Pediatric Primary Care Case Studies (15 page)

School Refusal Assessment Scale (SRAS)

Kearney and colleagues developed a model of school refusal behavior based on what motivates the child to avoid school; such motivators are what reinforce the child’s behavior (Kearney & Albano, 2004). Four reasons are identified, two based on negative reinforcement (avoid or escape anxiety-provoking situations) and two based on positive reinforcement (gaining pleasurable activities or rewards).
Table 4-1
summarizes these four motivating situations for school refusal behavior (Plante, 2007). In general, children with separation anxiety are motivated primarily by positive reinforcement such as attention from a parent; children with anxiety issues of various types are motivated by negative reinforcement such as escape from school teasing; and children with externalizing behaviors, who are often truants, are motivated by positive reinforcements such as obtaining drugs or video time (Kearney & Albano). There is often an overlap across the functions. A child may start with anxiety/negative reinforcement from being able to escape from school problems, but then as they stay home, also may begin to have positive reinforcers such as television or computer time that also maintain the school refusal behaviors.

Based on this model of what motivates school refusal behavior, Kearney and colleagues developed the School Refusal Assessment Scale (SRAS) (Kearney, 2002, 2006, 2007; Kearney & Albano, 2004). The SRAS measures the four functional areas that are thought to motivate school refusal behavior. There are two versions of the SRAS, one for children (SRAS-C) and one for parents (SRAS-P). Each version has 24 items on Likert scales, scored from 0
(never) to 6 (always). The highest scoring functional area is most likely the main reason for the school refusal behavior. The scales and further information can be found on the Internet.

Once information on the child’s school performance and behavioral concerns are obtained, in addition to the physical examination and medical history information, and the function of the school refusal behavior is identified, you can then develop an appropriate intervention strategy. This will require a team meeting of key individuals, including the family, school personnel, school nurse, mental health personnel, and primary care provider. The meeting may take place at the school and is an opportunity for the primary care provider to experience the child’s school environment and have direct interaction with school staff.

In Katie’s case, school attendance records verify that despite her recent increase in absences, her grades have not changed, and she visited the school nurse on the days she was in school with the primary complaint being nonspecific stomachaches. Behavioral assessments were not completed prior to Katie’s appointment with you. Your contact with the school results in an appointment arranged for the next day with Katie, her mother, and the school psychologist. Based on the results of the parent and child versions of the CBCL, and the discussion with the family, the psychologist notes that Katie has increased anxiety but no other identified behavior concerns. Completion of the SRAS reveals that Katie’s school refusal behavior is related to a desire to avoid school due to anxiety from some peer conflicts and, secondary to that, to obtain attention or positive reinforcement from her mother. A team meeting is scheduled for the following Monday to include both her mother and father, you as the primary care provider, the school psychologist, the school nurse, and Katie’s teachers.

Therapeutic plan: What will you do therapeutically?

As stated earlier, the immediate goal for children and adolescents with school refusal behavior is for the student to return to school (Fremont, 2003). Primary care providers should not provide excuses for school absences unless there is a medical reason for not attending school (Freemont). Treatment will vary based on the age and developmental and emotional needs of the child and the functional analysis of the school refusal behavior. In addition to assisting the child to return to school, the treatment plan may need to include ongoing mental health counseling for the child and/or parents if any family members need treatment for anxiety, depression, phobia, post-traumatic stress disorder, or other mental health concerns. Interventions may concentrate on the child and/or parents and involve school support personnel. The following discussion focuses on approaches for children with anxiety-related school refusal.

The plan to return the child to school often involves systematic desensitization (a gradual return to school) (Fremont, 2003; Kearney, 2006; Plante,
2007). Attending school for part of a day may be less stressful than attending for a full day. It is important that the parents and school personnel be consistent in carrying out the approach of gradual reintroduction. However, if the school refusal episode has not been long, it may be possible to have the student return to school full time immediately (Sewell, 2008).

Cognitive-behavioral approaches may help the child with school refusal behaviors (Fremont, 2003; Kearney & Albano, 2004). Children with anxiety may benefit from relaxation training, both muscle relaxation and controlled breathing. Children with difficulties with peers may benefit from social skills training. Positive reinforcement (e.g., verbal praise, earning time with a valued adult in the school such as a teacher or principal) for school attendance can support the child’s return to school. For older children, contingency management and developing a contract with parents and school personnel can be valuable tools. Older children and adolescents may benefit from understanding the patterns of their own emotional responses and resultant behaviors, such as school avoidance, through the use of diaries, discussions, and counseling. Cognitive restructuring therapy that assists the individual in identifying negative thoughts and modifying these thoughts can be helpful for students with illogical thinking related to their experiences at school. In conjunction with these cognitive-behavioral and counseling approaches, medication for the child’s underlying anxiety or depression problems may need to be considered (Fremont, 2003; Heyne, King, Tonge, & Cooper, 2001; Kearney, 2006).

Parents play a key role in the treatment of school refusal, and must work closely with school personnel to address the student’s school refusal behavior. Behavioral approaches such as systematic desensitization and contingency contracting require intense involvement from parents. Children who require counseling need the support of their parents as they learn how to cope with their anxiety. Parents may need support in recognizing that they are positively reinforcing the child’s school refusal behavior and in addressing their own behavior by learning to provide incentives to the child for coping and disincentives for maintaining the sick role and missing school (Plante, 2007). Parents may need treatment for their own anxiety or other mental health concerns.

School personnel, in partnership with the child’s family and often the child’s primary care provider, will typically develop a detailed management plan for the child’s return to school including how the child’s gradual return to school is to be carried out. For example, will the child take the bus or be brought to school by a parent? Who will meet the child at school? Which classes will the child attend? When will the amount of time at school be increased? Are rewards included for successful attendance? In addition to the management plan, other issues need to be addressed by school personnel. If the child has had an extended episode of school absence, plans for completing missed school work may need to be made. If the motivation for the school refusal behavior was to
avoid some aspect of school, such as teasing by other students or learning problems, school personnel need to address these difficulties.

At the team meeting, Katie’s parents learned about Katie’s general anxiety, and Ms. Murphy acknowledged that she now realized that while she enjoyed having Katie at home with her, that this was not in Katie’s best interest. A plan for gradual reintroduction to school was developed, with her attending half days for the next 3 days and then moving to full days the following week. Katie’s homeroom teacher would meet her each morning and provide support as needed. Missed coursework was discussed and a plan to make up missed assignments agreed on. The school psychologist planned to meet with Katie frequently in the next few weeks and to adjust the need for ongoing sessions as appropriate. Sessions with the school psychologist would focus on relaxation techniques and exploring some of the concerns that Katie has related to school, including assistance with peer relationships. Ms. Murphy decided that she would reward Katie with a special activity when Katie had completed a full week of school, and discussed ways to support Katie interacting more with her peers. In consultation with Katie’s parents, you recommend that at this point Katie does not need medication for her anxiety. However, you will reassess this decision at a follow-up visit. The decision was made that Ms. Murphy and the school psychologist will meet with Katie the next morning to discuss the plan. You plan to call the family and meet with Katie after that discussion to see if she will agree to counseling and the plan as arranged.

When do you want to see this patient back again?

The primary care provider may initiate follow-up with the student’s parent via telephone or written communication within a week to inquire about the effectiveness of the reintroduction plan and with an office visit scheduled in the next few weeks to confirm that the child has returned to school and to follow up on the family’s needs for counseling services. Children who are treated with medications will need to be monitored.

Katie returned for a follow-up visit in one month. She had returned to school, although she still reported stomachaches periodically. Ms. Murphy reported that she did not see any other physical symptoms so encouraged Katie to go to school. She had met with the school psychologist and had learned how to recognize the signs that she was becoming increasingly anxious and how to use some relaxation techniques in response to her anxiety. All of her missed schoolwork had been completed, and her grades seemed to be good. She was interacting more with her close friends, and Ms. Murphy felt that overall Katie seemed happy. Katie spoke more with you and said that she still worried at times, but that school was “OK” and that she was doing more things with her two best friends, including a sleepover planned for the next weekend.

Key Points from the Case

1. School refusal is a common problem that must be addressed immediately using a variety of assessment strategies.

2. School refusal may arise for a variety of reasons; the assessment needs to identify the appropriate causes for the individual child.

3. Management of school refusal requires a team effort, including the child, parents, healthcare provider, and school educators and counselors.