Evidence-Based Treatments for School Refusal Behavior

Whether you’re a parent whose child has difficulty attending school, or a school counselor or mental health professional trying to navigate this issue, you’re likely asking yourself, “What can I do?”

The problem with trying to treat school refusal behavior, at least in my opinion, is that each person is incredibly different. School refusal behavior is not a diagnosis. This is not like an anxiety disorder or depression where there are common elements or features that are shared. Unfortunately, this makes creating one treatment that is effective for all, VERY difficult. This is why some of the research shows mixed results to date. As a provider who regularly treats this issue, it is incredibly humbling. The treatments are a blunt instrument, not a finely tuned tool. But we do the best we can.

At least 3 studies have outlined the diagnostic features of kids who show school refusal behavior. Bear in mind that these are not massive studies and are based only on about 200 kids. But that’s all we can work with right now.

For Young Kids, Aged 9 And Below:

It seems that about 50% experience separation anxiety. This actually makes a lot of sense when you think about it. Developmentally, this is the time period when kids start to separate more from their parents and when many kids experience difficulty doing so. It makes complete sense that kids with separation anxiety would be associated with difficulty attending school: They don’t want to leave their parents when school begins!

For Kids Aged 10-14:

The results are more varied and there seem to be more co-occurring issues. For example, for kids this age who demonstrate school refusal behavior, there seems to be a 1/3rd chance that they meet criteria for at least one of the following disorders: Oppositional Defiant Disorder, Generalized Anxiety Disorder, Separation Anxiety Disorder, Social Anxiety Disorder, and/or Depression. This hopefully demonstrates how varied this issue really is.

For Kids Who Are Older:

There appears to be less data specific to this population, so the general presentations are unclear.

 

As I’ve previously discussed, we also know that the reason for school refusal behavior may not be related to any mental health disorder. It’s actually the function of the refusal behavior that is more important. But with all this information it just feels so confusing where to even begin! 

Evidence-Based Interventions for School Refusal Behavior

So what is the best intervention for this group? If your child shows school refusal behavior what sort of things should you consider? There are LOTS of interventions available to you. My goal is to talk more about what options exist, and when there is research on that intervention, what it shows. I’m going to try and give you practical steps to address the issue.

If It Were Easy You Would Already Have Solved It

Remember this: If your child starts refusing school I’m assuming you’ve already tried various tactics to get them to go back. This is not a matter of them just “getting over it.” If it were, schools wouldn’t be struggling so much with the issue and you wouldn’t be reading this article. This is hard stuff and you’re going to have to bring out the big guns (metaphorically of course) to solve it.

Today’s article will focus on one evidence-based intervention called cognitive-behavioral therapy. The short of it is that cognitive behavioral therapy (CBT) for school refusal behavior is effective, but the research has a LOT of shortcomings. I aim to take you through them all. Next time, I will present other interventions and the research behind them. For example, there are school-based and community interventions, in addition to various practical steps you can take. For now, let’s get to CBT.

Cognitive Behavioral Therapy for School Refusal Behavior

There are at least 6 randomized controlled trials (RCTs) on cognitive behavioral therapy. It is by far the most researched intervention, and it’s the only one to date with enough research to say that it is an evidence-based intervention. RCTs are the gold standard type of study. Let’s look at one example of a RCT examining cognitive-behavioral therapy for school refusal behavior:

King et al. (1998) recruited 34 kids who showed “persistent” school refusal behavior aged 5-15 years old. Seventeen of these kids were assigned to a 4-week CBT intervention, and the other seventeen had to wait 4 weeks on a waitlist until they could receive this intervention. They do this design so they can test an intervention against no treatment (i.e. the kids waiting for treatment), and then give the remaining kids the treatment too, in order to be ethical.

The CBT intervention for kids was 6 sessions where they were taught relaxation, some ways to restructure their thoughts, and then were reintroduced to school gradually through exposure. The parents received 5 sessions focused on contingency management, rewarding attendance and routines, and ignoring certain behaviors. After treatment, the researchers followed up again 12 weeks later.

What Did They Find?

Before treatment the kids were attending around 60% of their school classes on average. After treatment they were attending over 90% of their classes. After 12 weeks this progress was maintained. In addition, in general both kids and parents reported that anxiety and depression were about 20% better, although this is a gross generalization as they studied many factors.

What Does The Research In General Find?

This study is just one example, but in general the research on CBT intervention studies show that school attendance can be improved. This is not shown by all the studies, but most of them report this finding. There is also research that parents might play a critical role in treatment outcome, specifically depending on their level of accommodation, but we need further studies to know for sure. The research is mixed on whether outcomes like anxiety and depression can be improved within the timeframe of the studies. One theory is that going to school itself is the main treatment to alleviate the various problematic psychological factors, and thus it will take time for anxiety and depression to improve. I think this is probably accurate. I also think this shows that school refusal behavior and anxiety/depression are not completely linked. That is, you can turn around school refusal behavior without needing to necessarily fully treat anxiety or depression.

What Are The Problems With The Current Research?

I think there are a ton of problems in the research, and I’m going to take you through some of them so you can be an informed consumer. I think we have a long way to go to be expert at treating this issue.

First, most of the RCTs came out before smart phones and Internet use were common, and I think these are huge barriers to getting kids back to school. When a child refuses school, one of the interventions we use is to make home boring. However, when a child stays home these days, they are often using the Internet or their phone. That can be much more fun than going to school! It’s very difficult to block all technology in a household, so this presents parents with an extreme challenge. This is a big statement, but because most RCTs came out before the widespread use of phones, I think they could all be near redundant at this point. Just so you know (as far as I can find) I think there are only three RCTs published in the last 17 years, and only one in even the last 10 years!!!! That’s right…. one. I’ll write more on this issue another time.

Second, most studies only examine cases where anxiety is present. This means there is almost no guidance on treating the at least 50% of school refusal situations where there is no obvious anxiety. When a child who doesn’t have anxiety shows school refusal behavior, the research doesn’t help us on how to help that person.

Third, researchers rarely ever seem to define what constitutes “problematic school refusal behavior.” For example, in the above study the definition is wide. There are kids who have completely refused all school, and there are cases where refusal is very minimal. It’s therefore unclear whether interventions are applicable to the whole spectrum of cases. This is actually a really frustrating problem as it limits our ability to use interventions appropriately. For example, do the kids with complete refusal behavior need more treatment? Studies don’t really break this down enough.

Fourth, from my anecdotal experience, and also based on data with teens, oppositional behavior is quite common and adds a lot of complexity, yet it is often deliberately excluded in studies. This doesn’t give us much guidance on whether intervention for this group is effective or whether they need something different. The studies lack what’s called external validity.

Fifth, many studies mostly focus on child intervention. Parents might be included but it’s sometimes only at the end of session and it doesn’t always involve a structured intervention. I find this to be a massive oversight as parent behavior training principles and contingency management must be a critical part of treatment. If we return to my article on why kids refuse school, parents are key, so neglecting to study their role further is a problem.

Sixth, the interventions are extremely brief at only 6 sessions. Like, shockingly so. To give you context, most intervention studies in psychology are at least 12 sessions long. I am actually extremely skeptical about the ability of psychologists to turn around school refusal behavior in just 4 weeks with only 6 sessions. Having dealt with this issue a lot, the results they show are quite frankly miraculous. Many of my peers feel exactly the same way. Most of the literature is clear that this is an extremely challenging issue to treat. For example, more and more inpatient-like settings are popping up over the country because this issue is such a challenge to treat. Yet we have several studies showing that just 6 sessions of therapy completely turn it around. This seems like conflicting information.

I’m not questioning the findings of the research, but I suspect there are significant problems with it that mean the results may not be generalizable. For example, perhaps people in the research study were highly motivated, resulting in amazing improvements. Studies often pay people to participate and I’m sure this could affect findings. Research has also often found effects where participants work hard to meet the expected outcomes, in a self-fulfilling prophecy effect. I’m not sure any of these factors are enough to explain my disbelief, but I wonder whether my first point on technology suggests that the outcomes found almost 20 years ago would not be found today.

Seventh, I would love to know how many studies have been completed but not published because they didn’t find anything: This is called the publication bias and it is actually a huge problem in the research world. Given that school refusal has garnered more and more attention from school districts and providers, I find it fascinating that there are almost no RCTs in recent years and there have not been any great intervention developments in at least 15 years. I wonder whether researchers have just found that it’s hard to treat and if the results aren’t good then they will have difficulty acquiring future funding.

Summary

In summary, there is research to support that cognitive-behavioral therapy can improve school attendance to a “normal” level for school refusal behavior. However, there are problems with the research, and in recent years there has been a massive decline in randomized controlled studies. As such, you should take what the research says with a giant pinch of salt.

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