School Refusal What helps, and what is still needed? · 3 Quite typical of school refusal 1. Reluctance or refusal to attend 2. Usually at home 3. Severe emotional upset 4. Absence

1

School Refusal

What helps,and what is still needed?

May 2nd 2018

Dr David Heyne: [email protected]

Associate Professor, Leiden University Institute of Psychology

Absence of 0.5 yrs (across ages 7-11 )

--> 0.7 year delay in reading scores

--> 1.0 year delay in maths scores

(Carroll, School Psychology International, 2010)

Non-attendance puts youth at risk for school drop-out

(Christle et al., 2007)

Less likely to be employed 6 months after compulsory schooling

(Henry et al., 2012)

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Absenteeism often places a strain upon school staff (McAnanly, 1986)

Absenteeism affects teacher workload and morale

(Wilson et al., 2008)

e.g., monitoring attendance, deciding when to intervene, contacting parents, helping the young person keep up with schoolwork (Contessa & Paccione-Dyszlewski, 1981; Hersov, 1990; Heyne & King, 2004; Kearney & Hugelshofer, 2000)

Family functioning can also be affected by difficulty going

to school (e.g., Kearney & Bensaheb, 2006; McAnanly, 1986)

Sch

oo

l Att

end

ance

Pro

ble

ms

School Refusal

Truancy

School Withdrawal

School Exclusion

Sub-typing (school refusal / truancy)

Discouraged (e.g., Kearney, 2003; Lyon & Cotler, 2007)

▪ overlap between school refusal and truancy

▪ function is a better predictor than form (Kearney, 2007)

Sub-typing (school refusal / truancy)

Encouraged (e.g., Goodman & Scott, 2012; Hella & Bernstein, 2012)

▪ helps deal with heterogeneity/communication

▪ different r/ship with int/externalizing (Heyne et al., 2015)

▪ different risk factors identified (Egger et al., 2003)

▪ different interventions needed

School refusal

Truancy

Types of problematic absenteeism

School withdrawal

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Quite typical of school refusal

1. Reluctance or refusal to attend

2. Usually at home

3. Severe emotional upset

4. Absence of antisocial characteristics

5. Reasonable parental efforts

(Berg et al., Journal of Child Psychology and Psychiatry, 1969)

(Berg, Child and Adolescent Psychiatry, 2002)

School refusal

Avoidance BehavioursReported in the School Refusal Clinic

▪ locking self in toilet

▪ shaving head

▪ climbing on the roof

▪ waving a piece of wood

▪ jumping from the car

▪ threatening to harm self

▪ chicken noodle soup

School refusal

Truancy


School withdrawal

Quite typical of truancy

▪ Absence is willful (Williams, 1927)

▪ Absence without parent knowledge (Kahn & Nursten, 1962)

▪ Absence without parent consent (Galloway, 1985)

▪ Student conceals non-attendance (Berg, 1991)

▪ Student avoids home when absent (Berg, 1985)

▪ Missing school-time in situations not authorized by a medical practitioner and not sanctioned by parents, the school, or the law (Gentle-Genitty et al., 2015)

Truancy

4

School refusal

Truancy

5% (Berg et al., 1993; Egger et al., 2003)9% (Bools et al., 1990)17% (Berg et al., 1985)

School refusal

Truancy

School withdrawal


Quite typical of school withdrawal

▪ Withdrawal of the child because of the parents’ own needs (Kahn & Nursten, 1962)

▪ Condoned absence (Galloway, 1985) / Covert support for non-attendance (Blagg, 1987)

▪ Parent deliberately keeps a child home (Kearney, 2003)

School Withdrawal

School refusal

School withdrawal

"Peter’s mother, who suffered from agoraphobia, ardently desired that her son return to school; at the same time, she described the period during which he stayed with her at home as one of the happiest periods in her life."

(Christogiorgos & Giannakopoulos, J of Infant, Child, and Adolescent Psychotherapy, 2014)

School Withdrawal

School Refusal

Truancy1.6%5.8%

? %

0.5%

(Egger et al., JAACAP, 2003)

% of all

youth

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Prevalence Gender (F/M)* Average age

Unauthorized absence 10.7% (37) 54.1% / 45.9%

Truancy 0.6% (2) 0% / 100% 10.4 (range 7.9-13.3; SD: 1.6)

School refusal 2.6% (9) 55.6% / 44.4% 10.2 (range 7.9-13.3; SD: 1.9)

School withdrawal 5.8% (20) 60% / 40% 10.4 (range 7.9-12.8; SD: 1.3)

Combined type 1.7% (6) 50% / 50% 10.1 (range 8.5-12.9; SD: 1.7)

(Vuijk, Heyne, & Van Efferen, 2010; Kind en Adolescent)

School Attendance ProblemsRotterdam Primary School Children

School refusal

Truancy


School withdrawal

School

exclusion

School exclusion (Netherlands, 2016)

Excluded from sitting final exams

School exclusion (UK, September 2017)

Exclusion of youth with autism

School exclusion (USA, September 2017)

Higher rates of suspension and expulsion among African-American students

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1. Predisposing factors

2. Precipitating factors

3. Perpetuating factors

4. Protective factors

Assess -> Understand -> Respond

1. Predisposing factorsAnxious temperament

Parental distress

Isolated at school




News of mother’s illness

Increased academic requirements

Long break from school





Avoidance of worry while at school

Fear of questions about absence

Mother’s reinforcing responses


4. Protective factors




Supportive school staff

……………

YP’s connection with clinician

Assess -> Understand -> Respond Psssst, let me tell you something

about why I attended school ….

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We don’t have longitudinal data onthe factors that contribute to SR.

We can consider characteristics (correlates) of SRto understand more about possible contributing factors.

For example, an anxious school-refusing youthmay refuse to attend because of the anxiety.

Youth Family

Community

School

anxiety/depression

developmental factors

low self-efficacy

somatic complaints

absence

poor emotion regulation

negative thinkinglimited problem-solving

Going to school consists of 2 steps.

The 1st is to leave parents whom

children depend on or to leave home

where children feel comfortable.

Are there signs that the young person finds it hard to be away from their parents?

(Nishida et al., Acta Medica Okayama, 2004)

The 2nd step is to attend groups in schools, which they must join.

Primary school children

are stumbling at the 1st step,

and secondary school youth

at the 2nd step.

Are there signs that the young person feels disconnected, left out, lonely?

(Nishida et al., Acta Medica Okayama, 2004)





at the 2nd step.

Anxious attenders have more friends than anxious refusers (Ingul & Nordahl, 2013)

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at the 2nd step.

1/3 with SR are bullied (Egger et al., 2003; Havik et al., 2014)

This is the main reason for absence (Gren-Landell, 2015)





at the 2nd step.

Soc Anx Disorder: 67% SR adolescents (Bernstein et al., 2001);

Soc Anx Disorder: 65% SR adolescents (Heyne et al., 2011)

school refusal

“double dilemma”

social anxiety

(Heyne, Sauter, & Maynard, Moderators and mediators of

treatments for youth with school refusal or truancy, 2015)

Soc Anx Disorder: 67% SR adolescents (Bernstein et al., 2001);

Soc Anx Disorder: 65% SR adolescents (Heyne et al., 2011) Absence from

school reduces

the quality and

number of

opportunities to

increase social

interactions.

(Albano, Cognitive and Behavioral Practice, 1995)

Unhelpful coping / cognition• Problems seen as unsolvable (Place et al., 2000, 2002)

• Less cognitive reappraisal, more suppression (Hughes et al., 2010)

• More ‘overgeneralizing’ (Maric et al., 2012)

• More thoughts about personal failure (Maric et al., 2012)

• Low self-efficacy for answering peers’ questions (Heyne et al., 1998)

• Low self-efficacy perhaps maintaining school refusal (Maric et al., 2013)

unhelpful

parent psychopathologyparent overprotection

family functioning problems

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Parenting style

Intending to reassure a child with SR, unintentionally reinforcing the SR (Nienhuis, Schoolangst en schoolweigering bij kinderen, 2012)

Caring parent

providing

reassurance

Dependent child

seeking

reassurance

“complex cycle”

Parenting style + somatic symptoms

When a parent allows a ‘sick’ child to stay home, the child starts to feel better.

Then the parent may feel better about their decision to let the child stay at home.

Negative feelings and interactions are avoided.

(Nienhuis, Schoolangst en schoolweigering bij kinderen, 2012)

Parenting style + somatic symptoms

(Sheppard, Pastoral Care in Education, 2005)

problematic student-teacher relationshipunpredictability

bullying

isolationloneliness

academic problems

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Approach Positive Experiences and

Events

Avoid Negative Experiences and

Events

Push-Pull Effect

(Courtesy of W. Silverman)

Unhelpful thinking

Unfamiliar school

Social difficulties

High demands

Feeling unwell

Staff unaware

(Adapted from W. Silverman)

Spends time with

mum

Watches TV

Plays computer

gamesSleeps

Gets pizza delivered for lunch

Hangs out with peers

at mall


School Refusal Assessment Scale

functional categories

1: Avoidance of negative-affectivity provoking stimuli

e.g., “How often do you have bad feelings about going to school because you are afraid of something related to school (for example, tests, school bus, teacher, fire alarm)?”



2: Escape from aversive social/evaluative situations

e.g., “How often do you stay away from school becauseit is hard to speak with the other kids at school?”



3: Attention-seeking / separation anxiety

e.g., “How often do you feel you would rather be withyour parents than go to school?”

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4: Behaviour yielding positive tangible reinforcement

e.g., “When you are not in school during the week (Monday to Friday), how often do you leave the house and do something fun?”


Response to Intervention (RtI)

Tier 3

Intensive

Intervention

Tier 2

Targeted Intervention

Tier 1

Universal Intervention

(Skedgell & Kearney, Children and Youth Services Review, 2018)

Non-problematic absenteeism

Problematic absenteeism

Severe/chronic problematic absenteeism

Moderate problematic absenteeism1%, 3%, or 5% ?

10% or 15% ?

(Kearney & Graczyk, Child and Youth Care Forum, 2014)


Tier 3

Intensive

Intervention

Tier 2


Tier 1


Managing School Absenteeismat Multiple Tiers

(Kearney, 2016)

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Tier 3

Intensive

Intervention

Tier 2


Tier 1


Emerging school refusal: A school-based framework foridentifying early signs and risk factors

(Ingul, Havik, & Heyne, Cognitive and Behavioral Practice, accepted)


Tier 3

Intensive

Intervention

Tier 2


Tier 1


When Children Refuse School

(Kearney & Albano, 2007; new edition in 2018)


Tier 3

Intensive

Intervention

Tier 2


Tier 1


Aim of Treatment for School Refusal

▪ reduction …

▪ return …

▪ resumption …

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C – cognitions are targeted

B – behaviours are targeted

T – therapeutic relationship essential

Essence of CBT for School Refusal

▪ comprehensive; planned yet flexible

▪ requires collaboration & coordination

▪ preparation phase before implementation

▪ supports ‘transfer of control’

Essence of CBT for School Refusal

Common Treatment Elements(Across 5 English-Language CBT Manuals)

Last (1993)

Heyne & Rollings (2002)

Kearney & Albano (2007)

Heyne, Sauter, & van Hout (2008)

Tolin et al. (2009)

(Heyne, Sauter, & Maynard, Moderators and mediators of treatments for youth

with school refusal or truancy, 2015)

Common Treatment Elements(Across 5 English-Language CBT Manuals)

Individual format as opposed to group (5)

Consultation with school staff (5)

Between session tasks (5)

Graded exposure (5)

Family work on communication, problem-solving (4)

Treatment based on functions / case formulation (4)

(Heyne, Sauter, & Maynard, Moderators and mediators of treatments for youth

with school refusal or truancy, 2015)

unhelpful

Work with the young personcoping skills

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• I haven’t been well

• I’ve been doing a Monash school

• It’s none of your business

• I’ve been doing a herb course

• It doesn’t matter now. What’s been happening here?

• Our family was overseas

• ……..

Attendance Plans

▪ Importance of return to normal developmental contexts (Vasey & Dadds, 2001)

▪ Increase: “early full-time”, “early part-time”, “delayed” (Heyne & Sauter, 2013)

▪ “Early” increase in BT, CBT, psychodynamic, family-focused work (Heyne & Sauter, 2013)

▪ No empirical guidelines for “early full-time” vs “early part-time”; part-time may reduce drop-out (Last & Francis, 1988)

Increasing attendance: in theory Increasing attendance: in practice

1. Consider (school placement; preliminary exposure)

2. Decide (return type, steps, rewards, supports)

3. Arrange (lowered hurdles at school)

4. Start (with an ‘easily achievable challenge’)

5. Reinforce (effort as well as achievement)

6. Re-work the plan (in a relaxed fashion)

Imaginal Systematic DesensitizationVariations on a theme …

• Stay until 9.30, then 10.30, then 11.30 …

• Start at 2pm, then 1pm, then 12pm …

• Start with lunch, then work outward …

• Start with favourite class, then 2nd favourite, …

• Start full-time in library, then increase class time

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Work with parentsfacilitating exposure

Parent response: 4 key attitudes

1. Work together, hope for best, prepare for worst

2. Remain kind and firm

3. → avoid FA (so-called family accommodation)

4. Watch and reinforce, both effort and success

United Approach

“… Mr Thomson hoped that negotiation with the school about timetable, along with firm reassurance to Frank, would obtain their son’s return to school. Mrs Thomson, however, believed it was necessary to spend hours each day with Frank, to offer him support and understanding”

(Bryce & Baird, 1986)

Attendance Plan

Staying in class all day

Staying in class 1 hour

Going into class

Going to school in AM

Going to school in PM

Getting in car on school-day

Meeting support person

Problem Behaviour

1. Won’t get out of bed

2. Screaming, cursing, tantrums

3. Locks him/herself in the toilet or bedroom

4. Refuses to leave house

5. …….

Positive Opposite

1. Out of bed before 7:00

2. Speaks in a respectful manner

3. Remains in living room after getting dressed

4. Rides in the car

5. …….

Positive parent attention


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Parent response: 4 key actions

1. Normalize anticipatory anxiety

2. Set the stage

3. Form a partnership with school support person

4. Investigate reports of feeling unwell

What I think:

Don’t want to go

They’ll laugh at me

It’s too hard

What I feel:

Heart beating fast

Butterflies

Flushed

What I do:

Make myself late

Beg not to go

Say I’m sick

• Adhere to ‘school day’ routine• Prepare for school the night before• Go to bed at age appropriate time• Wake up in the morning• Get dressed• Remove competing activities

Set the stage: routines


Approach Positive Experiences and

Events

Avoid egativeExperiences and

Events

• What are the unintended rewards?

• How can these be managed?

Set the stage: minimize ‘rewards’

‘The Rule’

The student must be in school or at the doctor’s office during school hours. Physical complaints are not ignored; they are acknowledged as present but insufficient for missing regular activities. (Evans, 2000)

“I don’t feel good. Can I stay home?”

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How quickly should the young person return? And how firm should parents be?

Allow the young person to determine just when full-time attendance will be resumed (Patterson, 1965)

Rapid, enforced return managed by parents within a few sessions (Kennedy, 1965)

1. Pressure to the point of harshness (Klein, 1945)

2. Focusing on return interferes with therapy (Waldfogel et al., 1957)

3. Failing to insist on return feeds neurotic family patterns (Eisenberg, 1959)

4. Need compromise, adjust demands to the child’s capacity (Davidson, 1960)

5. Rapid, enforced return managed by parents in a few sessions (Kennedy, 1965)

6. Allow the YP to decide when attendance will be resumed (Patterson, 1965)

7. Child needs to lose a carefully constructed showdown (Leventhal et al., 1967)

8. Firmness is a support, not a hostile rejection of the YP’s needs (Hersov, 1985)

9. Precipitate a crisis; insist on the adolescent’s early return (Bryce & Baird, 1986)

10. Occasionally, forced attendance (Kearney & Bensaheb, 2006)

Allow the young person to determine just when full-time attendance will be resumed (Patterson, 1965)

Rapid, enforced return managed by parents within a few sessions (Kennedy, 1965)

Definitely Definitely Not

Hmm, it depends

1. Parents are responsible for getting the child to school.2. Parents need to be firm about school attendance.3. Parents can engage in physical escorting.4. There are contra-indications for physical escorting.

8 rigorous studies (6 RCTs, 2 QEDs)

– published (6) and unpublished (2)

– target: CBT (3), BT (1), CT (1), CBT+med (2), Rogerian (1)

– comparison: alternate (4), placebo (2), no-treatment (1), NS (1)

– conducted in Australia, US, England, Canada, Kuwait, China

– 399 youth (target intervention = 204, comparison = 195)

(Maynard, Heyne, et al., Research on Social Work Practice, 2015)

Systematic review & meta-analysis (SR)

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MEAN EFFECTS ON ATTENDANCE (PSYCHOSOCIAL) MEAN EFFECTS ON ANXIETY (PSYCHOSOCIAL)

Systematic review & meta-analysis (SR)

1. effect on attendance at post (an important goal)

2. no effect on anxiety at post (for the group)

• for some, ↓ anxiety may help ↑ attendance

• for others, ............. may help ↑ attendance

3. medication does not seem to improve effects

4. lack of rigorous support for non-CBT treatment

(Maynard, Heyne, et al., Research on Social Work Practice, 2015)

1. @school program(Heyne & Sauter, 2013)

Mo

dif

icat

ion

s

prepost

follow-up

0

10

20

30

40

50

60

70

80

90

100

7-10

11-12

13-14

(Heyne, King, Tonge et al., JAACAP, 2002)

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severity (more seriously ill)(e.g., Eisenberg,1959; Waldron et al.,1975)

severity (absenteeism)(e.g., Hansen et al., 1998; Heyne, 1999; Prabhuswamy et al., 2007)

severity (school-related fear)(e.g., Burnham et al., 2006; Nair et al., 2013)

complexity (# and type dx; more oppositional)(e.g., Last & Strauss, 1990; Kearney, 1993; Berg & Collins, 1974; Nishida et al., 2004)

complexity (tasks and transitions)(e.g., Nishida et al., 2004; Rubenstein & Hastings, 1980)

complexity (family dynamics) (e.g., Heyne et al., 2014)

1. @school program(Heyne & Sauter, 2013)

Mo

dif

icat

ion

s

Developmentally-sensitive design

– extra modules for adolescents/parents

– extra module for family

– special role for parents

Developmentally-sensitive delivery

– ‘basic’ and ‘advanced’ cognitive therapy

– complex/concrete instruction/materials

Figure 1: Guide for sequencing and pacing modules with the young person.

Note: Solid squares indicate the common timing of module introduction and continuation; hatched squares indicate possible introduction or continuation of a module. Excerpt from: Heyne, D., & Sauter, F. M. (2013). School refusal. In C. A. Essau, & T. H. Ollendick (Eds.), The Wiley-Blackwell handbook of the treatment of childhood and adolescent anxiety. Chichester: John Wiley & Sons Limited.

Y5 Solving Problems

Y6 Managing Stress

Y8 Dealing with Social Situations (Optional)

Y9 Dealing with Depression (Optional)

Y4 Setting Goals

Y1/P1 Reviewing the Overall Plan

Y7 Dealing with Cognition

Preparation Phase Implementation Phase

1 2 3 4 5 6 7

Incr

ease

in S

cho

ol A

tten

dan

ce

8 9 10 11 12

Y3 Thinking about the Teenage Years (Optional)

Y2 Putting Problems in Perspective

Y11 Attending School

Y12 Promoting Progress

Y10/P10 Solving Family Problems (Optional)

Figure 2: Guide for sequencing and pacing modules with the parents.

Note: Solid squares indicate the common timing of module introduction and continuation; hatched squares indicate possible introduction or continuation of a module. Excerpt from: Heyne, D., & Sauter, F. M. (2013). School refusal. In C. A. Essau, & T. H. Ollendick (Eds.), The Wiley-Blackwell handbook of the treatment of childhood and adolescent anxiety. Chichester: John Wiley & Sons Limited.

P5 Reducing Maintenance Factors

P6 Giving Effective Instructions

P8 Bolstering a Young Person’s Confidence

P9 Bolstering a Parent’s Confidence (Optional)

P4 Setting Goals

P1/Y1 Reviewing the Overall Plan

P7 Responding to Behavior

Preparation Phase Implementation Phase

1 2 3 4 5 6 7

Incr

ea

se in

sch

oo

l a

tte

nd

an

ce

8 9 10 11 12

P3 Thinking about the Teenage Years (Optional)

P2 Putting Problems in Perspective

P11 Facilitating School Attendance

P12 Promoting Progress

P10/Y10 Solving Family Problems (Optional)

autonomy-granting

(‘supportive’)

authoritative

(‘steering’)

2. Extra attention to social factors

Mo

dif

icat

ion

s

Longer treatment (Hudson et al., 2015; McShane et al., 2004)

Individual then group treatment (Albano, 1995)

Social skills; pharmacotherapy (Layne et al., 2003)

Greater flexibility at school (Heyne et al., 2011)

More intensive school-based intervention (Heyne et al., accepted)

Alternative settings (Kearney & Graczyk, 2014)

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Tier 3

Intensive

Intervention

Tier 2


Tier 1


3. LINK for chronic SR(Borghuis-Brouwer, Cognitive & Behavioral Practice, under review)

Mo

dif

icat

ion

s

• Alternative educational program

• Re-engagement with schooling

• Mental health services

• 6 – 12 months

• 10 students

4. CBT combined with fluoxetine(Melvin et al., Child Psychiatry Hum Dev, 2017)

Mo

dif

icat

ion

s

Background: Bernstein et al. (2000)

Design: CBT, CBT+FLX, CBT+PLA

Results: No differences; 54% Attendance at F-Up

Attachment

Attendance

Achievement

Child

Parent(s)

Family-School Attachment

School Refusal Truancy School Withdrawal

Attachment improves likely effectiveness of interventions focused on emotional distress (i.e., one less hurdle)

Attachment reduces a significant risk factor for the development and continuation of

truancy

Attachment, for parents and youth, is central to prevention and intervention for school withdrawal

Facilitating Parent Engagement(Tips from School Staff)

▪ Friendly face on arrival (front desk, office staff)▪ Take time to listen to the parents’ perspective▪ Visit the home, be ‘on their turf’▪ Be available (after school; open-door policy)▪ Make telephone contact, also about positive things▪ Other communication (email, newsletters)▪ Invite parents to support/attendance meetings▪ Shared decision-making▪ Sausage sizzle, parent evenings▪ Help with the family’s physical needs

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Tier 3

Intensive

Intervention

Tier 2


Tier 1


1. Social difficulties

2. Emotional difficulties

3. Academic difficulties

4. Other, namely: ………………

School-based interventiontreatment ≈ lowering the (various) hurdles

School-based interventiontreatment ≈ lowering the (various) hurdles

12 year old girl with social anxiety

– able to carry her school-bag with her

– moved locker location

– involvement in structured peer activities

12 year old boy with adjustment difficulty

– a ‘drill’ on arrival at school to encourage a coping attitude & outline daily expectations

– a meeting at the end of the school day to provide social and tangible reinforcement

School-based intervention (preparation)

1. Clarify (coordinator, mentor, communication flow)

2. Decide which hurdles to lower; arrange arrival

3. Prepare students and staff

4. Offer support to parents (e.g., coaching)

School-based intervention (implementation)

5. Monitor distress and attendance

6. Have a plan for somatic complaints

7. Communicate with parents

8. Reinforce small steps for big achievements

Somatic complaints during school-time ...

– Let staff know about the results of the medical check-up

– Identify a safety space

– Consider when/how the student can leave class to go to the safety space

– Consider when the student can make contact with parents

– Support the student’s use of anxiety-management skills

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[email protected]

Questions & Comments

Documents

School Refusal What helps, and what is still needed? · 3 Quite typical of school refusal 1. Reluctance or refusal to attend 2. Usually at home 3. Severe emotional upset 4. Absence