Presentation on theme: "Anxiety-related school refusal and working with parents"— Presentation transcript:
1 Anxiety-related school refusal and working with parents Lauren Ehret, Ph.D., LP, andJulie Lesser, M.D.Rogers Behavioral Health–MinneapolisMinnesota School Psychologists AssociationMidwinter conferencePlymouth, MN
2 Child / adolescent anxiety disorders: Phenomenology Childhood anxiety disorders are common.Lifetime prevalence = 31.9% for U.S. adolescents age 13-198.3% with severe impairment in major life roles such as being a studentNumerous 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 classesGo to school but have a lot of difficulty getting there due to crying clinging, tantrumingBecomes distressed during the school day that leads to pleas for going homeOften 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 MotivationMotivated 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 FeaturesSeparation, 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 RoleParents 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 parentsFunctionEscape, avoidance, or relief of negative emotions or unpleasant physical sensationsIncrease positive emotionsExampleAvoiding possibility of having a panic attack at schoolExcitement 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 diagnosisRates peak during transition yearsEntry into kindergarten, middle school, and high schoolAverage age of onset = years oldBoys and girls are equally affectedUnrelated to socioeconomic status (SES)No relationship with academic or intellectual abilityKearney et al., 2001; 2007
8 Interventions for school refusal Requires a collaborative team approach including:The child/adolescentParentsSchool staffMedical and mental health professionalsPrimary goal = return to school as soon as feasible
9 Interventions for school refusal Behavioral and cognitive behavioral therapy (CBT)Primarily exposure-based treatmentsChildren learn to confront their fears and modify negative thoughtsIncludes parents and possibly educators reducing unhelpful accommodations for anxietyMedication management for contributing mental health disordersKing 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 concernSet up a meeting with parents to problem-solveFunctional behavioral assessmentImplementation of reasonable IEP or 504 plan accommodations
11 Role of educatorsConsistently 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 classroomDiscuss concerns about need for higher level of care or alternative school setting in severe cases with parentsAssist with reintegration into school
12 Tackling school refusal Order of operations:AssessmentProviding 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 abuseAssess for any actual ongoing medical issues that may be contributingExamples: asthma, frequent vomiting or diarrhea, sleep problems, chronic painIdentify 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, 2002When in doubt, ask the student and his/her parents!
14 Four functions of school refusal To escape from school situations that cause distressTo escape from unpleasant social or performance situationsTo 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 symptomsCo-therapist model with parentsFamily 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?)
22 School exposure hierarchy sample DistressAttend full day of school + work on completing all assigned homework10Attend full day of school (reduced work load)9Attend a half day of school + work on completing all assigned homework8Attend a half day of school that includes one difficult class (reduced work load)Attend 3 classes (1 easy and 2 medium difficulty)7Attend 1 “easy” class (i.e., band, gym) and one “medium” difficulty class (i.e., English)6Attend 1 “easy” class (i.e., band, gym)5Meet with the counselor during school hours while other kids are in class4Walk through the school hallways during school hours (more crowded)3Practice 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)2Sit 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 approachUse age-appropriate language and metaphorsGreater use of goal-setting and reinforcementGreater family involvementMore collaboration in exposure selectionMore realistic discussion of riskMore identification of feared consequence, and greater use of disconfirmatory evidence
24 Implementing exposure treatment Exposures are conducted together with clientProcessing after exposuresHomework is assigned for self-exposures and ritual preventionAs client habituates to situations, work up to top of hierarchyMaintenance 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 refusalPositive self-statementsGoal 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/weekContinuously allowing multiple daily trips to the nurse/counselor’s officeNOTE: 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 servicesMcLeod, Wood, & Weisz, 2007
29 Treatment for school refusal: Role of parents Obtain necessary medical and mental health servicesContingency management and developing written contractsAssist in implementing CBT treatment plan, especially facilitating completion of exposuresEstablishing regular morning and evening routinesMake home as uncomfortable as possible if they stay home (i.e., no electronics)Provide attention-based consequences for school non-attendanceReducing excessive child questioning or reassurance seeking behaviorIncrease incentives for school attendance and decrease incentives for non-attendanceCommunicate 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 CBTPrevents habituationLimits opportunities for child to learn that feared consequences don’t happenReduces child’s motivation to changeMaintains rituals, escape, or avoidance behaviorIncreases stress for family and childHigher accommodation related to poorer treatment outcome for anxiety disorders.
31 Working with parents: Reducing accommodations Remove accommodation slowly and while apprising the child of changesEncourage parents to demonstrate compassion while not accommodatingHelp parents to separate disorder from child, and to reduce blameBoeding 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 AdviceReassuranceDistractionAvoidanceParticipation in escape/avoidance/ritual behaviorsPunishing anxiety behaviorsTaking control of therapySurprise interventions
33 Who is going to do what: An example SituationChild RoleParent RoleSchool RoleMorning RoutineGet out of bed.Get ready.Use coping card if neededUse empathy and encouragement.Make bedroom aversive.Possible phone call if reasonable per behavior plan.School ArrivalPractice 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 exposureCollaborate with graded exposure hierarchy per treatment plan.
34 Reasonable excuses to miss school Persistent vomitingSignificant bleeding due to acute injuryFever > 100° FSevere diarrheaLiceAcute flu-like symptomsExtreme medical conditionsExample: intense pain due to recovery from a surgical procedureOnly if intense medical symptoms are present!NOT physical symptoms better accounted for by anxiety.
35 When and where to referAdditional outpatient mental health treatment for the child and his/her parentsLook for providers who adhere to evidence-based treatment guidelinesFor 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 suicideThreat of legal charges related to truancy
36 Discussing need for mental health treatment with parents Psychoeducation about childhood anxiety disorders and principles of CBTInstill 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 symptomsAlly 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 treatmentsTheoretical rationale for treatment proceduresSpecific examples of how CBT might be appliedProvide resources where they can learn more.
38 Other resourcesBooksHelping School Refusing Children & Their Parents: A Guide for School-based Professionals – Christopher Kearney, 2008Getting Your Child to Say “Yes” to School: A Guide for Parents of Youth with School Refusal Behavior – Christopher Kearney, 2007Helping Your Anxious Child – Rapee, 2008
39 Other resourcesOrganizational 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 ReferencesKearney, 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