1. Alexian Brothers Behavioral Health Hospital
School Refusal or School Anxiety: Differentiation, Cognitive Behavioral Treatment and School-Based Interventions
Patrick B. McGrath, Ph.D.
Licensed Psychologist
Director, Alexian Brother s Center for Anxiety and Obsessive Compulsive Disorders Program
Co-Director, Alexian Brothers School Anxiety / School Refusal Program
Alexian Brothers Behavioral Health Hospital

2. School Refusal or School Anxiety: Differentiation
Functional Model – Kearney and Silverman
Negative Reinforcement Function
Avoidance of Stimuli that provoke a Sense of Negative Affectivity
Avoid Unpleasant Feelings
Unable to Identify Specific Fear-Related Stimuli
Escape from Aversive Social or Evaluative Situations
Avoid Identified People and/or Activities in the Educational Setting
McGrath, 2011

3. School Refusal or School Anxiety: Differentiation
Positive Reinforcement Function
Attention-Seeking Behavior
Increased Gains by Staying Home
Pursuit of Tangible Reinforcement Outside of School
School Refusal – Video Games, etc.
McGrath, 2011

4. School Refusal or School Anxiety: Differentiation
Initial Function of Behavior May Not Be Function That Sustains the Behavior
Fluid
Overlap
McGrath, 2011

5. School Refusal or School Anxiety: Differentiation
Diagnoses
Incidence
Onset
Duration
Causes
Genetic
Environmental
McGrath, 2011

6. School Refusal or School Anxiety: Differentiation
Symptoms/Behaviors
Physical Symptoms
Educational Impact of Physical Symptoms
Avoidance Mechanisms
Secondary Gains
Situational Aspect of Symptoms
Frequency and Intensity of Symptoms
McGrath, 2011

7. Identification Anxiety Disorders are:
Highly prevalent (most common class of mental disorder)
Real & potentially disabling
Found in all groups of people
Under-recognized & under-treated
Variable in presentation
Treatable
McGrath, 2011

8. What is Anxiety?
Normal, natural, built in through evolutionary processes
Response to the perception of future threat or danger
We need this to prepare for future potential difficulties
Some anxiety is actually good for performance (Yerkees-Dobson)
McGrath, 2011

9. McGrath, 2011

10. What is Panic? Normal, natural, built in through evolution
Response to the perception of immediate threat or danger
We need this to protect ourselves from danger
McGrath, 2011

11. Panic continued Panic is our “Fight-Flight-Freeze” response
Natural selection selected out those that did not have this response system
It is an alarm reaction
Good in short bursts, problem if returns when there is no external cue for danger
McGrath, 2011

12. Anxiety Disorders
Our Fight, Flight, or Freeze system gets activated when it does not need to
The fear is perceived but, by most standards, is far less than it is judged to be
Everyday occurrences become overwhelming
Behaviors interfere with daily functioning
McGrath, 2011

13. McGrath, 2011

14. Cognitive Behavioral Therapy (CBT)
Active, problem-focused.
Focused on Emotions/Feelings.
Focused on Thoughts.
Focused on Behaviors.
Client-centered, collaborative.
Present-centered.
The basis of all therapy ever done.
All work is based on Stimulus-Response model.
McGrath, 2011

15. Cognitive Behavior Therapy for Anxiety Disorders
Correct misinformation and faulty threat appraisals
Teach adaptive (nonavoidant) coping skills
Contain maladaptive (avoidant) coping
Facilitate exposure and readjustment to feared situations
Teach relapse prevention
McGrath, 2011

16. Advantages of CBT Favorable long-term outcome
Inexpensive in the long run
Minimal side effects
Nondrug approach
McGrath, 2011

17. PET Scans
McGrath, 2011

18. PET Scans
McGrath, 2011

19. Disadvantages of CBT Inaccessible in many areas
Takes effort and time commitment
Some patients prefer medications
More expensive than medication in the short run
McGrath, 2011

20. Basic Assumptions of CBT
Attends to overt behaviors and cognitions.
Behavior is learned – it can be relearned.
Integrating cognitive and behavioral approaches is key.
To change current behavior, it is best to focus on the present.
The student’s presenting problems are the focus of treatment.
McGrath, 2011

21. Basic Assumptions… Effective therapy requires specific goals.
The counselor is active, directive, and prescriptive.
The counselor/student relationship is important, but not all that is needed for change.
Based on research and empirical data.
McGrath, 2011

22. How It Works
What is actually going on in a person’s life isn’t as important as their thoughts about it.
Social Support research supports this.
Perceived versus received (McGrath et al., 2000)
Other theories place a lack of control on the person we are working with, while CBT removes control totally – control is an illusion.
McGrath, 2011

23. How It Works
The focus is on how one thinks about a situation and how that thinking helps or hinders the progress in their lives.
Then, CBT designs behavior programs to assist the person in challenging those thoughts and developing new ones.
Behaviors are designed to assist a person in challenging the thoughts and the emotions.
McGrath, 2011

24. How It Works
Cognitive Dissonance is really at play here. If you think one way, then you will act that way to keep things in line. But, if you change behavior, then the thoughts have to change in order to preserve a balance, or cognitive dissonance will occur, and that is not comfortable.
Example: $1 versus $20
McGrath, 2011

25. Thoughts
Behaviors
Feelings
Depression
McGrath, 2011

26. Thoughts
Behaviors
Feelings
Depression
Action
McGrath, 2011

27. Thoughts
Behaviors
Feelings
Depression
Action
McGrath, 2011

28. What May Underlie Difficulties
Cognitive distortions and ways of behaving can get all mixed up into one. These are seen as typical “core fear” themes. The core fear is hypothesized as the motivator for the behavior. It is testable.
McGrath, 2011

29. Four Basic Fears Threats to the integrity of: * Physical Status
* Mental Status
* Social Status
* Spiritual Status
McGrath, 2011

30. Common Distortions Severity Probability Efficacy
It will be the worst thing in the world and I will die
Probability
It will definitely happen, no question
Efficacy
I will not be able to handle it
McGrath, 2011

31. Core Fears Subjugation Vulnerability to Harm or Illness
Sacrifice of one’s own needs constantly for the needs of others.
Vulnerability to Harm or Illness
Disaster can strike at any time.
Losing Self-Control
Fear of the involuntary loss of control.
Emotional Deprivation
My needs will never be met.
McGrath, 2011

32. Core Fears Continued… Abandonment Mistrust Alienation Worthiness
Loss of close people and eternal isolation.
Mistrust
People are basically mean and want to hurt me.
Alienation
I am different from everyone else.
Worthiness
I am flawed and totally unlovable.
McGrath, 2011

33. Core Fears Continued… Social Undesirability Incompetent Guilt
Outward (ugly, boring, bad at conversations).
Incompetent
One cannot perform to high enough standards.
Guilt
Person deserves ethical punishment - or - cannot be motivated without huge guilt feelings.
Dependence
Cannot function without the support of others.
McGrath, 2011

34. Avoidant Coping Based on misappraisal of threat
Intention is to avoid fear stimulus or the danger it signals
Precludes adequate exposure to fear stimulus
Does not allow a disconfirmation of the threat misappraisal
McGrath, 2011

35. Cognitive Behavioral Model for the Treatment of Anxiety Disorders: Maintenance
Fear Stimulus
Misinterpretation of Threat
Anxiety
Avoidant Coping
Absence of Corrective Experience
McGrath, 2011

36. Avoidance Continued
People go for short term relief, at a long term cost
Therapeutic anxiety prevention relies on short term discomfort with a person waiting that pain out until it goes away on its own
They realize that there are not long term negative effects of suffering through the exposure
McGrath, 2011

37. Case Conceptualization
Important part of CBT.
Begin with list of problems described in concrete behavioral terms.
Use automatic thoughts to get at schema.
Reformulate conceptualization early, as needed.
Share conceptualization with the client.
McGrath, 2011

38. Thoughts “make me”…..
Nothing makes you do anything, other than you (example of a comedian).
Thoughts are not good or bad, they are just thoughts. If a student comes in and says that they have bad thoughts and you agree, you are confirming that their thoughts really are bad. They may be disturbing to the student, but they are really just thoughts.
McGrath, 2011

39. Cognitive Restructuring
Questions to Ask:
Are these thoughts helpful?
Do these thoughts contain cognitive distortions?
Are these thoughts consistent with the evidence?
Are there alternate explanations?
What would one say to a friend in the situation?*
How did one learn to think this way?
McGrath, 2011

40. Exercises Pleasure Predicting Thought Records
Have students rate their expected level of enjoyment prior to an activity and then rate the actual level after the activity. See how good/bad they are at predicting their feelings (sheet)
Thought Records
Record negative or automatic thoughts throughout the day along with rational responses to the thoughts (sheet)
McGrath, 2011

41. Burns’ Feeling Good Techniques
Daily Activity Schedule
On hourly increments, rate your pleasure associated with an activity.
Antiprocrastination Sheet
Predict pleasure and difficulty of activities and rate afterwards.
Pleasure Predicting
Predict your amount of pleasure before an activity and then compare that to the actual pleasure after it.
McGrath, 2011

42. Thought Records Helps to teach cognitive model. Promotes change.
Questions to ask themselves:
Are these thoughts helpful?
Do these thoughts contain cognitive distortions?
Are they consistent with evidence?
Are there alternate explanations?
What would you say to a friend?
How did you learn to think this way?
McGrath, 2011

43. Exercises continued But-Rebuttal Ignoring – Removal of Reinforcement
People are great at making excuses for not following through on their behavior - list the Buts and then the Rebuttals until all illogical arguments have been rebutted. Ignore your student.
Ignoring – Removal of Reinforcement
If they start to get irrational, warn them, and if they continue, turn your back on them until they stop.
McGrath, 2011

44. The Anxiety Disorders Panic Disorder, with/without Agoraphobia
Obsessive-Compulsive Disorder
Social Phobia
Specific Phobia
Post-Traumatic Stress Disorder
Acute Stress Disorder
Generalized Anxiety Disorder
McGrath, 2011

45. General Notes
To be diagnosed with an Anxiety Disorder, there must be significant interference in a person’s social, occupational, or other type of functioning
I will list some tips about seeking professional help after each diagnosis
For Diagnosis, we use the “Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text-Revised (DSM-IV-TR)”
McGrath, 2011

46. Separation Anxiety Disorder
Developmentally inappropriate and excessive anxiety concerning separation from home or those to whom the individual is attached, evidenced by three or more of the following:
Recurrent distress when separation from home or attachment figures occurs or is anticipated
McGrath, 2011

47. Separation Anxiety continued…
Persistent worry about losing or harm befalling major attachment figures
Worry that a feared event will lead to extended separation (as in being kidnapped)
Refusal to go to school or elsewhere due to fear of separation
Refusal to be alone or without major attachment figures
McGrath, 2011

48. Separation Anxiety continued…
Fear of going to sleep without being near attachment figures or to sleep away from home
Nightmares with themes of separation
Complaints of physical symptoms when separation occurs or is anticipated
Lasts at least 4 weeks
Onset before age 18
Clinically significant impairment
McGrath, 2011

49. Separation Anxiety Fear Stimulus Misinterpretation of threat Anxiety
Avoidant Coping
Absence of Corrective Experience
Leaving parent
Some thing horrible will happen and I will never see them again
Increased anxiety
Fights going to school, plays sick
Does not experience handling being separated; maintains faulty beliefs
McGrath, 2011

50. School Anxiety: Signs for Getting Some Help
Withdrawal in behavior Sunday evening, in anticipation of school the next day.
Reassurance seeking that the caregiver will be safe and there to pick them up.
Stomachaches in the mornings.
Wanting to call home throughout the day.
McGrath, 2011

51. DSM-IV-TR Criteria for Panic Attack
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed and reached a peak within 10 minutes…
Palpitations, Sweating, Trembling, Shortness of breath, Choking, Chest pain, Nausea, Dizziness, Derealization or depersonalization, Fears of losing control, Fears of dying, Numbness, Chills or hot flashes
McGrath, 2011

52. DSM-IV-TR criteria for Panic Disorder
Recurrent unexpected Panic Attacks
One of the attacks is followed by one month or more and one or more of the following:
Concern about having future attacks
Worry about the implications of an attack
Change in behaviors related to the attacks
McGrath, 2011

53. DSM-IV-TR criteria for Agoraphobia
Literally “fear of the marketplace”
A strategy for coping with panic attacks by avoiding situations in which escape might be difficult or help may not be available
Often includes avoidance of:
A particular location/setting or being away from a safe place or a safe person
McGrath, 2011

54. Signs for Getting Some Help
Frequent visits to the ER or cardiologist
Feeling the need to have a safe person around or to stay in a safe place
Use of medications to get through situations
Fears of bodily sensations or changes
McGrath, 2011

55. DSM-IV-TR Criteria for Obsessive Compulsive Disorder
Either Obsessions or Compulsions or both
Obsessions:
Recurrent thoughts, impulses, or images experienced as intrusive and that cause anxiety or distress
Compulsions:
Repetitive behaviors or mental acts that a person feels compelled to perform in response to an obsession or according to rigid rules with the goal of neutralizing the obsession
McGrath, 2011

56. Signs for Getting Some Help
Rituals are taking up more than an hour a day
Other people are used for reassurance and completing rituals
You would be embarrassed if others knew what you were doing
It amazes you that others do things so quickly
McGrath, 2011

57. DSM-IV-TR Criteria for Social Phobia
Marked and persistent fear of one or more social or performance situations in which a person is exposed to unfamiliar people or to the possible scrutiny of others. They fear they will act in a way that is humiliating or embarrassing.
Exposure to the feared situation provokes anxiety
McGrath, 2011

58. Signs for Getting Some Help
It is hard to even write your name in front of others
You cannot use a urinal or toilet if others are around
Speeches make you change your major
You are always worried about what everyone else will think about you
McGrath, 2011

59. DSM-IV-TR criteria for Specific Phobia
Persistent excessive fear cued by the presence or anticipation of an object or event
Exposure to the object or event brings about immediate significant anxiety or panic
Recognition that the fear is excessive
The feared object or event is avoided or endured with great difficulty
McGrath, 2011

60. Signs for Getting Some Help
Driving, which is more dangerous than flying, is preferred
A picture of a snake sends you fleeing
Blood or needles cause you to pass out
All tall buildings are avoided, even if a relative lives in one
McGrath, 2011

61. DSM-IV-TR criteria for Post-Traumatic Stress Disorder and Acute Stress Disorder
Person has been exposed to a traumatic event in which both of the following were present:
Actual or threatened death or serious injury was witnessed or experienced
The response to that event was intense fear, helplessness, or horror
McGrath, 2011

62. PTSD and ASD continued Re-experiencing of the event
Avoidance of stimuli that trigger memories of the event
High levels of anxiety and arousal
PTSD if the symptoms last over one month
ASD if the symptoms last under one month
McGrath, 2011

63. Signs for Getting Some Help
Events from years ago still haunt you
Startle response is above what is helpful for most situations
You take a very long way to get to places to avoid passing a place where you witnessed a traumatic event
Constant nightmares
Person becomes withdrawn
McGrath, 2011

64. DSM-IV-TR criteria for Generalized Anxiety Disorder
Excessive anxiety and worry for more than 6 months about a number of events or activities
It is difficult to control the worry
3 or more of the following are present
Restlessness, fatigue, mind going blank
Irritability, muscle tension, sleep difficulty
McGrath, 2011

65. Signs for Getting Some Help
Difficulties in making even small decisions
Constantly worrying about minor events
Procrastination – it’s easier to wait until the last minute and just get it done than to do it early and have to think about it and revise it
Restricting other’s behaviors so that you do not have to worry about them
McGrath, 2011

66. Possibilities for Treatment
Set up home to be just like a school.
Consider truancy or short-term stay.
Intensive Therapy.
Consider a teacher change if the refusal is linked to one specific class or teacher.
Lighten the expectations a bit – reduce class load and then work up to a full load.
If a child has missed days, there has to be leniency with make-up work.
McGrath, 2011

67. School Refusal
Allow a phone call or two a day at set times, and then slowly increase the distance in time, then reduce to one call, and again increase the distance in time from arrival at school.
Keep a worry log that contains all of the students worries and have them write answers in it – they can refer to it throughout the day.
Daily free pass to the school counselor for a decreasing amount of minutes each few days.
McGrath, 2011

68. Mistake Practice Great for Social Phobia and Perfectionism.
Go out and purposely make mistakes:
Order a Whopper at McDonalds.
Go into Sears and ask where Sears is.
Drop a handful of pennies at the mall.
Call a person the wrong name.
Sneeze very loudly at a movie.
McGrath, 2011

69. Mistake Practice Goals
Learn that the feared consequences typically do not happen.
Even if it is a negative experience, they can handle it.
They get a realistic idea of how people will respond to them, not just what their worst case scenarios tell them.
McGrath, 2011

70. Exercises continued
Practice making mistakes - both you and your student
I point out my mistakes in therapy to my clients. I laugh at myself for pronouncing words wrong and tell them stories of failures. I show them that it’s human to make mistakes.
McGrath, 2011

71. Exercises continued Confront extreme statements:
This always happens...
I am horrible because…
I can’t do that…
They make me so crazy…
It just has to be that way…
No one will ever understand…
McGrath, 2011

72. Exercises continued Role Play
Criticisms; both giving them and receiving them.
Compliments; both giving them and receiving them.
Future events; allows for practice before confronting a fear.
Beware doing past events - approach it in a “how to try again” mode, not “how you failed.”
McGrath, 2011

73. Examples
Why didn’t I finish that assignment today? “I don’t think I am good enough.”
THEMES: “I have to be the first one done to be accepted and I have to be perfect.”
RESTATEMENT: “Others that are not the first ones done are still good people, and no one in this class has a perfect grade on everything.”
McGrath, 2011

74. More Examples
Or, instead of a RESTATEMENT, have the student say to themselves:
“This is just an anxiety thought and I do not need to answer it or give it power.”
“While it may feel good to talk through this thought now, it will just increase the chances of doing it more in the future.”
McGrath, 2011

75. The Student Buzzword FAIR/UNFAIR
The only judges of fair and unfair in interpersonal activities are the people that are talking right there in the room (and both are giving their opinions). But, so many people want to just blame others with being unfair. This is not productive.
Whether or not people are being fair or unfair (whatever that means to them) matters little. What matters is the reaction to a situation.
McGrath, 2011

76. Don’t Try Harder, Try Different
“Should” is not a helpful word.
“Can’t” versus “won’t”.
Practice does not make perfect, it makes routine.
Control is an illusion.
Specialness.
Everything in the world is neutral.
All that there really is is perception or interpretation.
Avoidance/Reassurance seeking maintains and increases anxiety. *
Short-term versus long-term.
McGrath, 2011

77. Self Talk versus Other Talk
Take a situation where a student puts themselves down and then ask them what they would tell their parent/best friend/sibling who was in the very same situation.
Typically, you get two different stories. Why is it OK to put yourself down but not others?
McGrath, 2011

78. Self/Other Talk continued…
Two Assignments
Try today to treat yourself as if you were your best friend and talk to yourself as if you were him/her for the rest of the day.
Paradoxical Intervention: Today go out and treat everyone like you treat yourself – psychologically beat them up and call them the names that you call yourself and see how many friends you have left at the end of the day.
McGrath, 2011

79. Self/Other Talk continued…
Goals:
Get people to realize that positives work for them the way that they work for everyone else.
Get people to realize that negatives work for them the same way that they work for everyone else as well.
Seinfeld – George Kastanza’s “Opposite Man” idea – go out and live as if you were the opposite of what you are and see what happens.
McGrath, 2011

80. Schema Change Methods Historical test of schema. Core belief work:
Collect evidence to support new belief and contradict old beliefs (Vertical Arrow).
Positive Data Log: Track evidence to support balancing schema.
McGrath, 2011

81. Correction of a Potential Anxiety Disorder
Fear Stimulus
Next Presentation of Fear Stimulus
Misappraisal of Threat
Corrective Experience
Accurate Threat Appraisal
Anxiety
Adjustment of Threat Appraisal
Adaptive Emotional Response
Adaptive Coping
Adaptive Behavior
McGrath, 2011

82. Creating Exposures Almost anything can be made into an exposure.
Therapists need to decide what they are comfortable doing:
Looks, 45 Degree angles, Garbage cans
Bar soap, Mistakes, Toilets, Religion
Trains, Bridges
McGrath, 2011

83. Exposures continued…
I try to do the exposure with the student the first time.
Have them do it over and over – goal is habituation.
Continue to expose over days and weeks – beware of spontaneous recovery. There is very little symptom substitution.
McGrath, 2011

84. Worry Exposure
Worries are often an attempt to think of all of the negative events that may occur and then prepare for them.
Worries are also a cognitive experience, which is easier to deal with than a visual experience – prepare for the worst.
Worries are often used to control negative potential outcomes.
McGrath, 2011

85. Worry Exposure
Procrastination is a way to avoid having to think about what you have to do – if you wait until it is just about due, then you just do it and get it over with – no thinking about it before or after (as in how to revise it).
Example of how worries do not control anything.
Truth versus Belief exercises.
The meteor exercise.
McGrath, 2011

86. More Behavioral Approaches
Self-control therapy: Monitor and evaluate actions positively & reward self.
McGrath, 2011

87. Components of Session (Persons et al., 2001)
Orient student to structure of session
Check-in
Set agenda
Review homework
Work agenda
Periodic summaries
Assign homework
Summarize session & ask for feedback
McGrath, 2011

88. Bipolar – the New Bandwagon
There is typically not a distinct manic episode in children.
No idea of the prevalence in kids.
Called “Bipolar” because it is a mood issue, responds to mood medications, and insurance requires a diagnosis.
Relationship to School Anxiety.
McGrath, 2011

89. Obsessive Difficult Temperament
Irritability symptoms (negative mood, temper tantrums, oppositional, easily annoyed, tense, whiny)
Rigidity or Perfectionism (overly concerned about abilities, hard to shift tasks, impatient, sensitive to change or imperfection, negativism, avoidance of new situations)
McGrath, 2011

90. ODT continued…
Somatic symptoms (hard to sleep, fussy about foods, changing appetite, hard to soothe and easy to startle, agitated, mood swings).
Often come across as aggressive, procrastinators, or have to have things done their way. Frequent abdominal pain or headaches.
McGrath, 2011

91. Our Colleagues What if a colleague is a “client?”
“I have tried this already, it does not work.”
“This kid just needs some good parenting.”
“I see them more than you do each day – I know what needs to be done.”
“I have been teaching for ____ years and I think that I know what I am doing.”
“I just want to pass him and then he will be out of my hair.”
McGrath, 2011

92. Handling Our Colleagues
Ask them for their suggestions first and try to incorporate a few into the plan that you will be designing.
Let them know that you will be there to assist them and to model the new methods.
McGrath, 2011

93. Colleagues continued…
Create a friendly competition among a group of teachers – they can even self select the teams. Have each team come up with a method that they will utilize and have a standardized tool to evaluate across teams. This way the people that are on teams are invested in their method, and will not fear favoritism. Results may be accepted more this way.
McGrath, 2011

94. Colleagues continued…
Encourage a Behavioral View:
The student is acting in such a way to get something – for some reason the behavior is rewarding to the student.
What is the class or the teacher possibly contributing to the maintenance of the student’s behavior?
Is it only in her/his class?
Does it increase or decrease when attention is given?
McGrath, 2011

95. School-Based Interventions
Intervene Quickly
Approach
Understanding and Reassuring but Firm
Unified Collaborative Approach
Parents
School Staff
Encourage Comprehensive Physical Exam to Rule Out Organic Basis for Symptoms
McGrath, 2011

96. School-Based Interventions
“The Toolbox”
Pre- and Post-Referral
Coordinate efforts with Therapist
Behavioral Interventions
Coping Skills List
Anxiety Graph/Thermometer
Check-ins (1-5 Scale)
Breaks
Buddy System
McGrath, 2011

97. Books by Dr. McGrath

98. References Burns, D. D. (1999). Feeling Good. New York: Avon.
Friedburg, R. D. & McClure, J. M. (2002). Clinical practice of cognitive therapy with children and adolescents. New York: Guilford Press.
Garland, E. J., & Weiss, M. (1996). Case study: Obsessive difficult temperament and its response to serotonergic medication. Journal of the American Academy of Child and Adolescent Psychiatry, 35(7),
Kearney, C.A. (2001) School Refusal Behavior in Youth: American Psychological Association
McGrath, 2011

99. References
McGrath, P. B., Gutierrez, P. M., & Valadez, I. M. (2000). Introduction of the College Student Social Support Scale (CSSSS): Factor structure and reliability assessment. Journal of College Student Development, 41(4),
Masters, J. C., Burish, T. G., Hollon, S. D., & Rimm, D. C. (1987). Behavior therapy. Fort Worth: Harcourt Brace Jovanovich.
Persons, J. B. (1989). Cognitive therapy in practice. New York: W. W. Norton.
Reinecke, M. A., Dattilio, F. M., & Freeman, A. (2003). Cognitive therapy with children and adolescents. New York: Guilford Press.
McGrath, 2011

100. Recommended Readings Don’t Try Harder, Try Different (McGrath)
Dying of Embarrassment. Treatment for Social Phobia.
An End to Panic – or – Panic Attacks Workbook. Treatment of Panic and Agoraphobia.
When Once is not Enough. Treatment for OCD.
Feeling Good. Basic CBT for Depression
McGrath, 2011

101. Contact School Anxiety / School Refusal Cece Horan, Psy.D. ABBHH
Anxiety and OCD Program
Patrick B. McGrath, Ph.D.
McGrath, 2011