SCHOOL REFUSAL Presented by Valery Bailey MPA VP

SCHOOL REFUSAL Presented by: Valery Bailey, MPA, VP Operations Sonia Cohen, MSc, Marketing Director First Children Services

Prevalence is 2 -5% of enrolled students 3 Lifetime prevalence = 5% to 28%3 Occurs at all ages, but peaks at 5 -7, 11, and 144 • Equal between genders 5 • Females more anxiety-based • Males more for oppositional-based No known socioeconomic relationship 6 No known academic or intellectual ability relationship 6 DEMOGRAPHICS

RISK FACTORS Transition to new school, a new home, a new sibling, or sick parent Parent with anxiety disorders Family dysfunction Comorbid Conditions 7: • Separation Anxiety Disorder • Social phobia • Simple phobia • Panic disorder • PTSD • Major Depressive Disorder • Dysthymia • Adjustment disorder • Autism Spectrum Disorder

COMMON WARNING SIGNS • Frequent unexcused absences or tardiness • Absences on significant days (tests, presentations, physical education class) • Frequent requests to go to the nurse’s office despite no apparent signs of illness • Frequent requests to call home or go home during the day • Difficulty or resistance to getting out of bed in the morning to go to school despite no apparent signs of illness

1 2 Autonomic: dizziness, headaches, shakiness, palpitations, chest pains Gastrointestinal: abdominal pain, nausea, vomiting, diarrhea 3 Muscular: back pain, joint pain SOMATIC SYMPTOMS

Panic attacks Physical and verbal aggression EXTERNALIZING SYMPTOMS Avoidant behavior - refusing to get ready or running away Attention seeking behavior - crying, tantrums, suicide threats, self-harm Classroom misbehavior to force parent contact Missing the bus regularly

SYMPTOM TIMING Gradual onset Can Increase After Weekends Or Vacations Can increase at the beginning and end of the school year Can increase after stressful events at school or home Predictable patterns of absence

EARLY RESPONSE TO SCHOOL REFUSAL! • When symptoms begin, immediate action should be taken (recommended after three unexcused absences) • Consider allowing attendance to be systematically increased • Use a team approach to assessment and early intervention • Team should be multidisciplinary and include school staff, providers, and the family and student • Goals should be mutually developed and accepted • Participation of all parents/guardians/family members • Lower family stress levels • Remove all competing activities to school

ASSESSMENT Comprehensive assessment should include: CST evaluations (psychological, social, and learning), mental health/social evaluations, and a functional behavior assessment which includes: observation, interviews, review of medical and school records, and attendance history. Purpose of assessment is to identify the barriers to student attendance and develop a function based plan of intervention

TYPES OF INTERVENTIONS Cognitive Behavior Therapy Behavioral Intervention Plans (BIP) Goal Setting and Contracts Social Skills Training/Groups Parent Education/ Training Reentry Plans Pharmacological treatment

REENTRY PLAN TIPS FOR SCHOOL • Welcome the anxious student when he/she arrives at school • Provide a safe harbor with the counselor, nurse, or school psychologist where the student can go when feeling stressed or overwhelmed • Assign a peer buddy especially at recess or lunch to help a socially anxious student • Address school safety issues through antibullying and anti-violence initiatives • Issue personal invitations to events and activities to help the student feel welcome • Positive Reinforcement -praise and encourage the student and set up rewards for school attendance

REENTRY PLAN TIPS FOR SCHOOL Academic Interventions • Provide interventions and supports for students who have academic difficulties i. e. extra help, extended test times, etc. • Provide alternate test-taking environments • Address any sensory challenges the student may be experiencing • Show sensitivity to students with performance anxiety (reduce or eliminate the need for the student to give presentations or be called on) • Help the child become involved in getting organized for the school day

REENTRY PLAN TIPS FOR HOME • Encourage parents to set up regular evening and morning routines • Establish plan for parents for each step of getting their child from their bed to school • Help parents set up positive reinforcement plan for reentry steps • Work with parents to effectively respond to their child’s complaints about school, while clearly ensuring that the child attends school • Work with parents to monitor attendance, particularly for older students

Primary goal is early return to school Homebound instruction and home schooling will not resolve the problem Alternative programs and schools should be considered Enabling -the extra attention makes staying at home more attractive May mask the anxiety, but does not deal with the underlying anxiety May socially isolate the child and allow anxiety to strengthen ALTERNATIVE INSTRUCTION

IN-HOME SUPPORT Assessment of behaviors preventing school attendance Treatment planning with the home school district Function based strategies to improve school attendance Parent Training

TRANSITIONS PROGRAM § Full Day Programming § Therapeutic Environment § Counseling § Small Group Intruction § Behavior Analyst Consultation § Social Skills § Career Prep § Executive Functioning Skills § Life Skills

BEHAVIOR SUPPORT AFTERCARE TRANSITION PLANNING WHEN RETURNING TO HOME SCHOOL BEHAVIOR TECHNICIAN TO SUPPORT SUCCESSFUL TRANSITIONS BEHAVIOR PLANS TO PROACTIVELY ADDRESS ANY BARRIERS TO SUCCESSFUL TRANSITIONS

BEHAVIORAL HEALTH CONSULTATION Behavior Analyst and/or Licensed Mental Health Clinician Consultation School Refusal and Behavior Interventions Plans Positive Behavior Support in Schools (PBSIS) Psychological, Social, and Learning Evaluations Social and Emotional Learning Curriculum Specialized Classroom Design

BEHAVIORAL HEALTH SERVICES Group and Individual Counseling for Students with Emotional and Behavioral Difficulties Social and Psychoeducational Skills Groups Goal Setting and Monitoring Individualized, Evidenced-Based Interventions (ABA, CBT, PBS)

TRAINING AND EDUCATION SERVICES Parent/Family Education, Training, and Support • Individual Parent /Family Training and Education • Group Parent /Family Education and Support Staff Training and Professional Development • Various Mental Health and Behavior Topics Including Anxiety and School Refusal • Positive Behavior Support (PBS) • Social and Emotional Learning

Staffing Services • Behavior Technicians • One-to-one Aides Standard Home Instruction • Experienced Teachers in Educating Students with Anxiety Challenges • State certified teachers with proper content certification

REFERENCES 1. Kearney, C. A. (2008). School absenteeism and school refusal behavior in youth: a contemporary review. Clin Psychol Rev. 28(3), 451– 471. Published online 2007 Aug 3. doi: 10. 1016/j. cpr. 2007. 012 2. Fremont, W. P. (2003). School refusal in children and adolescents. Am Fam Physician. 68(8), 1555 -60. 3. Kearney, C. A. (2007). Forms and functions of school refusal behavior in youth: An empirical analysis of absenteeism severity. Journal of Child Psychology and Psychiatry, 48, 53 -61. 4. Ollendick, T. H. & Mayer, J. A. (1984). School phobia. In S. M. Turner (ed. ) Behavioral Theories and Treatment of Anxiety. New York: Plenum (pp. 36 -411). 5. King, N. J. & Bernstein, G. A. (2001). School refusal in children and adolescents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 197 -205. 6. Egger, H. , Costello, E. J. , & Angold, A. (2003). School refusal and psychiatric disorders: A community study. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 797 -807. Munkhaugen, E. K. et al. (2017). School refusal behaviour: Are children and adolescents with autism spectrum disorder at a higher risk? Research in Autism Spectrum Disorders, 41– 42, 31 -38.

FIRST CHILDREN’S PROGRAMS AND SERVICES FOR STUDENTS WITH ANXIETY AND SCHOOL REFUSAL For more information, please contact: (856) 888 -1097 referrals@firstchildrenservices. com www. firstchildrenservices. com