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Nora Maynard

on 28 August 2014

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Mrs. Jones brings 7 year old Felicia in at your request.
“Mrs. Jones, I have had two calls from North Elementary school about Felicia. The nurse says that it is now December and Felicia has missed 30 days of school this year. The nurse says that Felicia has had multiple stomach aches. I think we need to find out what is going on here so that we can get Felicia in school on a regular basis.”
Treatment Goal = Get Felicia Back to School Soon....
& Returning on a Regular Basis
5. Anticipatory Guidance

Should follow the
growth curve
but deviate at the growth spurt
Keep communication open between parent & child re:
puberty changes
Breast development
: ages 8-11 (then axillary/pubic hair, menarche, & growth spurt)
Sexually-oriented play & masturbation are common in this age group
(Colyar, 2003)
Although school refusal occurs at all ages, it is
more common in children five, six, 10, and 11 years of age
(Fremont, 2003)

More common during
major changes
in children’s lives such as entrance to kindergarten or the change from elementary to middle school (Wimmer, 2004)

This is the age around which
children begin (or recently began) attending school all day

That might explain some of it, but if Felicia is 7 y.o. we can assume this is not her first exposure to school
Further clinical questions
for Mrs. Jones or Felicia?

Colyar, M.R. (2003).
Well child assessment for primary care providers.
Philadelphia: F.A. Davis Company
Hella, B, & Bernstein, G. (2012). Panic disorder and school refusal.
Child and Adolescent Psychiatric Clinics of North America, 21
(3), 593-606. Retrieved from https://www.clinicalkey.com/#!/ContentPlayerCtrl/doPlayContent/1-s2.0-S1056499312000478
Heyne D., Sauter F.M., Van Widenfelt B.M.,et al: School refusal and anxiety in adolescence: non-randomized trial of a developmentally sensitive cognitive behavioral therapy. J Anxiety Disord 2011; 25: 870-878
Fremont, W. (2003).

School refusal in children and adolescents.
American Family Physician, 68
(8), 1555-1561. Retrieved from http://www.aafp.org/afp/2003/1015/p1555.html
Kearney, C.A. (2006). Confirmatory factor analysis of the school refusal assessment scale-revised: child and parent versions. Journal of Psychopathology and Behavioral Assessment, 28(3), 139-144. doi: 10.1007/s10862-005-9005-6
National Center for Education Statistics . The condition of education 2006. US Department of Education; Washington, DC: 2006
Puzzanchera C, Stahl AL, Finnegan TA, Tierney N, Snyder HN (2003). Juvenile court statistics 1998. U. S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention, National Center for Juvenile Justice; Washington, D.C.
2. Assessment

1. Meet Felicia

4. Management

6. Age-Related Characteristics

7. Controversies & Culture

8. References

Why Do School Avoidance & School Phobia Occur in This Age?
Cultural Factors & Controversies
Strategies must take into account...
Symptom severity
Comorbid diagnosis
Family dysfunction
Parental psychopathology (Fremont, 2003)

Literature review:
Hella, B, & Bernstein, G. (2012). Panic disorder and school refusal.
Child and Adolescent Psychiatric Clinics of North America, 21
(3), 593-606
School refusal (more general information including other etiologies):
Fremont, W. (2003).

School refusal in children and adolescents.
American Family Physician, 68
(8), 1555-1561

"Children and adolescents will benefit from the clinician, parents, and school professionals (eg, teachers, school counselors, and principal) joining together as a
multidisciplinary team
to successfully implement interventions for school refusal" (Hella & Bernstein, 2012)
Complete medical history and physical
Clinical interview with child and parents
History of onset and development of symptoms
Associated stressors
School history
Family psychiatric history
MSE (including eval for psych problems & substance abuse)
Assessment of family dynamics and functioning
Collaboration with school staff
Review of school attendance records, report cards, and psychoeducational evaluations
Psychologic assessment tools (e.g., clinical rating scales, self-report scales, parent and teacher report instruments)

(Fremont, 2003)
What is School Refusal?
Child-motivated refusal to attend school and/or difficulty remaining in school for the entire day (Kearney, 2006)
Not a DSM diagnosis, but may be
of separation anxiety, social anxiety, or disruptive behavior disorder (Fremont, 2003)
May present with autonomic, GI, or muscular
symptoms (Fremont, 2003)
Long term
= academic underachievement, employment difficulties, and increased risk for psychiatric illness (Fremont, 2003)
3. Diagnosis
SRAS-R (Kearney, 2006)

24-item scale to help identify the primary
of school refusal behavior
Parent and child versions

4 sub-scales:
1. To avoid negative emotions
2. To avoid aversive social/evaluative situations
3. To be with parents
4. To gain better alternative

Sub-scale with the highest score will be of particular attention when it comes to management

Other Associated Terms/Differentials:
School refusal
Psychoneurotic truancy (old term)
School refusal behavior
School withdrawal

(Wimmer, 2004)
Developmental & Behavioral Considerations:
Erikson's Industry vs. Inferiority stage
Bandura's theory of Self-Efficacy
Focus on
rather than
intrapsychic conflict
(Fremont, 2003)
Emphasize treatment in the context of the family and school (Fremont, 2003)
Especially effective for anxiety-based school refusal (Hella & Bernstein, 2012)

CBT: shown to be effective for school refusal r/t panic disorder & agorophobia
-Highly structured approach
Systematic desensitization
-Child is taught
coping strategies
Relaxation training
Emotive imagery
Contingency management
Social skills training
Training in physiologic symptom reduction
Challenging negative cognitions
Preventing relapse
-Parent education
(Hella & Bernstein, 2012)

Clinical sessions w/ parents
-Teaching behavior-management strategies
Escorting the child to school
Providing positive reinforcement for school attendance
Decreasing positive reinforcement for staying home
-Parents also benefit - reduce their own anxiety & understand their role in helping their child
(Fremont, 2003)

Consultation w/ school personnel
-Specific recommendations to school staff to prepare for the child's return
-Use of positive reinforcement
-Academic, social, and emotional accommodations (Fremont, 2003)

In Heyne, et al's 2002 study, treatment outcomes were compared between of
individual therapy w/ the child,
adult (ie, parent and teacher) training,
child therapy plus adult training
in 61 school-refusing children (ages 7–14 yrs)
Children receiving
individual therapy alone
less well
with respect to school attendance, self-reported anxiety symptoms, and parent-reported symptoms
(Hella & Bernstein, 2012)
Not the sole intervention: should be used in conjunction
with behavioral or psychotherapeutic interventions

Limited studies

Fluvoxamine (Luvox) and sertraline (Zoloft) have been approved for OCD tx in children

may be prescribed w/ SSRI to target acute symptoms of anxiety
Once SSRI has had time to produce effects, d/c benzo
SEs & risk for dependence --> only use benzos for short duration

(Hella & Bernstein, 2012)
Behavioral Strategies
Parent-Teacher Interventions
Education & Consultation
Educational-support therapy
Combination of informational presentations and supportive psychotherapy
As effective as behavior therapy
in managing school refusal
Talk about their fears & identify differences between fear, anxiety, & phobias
Info is provided to help child overcome fears about attending school
Written assignments to be discussed at follow-up sessions
Daily diary to describe their fears, thoughts, coping strategies, & feelings associated w/ their fears
Unlike CBT, children do

not receive specific instructions on how to confront their fears or positive reinforcement for school attendance

Child therapy
: individual sessions that incorporate...
Relaxation training
Cognitive therapy
Social skills training

(Fremont, 2003)

This is the time when
dietary habits
can become ingrained!

Teach Felicia to
between nutritious food & junk food, and avoid non-nutritious food

No more than 2-3 cups of skim milk/day & regular balanced meals w foods from the 4 basic food groups

At least
3 nutritious meals & 2 healthy snacks /day

Involve Felicia
in the planning, shopping for, and preparation of meals

(Colyar, 2003)
Encourage participation in
safety equipment
avoid riding in the dark

Warn Felicia about risk of being lured away by
Practice scenarios of what to do if approached by a stranger
Felicia should also know to
dial 911
in case of emergency

If a
must be kept in the home, gun & ammunition should be
locked in separate cabinets
"Felicia, what if you encountered a gun
at a friends house
Mrs. Jones should be reminded to ask parents of the child's friends whether guns are kept in their home

Should be able to
brush her own teeth
; may still need help with
until ~8 y.o.

Annual dental visits

Flouride supplementation
if water levels inadequate

(Colyar, 2003)
Mrs. Jones should understand the importance of providing opportunities for Felicia to
become more independent
while also adding
new responsibilities

Praise & support
Felicia's activities, get to know the child's friends & their families, &
w/ their teachers

active time
w/ Felicia, teaching conflict resolution & actively listening

in the home

must be set &
e.g. loss of privileges & grounding, must be discussed

TV, video/computer games, high-fat/high-sugar foods

reading, adequate sleep, & extracurricular activities
(Colyar, 2003)
Dental Care
Growth & Development
Discipline & Parenting
Swimming / Playing in
of parents or responsible adult
swim in canals or fast-moving water

Safest place at this age is the
back seat
, w/ both lap and shoulder

(Colyar, 2003)
In the US, ethnic minority and low-SES groups are more likely to experience absenteeism than other youth.
(Puzzanchera, Stahl, Finnegan, Tierney, & Snyder, 2003; National Center for Education Statistics, 2006)

Other cultural factors
School & community culture / perceived value of education
Recent attendance scandals...absenteeism a bigger problem than what's reported?
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