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§ Sent him to school when he had strep throat. Did not find out
until after school.
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He used it against parents.
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Turned around on him. His behavior has lowered trust in his judgment.
Case examples
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Complications
§ Case where patient vomited in school due to anxiety.
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School adjusted rules to allow him to stay in school when vomiting.
§ Suicidal threats.
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Patient whose SRAS indicated Attention Getting Behavior, made
threats to harm self when school attendance was proposed.
§ Parents took it seriously.
§ No discussions.
§ Took patient to hospital at threats.
§ No time with friends while she was suicidal.
Case examples
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Complications
§ Family and student not invested in treatment.
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There by court order.
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Agreement with school.
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Stay firm with family. Cancel treatment and report follow up.
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Family needs to understand seriousness of school refusal.
§ Child resisting all behavior plans/parents struggling with behavior
plans.
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Find out local laws
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Truancy
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Child Protective Services
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Get parents to commit to filing with courts or family with service needs.
Accommodations
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Accommodations to increase school attendance.
§ Alter school schedule.
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What classes are needed.
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Start later in day or end early in day.
§ Set up a point person with whom parents/student discusses
problems.
§ Passes
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Passes with limits: Example: 5 passes a week for 10 minutes
§ Makes child think about when they really need it.
§ Less likely to use multiple passes on Monday.
Accommodations
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Make up work
§ Work with school to identify the necessary assignments
§ Tutoring/extra help
§ Keep contact with school to assess make up work.
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Are teachers following plan.
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Find point person to help advocate for student with teachers.
Treatment structure
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Session frequency/duration
§ Tolin, et. al (2009)
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15 sessions over 3 weeks.
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2 hours per session
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75% returned to school
§ Other schedules
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Weekly
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Twice weekly
Treatment structure
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Where
§ In office
§ At school
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Dealing with privacy
§ Other locations that bring on anxiety
§ At child’s home
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Mornings before school. Work with parents.
Treatment structure
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Timing of transition
§ Take an assessment of the child and their ability to transition.
§ In general a moderate pace is most effective. Increase time in
school over 2-3 weeks.
§ Drawing it out much longer can lead to problems.
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Each transition (increase in schedule) can be taxing. You run the risk of
prolonging this process and reinforcing anxiety over school.
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Run into vacations, which tend to bring up avoidance.
§ Some students may choose to make a big leap to avoid
questions from peers. Assess their readiness.
Results
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CBT is effective in transitioning children back to school
§ Heyne, et al. (2011):
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Increase in school attendance.
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Decrease in anxiety
§ King, et al. (1998).
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4 week CBT
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Increase in school attendance
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Improvements in self reports of anxiety and depression
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Improvements in ratings by parents and clinicians
§ King, et al. (2001)
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Follow up on 4 week program.
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18% showed attendance problems.
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3-5 year follow up: 84% rate of attendance
Results
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CBT is effective in transitioning children back to school
§ Heyne, et al. (2002)
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Parental involvement associated with increased school attendance.
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Parental involvement associated with fewer internalizing problems.
§ Case Studies: Show improvement in school attendance.
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Tolin et al. (2009)
§ *75% improvement, but relapses. 75% completed school in other formats
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Kearney (2002)
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Kearney (2001)