Evaluation of Child Therapy and Caregiver Training in the Treatment of School Refusal

doi:10.1097/00004583-200206000-00008

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 41, Issue 6, June 2002, Pages 687-695

https://doi.org/10.1097/00004583-200206000-00008 Get rights and content

ABSTRACT

Objective

To evaluate the relative efficacy of (1) child therapy, (2) parent/teacher training, and (3) the combination of child therapy and parent/teacher training in the treatment of anxiety-based school refusal.

Method

Sixty-one school-refusing children (aged 7–14 years) from throughout Melbourne, Australia, were randomized to a child therapy program, a parent and teacher training program, or a combination of the two. Children were assessed before and after treatment, and at 4.5-month follow-up, by means of attendance records, self-report of emotional distress and self-efficacy, parent and teacher reports of emotional distress, and clinician ratings of overall functioning.

Results

Statistically and clinically significant pretreatment-posttreatment change occurred for each group. Immediately posttreatment, child therapy appeared to be the least effective in increasing attendance. By follow-up, the attendance and adjustment of those in the child therapy group equalled that of children whose parents and teachers were involved in treatment, whether on their own (parent/ teacher training) or together with their children (combined child therapy and parent/teacher training).

Conclusion

Contrary to expectations, combined child therapy and parent/teacher training did not produce better outcomes at posttreatment or follow-up.

Section snippets

SUBJECTS

Subjects aged between 7 and 14 years were drawn from the School Refusal Clinic (SRC), located in the Child and Adolescent Mental Health Service at Monash Medical Centre in Melbourne, Australia. Referrals were made by education staff, mental health professionals, and general practitioners. In some cases families were self-referred.

Children and adolescents were selected into the study on the basis of the school refusal criteria provided by Berg and colleagues (Berg, 1996;Berg et al., 1969),

PRETREATMENT COMPARISON OF GROUPS

The three treatment groups were comparable on all of the demographic characteristics and all of the variables pertaining to school refusal behavior. Likewise there were no significant differences between the groups on any of the dependent variables at pretreatment.

TREATMENT OUTCOME

Significant phase effects (p values < .001) indicated improvement over time, across the treatment conditions, for all of the measures of child functioning.

DISCUSSION

For children in all three treatment programs, improvements in attendance were accompanied by a reduction in emotional distress and an increase in self-efficacy. The clinical significance of this change is perhaps best reflected in the diagnostic composition of the sample. Whereas every child warranted at least one DSM-IV disorder at pretreatment, 69% of the children no longer met criteria for an anxiety disorder at follow-up, and 60% did not meet criteria for any disorder. The outcomes for

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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.
Supporting the parents of children and young people with anxiety and depressive disorders is an opportunity not to be missed: a scoping review
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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.
Antidepressant Medication: Is It a Viable and Valuable Adjunct to Cognitive-Behavioral Therapy for School Refusal?
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Cognitive-behavioral therapy (CBT) is an evidence-based treatment for school refusal. However, some youth do not respond to CBT. The serious risks associated with school nonattendance call for novel approaches to help those who do not respond to CBT. Because school refusal is commonly associated with anxiety disorders, and the combination of CBT and antidepressant medication enhances outcomes in the treatment of anxiety disorders, combined treatment may be effective for school refusal. This narrative review evaluates the current evidence base for adding antidepressant treatment to CBT for school refusal. Six randomized controlled trials (RCTs), two open trials, six case studies/series, and one observational study were identified and reviewed. There is support for combined CBT and imipramine, but this medication is not typically used due to the risk of concerning side effects. Two recent RCTs failed to provide evidence for the superiority of combined CBT and fluoxetine. Further research in this area is required because the extant studies have a number of methodological limitations. Recommendations are provided for clinicians who consider prescribing antidepressant medication or referring for adjunctive antidepressant treatment for school refusal.
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Citation Excerpt :
The distinction between SR and TR is based on the notion that SR involves the following: reluctance or refusal to attend in association with emotional distress (e.g., Bahali, Tahiroglu, Avci, & Seydaoglu, 2011; Carless, Melvin, Tonge, & Newman, 2015; Doobay, 2008; Egger et al., 2003; Havik et al., 2015a; Heyne et al., 2002; Maric, Heyne, MacKinnon, van Widenfelt, & Westenberg, 2013; Martin, Cabrol, Bouvard, Lepine, & Mouren-Simeoni, 1999; Maynard et al., 2015; Nuttall & Woods, 2013); the absence of serious antisocial behavior (e.g., Bernstein et al., 2000; Doobay, 2008; Hella & Bernstein, 2012; Honjo et al., 2001; McShane, Walter, & Rey, 2001; Place, Hulsmeier, Brownrigg, & Soulsby, 2005); and the young person staying at home and/or not concealing their absence from parents (e.g., Hansen, Sanders, Massaro, & Last, 1998; Hughes, Gullone, Dudley, & Tonge, 2010; Kameguchi & Murphy-Shigematsu, 2001; Okuyama, Okada, Kuribayashi, & Kaneko, 1999; Timberlake, 1984; Wu et al., 2013). Differentiation between SR and SW is often based on parents having made reasonable efforts to enforce school attendance or expressing their commitment to work towards school attendance (e.g., Heyne et al., 2002; Maric, Heyne, de Heus, van Widenfelt, & Westenberg, 2012; McKay-Brown et al., accepted; Melvin et al., 2017). Anecdotal support for differentiation between SAP types is not confined to its common practice.
School attendance problems (SAPs) are heterogeneous with respect to etiology and presentation. The long history of conceptualizing SAPs has led to a vast array of terms and definitions as well as different perspectives on the most helpful approach to classification. For educators, practitioners, researchers, and policymakers, this presents a challenge in understanding, assessing, and intervening with SAPs. This paper outlines evolution in the conceptualization of SAPs, focusing on two contemporary approaches to differentiating between them. One approach draws on the longstanding differentiation between SAP types labeled school refusal, truancy, and school withdrawal. A fourth type of SAP, labeled school exclusion, is also considered. The other approach focuses on the function of absenteeism, measured via the School Refusal Assessment Scale (SRAS). Anecdotal and scientific support for the SAP typology is presented, along with the benefits and shortcomings of the SRAS approach to differentiation. The paper offers suggestions for how to differentiate between SAPs and introduces the SNACK, a brief screening measure that permits differentiation by SAP type.
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: This study was conducted with the support of the National Health and Medical Research Council (project grant 940572 ).

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ARTICLESEvaluation of Child Therapy and Caregiver Training in the Treatment of School Refusal

ABSTRACT

Objective

Method

Results

Conclusion

Section snippets

SUBJECTS

PRETREATMENT COMPARISON OF GROUPS

TREATMENT OUTCOME

DISCUSSION

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Behav Res Ther

Behav Ther

Clin Psychol Rev

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Manual for the Child Behavior Checklist/4–18 and 1991 Profile

Manual for the Teacher's Report Form and 1991 Profile

Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)

Family treatment of childhood anxiety: a controlled trial

J Consult Clin Psychol

School avoidance, school phobia, and truancy

School phobia: its classification and relationship to dependency

J Child Psychol Psychiatry

Social stratification in Australia

ARTICLES
Evaluation of Child Therapy and Caregiver Training in the Treatment of School Refusal