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1/23/13
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Understanding School Refusal Behaviors: Strategies for School-‐Based Staff & Parents
Topics Covered 0 Who am I? 0 Goals of the Presentation 0 What are “School Refusal Behaviors?” 0 Functions of School Refusal 0 Treatment Approaches 0 Challenges Faced by Staff and Treatment Providers 0 Treatment Options in HRM
Who Am I? 0 Daniel Chorney, Ph.D.
0 Registered Clinical Psychologist 0 Owner/Psychologist @ Dr. Daniel Chorney & Associates
0 Dr. Jason Chatman, Dr. Alissa Pencer, Dr. Tricia Beattie, Dr. Lindsay Uman
0 Former IWK Anxiety Team Leader & Community Mental Health staff psychologist
0 Previous research in anxiety development and expression across the lifespan
0 Education: 0 B.A. Psychology – UBC 2004 0 M.A. Psychology – West Virginia University 2006 0 Ph.D. Psychology – West Virginia University 2009 0 Clinical Internship – Brown University 2009
Goals 0 1. Basic understanding of what constitutes school refusal (aside from the obvious!)
0 2. Ability to identify why a child is avoiding school
0 3. Ability to develop a basic school-‐based behavioral plan to help reduce non-‐attendance
0 4. Ability to identify & refer complex/severe situations to appropriate services
What IS Anxiety? 0 “a feeling of worry, nervousness, or unease about something with an uncertain outcome” – Oxford English Dictionary
Disclaimer! 0 Not all school refusal is due to anxiety. 0 Not all school refusal is due to anxiety. 0 Not all school refusal is due to anxiety. 0 Not all school refusal is due to anxiety. 0 Decinitely not all school refusal is due to anxiety
0 Anxiety sometimes becomes the ‘default’ when no one knows what to do
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Decinitions 0 “School Refusal Behavior(s)” 0 Child-‐motivated refusal to attend school and/or problems remaining in class for an entire day 0 Refers to a continuum of behaviors (next slide)
0 An umbrella term that subsumes constructs such as: 0 truancy (unexcused, non-‐anxiety based absence) 0 school refusal (anxiety-‐based due to separation, social, or generalized anxiety)
0 school phobia (older term rarely used now)
School attendance with stress and pleas for non-‐attendance
Repeated misbehaviors
in the morning to avoid school
Repeated tardiness in the morning followed by attendance
Periodic absences or skipping of classes
Repeated absences or skipping of classes mixed
with attendance
Complete absence from school during a certain period of time
Complete absence from school for an extended period of time
How Common Is It? 0 If including all behaviors from previous graphics, prevalence can be as high as 28% (Kearney, 2001) 0 Difcicult to quantify due to heterogeneous nature (some children miss some school, some drop out entirely, etc)
0 Community studies suggest approximately 8.2%
0 school refusal and truancy, not including those who attended with distress
0 School refusal behavior not closely linked to gender, race, or socioeconomic status 0 Typical age of onset is between ages 10-‐13 (middle school entry)
0 Dropout rates are more common in: 0 Males 0 Ethnic minorities 0 Children/families of lower socioeconomic status 0 Children with disabilities
Function Junction Four Primary Reasons (“Functions”) Children Refuse School
1. Avoid School-‐Related Stimuli That Provokes Negative Affectivity 2. Escape Aversive Social and/or Evaluative Situations 3. For Attention (Positive and/or Negative) 4. Tangible Rewards Outside of School
• Something bad • Socially anxious Anxiety
• Parental Attention • Fun Stuff at Home Rewards
#1 – Refusal Due to Anxiety 0 To avoid school-‐related school-‐related stress or stimuli that provoke negative affectivity (symptoms of dread, anxiety, depression, and somatic complaints that are negatively reinforced)
0 Translation: “Something at school makes them mad, sad, scared, or upset”
0 Examples: buses, cire alarms, gymnasia, playgrounds, hallways, classroom items, learning/academic issues
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Characteristics #1 0 Most often younger children (5-‐10 years old) 0 Often display difciculty with transitions due to fear 0 Can relax once in a place for extended time
0 Difciculty articulating what the source of fear is 0 “Something bad” will happen 0 Source is not actual/legitimate or reaction is excessive 0 E.g., they are not avoiding due to true bullying or true threat
0 More concerned with NOT being in school than being at home (Function #4)
Common Behaviors 0 Difciculty concentrating due to distress 0 Excessive crying or tearfulness 0 Fear of a specicic school-‐related object or situation 0 Feigned illness to avoid school/class/projects 0 Irritability, restlessness, tense 0 Vague physical complaints – head, stomach, nausea, fatigue 0 Sadness or withdrawal from peers and teachers 0 Shaky hands, voice, general nervousness/anxiety
0 Many of these behaviors are seen throughout all 4 functions of school behaviors (at times feigned)
#2 -‐ Refusal Due to Anxiety 0 To escape aversive social and/or evaluative situations at school (negatively reinforced)
0 Translation: “Feeling judged, evaluated, or put in front of an audience or peers makes them excessively shy/anxious”
0 Examples: Interactions with teachers, principals, and verbally or physically aggressive peers, tests, recitals, athletic performances, speaking or writing in front of others, or walking into class with others present
Characteristics #2 0 Typically slightly older (11-‐17 years old) 0 May show heightened anxiety in relation to one class or section of the school day
0 E.g., changing in front of others in PE, music class, drama, skips class on test/performance days, or when something is due
0 May have difciculty handing in assignments despite completing them
0 Pattern is often one of avoiding interactions with others 0 Eating lunch alone, escaping crowded places quickly, trying not to get called on in class (even if they know the answer)
0 Similar to Function 1 – goal is to get away from something distressing at school
0 Different from following functions (3/4) where goal is to get something positive outside of school
#3 -‐ Refusal Due to Rewards 0 To pursue attention from signiVicant others 0 Translation: “The commotion involved in missing school or just staying home is fun/exciting/rewarding/stimulating/enjoyable
OR I have hard being away from my parents” 0 Examples: 0 Attention from parents, extended family, overt noncompliance and deciance, tantrums, manipulative and oppositional behavior, stubbornness and resistance, guilt-‐inducing behaviors, physical symptom complaints still present, refusal to get ready/leave house in the AM,
Characteristics #3 0 Typically younger (5-‐10 years of age)
0 Deciance re: school in the AM (often tantrums or just verbal statements re: wanting to stay home
0 Stubborn, willful, manipulative, or guilt-‐inducing behaviors to try to stay home
0 Commonly seen behaviors: 0 Frequent calls home during the day 0 Desire for parents to attend school with the child or eat lunch with them (or at home)
0 Constant questions re: when pickup time is afterschool 0 Reassurance seeking behaviors (fear something bad may happen to parents when separated)
0 Running away from school to get home
0 May not “hate school” à more so concerned about being with parents
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Characteristics #3 Cont’d 0 Other separation difViculties may be present (sleepovers, birthday parties, baby sitters, etc)
0 Attendance pattern is typically tardiness/absence in the AM (due to difViculties mentioned)
0 Worry can form a component of behavior 0 Something bad will happen to parents OR me 0 “What if” my parents are in an accident 0 Can occur following major changes at home (hospitalization, moves, cighting/divorce, trafcic accident, etc)
0 Frequent feeling/desire to “check-‐in” with parents 0 Fear of being kidnapped at school or parents will forget them
0 Distress is focused on separation from parents, less about school 0 Will become deciant and oppositional in their behavior to succeed at staying home with parents
#4 -‐ Refusal Due to Rewards
0 Tangible rewards outside of school
0 Translation: “It’s more fun to be outside of school than in” 0 Examples: Enjoys sleeping in late, watching TV, playing Xbox/PS3, internet use (FB, etc), working at a job, getting into legal trouble, drug usage, sexual activity
Characteristics #4 0 Typically age 11-‐17
0 Attendance pattern = skipping individual classes, half-‐days, or full-‐days depending on severity
0 Often with friends who encourage the behavior 0 Boredom at school or lack of motivation (or learning issue?) 0 May frequently bring up dropping out or getting a job 0 Often will sleep in or stay home altogether with little regard for consequences
Treatment Approaches
Medical First 0 Physical complaints are often real (esp in the anxiety cases) and should ALWAYS be checked medically cirst
0 Asthma/respiratory illness 0 Allergies or irritable bowl/Crohn’s/celiac 0 Cancer/tumor 0 Sleep problems 0 Pain/discomfort during menstrual period 0 Diabetes
Medical First 0 Things to never ignore à ensure these are checked:
0 A temperature of 100 degrees or more 0 Frequent vomiting 0 Bleeding 0 Lice 0 Severe diarrhea 0 Severe clu-‐like symptoms 0 Intense chronic pain, sharp pain, etc
0 In some cases these would not necessarily mean non-‐attendance 0 E.g., mild nausea and diarrhea or vomiting in the morning
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Accommodation Gone Awry 0 Modifying the environment is never a problem in moderation 0 Many kids may require 1-‐2 changes to assist with achieving optimum academic output
0 E.g. 5 minutes to relax before a test, option to visit counselor 1-‐2x week
0 When accommodation(s) no longer help, are never enough, or only seem to make matters worse (for child and teaching staff)
0 E.g., doctors notes for missed exams, requiring presentations to be done in private, multiple daily trips to nurse/guidance/etc
• Something bad • Socially anxious Anxiety
• Parental Attention • Fun Stuff at Home Rewards
Identifying the Chain of Behaviors
Anxiety
Behaviors
Feelings/Emotions Thoughts
Order of Operations 0 Understanding the initial trigger/event/emotion can help identify a starting point
0 For many mental health concerns, increased awareness/education is a strong starting point
0 In some cases, children (and even adults!) are just acting on what makes sense given what their body and/or minds are telling them
• I feel sick that I have to go to school
• My head/stomach hurts
Physical
• I will be embarrassed • I am going to vomit at school
• I don’t want to go
Cognitive • Tantrum • Crying • Refusal to move • Running away • General avoidance
Behavioral
• I hate school! • I don’t want to go! • NO! • They can’t make me!
Cognitive
• I have to use the bathroom
• Now my stomach hurts and I feel sick!
• I’m shaking/angry
Physical • Crying • Hiding • Tantrum • Not getting on bus/out of door
Behavioral
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• Crying • Whining • Refusal to get out of bed or ready
Behavioral
• I don’t want to go! • Please don’t make me go!
• I want to stay home!
Cognitive • Sick and nauseous on way to school
• Frequent urination/diarrhea
Physical
Anxiety Based Treatment
• Creating Fear Stepladder
• Graduated exposure
Behavioral
• Reduce reassurance
• Realistic Thinking • Coping Cards
Cognitive • Calm Breathing
• Progressive Muscle Relaxation
Physical
www.anxietybc.com for detailed handouts
Behaviors 0 Slow, consistent, planned exposures
0 If a child can attend AM only, attend AM! 0 Build on 100 small successes instead of 2 hits, 1 miss 0 Don’t allow backslides or “all or nothing” approaches 0 If the child refuses to enter building, have them stand outside until anxiety subsides
0 Forward or Backward based approaches 0 Attending cirst classes then leaving after set time (adding time forwards) 0 Attending last class and leaving when school ends (adding time backwards)
Behavioral
Thinking 0 STOP Plan (Silverman & Kurtines, 1996)
S: Am I Scared or nervous about a certain social or performance situation? T: What Thoughts am I having in this situations?
O: What Other, more realistic thoughts can I have instead?
P: Praise myself for thinking more realistic thoughts.
0 Use “Coping Cards” (reminder cards) for frequently encountered situations
Cognitive
Physical 0 Daily practice of relaxation techniques
0 Remind children that no one can tell when they’re slowing their breathing – it’s private 0 Practice 3x daily – morning, school, evening
0 Remind everyone involved to NOT attend to external physical signs of anxiety
0 Crying, whining, etc will resolve by itself 0 Reassurance only provides attention to the anxiety and increases physical arousal
0 If it worked, the problem should be gone by now!! 0 Real ignoring vs. quasi-‐ignoring à Walk away entirely
Physical
The Other Side 0 School is not the only place for intervention 0 Parents and families can and need to play a huge part in helping overcome school refusal, regardless of the function
0 Anxiety Based 0 Focus on less protectiveness, reassurance, and allowing avoidance/escape behaviors to continue
0 Reward Based 0 Implementing a consistent behavioral plan to manage noncompliance/deciance and discontinue rewards for nonattendance (while rewarding attendance)
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Helping Parents Help Kids 1. Attend any/all orientation or welcome sessions held at the school
before the start of the school year (bring the child as well so they hear cirst hand)
2. Purchase all necessary school supplies and needs at least 1-‐2 weeks beforehand to avoid a last minute rush/panic
3. Go through any school bus routine if applicable (number of stops, times, what to do if missed, etc.)
4. Take the child to the school 1-‐2 weeks beforehand to become familiar with the school layout. Point out relevant classrooms, cafeteria, gym, library, playground, main ofcice and guidance ofcices. Ask the child if they have questions re: how to get from A to B, and offer to practice getting from place to place and who can help if they get lost.
Helping Parents Help Kids 5. Arrange for a meeting with school guidance staff/teachers if possible,
even a brief meet and greet so they know you’re available and where you are.
6. Start the school “routine” at least two weeks before school starts. This includes night/wake time, breakfast, clothing/eating – everything. This also reduces the stress of Day 1.
7. The night before school starts, have a relaxed conversation with the child about any last minute concerns they may have. Address each concern once, without reinforcing whining/crying/avoidance behaviors. 0 If necessary, create a cheat sheet or “coping card” for them outlining the problem
and solutions
8. Ensure parents plan for clexibility on the cirst day – not to pick them up, but to ensure they attend, be neutral and cirm (yet supportive) when requiring them to attend school.
• Something bad • Socially anxious Anxiety
• Parental Attention • Fun Stuff at Home Rewards
Screaming, crying, tantrums, physical complaints, constant statements re: staying home,
dawdling, refusing to move, hiding, deciance, noncompliance
Response to Child’s School Refusal Behavior
Yelling, Lecturing, criticism, negotiation, bribery, responding to statements and questions about wanting to stay home, comforting minor physical complaints, going to
school with the child
Parent Attention to NEGATIVE Behaviors Reinforces Child
Behavior
Child’s School Refusal Behaviors
Negative Attention Cycle
Getting ready for school, understanding what is expected, complaining less about having to go to school, walking into school with less fuss, calling less during the school day, being in
school without you
Parent behavior
Clear step-‐by-‐step morning routine, calm attitude, brief commands and reminders, praise and formal rewards for getting ready, ignoring and formal punishments
for not getting ready
Parent Attention to POSITIVE Behaviors
Reinforces Child Behavior
Child’s expected responses to parent behavior
Positive Attention Cycle
Behavioral Based Treatment 0 Insert structured morning routine 0 Ensure ample time to complete all steps without stress
0 List all the steps for all to see, assign estimated time for each step (then +5min, then +buffer time)
0 Focus on praising positives, ignoring negatives 0 Use attention to increase behaviors you want to see more of – “Thank you for listening!” or “You got ready so quickly, I’m so proud of you!”
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Behavioral Treatment 0 Formal rewards for attending
0 Access to friends, privileges, or tangibles for attending school or decreasing negative behavior in AM
0 Signed contracts with explicit expectations can assist with this 0 e.g. “For the privilege of seeing friends on the weekend, Daniel agrees to have no more than zero marked absences this week.”
0 Formal punishment for negative behaviors 0 Losing privileges for dawdling, tantrums, etc 0 E.g. losing TV/computer/phone time in the evening for twice the
amount of time the negative behavior occurred 0 Allowing privilege for “free time” – if ready for school early,
allow the extra time for TV or fun activities 0 Punishment should focus on removing what they want –
attention from you 0 Time in room, time-‐out for younger kids, removal of time with you
Behavioral Treatment 0 Clingy behavior
0 Have school staff meet parents outside & trade-‐off 0 Never ever let the child go home immediately – starting school at 10:30am is better than nothing
0 Flight risks – children who run 0 Increased monitoring in class, during breaks, and escorts between rooms/bathroom breaks 0 Have a plan for runs – notify police, if child comes home they are returned to school immediately 0 Ensure staff know when the child is legitimately absent
My Kid is Home – Now What? 0 Goal: Make home as aversive as possible 0 Child should remain in their room (if it is free of reinforcers) or a dull room for most of the day
0 School work should be completed, textbooks read, supplemental worksheets/essays provided
0 Even after school hours would be done, the child should be restricted from any reinforcers
0 Household chores completed, staying in room, complete restriction from Xbox, Facebook, friends, TV time, family time, or anything else that sends the message it’s OK to stay home
0 Harsh consequences are often necessary to send a clear message 0 Especially true in cases where the child is not “afraid” to attend school but rather “prefers” to stay at home or with parents
0 Compliment harsh consequences with equally large rewards for attending
When To Get Help 0 Impairment becomes daily, chronic, or severe – school, home, friends 0 When a family starts living life AROUND anxiety or behavioral problems 0 The list of “things to avoid” grows, or the family is constantly on edge 0 School, friends, family start noticing anxiety or noncompliance & deciance is more than “just a phase”
0 When you notice there have been multiple treatment providers, and it’s still an ongoing issue
0 When you’ve been thinking “they’ll grow out of it” for years 0 When it’s causing the family signicicant distress (you, your relationship(s), siblings, etc.)
0 Different families have different tolerance levels for distress
Review & Summary 0 What is anxiety and what is school refusal behavior? 0 What are the four primary reasons a child may be avoiding school (multiple functions of a behavior)
0 Can I create a basic school-‐based behavioral plan to help reduce non-‐attendance
0 Do I know where to get assistance in complex/severe situations
Resources 0 Professional Information 0 Private Practice(s) that focus on children & adolescents & evidence-‐based treatments such as CBT (www.chorneyandassociates.com)
0 IWK Treatment of Anxiety Group (Central Referral = 464-‐4110) 0 Family Service Association of Nova Scotia (fshalifax.com)
0 Websites 0 www.anxietybc.com 0 www.apns.ca (Find local psychologists) 0 www.teenmentalhealth.org
0 Books 0 Helping School Refusing Children and Their Parents: A Guide for School-‐Based Professionals (Kearney, 2007)
0 Getting Your Child to Say “Yes” to School: A Guide for Parents of Youth with School Refusal Behavior (Kearney, 2007)
0 Helping Your Anxious Child (Rapee 2008)
