Webinar Q&A Recap on School Refusal Behavior

Webinar Q&A Recap on School Refusal Behavior

Q: My son is generally anxious and has trouble sleeping at night due to insomnia. Now that he is 18, it is physically impossible to get him out of bed at times. I have taken away things that he enjoys – his cell phone and access to music plus no rides to see friends or go to stores. But this does not help. Then I have given him difficult chores to do when he stays home to see if this encourages him to prefer to go to school. This idea does not help either. What can I do to motivate him to go to school?
This is a case of a mom who is willing to do the behavioral work, which is usually what people hesitate to do. She has seen very little response to this approach, which leads me to believe there is a deeper emotional issue that needs to be addressed. If a student is truly depressed, there’s not a clear positive or negative motivation for staying home. You cannot motivate a seriously depressed person to go to school so I would suggest a thorough psychiatric diagnosis for this student and getting into therapy to understand the severity of the depression. Then understand the form (how) and function (why) of it and that will guide the interventions.
Q: How do you distinguish school refusal behavior from untreated anxiety or depression?
One could have school refusal behavior and not have any anxiety or depression. The key is to understand the form and function to see if there is real anxiety. A good clinician will be able to pick up on whether there is really debilitating anxiety or depression.
Q: What about a child with attachment issues? Often the consequences/reward system has no effect.
You have to treat the attachment disorder. Here is a case when the behavioral stuff isn’t likely to work. This might be a case in which the student has had trouble making a connection and now you’re trying to help this person form a connection. Obviously attachment disorders are complex and are difficult to treat and this takes time. The attachment issue may be the underlying cause of the school refusal behavior, or there may be something else at work. I think the other thing you need to keep in mind is what we said earlier about diagnosis. School refusal behavior is not usually tied to a single diagnosis. I would dig into the function a little bit and see what else might be causing the school refusing behavior.
Q: How effective is it to involve the local police as a step to assist a parent in getting a student who refuses to get out of bed to go to school after school refusal has cycled between improvement and regression?
In most cases, you don’t have to use the courts or police. Police or court involvement may be necessary in cases where you have a school refusing student as well as a school refusing parent – an adversarial situation. We don’t come across this all that often but you have to remember and underscore that it is ultimately the parents’ job to get the student to school. Often they will want make it our responsibility. The school is responsible to the extent that we have to understand what is going on,  to formulate appropriate  interventions and try to make school the most inviting place as possible, but the parents have to be the authority in this case.
Q: What about the students whose parents are not cooperative?
This is the step where you might have to involve law enforcement. This is rare but at times getting the law involved can be the most empathic thing. If there is no movement the prognosis for a productive adulthood is compromised. Sometimes those measures that seem un-therapeutic actually help people engage in a therapeutic process.
Q: I am a school counselor and have a particularly challenging student who has no problem with coming to school but does nothing while he is here. Have you had similar cases? What interventions have worked?
Well that’s similar to a case presented earlier when the school refusal was taking the form of not performing in school. It’s hard to say, because there is not one thing that is causing that. It could be that something is being acted out, such as an authority issue. Or, there may be an undiagnosed learning disability in which  the student is not working because the student is afraid to show the disability; he or she may feel humiliated. I think we have to be patient and ensure we understand the function of the work refusal in this case.  Many times, a student at Sage will be happy to come to school but is not ready to do work. Understanding the purpose of not doing the work or identifying the disability that may get in the way is important. You don’t want to just assume the student is being resistant and rebellious because there could be something else getting in the way. Work refusal is on the continuum of school refusal, and, as with any instance of school refusal, understanding the function is essential.
Q: In a public school what should the roles be of all involved (Principal, CST, Guidance, Teachers, Nurse, Attendance office?) Who should take the lead?
It could be any of those people taking the lead. At Sage Day it is usually the case manager, or therapist, but there is a whole team of teachers, the principal, clinical directors all intimately involved. If it is a non-classified student, it could be the SAC, or the guidance counselor. If it’s a classified student it is usually the case manager that gets involved.  One job of that point person is to make sure the teachers understand if any special accommodations need to be made.  For instance, if a student has permission to leave class if he or she feels anxious, the teachers will need to know that and to help the student leave the class without a lot of attention. By in large teachers are understanding to what’s going on if they are adequately informed as to what is going on and what is needed.
Q: What is the best way to engage parents struggling with their child refusing to attend school? 
Your goal is to establish the parent as an ally in helping the student return to school. Remember that your interventions in school refusal should always be driven by your assessment of form, function and family dynamics.  If the function of the school refusal is driven by positive reinforcement you need to assess what need may be inducing the parent to allow the child to stay home. If the school refusal is driven by negative reinforcement, you will need to support the parent in encouraging the student to face a school-based source of stress.  In a conflictual family you will need to lay the groundwork for some basic agreements between parent and child.  In an enmeshed family you will need to interrupt the comfortable dyad between parent and child and help parents see that school attendance will be in the child’s best interest. In an isolated family you will need to help reduce the family’s perception that school is an unsafe place.  Always bear in mind that parents who display resistance are clinging their customary solutions based on fear of unpleasant alternatives.  It is important to respect defenses and move slowly.
Q: How do you decide when public school is not the least restrictive environment?
The public school is commonly understood to be the least restrictive environment because the mainstreamed student is not relying on as many supports and special services as he or she would be in an out-of-district (OOD) placement. You can tell that the mainstream public school environment is not least restrictive for the student when the student is not able to participate in his or her program with a general sense of ease and consistency.  Students who frequently seek out the school nurse for non-medically based somatic issues, or who are frequently absent, or who are unable to remain in class without distress or disruption are likely demonstrating that the mainstream environment is actually too restrictive for them.  Some of these students can remain in the mainstream environment with regular therapeutic support. Others may require the more intensively supportive milieu of a small therapeutic school.
Q: What are some strategies in transitioning students back to school, after receiving home instruction for school phobia? 
Transition is a process that has to be tailored to the specific needs of the student. When transitioning from home to school, we try to move the contact with the student out of the home as soon as possible and to gradually increase the time the student can be in school. If a student is not able to enter the school, choose another public site to do the tutoring and counseling. The time frame could be 1 week – months depending on the unique circumstances. It is important to have a lead person to help coordinate the transition back into school. The lead person is usually the case manager or someone serving a counseling function for the student. When ready to come into the building we have had students come in after school or in between classess for counseling sessions and to slowly move them into spending more time during the day, starting with classes that the student can manage. If there is a self-contained classroom that may be used for the academic transition.
Q: How do you effectively work with parents who have difficulty setting limits or have limited insight into the dynamics that often perpetuate school avoidance/refusal? 
Once an assessment has been made and there is an understanding of the form and function as well as the family dynamics it is important that the person working with the family share their observations as to the dynamics of the behavior.  If there is a dynamic where the mother is over involved with the student and the father is under underinvolved, the therapist can help the parents come up with expectations for each other and for their child and work to help the parents to support each other and hold firm when the student resists.  The parents need to be prepared that the student may up the ante but that they will need to hold firm to their expectations.  The therapist’s support of the parents is important.  In addition the therapist needs to help  the student to  accept the change in dynamics and understand the consequences to not following through.
Q: What can be done to get a student to school, when the parent is working and the student goes back to sleep after the parent leaves for work ? Assuming that the student is not suffering from debilitating depression and is moreso in an oppositional position, the parents will need to be clear on the expectations of school attendance and to be clear on what the consequences will be for not attending school. In addition,  if a student does stay home, staying home must not be rewarding,  no tv, no computer,  no leaving the house, no use of  cell phone, etc. Both parents may need to change their work schedule to go in later to let the student know that things are going to change and so the parents are presenting a united front. These measures usually result in a change,  but in extreme cases, parents may need to get the equivalent of the family Crisis Unit involved which could bring the student in front of the judge who has clear consequences if the student continues to refuse.
Q: What are some strategies to re-integrate students into school after they have been out for an extended period of time due to school refusal? 
The most important first step is to establish a relationship and working alliance with the student. Begin by meeting the student where he or she is. When the student won’t come to you, you may need to start with a home visit. As soon as you can, begin moving your meetings with the student outside the home. If the student isn’t quite ready to meet you in the school building, you can meet at a coffee shop, a library or other alternate site. Always move away from home toward school while establishing your working alliance. This allows you to begin to provide a holding, soothing function, that the student can lean on when he or she is experiencing the stressful transition back to school. For students prone to panic episodes, move slowly and provide relaxation techniques. A second key step is to build a team of professionals to support the student. Your team should include teachers, guidance counselor, case manager, the principal and any other key personnel who will be working with the student. Consider the following questions:
– When the student begins returning to school will he or she need someone to meet him/her at the door?
– What classes will the student attend?
– Will there be a modified schedule?
– How will the schedule change over time?
– What experiences will likely trigger distress in the student?
It is vital to make sure the student knows the options available when he or she begins to feel distress.