Relapse Prevention and Special Circumstances

Chapter 8 describes slips and relapse and provides an overview of how to help children and families prevent a return to school refusal behavior. Activities to help with relapse prevention include taking photographs of the child during in vivo exposure practices; creating a poster, journal, or storybook of the child’s accomplishments using photographs of the child’s exposures; and asking the child’s help in producing a video “commercial” aimed at teaching other children how to overcome the problem of school refusal behavior. Special circumstances such as how to handle long breaks from school (like summer vacation) and starting a new school are discussed. For children with chronic or extremely severe school refusal behavior, relapse prevention can be challenging. A list is provided of key skills that older adolescents/young adults will need as they live independently or move away to college.

Introductory Information for Therapists

Chapter 1 introduces the primary focus of this treatment program—problematic school absenteeism. The authors use the term “school refusal behavior” as an overarching construct to represent an inability to maintain age-appropriate functioning vis-à-vis school attendance and/or to adaptively cope with school-related stressors that contribute to nonattendance. School refusal behavior refers to school-aged youths (5–17 years). The treatment program is based on a functional model of school refusal behavior that classifies youths on the basis of what reinforces absenteeism. The procedures are generally cognitive-behavioral in nature. The interventions are sensitive to age and cognitive developmental level as well as key developmental milestones that children and adolescents must achieve. The development of this treatment program and its evidence base, benefits, and risks are presented.

Children Refusing School for Attention

Chapter 6 describes treatment procedures for children refusing school for attention. Common behaviors in this functional group include noncompliance (refusing parent and/or teacher commands), overall disruptive behavior to stay out of school, clinging, refusal to move, tantrums, running away, constant telephoning or texting, and guilt-inducing behaviors. The major focus of treatment is the parents, and the major goal of treatment is to shift the parents’ attention away from school refusal behaviors and toward appropriate school attendance behaviors. Parents are taught to issue unambiguous commands to the child without insulting or lecturing. They are encouraged to set up and adhere to a morning routine is discussed. The importance of identifying and consistently applying rewards and consequences is emphasized.

Children Refusing School to Escape Aversive Social and/or Evaluative Situations

Chapter 5 describes treatment procedures for children whose anxiety in social and evaluative situations is so distressing that they cannot tolerate these situations, and avoidance behavior takes over. Treatment for children who refuse school to escape aversive social and/or evaluative situations involves teaching them to identify what they tell themselves in anxiety-provoking situations and how to replace negative thoughts with coping, helpful statements. The child will experience graduated exposure to anxiety-provoking social or evaluative situations in session with the therapist and will gradually increasing school attendance. An important part of treatment for this population is practicing coping skills in real-life social and evaluative situations. Special topics covered in this chapter are panic attacks, extracurricular activities, teasing, gym class, and perfectionism.

Children Refusing School for Tangible Rewards Outside of School

Chapter 7 describes treatment procedures for children who refuse school to pursue tangible rewards outside of school. Common behaviors in this functional group include secrecy to hide school absences, verbal and physical aggression, running away, spending an excessive amount of time with friends, disruptive behavior to stay out of school, hostile attitude, refusal to talk, drug use, and excessive sleep. The major focus of treatment is relevant family members, most likely the parents and the child (more likely adolescent) refusing school. The major goal is to provide family members with a better way of solving problems, reducing conflict, increasing rewards for school attendance, and decreasing rewards for school absence. Ways of improving family communication, solving problems by establishing and sticking to contracts, and dealing with peers are discussed. Special topics covered are 504 plans and individualized education plans, alternative educational placements, the need to involve law enforcement, and problems getting out of bed.

Consultation Session and General Treatment Session Procedures

Chapter 3 provides an overview of the recommended procedures during the consultation session. Suggestions are provided for summarizing assessment results and making treatment recommendations to the family. General considerations for each treatment phase in this therapist guide are discussed. An outline of the eight treatment sessions is provided. Recommendations are made regarding immediate, generic suggestions that can apply to parents and youths with all types of school refusal behavior.

Children Refusing School to Avoid School-Related Stimuli That Provoke Negative Affectivity

Chapter 4 describes treatment procedures for children whose school refusal behavior is motivated by a desire to avoid symptoms of dread, anxiety, panic, or depression associated with certain school-related stimuli. For these children, the main goal of treatment is to change avoidance behavior and build coping and active school attendance behaviors. Detailed descriptions of each session are provided, along with homework assignments. The child is taught skills such as relaxation and deep breathing. The use of medications for children with severe anxiety is discussed. Case vignettes and sample dialogues are included.

Tier 3 Interventions

Chapter 9 discusses Tier 3 cases, youths who have severe, chronic, and complicated absenteeism. Such students have often exceeded the legal limit for truancy, attend class sporadically when they do go to school, and/or frequently leave school prematurely. Attendance problems have lasted for months or years. Youths with Tier 3 problems have failing grades, few credits, and little knowledge of their current coursework. They are often socially detached and may display anxiety and oppositional behavior about the prospect of returning to school. Tier 3 attendance problems often involve deteriorating relationships between parents and school officials. Interventions include addressing comorbid problems and contextual variables, enhancing academic remediation and integration, establishing school attendance, and increasing parent and family involvement in school attendance. Intervention strategies may involve an expansion of the procedures described in this therapist guide, alternative educational schools and programs, specialized programs, and second-chance programs.

Assessment

Chapter 2 provides an overview of the recommended assessment process for youths with school refusal behavior. The purpose of formally assessing a child with school refusal behavior is to obtain answers to three critical questions: What is the behavior problem? What is maintaining school refusal behavior? and What is the best treatment for school refusal behavior? Recommended assessment methods such as interviews, child self-report measures, and parent and teacher checklists are presented. The chapter also presents descriptive procedures (such as questionnaires to initially identify variables that maintain school refusal behavior) and experimental procedures (in the form of observations to confirm the presence of these maintaining variables). Assessment forms and logbooks to record observations are provided.