Evaluation of child therapy and caregiver training in the treatment of school refusal

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).

Adapting a coach-assisted web-based intervention for parents of adolescents who refuse school: qualitative study with users of the Partners in Parenting Plus programme

BACKGROUND

School refusal is a heterogenous problem which typically emerges in adolescence and co-occurs with internalising disorders. A substantial proportion of adolescents do not respond to existing treatment modalities; thus, novel, effective intervention options are needed. Partners in Parenting Plus (PiP+) is a coach-assisted, web-based intervention designed to empower parents to respond to adolescent internalising disorders.

AIMS

To conduct a process evaluation of PiP+ and identify programme adaptations required to meet the needs of parents of adolescents who refuse school.

METHOD

Semi-structured interviews were conducted with 14 Australian mothers who had: (a) received the PiP+ programme (not tailored for school refusal) during a prior research trial; and (b) reported that their adolescent was refusing school during their participation in PiP+. Inductive thematic analysis was used to analyse interview transcripts.

RESULTS

Participants were 41-53 years old (M = 47.8) and parenting adolescent children aged 14-17 years (M = 14.9). Three themes illustrated how PiP+ features met or could better meet the needs of parents of adolescents who were refusing school: (a) feeling heard, supported and respected; (b) relevance to me and my context; and (c) seeing positive changes. Participants had favourable views of PiP+, especially coached components. Participants requested programme enhancements to better meet the needs of parents of neurodiverse adolescents and discussed the impact of cumulative help-seeking 'failures' on self-efficacy and locus of control.

CONCLUSIONS

PiP+ was highly acceptable to the majority of parents navigating the issue of school refusal. This has implications for the enhancement of coach-assisted parenting interventions and the context-specific adaptation of PiP+ for 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.

School-based supports and accommodations among anxious youth in treatment

Within pediatric anxiety, accommodation describes ways caregivers modify their behavior in an effort to alleviate distress shown by anxious youth. In schools, accommodation refers to school-based supports (SBS) placed to increase academic success for students with disabilities. The present study, using school documents provided at treatment, examined the types of SBS provided to youth (N = 76; ages 7-17; mean age 11.07; 47.4 % female) diagnosed with an anxiety disorder. SBS were rated by a panel of youth anxiety experts on the degree to which each SBS promoted (a) approach or (b) avoidance. School documents were coded for the presence of SBS and each SBS received a (a) total approach and (b) total avoidance score. Analyses revealed (a) approach and (b) avoidance promoting SBS were differentially associated with diagnostic status: youth with social anxiety disorder were more likely to be recommended SBS promoting avoidance and youth with a specific phobia were more likely to be recommended SBS promoting approach. Overall, the present study characterizes types of SBS being received by anxious youth and finds that SBS recommended to anxious youth vary in type and quality. Discussion considers the need for observations in schools to further address the merits/demerits of anxiety-related SBS.

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.

Signposts for School Refusal Interventions, Based on the Views of Stakeholders

School refusal (SR) signals a young person's difficulty attending school. It jeopardizes their development, often contributes to distress for parents, and places an extra burden on school personnel. Reviews of empirical studies indicate that intervention for SR helps to increase school attendance, but not for all youths. This practice-based manuscript aims to support practitioners and organisations addressing the needs of youths and families affected by SR. Specifically, we present 14 signposts for the development and delivery of intervention for SR. The signposts represent important conditions for effective intervention based on key findings from the Knowing What Works project in the Netherlands. During that project, 76 professionals shared their views about the important elements in SR interventions they delivered, and 39 youths and 86 parents shared their views about the helpful elements in SR interventions in which they participated. These 201 stakeholders were variously associated with 21 SR interventions across 9 of the 12 Dutch provinces, most situated in mainstream or special education settings. Their responses informed the development of the 14 signposts presented here, supported by the extant literature on SR intervention. We describe the essence of each signpost and conclude with suggestions for using the signposts and evaluating their utility.

Supporting the parents of children and young people with anxiety and depressive disorders is an opportunity not to be missed: a scoping review

Guidance is scarce on whether and how to involve parents in treatment for anxiety and depressive disorders in children and young people. We did a scoping review of randomised controlled trials of psychological interventions for anxiety and depressive disorders in children and young people, in which parents were involved in treatment, to identify how parents and carers have been involved in such treatments, how this relates to both child and broader outcomes, and where research should focus. We identified 73 trials: 62 focused on anxiety and 11 on depressive disorders. How parents were involved in treatments varied greatly, with at least 13 different combinations of ways of involving parents in the anxiety trials and seven different combinations in the depression trials. Including parents in treatment did not impair children's and young people's outcomes, but the wide variability in how they were involved prevents clarity about why some trials favoured parent involvement and others did not. Studies must consider the long-term and wider benefits beyond children's and young people's mental health, such as enhanced engagement, family wellbeing, and economic gains.

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.

Brief, Non-Pharmacological, Interventions for Pediatric Anxiety: Meta-Analysis and Evidence Base Status

In 1998, Ost published [One-session treatment of specific phobias-a rapid and effective method] [in Swedish] giving rise to the idea that brief, intensive, and concentrated psychosocial interventions could exhibit public health impact. At this juncture, and per criteria of the Society for Clinical Child and Adolescent Psychology, there are data supporting that brief, non-pharmacological intervention [prescriptions] for pediatric anxiety can be considered well-established or probably efficacious. In addition, data from 76 randomized controlled trials (N = 17,203 youth) yield an overall mean effect size of 0.19 on pediatric anxiety outcomes (pre-post). Note, however, that effect sizes vary significantly. These data point to the capacity for clinical change coming from in-vivo exposures for specific phobias (~3 h, one session), CBT with social skills training (~3 h, six sessions for indicated prevention and early intervention), and CBT-based parent training (~6 h, eight digital modules with clinician support). Given such evidence, we recommend efforts be made to establish ways to position such treatment innovations for rapid deployment facilitated by high-quality training, monitoring, technical assistance, and ongoing disclosures.

Internalizing Symptoms as Predictors of School Absenteeism Severity at Multiple Levels: Ensemble and Classification and Regression Tree Analysis

School attendance problems are highly prevalent worldwide, leading researchers to investigate many different risk factors for this population. Of considerable controversy is how internalizing behavior problems might help to distinguish different types of youth with school attendance problems. In addition, efforts are ongoing to identify the point at which children and adolescents move from appropriate school attendance to problematic school absenteeism. The present study utilized ensemble and classification and regression tree analysis to identify potential internalizing behavior risk factors among youth at different levels of school absenteeism severity (i.e., 1+%, 3+%, 5+%, 10+%). Higher levels of absenteeism were also examined on an exploratory basis. Participants included 160 youth aged 6-19 years (M = 13.7; SD = 2.9) and their families from an outpatient therapy clinic (39.4%) and community (60.6%) setting, the latter from a family court and truancy diversion program cohort. One particular item relating to lack of enjoyment was most predictive of absenteeism severity at different levels, though not among the highest levels. Other internalizing items were also predictive of various levels of absenteeism severity, but only in a negatively endorsed fashion. Internalizing symptoms of worry and fatigue tended to be endorsed higher across less severe and more severe absenteeism severity levels. A general expectation that predictors would tend to be more homogeneous at higher than lower levels of absenteeism severity was not generally supported. The results help confirm the difficulty of conceptualizing this population based on forms of behavior but may support the need for early warning sign screening for youth at risk for school attendance problems.

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.

Reconciling Contemporary Approaches to School Attendance and School Absenteeism: Toward Promotion and Nimble Response, Global Policy Review and Implementation, and Future Adaptability (Part 1)

School attendance is an important foundational competency for children and adolescents, and school absenteeism has been linked to myriad short- and long-term negative consequences, even into adulthood. Many efforts have been made to conceptualize and address this population across various categories and dimensions of functioning and across multiple disciplines, resulting in both a rich literature base and a splintered view regarding this population. This article (Part 1 of 2) reviews and critiques key categorical and dimensional approaches to conceptualizing school attendance and school absenteeism, with an eye toward reconciling these approaches (Part 2 of 2) to develop a roadmap for preventative and intervention strategies, early warning systems and nimble response, global policy review, dissemination and implementation, and adaptations to future changes in education and technology. This article sets the stage for a discussion of a multidimensional, multi-tiered system of supports pyramid model as a heuristic framework for conceptualizing the manifold aspects of school attendance and school 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.

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.

To go or not to go: School refusal and its clinical correlates

Problematic school refusal that is child motivated is a serious but common presentation and a child psychiatric emergency. Mental health professionals, paediatricians, educators and parents are often required to work in tandem to alleviate concerns due to this. Prolonged absence from school may lead to immediate (educational backwardness) and far-reaching effects (psycho-social and educational maladjustment). Psychiatric morbidity is high in school-refusing children presenting to secondary and tertiary services and is associated with temperamental, family and environmental adversities. Outcomes can vary according to their age, duration of school refusal and environmental variables.

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.

School Absenteeism: An Online Survey via Social Networks

School absenteeism is a significant social and public health problem. However, existing prevalence rates are often not representative due to biased assessment processes at schools. The present study assessed school absenteeism in Germany using a nationwide online self-report survey. Although our definition of school absenteeism was more conservative than in previous studies, nearly 9 % of the 1359 high school students reported school absenteeism within the past 7 days. Absent students lived less often with both parents, were on average of lower socioeconomic status, and reported more emotional problems, behavioral problems and less prosocial behavior than attending students. Being an indicator of a wide variety of problems in children and adolescents, school absenteeism deserves much more attention. Future directions for research and implications for prevention and intervention programs are discussed.

[School absenteeism: Preliminary developments and maintaining persisting challenges]

A first step when considering school absenteeism is to understand the meaning and definition of the term. School absenteeism encompasses several terms such as school refusal, truancy and school phobia, all of which have been used inconsistently and confusingly in the past. Furthermore, the question of how many days of absence can be seen as problematic remains unclear. Due to these definitional problems, available data is inconsistent. Therefore, the prevalence rates of school absenteeism can only be estimated (about 5 % of all students). School absenteeism affects not only individual students, but also family, school and society structures. In order to establish appropriate support and intervention programs, a multimodal as well as an individual approach should be considered to address this interdependency. The primary goal, however, should be the students’ resumption of a regular school attendance, which requires a strong cooperation between parents, schools, youth welfare services and psychotherapeutic offers. If therapeutic interventions are required, it is highly recommended to start with outpatient treatment. If school attendance still remains irregular an inpatient treatment should follow.

Parental Involvement in Cognitive-Behavioral Intervention for Anxious Children: Parents' In-Session and Out-Session Activities and Their Relationship with Treatment Outcome

The present study explored the role of parents' in-session and out-session involvement in CBT for anxious children. Fifty 8- to 12-year-old children with a principal DSM-IV anxiety disorder participated in a group CBT program. Parental involvement in the therapy was assessed by the clinician and the children and parents completed a standardized anxiety scale as the main therapy outcome measure, at pre- and post-intervention. In addition, the parents completed questionnaires to evaluate a number of possible correlates of parental involvement, namely, child's anxiety symptoms intensity and interference, parental beliefs about anxiety, expectancies regarding the efficacy of the intervention, and parental anxiety. The results indicated that the parents were moderately involved in the therapy and that socio-economic status and parental beliefs about anxiety were significant correlates of parental involvement. Finally, partial support was found for the idea that parents' involvement in the therapy might have a positive impact on therapy outcome.

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.

Can parent training for parents with high levels of expressed emotion have a positive effect on their child's social anxiety improvement?

The role that parents' involvement may play in improving their child's social anxiety is still under debate. This paper aimed to investigate whether training parents with high expressed emotion (EE) could improve outcomes for adolescent social anxiety intervention. Fifty-two socially anxious adolescents (aged 13-18 years), whose parents exhibited high levels of expressed emotion, were assigned to either (a) a school-based intervention with an added parent training component, or (b) a school-based program focused solely on intervening with the adolescent (no parental involvement). Post-treatment and 12-month follow-up findings showed that school-based intervention with parent training was superior to the adolescent-specific program, yielding significant reductions in diagnosis remission, social and depressive symptomatology, particularly when the EE status of parents changed. Overall, the findings suggest that high-EE parents of children with social anxiety need to be involved in their child's therapy.

Ten year follow-up of children with school refusal

Objectives: To assess school refusal (school phobia) outcome in adult life.

Method: A 10 year follow-up used questionnaires completed by the target group of young adults and their parents and telephone interviews with their parents. Comparison groups were used.

Results: Psychiatric disorder was present in 30 % and caseness in a further 20%.

Conclusions: There is a need to identify interventions with long lasting effectiveness in this childhood disorder.

Prevalence of sleep problems and relationship between sleep problems and school refusal behavior in school-aged children in children's and parents' ratings

OBJECTIVE

This cross-section study investigated the prevalence of sleep disorders and the relationship between sleep problems (insomnias, parasomnias, and daytime sleepiness) and school refusal behavior in school-age children (fourth grade elementary school in Cologne, Germany).

METHOD

A sample of 1,490 children (age range: 8-11 years) and their parents each completed a sleep questionnaire and the School Refusal Assessment Scale.

RESULTS

The results indicate that sleep problems in childhood are frequent. Furthermore, the results of the study clearly indicate that there is a relationship between sleep problems and school refusal behavior. Children suffering from insomnias (sleep onset problems, difficulties maintaining sleep), parasomnias (nightmares, night terrors), and daytime sleepiness showed without exception significantly higher scores in 3 out of 4 school refusal behavior maintaining conditions compared to children without sleep problems. These three conditions are all associated with anxiety disorders (anxiety or depressive disorder, as well as separation anxiety disorder). Only in the fourth condition, which is associated with oppositional defiant or conduct disorders, truancy, or no disorder at all, were there no significant differences between children with and children without sleep problems.

CONCLUSIONS

For research and clinical practice, it is important to view sleep problems and school refusal behavior in relation to each other rather than as isolated phenomena.

Children's social/emotional characteristics at entry to school: implications for school nurses

Children entering school need to build healthy peer relationships; school, however, is the central place for bullying. School nurses have a growing focus on providing care for students with social, emotional and behavioural problems. We examined the relational development of children at school entry in regard to aggression and empathy, showing that teacher-reported aggression decreased between Pre-primary and Year One, while empathy increased between Year One and Year Two classes. No gender difference was found in teacher-reported total, or covert aggression. Understanding how development of empathy can be supported in children at school entry is important, thereby supporting development of pro-social behaviour and decreasing bullying. School nurses must understand the importance of surrounding children with safety in relationships as they begin school.

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.

Targeting parental psychopathology in child anxiety

The increased risk of anxiety in children of parents with psychopathology is a significant public health problem, as early-onset is associated with a variety of difficulties later in life. The aim of this article is to determine if treating parents is associated with improvements in child anxiety through the review of both top-down (parent identified for treatment) and family-focused child anxiety treatment studies. The authors present conclusions based on the state of the current literature, discuss implications for research and clinical practice, and propose utilizing a family-based model for treating parental psychopathology, parental behavior, and child anxiety.

CBT for the treatment of child anxiety disorders: a review of why parental involvement has not enhanced outcomes

Anxiety affects 10% of all children and disrupts educational, socio-emotional development and overall functioning of the child and family. Research has shown that parenting factors (i.e. intrusiveness, negativity, distorted cognitions) contribute to the development and maintenance of childhood anxiety. Recent studies have therefore investigated if the treatment effect of traditional cognitive behavioural therapy may be enhanced by adding a parental component. However, randomised controlled trials have not shown unequivocal support for this assumption. The results are inconsistent and ambiguous. This article investigates possible reasons for this inconsistency and in particular differences in methodology and the theoretical relevance of the applied parental components are highlighted as possible contributory factors. Another factor is that treatment effect is mainly measured by change in the child's diagnostic status rather than changes in parental or family functioning.

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

The main objectives were to evaluate efficacy and acceptability of a developmentally sensitive cognitive behavioral therapy for anxiety-based school refusal in adolescence. Twenty school-refusing adolescents meeting DSM-IV anxiety disorder criteria participated in a non-randomized trial, together with parents and school staff. Outcome was assessed at post-treatment and 2-month follow-up. Treated adolescents showed significant and maintained improvements across primary outcome variables (school attendance; school-related fear; anxiety), with medium to large effect sizes. Half of the adolescents were free of any anxiety disorder at follow-up. Additional improvements were observed across secondary outcome variables (depression; overall functioning; adolescent and parent self-efficacy). The treatment was rated as acceptable by adolescents, parents, and school staff, which may help explain the very low attrition rate. Social anxiety disorder was the most common disorder among adolescents still meeting anxiety disorder criteria at follow-up. Treatment modifications to improve efficacy for school-refusing adolescents presenting with social anxiety disorder are suggested.

The Role of Cognition in School Refusal: An Investigation of Automatic Thoughts and Cognitive Errors

Aims: The purpose of this study was to investigate the cognitions of anxious school refusers. The cognitive constructs under investigation included negative cognition commonly linked to youth anxiety (i.e. negative automatic thoughts and cognitive errors) and positive automatic thoughts. Method: The cognition of school refusers (n = 50) and youth from a community sample (n = 181) was assessed with the Children's Automatic Thoughts Scale-Negative/Positive and the Children's Negative Cognitive Error Questionnaire-Revised. Results: When controlling for anxiety, school refusers were found to report more negative automatic thoughts concerning personal failure, fewer negative automatic thoughts concerning hostility, and fewer positive automatic thoughts. Negative automatic thoughts concerning personal failure and hostility, and the negative cognitive error of overgeneralizing were found to independently predict school refusal. Conclusions: The findings underscore the importance of further researching the role of cognition in the development, maintenance, and treatment of anxiety-based school refusal.

Cognitive Behavioral Therapy for Anxiety Disorders in Youth

Cognitive-behavioral therapies (CBTs) have been shown to be efficacious for the treatment of anxiety disorders in children and adolescents. Randomized clinical trials indicate that approximately two-thirds of children treated with CBT will be free of their primary diagnosis at posttreatment. Although several CBT treatment packages have been investigated in youth with diverse anxiety disorders, common core components have been identified. A comprehensive assessment, development of a good therapeutic relationship and working alliance, cognitive restructuring, repeated exposure with reduction of avoidance behavior, and skills training comprise the core procedures for the treatment of anxiety disorders in youth.