Transcript School-refusal

School Refusal
Labels for children who have trouble
with school attendance
Truant
School phobic
School Refusing: a term used to describe a
child-motivated refusal to attend school or
to remain in school all day
Some Reasons for Refusal
• To escape uncomfortable peer interactions
– Break up with boyfriend/girlfriend
– Bullying
– Not “fitting in”/ self esteem issues
• Body image issues
• Gender dysphoria
Some Reasons for Refusal
• To avoid uncomfortable academic
situations
–Test taking
–Oral presentations
–Learning issues
Some Reasons for Refusal
• To receive attention from significant
others outside of school
–Parents
–Peers
• Fear that something will happen to a
parent after he/she is in school
Statistics
• 28% of school aged children in America refuse
school at some point during their education
• Prevalence: boys = girls
• Most common at times of transition to new
schools
• More prevalent in some urban areas
• Equal across socioeconomic levels
Presentation
•
•
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•
Entirely absent from school
Attend school but leave during the day
Attend school but skip classes
Go to school but have a lot of difficulty
getting there due to crying, clinging,
tantruming
Presentation
•Become distressed during school
days that lead to pleas for future
absenteeism
•Often in the Nurses office with
psychosomatic complaints
School Refusal Vs Truancy
School Refusal
Severe emotional
distress about
attending school; may
include anxiety,
temper tantrums,
depression, or somatic
symptoms.
Truancy
Lack of excessive
anxiety or fear about
attending school
School Refusal Vs Truancy
School Refusal
Truancy
Parents are aware of
absence
Child often tries to
persuade parents to
allow him or her to
stay home.
Child often attempts to
conceal absence from
parents.
School Refusal Vs Truancy
School Refusal
Truancy
Absence of significant
antisocial behaviors
such as juvenile
delinquency
Frequent antisocial
behavior, including
delinquent and
disruptive acts (e.g.,
lying, stealing), often
in the company of
antisocial peers.
Other reasons for absenteeism that would not be
considered “school refusal” because they are not
initiated by the child include:
Physical illness
Withdrawal that is motivated by parents
Sociological reasons such as homelessness
Family dysfunction can significantly
exacerbate the problem
The Apple Doesn’t Fall Far from
the Tree
• Parents of children with school
avoidance and separation anxiety
have an increased rate of panic
disorder and agoraphobia
• Often there is over dependency
• Often there are Communications
problems
Problems with roles/ boundaries
• Single-parent families
• Children who stay home because
they feel they need to care for a
parent who is physically ill,
psychiatrically ill, or substance
abusing
Most Common Psychiatric
Diagnosis
• Separation anxiety
• Social Anxiety Disorder (Social
Phobia)
• Panic Disorder
• Depression
Separation Anxiety
• Developmentally inappropriate and excessive anxiety
concerning separation from home or from those to
whom the individual is attached
– Child regularly complains about feeling sick or asks to stay
home from school with minor physical complaints
– Paralyzing fear of leaving the safety of their parents and home
– Persistent and excessive worry about losing, or about possible
harm befalling, major attachment figures
– May begin or worsens following a period at home in which the
child has become closer to the parent, such as a summer
vacation, a holiday break, or a brief illness.
– May begin following a stressful occurrence, such as the death
of a pet or relative, a change in schools, or a move to a new
neighborhood.
•
Separation Anxiety
Since the panic comes from leaving home rather than being in
school, frequently the child is calm once in school
Social Anxiety Disorder
• A marked and persistent fear of one or more social or
performance situations in which the person is exposed
to unfamiliar people or to possible scrutiny by others.
• The individual fears that he or she will act in a way (or
show anxiety symptoms) that will be humiliating or
embarrassing.
• Child has the capacity for age-appropriate social
relationships with familiar people
• The anxiety must occur in peer settings, not just in
interactions with adults.
Social Anxiety Disorder
• Often begins in early adolescence although
can start earlier during the elementary school
years.
• Students may avoid oral presentations or
speaking up in class
• They may avoid socializing with peers
• They may avoid eating in front of others
Panic Disorder
• Unexpected and repeated periods of intense
fear or discomfort
• Symptoms may include
– Racing heartbeat
– feeling short of breath
– Shaking
– Sweating
– Dizziness
– Fair of dying or losing control
Panic Disorder
• Children may begin to feel anxious most of the time,
even when they are not having panic attacks
• Some begin to avoid situations where they fear a
panic attack may occur, or situations where help may
not be available.
– A child may be reluctant to go to school or be
separated from his or her parents
– In severe cases, the child or adolescent may be
afraid to leave home.
Depression
• Child may look irritable rather than depressed
• May look “fine” in certain settings especially
with peers
• May have a sleep disturbance that makes it
difficult to get to school
• May have an increase or decrease in appetite
• Change in ADL’s
• Change in Peer group
• Isolative
Treatment
• Some times a brief period of Initial school refusal
behavior period may resolve on its own however if
the behavior lasts for longer than 2 weeks some form
of intervention is needed.
• Treatment strategies must take into account the
severity of symptoms, co morbid diagnosis, family
dysfunction, and parental psychopathology.
• A multimodal, collaborative team approach should
include the child, parents, school staff, and mental
health professional.
The longer the child stays out of school,
the more difficult it is to return
Interventions
RTI for Behavioral Support
School Wide Strategies for
Attendance
TIER I
• District Attendance Policy
– Monitored weekly for school wide absenteeism rate by
attendance coordinator
– Identifies at risk children
– Reward/Incentives for good attendance
Identify student
Phone call
home
5 day letter
Invitation to
meeting
RTI team
develops
intervention
TIER I
School Wide Strategies for
Attendance
• Bullying Prevention /Positive Behavioral
Support
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–
–
Steps to Respect (Committee for Children, 2005)
Olweus Prevention Program (Olweus et al., 2007)
Bucket Filler (McCloud, 2005)
Tribes (Gibbs, 2001)
TIER I
Family & Community
Strategies
Boys and girls club
• YMCA
Progress monitoring
• Parent/Educator
Encourage Afterschool involvement
• Athletic teams/clubs
• Assistance with classroom
Accessibility to computer labs
Breakfast – at times clothing
Workshop for parents
• “Setting Limits”
• Implementing a Family Schedule
• * Creates alliance with school, “How can we help you?” model
Functional Behavioral
Assessment
Data Collection
Interview of
Educational Staff
Observation
• Home
• Family
• School
• Referral source
• Support staff
• Social/academic
functioning
• Presentation
• AMvPM/AvB
Does the Student understand the
need for intervention?
FBA
SRAS-R
• Parent
• Child
Assessment
Tools
Conner’s III
Rating Scale
• Parent
• Self Report
• Educator
MAS
• Educator
• Support staff
Functions of School Refusal Behavior
4 Domains (Kearney & Albano 2007)
Domain 1
• Sensory
• To avoid negative affectivity
Domain 2
• Escape
• To escape social situations or evaluations
Domain 3
• Attention
• To gain attention
Domain 4
• Tangible
• To pursue tangible reinforcement
TIER II TIER III Interventions
Individual Interventions
Psycho
Education
Individual Interventions
Self Monitoring
Somatic Control Exercises
Individual Interventions
Cognitive Behavioral
Interventions
Individual Interventions
Exposure
Based
Practice
Habituation
Emotional
processing
Self-Efficacy
Individual Interventions
Secondary
Education
Enhanced Supervision
Schedule Modification
Coursework Modification
Safety Plan
Individual Interventions
Secondary
Education
Increased Involvement
Positive Behavior Support
Frequent Parent/School Meetings
Collaboration
Individual
Family
Community
Family Interventions
Contingency Contracts
• Incentives
• Should demonstrate success initially
Peer Refusal Role Playing
Lack of reinforcement
Morning/ Evening Schedule
• 90-120 minutes
• Meal, wash, dress and prepare
Individual
Outpatient
Family
• Services
• Referrals
Partial
Hospitalization
• Requirements
• Services
Returning from
OP/APHP
• Role Playing
• Scripting Educators
Community
School Refusal Behavior
Short Term
Long Term
Home Schooling
Accommodation
Risks/Benefits
Reintegration
References
Beidel, D.C., Turner, S. M., & Morris, T. L. (1995). A new inventory to assess childhood social anxiety
and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 7379.
Hibbett, A., Fogelman, K., & Manor, O. (1990). Occupational outcomes of truancy. British Journal of
Educational Psychology, 60, 23-36.
Kearney, C.A., & Albano, A.M. (2000). When children refuse school: A cognitive-behavioral therapy
approach/therapist’s guide. San Antonio, TX: The Psychological Corporation.
Kearney, C.A., (2001). School refusal behavior in youth: A functional approach to assessment and
treatment. Washington, DC: American Psychological Association.
Kearney, C.A., (2005). Social anxiety and social phobia in youth: Characteristics, assessment, and
psychological treatment. New York: Kluwer Academic/Plenum
Mennuti, R. B., Freeman, A., & Christner, R.W., (2006). Cognitive-Behavioral Interventions in
Educational Settings. New York: Taylor and Francis Group.