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Contact
Steven R. Fricke
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Treatment Approaches (see
chart)
Treatment varies
according to severity and onset of symptoms related to the school refusal
behavior. Favorable prognosis for treatment of chronic refusal appears related
to how quickly the student regularly attends some portion of school; mutual
agreement of goals by parents, school personnel, and other professionals;
participation of both parents in the treatment plan; decrease in family stress,
and the presence of contingency plans (Evans, 2000).
The American Academy
of Child and Adolescent Psychiatry (AACAP; King & Bernstein, 2001) recommends a
multi-modal treatment plan for children; with treatment components based on the
maintaining variables identified in the functional assessment process (Kearney,
2001; Elliott, 1999; Lee & Miltenberger, 1996). Consideration should be given
to the following components: education and consultation, behavioral
(exposure/return to school) or cognitive-behavioral strategies, family
interventions, and pharmacological interventions if warranted by severity of
symptoms (King & Bernstein, 2001).
The aim of these
strategies is to disconfirm negative beliefs and thoughts about
anxiety-provoking social situations following the
"Prepare-Exposure-Tests-Summarize" (P-E-T-S) model (Wells & Papageorgiou,
2001).
Behavioral Approaches
The following
behavioral approaches have proved to be most effective in reducing children's
anxiety:
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Systematic
desensitization:
involves
three main steps: (1) progressive relaxation training; (2) developing a
fear-producing stimulus hierarchy; (3) systematically graduated pair of items
on the hierarchy with relaxation techniques. This treatment may be more
successful with older children, because younger children may have some
difficulties in acquiring the muscular relaxation response with an image of
stressful stimulus (Terry, 1998; Lee & Miltenberger, 1996).
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Exposure therapy:
used to
treat negative emotional reactions (e.g., anxiety) and involves prolonged
exposure to anxiety-provoking stimuli or events until the fear response is
either extinguished or diminished (Greco & Morris, 2001). "In vivo" exposure
therapy involves a gradual reentry into feared social situations. Implosive
therapy or flooding is a rapid reentry. |
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Modeling:
based on
Bandura's social learning theory, modeling entails demonstrating nonfearful
behavior in the anxiety-producing situation and showing the child appropriate
responses for handling the feared stimuli. Three types of modeling have been
used with children including video modeling, live modeling, and participant
modeling. Participant modeling, in which the child observes a model perform
the desired behavior and subsequently performs the behavior with the aid of
the therapist, has been found to be the most effective of the three. Role
playing social situations with the child and providing praise and feedback on
the child's performance are also recommended as methods of teaching the child
social skills (Lee & Miltenberger, 1996; Terry, 1998).
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Cognitive Behavioral
Therapy (CBT)
Based on the theory
that faulty cognitive processing on the part of the individual may be a central
determinant of anxiety. With regard to school refusal, it is considered that the
child usually perceives an aspect of school attendance as threatening (either
harmful to the child in school or the caregiver at home) and feels that he or
she is incapable of managing the situation. By remaining at home, the problem is
avoided, anxiety is reduced, and school refusal is negatively reinforced
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Cognitive restructuring
teaches the child to identify and monitor self-statements that result in
anxiety. Thus, anxiety-provoking perceptions (e.g. ``The other kids in the
class will laugh at me if I answer a question incorrectly '') are contrasted
with alternative, more positive perspectives (``Everyone makes mistakes; the
others are unlikely to take much notice of mine'') and the child is shown how
such cognitions increase or decrease anxiety |
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Social skills training
may involve verbal and nonverbal skills that facilitate social effectiveness,
such as initiating and maintaining conversation, making appropriate eye
contact and asserting oneself appropriately |
Pharmacological Treatments
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Tricyclic
antidepressant (imipramine) - Tofranil |
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Selective serotonin
reuptake inhibitors (SSRIs) - Paxil, Zoloft, Luvox |
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Fluoxetine -
Prozac |
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Benzodiazepines (given on a short-term basis because of side effects &
addictive qualities, either alone or in combination with an SSRI or tricyclic
antidepressant)
- Ativan, Valium, Xanax |
Family Involvement
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(Elliott,
1999; Terry, 1998)
The parental role and
involvement is a crucial component in assisting the school with diagnosing and
remediating any fear the child may be suffering. It is critically important to
help the student recognize the benefits of positive and supportive family
communications and to let the child know the school and parents are working
together.
Role of the school
psychologist in working with families (Kearney, 2001; Kearney & Sims, 1997):
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assure the family
that they are not alone in experiencing children who refuse school and to
educate family members about school refusal. |
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train parents in more effective ways of interacting with their child (e.g.,
specifically, restructuring parental directives, establishing morning and
evening routines, and shifting parental attention away from school
nonattendance and toward attendance) |
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help to negotiate oral/written contracts among relevant family members
(usually the child and his or her parents) to provide the family with a method
of appropriate problem solving and to increase rewards for going to school and
decrease rewards for missing school |
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