Developmentally sensitive cognitive behavioral therapy for adolescent school refusal: rationale and case illustration

School Refusal Behaviors: The Roles of Adolescent and Parental Factors

School refusal behaviors in adolescents have deleterious immediate and long-term consequences and are associated with mental ill-health such as anxiety and depression. Understanding factors that place youth at higher risk of school refusal behavior may assist in developing effective management approaches. We investigated parental and adolescent factors that may be associated with school refusal behaviors by specifically focusing on the role of parental and adolescent emotion dysregulation, their anxiety and depression, and parental rearing style. First, we hypothesized that adolescents with school refusal behaviors, as well as their parents, will report higher levels of emotion dysregulation, anxiety, and depression compared to their counterparts without school refusal behaviors. Furthermore, we hypothesized that multivariate models testing the role of parental and child factors concurrently will show that parental (emotion dysregulation, anxiety and depression, and rearing styles) and adolescent (emotion dysregulation, anxiety, and depression) factors are associated with school refusal behaviors. One hundred and six adolescents aged 12 to 18 years and their parents completed an online questionnaire measuring both parental and adolescent emotion dysregulation, anxiety, depression, parental rearing styles, and adolescents' school refusal behaviors. Adolescents with school refusal behaviors reported greater anxiety and depression, with their parents showing greater emotion dysregulation. Multivariate analyses showed that parental emotion dysregulation and adolescent age were associated with school refusal behaviors independently. Future management for school refusal behaviors should consider age-tailored approaches by incorporating training for parental emotion regulation skills.

The Effectiveness of Modular Transdiagnostic Cognitive Behavioral Therapy Versus Treatment as Usual for Youths Displaying School Attendance Problems: A Randomized Controlled Trial

School attendance problems (SAPs) are associated with negative short- and long-term outcomes. Despite high prevalence of SAPs, there is a shortage of evidence-based interventions. Existing approaches often target either school refusal or truancy, leaving a gap in effective interventions addressing both types of SAPs. This randomized controlled trial (RCT) assessed the effectiveness of Back2School (B2S), a modular transdiagnostic cognitive behavioral therapy (CBT) for SAPs, compared to treatment as usual (TAU). Outcomes included youths' school attendance and mental health. A group (B2S, TAU) × time (Pre, Post, 3-Month Follow-Up) design involving 152 youths (B2S; n = 74, TAU; n = 78) with SAPs (i.e., ≥ 10% absence in the past three months), aged 6-16 years (M = 12.2, SD = 2.2, males = 60%) were used. B2S comprised three months of CBT with youths, parents, and school involvement, while TAU comprised public and/or private intervention services. On average, youths in B2S received 15.0, (SD = 3.9) hours of intervention, while those in TAU received 13.4, (SD = 21.6). Intervention effects were investigated using mixed linear models. Both B2S and TAU exhibited significant within-group improvements in school attendance, with no significant differences between them. However, the B2S group significantly outperformed TAU in reducing youths' emotional problems, conduct problems, problems with peers, the overall impact of problems, and increasing youths self-efficacy for attending school and parent self-efficacy for dealing with a SAP. This RCT represents the first evaluation of a modular transdiagnostic CBT for youths displaying SAPs, showing significant mental health and self-efficacy benefits.  (Clinical trial registration: ClinicalTrials.gov: NCT03459677).

Outcome of a Multi-modal CBT-based Treatment Program for Chronic School Refusal

School refusal (SR) can have several negative consequences, but effective treatments are available. When chronic, school absence requires comprehensive treatment. This study evaluates an intervention for SR based on a Cognitive Behavioral Therapy (CBT) model, Hemmasittarprogrammet (HSP). Attendance, anxiety, depression, quality of life, and emotional and behavioral symptoms were measured at pre-treatment, post-treatment, and follow-up. The participants (n = 84; 69% male) were SR students between 10 and 17 years old and their parents. School attendance increased after treatment and at follow-up. The proportion of students totally absent from school decreased and the number of students with an acceptable level of school attendance increased. Levels of anxiety and depression were lower both post-treatment and at follow-up for the youths and their parents. HSP, a promising treatment program for school refusal, builds on the literature of CBT-based programs, which has been shown to be effective for SR treatment. However, more research about the effectiveness of the program is needed. Future studies should have a stronger research design, include a measure of fidelity, and be evaluated independent of the founders of the program under investigation.

A Scoping Review of Constructs Measured Following Intervention for School Refusal: Are We Measuring Up?

Reviews of the effectiveness of interventions for school refusal (SR) rely upon well-conducted primary studies. Currently there are no guidelines for those conducting primary studies about the measurement of outcome following intervention for SR. Most people would agree that it is important to measure school attendance as an outcome but there has been little discussion about other constructs that warrant measurement. To facilitate this discussion and support the development of guidelines, we conducted a scoping review of constructs measured in studies evaluating intervention for SR. We screened the title and abstract of 3,213 publications found in peer-reviewed journals between 1980 and 2019. After full text review of 271 publications, 50 publications describing 51 studies were included. Results address the frequency with which constructs were measured, along with instruments used, informants, and time-points for measurement. Based on the results, we offer guidelines for choosing constructs to measure following intervention for SR and considerations for how to measure the constructs. Guidelines can increase consistency across primary studies, with benefits for future meta-analyses and international comparisons. They also provide support for practitioners contemplating routine evaluation of their interventions for SR. Ultimately, a core outcome set for SR can be developed.

Feasibility Study of Back2School, a Modular Cognitive Behavioral Intervention for Youth With School Attendance Problems

There is large heterogeneity among youth with school attendance problems (SAPs). For this reason, protocols for the treatment of SAPs need to be flexible. Back2School (B2S) is a new manual-based, modular transdiagnostic cognitive behavioral intervention to increase school attendance among youth with SAPs. It also aims to increase the self-efficacy of these youth and their parents. B2S includes evidence-based modules addressing youth anxiety, depression, and behavior problems, together with modules focused on parent guidance and school consultation. The current study examined the feasibility of evaluating B2S in an randomized controlled trial and acceptability of the B2S program in a non-randomized trial, including both qualitative and quantitative data, in preparation for a randomized controlled trial of its effectiveness. Youth, parents, and teachers completed questionnaires at baseline, post-intervention, and follow-up. School attendance data were collected from school registers. Twenty-four youth with a SAP (defined as more than 10% absenteeism during the last 3 months) were recruited from primary and lower secondary schools in Aarhus Municipality, Denmark. Their parents also participated in B2S. Two of the 24 families withdrew during the intervention, after sessions two and six respectively. Of the remaining 22 families, 19 (86%) completed all 10 sessions. Parents and youth rated their satisfaction with B2S as high, and high levels of satisfaction were maintained 1 year after the intervention. Teacher satisfaction was lower than that of youth and parents, but the majority found the school’s participation in the intervention helpful. Preliminary evaluation of intervention outcomes showed significant increase in school attendance and decrease in psychological symptoms, as well as a significant increase in self-efficacy for both youth and parents. Based on this feasibility data, adaptations were made to the B2S manual and study procedures prior to commencement of a randomized controlled effectiveness trial. The main adaptation to the manual was to increase school consultation. The main procedural adaptation was to broaden recruitment. Furthermore, it was necessary to increase level of staffing by psychologists because treatment delivery was more time consuming than expected.

Rapid Return for School Refusal: A School-Based Approach Applied With Japanese Adolescents

Cognitive behavioral therapy (CBT) is often effective in the treatment of school refusal (SR). Its usefulness is limited, however, if youth displaying SR also refuse to attend treatment sessions. In these cases parents and school staff may consider using school-based interventions that do not rely on face-to-face assessment and treatment with the young person. The current study examined the effectiveness of a school-based intervention applied in Japan to achieve rapid return to school among adolescents displaying SR. Between 2009 and 2015, the parents of 62 adolescents displaying SR were invited to implement a school-based rapid return approach. Thirty-nine parents agreed to implement the approach and 23 decided to wait until their child spontaneously attended school. Of the 39 cases in which the approach was implemented, 28 adolescents (72%) resumed attendance at their original school, 2 (5%) transferred to another school, and 9 (23%) did not resume attendance. In contrast, all 23 non-intervention cases continued to refuse to attend school for 3 months or longer, and none of these adolescents returned to regular school attendance within 9 months. This study tentatively suggests that the rapid return approach may be an effective form of intervention for adolescents displaying SR and simultaneously refusing to attend individual therapy. Because this approach is ethically complex, involving forced school attendance in adolescence, it should only be employed under specific circumstances. These circumstances are discussed.

School Refusal and Absenteeism: Perception of Teacher Behaviors, Psychological Basic Needs, and Academic Achievement

School refusal (SR) is a complex problem that may be caused by different risk factors such as individual and contextual factors (Kearney, 2007; Maynard et al., 2018; Heyne et al., 2019). These mechanisms can be described in the context of self-determination theory (SDT). For these reasons, the purpose of the present study is investigate the relationship between teacher perceived psychological control and support, psychological basic needs, SR behavior, and academic achievement, on adolescent sample. It is hypothesized that teacher perceived psychological control and autonomy support play a role on need frustration and need satisfaction; in turn, need satisfaction could reduce while need frustration could promote SR behavior and number of absences. Finally, SR behavior and number of absences could reduce academic achievement. 263 students (196 females, 67 males) with an average age of 16.14 (SD = 1.35; range 13-20 years). SEM analyses with observed variables have shown that the final model fit well the data, χ2(8) = 16.34, p = 0.04, CFI = 0.96, SRMR = 0.04, RMSEA (90% CI) = 0.06 (0.01; 0.10), showing the following significant path: need satisfaction was positively predicted by perceived teacher support and negatively predicted by teacher perceived psychological control; need frustration was positively predicted by teacher perceived psychological control; number of absences was negatively predicted by need satisfaction; SR was positively predicted by need frustration; school achievement was negatively predicted by SR and number of absences. These results have several implications for the school context and the deepening of the construct of SR and absenteeism.

The Back2School modular cognitive behavioral intervention for youths with problematic school absenteeism: study protocol for a randomized controlled trial

BACKGROUND

School absenteeism (SA) is associated with anxiety, depression, and disruptive behavior. It is a risk factor for academic difficulties and school dropout, which predict problems in adulthood such as social, work-related, and health problems. The main goal of this study is to examine the initial effectiveness of a modular transdiagnostic cognitive behavioral therapy (CBT) intervention (Back2School) for increasing school attendance and decreasing psychological problems, relative to a comparator control arm (treatment as usual [TAU]).

METHODS/DESIGN

One hundred sixty children, aged 7 to 16 years, will be randomly assigned to either Back2School or TAU. The design is a two (Back2School and TAU) by four (preassessment [T1], postassessment [T2], and 3-month [T3] and 1-year [T4] assessments) mixed between-within design. The primary outcome is school attendance based on daily registration. Secondary outcomes pertain to youth psychosocial functioning, quality of life, bullying, self-efficacy, and teacher-parent collaboration. These secondary outcomes are measured via youth, parent, and teacher reports.

DISCUSSION

This study will provide critically needed empirical evidence on the initial effectiveness of a manualized treatment program for youth with SA. If the intervention is found to be effective, the program can be further implemented and tested in a larger school health effectiveness trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03459677 . Retrospectively registered on 9 March 2018.

Feasibility and acceptability of a toolkit to facilitate clinician use of exposure therapy for youth

Exposure therapy is a key element of cognitive-behavioral therapy for youth with anxiety. However, few clinicians outside of specialty anxiety clinics routinely use exposures with anxious youth. This study reports on the acceptability and feasibility of a clinician support toolkit for exposures with anxious youth in community settings. The toolkit was developed through an extensive literature review of exposure science and cited barriers to exposure therapy, with input from multiple experts in pediatric anxiety (n = 10). Acceptability and feasibility data was gathered via survey from 70 community clinicians attending a training on exposure therapy for youth. Qualitative data was collected from a subset of participants who used the toolkit with youth on their caseload for approximately one month. Survey data suggested that the toolkit was viewed highly favorably. Qualitative interviews indicated that the toolkit was viewed as a feasible therapeutic tool that positively impacted clinician motivation to use exposure. Primary challenges related to exposure use more generally, and included client and service setting barriers. Results suggested initial toolkit acceptability and feasibility. Future work to refine the toolkit and test its efficacy as an implementation strategy to increase clinician use of exposure therapy is warranted. Next steps include development of additional content in partnership with key stakeholders, and testing the toolkit's impact on increasing clinician use of exposure therapy.