School refusal 2

What is school refusal?

Child-motivated refusal to attend school or difficulty remaining in class for a full day, often driven by severe emotional distress, anxiety, or depression

How is school refusal different from truancy?

Intention/motivation

-related to emotional presentation; fear, anxiety, depression, emotional distress (including bullying)

-truancy is more related to rebellion, anti-social tendencies, preference for other activities

emotional presentation

-accompanied by severe emotional distress, anxiety, or depression

level of family involvement/awareness

-parents know that children aren't going to school

Signs of school refusal

Frequent somatic complaints (headaches/stomachaches), especially before or during school

expressing negative/anxious feelings about school

behaviors outside of school (protesting, outbursts on school mornings)

refusal to get dressed or leave the house on school mornings

avoiding homework

big weekend mood shifts- fine on friday night but deteriorated on sunday night

behaviors when at school (asking to leave early)

constant trips to the school nurse

Avoiding classroom discussions

emotional and psychosocial challenges

increased irritability, clinginess, or emotional withdrawal

Are age and sex associated with school refusal?

Changes with age and race, not so much with sex. Different reasons as to why they don't want to go to school (e.g. females: social anxiety, perfectionism). Girls may be more affected.

More common ages 5-6 and 10-11

The four functions of school refusal

negative reinforcement

-avoid school-stimuli that provokes negative affectivity (general trigger)

-escape from aversive social/evaluative situations at school (more specific trigger)

positive reinforcement

-pursue attention from significant others

-pursue tangible reinforcement outside of school settings

Why is it important to assess and understand the specific functions of school refusal for a particular student?

Once you can identify the functions, that's when you can provide the most fitting interventions.

School Refusal Assessment Scale-Revised

Treatments for school refusal

early and multisystemic intervention

exposure therapy + response prevention

social skills training

alternative educational programs

engage parents

risk factors for school refusal

low family SES

mental health/disorders

low self-esteem or heightened sensitivity to school failure

learning differences

transition to a new school or environment

relationships difficulties school violence/victimization

school climate and connectedness

parents psychiatric

parent emotional dysregulation

problematic parenting practices

Treatments for General school related stimuli avoidance

Psychoeducation

CBT

Relaxation training skills (somatic management skills to decrease negative emotional arousal)

Systematic exposure to anxiety cues and create an avoidance and fear hierarchy

Reinforcement plan

Treatments for escape from aversive social/evaluative situations at school

Psychoeducation

CBT

Relaxation training skills (somatic management skills to decrease negative emotional arousal)

Cognitive restructuring to modify irrational thoughts

Practice coping skills in real-life social and evaluative situations

Gradual re-exposure to school setting useing anxiety and avoidance hierarchy

Reinforcement plan

Treatments for pursue attention from significant others

parent-based treatment

parent management training and focus on restructuring home environment

have parents identify and describe the school-day morning routine

teach parents to provide effective commands

establish consequences for school refusal behavior

establish rewards for attendance behavior, such as special time or shared activities

emphasis on daily routines and contingency management

Treatments for pursue tangible reinforcement outside of school settings

parent-based treatment

emphasis on restructuring home environment

assess reinforcers in the environment

remove reinforcers

develop a contingency plan to increase rewards for attendance to school and decrease rewards for absences

increase attendance monitoring

response prevention

make sure someone can't avoid the situation during exposure

School Refusal Assessment Scale-Revised

Lets us know school refusal function

What should the goal be when working toward full response prevention?

Eliminating all safety behaviors

Function: Avoidance of school-related stimuli (for known or unknown factors) that provoke negative affectivity, such as anxiety or depression

o Typical age range: all school-age children and adolescents

o For younger students: may have difficulty identifying the cause of their distress at school, but refuse to attend because of some discomfort there

o Discomfort may be related to transitional stimuli - between classes or periods, entry into school or a particular classroom, riding the bus

o Associated with Generalized Anxiety Disorder

o Associated with student somatic complaints, tardiness, pleas to parents for school non-attendance

Function: Escape from Aversive Social/Evaluative Situations

Escape from aversive social and/or evaluative situations at school

o Typical age range: older children and adolescents

o Students who have social difficulty interacting with peers or others at school

o Students who have difficulty with evaluative situations such as exams, oral presentations, recitals, athletic performances, eating in the cafeteria

o Associated with Generalized Anxiety Disorder and Social Anxiety Disorder

o Associated with shyness and withdrawn behaviors

Function: Pursuing Attention

o Pursuit of attention from others

o Typical age range: younger children

o Refuse school to remain home with parents or others

o School itself not aversive - child has preference to be home with parents, or at a parent's workplace

o Associated diagnoses include separation anxiety disorder and Oppositional Defiant Disorder (ODD) (excessive worry about separation from parents not always present)

o Associated behaviors include tantrums, running away from school, and noncompliance

Function: Tangible Reinforcement

o Pursuit of tangible reinforcers outside school setting

o Typical age range: older children and adolescents

o Refuse school to pursue more pleasurable activities outside of school

§ Assess engagement in other activities - such as TV, video games, spending time with friends, engaging in problematic or risky behaviors such as substance use

o Associated diagnoses include Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)

o Associated problems include family conflict and history of delinquent or rule-breaking behaviors

Understand treatments for school refusal.

early and multisystemic intervention

exposure therapy + response prevention

social skills training

alternative educational programs

engage parents

Risk factors for school refusal

Sociodemographic

low family SES

Psychopathological

mental health/disorders

low self-esteem or heightened sensitivity to school failure

learning differences

School factors

transition to a new school or environment

relationships difficulties

school violence/victimization

school climate and connectedness

Family factors

parents psychiatric

parent emotional dysregulation

problematic parenting practices

Conditions comorbid with school refusal

Internalizing disorders:

Separation Anxiety Disorder

Generalized Anxiety Disorder

Specific Phobia

Depression

Externalizing/Conduct disorders:

Oppositional Defiant Disorder

Conduct Disorder

Substance use

Assessments for school refusal

Anxiety and Related Disorders Interview Schedule for DSM-5, Child and Parent Version (ARDIS-5-C/P)

School Refusal Assessment Scale-Revised (SRAS-R) - Parent and Child Versions (Designed to help identify the primary function of a child's school refusal behavior.)

School Refusal Assessment Scale-Revised (SRAS-R) – Parent and Child Versions

Designed to help identify the primary function of a child’s school refusal behavior.