their education • Prevalence: boys = girls • Most common at times of transition to new schools • More prevalent in some urban areas • Equal across socioeconomic levels

Presentation • • Entirely absent from school Attend school but leave during the day Attend school but skip classes Go to school but have a lot of difficulty getting there due to crying, clinging, tantruming

Presentation • Become distressed during school days that lead to pleas for future absenteeism • Often in the Nurses office with psychosomatic complaints

School Refusal Vs Truancy School Refusal Severe emotional distress about attending school; may include anxiety, temper tantrums, depression, or somatic symptoms. Truancy Lack of excessive anxiety or fear about attending school

School Refusal Vs Truancy School Refusal Truancy Parents are aware of absence Child often tries to persuade parents to allow him or her to stay home. Child often attempts to conceal absence from parents.

School Refusal Vs Truancy School Refusal Truancy Absence of significant antisocial behaviors such as juvenile delinquency Frequent antisocial behavior, including delinquent and disruptive acts (e. g. , lying, stealing), often in the company of antisocial peers.

Other reasons for absenteeism that would not be considered “school refusal” because they are not initiated by the child include: Physical illness Withdrawal that is motivated by parents Sociological reasons such as homelessness

Family dysfunction can significantly exacerbate the problem

The Apple Doesn’t Fall Far from the Tree

• Parents of children with school avoidance and separation anxiety have an increased rate of panic disorder and agoraphobia • Often there is over dependency • Often there are Communications problems

Problems with roles/ boundaries • Single-parent families • Children who stay home because they feel they need to care for a parent who is physically ill, psychiatrically ill, or substance abusing

Most Common Psychiatric Diagnosis • Separation anxiety • Social Anxiety Disorder (Social Phobia) • Panic Disorder • Depression

Separation Anxiety • Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached – Child regularly complains about feeling sick or asks to stay home from school with minor physical complaints – Paralyzing fear of leaving the safety of their parents and home – Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures – May begin or worsens following a period at home in which the child has become closer to the parent, such as a summer vacation, a holiday break, or a brief illness. – May begin following a stressful occurrence, such as the death of a pet or relative, a change in schools, or a move to a new neighborhood. •

Separation Anxiety Since the panic comes from leaving home rather than being in school, frequently the child is calm once in school

Social Anxiety Disorder • A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. • The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. • Child has the capacity for age-appropriate social relationships with familiar people • The anxiety must occur in peer settings, not just in interactions with adults.

Social Anxiety Disorder • Often begins in early adolescence although can start earlier during the elementary school years. • Students may avoid oral presentations or speaking up in class • They may avoid socializing with peers • They may avoid eating in front of others

Panic Disorder • Unexpected and repeated periods of intense fear or discomfort • Symptoms may include – Racing heartbeat – feeling short of breath – Shaking – Sweating – Dizziness – Fair of dying or losing control

Panic Disorder • Children may begin to feel anxious most of the time, even when they are not having panic attacks • Some begin to avoid situations where they fear a panic attack may occur, or situations where help may not be available. – A child may be reluctant to go to school or be separated from his or her parents – In severe cases, the child or adolescent may be afraid to leave home.

Depression • Child may look irritable rather than depressed • May look “fine” in certain settings especially with peers • May have a sleep disturbance that makes it difficult to get to school • May have an increase or decrease in appetite • Change in ADL’s • Change in Peer group • Isolative

Treatment • Some times a brief period of Initial school refusal behavior period may resolve on its own however if the behavior lasts for longer than 2 weeks some form of intervention is needed. • Treatment strategies must take into account the severity of symptoms, co morbid diagnosis, family dysfunction, and parental psychopathology. • A multimodal, collaborative team approach should include the child, parents, school staff, and mental health professional.

The longer the child stays out of school, the more difficult it is to return

Interventions

RTI for Behavioral Support

School Wide Strategies for Attendance TIER I • District Attendance Policy – Monitored weekly for school wide absenteeism rate by attendance coordinator – Identifies at risk children – Reward/Incentives for good attendance Identify student Phone call home 5 day letter Invitation to meeting RTI team develops intervention

TIER I School Wide Strategies for Attendance • Bullying Prevention /Positive Behavioral Support – – Steps to Respect (Committee for Children, 2005) Olweus Prevention Program (Olweus et al. , 2007) Bucket Filler (Mc. Cloud, 2005) Tribes (Gibbs, 2001)

TIER I Family & Community Strategies Boys and girls club • YMCA Progress monitoring • Parent/Educator Encourage Afterschool involvement • Athletic teams/clubs • Assistance with classroom Accessibility to computer labs Breakfast – at times clothing Workshop for parents • “Setting Limits” • Implementing a Family Schedule • * Creates alliance with school, “How can we help you? ” model

TIER II Functional Behavioral Assessment Data Collection Interview of Educational Staff Observation • Home • Family • School • Referral source • Support staff • Social/academic functioning • Presentation • AMv. PM/Av. B Does the Student understand the need for intervention?

FBA SRAS-R • Parent • Child Assessment Tools Conner’s III Rating Scale • Parent • Self Report • Educator MAS • Educator • Support staff

Functions of School Refusal Behavior 4 Domains (Kearney & Albano 2007) Domain 1 Domain 2 Domain 3 Domain 4 • Sensory • To avoid negative affectivity • Escape • To escape social situations or evaluations • Attention • To gain attention • Tangible • To pursue tangible reinforcement

TIER III Interventions Individual Family Community

Individual Interventions Psycho Education

Individual Interventions Self Monitoring Somatic Control Exercises

Individual Interventions Cognitive Behavioral Interventions Where’s the evidence?

Individual Interventions Exposure Based Practice Habituation Emotional processing Self-Efficacy

Individual Interventions Secondary Education Enhanced Supervision Schedule Modification Coursework Modification Safety Plan

Individual Interventions Secondary Education Increased Involvement Positive Behavior Support Frequent Parent/School Meetings Collaboration

Individual Family Community

Family Interventions Contingency Contracts • Incentives • Should demonstrate success initially Peer Refusal Role Playing Lack of reinforcement Morning/ Evening Schedule • 90 -120 minutes • Meal, wash, dress and prepare

Individual Outpatient Family • Services • Referrals Partial Hospitalization • Requirements • Services Returning from OP/APHP • Role Playing • Scripting Educators Community

School Refusal Behavior Short Term Long Term

Home Schooling Accommodation Risks/Benefits Reintegration

References Beidel, D. C. , Turner, S. M. , & Morris, T. L. (1995). A new inventory to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 7379. Hibbett, A. , Fogelman, K. , & Manor, O. (1990). Occupational outcomes of truancy. British Journal of Educational Psychology, 60, 23 -36. Kearney, C. A. , & Albano, A. M. (2000). When children refuse school: A cognitive-behavioral therapy approach/therapist’s guide. San Antonio, TX: The Psychological Corporation. Kearney, C. A. , (2001). School refusal behavior in youth: A functional approach to assessment and treatment. Washington, DC: American Psychological Association. Kearney, C. A. , (2005). Social anxiety and social phobia in youth: Characteristics, assessment, and psychological treatment. New York: Kluwer Academic/Plenum Mennuti, R. B. , Freeman, A. , & Christner, R. W. , (2006). Cognitive-Behavioral Interventions in Educational Settings. New York: Taylor and Francis Group.