Anxiety-related school refusal and working with parents Lauren Ehret, Ph.D., LP, and Julie Lesser, M.D. Rogers Behavioral Health–Minneapolis Minnesota School Psychologists Association Midwinter conference Plymouth, MN

Child / adolescent anxiety disorders: Phenomenology Childhood anxiety disorders are common. Lifetime prevalence = 31.9% for U.S. adolescents age 13-19 8.3% with severe impairment in major life roles such as being a student Numerous highly effective evidence-based behavioral and pharmacological treatments exist to treat these disorders, yet >80% of afflicted children fail to access such treatment. School personnel are uniquely placed to identify anxious youth and communicate information about how to proceed with parents. Ishikawa et al., 2007; Merikangas et al., 2010; 2011; & Strawn et al., 2015

Definition of school refusal Child-motivated refusal to attend school and/or remain in class for the entire day due at least in part to anxiety or mood problems… Not the same thing as truancy.

School refusal behaviors Entirely absent from school. Attends school but leaves during the day. Attends school but skips classes Go to school but have a lot of difficulty getting there due to crying clinging, tantruming Becomes distressed during the school day that leads to pleas for going home Often in the nurse’s office with psychosomatic complaints

NOTE: Not all school refusal is due to anxiety, but a lot of it is NOTE: Not all school refusal is due to anxiety, but a lot of it is. That will be the main focus of this presentation today. Taken from Kearney & Albano, 2004

School refusal vs. truancy Motivation Motivated by severe emotional distress.. Child is more concerned with not being at school than being at home. Goal is not to just “blow off” school. Would like to feel more comfortable at school and be able to attend. Surreptitious absences, motivated by pleasure, not anxiety-based, lack of emotional distress. Associated Features Separation, generalized, or social anxiety, somatic complaints, and/or depression. Not related to SES or academic ability. Linked with delinquency, academic problems, or social problems such as homelessness or poverty. Parent Role Parents are aware that the child is not attending. Child often persuades parents to try to not make them go. Child often tries to conceal absences from parents Function Escape, avoidance, or relief of negative emotions or unpleasant physical sensations Increase positive emotions Example Avoiding possibility of having a panic attack at school Excitement of skipping class to play videogames and smoke marijuana

Facts about school refusal Lifetime prevalence = up to 28% Community point-prevalence estimates = 8.2% Up to 56% of kids who refuse school have a primary anxiety disorder diagnosis Rates peak during transition years Entry into kindergarten, middle school, and high school Average age of onset = 10-13 years old Boys and girls are equally affected Unrelated to socioeconomic status (SES) No relationship with academic or intellectual ability Kearney et al., 2001; 2007

Interventions for school refusal Requires a collaborative team approach including: The child/adolescent Parents School staff Medical and mental health professionals Primary goal = return to school as soon as feasible

Interventions for school refusal Behavioral and cognitive behavioral therapy (CBT) Primarily exposure-based treatments Children learn to confront their fears and modify negative thoughts Includes parents and possibly educators reducing unhelpful accommodations for anxiety Medication management for contributing mental health disorders King et al., 1998; for reviews, see Kearney, 2006, & Fremont Pina et al., 2009

Role of educators Identify at-risk children Call parents – identify the problem and express empathic concern Set up a meeting with parents to problem-solve Functional behavioral assessment Implementation of reasonable IEP or 504 plan accommodations

Role of educators Consistently apply behavior plan established with the child/teen, parents, and mental health professionals. Example: Provide agreed-upon rewards/incentives for good attendance and remaining in the classroom Discuss concerns about need for higher level of care or alternative school setting in severe cases with parents Assist with reintegration into school

Tackling school refusal Order of operations: Assessment Providing education to the child and his/her parents about anxiety and school refusal. Collaborate with the child and his/her parents to develop a plan to help the child successfully ease back into the classroom. Discuss need for any additional outpatient health or mental health treatment resources. Continue to collaborate on school reintegration plan.

Starting assessment of school refusal behaviors Must assess if there is an actual ongoing safety threat at school. Examples: Severe bullying, physical or sexual abuse Assess for any actual ongoing medical issues that may be contributing Examples: asthma, frequent vomiting or diarrhea, sleep problems, chronic pain Identify the function of school refusal behaviors. What factors are associated with the onset and maintenance of school refusal? May involve use of empirically validated assessment tools “School Refusal Assessment Scale – Revised” – Kearney, 2002 When in doubt, ask the student and his/her parents!

Four functions of school refusal To escape from school situations that cause distress To escape from unpleasant social or performance situations To gain attention from others (i.e., parent) To pursue fun activities outside of school

Psychoeducation and parent training Psychoeducation about principles of CBT and how they can be applied to helping to decrease school refusal. Parent training to reduce accommodation of anxious behaviors, establish structure/routine, positive reinforcement and monitoring of symptoms Co-therapist model with parents Family based CBT, has evidence of increased efficacy in school-age children

Anxiety and school refusal: Cognitive behavioral model Physical Feelings/Emotions (abdominal distress, racing heart, anxiousness) Behaviors (tantrum about leaving for school) Thoughts (What if I throw up?)

Typical phobic scenario: Confrontation High (Anxiety Level) Low Trigger 60 sec 10 min (Time)

Typical phobic scenario: Escape / Avoid High (Anxiety Level) Low Escape! 60 sec 10 min (Time)

Exposure! High (Anxiety Level) Low Exposure Stick with it! Habituation 60 sec 10 min (Time)

Habituation Exposure High (Anxiety Level) Low Stick it out - no escaping or avoiding 1st 2nd 3rd 4th 5th 60 sec 10 min (Time)

Video!

School exposure hierarchy sample Distress Attend full day of school + work on completing all assigned homework 10 Attend full day of school (reduced work load) 9 Attend a half day of school + work on completing all assigned homework 8 Attend a half day of school that includes one difficult class (reduced work load) Attend 3 classes (1 easy and 2 medium difficulty) 7 Attend 1 “easy” class (i.e., band, gym) and one “medium” difficulty class (i.e., English) 6 Attend 1 “easy” class (i.e., band, gym) 5 Meet with the counselor during school hours while other kids are in class 4 Walk through the school hallways during school hours (more crowded) 3 Practice the school drop-off process during pick-up/drop-off time by enter the school and going to my locker. Do not go to an in-person class right afterward. Walk through the school hallways after school hours (less crowded) 2 Sit in the school parking lot in the car with my parents during pick-up/drop-off time

Developmental considerations Younger children: Adolescents: More directive approach Use age-appropriate language and metaphors Greater use of goal-setting and reinforcement Greater family involvement More collaboration in exposure selection More realistic discussion of risk More identification of feared consequence, and greater use of disconfirmatory evidence

Implementing exposure treatment Exposures are conducted together with client Processing after exposures Homework is assigned for self-exposures and ritual prevention As client habituates to situations, work up to top of hierarchy Maintenance and relapse prevention (i.e., living the exposure lifestyle)

Externalize the anxiety disorder Anxiety is externalized as an entity separate from the child/teen. “I am not my anxiety.” Young children can even give their anxiety a name (e.g., “Germy”) Therapy is conceptualized as a fight being waged against the anxiety by the child, therapist, family, and school staff. “Germy” By: A kid with OCD

Cognitive training with youth Developing ways to “boss back” to anxiety related to school refusal Positive self-statements Goal of cognitive strategies should be to help the child/teen tolerate and benefit from exposures and to increase motivation to get back in the classroom.

Helpful vs. unhelpful school accommodations Accepting absences as excused based upon having a medical condition makes it necessary for them to stay home. Working with parents and the child to define this. Continuously accepting anxiety-related excuses for children to stay out of school as excused absences. Collaborating with the child’s parents and medical and mental health providers on a school re-entry plan. Take a problem-solving approach. Suggesting home or online schooling because school is too stressful. Work with the child on using another strategy to manage his/her distress during the school day other than calling a parent or going home. Allowing students to go home from school when experiencing anxiety or physical symptoms accounted for by anxiety right away with no questions asked. Option to meet with a school counselor 1-2x/week Continuously allowing multiple daily trips to the nurse/counselor’s office NOTE: What is helpful for one child may be very unhelpful for another! Must collaborate with the child, family, and healthcare providers to determine appropriate expectations.

Working with parents in school Parents do not cause anxiety disorders! Parenting only accounts for 4% of the variance in childhood anxiety symptoms per recent meta analysis. Partner with parents to tackle school refusal behaviors through an agreed upon behavior plan rather than blame. Encourage parents to demonstrate compassion while not accommodating anxiety symptoms or being excessively harsh or critical. Help them identify mental health services McLeod, Wood, & Weisz, 2007

Treatment for school refusal: Role of parents Obtain necessary medical and mental health services Contingency management and developing written contracts Assist in implementing CBT treatment plan, especially facilitating completion of exposures Establishing regular morning and evening routines Make home as uncomfortable as possible if they stay home (i.e., no electronics) Provide attention-based consequences for school non-attendance Reducing excessive child questioning or reassurance seeking behavior Increase incentives for school attendance and decrease incentives for non-attendance Communicate effectively with school and healthcare providers. For a review, see Kearny 2006

Working with parents: Rationale for reducing accommodations Accommodation conflicts with goals of CBT Prevents habituation Limits opportunities for child to learn that feared consequences don’t happen Reduces child’s motivation to change Maintains rituals, escape, or avoidance behavior Increases stress for family and child Higher accommodation related to poorer treatment outcome for anxiety disorders.

Working with parents: Reducing accommodations Remove accommodation slowly and while apprising the child of changes Encourage parents to demonstrate compassion while not accommodating Help parents to separate disorder from child, and to reduce blame Boeding et al., 2013; Chambless & Steketee, 1999; Ferrao et al., 2006; Garcia et al., 2010; Storch, Merlo, Larson et al., 2008)

Strategies that do not help Advice Reassurance Distraction Avoidance Participation in escape/avoidance/ritual behaviors Punishing anxiety behaviors Taking control of therapy Surprise interventions

Who is going to do what: An example Situation Child Role Parent Role School Role Morning Routine Get out of bed. Get ready. Use coping card if needed Use empathy and encouragement. Make bedroom aversive. Possible phone call if reasonable per behavior plan. School Arrival Practice facing challenging but manageable feared situations (do assigned exposures) “Talk back” to anxiety (challenge thoughts) Use coping card. Empathize and encourage to face fears. Be directive but don’t solve problems. Remind of rewards. Allow for a school staff member to meet the child outside upon arrival per assigned exposure Collaborate with graded exposure hierarchy per treatment plan.

Reasonable excuses to miss school Persistent vomiting Significant bleeding due to acute injury Fever > 100° F Severe diarrhea Lice Acute flu-like symptoms Extreme medical conditions Example: intense pain due to recovery from a surgical procedure Only if intense medical symptoms are present! NOT physical symptoms better accounted for by anxiety.

When and where to refer Additional outpatient mental health treatment for the child and his/her parents Look for providers who adhere to evidence-based treatment guidelines For child/adolescent anxiety disorders, this means CBT. When to discuss higher level of mental health care or alternative school setting: Child is not making progress (or getting worse) despite parent, school, and outpatient mental health providers’ best efforts. Safety concerns: increasing self-harm and thoughts of suicide Threat of legal charges related to truancy

Discussing need for mental health treatment with parents Psychoeducation about childhood anxiety disorders and principles of CBT Instill hope by noting that we have treatments that are very helpful for reducing anxiety symptoms and helping their child get back in school. Reinforce the idea that their child’s anxiety is not their fault but that they are going to be very instrumental in their child’s recovery and school re-entry. Provide information on how to reduce accommodation of anxious behaviors, establish structure/routine, positive reinforcement and monitoring of symptoms Ally with parents when working on in-school behavior plan and when encouraging them to seek outside mental health treatment.

Pitching CBT to parents Outcome data for CBT and other treatments Theoretical rationale for treatment procedures Specific examples of how CBT might be applied Provide resources where they can learn more.

Other resources Books Helping School Refusing Children & Their Parents: A Guide for School-based Professionals – Christopher Kearney, 2008 Getting Your Child to Say “Yes” to School: A Guide for Parents of Youth with School Refusal Behavior – Christopher Kearney, 2007 Helping Your Anxious Child – Rapee, 2008

Other resources Organizational websites with links on finding a CBT provider: Anxiety and Depression Association of America (ADAA) School refusal information: https://adaa.org/living-with-anxiety/children/school-refusal Association for Behavioral and Cognitive Therapies (ABCT) International OCD Foundation (IOCDF)

References Kearney, C.A. (2008) School absenteeism and school refusal behavior in youth: A contemporary review. Clinical Psychology Review, 28, 451-471. doi: 10.1016/j.cpr.2007.07.012. Kearney, C. A., & Albano, A. M. (2007). When Children Refuse School: A Cognitive-Behavioral Therapy Approach – Therapist Guide, 2nd Edition. New York, New York: Oxford University Press. https://www.ncbi.nlm.nih.gov/pubmed/9549960 McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007). Examining the association between parenting and childhood anxiety: A meta-analysis. Clinical Psychology Review, 27, 155-172. doi: 10.1016/j.cpr.2006.09.002. http://www.jaacap.com/article/S0890-8567(09)61023-6/fulltext

Thank you! Questions?