1. 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

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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 = 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

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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!

14. 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

15. 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

16. 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?)

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

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

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

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

21. Video!

22. 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

23. 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

24. 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)

25. 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

26. 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.

27. 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.

28. 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

29. 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

30. 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.

31. 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)

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

33. 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.

34. 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.

35. 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

36. 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.

37. 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.

38. 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

39. Other resources
Organizational websites with links on finding a CBT provider:
Anxiety and Depression Association of America (ADAA)
School refusal information:
Association for Behavioral and Cognitive Therapies (ABCT)
International OCD Foundation (IOCDF)

40. References
Kearney, C.A. (2008) School absenteeism and school refusal behavior in youth: A contemporary review. Clinical Psychology Review, 28, doi: /j.cpr 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. 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, doi: /j.cpr

41. Thank you!
Questions?