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

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.

A Systematic Review of Somatic Symptoms in School Refusal

OBJECTIVE

School refusers often display somatic symptoms that are temporally related to school attendance. The aim of this systematic review is to summarize characteristics and causes of somatic symptoms and their management in the context of school refusal. Findings of this review may help clinicians in their daily practice.

METHODS

PubMed and PsycINFO databases were systematically searched (according to PRISMA guidelines) for articles mentioning somatic symptoms in school refusal by May 2020. Among 1025 identified studies, 148 were included.

RESULTS

Unspecific somatic symptoms were frequently the first complaints in school refusal. Abdominal pain, headache, nausea, vomiting, muscular or joint ache, diarrhea, dizziness, fatigue, and palpitation were the most commonly encountered symptoms and were usually not accounted for by an identifiable physical disease. Anxiety was the most recurrent etiology found, but physicians' lack of awareness about psychological comorbidities often delayed psychological/psychiatric referral. Successful therapies consisted of dialectical behavior therapy, anxiety management through relaxation/breathing training, and ignoring the somatic symptoms.

CONCLUSIONS

Somatic symptoms in school refusal are frequent but poorly understood. Their management could include interventions targeting anxiety, psychotherapies such as emotional awareness and expression therapy, third-wave behavioral therapies, and psychoeducation. A multidisciplinary approach through strengthened collaboration between school staff, physicians, and psychologists/psychiatrists is needed to improve well-being in children who experience somatic symptoms as related to school avoidance.