Sunday, March 29, 2015

School refusal and kids: What can you do?

"School refusal" refers to repeated instances of absenteeism for what are "non-legitimate" reasons. Here's what you can do to help your child return to school.

School refusal and kids: What can you do?

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A significant part of my work as a cognitive-behavioral therapist specializing in anxiety and related disorders is providing families with recommendations for good resources. “Good resources,” in these cases, are usually books and websites that offer general, up-to-date information on the disorder for which I am treating the child, as well as sound suggestions for at-home interventions (i.e., parent manuals).  Of course I provide such psychoeducation in session, but I like parents to be able to hear the information more than once, from more than one source, and for it to be accessible to them outside of the therapy hour.

What I do not want is for families to garner information or recommendations for treatments from “unsafe” sources – that is, sources that provide information that is not scientifically supported or has been directly contradicted by science.  In fact, I explicitly warn families about this, because there is so much misinformation on the web. During initial sessions, when giving my families handouts printed with what I think are the best and safest sources of information on their child’s disorder and treatment for that disorder, I typically say: “Please DO NOT put the name of your child’s diagnosis into Google search and hit ‘return.’ You will receive millions of hits, many of them from untrustworthy sources having something to sell, and you will feel even more overwhelmed than you already do.  Instead, start with these I am recommending – you can always read more later.”

I've given my recommendations for resources on obsessive-compulsive disorder,for children who have difficulty with pill swallowing, and tic disorders. What follows are my current recommendations for good resources on school refusal.

School Refusal:

I see lots of desperate parents in my office, and the winners of the tearing-their-hair-out sweepstakes are those with the school refusing child.  “School refusal” refers to repeated instances of absenteeism for what are “non-legitimate” reasons. Contrast: “I’m in a coma” or “I have a measurable fever” with “I have a stomach ache/head ache/muscle ache/just don’t feel quite right – but all that clears up magically when you say I can stay home!” 

Children can miss half days or full days, just a few days or a full semester.  The start of the school year and the return after winter/spring vacation are the harshest times and Mondays are the cruelest day.  While their parents plead (often loudly!) their children cry, freeze, dawdle, refuse to get ready, refuse to leave for the bus, refuse to get out of the car, refuse to listen to reason, and everyone just feels helpless and lousy.

School refusal used to be termed “school phobia,” but that’s a misnomer – there are plenty of things other than “fear of school” that keep a child preferring home over attending school.  Research suggests that there are a few main reasons that children to refuse school, which can occur in combination: separation anxiety, avoiding painful emotions they may encounter at school (performance anxiety, social anxiety, loneliness, boredom), the myriad rewards of staying at home (Video games! All day video games!). Prevalence studies suggest that between 5-10% of children show school refusal behavior and that it is most likely to start at two ages: 5-6 (entry to KG or elementary school) and 10-12 (entry to middle school).

There are no well-established, evidence-based treatments for school refusal. Too often, I hear of clinicians spending session after session talking with a child individually about why he doesn’t want to attend school.  This is a shame because, in my experience:

  1. NO AMOUNT OF JUST TALKING will get a child to return to school.
  2. The longer a child is out of school, the harder it is to get him back (he gets used to staying at home, and distress about what he would possibly tell peers about why he was away/why he is back mounts with each passing day).

However, the available research supports behavioral therapy, specifically a combination of the empirically supported treatments for anxiety (gradual exposure) and oppositional behavior (parent training in contingency management). That is, successful treatment usually involves a combination of helping a child develop some coping strategies to get back into the school building while working with parents to provide a system of reinforcement for increasing attendance and eliminate any tangible rewards for staying at home (i.e., access to preferred activities). School personnel must be involved in the treatment.

Books:

There is only one I recommend: Christopher Kearney’s Getting Your Child to Say ‘Yes’ to School: A Guide for Parents of Youth with School Refusal Behavior.  Kearney is the national expert on assessment and treatment of school refusal, and his book is refreshingly no-nonsense.

Online:

No family with a school refusing child leaves my office without the following handouts, all of them short and all of them free off the web. I ask parents to copy them and give to any caregiver in the child’s life (teachers, doctors, grandparents, nannies, etc):

Interview with the Expert: Dr. Christopher Kearney on School Refusal 

“School Refusal in Children and Adolescents,” from the American Academy of Family Physicians

Mary Wimmer’s “School Refusal: Information for Educators” from the National Association of School Psychologists.

Hilarity Corner:

Shel Silverstein’s classic children’s poem “I Cannot Go to School Today!” (psst: It’s actually for parents). (And, come to think of it, it’s really not all that funny).

Finally, parents, are there any requests for future blog posts on recommended resources?


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Katherine K. Dahlsgaard, Ph.D. Lead Psychologist of The Anxiety Behaviors Clinic at Children's Hospital of Philadelphia
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The Healthy Kids blog is your window into the latest news, research and advice around children's health. Learn more about our growing list of contributors here.

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Anna Nguyen Healthy Kids blog Editor
Sarah Levin Allen, Ph.D., CBIS Assistant Professor of Psychology at Philadelphia College of Osteopathic Medicine
Stephen Aronoff, M.D., M.B.A. Chair of the Department of Pediatrics at Temple University Hospital
Peter Bidey, D.O. Medical Director of Family Medicine at Philadelphia College of Osteopathic Medicine
Christopher C. Chang, MD, PhD, MBA, FAAAAI, FACAAI Associate Professor of Medicine in division of Rheumatology, Allergy and Clinical Immunology at UC Davis
Katherine K. Dahlsgaard, Ph.D. Lead Psychologist of The Anxiety Behaviors Clinic at Children's Hospital of Philadelphia
Gary A. Emmett, M.D., F.A.A.P Director of Hospital Pediatrics at TJU Hospital & Pediatrics Professor at Thomas Jefferson Univ.
Magee DeFelice, M.D. Division Chief of Allergy and Immunology at Nemours/Alfred I. duPont Hospital for Children
Hazel Guinto-Ocampo, M.D. Chief of Pediatric Emergency Services at Nemours duPont Pediatrics/Bryn Mawr Hospital
Rima Himelstein, M.D. Adolescent Medicine Specialist at Crozer-Keystone Health System
Jessica Kendorski, PhD, NCSP, BCBA-D Associate Professor in School Psychology/Applied Behavior Analysis at Philadelphia College of Osteopathic Medicine
Anita Kulick President & CEO, Educating Communities for Parenting
Janet Rosenzweig, MS, PhD, MPA VP for Programs & Research for Prevent Child Abuse America
Beth Wallace Smith, R.D. Registered Dietitian at Children's Hospital of Philadelphia
Emiliano Tatar, M.D. Pediatrician at Einstein Healthcare Network Roxborough Plaza
Jeanette Trella, Pharm.D Managing Director at The Poison Control Center at CHOP
W. Douglas Tynan, Ph.D., ABPP Director of Integrated Health Care for American Psychological Association
Flaura Koplin Winston, M.D., Ph.D. Scientific Director of the Children’s Hospital of Philadelphia’s Center for Injury Research and Prevention
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