School refusal and anxiety in adolescence: non-randomized trial of a developmentally sensitive cognitive behavioral therapy

Cognitive Behavioral Interventions for School Attendance Problems: A Systematic Review and Meta-analysis

This pre-registered (#CRD42024509947) systematic review synthesized evidence on cognitive behavioral interventions (CBTs) for youths with school attendance problems (SAPs). The PsycINFO, PubMed, ERIC, and Scopus databases were searched through 1985-2024 for randomized controlled trials (RCTs), non-RCTs, and open trials (OTs) evaluating SAP-focused CBT. Data were synthesized narratively and through meta-analysis. Four RCTs and eleven OTs met eligibility criteria, including 932 youths. Meta-analyses revealed small to large uncontrolled pre- to post-intervention effects for school attendance (g = 1.02), anxiety (g = - 0.57), depression (g = - 0.66), and behavioral problems (g = - 0.40), which were maintained at follow-up. When compared to a control, CBT had a medium effect on school attendance (g = 0.44) but non-significant effects on anxiety (g = - 0.09) and depression (g = - 0.14). While the results hold promise for SAP-focused CBTs, evidence was limited by study heterogeneity, bias risks, methodological limitations, and inconsistent outcome measures, highlighting the needed for further RCTs.

Virtual Reality Exposure Therapy for Reducing School Anxiety in Adolescents: Pilot Study

BACKGROUND

Virtual reality exposure therapy (VRET) is a promising treatment approach for anxiety disorders. However, while its efficacy has been demonstrated in adults, research on the efficacy of VRET in the treatment of adolescents with anxiety disorders is largely lacking.

OBJECTIVE

A pilot study was carried out to test whether exposure to a virtual reality (VR) school environment elicits state anxiety and autonomic arousal in adolescents with school anxiety (diagnoses covering social anxiety disorder or specific phobia involving school contexts). In addition, we examined whether repeated VR exposure led to a reduction in this fear response, trait school anxiety, and social anxiety symptoms. Moreover, the relationship of presence, the subjective sense of "being there," during VR exposure with anxiety measures and treatment response was examined.

METHODS

In a pilot study, 10 adolescents with school anxiety (age range 14 to 17 years) participated in five VRET sessions. Self-reported state anxiety, heart rate, and presence during exposure, as well as trait school anxiety and social anxiety before and after treatment, were measured.

RESULTS

The VR scenario induced state anxiety and autonomic arousal. After VRET, a significant reduction in state anxiety (η2=0.74) and social anxiety symptoms (d=0.82) as well as a trend toward a decrease in trait school anxiety were observed, while autonomic arousal did not change. In addition, presence during VR exposure was associated with state anxiety and treatment response.

CONCLUSIONS

Our findings indicate the feasibility and potential effectiveness of VRET as a treatment method for symptoms of school and social anxiety in adolescents.

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).

School Refusal in Youth: A Systematic Review of Ecological Factors

To guide school practitioners in the identification and intervention of youth with anxious school refusal, this systematic review used an ecological lens to examine the factors that differentiated children and adolescents with school refusal from those without. Based on the rigorous protocol from the Center for Reviews and Dissemination's (CRD) internationally recognized guidelines, 15 studies examining 67 different factors were identified. Results reveal 44 individual, social and contextual factors that differentiate youth with school refusal from peers without school refusal. Findings highlight the centrality of anxiety, or anxiety-related symptoms, and diverse learning needs as main points of contrast between youth with school refusal and those without. Implications of an ecological understanding of the factors associated with school refusal for selective and indicative prevention by school and mental health practitioners are discussed.

Functional analysis of school refusal: An exploratory study in the Indian context

Background

School refusal behaviour is an umbrella term that often subsumes constructs such as truancy, school refusal, and school phobia. It is influenced by various psychological and psychosocial factors and can lead to significant distress to the child and the family.

Aim

To assess the clinical and functional profile of school refusal behavior in children and adolescents presenting to a tertiary care child and adolescent psychiatry center in the Indian context.

Materials and Methods

Thirty-six subjects (6-17 years) presenting to a tertiary Child and Adolescent Psychiatry service with school refusal behavior (SRB) were evaluated using the MINI-KID 6.0 and School Refusal Assessment Scale-Revised (SRAS-R). The sociodemographic and clinical characteristics of the sample were studied using frequency analysis and central tendencies. The association between school refusal and these variables was examined using Cramer's V coefficient.

Results

Anxiety in social/evaluative situations associated with tangible rewards at home was the predominant primary reason for school refusal in this sample. There was a significant statistical association between functions of school refusal and scholastic performance, psychiatric diagnosis, and family stressors. The Children's Global Assessment Scale (CGAS) scores varied widely from 30 to 80 indicating an inability to function in almost all areas to no more than a slight impairment in functioning.

Conclusions

School refusal is a complex multifactorial phenomenon with both individual and psychosocial contributing factors. Understanding the phenomenon from a functional perspective helps in devising an individualized treatment plan that may lead to better outcomes.

Effectiveness of cognitive-behavioral group play therapy on anxiety-based school refusal and behavioral problems in elementary school boys: a preliminary randomized controlled trial

This study aimed to examine the effectiveness of cognitive-behavioral group play therapy on anxiety-based school refusal and behavioral issues in elementary school boys. A randomized controlled trial design (pretest-posttest with a control group) was utilized. Thirty elementary school boys with school refusal issues were randomly assigned to intervention (n = 15) and control (n = 15) groups. The intervention group received ten sessions of cognitive-behavioral group play therapy. The Screen for Child Anxiety-Related Emotional Disorders (SCARED) questionnaire and Rutter's Children's Behavior Questionnaire were used as assessment tools. Mean scores for anxiety-based school refusal and behavioral problems in the intervention group showed a significant decrease (p < 0.001). Cognitive-behavioral group play therapy is a practical approach to reducing anxiety levels and behavior problems in children with anxiety-based school refusal in primary school grades.

School refusal behavior in children and adolescents: a five-year narrative review of clinical significance and psychopathological profiles

The aim of the study was to explore the clinical significance of school refusal behavior, its negative impact on psychological well-being of children and adolescents and its relationship with the most common psychopathological conditions during childhood and adolescence (e.g. neurodevelopmental disorders, psychiatric disorders). School refusal behavior refers to a distressing condition experienced by children and adolescents that compromise regular school attendance and determine negative consequences on mental health and adaptive functioning. A narrative review of the literature published between January 2019 and March 2023 was conducted. Ten studies (n = 10) were included from a literature search of the electronic databases PubMed, CINAHL, PsycInfo, MedLine, and Cochrane Library. The results indicate that school refusal is highly present in neurodevelopmental disorders such as autism and attention-deficit/hyperactivity disorder due to the presence of behavioral problems and deficits in communication skills. As for psychiatric disorders, school refusal appears to be highly common in anxiety disorders, depressive disorders, and somatic symptoms. We also found that school refusal behavior may be associated with various emotional and behavioral conditions that act as risk factors. Especially, but are not limited to, it may be associated with a diminished self-concept, exposure to cyberbullying, specific affective profiles and excessive technology usage. Our results indicate that school refusal is a condition with many clinical facets. It can be attributed to both vulnerability factors, both temperamental and relational, and to various psychopathological conditions that differ significantly from each other, such as neurodevelopmental disorders and psychiatric disorders. Recognizing these aspects can improve the implementation of patient-tailored therapeutic interventions that are consequently more likely to produce effective outcomes. The therapeutic intervention should facilitate the recognition of cognitive biases regarding school as a threatening environment, while regulating negative emotions associated with school attendance. Additionally, therapeutic intervention programs linked to social skill training and problem-solving training, conducted directly within the school setting, can enhance children's abilities to cope with academic performance and social relationships, ultimately preventing school refusal.

Modifiable Parent Factors Associated with Child and Adolescent School Refusal: A Systematic Review

School refusal is a complex problem that refers to difficulty attending/remaining at school due to emotional distress about attendance. Despite its occurrence being associated with negative outcomes, many are unresponsive to the current treatment options. While parent factors have a key role to play in school refusal, they are not adequately addressed in existing treatments. Further research is needed to consolidate understanding and implement new treatments. Employing the PRISMA method, this review aims to identify modifiable parent factors associated with child and/or adolescent school refusal. Eight studies met inclusion criteria from which nine factors were identified. Factors found to be associated with school refusal included: parent psychopathology, family functioning and maternal overprotection (communication subdomain). Other factors such as maternal overprotection (affection, assistance and travel subdomains) and parental self-efficacy had weak or inconsistent results warranting further investigation. Overall, findings call for action in this field that has sparse and dated literature.

Practitioner Review: Signposts for Enhancing Cognitive-Behavioral Therapy for School Refusal in Adolescence

Factors associated with adolescent development influence the occurrence and presentation of school refusal (SR). Cognitive-behavioral therapy (CBT) manuals for the treatment of SR account for these developmental issues to varying degrees. Some multimodal treatments aim to address the complexity of adolescent SR by incorporating interventions alongside CBT, such as medication, inpatient treatment, and educational support in a special setting. However, CBT manuals and multimodal treatments appear to fail to help approximately one-third to two-thirds of adolescents, with respect to achieving regular school attendance. This paper provides an overview of suggestions in the literature for improving treatment for SR, with a focus on adolescent SR. Seven signposts emerge from the literature, namely, increased number or frequency of sessions, greater attention to social anxiety disorder and social functioning, greater attention to depression, greater attention to emotion regulation, careful consideration of the role of parents, greater attention to parent-adolescent communication and problem-solving, and the use of alternative educational settings. Professionals may find these signposts helpful when planning and delivering treatment for SR in adolescents. Research is needed to determine the benefit of including one or more of these adaptations alongside an existing SR treatment.

Social anxiety disorder in adolescents who stutter: A risk for school refusal

BACKGROUND

Stuttering is a childhood-onset fluency disorder. Part of the counseling for middle and high school students with persistent stuttering is related to school refusal. Anxiety disorders are known to contribute to school refusal. However, it is not known whether social anxiety disorder (SAD) is a factor in school refusal among adolescents who stutter.

METHODS

In our first study, we examined the relationship between school refusal and SAD in 84 middle and high school students who stutter; 26% of the 84 students were in the school refusal group and the remaining 74% were in the school attendance group. The second study examined whether SAD was associated with 10 factors related to speech and stuttering frequency using the Japanese version of the Liebowitz Social Anxiety Scale for Children and Adolescents to determine the presence of SAD. Of the 84 students in the first study, 40 participated in the second study.

RESULTS

The school refusal group of adolescents who stutter had significantly higher rates of SAD than the school attendance group. Fifty percent of adolescents who stutter met the criteria for SAD. Moreover, adolescents who stutter with SAD had significantly higher scores on the items "When speaking in public, do you experience tremors in your limbs?" and "After you stutter, do you have negative thoughts about yourself?" than the adolescents who stutter without SAD.

CONCLUSIONS

When examining adolescents who stutter, checking for comorbid SAD may lead to better support. Moreover, noticing their repetitive negative thinking, nervousness, and trembling during speech may help to resolve SAD.

School refusal and anxiety among children and adolescents: A systematic scoping review

School refusal and anxiety are considerable problems among children and adolescents. While numerous studies were published, no review on the issue has been conducted to holistically reveal the current research results. This study uses a systematic scoping review design and aims to synthesize the results of the current studies on seeking an answer to the relationship between school refusal and anxiety to make recommendations for teachers, school counselors and administrators, and educational researchers for further research. Included studies were designed as qualitative, experimental, correlational, descriptive, or mixed-method, while studies designed as a thematic review, systematic review, and meta-analysis were excluded. The study identified 30 research articles that met the inclusion criteria within this scope. Results showed that anxiety is a prevalent factor associated with school refusal, whereas school refusal is directly and closely related to state and trait anxiety, social anxiety, school anxiety, and separation anxiety. Another finding was that school punishment, bad family functioning, parental depression, and parental anxiety are strong predictors of school refusal.

"No One Really Likes Crying in School": The Influences of Classroom and Institutional Dynamics Upon Student Absenteeism During COVID-19

The COVID-19 pandemic has worsened the already problematic issue of student absenteeism. This study uniquely employs an ecological agency approach to better understand student absenteeism during COVID-19. Using a case study methodology, the study captures the experiences of two absentee students within a United States suburban high school during the 2020-2021 school year to better understand the institutional structures motivating their daily decision to attend or miss school. In the remote learning environment, rigorous curricular expectations, minimal social interactions, teacher-led instruction as a response to student disengagement from student-led instruction, and lower teacher expectations contributed to the participants' daily decision to miss school. In the remote, hybrid, and full-time in-person learning spaces, staff apathy toward bullying, minimal space to escape feelings of anxiety, and fewer tutoring outlets motivated student absenteeism. Therefore, the school environment can better promote attendance during COVID-19 by establishing an in-school space to escape heightened anxiety, academic supports to reduce grade-induced anxiety, shifting from nonintervention to prosocial instructional interventions in all learning environments, teacher voices in policy design, reducing teacher-led instruction, and shifting teacher beliefs to an asset mindset. Recommendations for future research are included.

Developmental Issues Associated with Adolescent School Refusal and Cognitive-Behavioral Therapy Manuals

It is important to consider developmental issues when addressing school refusal (SR) in adolescence. Referral rates appear to be higher among adolescents relative to children, and treatment appears to be less effective among adolescents. This paper provides an in-depth review of developmental issues associated with adolescent SR and treatment via cognitive-behavioral therapy (CBT). It begins by considering the reasons for the higher referral and poorer treatment outcomes, including the higher level of absenteeism in adolescence, higher rates of concurrent social anxiety disorder and depressive disorder, and the developmental challenges inherent to adolescence. Such challenges include increased academic and social demands in the secondary-school environment, and increasing autonomy which may contribute to family conflict. These developmental issues may potentiate and exacerbate an adolescent's difficulty attending school, make it difficult for families to cope, and complicate practitioners' efforts to provide effective treatment for SR. Further, the review describes CBT manuals for SR and the extent to which they are developmentally sensitive. There are five CBT manuals, which vary in their sensitivity to developmental issues. Various multimodal treatments employ interventions in addition to CBT, such as medication or inpatient treatment, to address the complexity of SR in adolescence. Nevertheless, nonresponse to treatment for adolescent SR ranges from one-third to two-thirds of youths. Attention thus needs to be given to ways of improving treatment outcomes.

Clinical practitioners' experiences of psychological treatment for autistic children and adolescents with school attendance problems: a qualitative study

BACKGROUND

School attendance problems (SAPs) are common among children and adolescents with autism spectrum disorder (ASD). Currently, there is a lack of guidelines for treatment or interventions aimed at this group.

METHOD

Twelve clinical practitioners were interviewed via in-depth interviews using a semi-structured question guide. Interviews were audiotaped, transcribed verbatim, and initially independently coded by two coders. The interviews were analyzed according to thematic analysis.

RESULTS

The majority of the clinicians reported that it was common that children and adolescents with ASD at CAP had prolonged SAPs. A total of four themes and 22 sub-themes were identified in the analysis: the treatment situation; treatment goals at CAP; treatment interventions; and desired development. Insufficient adaptations in response to core impairment of ASD and lack of support in their daily life could be factors to the development of SAPs. Prolonged social isolation in combination with severe psychiatric comorbidities was reported as a treatment barrier. Also, insufficient collaboration between mental health care services, school and social services obstructed the return to school for this group of students. Favorable factors for positive treatment outcome were: early detection, accurate assessment and coordination between mental health care and schools and environmental adaptation at school as well as at home, parent support and sometimes change of school. Concerning useful therapeutic techniques, exposure from cognitive-behavioral treatment was reported.

CONCLUSION

Children and adolescents with ASD with limited societal support tend to develop SAPs. Important factors that impact the outcome of treatment were the length of the absence from school and the severity of psychiatric comorbidities. Tailored and adapted interventions at school, parent support and mental health care are needed. Research about assessment and treatment for children and adolescents with ASD and SAPs is needed.

Sociodemographic and clinical characteristics of youths and parents seeking psychological treatment for school attendance problems

BACKGROUND

Knowledge of school attendance problems (SAPs) is needed to inform treatments targeting SAPs and protecting youths from negative outcomes associated with SAPs.

OBJECTIVES

This study examined the school absence, absence categories (i.e., absence due to illness, excused, non-excused), sociodemographic characteristics, and mental health problems among youths seeking psychological treatment for SAPs.

METHODS

The study used a cross-sectional design. Sociodemographic and clinical characteristics of 152 help-seeking youths with SAPs (i.e., >10% absenteeism) and their parents were examined. The data were derived from the baseline assessment conducted before treatment start.

RESULTS

Older youths, youths with mental health problems, and youths whose parents had mental health problems exhibited higher levels of absence. Lower levels of non-excused absence were found among youths with highly educated fathers, and youths living with both parents. Many youths had clinical levels of anxiety, depression, or 'emotional and behavioral difficulties'.

CONCLUSION

The study highlights the need for early intervention, addressing a broad range of mental health problems.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT03459677.

Is Bullying Associated with Emerging School Refusal in Autistic Boys?

The experience of being bullied is widespread among autistic youth. Relatively little empirical work has been done on the relationship between the bullying of these youth and school refusal (SR). This study of 67 school-age autistic boys (M = 11.7 years, SD = 2.3 years) examined several factors that may contribute to SR. Data regarding boys' age, generalised anxiety disorder (GAD), major depressive disorder (MDD), key ASD diagnostic criteria, and frequency of being bullied were collected. Results indicated that, while boys displaying emerging SR also had significantly higher GAD and MDD than boys without emerging SR, only the frequency of being bullied made a significant contribution to emerging SR. Implications for prevention and treatment of SR among autistic youth are discussed.

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.

The Relationship Between Social Anxiety and Internalized Racism in Black Young Adults

The study examined the relationships between social anxiety (SA), generalized anxiety (GA), and depression with racial microaggressions and internalized racism (IR) among Black young adults. Given SA's core features, we expected it to have a unique association with IR, and to moderate the connection between racial microaggressions and IR. Participants were 182 Black university students who completed measures of SA, GA, depressive symptoms, racial microaggressions, and IR. Linear regression models indicated that IR was a significant predictor of SA, but not GA or depression. Racial microaggressions were only positively associated with depressive symptoms. SA and racial microaggressions each predicted IR, but no interaction was found. Black young adults with elevated concerns of others' evaluation may be more prone to accepting negative stereotypes about one's racial group.

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.

A pilot and feasibility study of a cognitive behavioural therapy-based anxiety prevention programme for junior high school students in Japan: a quasi-experimental study

BACKGROUND

There is a good deal of evidence that cognitive behavioural therapy is effective for children and adolescents with anxiety-related problems. In Japan, an anxiety prevention programme based on cognitive behavioural therapy called 'Journey of the Brave' has been developed, and it has been demonstrated to be effective for elementary school students (aged 10-11 years). The purpose of this study was to have classroom teachers deliver the programme to junior high school students (aged 12-13 years) and to test the feasibility and efficacy of the programme in this setting.

METHODS

This study was a prospective observational study and was approved by the Chiba University Review Board. An intervention group consisting of six classes of students in their first year of junior high school at two different schools (n = 149; 81 boys, 68 girls) received seven 50-min programme sessions. Participants in the control group were recruited from four classes of students in their second year of junior high school at one school (n = 89; 51 boys, 38 girls). All participants completed the Spence Children's Anxiety Scale at pre-test, post-test, and 2-3 month follow-up. Statistical analysis was conducted using a mixed-effects model for repeated measures model.

RESULTS

Mean total anxiety scores indicated a non-significant decrease at the 2-3 month follow-up for the intervention group compared to the control group. The group differences on the SCAS from baseline to post-test was - .71 (95% CI - 2.48 to 1.06, p = .43), and the 2-3 month follow-up was - .49 (95% CI - 2.60 to 1.61, p = .64).

CONCLUSIONS

In this pilot study, implementation of the programme confirmed the partial feasibility of the programme but did not elicit a significant reduction in anxiety scores. In addition, there are several methodological limitations to this study. In the future, we propose to test the feasibility and efficacy of the programme with the required sample size and by comparing groups with equal characteristics as well as by carrying out additional follow-up assessments.Trial registration UMIN000032517.

Identifying Risk Profiles of School Refusal Behavior: Differences in Social Anxiety and Family Functioning Among Spanish Adolescents

School attendance problems negatively affect students' development. This study attempted to identify different school refusal behavior profiles and to examine their relationship with three dimensions of social anxiety (fear of negative evaluation, social avoidance and distress in new situations, and social avoidance and distress that is experienced more generally in the company of peers) and the perception of family functioning. Participants included 1842 Spanish adolescents (53% girls) aged 15-18 years (M = 16.43; SD = 1.05). The School Refusal Assessment Scale-Revised (SRAS-R), the Social Anxiety Scale for Adolescents (SAS-A), and the Family APGAR Scale (APGAR: Adaptation, Partnership, Growth, Affection, and Resolve) were administered. Latent class analysis revealed four school refusal behavior profiles: non-school refusal behavior, high school refusal behavior, moderately low school refusal behavior, and moderately high school refusal behavior. Analyses of variance (ANOVA) indicated that adolescents' with the profile of high school refusal behavior showed higher scores in all the subscales of social anxiety. In contrast, the non-school refusal behavior group revealed higher scores in the perception of good family functioning, whereas the high school refusal behavior profile obtained the lowest scores in this scale. These findings suggest that students who reject school are at a higher risk of developing social anxiety problems and manifesting family conflicts. These students should be prioritized in order to attend to their needs, promoting self-help to overcome social anxiety and family problems with the purpose of preventing school refusal behaviors.

Working with school-refusing young people in Tower Hamlets, London

This study looks at the local context, describing quantitative data from a subset of young people seen within the inner London Tower Hamlets Pupil Referral Unit (PRU) that are extremely socially withdrawn and unable to attend mainstream education. The core aim of this research was to examine the views of professionals who work with and for these young people. Qualitative group interviews were used to gain a deeper understanding of the needs of these young people, what might contribute to their withdrawal from school and what needs to be done to help them reintegrate. Professionals reported that these young people were highly complex in terms of their needs and presentation and that there is a lack of clarity around what causes these young people to withdraw. They agreed that a more intensive multilayered intervention was required to meet their needs. Interventions that include gradual socialization, parental involvement and which address the role of technology were indicated. However, more research is needed to clarify how to effectively intervene.

Child and Adolescent Social Adaptive Functioning Scale: Factorial Invariance, Latent Mean Differences, and Its Impact on School Refusal Behavior in Spanish Children

This study aims to examine the factorial invariance and latent mean differences across gender of the Spanish version of the Child and Adolescent Social Adaptive Functioning Scale (Study 1) and to value the function of social functioning as a protective ability of school refusal behavior (Study 2). Participants were Spanish students aged 8–12 years carefully chosen by simple random cluster, 345 for the first study (M = 9.17; SD = 1.03) and 1,032 students for the second study (M = 10.02; SD = 1.77). The measures used were the Child and Adolescent Social Adaptive Functioning Scale (CASAFS) and the School Refusal Assessment Scale-Revised (SRAS-R). Results about the validation of the scale supported the model proposed in this study for the CASAFS, with 15 items and a four-factor structure (school performance, peer relationships, family relationships, and home duties/self-care). Findings revealed invariance across gender for this model and good internal consistency levels were exhibited in each of the four dimensions of the CASAFS (0.76, 0.72, 0.74, and 0.71). Latent mean differences did not report differences between boys and girls. Regarding the second study, the social functioning acted as a protective factor of school refusal behavior by negatively and significantly predicting high scores in school refusal behavior due to anxiety symptoms or feelings of negative affect linked to the obligation to attend school. Opposite results were found for those students who justify their refusal to attend school in pursuing tangible reinforcements outside the school setting. These findings strengthen the reliability and validity of the CASAFS and the idea of social functioning as a person’s ability which could prevent school refusal behavior is discussed.

Practitioner Review: School refusal: developments in conceptualisation and treatment since 2000

BACKGROUND

A generation has passed since the literature on the conceptualisation, assessment and treatment of school refusal was reviewed in this journal (Elliott, ). In the light of considerable gaps in the literature, identified at that time, and growing international interest, the current paper sought to identify progress subsequently made this century.

METHODS

We open with discussion of continuing conceptual uncertainty as to whether school refusal should incorporate both truancy and absenteeism marked by anxiety and distress. We then consider progress in treatment, and conclude by examining prognosis and subsequent adult functioning. In selecting intervention studies for review, our primary focus has been upon RCTS, systematic reviews and meta-analyses.

RESULTS

The literature review indicates that, since the turn of the century, there has been little substantial advance in knowledge that can guide practitioners. Many of the issues raised in the 1999 paper, in particular, conceptual confusion over this heterogeneous condition, a dearth of rigorous RCT designs, limited knowledge of underlying mechanisms and uncertainty as to the long-term effects of specific forms of intervention, are little clearer than before.

CONCLUSIONS

While several sound publications are available to guide intervention for school refusal, there is a continuing need for rigorous studies that can provide evidence to support individualised and tailored responses to an incapacitating problem with many causes and manifestations. While a multisystemic response to intervention approach is considered attractive, the practicalities of operating this across disparate professional borders are likely to present a long-term challenge.

Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial

This study investigates whether the augmentation of cognitive behavior therapy (CBT) with fluoxetine improves outcomes in anxious school refusing adolescents (11-16.5 years). Sixty-two participants were randomly allocated to CBT alone, CBT + fluoxetine or CBT + placebo. All treatments were well tolerated; with one suicide-attempt in the CBT + placebo group. All groups improved significantly on primary (school attendance) and secondary outcome measures (anxiety, depression, self-efficacy and clinician-rated global functioning); with gains largely maintained at 6-months and 1-year. Few participants were anxiety disorder free after acute treatment. During the follow-up period anxiety and depressive disorders continued to decline whilst school attendance remained stable, at around 54 %. The only significant between-group difference was greater adolescent-reported treatment satisfaction in the CBT + fluoxetine group than the CBT alone group. These results indicate the chronicity of school refusal, and the need for future research into how to best improve school attendance rates.

[Economic evaluation of a manual-based, multimodal cognitive behavioural therapy for school avoiding children with psychiatric disorder]

Objective

Untreated school refusal increases the risk of a premature discontinuation of the educational career. The aim of this study is the economic evaluation of a manual-based treatment for school refusal in comparison to the standard treatment.

Method

Within the cost-minimisation analysis, resource use is measured retrospectively for six months using the CSSRI questionnaire. Unit costs for most health care services are derived from published standard prices. Costs are calculated from the societal perspective based on prices compiled in 2011. The cost comparison during the one-year intervention period applies a difference in differences Approach.

Results

The most common diagnoses among the 112 participants are phobic and emotional disorders. The average cost per patient during the intervention period amounts to 7197 € (95 %-CI: 4746 € – 10 079 €) for the manual group and 9294 € (95 %-CI: 6313 € – 12 878 €) for the control group. The difference in adjusted costs of 1453 € in favour of the manual group is not statistically relevant.

Conclusions

The manual-based treatment is equivalent if not slightly advantageous compared to the standard treatment considering the clinical outcomes and cost of illness.

A Randomized Controlled Comparison of Emotional Freedom Technique and Cognitive-Behavioral Therapy to Reduce Adolescent Anxiety: A Pilot Study

OBJECTIVE

The objective of this pilot study was to compare the efficacy of Emotional Freedom Techniques (EFT) with that of Cognitive-Behavioral Therapy (CBT) in reducing adolescent anxiety.

DESIGN

Randomized controlled study.

SETTINGS

This study took place in 10 schools (8 public/2 private; 4 high schools/6 middle schools) in 2 northeastern states in the United States.

PARTICIPANTS

Sixty-three high-ability students in grades 6-12, ages 10-18 years, who scored in the moderate to high ranges for anxiety on the Revised Children's Manifest Anxiety Scale-2 (RCMAS-2) were randomly assigned to CBT (n = 21), EFT (n = 21), or waitlist control (n = 21) intervention groups.

INTERVENTIONS

CBT is the gold standard of anxiety treatment for adolescent anxiety. EFT is an evidence-based treatment for anxiety that incorporates acupoint stimulation. Students assigned to the CBT or EFT treatment groups received three individual sessions of the identified protocols from trained graduate counseling, psychology, or social work students enrolled at a large northeastern research university.

OUTCOME MEASURES

The RCMAS-2 was used to assess preintervention and postintervention anxiety levels in participants.

RESULTS

EFT participants (n = 20; M = 52.16, SD = 9.23) showed significant reduction in anxiety levels compared with the waitlist control group (n = 21; M = 57.93, SD = 6.02) (p = 0.005, d = 0.74, 95% CI [-9.76, -1.77]) with a moderate to large effect size. CBT participants (n = 21; M = 54.82, SD = 5.81) showed reduction in anxiety but did not differ significantly from the EFT (p = 0.18, d = 0.34; 95% CI [-6.61, 1.30]) or control (p = 0.12, d = 0.53, 95% CI [-7.06, .84]).

CONCLUSIONS

EFT is an efficacious intervention to significantly reduce anxiety for high-ability adolescents.

Does psychotherapy work with school-aged youth? A meta-analytic examination of moderator variables that influence therapeutic outcomes

The present study is a quantitative synthesis of the available literature to investigate the efficacy of psychotherapy for children's mental health outcomes. In particular, this study focuses on potential moderating variables-study design, treatment, client, and therapist characteristics-that may influence therapeutic outcomes for youth but have not been thoroughly accounted for in prior meta-analytic studies. An electronic search of relevant databases resulted in 190 unpublished and published studies that met criteria for inclusion in the analysis. Effect sizes differed by study design. Pre-post-test designs resulted in absolute magnitudes of treatment effects ranging from |-0.02| to |-0.76| while treatment versus control group comparison designs resulted in absolute magnitudes of treatment effects ranging from |-0.14| to |-2.39|. Changes in youth outcomes larger than 20% were found, irrespective of study design, for outcomes focused on psychosomatization (29% reduction), school attendance (25% increase), and stress (48% reduction). The magnitude of changes after psychotherapy ranged from 6% (externalizing problems) to 48% (stress). Several moderator variables significantly influenced psychotherapy treatment effect sizes, including frequency and length of treatment as well as treatment format. However, results did not support the superiority of a single type of intervention for most outcomes. Implications for therapy with school-aged youth and future research are discussed.

The Treatment of School Avoidance in Children and Adolescents With Psychiatric Illness

BACKGROUND

5-10% of schoolchildren in Germany are absent from school without an excuse more than five times per year. We investigate the effectiveness of manual-based, multimodal cognitive behavioral therapy focusing on school-avoidant behavior and on the underlying mental disorders.

METHODS

112 school avoiders were recruited from an outpatient child and adolescent psychiatric clinic and adaptively randomized into two treatment groups. The first group received manual-based multimodal treatment (MT), the second group treatment as usual (TAU) in the child and adolescent mental health care system. The primary outcome of the study was the percentage of classes attended in the five days prior to first measurement (before the intervention), as well as 6 and 12 months afterward. In each of these periods, school attendance was characterized as regular, partial, or none. Secondary outcomes were the severity of anxiety and depressive symptoms, self-efficacy, and quality of family life.

RESULTS

In both treatment arms, the percentage of regular school attenders rose to about 60% in 6 months, regardless of the intervention (MT 60.6%, TAU 58.3%; odds ratio [OR] for changes over baseline 6.94, 95% confidence interval [CI] 3.98-12.12, p< 0.001; OR for MT versus TAU 1.05, 95% CI 0.58-1.90, p = 0.875). The improvement persisted 12 months after inclusion.

CONCLUSION

In accordance with earlier studies, we found that manual-based multimodal treatment did not improve school avoidance to any greater extent than treatment as usual. Future studies should focus on the conditions for successful reintegration in school and on the differential indicators for outpatient versus inpatient treatment.

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

School refusal can be difficult to treat and the poorest treatment response is observed among older school refusers. This poor response may be explained, in part, by the impact of developmental transitions and tasks upon the young person, their family, and the treatment process. This paper describes and illustrates the @school program, a cognitive behavioral therapy (CBT) designed to promote developmental sensitivity when planning and delivering treatment for adolescent school refusal. Treatment is modularized and it incorporates progress reviews, fostering a planned yet flexible approach to CBT. The treatment is illustrated in the case of Allison, a 16-year-old female presenting with major depressive disorder and generalized anxiety disorder. A case formulation guided the selection, sequencing, and pacing of modules targeting predisposing, precipitating, perpetuating, and protective factors. Treatment comprised 16 sessions with Allison (interventions addressing depression, anxiety, and school attendance) and 15 concurrent sessions with her mother (strategies to facilitate an adolescent's school attendance), including two sessions with Allison and mother together (family communication and problem solving to reduce parent-adolescent conflict). Two treatment-related consultations were also conducted with Allison's homeroom teacher. Allison's school attendance improved during the course of treatment. By post-treatment, there was a decrease in internalizing behavior, an increase in self-efficacy, and remission of depressive disorder and anxiety disorder. Clinically significant treatment gains were maintained at 2-month follow-up. Factors influencing outcome may include those inherent to the @school program together with less specific factors. Special consideration is given to parents' use of both authoritative and autonomy-granting approaches when helping an adolescent to attend school.

Alexithymia and personality in relation to social anxiety among university students

The aims of the present study were to investigate the relationship of social anxiety symptoms with alexithymia and personality dimensions in university students and to control the effects of depression and anxiety on this relationship. A total of 319 university students (85 males and 234 females) from two different universities in Ankara were investigated with the Liebowitz Social Anxiety Scale (LSAS), the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the Toronto Alexithymia Scale (TAS-20) and the Temperament and Character Inventory (TCI). We found that subscales of the LSAS (fear or anxiety and avoidance) were positively correlated with depression and alexithymia and "difficulty in identifying feelings" (DIF) and "difficulty in describing feelings" (DDF) subscales of the TAS-20. Harm avoidance (HA) showed positive correlations with subscales of the LSAS, whereas self-directedness (SD) showed negative correlations with these subscales. High TAS-20 DDFand HA and low SD predicted fear or anxiety LSAS subscale scores, whereas high TAS-20 DDF, HA and depression scores were predictors for LSAS avoidance subscale scores. Although our sample is not representative of the whole Turkish university student population, we conclude that both fear or anxiety and avoidance were mainly interrelated with DDF and HA, although the causal relationship is not clear.

Anxiety as a risk factor for school absenteeism: what differentiates anxious school attenders from non-attenders?

BACKGROUND

Anxiety is a major risk factor for problematic school absenteeism. However, most anxious students attend school. What differentiates anxious attenders from non-attenders?

METHOD

High school students (N = 865) were assigned to groups based on anxiety and absenteeism scores. These groups were then tested for differences in risk factor profiles using discriminant analysis.

RESULTS

Anxious school attenders were less affected by negative personality traits, total number of risk factors, social anxiety, panic, and behavioural and family problems. They also displayed greater resilience.

CONCLUSIONS

This study indicates that the risk for problematic school absenteeism increases as the number of risk factors aggregate and that treatment for anxious school refusal should be based on a profile of the individual's risk factors.

Cognitive mediation of cognitive-behavioural therapy outcomes for anxiety-based school refusal

BACKGROUND

Cognitive-behavioural therapy (CBT) has proven to be effective for anxiety-based school refusal, but it is still unknown how CBT for school refusal works, or through which mechanisms.

AIMS

Innovative statistical approaches for analyzing small uncontrolled samples were used to investigate the role of self-efficacy in mediating CBT outcomes for anxiety-based school refusal.

METHOD

Participants were 19 adolescents (12 to 17 years) who completed a manual-based cognitive-behavioural treatment. Primary outcomes (school attendance; school-related fear; anxiety) and secondary outcomes (depression; internalizing problems) were assessed at post-treatment and 2-month follow-up.

RESULTS

Post-treatment increases in school attendance and decreases in fear about attending school the next day were found to be mediated by self-efficacy. Mediating effects were not observed at 2-month follow-up.

CONCLUSIONS

These findings provide partial support for the role of self-efficacy in mediating the outcome of CBT for school refusal. They contribute to a small body of literature suggesting that cognitive change enhances CBT outcomes for young people with internalizing problems. Regarding methodology, the product of coefficient test appears to be a valuable way to study mediation in outcome studies involving small samples.

Panic disorder and school refusal

This article provides clinical and research information about panic disorder, agoraphobia, and school refusal. Proposed changes to the definition of panic disorder and agoraphobia for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition are outlined. Treatment of panic disorder, and school refusal in children and adolescents is also discussed.