02 School Refusal - Cognitive Behavior

The enclosed techniques and procedures, though generally in the public domain, are an adaption of protocols in a book titled When Children Refuse School – Therapists Guide, written by Christopher A. Kearney and Ann Marie Albano. The book was published by TherapyWorks in 2000. We have obviously adapted the material to meet our purposes. We also have referred to the McCay, Davis & Fanning materials dealing with the specific techniques and procedures in more detail. On the other hand, the Kearney/Albano material is specifically focused on school refusal, and we have used some of their charts and graphs and outline their suggested approaches to using the techniques and procedures. Finally, we have used some information from The Tough Kind Tool Box, by Jenson, Rhode and Reavis, published by Sopris West, 1994.

SICK

“I cannot go to school today”
Said little Peggy Ann McKay.
“I have the measles and the mumps,
A gash, a rash and purple bumps.
I’m going blind in my right eye.
My tonsils are as big as rocks,
I’ve counted sixteen chicken pox
And there’s one more – that’s seventeen,
And don’t you think my face looks green”
My leg is cut, my eyes are blue –
It might be instamatic flu.
I cough and sneeze and gasp and choke,
I’m sure that my left leg is broke –
My hip hurts when I move my chin,
My belly button’s caving in,
My back is wrenched, my ankle’s sprained,
My ‘pendix pains each time it rains.
My nose is cold, my toes are numb,
I have a sliver in my thumb.
My neck is stiff, my voice is weak,
I hardly whisper when I speak.
My tongue is filling up my mouth,
I think my hair is falling out.
My elbow’s bent, my spine ain’t straight,
My temperature is one-o-eight.
My brain is shrunk, I cannot hear,
There is a hole inside my ear.
I have a hangnail, and my heart is – what?
What’s that? What’s that you say?
You say today is …Saturday?
G’bye, I’m going out to play!”

Shel Silverstein

NOTE: This material is a compilation of four protocols to address each of the defined maintaining variables of school refusal. With rare exception, the actual techniques and procedures used are those found in other numbered publications. In order to keep the material focused, we sometimes use different graphs and charts than are found in the more generic uses of the techniques and procedures.

INTRODUCTION

School refusal behavior is a common and highly vexing problem for educators and clinicians. Problematic absenteeism from school has been defined as truancy or school phobia depending on the context or perspective of the observer. But these are dubious labels because they do not represent the recursive experiences that children and their families have when not going to school. School refusal behavior is defined as substantial, child-motivated refusal to attend school and/or difficulties in remaining in classes for an entire day. The behavior essentially represents a child’s inability to achieve or maintain age-appropriate functioning or adaptive coping with school-related stressors for whatever reasons. On the other hand, such behavior is often relationship interactive, and in many cases the family enables or even specifically initiates and maintains the behavior.

Of course there are other reasons that a child misses school including legitimate illnesses, societal or family conditions that predominate in a child’s life. These are not considered in the same class as school refusal which is a choice made by the child for reasons that are not always apparent, or which are not what they seem.

It is important to note that these ‘absences by choice’ may generally be considered as unexcused absences and that three [03] or more such absences constitute truancy in most school districts. Truancy requires a filing by the school district with District Court which normally leads to a hearing in which the court determines liability. Many school districts, either because of feelings of concern for the child or the family, fail to file appropriately. This is not only against the law, it is distinctly, not helpful to the child/family.

If there are other issues which are making the child truant, these issues need to be identified and resolved. If the behavior is clearly the child’s choice and the parents are unable to overcome this attitude and are not enabling the behavior, they clearly need help in addressing these issues. If the parents are consciously or nonconsciously, enabling or initiating and maintaining the behaviors, specific services need to be directed to them. Children with such difficulties are often allowed to fall behind academically when the district tries to ‘work it out’. The result often provides the child an additional reason to refuse school: s/he is too far behind.

The action of bringing the issue to the court is one of ‘focusing’ the participants on the causes of the behavior and exploring effective interventions, before the secondary effects of school absence escalate beyond redemption.

Characteristics

Specifically, school refusal behavior is identified in children aged five [05] to seventeen [17] years of age who:

are completely absent from school, and/or
attend but then leave school during the course of the day, and/or
go to school following intense behavior problems [e.g., tantrums, refusal to move] in the morning, and/or
display unusual distress during school days that leads to pleas for future nonattendance that are directed to parents or others.

School refusal behaviors are thus seen as a spectrum that includes children who always miss school as well as those who rarely miss school but attend under substantial duress. Substantial school refusal behavior is defined as those cases lasting at least two weeks. Acute school refusal behavior refers to cases lasting two weeks to one calendar year, having been a problem for a majority of that time. Chronic school refusal behavior refers to cases lasting more than one calendar year.

It is suggested that 28% of American school-aged children refuse school at one time or another. The characteristic is generally seen equally in boys and girls and among families of various socio-economic status. Dozens of presenting behaviors typify this population, With respect to internalizing problems, the most common are general anxiety, social anxiety and withdrawal, depression, fear, fatigue and some somatic complaints (especially stomachaches, headaches, nausea and tremors), with respect to externalizing behaviors, the most common are tantrums (including crying, screaming, flailing), verbal and physically aggression, reassurance-seeking, clinging, refusal to move, noncompliance and running away from school.

Maintaining Variables

Children generally refuse school for one or more of the following reasons:

for negative reinforcement [i.e., to get away from something unpleasant at school].

Typically this would be to avoid:

school-related objects or situations such as buses, fire alarms, gymnasiums, playgrounds, hallways, and classroom items;
social situations such as interactions with teachers, principals, and peers; and/or
evaluative situations such as tests, recitals, athletic performances, speaking or writing in front of others, or walking into class as others watch.

for reinforcement [i.e., to pursue someone or something outside of school].

Typically this may be related to separation anxiety for younger children. Older children and adolescents often refuse school for tangible reinforcements such as watching television, sleeping, playing sports, shopping, gambling, engaging in social activities with friends, and using alcohol or drugs.

Many children, however, combine these variables. Some children are initially upset about school activities and try to remain at home to avoid them. They may then realize the attractiveness of staying home and thus refuse school for both negative and positive reinforcement. Conversely, some children may miss school for long periods of time for positive reinforcement, but later must return to school and face classes, teacher and peers in an anxiety provoking context. These complex issues must be sorted and dealt with individually.

Protocols

Recognizing the differential aspects of school refusal, this guide presents four basic protocols which include the listed techniques and procedures. When the child refuses school:

to avoid objects or situations: psychoeducation, somatic management skills, gradual reintroduction (exposure) to the classroom setting, and self reinforcement. Protocol for this condition includes the techniques:
- psychoeducation (language and concepts),
- building an anxiety and avoidance hierarchy of stimuli,
- teaching somatic management [relaxation] skills to decrease negative emotional arousal
- conducting systematic exposure [imaginal and in vivo] to anxiety cues identified on a hierarchy in a step-by-step fashion, and
- having the child access self-reinforcement for coping with transient negative emotions.
to escape aversive social and/or evaluative situations: psychoeducation, role-play, practice in vivo, and cognitive error correction. Protocol for this condition includes the techniques:
- psychoeducation (language and concepts),
- teaching the child to identify what s/he tells him/herself in anxiety provoking situations,
- teaching a method to change those thoughts to coping, helpful statement,
- developing graduated exposure to anxiety-provoking social or evaluative situations in session, and
- practicing coping skills in real-life social and evaluative situations.
for attention: parent training in the use of contingency management with specific focus on changing parent commands, establishing routines and setting up rewards and punishments. Forced school attendance is sometimes added. Protocol for this condition includes the techniques:
- psychoeducation (language and concepts),
- restructuring parent requests/directives,
- establishing fixed daily routines,
- setting up punishments for school refusals, and
- setting up rewards for school attendance.
to pursue tangible reinforcement: contingency contracting among all relevant family members. This is done to a) increase incentives for school attendance, b) curtail social and other activities as a result of nonattendance, and c) provide the family with an alternative problem-solving strategy to reduce conflict. Communications skills and peer refusal training are sometimes added to this process. Protocol for this condition includes the techniques:
- psychoeducation (language and concepts),
- setting up times and places to negotiate solutions to problems,
- defining behavior problems,
- designing written contracts between the parents and the child to address the problem, and
- implementing contracts.

The first two protocols are more child-based in nature which contrasts from the third which is more parent-based and the fourth which is family-based. Although the specific protocols are different, a key characteristic of each is reintroducing the child to the school setting. Methods include exposure, physically bringing the child to school, or increasing incentives for attendance; while reducing maintenance or enabling reinforcements.

When multiple maintaining variables are manifest, the clinical supervisor will need to organize the priority schedule for addressing each variable. Obviously, a clear assessment of these variables is important to successful conclusion. The assessment process will need to address specifically the interactive quality of the relationships with families that enable, initiate and/or maintain these behaviors. Observations may include experimental functional analysis. Some experimental variables are suggested at the end of this document.

Assessment

Assessment is of critical importance in determining which of the techniques and procedures need to be addressed in clinical practice. We strongly recommend that a Functional Cognitive Behavior Assessment be completed which includes the Initial Line of Inquiry done in a group with child, parents, teacher and significant others involved; direct observation of child and child managers; and experimental functional analysis to test the hypothesis.

NOTE: be specifically aware of the ‘double bind’ where the parent encourages the child to attend school and even takes action to see that s/he does, while continuing to state reasons why the child cannot comply.

Monitoring

Following the formal assessment, continued monitoring of the child’s daily school refusal behaviors and school attendance behaviors are required to gauge the family’s commitment to homework assignments, increase family members’ awareness of what is happening and note whether positive or negative changes in behavior are occurring across time.

Specifically, ask your clients to provide ratings in CBP#02-001 Child Daily Logbook & CBP#02-002 Parent Daily Logbook. Ratings should be done separately to examine patterns of differences in child and parent ratings and further convey to the child that his or her input will be considered as valuable as his or her parents’ input. Ask parents not to influence their child’s ratings in any way, even if it seems the child is not taking the task seriously or giving very different ratings. Have the parents remind the child to complete the forms. Tell the child to contact you as soon as possible if s/he has a question about what rating to give.

Following consent of the parents, the school should be asked for additional information involving, among other things:

course schedules, grades, written work and required make-up
goals and attitudes of school officials and peers regarding the child
procedures and timeliness for reintegrating the child into school
potential obstacles to reintegrating the child into school
confirmation of past school refusal behavior
general social or other behaviors of the child in school
floorplan of the school [e.g., lockers, cafeteria, library, etc.]
feedback as to the effectiveness of the intervention procedures
disciplinary procedures and procedures for contacting parents
rules about absenteeism, conduct or leaving school areas
alternative school programs
advice previously or currently given to parents about handling the school refusal situation [e.g., home schooling, cyber-charter schools, drug therapy, forced school attendance]

NOTE: Many parents and children experience considerable friction with school officials and may not want you to cooperate with them. In fact, parental anger at school personnel may contribute to a ‘double bind’ message from the parents to the child: on the one hand, ‘those people are incompetent’ and on the other, ‘school is important for you’. Cooperation with school officials is necessary, not only for reintegration and for keeping the child in school, but for sorting out the double bind. Convincing the family to allow you to act as a mediator between them and the school officials may be a viable option, allowing you to both communicate effectively and to model appropriate communication processes.

Effectiveness

Success in this population is sometimes defined as full-time school attendance for at least two weeks and/or a substantial [>75%] reduction in self-reported daily stress level. Each case is different, of course, and so your definition of success may change accordingly. In many cases, full-time school attendance for several weeks or even months is necessary before deciding that the protocol was successful. In addition, even small amounts of remaining distress about school can trigger relapse in some cases. Therefore, a nearly complete eradication of a child’s anxiety about school may also be necessary to define success. However, in other cases, especially more chronic ones, even part-time school attendance in an alternative school may define success. You will need to use your clinical judgement as to whether a particularly family has appropriately reached outcome expectations.

Time for Mastery

The protocol usually includes nine sessions spread over nine weeks. This may vary based on the complexity of the maintaining variables and corollary issues that must be dealt with. It is recommended that you continue follow-up contact for at least three weeks after the primary procedures have been completed and the child is back in school. Some parents and children prefer to end the relationship as soon as this happens, but this is to be discouraged. In many cases, residual problems and questions remain, or the child ‘tests’ his/her parents by refusing school later or ‘tests’ school personnel with atypical behaviors. Issues may develop between the parent or child and school which brings up ‘new’ issues. Teaching both parents and teachers the ‘language’ of supportive, antecedent internal attribution and avoidance of ‘double bind’ messages is relatively easy. Having them incorporate such language into their nonconscious behavior is another thing entirely which requires repetition and habituation.

In other cases, families are beset with problems that go beyond the child’s school refusal behavior. Interventions regarding these other problems should therefore continue even if the child is back in school. Common examples include general family conflict, anxiety, depression, lack of motivation, delinquent and oppositional behavior, learning disabilities, and hyperactivity.

Teaching the skills of child management in regard to school attendance is relatively easy and should not take longer than the time identified. However, school refusal often has related issues which make it difficult for the implementation of these skills. A mother with depression is unlikely to be able to effectively carry out her part of the responsibility unless or until the depression is dealt with.

See Social Learning Family Interventions in the Appendix.

SECTION 1. INSTRUCTIONS

We will first generalize what the typical process is, and then will return to discuss specific techniques used in this process.

THE CONSULTATION SESSION

Begin the consultation by speaking with the child and parents separately and speak with the child first. Remind each party about both the limits of confidentiality and the need for open communication with school or other related parties and discuss the issues or concerns, seeking the widest latitude for openness. Ask about the past few days or week and elicit as much detail as possible about maintaining variables. Once the clients have articulated their understanding of what the variables are, you will be free to raise the specific hypothesis from the FCBA and discuss the family’s perspectives concerning this. Specific feedback can be obtained, for example, about time missed from school, how the time was spent, parental responses to the child’s refusal/replacement activities, etc. Have the parents describe a single day when the child did not go to school and what each [child/parent] did.

Discuss thoroughly the process that you expect to follow and particularly emphasize the use of the daily logbooks. The logbooks provide an excellent assessment of the family’s motivation. If the logbooks are forgotten, incomplete or done haphazardly, this may reflect poorly on the interest or desire for behavior change. In this case, you will need to review the logbook procedures and refer back to what was said in this session. An instructive and directive approach is very useful in this process. Finally, you will want to watch for, and reconcile, any discrepancies between what family members record in their logbooks and what they say to you. Failure to respond to the information in the logbooks will make them irrelevant.

Discuss the assessment results, describing the results with the child and parents separately. Care should be taken not to insinuate blame during this process, but rather to emphasize the multifaceted nature of the school refusal problem. On the other hand, you must be specific about the child, parent and/or teacher behaviors that you believe contribute to the school refusal problem and how the techniques and procedures will provide the skills to change these behaviors.

The child is least likely to see benefit from changing the behavior and therefore you will need to provide for the child a rationale for this intervention. The rationale will usually be predicated on the learned behavior in response to negative feelings and the process of both reducing negative feelings and learning new, improved methods of handling these concerns. The following factors may be included in the rationale.

statement of the problem: experienced trouble going to school
statement of current responses: your present course of action to reduce negative feelings has provided short term gains
flaws in the response: increase failure in life, increased conflict with family and friends, continued negative feelings
responses are learned: you have learned the present response through trial and error; now we want to take a good look and see if we can find a better response
it may get worse before it gets better: at first it may feel even worse, but as you learn the skills, you will be able to control these feelings much better
the question: are you ready to take this responsibility for your own growth and development?

The parents may also need a clear understanding of what they are undertaking and their own role in the school refusal behavior. The rationale for parents might include the following factors:

statement of the problem: the inability to help their child go to school
statement of the current responses: your present course of action has not worked, and in fact, may have made the situation worse
flaws in the response: e.g., basically, your family has learned a certain way of responding to noncompliance which has increased conflict, and perhaps, even initiated, enabled or maintained school refusal behaviors
it may get worse before it gets better: Teaching a different way of coping requires a personal change; you may find yourself increasingly frustrated because you do not remember to use the proper language or behaviors
the question: Are you ready to take this responsibility? Do you really want the school refusal behavior to change?

Obviously, the clinician will need to tailor these responses to the specific child/family. The rationale may include specific statements about skills that will be taught. A contract with the child and with the parents, in which agreement is made to participate fully in the process and procedures is the outcome which is sought from this meeting. It is important that this be an informed consent in which the client is fully aware of expectations, difficulties, and procedures before agreeing to participate.

Scheduling for the next sessions is then done. If possible, tie down the specific dates for all of the specific sessions and indicate what is expected from both yourself and them between sessions.

SESSION 1

Discuss thoroughly with the child/family the regular school-day as it now exists, including attempts to get the child up, when does s/he get dressed, etc.; how late the child sleeps if refusing school, what the child does when s/he awakens, how the child spends his/her day, when does the child leave the house, where does s/he go and what does s/he do, when does s/he return to the house, when does s/he prepare for bed, when does s/he go to sleep.

Discuss thoroughly the regular school-day schedule as if going to school, including early wakening, dressing and preparing for school, eating breakfast, walking to school, meeting the school bus or going in the car, returning home from school, completing school assignments, leisure time [can s/he go out?], meals, preparing for bed and going to sleep.

Develop specific language/concepts and behaviors that the child and parents will be encouraged to adhere to in following a regular school schedule [e.g., regardless of whether the child goes to school, s/he will be up by x o’clock, get dressed and have breakfast; the child will then proceed to do chores before any leisure occurs OR regardless of the time the child arises and gets dressed, s/he will go to school.] The decision on the nature of the proposed response, of course, rests with the nature of the problem as perceived by the clinician. Procedures need to address the maintaining variables.

SESSION 2

This is often the most informative meeting for several reasons. If the family comes with a completed first homework assignment and logbooks, the motivation level and perhaps the prognosis are probably good. Trends in the child’s school refusal behavior should be more evident as found in the logbooks, which may help you decide how quickly to proceed. Finally, rapport with the family should be fairly well-developed at this point.

You may find that as family members become more familiar with the prescriptive procedures, new ideas for improvement from them become more prevalent. Be cautious, however of family members who want to shield or protect the child from certain anxiety-producing situations.

SESSIONS 3 – 4

The relationship should be starting to mature and the family’s motivation for behavior change becoming more clear. Also a close working relationship between you and school officials should be continuing to develop.

Sessions 3 – 4 often represents the ‘heavy lifting’ portion of the process. During this period the child’s school attendance will start, increase, or be subject to additional consequences. As a result, these sessions may become lengthy, taking more time to hear family member concerns, implement procedures, adjust them as necessary, assign homework, and address related problems. During this period you should continue to provide daily support and feedback to the family and encourage them to continue the homework assignments. The risk of dropout is often highest during these sessions because family members are faced with hard choices and must increase their efforts. Some family members may start to balk at the procedures and/or stay interested more in blame than behavior change. Any action on your part to change this process will generally promote successful outcome.

SESSIONS 5 – 6

By these sessions, prescriptive interventions should be quite intense and focused. If the child has started going to school, the specific procedures [realistic thinking, social/evaluative exposure and restructuring ] may be used. However, if the child or family is continuing to struggle with the early procedures, then you may wish to spend more time covering those initial procedures. In many stubborn cases, ‘backtracking’ to correct new or ongoing problem or relapses is necessary. Remember the procedures outlined are meant to be flexible enough to fit the particular case.

SESSIONS 7 – 8

The child’s school refusal problems should be nearly resolved. As a result, these sessions my focus on tying up loose ends: branching out into other areas of concern, setting up long-term follow-up procedures, bracing for termination, and/or obtaining post-intervention information. If you feel the need to extend longer then you should structure additional sessions using the techniques and principles described.

SESSION 9

This is the follow-up period and may not really be a session. However, the clinician will need to monitor the experiences of the child/family and school and encourage the continued use of the daily guides.

SECTION 2: PROTOCOLS

I. Maintaining Variable: avoidance of objects and situations that provoke general distress and negative affectivity

This protocol includes:

psychoeducation,
building an anxiety and avoidance hierarchy of stimuli,
teaching somatic management (relaxation) skills to decrease negative emotional arousal
conducting systematic (imaginal and in vivo) exposure to anxiety cues identified on a hierarchy in a step-by-step fashion, and
having the child access self-reinforcement for coping with transient negative emotions.

PSYCHOEDUCATION

It is important that the child/family understand the language & concepts of cognitive behavior management. If the child’s school refusal behavior is motivated by a desire to avoid emotions such as dread, anxiety, panic or depression that can become associated with certain school-related stimuli, the nature and process of anxiety will need to be discussed.

See Anxiety Model CBP#02-003. After presenting the model, fill in with the child’s personally relevant responses for each of the three components of anxiety: physical [What I feel], cognitive [What I think] and behavioral [what I do]. With the child, begin to identify targets for change within each component. Cognitive behavior management relies heavily on the Socratic method, or questioning the client so that s/he becomes an active participant. Questioning is designed to lead the client to uncover his/her own biases, beliefs, behavioral patterns and coping resources. You will initially lead the questioning process but, as the questioning method becomes a learned response, the child will be able to engage independently in the process of deductive, rational thinking.

BUILDING AN ANXIETY AND AVOIDANCE HIERARCHY [See Cognitive Behavior Technique #08]

The Anxiety and Avoidance Hierarchy – [AAH] CBP#02-004 is a list of objects or situations that are most upsetting to the child and that will be actively targeted during the process. The information is organized into gradual steps so the child may begin with the easiest [or lowest] item and then progress up to the most difficult [highest] hierarchy item. Most children progress through several hierarchies over a full intervention until all of their upsetting situations or activities are challenged.

To create an AAH, review information gathered form the child and parents during assessment and note any additional objects or situations you may have learned. Organize the information by writing each object or situation on a separate index card. Keep several blank cards for additional information you might uncover. Present the index cards to the child and ask him/her to sort the situations into categories based on the Feelings Thermometer CBP#02-005 to identify and rate the degree of anxiety/distress for each situation. Based on the child’s ratings, construct the first 10 items into a hierarchy, using the ten lowest ranked items. At each formal session, have the child rate the anxiety about these object or situations to provide you with feedback.

Ask the parents to complete the ratings separately from the child, thereby providing valuable cross-informant information and a broader and more accurate view of the child’s presentation and functioning. Begin all sessions with one AAH form for the child and one for each parent.

Relaxation training and Breathing Retraining Exercises [See Cognitive Behavior Technique #04]

The next component is to teach the child relaxation training and deep diaphragmatic breathing. Ideally, this segment should be audio taped for the child to use it at home. Relaxation training involves talking the child through a series of muscle tension and relaxation exercises, each designed to teach the child to discriminate between the physical sensations of tension and calmness. Technique #04 also includes cue relaxation for in vivo exposure. You may also want to explore the Calm Technique #26, if extended relaxation is needed or desired.

Homework

Homework assignments for the child and parents after this session may include:

Practice the relaxation and breathing procedures at home every day, twice a day, if possible. Record each practice on the Relaxation Log CBP#02-006, Note any particularly difficulties encountered during the practice [e.g., inability to concentrate, falling asleep during practice].
Continue to complete the daily logbooks, noting any specific issues or situations that arise during the week.

Preparing for Systematic Desensitization [See Cognitive Behavior Techniques #09 & #11]

Psychoeducation: Explain the term ‘systematic desensitization to the child if s/he is an older adolescent and can understand the concept. Otherwise provide the child with an explanation like the following:

Probe until you find some activity that the child is able to perform with some skill [ride a bike, swim, ski, etc.]
Ask about experiences when performing.
Ask what s/he thinks about when doing something specific with the skill.
Ask what you s/he is doing with her hands, feet and eyes when performing this aspect.
Summarize – Okay. So, what you are telling me is that you get on the bike, ride along the sidewalk and street, pedal along and watch where you are going, and you don’t think about those things. Instead, you think about what you are going to do with your friends. Right?
Talk about how automatic the ride is now, but then ask “When you had to learn how to do these things, do you remember how it used to be scary?”.

The point is to use one of the child’s own experiences to demonstrate how what once was ‘scary’ is now just habit. Using the Socratic questioning method, question the child and prompt him/her to recall the first time riding a bike or doing some similar activity that requires skill, then ask the child about any physical feelings, thoughts and behaviors that may occur in someone who is learning to ride for the first time. Ask the child about his/her personal reactions during his or her initial learning experiences. Focus the child on how the initial steps to learning this skill were small, but with practice s/he developed skill and mastery. The main point to make is that continued practice and overlearning has made the situation easy and automatic. Next ask the child about what happened to his or her initial anxieties.

Introduce the concept of taking steps, one at a time, and mastering each step until very little or no anxiety is felt. The imaginal desensitization process can be presented to the child as ‘practicing thinking about the troubling situations’. Imagining desensitization involves training the child in progressive muscle relaxation procedures and then alternating the presentation of relaxation scenes with an anxiety scenario, constructed from the child’s AAH. When the child indicates that his/her anxiety is rising to an uncomfortable level during an anxiety scenario, quickly switch back to the relaxing scene. The child is instructed to raise his/her hand when anxiety gets to the point of being uncomfortable.

Constructing the Anxiety Scenario

You should audiotape this procedure for later processing and for home use – a ‘Show That I Can’ or STIC task.

Begin with one of the easier situations on the AAH. This will be the first situation to confront through imagination. Ask the child what s/he thinks will happen in the situation and develop a scenario about that situation based on the child’s expectations. You may embellish the scenario to some degree. Often, parents are surprised at the graphic nature and intensity of their child’s anxieties. However, it is important to note that these are the child’s anxieties and, left to his/her own imagination, anxieties can continue to develop unchecked. Hence, you must guide the child in thinking about these anxieties, mix in relaxing scenes so the thoughts themselves are no longer frightening, and discuss what is realistic for any given situation. The goal is to gradually get the child to listen to an entire anxiety scenario ‘as if watching a movie’ and realize that the scenario is not that frightening. Another goal is to have the child recognize that just about any scenario can be coped with in a positive, proactive way. Finally, the procedure will offer the opportunity for the child to think about and practice without danger, new, more effective coping strategies.

The following is a sample scenario. While specific symptoms can be exaggerated to increase the emotional impact of the scene – new symptoms should not be added by the clinician. This should be a real expectation of the child’s in regard to a specific situation that s/he is anxious about. Have the child describe his/her expectations of what would happen in a particular situation. Probe for detail as you enhance the script. Perhaps ask, what would be the ‘worst case scenario’, ‘what is the worst that can happen to you in this situation’, and add this to the script. As the scene is fleshed out – have the child record it.

It is after two o’clock, and Mom and I are driving to school to see the teacher. I have to go in and get my own homework. I haven’t been in school for three weeks, and haven’t really seen any of the other kids or the teacher. The last time I was there I felt real funny in my stomach, and felt like throwing up. As I get closer to school, I start to feel a bit dizzy, and start to sweat a bit. I look at Mom, and want her to turn the car around, but she says I have to get the work. Mom has to stay in the car, because there is no place to park, so I have to go in alone. Mom drives up to the front door of the school. Some kids are there, and some teachers, but not mine or anyone I know. I open the car door, and feel really dizzy now, and my stomach feels like I’m on a roller coaster. I start to walk up to the door, and feel so dizzy that I have to hold on to the wall to stay standing. Some kids walk by and laugh. I’m really feeling scared now, and it is getting harder to breathe. What if I faint, and no one comes to get me and help me? What if Mom just stays in the car? I start walking down the long hall to the classroom and when I get they’re, several kids are in line to see the teacher. So, I have to wait. It’s really hot in the classroom and I feel like I can throw up gain. I am so dizzy now and can taste real sour stuff coming up in my throat. I feel dizzy and faint, and wish that the teacher would look at me and help you, but she is talking to someone else. I can feel it coming now, it’s at the top of my throat. I yell out for help and when I do, I get sick all over the place. The teacher and all the kids are looking at me now with wide eyes. I really feel sick and really embarrassed. If only my mother had come in with me.

Throughout the procedure, as the child visualizes him/herself in the scenario , ask the child to rate his/her anxiety levels on the Feeling Thermometer. Record the child’s ratings. This way, you can illustrate, using charts or graphs, what happened to the child’s anxiety during the process, showing how the child gradually mastered the anxiety.

Some children are able to track their own anxiety levels. Recording these ratings gives children instant information about how they handled certain situations. The ratings can illustrate how s/he coped with panic symptoms, separation concerns, anxiety about specific objects or situations, or any other situation where anxiety ratings can be taken and recorded. You may suggest that the parents keep the child’s rating in a log or notebook to remind the child of progress made.

Invite the parents into the session to discuss the child’s progress. To facilitate understanding of the process, play a portion of the audiotape for the parents. Encourage the child to explain and demonstrate the process to the parents. Ask the child what happened to his/her anxiety during the practice. The typical response is that anxiety dropped during the session and that the child’s tolerance increased with repeated presentations. Illustrate the process of habituation of anxiety during the process by drawing an inverted U curve of the child’s anxiety ratings.

If the child does not habituate [i.e., anxiety does not drop], then praise him/her for any effort or degree of participation and process what may have been particularly difficult. Divide the scenario into smaller steps or less volatile scenes. It is important that the child be given praise and encouragement for making any step, regardless of how small. By praising the child for effort, you will be modeling this behavior for the parents. Typically, desensitization begins slowly, and the pace increases with time. This may occur in one session or across several.

Homework:

continue to practice the relaxation procedures before bedtime each night
listen to the desensitization tape and go through an imaginal practice. Do this at least once daily. The parents may assist the child by asking for anxiety ratings or by keeping other children in the home from interrupting the procedure. A parent should talk with the child after each practice to process the session. Focus the child on how his/her anxiety dissipated and offer praise and encouragement for trying and/or completing the practice.
wake the child about 90-120 minutes before school is scheduled to start and implement the normal school-day routine. Follow this routine as closely as possible. During the day, the child should do school work and read school-related books if at home.
Continue to complete the daily logbooks, noting any specific issues or situations that arise during the week.

IN VIVO EXPOSURE [See Cognitive Behavior Technique #11]

Continue the desensitization process until comfortable that the child is making progress and introduce in vivo desensitization which involves having the child gradually enter a real life anxiety-provoking situation and use his/her relaxation techniques to manage the anxiety. Parents will be expected to arrange the time and place of the in vivo process and help the child engage the situation. Parental involvement is, of course, determined by your consideration of the child’s age, developmental level and severity of the presenting problems.

In introducing the in vivo process you should begin by prompting the child to think about the differences between the imagined confrontation of an anxiety provoking experience and actually entering the situation. The following is a sample dialogue of how you might approach it.

Clinician: Lets think about something. Remember when we talked about how you learned to ride a bicycle?

Child Yes, from practice.

Clinician: Right. And you have been doing a great job practicing here and at home imagining doing these things that used to make you upset.

Child Yes, I ‘Show That I Can’ all the time. I do my practice every day!

Clinician: That’s great! Let’s think about something. Suppose that you didn’t know how to ride a bicycle. Suppose it was back to that time before you learned how to do that. Can you remember that?

Child Yes.

Clinician: Okay, now suppose that I show you a movie about how to ride a bicycle, and you watch the movie again and again. But you just watch the movie, you never really get to try a bicycle. Do you think it would be easy just to get on a bike and ride?

Child No, I have to practice on a bike. I’d be all wobbly and could fall down if I don’t practice.

Clinician: Right! So, watching the movie may help you to know what it looks like to ride. And it may show you some of the things to think about while you ride. But you really have to try a bicycle again and again, to practice and learn how to ride.

Child That’s right. You have to get on the bicycle to learn how to ride it.

Clinician: Well, the same thing goes here. We have been imagining going into these situations that scare you, and you have been doing a great job of learning that you don’t have to be scared. But, we need to help you really go into those situations and practice being there. Do you understand what I mean?

Child: So, I have to ride the school bus.

Clinician: Well, eventually, yes. But first, we will only practice for real situations we’ve done in here and have on tape. And we will work up to the bus and those other things that are really scary for you. We’ll do this step-by-step, just like we do in your imagination. Taking it easy, going one step at a time, and we’ll get Mom and Dad to help our here and there.

Initiate in vivo desensitization by having the child role play one of the easier items from the AAH. This role play, made as close to reality as possible, will involve the child acting out and confronting an anxiety provoking situation. For example, if the child is anxious about being alone either at school or home, construct a situation where the child waits in a room by him/herself for a period of time. Initially, set the situation to be minimally anxiety provoking and encourage the child to use the relaxation and deep breathing skills to manage anxiety. As the child develops tolerance of the situation, slowly make the situation more challenging and encourage the child to refrain from using any safety behaviors to make him/herself feel better. As examples:

Sitting alone in the room for 3 and then 5 minutes, knowing that you are in the hall.
Sitting alone in the room for 5 minute and then 10 minutes, knowing that you may not be in the hall.
Sitting alone in the room for 10 minute, with the lights dimmed and no one in the hall.
Sitting alone in the room, not knowing how long it will be, with the lights dimmed and no one in the hall.

Desensitization trials begin with assistance and with relatively easier situations, with demands increasing with each successive trial. The child’s expectations also are addressed as s/he initially knows what to expect in the situation, but later is exposed to unknowns. This process is designed to build the child’s ability to cope with ambiguous, challenging and often uncontrollable situations. Anxiety often results from feeling unable to control or predict what could happen and from concern that something very negative will occur. The process is focused on teaching the child that even when a person does not have total control, s/he can still cope effectively and the worst scenario is not likely to occur. The child learns to tolerate normal levels of arousal while gathering information about his/her coping resources and skills.

Review each session’s progress with the child and parents. Encourage the child to tell the parents about the process. Offer corrective information or detail during the child’s summary. Shape the child’s ability to accurately communicate the process and progress experienced. It is also helpful to review with the child and parents any progress in managing the daily routine. Provide instructions as to what steps to take next in adjusting to the school routine. For example, you may suggest that the nest STIC task involve a trip to the school library or meeting after school hours with the teacher to pick up homework. These activities combine the in vivo desensitization process with the STIC tasks.

ELIMINATING SAFETY SIGNALS

One focus of the child’s desensitization practices should be to enter into difficult situations without help or the use of ‘safety signals’. A safety signal is any object or person that one relies on to feel better or less anxious in a situation. Although a safety signal may lessen a child’s anxiety in the short-term, the long-term use of safety signals maintains anxiety and prevents the child from learning that s/he can manage the situation. This may be very difficult for parents to accept. Parental instincts are generally to comfort their child. However, frequently doing so may prevent the child from learning to manage normal levels of discomforts, thus maintaining the school refusal behaviors. Children with anxiety disorders who refuse to attend school due to these negative emotions can often be ‘bribed’ into entering these situations with assistance of these ‘safety signals’. Parents, in seeking to get their child to school AND to protect them from the anxiety, may have come to rely on a complex set of such ‘bribes’, each one weakening the child’s expectation that s/he can attend without them.

Increasing the complexity and challenge of the STIC tasks is important to uncover, and then dispose of, as many of these unnecessary and unhelpful safety signals as possible. CBP#02-007 lists some common safety signals for children who refuse school. It is important to help the child construct in vivo practices to confront and challenge these negative emotions. As each practice progresses, accompanying safety signals will be systematically taken away to give the child the opportunity to learn for him/herself how to manage the situation alone.

Panic attacks occur in a variety of situations or places and may cause nausea, dizziness, shortness of breath, heart palpitations, sweating, shaking, numbing or tingling sensations and feelings of unreality. These attacks seem to come ‘out of the blue’ and may have happened to the child in school, on the bus, in public places such as malls and movie theaters, and/or in crowds. [See Cognitive Behavior Technique #08] Again, both the child and the parents will need to understand the nature of these ‘attacks’ and what they actually represent.

For such children, interoceptive exposure exercises help desensitize the child to the physical sensations that accompany panic. Individuals who experience panic begin to feel a change in their physical state and become very vigilant about the change and afraid of its implications. They thus typically avoid running up stairs, aerobic activity, drinking beverages with caffeine, or other situations or activities that may cause physical change. One key to overcoming panic is to learn to tolerate normal physical arousal and changes without becoming frightened and distressed. Interoceptive exposure involves the systematic provocation of these sensations over repeated trials to reduce anxiety. Construct a hierarchy of sensations that scare the child and begin exposure with the least anxiety provoking sensation, then gradually progress to exercises designed to elicit the sensation at higher and higher intensities. Typical exercises and their targets are listed in CBP#02-008. The goal of having the child engage in these exercises is to teach him/her that these sensations are temporary, predictable and controllable. Most importantly, the child learns that changes in physical states are normal and harmless. Forewarn parents that the child will be somewhat uncomfortable, but only temporarily.

The in vivo process teaches the child to experience less than perfect or desired circumstance and accept the consequences without asking for reassurance and teaches parents that their child can attain mastery over what appear to be painful situations. Reassure the parents that they can be ‘good parents’ without protecting their child from every distressing experience and that the process of mastery entails some risks. Help parents set limits on reassurance seeking.

Homework

Continue to practice the relaxation tape at bedtime and complete daily logbooks, noting any specific issues or situations that arise during the week.
Complete STIC tasks that will involve various in vivo desensitization plans, in addition to imaginal desensitization as needed.
Increase attendance at school over the course of these sessions, with the goal of having the child attend most of the day, everyday.

COMPLETING THE PROCESS

The main focus of this part of the process is to provide the child with Stress Inoculation skills [See Cognitive Behavior Technique #10] and positive internal attributions [See Cognitive Behavior Technique #24] One skill, identified in Technique #04 is cue controlled relaxation, which is a form of self verbalization. [See Cognitive Behavior Technique #21] The goal is to provide the child with new behaviors which will support their sense of competence and ward against new stresses that may arise.

Parents should be instructed as to how to use the antecedent internal attributions to support positive behaviors and to continue with both the child and parent Daily Logs as long as they are helpful. Intermittent appointments may be made to ‘keep in touch’ to see that the outcome expectations are continuing. Finally, parents should be helped to identify potential recurrence of thinking or behavior that might become problematic and to have a process to determine if a refresher is necessary.

Preventing relapse will be discussed further at the end of the protocol section.

This section includes the following forms and charts:

CBP#02-001 Child Daily Log
CBP#02-002 Parent Daily Log
CBP#02-003 Anxiety Model
CBP#02-004 Anxiety & Avoidance Hierarchy
CBP#02-005 Feeling Thermometer
CBP#02-006 Relaxation Log
CBP#02-007 Safety Signals
CBP#02-008 Interoceptive Exposure

II. Maintaining Variable: escaping aversive social and/or evaluative situations.

This protocol includes:

psychoeducation,
teaching the child to identify what s/he tells him/herself in anxiety provoking situations,
teaching a method to change those negative thoughts to coping, helpful statements,
developing graduated exposure to anxiety-producing social or evaluative situations in session with the clinician, and
practicing coping skills in real-life social and evaluative situations.

PSYCHOEDUCATION

It is important that the child/family understand the language & concepts of cognitive behavior management. If the child’s school refusal behavior is motivated by a desire to avoid social and evaluative situations, you will need to begin with an explanation of the nature and process of such anxiety.

Anxiety is divided into three components [See Anxiety Model CBP#02-003]. After presenting the model, fill in with the child’s personally relevant responses for each of the three components of anxiety: physical [What I feel], cognitive [What I think] and behavioral [what I do]. The following is an example of how to explain to the child how the interactions of these components maintain social anxiety.

Do you remember what it was like the first time you tried to ride a bicycle? Think back to how you felt getting on the bike for the first time. Did you feel shaky and think you might fall? Do you think about how scared you were, whenever you jump on a bike now? Of course not! Because you got used to riding the bike, now you don’t even notice if you feel a little shaky at first.

Now, what do you think would have happened if, that first time you were on a bike, feeling all shaky, you got off the bike and never got back on it again? What if you told yourself, ‘This is too scary’, I may fall and then I could get hurt.’ If you tell yourself something scary, and that you can’t do something, then it really feels scary and it keeps you from wanting to try again.

Because people tell themselves that it’s a scary situation, and that they feel shaky or butterflies or such, then they don’t want to do those things anymore. And the more they avoid those things, the worse it can get. This is because they feel more afraid than they really would be in that situation.

It is often useful to use cartoons or pictures from magazines that depict children in various situations [e.g., standing near a group of children, talking with an adult, standing off to the side and watching others talk]. Find pictures of social situations that most resemble the child’s presenting problems. Above the pictures, draw thought bubbles and ask the child to describe what the child in the picture may be thinking, feeling and what s/he may do. This will help you understand what provokes the child’s anxiety and how the child interprets various situations, and what the child thinks about and does. See also the Functional Cognitive Behavior Assessment Initial Inquiry process to get a perspective on the ‘leakage’ of self talk that occurs in these situations as observed by child managers.

Building an Anxiety and Avoidance Hierarchy [See Cognitive Behavior Technique #08]

To create an AAH, review information gathered from the child and parents during assessment and note any additional objects or situations you may have learned. You can organize the information by writing each situation on a separate index card. Keep several blank cards for additional information that you uncover during the process. Present the index cards to the child and ask him/her to sort the situations into categories based on the Feeling Thermometer CBP#02-005 which ranges from 0 (no feelings) to 8 (very, very strong feelings). Based on the child’s ratings, construct the first ten items Anxiety and Avoidance Hierarchy CBP#02-004 [AAH], using the ten lowest ranked items. For the remainder of the protocol, have the child rate his/her anxiety and avoidance of these situations.

IDENTIFYING NEGATIVE THOUGHTS [See Cognitive Behavior Technique # 01]

Anxiety about social and evaluative situations is largely the result of negative thoughts or ‘self talk’. When anticipating a social or evaluative situation, the anxious child is likely to focus on what could go wrong, how bad s/he will look, or on the belief that others will laugh or think badly of him/her. During these situations, children may focus on negative thoughts instead of how things are really progressing. As a result, anxiety increases and can overwhelm the child. You will help the child develop a plan to identify and change these negative automatic thoughts.

For young children, the acronym STOP may be used to help identify and change such thoughts.

S stands for: Are you feeling Scared?
T stands for: What are you Thinking?
O points you towards Other helpful thoughts
P is to Praise yourself for using these steps, and Plan for the next time.

Depending on the child’s age and developmental level, you may rehearse these steps sequentially with the child and focus on using the steps in different social or evaluative situations. It is not critical that the child learn the steps in detail. In fact, younger children and those with limited cognitive abilities respond well to a picture of a STOP sign, which can be used as a signal to stop and thing when confronting an anxious situation.

Older children and adolescents can be taught to identify automatic or reflexive thoughts. Such thoughts are negative, unhelpful, anxiety provoking, seem to happen automatically, and focus us on what is dangerous or alarming about a situation. These automatic thoughts tend to fall into patterns such as:

All or None thinking: I must be perfect. I can’t do this at all.
Catastrophizing: this is the worst thing that can happen.
Overgeneralization: I never do anything right.
Negative Labeling: I am such an idiot. I am so stupid.
Can’ts or Should’s: I can’t ever get this right. I can’t do this. I should have done better.
Mind Reading: She thinks I’m stupid. I know they don’t like me.
Fortune Telling: I am going to fail this test. Nobody is going to talk to me.
Canceling the Positive (usually occurs when someone gives a compliment): I should have done better. This wasn’t my best work.

For another listing – see CBT#02-005. See also Altering Limited Thinking – Technique #02 and its alternative strategy, Changing Distressing Thoughts – Technique #03.

In the first session your main focus is to help the child identify his/her distressing thoughts. Step one will be to teach the child to recognize the cues, or ‘triggers’ for his/her anxiety [the S step in STOP]. It is helpful to have younger children draw pictures of those things that cause anxiety. You may want to review Technique #01 – Perceiving Reflex thoughts, so that you can ask older children to keep a Thought Journal [CBT#01-001] or list of situations that cause anxiety and to keep a list of thoughts that occur when they encounter anxiety provoking situations.

Begin with one of the easier situations on the AAH. This will be the first situation to confront imaginally. Ask the child about what s/he thinks will happen in the situation and develop a scenario about that situation based on the child’s expectations. You may embellish the scenario to some degree. Often, parents are surprised at the graphic nature and intensity of their child’s anxieties. However, it is important to note that these are the child’s anxieties and, left to his/her own imagination, anxieties can continue to develop unchecked. Hence, you must guide the child in thinking about these anxieties, mix in relaxing scenes so the thoughts themselves are no longer frightening, and discuss what is realistic for any given situation. The goal is to gradually get the child to listen to and then visualize [Technique #09] an entire anxiety scenario ‘as if watching a movie’ and realize that the scenario is not that frightening. Another goal is to have the child recognize that just about any scenario can be coped with in a positive, proactive way. Finally, the procedure will offer the opportunity for the child to think about and practice without danger, new, more effective coping strategies.

Coaching

It is often useful to help the parents and child think of the concept of working as a team. You might ask the child about his/her favorite sport and use it as the analogy [you as head coach, parents as sideline or specialty coaches and the child as the star athlete]. Such an analogy can illustrate for the parents the process of helping the child learn the anxiety management skills and exposure plans and set up the initial exposures. With time and practice, the child will assume greater responsibility for his/her own growth and development. A primary reason for using the coaching analogy with families is to help change family interactions that have developed since the onset of the school refusal behavior. Typically, parents and children have developed patterns of struggling, arguing, and fighting in response to the child’s behavior. Because it is likely that some parents ‘have tried everything’ to get the child to attend school, they may feel frustrated and hopeless about what will work. Coercive processes have often been developed in which each new episode begins at a higher level than before and intensifies quickly.

The analogy is intended to help put the parent-child relationship on neutral ground while gradually building a healthy and productive style of problem solving and positive interactions. Instruct the coaches to offer praise and other forms of positive attention [smiles/hugs] when the child is successful. However, if the child is unsuccessful, ask the parents to remain neutral and not get emotionally involved with the child’s intentions; but rather to return to the basics of instruction as to how to deal with the anxiety and ‘run the play’. If necessary, you can help the family members coach the child’s behavior by introducing contingency management and communication skills training techniques, which will be explored in later sections. You may, after noting the difficulties as reported by the coach and player, break the ‘play’ into smaller components or suggest a new ‘play’. The ‘plays’ are represented by the procedures within the techniques that have been identified.

Homework

the child should maintain a Thought Journal
parents and child should maintain the Daily Log, noting any specific issues or situations that arise during the week.

ALTERING LIMITED THINKING [See Techniques #02 & #03]

While continuing to focus on the child’s self-talk and identification of the types of cognitive errors that s/he generally uses, you will need to move on to helping the child dispute negative, unhelpful thoughts. Through the use of behavioral exposures, you will prompt the child’s anxiety reactions and his/her use of coping self talk skills. In a behavioral exposure, you and the child role play an anxiety producing situation. The purpose of the role play is to prompt the child to experience anxiety and to identify his/her thoughts that perpetuate the anxiety. You can then help the child dispute these thoughts. Behavioral exposure will allow the child to practice gradually entering situations that cause anxiety, gain experience, and eventually master these situations. Real life [in vivo] practice entering these situations occurs between sessions, often with parental assistance. These in vivo practices are called ‘Show That I Can’, or STIC tasks and reinforce what was addressed with you.

The degree of parental involvement will depend on the age and development level of the child and the individual characteristics of the situation. Younger children may benefit from more parental involvement and assistance than adolescents. Parents of younger children can coach the child in using the cognitive error correction procedures and can assist by setting up in vivo practices for the child.

Adolescents [13 and older] can take more responsibility for arranging and conducting their own in vivo practices, but this decision varies according to the adolescent’s developmental level and the clinical severity of the behavior. Parents can help set up the logistics of an exposure, but the burden of actually conducting the exposure cannot be taken from the adolescent. One of the difficult things for parents to learn is that their adolescent children will do exactly what they decide to do and nothing else. Punishment may provide new information, but by adolescence it is unlikely to be sufficient to help initiate the behavior change the parents would like to see. The adolescent needs sufficient new information to believe that such change is possible, that they can successfully achieve the change, and that the change is worthwhile. Cognitive behavior management provides such information.

Review the past week and focus on identifying the triggers of the child’s anxiety as well as corresponding negative thoughts and images. Using a chalkboard or flip chart, help the child identify his/her specific pattern of arousal and negative thoughts. This process will include: identification of 1. the situation that aroused distress, 2. exactly what ‘scared the child’, 3. the automatic thoughts that occurred, 4. the classification of these cognitive errors, 5. some alternative thoughts that may be more helpful, 6. A plan to replace the cognitive errors with these helpful thoughts [e.g., a coping mantra], and 7. a self-talk reinforcement [praise] for carrying out the ‘play’.

The child must understand the nature of the ‘game’ that they are playing, the language and concepts, and the specific ‘plays’. If 1 through 4 occur – run ‘play 6’ followed by 7. A Socratic questioning method is preferred to encourage the child to think through the situation and identify his/her own reactions and to develop the plan. You as the ‘head coach’ will authorize the play; selecting from the child’s suggestions.

It is important to question the child about each negative thought and urge the child to think about his/her experience for these thought and to dispute the thought with rational, realistic thinking. The following questions, called ‘dispute handlers’ are commonly used to refute anxious thoughts:

Am I 100% sure that this will happen?
Can I really know what that person thinks of me?
What’s the worse thing that can really happen?
Have I ever been in a situation like this before, and was it really that bad?
How many times has this terrible thing actually happened?
So what if I don’t get a perfect grade on this test?
Am I the only person that has ever had to deal with this situation?

Help the child process several troublesome situations. This will help the child practice challenging and changing negative thoughts. Once the child has worked through various examples, proceed to behavioral exposure.

BEHAVIORAL EXPOSURE

There are three levels of exposure, 1) imaginal or visual, 2) behavioral or role-play, and 3) real life or in vivo. The child has practiced the imaginal scenarios with you and during the time between sessions. As with these exposures, before each behavioral exposure, ask the child for an anxiety rating. This is the child’s best estimate of how anxious s/he feels. Take an anxiety rating every minute during the exposure. Most exposures last 10-15 minutes, although you have the ability to stop or prolong the exposure based on the child’s reactions. Record the child’s ratings through the process. Also, prior to the exposure, ask the child to define several specific goals for the exposure. These goals should be concrete, observable and attainable behaviors or actions that the child will work toward performing. For example, in an exposure focused on starting and maintaining a conversation, a child may have the goals: I introduce myself and say hello, I ask two questions, and I look up and make good eye contact during the conversation.

Keep track of whether the child meets these goals during the exposure. After the exposure, discuss with the child how s/he feels, and whether s/he thinks the goals were met. Using graphics on a flip chart or chalkboard, present the child’s anxiety ratings and evaluate each goal. Process the exposure with the child, focusing on his/her behavior, whether the anxiety interfered with performance and whether the child was able to use the coping procedures [play] to change any negative thoughts. Discuss strategies for building on successes and overcoming any trouble encountered. The main lesson is that practice helps and that anxiety will naturally go away as the child learns to focus on the situation instead of his/her thoughts & feelings.

Children who are able to track their own anxiety levels are able to get instant information about how they handled a certain situation. You may ask the child to keep his/her ratings in a log to remind him/her of progress made. For those not doing their own tracking, use CBP#02-009 Exposure Record Form to track the child’s progress. Give the child feedback about what is happening to his/her anxiety throughout the process. Illustrate the process of mastering anxiety and negative feelings by drawing a graph of the ratings. Encourage child and parents to keep these charts or graphs in a logbook to later remind the child of his/her progress as habituation occurs.

There are several ways to conduct behavioral or in vivo practices to manipulate the pace of exposure. A slower pace is ideal for younger children, those with special needs, and those with exceptionally high levels of anxiety. Moving slower allows the child to habituate to the anxiety and trust building that s/he will not be forced into something overwhelming. However, keep clear in the child’s mind that performance on the ‘playing field’ is what really counts.

In assisted exposure, you or the parents perform the exposure with the child. This allows the child to receive support from a trusted individual and observe a model who manages the situation. These procedures are especially helpful early on, when confronting anxious situations for the first time, or when more challenging exposures are developed. Educate parents to the difference between modeling, in which s/he shows a child how to manage a situation, and rescuing, in which a parent takes over and manages the situation for the child. A child’s anxieties may interact with the parent’s natural instinct to comfort their children and lead to rescuing. Instruct parents to allow their child to experience normal rises in anxiety. Modeling and assisted exposure keep the focus on the child, with the goal of having him/her confront anxious situations alone.

First, model how to deal with the situation as the child observes. During this step, say aloud the STOP steps. This gives the child a chance to observe how you process and manage a difficult situation. Second, help the child manage the situation together as a team with you and/or a parent. Third have the child manage the situation on his/her own as words of encouragement are given by the ‘coach’. Prompt the child to use the STOP steps on the somatic controls exercise or other coping skills during this procedure. Fourth, have the child engage in the situation on his/her own while verbalizing self reinforcement for performing the in vivo experience.

Homework

Keep the Basic Thought Journal
Practice in vivo exposure experiences as STIC tasks.
Wake child 90 – 120 minutes before school is scheduled to start and follow the normal school day routine. Follow this routine as closely as possible. During the day, the child should do school work and read school related books when at home.
Continue to complete the Daily Logbooks, noting any specific issues or situations that arise during the period.

GO TO THE CORE BELIEFS

Begin by reviewing the child’s STIC tasks and a discussion of any difficulties in conducting and following through with homework. It is helpful to role play any difficulties encountered by the child since the last session, including any troubles that may have occurred. The main focus of this period will be to guide the child to confront more challenging situations. This is accomplished by creating exposure situations that are increasingly more difficult for the child. You will need to be creative in developing challenging scenarios where the outcome is less than desirable and where the child will have to cope with rising levels of anxiety.

In your review of the assignments, be vigilant for any signs of avoidance, escape or otherwise inappropriate management of the situation by either the ‘coaches’ or the child. If the child did not complete any of the assigned tasks, ask the child to use the STOP procedure to examine what cognitive errors or ‘thinking traps’ may have interfered.

To help the child process his/her avoidance of tasks, use the ‘dispute handles’ to challenge negative thoughts. If the child completed the STIC assignments, examine any difficulties, success or other issues, with the goal of reinforcing the completion of the homework. It is helpful to focus the child on what it felt like to actually complete the STIC tasks, what actually happened, and how the child coped with the situation.

Continue the process of identifying the seven [07] steps required in the process and help the child particularly with number six [06] the development of alternative thoughts and self instruction. It is important to spend considerable time with the child examining the thoughts and behavior that occurred in exposure. Many children quickly come to understand that it is normal to make mistakes, be embarrassed or uncomfortable, or for other individuals to be rude. These children recognize that the discomfort is momentary and that, in spite of being anxious or slightly embarrassed, they will do fine. However, some children push for the situation to turn out perfectly, and it is much more difficult for them to tolerate being anything less than perfect. They are anxious about embarrassment, rejection, or humiliation and their overriding thought is No one will like me or want to be around me.

To process the exposure, take the child through the scenario step by step. Help the child thoroughly analyze his/her thoughts, anxiety ratings and actual performance behaviors. ALWAYS provide positive internal attributions.

For a child who is particularly self critical, a perspective taking [or role reversal] practice may prove helpful. Here, the clinician probes for what the child is most anxious about in a social situation. Begin by asking whether s/he has ever noticed any other child in this situation.

Construct an exposure that involves the child interacting with participants who have erred in the way the child expects to err. Encourage the child to ‘make the error’ to have the experience of making mistakes in front of others. The essential point of these exposures is to illustrate that personal discomfort is temporary, and that most people’s reactions are also temporary.

Cognitive error correction involves processing the exposure until the core anxiety is uncovered and disputed. By constructing the increasingly more challenging exposures, you will be able to elicit these core anxieties and allow the child to challenge them directly. This gives the child evidence of coping and mastering a situation. You can also consider using the Vertical Arrow or Laddering procedure in which, instead of disputing negative thoughts, you ask ‘If this thought were true, why would it be so upsetting to me?’. Start by writing the negative thought and drawing an arrow down to the next item which is the answer to the question. Then ask the question again and draw an arrow down to the next answer. This will generate a series of negative thoughts which will lead to more clearly defined core beliefs. Beware of incomplete cognitive error correction where underlying core beliefs are left unrecognized. Do not necessarily accept the child’s word that ‘everything is okay, this doesn’t bother me anymore’. In such cases, further probing and conducting a behavioral exposure may reveal anxiety and suggest that the child is actually trying to ‘look good’ or please you. A complete analysis of the child’s core beliefs about self, others and future prospects may indicate a need for more intensive cognitive restructuring work. If that is the case, we would suggest completion of the present cognitive error correction protocol and returning the child to school, before undertaking the additional services.

Homework

Continue the Daily Logs.
Move to the Thought Journal +3 [CBT#02-004] The child should practice the identification and changing of negative thoughts.
The child must practice role behavioral or in vivo exposure at least three time during a week. Example, if the child’s difficulty is calling a classmate on the telephone, the assignment will be to role play telephoning, record anxiety immediately prior to, and immediately after, the exercise.
Continue to implement the normal school day routine and adhere to it as closely as possible. During the day, the child should do schoolwork and read school related books when at home.

REALISTIC THINKING

This section will involve helping the child progress through the main portion of his/her AAH. As usual you will begin each session with a review of the child’s weekly STIC tasks.

The popular press once promoted the concept of positive thinking as a way to overcome negative and distressing emotions. Positive thinking entails repeating thoughts to oneself such as I can do this, I’m smart, and I’m a good person. Research and clinical experience explain why some people never get better through the use of positive thinking as it has been shown to interfere with focusing on and accomplishing the task.

By emphasizing how a child feels, at the expense of what the child does – mastery, persistence, overcoming frustration and boredom, and meeting challenges – parents and teachers are making this generation of children more vulnerable to depression.

People guided by the popular ‘feeling good’ viewpoint are ready to intervene to make the child feel better. People guided by the ‘doing well’ approach are ready to intervene to change the child’s thinking about failure, to encourage frustration-tolerance, and to reward persistence rather than mere success.

The doing-well advocates have two new technologies: one for changing pessimism into optimism, and one for changing happiness into mastery. Seligman – 1995]

Positive thoughts do not provide any real information or copying solutions for the child to rely on and use in a given situation. As the child recognizes the task is not getting completed, his/her levels of frustration and physical tension increase. This sets into motion the cycle of disruptive physical sensations, thoughts and behaviors, each reinforcing each other and making the situation worse. In this case saying, I am smart leads to sensations such as muscle tension or headache, disruption in completing the task, and the resultant Oh no, I can’t do this after all! That further perpetuates the child’s tension, negative thoughts and poor performance.

In contrast to positive thinking, research demonstrates that healthy thinking is the predominant style of thought used by well-adjusted individuals. Healthy thinking is characterized by realistically examining a situation and the resources available to manage it. Healthy thinking is reality based, focused on problem-solving and task management and characterized by adaptive thoughts.

Involving Other People

The successful intervention of social and performance anxiety often depends on the involvement of other people in the process. This involvement may be direct or indirect. Some programs actively recruit non-anxious children to help children with shyness or social phobia practice the skills. These procedures are called peer pairing and are based on the findings that shy children are neglected by their peers because they become somewhat invisible to others. Children recruited to assist with a child’s intervention do not need to know personal information about a child’s status, but only that the child may need help feeling less shy and getting to know the other kids.

Parents can also arrange for less formal interactions with peers and other individuals. Suggest that parents arrange play dates, outings and similar social events to facilitate their child’s contact with others. These semi-structured activities provide the child an opportunity to practice social skills. These activities can also be arranged for classroom situations. For example, if a child is shy o quiet, it is possible that individuals expect less interaction with them. The child’s teacher may need to be contacted to assist with school based exposures. The teacher may call on the child or otherwise give the child experience in performing in front of others. Similarly, parents and others should no longer speak for the shy child [e.g., order in a restaurant or pay at a store]. All family members also need to be educated about the child’s goal of interacting with others more comfortably and independently. The involvement with other individuals and various social institutions will be the focus of the child STIC tasks throughout the remainder of the process.

Homework

Continue the Daily Logs.
Continue the Thought Journal +3 [CBT#002-04]. The child should practice the identification and changing of negative thoughts.
Practice in vivo [STIC] tasks to complete between sessions, along with appropriate cognitive error correction exercises for each task.
Practice STIC tasks assigned for school related situations [the child should be attending at least part of the school day by now]. These STIC tasks will increasingly involve the child interacting with both children and adults; be sure to have the parents help the child follow through with these exposures. This may require some adjustment on the part of the parents if they are used to a child who has a quiet schedule or does not invite other children to the house. It is important for the parent(s) to schedule time so that they can get the child to school or to social situations involving different people. Although it may seem excessive to have the child attend some type of social outing three or more times a week, the frequency of these outings will be cut back to a normal level later.

COMPLETING THE PROCESS

The main focus here is to have the child spend increasingly longer periods of time in school, with the eventual goal of full time attendance. Initially, you may which to accompany the child to school or to arrange your appointments in a private office in the school building during the day. These assisted exposures may prompt the child to progress more rapidly to full time attendance. Once the child has returned to school regularly, appointments should avoid school hours, although they can continue at school after hours, if appropriate. At this point ensure that the child takes most of the responsibility for the process and applies what was learned in real life situations. Continue to implement techniques to help the child achieve this goal.

This section includes the following forms and charts:

CBP#02-001 Child Daily Log
CBP#02-002 Parent Daily Log
CBP#02-003 Anxiety Model
CBP#02-004 Anxiety & Avoidance Hierarchy
CBP#02-005 Feeling Thermometer
CBT#01-001 Exposure Record Form
CBT#02-004 Thought Journal +3

III. Maintaining Variable: for attention.

This protocol includes:

psychoeducation,
restructuring parent requests/directives,
establishing fixed daily routines,
setting up consequences for school refusal, and
setting up rewards for school attendance.

PSYCHOEDUCATION

Common behaviors of children in this functional group include noncompliance [i.e., refusing parent and/or teacher directions], overall disruptive behavior to stay out of school, clinging, refusal to move, tantrums, running away, constant telephoning, and guilt-inducing behaviors. The major focus of the protocol is the parent(s). Therefore, intervention will be different from what is described in the prior approaches. The major goal will be to shift parental attention away from school refusal behavior and toward appropriate school attendance behaviors.

We seek to establish a mutually agreed upon rate of exchange between the child and the parents in order to achieve an acceptable balance of payments. In practice, we usually ‘get what we pay for’. In parent-child relationships there is an implicit agreement or understanding that the parent provides for the needs of the child in return for which the child performs the age-appropriate request/directives of the parents. In problematic situations, the child sometimes comes to recognize that s/he can obtain the ‘payments’ from parents without fulfilling their part of the ‘bargain’. In retaliation, parents may resort to punishment – taking things away in an effort to coerce the youngster to comply. However, at the same time the parents may also continue to provide some ‘payments’ to the child. A confusing dynamic is thereby set up. As a means of re-establishing the equitable exchange rate and balance of payments under which most people operate, it is necessary for the parent-child to review the basic premise e.g., ‘you get what you pay for’. Accordingly, it is to be understood that parents have a legal responsibility to provide the child with food, shelter and clothing. The child, however, does not have any entitlement to desserts, favorite foods, designer clothes, computer games, etc. These are provided by the good graces of ‘loving’ parents. However, to continue to issue such ‘payments’ free, sets up unrealistic expectations in the child that will not serve him/her well as they move into society which operates on a ‘pay as you go basis’.

Thus, the challenge is to enable the child to get what, and only what, s/he earns. To accomplish this is time consuming and difficult. It also requires attention and energy to monitor and follow through. This must be clearly understood in advance. Unless the parents are committed to this entire process, it is best not to initiate it at all. You will need to discuss with the parents the commitment level necessary and if they choose not to undertake the process outlined, try to give them additional information so that they can make a better decision . Inevitably, the child will test the new process to determine whether the parents are serious. This is not a problem if the parents are firm in demonstrating that they stand fully prepared to ‘pay off’ for desired behaviors. Failure to perform desired behaviors results in the child’s failure to earn the things s/he wants. This then becomes their choice. The parents restore their role as ‘givers’ rather than ‘punishers’ and the child learns the important lessons that they are responsible for establishing their own priorities and decide whether they wish to go on working for and achieving them. Coincidentally, doing so has the additional benefit of enhancing the child’s self-esteem since s/he will have the satisfaction of achieving personal goals through his/her own effort.

The language and concepts of Session #1 the ABCs of Behavior of the Behavior Skill Training Program and of the Attribution Training Technique #24 will be of significant importance in helping families identify and change their thinking about child management. In addition, some of the concepts of expectancy theory may be helpful.

In general, parents will need to be helped to understand the habitual and nonconscious ‘exchange process’ that takes place in any human interaction, but is of profound importance in child management. This exchange is based on the unstated acceptance that each of us must contribute to the well being of the other through physical and/or psychological reinforcement. As discussed above, children contribute their share to parents through performing a variety of functions [e.g., chores, schoolwork, church attendance, sports] which please the parents and psychological satisfactions and gratifications through eye contact, smiles, hugs, and the like. Of course these expectations change over time as children grow and mature. Parents additionally perform certain functions [feeding, clothing, sheltering, teaching] and, of course they also provide psychological satisfactions and gratifications. The fact that the importance of various parts of this exchange are contingent upon unspoken principles which may or may not be significant leaves a lot of area for confusion. Often we hear that a child says that the parent ‘do not care about me’, when the parents believe they ‘bend over backwards’ to give what the child wants. This an indication that the nonconscious side of the exchange is ‘out of wack’. What one thinks is an important part of the exchange is not; and the other one fails to notice.

When children ‘rebel’ against direction, school, chores, etc., we have a balance of payments that is not equivalent. Often the breakdown is escalated by the parents, who in an attempt to seek to get back on course, decide to ‘take away’ what they are giving as a means of restitution or ‘punishment’.

What for many families will always remain a nonconscious process, must now, for this family become conscious. Parents and children will need to begin to examine consciously the ‘exchange rate’ and determine how to restore order. Since a part of this exchange rate is psychological satisfaction and gratification, which in itself may not be conscious, this is not an easy process. Parents and children build up strong emotions about their ‘bank account’ and beliefs about how the other is taking advantage. These emotions and beliefs need to be addressed along with restoring the exchange rate.

If the parents and child can begin to understand the concepts involved there is clearly hope for restoration of order. But this is a new area of understanding and one which not all families need to explore. Some do it intuitively.

What are the coins of exchange? There is the language used in communication. The commands, requests, directives, that the parent makes are potentially ambiguous or not helpful. Is the language respectful? Is it clear? Does it provide proper directions? Does it indicate consequences of action or failure to act? There is the expectancy of the expector. What does the parent expect the child to do when asked? What does the child expect the parent to do when achieved/failed? This is not the expectancy of normative behavior, but the expectancy of personal belief.

If you believe you can, or you believe that you can’t; you are probably right. Henry Ford

There is the interaction of routines. How do the parents schedule the period of time in which the activities are to take place. Does the parent provide adequate time to do what needs to be done? Adequate space to do it? Adequate resources? Is the schedule known in advance? Who else has participated in creating the routine?

There are the responses to action/inaction. All actions have consequences. Are these consequences reinforcing of the behavior? Do they reinforce proper behavior? Do they reinforce improper behavior?

Participants [child/parent] need to become aware of what exists in the exchange rate; must attend to the exchange rate; must analyze the exchange rate for effectiveness; must develop alternative exchanges; and must find ways to adapt to a new rate of exchange in order to restore the balance of payments.

Since the exchange rate is predicated on what each person does [acts, says], the process of change will demand a change of behavior, not just on the part of the child, but on the part of those who manage the child.

You will need, therefore, to describe in some detail the conditional relationship between two events and the probability of event A given event B along with the probability of event A in the absence of event B. At minimum, this will require a discussion of Session #1 of the Behavior Skill Training Program – The ABCs of Behavior regarding the language and concepts of antecedents, behavior and consequences. You will need to decide what level of teaching is required for each family.

You will spend almost all of your time with the parents. However, the child should be invited to the sessions and be told what is going to happen. The child should have the opportunity to ask questions and think about the consequences that will occur. Keeping the child informed allows you to remind the child that his/her behavior will determine whether punishment or rewards will be earned or ‘chosen’ by the child.

You may invite the child to give feedback and in some cases make minor changes based on valid reasons. However, you can not allow the child to ‘negotiate’ the procedures that have been set. A controlling, attention seeking child who sets the family agenda is often the very problem that parents have in the first place. One goal of intervention is to modify the child’s controlling, attention seeking behaviors and put the parents in charge of what is happening at home. Your tactics with the child will ‘model’ the nature of the interaction and what needs to change.

It may be helpful to tell other children in the family what is going on to get their support and/or to assure them that they will not be forgotten. Siblings sometimes misbehave for attention when they realize that one child is getting extra attention for ‘bad’ behavior. Watch for and address this as soon as possible. One solution is to implement the techniques for all of the children in the family [e.g., establish a routine for everyone]. Be sure to probe for any new child problems during the entire intervention process.

ELICITING THE STATUS QUO

Child management practices are a major factor in the development of social skills. Given this fact, the following elicitations of information are critical. See Assessing Children for help in eliciting information. Based on your understanding of the family dynamics, you will choose the level of intervention required, which can range from a relatively simple reconstruction of the ‘rate of exchange’ to a more elaborate Social Learning Family Intervention which may include both training and personal cognitive restructuring for one or more child managers.

Identifying Parent Commands

An attention seeking child often successfully negotiates what s/he wants by drawing the parents into a long discussion. One goal is to shorten these conversations into a simple parent request, a simple child response, and a simple parent response.

Begin by asking each parent to independently list ten [10] typical requests or directives s/he has given the child in the last few days. Be sure the parents state the requests/directives exactly as they had worded it to the child. These requests/directives should include situations such as chores, interactions with siblings, finding things, or stopping disruptive behaviors. Next, ask the parents to list ten typical requests/directives to the child about school attendance. Probe for any extenuating circumstances or other reasons for why and how certain requests/directives were given.

Compare the lists to see if they are roughly similar or dissimilar in nature. If they are dissimilar, ask the parents why this is the case. Knowing whether discrepancies exist in the way each parent thinks about child management will help you to decide the scope of intervention. If parent requests/directives are effective in many situations but not for school attendance, then the intervention may be narrow in scope. However, if parent requests/directives are ineffective in many situations, including mornings before school, then the intervention may need to be broader to include these other areas.

Check the list for key errors that parents make when giving direction to their child. Such errors include:

directions given in the form of a question,
those that are vague and incomplete,
requests that are interrupted and carried out by someone else,
directives that are too difficult for the child, or
directives given in the form of lectures.

Look for patterns of errors that the parents may be making and provide constructive feedback.

These communication errors and patterns of errors are messages in and of themselves. Communication is a two way involvement of speaker and receiver. Not only does the speaker tend to use ‘shorthand’ phrases to convey messages; their emotional state and beliefs and attitudes are generally bound in the language. Thus, a parent who does not believe that his/her request will be fulfilled, will often state this thought in the request. For example: ‘I don’t suppose you would like to take your feet off the furniture”.

Identifying Regular Routines

Ask the parents to give you a detailed description of a typical school day morning in their house. Ask them to be very specific about this routine, perhaps even describing it in 10 minute increments. If the routine differs depending on the day of the week, have them describe routines for each day. If the parents expect changes in their routine over the next 3-4 weeks [e.g., due to vacations, holidays, changes in work schedules, school breaks], have them mention these as well. Probe terms such as hate, love or ‘stormed out of the room’ to determine exactly what the parent means by these terms. Probe also those areas that the parent takes for granted, characterized by a statement like, ‘I just know’. These are areas where meaning and communication may vary between participants.

As the parents describe their routine, pay special attention to the times the children rise from bed, wash and get dressed, eat, brush their teeth, do extra activities such as watch television, prepare for school and leave the house to go to school. If these times or activities differ from child to child, obtain a description for each but especially for the child with school refusal behavior. In addition, find out about the parents’ typical morning routine as well as any differences in routines between the two of them. The latter is especially important in cases where the child takes advantage of one parent’s absence to force the other parent to keep him/her home from school.

Probe as well for how the parents respond to their child’s behavior in the morning. Again, pay special attention to the behaviors directed toward the child refusing to go to school. Focus on behaviors such as ignoring, calming the child, yelling, physical interactions or lecturing. Encourage the parents to be honest about what is happening. Many parents are embarrassed that their lives revolve around a controlling child, but information about their interactions with that child will be important for potential change. Examples of pertinent questions may include the following:

When your child throws a tantrum or clings to the banister to refuse school, what exactly do you do?
How long does this interaction take place?
Do you eventually give in to your child because of other important matters?
What does your child do with or without you during the course of the day?
What do you say to each other and what is the emotional atmosphere like?

You will need to try to establish a pattern of how each parent responds to the child’s behavior and provide feedback. Remember that a central strategy is to reward school attendance behavior and not reinforce school refusal behavior [e.g., excessive physical complaints, clinging, tantrums] as much as possible and give attention to appropriate behaviors [e.g., getting out of bed, eating breakfast on time]. Because many parents have gotten used to attending to a child only when s/he shows ‘bad’ behavior, it is important that they start practicing a shift in attention toward positive behaviors.

Identifying Consequences For School Refusal Behavior

Ask the parents to list any consequences they have used in the past few days to discipline their child or make it known that a certain behavior was unacceptable. Have them rate each consequence for its effectiveness and identify those that are still used. Examples include lectures, spankings, grounding, restriction of privileges, loss of valued items, and fines, among other things. It is also possible that the parents have used very few consequences in the past or that they wait until their child’s behavior is severe before ‘giving consequences’. Other parents have simply ‘given up’ trying to deal with consequences in a formal way since ‘nothing seems to work’. Finally, others may have been severely punitive and found that they have reached an impasse with the child, where even a ‘spanking’ is not effective. This often develops into an escalation of punishments, which may border on abuse.

Check to see if the consequence usage differs from child to child. Is this pattern a trait of the parent, or a state generated by how they think about the child? Some parents punish their child with school refusal behavior much more than their other children. If this is the case, have them describe in detail what has been going on. In addition, ask whether each punishment was effective and whether the parents still use it. Identify the uses of each punishment over the past few days and how their child responded.

Get details. What procedures did they use? How long did it last?. Did both parents implement it? Did the child know the house rules before implementation? How clear and consistent is the family child management strategy. Are expectations and consequences outlined and understood by all – or do they appear incident by incident? Did the child leave the house anyway when grounded, tear up the bedroom, or say ‘I don’t care’. All past consequences must be explored in depth. In exploring these past examples, assess the parent’s attitudes about how effective they think further consequences will be in changing their child’s behavior. If possible, propose new expectations and consequences and get the parents’ feedback, so that you have an idea as to what their belief system will accept/reject. If parents have a strong belief that ‘children should not be bribed to behave’, this will have to be considered in teaching about reinforcement. In the same manner, if a parent believes that they must be the ‘boss’, the use of ‘please and thank you’, may be seen as an erosion of that authority.

Identifying Reinforcement For School Attendance

Ask the parents to list rewards they have used in the past few days to encourage appropriate behavior. As with punishments, have the parents rate each consequence for its effectiveness and/or desirability to the child. Discover whether they still use the reward. Examples include verbal praise, attention, extra play or reading time [with or without parents], food, toys, money or an easing of responsibilities. Also ask whether these rewards differ from child to child.

Explore how the parents used rewards in the past few weeks or months. Did they set up a system of rewards for the child for a few days but found it ineffective? Also, assess the parents’ attitudes about how effective they think future positive reinforcement will be in changing their child’s behavior. If possible, propose new rewards and get the parents’ feedback. Note that the child should be queried about potential rewards that s/he finds desirable to ensure that they will provide the desired motivational effect. Finally check the family’s time and financial resources to make sure all possible consequences, both negative and positive are realistic.

Home Work

Keep a list of the requests/directives the parent gives to each child between this session and the next one. Write these in exact wording used.
Keep a daily record of the family’s morning routine between this session and the next one.
Think about changes in the morning routine that may help the child go to school.
Think about other consequences and reinforcements the parent may have used in the past and possible new ones that you could use in the future.
Continue to complete the daily logbooks, noting any specific issues or situations that arise during the week.

DETERMINING PATTERNS AND THEIR MEANING

You should now have enough information to begin to understand the style and intensity of the parent/child interactions and be able to classify the pattern and determine the significance for the children of the family. These interactions are some of the most critical of the child’s developmental years, and therefore are worth considerable concern. Generally, there are four major classification for child management styles:

Authoritarian: this is usually characterized by command and control.
Authoritative: this is usually characterized by training, positive expectation, instructional feedback and reinforcement
Laizze-Faire: this is usually characterized by lack of monitoring
Some combination of the above.

The combination of practices, or lack of coherence in any singular strategy, is probably most problematic for the child as it allows for both confusion and manipulation. Inconsistency may occur due to differences between the parents, which provides the ability to play one against the other [and may also be a point of parental conflict], or may occur as a general pattern across both parents.

While generally not effective, the authoritarian and/or laizze-faire styles may work effectively depending on the nature of the child. On the other hand, both hold major potentials for child development difficulty.

The authoritative style is one that provides the best option for positive child development and is a style that can be learned. These classifications are part of the language and concepts that parents should come to understand. They should be able to identify which classification they are generally in [trait] and which they are in with specific actions [state].

Given the critical role that parents play in child development, you may need to decide whether it is necessary to provide a full social learning family intervention, instead of limiting the scope to just school refusal.

Parenting interactions are clearly the most well researched and most important proximal cause of conduct problems. At the same time, these management practices constitute reasonably malleable factors and represent a promising area for major intervention. The basic criterion for a choice about intensity is the scope and consistency of the child management errors. If these errors are generally applied to all of the children in the family, are a trait of the parents and seem to have demonstrated or hold the potential for severe negative results [lack of interpersonal skills and relationships/antisocial behaviors]; the focus on providing a full social learning family intervention must be considered. Another criterion, of course is the emotional intensity displayed by the parents in utilizing the practices. For example, the absolute belief in the ‘rightness’ of a given practice, even in the face of continued and continual failure to gain expected results, would indicate potential for serious problems in the future. To place emotion is to give value, and strong values tend toward rigidity; which in the context of human interactions can lead to poor practices.

Parent and family characteristics and behaviors, particularly in the area of child management and monitoring, are among the most well-documented precursors and covariates of childhood disorders. In addition, researchers have convincingly demonstrated that parent and family characteristics such as marital distress, spousal abuse, lack of a supportive partner, maternal depression, poor problem solving skills, and high life stress [socioeconomic disadvantages and a lack of social support for the mother outside the home (e.g., few positive social contacts with family or friends) are likely to lead to serious defects in child and family management practices. Child management errors, it seems, may be caused by a parental deficit caused by lack of training by appropriate models or as a response to a frustrating specific situation which overwhelms normal parenting, or a distortion caused by feelings of despair, anger, shame, fear and helplessness connected to the personal problems of the parent. Social Learning Family Intervention includes both a training and a cognitive rehabilitation aspect.

Social Learning Family Intervention

Attempts to address the issues of child management in regard to school refusal, therefore, may be expected not to achieve success, unless some of these larger adult personality issues are directly addressed. A Social Learning Family Intervention is a comprehensive approach which combines training with clinical intervention and enhancement of natural supports. If you elect to proceed on the SLFI path, this process would include:

Child Management Training:

The parents are taught a step-by-step approach where each newly learned skill forms the foundation for the next skill to be learned. Nine [09] child management practices form the core content components of the program.

they are taught how to pinpoint problem behaviors of concern and to track them at home [e.g., compliance versus noncompliance];
they are taught social and tangible reinforcement techniques [e.g., praise, point systems, privileges, treats]. Over time, the tangible reinforcers are replaced by the parents’ social reinforcement;
they are taught discipline procedures, focusing on discipline as a noun instead of as a verb. Discipline is seen as a method of teaching the child how to discipline him/herself and take responsibility. When parents see their child behave inappropriately, they learn to apply a mild consequence such as a five-minute time out combined with a learning experience [either written (Individual Behavior Learning Packet), or in discussion about what constitutes appropriate behavior]. Response costs and work chores are advocated for older children;
they are taught to ‘monitor’ their children, even when the children are away from home. This involves parents knowing where their children are at all times, what they are doing, and who they are with and when they will be home;
they are taught how to set up a time and area for homework and the best methods to help their children finish homework assignments. They are taught how to contract with the school to receive daily notes regarding assignments and completion;
they are taught problem solving and negotiation strategies and become increasingly responsible for designing their own programs;
they are taught how to play with their children in a non-directive way, and how to reward children’s prosocial behaviors through praise and attention. The objective is for parents to learn to break the coercive cycle by increasing social rewards and attention for positive behaviors and reducing their commands, question and criticisms;
they are taught how to communicate transactionally, adult to adult; and
they are taught ways to communicate direct, concise and effective directions for mastery.

Training methods include role-playing, modeling and coaching. Homework is assigned in the form of daily ten minute practice sessions with the child using the strategies learned. Based on Bandura’s modeling theory, the program often utilizes video tape modeling methods. Efforts are made to promote the modeling effects for parents by creating positive feelings about the models shown, using models of differing sexes, ages, cultures, socioeconomic backgrounds and temperaments so that parents will perceive the models as similar to themselves and their children. Video tapes show parent models in natural situations [unrehearsed] doing it right and doing it wrong in order to demystify the notion that there is ‘perfect parenting’ and to illustrate how one can learn from one’s mistakes. After each session, the trainer leads a family discussion of the relevant interactions and encourages parent ideas.

The process takes a minimum of thirty hours with additional time for follow-up and reinforcement.

Modifications for adolescents include targeting behaviors believed to put the adolescent at risk for further delinquency [e.g., curfew violations, drug use, time with ‘bad company’]; emphasizing the importance of parental monitoring and supervision especially with respect to school attendance; and using punishment procedures such as work details and restriction of free time. Parents also are asked to report legal offenses to juvenile authorities and then act as advocates for their children in court.

Specific Clinical Interventions:

Where necessary, individual or family clinical interventions will take place with sufficient intensity to at least prepare the individual and/or family to take the initiative to address the personal problems on their own. Such interventions will be cognitive behavioral in nature, and consistent with the principles of social learning, teaching the individual specific skills which will enable them to take responsibility for their own lives.

Since these incongruities in child management can set in motion many behaviors in children that are considered unacceptable in school, there may be reciprocal actions taken in school which support the cognitive notions of the child that support the desire to stay away. Therefore, if the child management and monitoring strategies are severe enough to require social learning family intervention on a full scale, the response of school personnel may also need to be explored and possibly changed.

If you decide that this level of intensity is not required, you may proceed to help the parents look at child management as a specific school refusal issue. The major focus will continue to be on the parents and the major goal will be to shift parental attention away from school refusal and toward school attendance.

INTENSIFYING THE PROCESS

This section describes how to intensify procedures for a child refusing school for attention.

Changing Parent Requests/Directions

Begin the session by reviewing the list of requests/directions given by the parents to their children over the past few days. Pay particular attention to those given to the child who is refusing school. Review with the parents key errors such as question-like, vagueness, criticism, interrupted, incomplete, directives ultimately ignored by the parent giving it, directives with too many steps and requests/directions give in the form of lectures. Discuss patterns of errors that the parent(s) may be making; and whether this is a trait or state pattern.

Place the pattern of errors into the context of antecedents, behavior and consequences identified in the psychoeducational component. Discuss ways to make these requests/directions informative, clear and concise. Discuss how to offer choices within directives without becoming too confusing. In general, identify the patterns and direct your attentions at correction of the major errors.

Engage the parents in a dialogue that questions them about the patterns, the emotional value of the pattern, the effective outcomes of the pattern, and how change might be made. In other words:

make the parents aware of the patterns that are occurring and the outcomes of those patterns,
have them attend to these patterns through use of the Child Management Journal [CBP#02-010],
have them analyze these patterns for simplicity, effectiveness and in light of the ABCs of behavior,
have them create alternative patterns which may be more effective in reaching desired outcomes, and
help them adapt to these new patterns.

At this point, it might be most helpful to have the parents begin to change some of the statements they make to their child. Using written examples from earlier meetings and journals, have the parents dissect the statement identifying errors and making recommendations about wording, including, but not limited to:

is the directive authoritarian, laizze-faire or authoritative in nature?
does the directive include specifically what is expected of the child?
is the directive ambiguous or clear?
does the directive include all necessary elements [action expected, directions, timeliness, and consequences]?
when the directive is given, does the parent have the child’s undivided attention?

As the parents are able to articulate and discuss these specific components of good directives, review again some of the problems with such directives as:

• Clean your room!
• Please start now to pick up your clothes from the bedroom floor and hang them up on hangers in the closet and continue until finished.

• Stop hanging on me!
• Please take your hands off me, now.

Parents should eliminate criticism and sarcasm from the directives and from resultant commentary.

Parents should try to cut down on extra speech during a directive and be sure the child is not rewarded by having someone else carry out the directive.

Parents should try to engage in a task with the child after giving a command [e.g., pick up toys in a room with the child].

Parents should always provide reinforcement for obeying a directive [smile, thank you] and consequences for failure to obey [response costs].

Go through all of the directives on the parents’ lists and change them as necessary. As much as possible, have the parents change the statements themselves so they can learn to build effective directives of their own. Focus especially on commands given in the morning for school attendance. In addition, if excessive reassurance seeking is a problem now, consider the possibility of starting procedures to address this behavior.

Setting Up Regular Routines

Review with the parents their description of a typical school-day morning in their house. As before, pay special attention to the times the children rise from bed, wash and get dressed, eat, brush teeth, do extra activities such as watch television, prepare for school and leave the house to go to school. In addition, review with the parents what their typical routine is during the morning, including their behavior directed toward their children.

Discuss with the parents, the context of breakdown. When does the target child first display refusal behavior, what is the typical response, how does it work? Ask the parents to define specifically what they would like to see happen short term and long term. Ask them to analyze their routine for flaws and suggest changes.

Give feedback about changes you think are necessary to regulate this morning routine and improve the childrens’ responses to their parents. For example, set up regular times for all the child’s activities in the morning. Be sure to give the family enough time to complete all of their morning tasks. Consider the possibility that you are recommending a much stricter routine than what family members are used to. Parents should have the child rise from bed about 90 to 120 minutes before school is supposed to start. This should be done even when the child is not currently attending school.

The following schedule can be used as a guide:

6:50 a.m. Wake the child.
7:00 – 7:20 a.m. Child goes to the bathroom and washes as necessary.
7:20 – 7:40 a.m. Child dresses.
7:40 – 8:00 a.m. Child eats breakfast and discusses day with parents.
8:00 – 8:20 a.m. Child makes final preparation for school [e.g., books, jacket]
8:20 – 8:35 a.m. Child goes to school
8:40 a.m. Child enters school and classroom

Many parents will find such a schedule ludicrous. They will state that they cannot expect that such a schedule would work. The purpose of the schedule guide is to begin to flesh out the commitment of the parents to the process of change. Changing a child’s school refusal behavior will take time and energy, which parents don’t always expect. In actuality, it is not new energy that is required, but redirected energy. Parents in this situation have been wasting a lot of energy on ineffective means – now the question is posed; do they want it to stop? If they do, this will require that they take new responsibilities and follow a new regimen as well as their child.

Gaining agreement for a new schedule may be the defining part of the change process. But obviously a simple change in schedule will not work if the child simply continues to choose not to participate. If the child does not go to the bathroom within ten minutes after being awakened, what happens? To ensure that the child will choose to comply will require a management of contingencies.

As part of the focus on developing a routine for the day, the parents will need to be helped to consider the value of a clearly specified set of expectations and consequences. If the child is expected to get up at 6:50 a.m., what are the consequences of his/her not getting up? How can we think out the scenario in completion? If the child does not get up X will happen. What are the five or six most likely things the child will respond with if X happens? Should we include the child in this discussion? What will happen when child responds with 1, 2, 3, 4, 5, or 6? Parents will need to experience the process of anticipating the responses and be prepared to deal with each response effectively to an end point. Most parents have not thought in this detail about what the ‘rate of exchange’ will be and how they will feel about it.

This does not preclude consequences for compliance behaviors. If the child gets up, follows the routine and goes to school, what are the consequences? How do these differ from the consequences for failure? How do they meet the bargaining needs of the child?

Setting Up Consequences for School Refusal Behavior

Review with the parents the list of consequences they have used in the past to teach their child discipline. Specifically review how the parents used these consequences, the effectiveness of each and the consequences still used. Finally, review the parents’ attitudes about these consequences and any new rules or consequences they wish to raise.

Parents will be asked to not only define a specific schedule of events for the family, but to have a clearly outlined set of rules [expectations and consequences] for each member of the family. What happens if a parent does not follow the schedule? There should be defined consequences for such an event. In the case of the any individual not conforming to the agreed upon schedule and rules, there is not an assumption of ‘wrong doing’. Rather there is an assumption of failure to achieve. When we fail to achieve in life there are consequences. Children need to understand this concept and parents need to diminish the emotional content of such failure to achieve. Failure to achieve does not mean ‘S/he did that on purpose!’.

The strategy, therefore is total, not piecemeal. However, parents may need to have pieces to work on as the process of creating a total environment [ecosystem] is being developed.

One way to do that is to choose five [05] specific school refusal behaviors to target. These are chosen from the information gathered during formal assessment or as discussed by the parents at earlier sessions. These should be ranked from the most problematic to the least problematic. For example:

Refusal to move [most problematic]
Aggression/hitting one’s sister or parent
Crying
Excessive reassurance-seeking [asking the same question more than twice in one hour]
Screaming [least problematic]

Next, ask the parents to choose a specific consequence algorithm [a series of responses that will be implemented in order to achieve a state of rest ] to be given for the two lowest-severity behaviors. The consequence should be something that is practical and can be given both in the morning and after school. The latter is important so the child knows that school refusal behavior is serious and will be addressed at all times of the day, not just in the morning. Examples for an attention-seeking child include ignoring, time-out, working through misbehavior without extra attention, and going to bed early.

It is important to focus on the lower level behaviors so that parents can practice what to do with less effort and experience some success with the process. However, if you or the parents feel comfortable addressing more of the child’s misbehavior at this time, then you can proceed to do so. Consequences should also be set for noncompliance to directives [e.g., failure to comply to a expectation to get out of bed or get dressed] within a specified time limit.

Be sure to go over all possible scenarios that could occur in the next few mornings and form a plan with the parents to address each one. Try as much as possible to include both parents in the plan. Although this may take some time, making sure the parents know how to respond to any behavior is an essential component of this protocol and for eventually getting the child to school.

In many cases, the child will escalate his or her behavior to get the parents to give in. This is an ‘extinction burst’, or an upsurge of misbehavior over and above the previously highest level of misbehavior. An extinction burst can seriously damage the process. Therefore, warn the parents of this possibility and encourage them to diligently follow through on the consequent algorithms. Warn them that if the child successfully forces them to give up now, s/he may misbehave even more later when the parents try to reassert themselves.

Setting Up Rewards for School Attendance

As noted earlier, the most important aspect of the program is to reward appropriate behavior. Under normal circumstances this is done nonconsciously through everyday processes. In this situation, the need for clinical intervention has made it necessary to make conscious that which typically is a nonconscious matter. In any ‘exchange’ both sides should ‘win’. This is a requirement of an on-going system. You may ‘cheat’ someone once and get away with it. But if you must deal with that person over time, you create problems of attitude by ‘cheating’ or ‘forcing’ an exchange. Thus, the rewards for appropriate behavior need to be spelled out. In our opening paragraphs of this section, we noted that ‘you get what you pay for’. Thus a child gets food, clothing and shelter as a basic budget and all else is negotiable. In order to negotiate effectively, you must gain some understanding of the opposition’s agenda – you will need to discover what counts to both the parents and the child.

This may entail a process of negotiation which is a means by which parties agree to anticipated behaviors and outcomes. The process is to reach an agreement between parties settling what each gives or receives in a transaction between them. Other means of achieving ends, including persuasion, education, appeal to authority, threat or coercion lack any long term cohesion. Bargaining behavior can be regarded as a form of social influencing and consequently be analyzed through social influence concepts. It is not necessary that the parties be equally powerful nor have equal experience. Negotiations are a communications encounter in which information [the difference that makes a difference] is crucial. The early initiation of cooperative behavior tends to promote the development of trust and a mutually beneficial, cooperative relationship; early competitive behavior, on the other hand, tends to induce mutual suspicion and competition,

A negotiator wants to believe s/he is capable of shaping the other’s behavior, of causing the other to choose as s/he does. However, negotiators are influenced by the information they obtain, or are exposed to, about the other and, in turn, exert influence themselves through the information they disclose. It is the exchange of information, the attributions to which it leads, and the way in which it is shaped for the purpose of mutual social influence, that represents the fundamental strategic issue.

The clinician must ensure that the negotiation is:

limited in scope to defining acceptable rewards
is a sharing of information about needs/wants
is able to separate needs/wants
is seeking a win/win solution
is thought of as a beginning

Much of the time spent with the parents to this point has been focused on giving them new information about how to look at their interactions with the child. Hopefully, negotiating rewards will demonstrate the efficacy of this training. What is being sought is a clear understanding between the parties of what is the ‘basic exchange system’ and what additional rewards can be earned and how that may be done. The child clearly expects something physical or psychological from the parents and is not getting it contingent on school attendance behavior. The parents expect the child to attend school and need not provide rewards if the child does not attend. However, simply setting up rewards on their own does not necessarily meet the desires of the child. The parents may promise time watching television when this is of little or no concern to the child. The questions that will be raised are: a) what does the child expect, b) is this expectation realistic [within the physical and psychological capacity of the parents, and c) if not, what is the next best alternative. The parents will need to develop specific criteria about what constitutes appropriate behavior and get agreement with the child on these specifics. It does no good to make the statement ‘I want you to attend school,’ only to find that the child goes to school, but not to class.

Notice that there is no negotiation procedure concerning negative consequences. These are established by the parents [with the help of the clinician] and the child is informed of the expectations and negative consequences for failure to achieve. However, if the child achieves or overachieves the parents expectations, s/he might be provided an appropriate reward, with appropriate being proposed by the child and accepted/rejected by the parents. Obviously if the parent is not accepting of the reward, cannot afford it, or in some other way is unable or unwilling to give it; this can cause a breakdown in the whole system. If a child’s next best alternative can be found which is acceptable and achievable by the parents, this can be the basis for an agreement .

The clinician’s role might be one of bystander, mediator or arbitrator depending on the need. If the child/parent(s) can negotiate an appropriate reward system, this is a major step in the development of a new relationship.

Using Antecedent Attributions [See Technique #24]

Human beings have a strong need to understand and explain what is going on in the world. To answer the question ‘why’? Attribution relates to the placement of a cause to explain the effects of events and experiences.

Because people seek to explain the world, it opens up some interesting influence possibilities. If you can affect how the child understands and explains what is going on, you might be able to influence how s/he behaves and therefore, potentially change the outcomes and consequences.

Changing personal attributions can occur either through individual self examination or external manipulation. External manipulation can occur either within the total culture or with a single significant individual.

While individual studies have shown dramatic and almost immediate changes in individuals who experience external manipulation of attributions, there is no clear indication of how quickly absorbed and how long lasting such effects are. The converse aspect, however, is reasonably well documented, that negative external attributions are detrimental and produce long lasting effects. We are additionally aware that even in the best of circumstances, negative external attributions outweigh positive external attributions some four or five to one. Thus it makes eminent good sense to develop the habit of consistent use of positive internal attributions as well as providing the child with a basis for beginning to understand his/her own thinking in regard to cause and effect.

When you explain the term attribution, it should correlate with the term explanation as a synonym. Attribution is the process through which we seek explanation for, or try to identify the causes of, the behavior of ourselves and others. How does the child explain the outcome?

I ask why did this happen
I provide an explanation
my future depends upon the explanation

We tend to take credit for our successes and disassociate with our failure, blaming external factors.

To achieve obvious and apparently enduring effects, all you have to do is make a few well timed and appropriate antecedent internal attributions. There is no great deception or elaborate machinations.

There are three steps to effective use of an attribution:

it must be applied in a situation where people are thinking about why things are happening,
the explanation must be an internal attribution, and
the attribution must convey a positive message.

Thus, after a discussion of school attendance, the parent may make a statement such as: “I know this new plan will work, because you are such a responsible kid.”

Attribution theory gives credence to the maxim ‘less is more’. The less you do and the more you let the receiver think, then the more change you can get. You just have to make sure that the little things you do lead to internal attributions.

Essentially, the clinician will begin to help the parents understand that they must begin to attribute to their child, characteristics such as responsibility, honesty, good intentions, etc.

Once the parents understand the concept of antecedent attributions, and can make up some on their own, you may want to spend some time scripting some specific attribution statements that you think will be helpful to the child. You may also want to develop a specific schedule for using the scripts, tying them, for example, to the daily routine.

The use of these attributions should be indicated in the Child Management Journal.

Homework

Use the Child Management Journal
Use the consequences [rewards & punishment] for the two behaviors selected.
Implement the new routines with the rules [expectations & consequences].

IMPLEMENTATION & MONITORING

By this time the child should be rising at a specific time in the morning and getting ready for school. S/he may not yet be going to school, but s/he is no longer getting the attention and benefits which s/he had previously. The child is clear about the overall approach:

a new language for communication
a baseline of expectation and consequences
a clear understanding of the inevitability of the plan

The child may, in fact, have found the process sufficiently salient to begin attending school. The parents need to make a specific decision as to when to ask the child to ‘sign on the dotted line’, to use a sales analogy. At this point, the child is expected to go to school after the morning routine and failure to achieve is met with a specific set of ‘known in advance’ consequences. If the child does attend school, the parents will need to reinforce this behavior, not only with the agreed upon rewards, but with psychological stimuli of attention and gratification. Increased antecedent internal attributions might be scripted to support the behavior.

If the child still is refusing school, the consequences should include a specified routine, such as: no television, no leaving the house without the parent, specific chores which need to be done, specific academic work [work sent by the school or grade level reading, etc.], no phone calls, no computer, etc. The routine should be one that is oriented toward productivity of the child, not pleasure in being home.

The parents won’t:

get emotional about the refusal, you have a consequence algorithm, follow it,
get pulled into debates about the rightness or wrongness of the agreement,
ridicule or humiliate the child, or
criticize the spouse who is responsible for the child management.

The parents will:

follow the plan – including playing out the consequence algorithms,
continue to place positive expectations, and
contact the clinician, if they believe it is necessary.

The clinician will:

visit the home to talk to the child/parent(s),
reiterate the agreement,
support the parents to the child,
help the parent(s) rethink mistakes, and
re-emphasize the inevitability of the plan. [It will work]

The clinician won’t:

assume the parental role.

NOTES:

Many children complain of physical symptoms early in the day, and it is sometimes difficult to tell whether these are real. Most schools would encourage you to send the child anyway and alert the school nurse, who will make the decision as to whether the child will stay in school. This kind of agreement should be developed with the school. Unless the child has a fever of at least 100 degrees, or has obvious physical symptoms such as vomiting, bleeding, or diarrhea, the parents then will simply state that if the symptoms continue, the child should ask to see the school nurse. If the symptoms listed above occur, the child will remain home in bed, and the parent will call the doctor.

If the child refuses school by not getting up or getting dressed on time, the plan might include taking them to school whenever they are up and dressed. It may also be a part of the plan that on these occasions, the parent will stay at the school, even in the classroom to ensure attendance in attitude as well as physicality.

If both parents work and the child is refusing school, the parents will either need to ensure that the child manager replacement has specific responsibilities to the routine, or one parent may take the child to work and give him/her specific duties to perform. Advise co-workers in advance that you have a school refusal problem and encourage them to not give too much positive attention. In fact, the parents and clinician can discuss an internal attribution script that co-workers can use. [e.g., “Your mother has told me how responsible you are, so I am surprised you are not in school.”]

If the child stayed home for the entire day, then s/he should not be allowed to enjoy fun activities at night. Instruct parents to get their child’s schoolwork for that day from the teacher and have him/her work on it at night. Suspend activities such as television, video games, or social engagements.

Whether or not the child attended school that day, his/her routine should also be set after school hours and at night. After school activities, homework, and later recreational activities should be set to a specific time and tied to school attendance. For example, if the child eventually attended school but refused to move in the morning for ten minutes to avoid school, s/he may be grounded for the evening, required to do additional homework, and/or be sent to bed early. All of this, of course, should be known in advance.

When implementing routines and administering consequences for a child with very persistent school refusal behavior, some family members feel a lot of guilt and frustration. In other cases, family members may feel the procedures are too mechanical or too foreign to the family’s normal way of interacting. It may be necessary for families to set aside procedures on the weekend and just enjoy some fun activities together. You will need to decide whether respite from the plan should be built in.

In many cases, excessive reassurance seeking continues to be a problem. Excessive reassurance seeking may come in several forms, including a) constantly asking the same question(s) over and over, b) attending school but constantly telephoning the parents at home or work, and/or c) attending school but constantly demanding attention of the teacher or deliberately becoming disruptive to be sent home.

To address a child who asks the same question(s) over and over, follow these procedures: if the child asks a question, parents should answer it one time. If the parent is asked again, s/he should calmly remind the child only once that the child knows the answer. If the parent is asked again, s/he should turn away from the child.

You may wish to set a limit on how many times a child can ask a particular question. One rule for young children with highly excessive reassurance seeking behavior is to allow one question about school per hour. Following this question and an answer by the parent, the child’s school related questions are ignored until the following hour. This period of time is then gradually increased.

Homework

• Continue to keep the Child Management Journal

MOVING TOWARD CLOSURE

The process we have been pursuing can be described as nothing less than an attempt to influence a change in the family culture. Changing a family culture is not a science. This is not because there are not structures from cognitive and behavioral science that can be utilized, but rather because culture is so pervasive and complex. Within every culture there are established presuppositions which tend to become unconscious. Whatever we believe with absolute certainty we tend to take for granted. We lose sight of the fact that alternatives to our stable presuppositions can even be entertained.

Thus a culture is a many faceted perspective, perhaps best seen as a set of control mechanisms – plans, recipes, rules, instructions, which are the principal bases for the specificity of behavior and an essential condition for governing it. Since these variables have generally become repetitious and habitual, they become nonconscious mental contexts, that, for people who are committed to them, there becomes an inability to consciously think consistently of the alternatives to their own, stable presuppositions.

In individual families, the culture may be fragmented. After all, the individual parents may have grown and developed in significantly different family cultures with quite different presuppositions about child management strategies. It may be that the very clash of cultural presuppositions is an underlying aspect of the presenting problems. Newlyweds tend to muddle through toward the creation of a new cultural recipe, enhanced by a singular goal of making a family, a goal which helps them pull together, make compromises and accept change. The addition of a child may, however, open up an as yet unaddressed breach. Generally speaking, the mother will set the major tone for child management practices, but if the father disagrees on the presuppositions, he is likely to point out areas of ‘messiness’, adding to the stress of a new experience for the mother and causing anxiety in the husband/wife roles.

The issue is not who is correct. The issue is to consciously seek to establish specific methods of child management that can be implemented unilaterally and for which all parties can find an acceptability. The process we have recommended is to make presuppositions and resultant behaviors conscious so that they can be examined and, if necessary, changed. The criterion has been effectiveness. If the parents together have been able to develop new communication and consequence strategies and these have proved successful, there will be a need to institutionalize these gains.

The first step in such institutionalization will be to ensure that there are no residual beliefs, thoughts, attitudes and feelings that will impinge upon future development. It reminds one of a family who set up a point system to change the behavior of their child. The rewards were so magnificent that the child’s behavior changed dramatically. However, at one point, instead of basking in his success, he blurted out how much he hated his mother and father for ‘doing this to me’. Obviously, he was choosing to behave in order to attain the reward, but he didn’t feel good about it. Just as obviously, if the thought driving his feeling remained, the ‘success’ could not be maintained. Perhaps, he would come to enjoy the other social benefits that came from his new behaviors, and this would sustain him. But perhaps not. Perhaps his anger would grow and we would suddenly have a well behaved child commit some atrocious act to appease his anger.

The operation can be a success and the patient can die. To ensure that this will not be the case with this family, the clinician will need to inquire, probe and delve into how the family feels about the changes in culture that have occurred. Are there residual presuppositions such as:

I have ‘bribed’ my child and this is immoral.
I am not being as loving as I should be.
I have lost control of my family; I am no longer in charge.
My ‘parent’ never needed to do this; s/he just said ‘Do it!’ and it got done.

If such attitudes or thoughts do exist, they can be examined ‘in the light of day’ and a conscious decision about them can be made. Alterations which adjust to the concerns or alterations of the interfering thoughts may allow for the change to continue. Or there may be a decision to just ‘live with it’ for a while and to develop a scheduled follow up where the concerns can be readdressed after the family has had more time to test the new culture and acclimate to it. Of particular concern is to find a way to ensure that the parents are at least reasonably in agreement with the plan. A successful implementation which leads to increased parental conflict is not a good thing.

Using the Child Management Journal, the clinician should help the family ‘take stock’ of what is occurring. What are the individual changes in factors [language, communication, routine (expectations and consequences)] and what impact have they had on the broader family life. Are they something that the parents have found useful in other areas of their lives or do they remain somehow foreign? Are the parents ready to have ‘family meetings’ in which they and their children discuss the ‘new culture’ of the family to ensure that all family members have clear understanding of expectations and consequences, or are they simply glad that their child is back in school and anxious to be quit of this process. Make sure you know what the parents, individually and collectively, think about the new cultural procedures under which they are operating.

Depending upon these thoughts, the clinician must find a way to place closure on the immediate process and, if necessary, have a way to revisit any continuing concerns.

CBP#02-010 Child Management Journal

IV. Maintaining Variable: to pursue tangible rewards outside of school

Common behaviors in this group include secrecy to hide school absences, verbal and physical aggression, running away, spending an excessive amount of time with friends, disruptive behavior to stay out of school, hostile attitude, refusal to talk, drug use, gambling and excessive sleep.

The major focus is the relevant family members, most likely the parents and the child refusing school. The major goal is to provide the family with a better way of solving problems, reducing conflict, increasing rewards for school attendance and decreasing rewards for school absence.

This protocol includes:

psychoeducation,
building an infrastructure
designing written contracts between parent and child to address problem behaviors, and
implementing contracts.

PSYCHOEDUCATION

The plan involves key elements of a contingency contracting approach. This will requires that the language and concepts of behavioral contracting be understood. A behavioral or contingent contract involves placing contingencies for reinforcement into a written document which is agreed to and signed by the child and parents and any other persons who are involved with the contract. Contracts may be effectively used with students of all ages to increase desired behaviors or decrease undesired ones.

Contracts have an everyday meaning and are used in conjunction with many adult behaviors because they are explicit and set expectations. In order for the participants to fully understand the structure of the behavioral contract they hope to negotiate, it will be important that they learn the language and concepts of operant behavior. This will require, at minimum, a review of the content of Session #1 the ABCs of Behavior of the Behavior Skill Training Program. The understanding of antecedents and consequences, reinforcement of positive and negative outcomes, and so on will become a part of the way the contract is structured.

Additionally, we will need to have a basic understanding of negotiation. Negotiation is a means by which parties agree to anticipated behaviors and outcomes. The process is to reach an agreement between parties settling what each gives or receives in a transaction between them. Other means of achieving ends, including persuasion, education, appeal to authority, threat or coercion lack any long term cohesion. Bargaining behavior can be regarded as a form of social influencing and consequently be analyzed through social influence concepts. It is not necessary that the parties be equally powerful nor have equal experience. Negotiations are a communications encounter in which information [the difference that makes a difference] is crucial. The early initiation of cooperative behavior tends to promote the development of trust and a mutually beneficial, cooperative relationship; early competitive behavior, on the other hand, tends to induce mutual suspicion and competition,

A negotiator wants to believe s/he is capable of shaping the other’s behavior, of causing the other to choose as s/he does. However, negotiators are influenced by the information they obtain or are exposed to about the other and, in turn, exert influence themselves through the information they disclose. It is the exchange of information, the attributions to which it leads, and the way in which it is shaped for the purpose of mutual social influence, that represents the fundamental strategic issue.

The clinician must ensure that the negotiation is:

limited in scope to defining acceptable rewards
is a sharing of information about needs/wants
is able to separate needs/wants
is seeking a win/win solution
is thought of as a beginning

Time spent with the parents should be focused on giving them new information about how to look at their interactions with the child. What is being sought is a clear understand between the parties of what is the ‘basic exchange system’ and what additional rewards can be earned and how that may be done. The child clearly expects something physical or psychological from the parents and is not getting it contingent on school attendance behavior. The parents expect the child to attend school and need not provide rewards if the child does not attend.

The clinicians role might be one of bystander, mediator or arbitrator depending on the need. If the child/parent(s) can negotiate an appropriate reward system, this is a major step in the development of a new relationship.

Finally, we may need to spend some time on the concepts of WANTS and MUSTS. Not every situation will have MUST objectives, which are those that are generally non-negotiable, but most decisions have objectives that, while not essential, are nevertheless desirable. These are the WANT objectives, and they usually vary in their degree of importance. Therefore, you may want to additionally classify the WANT objectives, by listing all of the WANTS and weighing the relative importance on a scale from 10 to 1. The rating is the client’s, not yours. Once having developed and classified the objectives, it is helpful to step back and review them. The objectives should be stated so that the MUSTS are measurable and the WANTS are well defined.

A MUST, or non-negotiable items for the parents is that they must provide home, food and clothing to a child who is under the age of eighteen. This is supported by the law and to do less would be considered to be at least negligence, and potentially abuse. The WANTS, however, of desserts, designer clothes, etc. are not required and, therefore, if the child wants to receive them, s/he will need to find some way to pay for them. ‘Pay’ is not used here in the monetary sense, but in the sense that a ‘quid pro quo’ occur – the parents receive something they want in return.

Other specific concepts that are to be discussed include:

Agreeing: You must negotiate the consequences and reinforcements for specific behaviors. Negotiations are not one sided. No one dictates the terms to which each party agrees. Negotiating does not diminish the parental role. Only those things that are negotiable are considered. Parental rights and responsibilities remain intact, although the process may provide some better ways to achieve parental goals.

Formal Exchange: The reward is always given after the behavior is produced. You must not relax the behavioral requirements at any point in the contract period, once it has begun.

Behavior: the target behavior must be specifically and objectively defined, including an expected performance standard and time deadlines.

Goal Setting: Contracting and goal setting can be combined to assist the child in setting his/her own goals. A penalty clause may also be useful with goal setting. [See Technique #27 – (formerly #30) – Motivation and Goal Setting]

Advertising for Success: contracts should be publically posted.

Group Contingencies: contracts can be developed for the whole family or an individual child. The procedures are basically the same.

Level System Contracting: a more sophisticated contract a ‘level system’ can be used to help shape desired behavior over a period of time by automatically adjusting access to privileges based on how well they meet family expectations during the contracting period.

Setting The Stage

You will need to split your initial time equally between the parents and child. First ask the child for his/her input and negotiate initial contracts separately with the child and the parents. Meeting with the child first is sometimes key to getting him/her to ‘buy in’ to the process. It is important for the child to know that you are considering his/her point of view as much as the parents’ view. In other words, the child must understand that the clinician and parents are not simply ‘ganging’ up on him/her. This is especially pertinent to adolescents who are hostile to involvement or to those you hope will be more forthcoming and more motivated over time. A key element will be to ensure that each party is willing to participate and to do so in a sincere manner. As a result, it may be necessary to shift your alliance among different family members at different times. In this way, one party may feel more empowered and thus more willing to contribute to or maintain a contract. The child and the parents will need to give a reasonable account of what they are willing to do and what they consider to be unfair or unworkable. Probe for anything anyone seems uneasy about.

To get the family acquainted with the contracting process, design the first contract around a relatively basic and circumscribed problem. In fact, it is better if the first problem to be addressed has nothing to do with the child’s school refusal behavior or potentially even with the school refusal child, although this may seem counterintuitive to the family. While it is important to get to the school refusal issues, it is equally important that the contracting process not be seen as a singular event in which the school refusal child is the target. It should be presented as a family problem solving device which includes learning how to negotiate and how to reach agreement. Such a process may be used by the family in the future to address any number of future problems.

Ask the family to choose something that has recently occurred as a minor problem. Examples may include not doing chores, not going to bed on time, not checking in with parents or not completing a homework assignment. These should not be trait problems [the child never does chores], but state problems [every once in a while]. After choosing a behavior problem, ask each family member to define the problem. You may be surprised at the differences in definitions, so some blending of differences may be necessary. For example, a parent may define a problem as, “He never takes the garbage out when I ask him”, while the child might define the problem as “ S/he only wants me to take out the garbage when the game is on.”. Each definition, though vague, points to a communication problem. You might redefine the problem as “The garbage is not being taken out by X when s/he is asked.”.

The statement of the problem must be agreed upon if a solution is to be found. The process of defining the problem is one which provides a great deal of information. One can see some of the WANTs connected with the interaction. The parent seems to WANT the child to react to his/her request. The child seems to WANT to be undisturbed when there is a game on television. Can both of these WANTs be met in an agreement?

Once the problem has been stated to everyone’s satisfaction, we suggest that you meet with each individual and begin a ‘shuttle diplomacy’ by working your way back and forth from one party to the other. You might begin by helping each person develop a list of MUSTs and WANTs and to weigh the WANTS so that they have thought out their own positions thoroughly. Any individual may insist on MUSTs which are unreasonable, and you can help them understand that they are unreasonable, and redefine them as WANTs, given proper weight.

Once each person is clear about his/her own position, you ask each, starting with the child, to describe as many potential solutions to the problem as possible. Include them all, even “Hiring a maid to take out the garbage.”.

Try to get about five to ten proposed solutions and then have people rank them in order of desirability. Desirability depends on whether the solution is practical, realistic, specific and potentially agreeable to everyone.

Next ask the family to choose one proposed solution that is the most desirable. Try to ensure that each family member bargains in good faith and lets you know if the solution is acceptable or not. You may even want to raise objections yourself to see if the family member has alternatives to offer or if the objections you raise are not a problem to them. Ask each person to consider the other – focus on consensus – find a solution that each believes s/he can accept. A good solution might be that the child is never asked to take out the garbage when a game is on television, but that when asked at any other time s/he will respond immediately.

This statement of the possible solution is one which sets the antecedents of the action, but what are the consequences? Obviously if the child follows the contract and does what is asked, s/he is rewarded by not being asked when there is a game on television. This is a quid pro quo built into the contract. Conversely, it the parent asks only when there is no game on television, s/he is rewarded by the child’s response. But what if the parent asks during a game or the child does not respond when asked when there is no game? This is a breach of contract. Usually a contract will include language that will deal with such a breach.

Rewards and punishments might be built into the contract in various ways. If, for example the child responds ten times in a row, the parents may think this is worth an extra reward. On the other hand, if the child fails to respond, the parent may believe that the child must ‘pay’. In the same manner as you did in defining the problem, you will want to talk to each person separately about rewards and punishments, Focus on those that are most desirable and agreeable to everyone. The first contract should be quite simple and read something like this:

(Child) agrees to take out the garbage immediately upon being asked if there is no game on television. (Parent) agrees not to ask the child to take the garbage out while a game is on television . If the child asked and complied on five consecutive occasions, the child will receive an extra $1.00 allowance the following week, and another cycle begins. If asked and the child does not respond within one minute, the child will lose one hour of television during the following day. Time to be set by the parent. If the parent asks while a game is on television [and persists after gaining this information], the child will receive 50¢ additional allowance in the next week. If the child responds by taking out the garbage, even though there is a game on, s/he will receive and additional $1.00 the following week. The family will convene once per week [Saturday evening] to discuss any contractual concerns. All appeals will go to the [clinician] for arbitration.

If siblings were added to the process, they may or may not have positions on the discussion. If not, they might choose to participate with one of the other parties, but are not decision makers for them. The point is that they should learn the skill of contract negotiation and group problem solving as well.

Steps for Contingency Contracting include:

Define the specific behavior for which the contract is being implemented.
Break the initial contract behavior into smaller steps, if necessary, so that the child will be successful. It is important for the child to be successful in earning the contract reinforcer so that s/he will be motivated to continue.
Select the contract reinforcer(s) with all parties participating.
Reinforces should not take a lot of time to deliver, nor should they be expensive.
Define the contract criteria – including the amount of the behavior required, the amount of reinforcement to be provided and the time limits for performance. Be as specific as possible and anticipate and address special circumstances. Don ‘assume’.
Cumulative criteria are usually preferable to consecutive criteria. Cumulative criteria allow the child to make mistakes (some periods of not meeting the criteria) without having to start over from the beginning. Consecutive criteria can be very discouraging to the participants.
If desirable, include a bonus clause for exceptional performance.
Consider adding a penalty clause for non-performance over the life of the contract.
Negotiate the contract; don’t simply present it.
1. Indicate why a contract is necessary and helpful
2. Identify WANTs and MUSTs
3. Discuss and agree upon the target behavior, reinforcement, and performance criteria
4. Make sure that all standards are realistic
5. Include options for review and/or renegotiation
Put the terms of the contract in writing
Writing and signing a contract prevents misunderstandings and indicates agreement with the terms at the time that all are participating.
Have all participating parties sign and date the contract. Make a copy for each participant
All contracts should be considered as ‘working documents’ until they are successfully completed. By working documents, we mean to indicate that they can be revisited and revised.

Implementing The Contract

Once the contract has been designed and worded, read the final product with each party separately to see whether they can agree to it. Probe for reservations. If agreement is reached, signatures and dating should be done together formally. You will want to praise the family for the accomplishment and make recommendations for implementing the contract. It is helpful to alert all participants to the distinct possibility that something will come up that had not been anticipated and addressed in the contract. Establish a procedure for dealing with such and eventuality without conflict – with the understanding that this will then entail rewording at re-negotiation of the contract with the clinician present.

You might suggest that a copy of the contract be displayed [perhaps on the refrigerator] where it can be read, referred to and initialed daily by each party in a spot indicating that the contract has worked or not worked for that day. If all agreed it worked or did not work, the components of the contract should control the actions. If there is disagreement over whether there was a breach of contract, this should be noted for discussion with the clinician; or if severe issues occur in regard to the breach, a call to the clinician might be appropriate. Such display adds to the conscious memory both of the accomplishment and the responsibility.

Remind the family that this is simply the ‘pilot’ project in a process of problem solving and that contract breach may have more to do with poor contracting language than with personal failure. Give the family a ‘pep talk’ about what has been accomplished and add your confidence that they will do well both in implementation of this ‘pilot contract’ and with the continued process [antecedent internal attribution]. In addition, convey the notion that if this contract is successful, then solving more difficult problems should follow naturally. Remind the child and parent to do the homework.

Homework

Think about regular times and places where the family can work on problem solving in the future.
Think about problems and potential solutions for the next contract.
Implement the current contract.
Complete the Daily Logbooks, noting any specific issues or situations that arise during the period.

BUILDING INFRASTRUCTURE

Three specific goals are defined in this process:

Building a structure for the family to problem solve [time, place, Rules of Order].
Learning to implement problem solving contract negotiations.
Developing as an end product a comprehensive School Refusal Contract.

Many families need to have consciously constructed regular routines for problems solving in order to improve the quality of family life. By helping the family consider a specific and regular time and place in the home to meet, you are helping them to consciously think about family problem solving. First, there needs to be a place where the family can sit together and talk. Usually this will be the kitchen or dining room table. It may be at a table which is set up for the purpose in some other room. It is probably not wise to meet in the living room or family room in comfortable chairs with a lot of seductive items [T.V., stereo] around. Once a place has been identified, a time must be selected which will a) be convenient to all members of the family, b) not interfere with regularly scheduled events, and c) not burden people in or tangential to the family. The family should schedule a regular time once a week to begin, and then cancel if no specific issues exist to be discussed. Experience with the problem solving process will dictate whether they need to be scheduled more or less often later.

At the start, you will be the chairperson of the meeting , but later you will ask each parent to take a turn. At some point down the road, the parents may like to have the children ‘run’ a meeting for the sake of the experience. The family members need to understand that the ‘chair’ has both power and limitations. Since the primary responsibility of the chair is to see that the agenda is considered and that all members participate, s/he should not dominate the discussion. In fact, the chair should withhold comment until all other parties have had their say. S/he can sum up the meeting or add to the sum at the end with comments of his/her own. You will be responsible for both articulating and modeling this role.

Help the family understand that at the beginning, the ‘chair’ will formalize the input process by assigning a specific amount of time for each person to have his ‘say’ – a ‘circle commentary’. If, for example, the assigned time is three minutes, each person in turn will be given three minutes to comment on the subject at hand. No one will interrupt, ask questions, or otherwise comment during the other person’s three minutes. If the person does not use the full three minutes, the participants will be asked to sit quietly contemplating what was said and preparing notes, question or comments for their own turn. If a family member does not wish to talk, s/he can simply sit and listen to the others. The chair can make a decision as to whether to have the group move on or sit quietly, however, s/he may want to get input from the members. Later, you will add additional time to the meeting to provide for more free discussion, but it is probably a good idea for the family to think about always having an opportunity for individual comment, without immediate feedback. In the meantime, you can encourage note taking and supply each participant with a pad and pencil or pen.

The first meeting, may be quite short, and may focus on each party reading [or having read to them] this set of rules and commenting on them. If there are five family members and yourself, the meeting might be scheduled for eighteen minutes. After each member has commented [you will need to time each person and ‘cut them off’ when they have reached the end of the allotted time], you can sum up and ask them to consider these comments for the next meeting. The expectation being that the family members will develop an agreement on when, where, how and why to meet.

After this initial meeting, you can spend individual time with members seeking feedback to the process. Encourage the family members to stay at the meeting for its entire duration. Praise everyone for attending. Remember you are seeking consensus, not a majority vote.

If the meeting does not go well, end it and schedule another at a later time. After the first meeting, if the meeting goes well and a healthy discussion is taking place, the chair should feel free to extend it. However, the chair will need to accept that the family committed to a specific time and some members may have made other commitments for the time following the meeting. Be cautious not to carry on too much discussion without full participation and no voting [voting may be used to elicit how close you are to consensus] or consensus making should occur without all family members at the table.

When the second meeting is convened, each family member will be asked to comment on the comments of the others in the first meeting, and to suggest changes in the family meeting format. If there is consensus, changes can be made. If not, write up the rules with options included and ask each family member to take time until the next meeting to decide on which option s/he prefers, or to offer further options.

Allow humor to enter the process, but be on the watch for sarcasm and/or ridicule. If you think this is occurring, stop and point out specifically what is problematic about the occurrence. This commentary time should not be considered a part of the timed ‘circle of commentary’ process, but also should not go on very long. This is not a debate as to whether or not the family member was, or intended to, be sarcastic or to ridicule. It is an opportunity to identify sarcasm and ridicule, talk about its elements and its potential dangers.

By the end of one meetings, the family should have a family meeting Rules of Order memorandum, which each has signed. The Rules of Order will then be posted on the family bulletin board [refrigerator] for continued consumption.

Having built up a problem solving process upon a reasonably noncontroversial content, you are now ready to design a School Refusal Contract. As before, you are going to start with a statement of the problem. The problem is not the totality of the school refusal, but should be a part of that issue [e.g., the child won’t get up in the morning]. You will probably need to hold a tight rein to ensure that family members do not interrupt and/or respond during the other person’s time. The first ‘go round’ of circle commentary will probably lay out different aspects of the school refusal behavior, and the family will need to target which piece to address first. Remind the participants that you would prefer that they start with something reasonably simple, not the most difficult issue. You will want to keep a list of all of the identified ‘parts’ of the problem in writing, so that they can later be prioritized and addressed sequentially.

Continue ‘round robin’ [this may go more than one meeting,] with you as the chair offering a summary statement of the partialized problem after each round. The next round will comment on the summary, until the summary articulates the statement of the problem in a manner which is agreeable to all parties. Once this is achieved, have all parties initial and date that clause of the contract.

Then move on to having each person articulate his/her WANTs [and MUSTs, if any need articulation] and prioritization of these WANTs to the family. The next go round will be commentary of the WANTs articulated by other members. What might be problematic, what compromises might be offered, etc.

Once these WANTs are understood around the table, you will want to address the consequences [rewards and punishments] that might be used in the contract. Remind the participants that there are constraints of reasonableness on these consequences [cost, time, etc.], and have a commentary round on the rewards and punishments. Ask the participants to consider DRAFTS of a contract, including the individual clauses.

The DRAFTS should be written out and each member should consider the elements.

Problem statement
Expected behaviors
Rewards for successful performance – individual/cumulative
Punishment for unsuccessful performance – individual/cumulative
Time limits – between antecedent and behavioral performance
Time limits – until review and possible revision
Trouble shooting’ – what to do when something goes wrong.

As each element is reviewed, a circle of commentary should occur. As the commentary nears consensus, you may want to allow a short period of discussion, which is comprised of ‘give and take’ commentary, rather than pure one person in order commentary. This short discussion period will help you to decide how well the family has learned to listen and respond appropriately. If the family does discussion well, you may want to move to more of it , since it is a more efficient use of time than circle commentary. However, you will want the meetings always to contain some segment of circle commentary to ensure that each member has an uninterrupted opportunity to make him/herself heard.

On a regular schedule the family will address each of the specific behavior problems which make up the school refusal pattern. As each element is developed, it should be both a stand alone contract, and be incorporated into a School Refusal Contract.

Homework

Think about the contracting elements and come to the family problem solving meetings prepared to offer recommendations.
Keep a daily log which notes possible implementation problems or new issues which arise.

Implementation

Each segment of the contract should be implemented as it is completed, building hopefully into a comprehensive program to address school refusal. As each piece of the contract is added on, it will increase the degree of complexity in the new relationship between family members. You will continue to meet individually with family members to discuss with them concerns and reservations and to determine the effectiveness of the contracts that are in place.

Each clause of the contract should be initialed daily to indicate a) the contract is working and the behavior performance is taking place, b) the contract is not working, except in so far as negative consequences are being implemented, and/or c) the contract needs reconsideration. If item b) is being checked regularly, you may need to interject the need to revisit and revise certain clauses of the contract, and/or have individual discussion with the child to determine the cause for failure to perform.

If the implementation is going along successfully, you may want to challenge the family meeting to address other issues of conflict, other than the school refusal issues. You should also be ready to turn the gavel over. First, to each parent on a trial basis, and then finally to the parents as an on-going token of their achievement. You may want to make up a certificate to go along with the presentation.

If the child is still refusing school and the contract(s) are not working, they need to be revisited and reworked. You may need to revert to ‘shuttle diplomacy’ to help this process. Continued failure may indicate a need to move to a fully Social Learning Family Intervention as described in the previous protocol.

Common problems that arise at this point are when a child agrees to the contract because s/he feels pressured to do so or because s/he is frustrated and want to get out of the clinical process as soon as possible. It is a good idea to contact the child individually and to discuss possible changes in wording of the contract.

In related fashion, you may have an adolescent client who finds the contracting process silly or useless, and/or simply does not believe that his/her parents will follow through on any provisions of a contract. In cases where the child has completely given up on the contract, you may need to find alternative problem solving solutions. One consideration, of course is the Social Learning Family Intervention discussed in the prior section. For the child, you may want to concentrate on Motivation and Goal Development [Technique #27 – formerly #30] to help you determine what goals are important to him/her as a means of finding contracts that make sense.

As with any protocol, you will need to find what works, and this is defined by what the parties are willing to participate in to reach their goals. Continuing to provide services which have been abandoned by the people being served, is not only unwise, it is destructive.

Communication Skill Training

The Meaning of Your Communication is the Response it Elicits.

If you compliment someone and they slap you, it is more intelligent to remember that’s the way to insult them, and try something else if you want to make them feel good.

If the family is continuing to participate, the development of communication skills is very important. This is often done with role-play and feedback. At the basic level this involves having one family member make a statement to, or ask a question of, another family member who is asked to listen quietly. Following the first person’ statement, the second person is asked to repeat or paraphrase what was said to ensure that the message was correctly heard and understood.

During this step, you should concentrate on addressing basic problems in communication. Examples of such problems include interruption, incorrect paraphrasing, refusal to respond to the request, and escalating negative interactions. Chart CBP#02-011 Common Speaker and Listener Behavior Problems and Alternatives [from Foster & Robin, 1977] provides some examples. You may also want to review Assessing Children With Problems In Living for further information about deletions, generalizations and distortions of language.

In advancing the communications skills, you should help the child/family understand the language and concepts of Transactional Communication. There are three fundamental constructs which must be understood to effectively communicate transactionaly.

Child Attitude: I want what I want when I want it.
Parent Attitude: You will do it because I told you so.
Adult Attitude: Can we talk?

While the descriptions of each of these three attitudes is brief, they convey accurately the focus of and attitude which leads to a behavior. It is important to note that each of the three attitudes is held by all people. Each parent has an ability to act as a child, a parent or an adult. Children can often be seen ‘acting as a parent’ with other children, telling them when and how to do something that they expect to get done. One potentially confusing aspect is that the parent/child relationship in this model, is not considered to be a good relationship and is not sought. This may appear to be counterintuitive, but help the participants consider the definitions, not just the titles. Despite this negative connotation, the child/parent relationship seems to be a naturally attractive one. The expected effort is to have each family member appeal to the adult attitude in the other and this can only be done by invoking the adult attitude in themselves. Most people fall into the trap of responding to the actions of the other person. When a child acts upon his child attitude, adults inherently become parents. If fact, it takes an act of will not to become a parent. Further, it demands a will struggle to ‘force’ the other to move to an adult attitude.

The parent, for example, is asked to communicate to the child from the adult attitude at all times. Acting from the parent attitude or child attitude is never acceptable. Since the child will expect to attract the parent attitude, there may be a struggle of wills to see whether the parent will assume a parent attitude, or the child will assume an adult attitude.

Carrying out such communication is the essences to the authoritative style of child management. The parent in no way gives up authority by maintaining an adult attitude. S/he continues to require that the child listen and respond to his/her requests or directives. The difference is in the quality of the interaction, which reduces emotionalism and increases information sharing. In order to maintain an adult attitude the parent will need to continue to give further information about what is expected.

While there may be concern about the ‘energy’ expended in staying with the conversation and getting to the adult attitude in the child, this is minor compared to the energy expended in emotional conflict between the child attitude and the parent attitude.

Communication is the primary exchange procedure of relationship. There are three basic methods of communicating: 1) through verbal articulation, 2) through non-verbal modeling, and 3) through emotional contagion. Of the three, we know the least about the third. How emotional contagion works is unknown, the fact that it works is clearly understood by anyone who thinks about it. The process of enhancing communication within families and other important relationships, is often predicated on diminishing emotionality and replacing it with appropriate verbal and non-verbal communication; improving the message in verbal communication; and awareness to behavior modeling and ostensive communication . As you work with the family, you will want to identify the areas in each of the three methods which can be improved upon and work with the family to change the communication process.

Practicing conversation without negative emotions or words is a helpful process. To start, suggest certain rules about what should be avoided in a conversation. Encourage family members to avoid name calling, insults, sarcasm, inappropriate suggestions, and screaming, among other behaviors. If these behaviors are not a problem, then less serious problems [e.g., lack of eye contact, articulation] may be addressed.

Conversations between family members should first be short, involve two family members only, and be closely monitored by you. Use the role play and feedback procedure. This might first involve a one on one conversation between one family member and yourself in front of other family members. In the following example, the clinician plays the role of the father speaking to his teenage son. This technique is especially advisable if two family members are having severe problems communicating with one another or have not done so in a long time. The intention is to have the one party [in this example, the father] and other family members model an appropriate conversation.

Son: I just don’t understand why I have to go to school. I’m almost 16 years old and everybody keeps treating me like a little kid.
Clinician: (acting as father and looking directly at the child). It sounds like you are kind of angry?

S: Yeah, I am. Why can’t everybody just leave me alone to do my own thing?

C(F): Can you be more specific? I am not sure what you mean.

S: I want to spend more time with my friends. I should be able to go out if I want to.

C(F): Okay, it sounds to me like you feel confined and feel that you don’t spend enough time with your friends – is that right?

S: Yeah, why can’t I do what I have to do at home and then go out without a hassle?

After this brief role play, give feedback to everyone about the appropriate behavior that occurred during the conversation. Important points to consider are calmness of tone, lack of interruptions, acknowledging another person’s point of view, correct paraphrasing, and lack of insults or other derogatory remarks. In this example, the clinician/father gathered information from the teenager without judgement or defensiveness. In this way, a problem [i.e., time with friends could be identified and defined accurately and negative emotions could be vented appropriately.

During this feedback process, be sure to address any questions family members may have. You may practice this one on one conversation with the child or with other family members to help them get the ‘feel’ of the expectations and provide direct feedback. Remind them of the adult to adult aspect of the conversation. You may then ask two family members [e.g., father, son] to speak directly to one another in a short conversation. Observe this conversation closely and interrupt and give feedback if problems develop. For example:

S: Like I said before, I always get hassled and don’t spend enough time with my friends.

F: I don’t get it, you’re with your friends all the time.

C. Mr. Williams, try to repeat what your son just said.

F: He said he doesn’t spend enough time with his friends.

C: Good. Let’s find out exactly what concerns your son. [Motions to do so.]

F: Okay. What exactly concerns you?

S: I do my chores and homework, so then I should be allowed to see my friends. Now that I have to go to school more, I don’t get to see them that often.

F: Okay, how much time do you want to spend with your friends? [Clinician nods approval of this statement.]

S: I don’t know, maybe a couple of hours a night. What’s the big deal about that?

C: Okay, John, stick to answering the question. Try to leave out statements or questions that are sarcastic or negative.

S: Okay, I’d like to spend at least a couple of hours a night with my friends. Maybe some more time on the weekends. [Clinician nods.]

F: So two hours a night on a school night after chores and homework and dinner are done? Does that sound about right?

S: Yeah.

Introduce different issues in these dialogues between two family members to help them practice appropriate communication. Once a child/parent dialogue is progressing well, another parent can be added. Care should be taken, however, to avoid overly strict alliance [e.g., two parents versus one child] that could damage the communication process.

S: When I am with my friends, I should be able to do what I want.

F: Okay, it sounds like you want more freedom. Is that right?

S: Yeah, I guess so. I am almost an adult.

F: Well, you’re getting there …

M. [To father:] Frank, he is not an adult.

F: I realize that, but John seems to believe he is becoming an adult. [To son:] Right?

S: Yeah, and so I should be able to do what I want.

M: Well, you can’t do anything you want. Your father and I will discuss what you can and can’t do.

C: Okay, Mrs. Williams, let’s focus on paraphrasing what John just said and then gathering information about it.

M: Okay, he said he wants to do what he wants. [To child:] What kinds of things do you want to do? [Clinician nods.]

Note the three factors of these conversations: 1) the control of emotion and negativity, 2) the paraphrasing of the other’s position and seeking confirmation, and 3) the seeking of further information. The maintenance of an adult to adult conversation requires at minimum, these skills. The process of asking for more information serves a two-fold purpose. On the one hand, it helps the inquirer understand better what is being suggested/requested, and two, it forces the suggester/requester to think further about what s/he really wants. We often demand response to suggestions/requests without having seriously analyzed our reasons for demanding. Often the reasons are contextual – I want the other person to give in – and have little to do with the actual suggestion/request. In the above example, it may be that the son simply wants the parents to acknowledge his emerging adulthood, but really doesn’t want to be able to do anything differently. On the other hand, the son may want the parent to be responsible adults and to take action to protect him from his own lack of ability to say ‘no’ to his friends. He may ask the most atrocious permission that he can think of so that they will respond with structure which permits him to avoid his ‘friends’. Most difficult of all, the son may not even know which of these is the case when he starts the conversation.

If the family members have done well in listening, paraphrasing and remaining calm in short conversation they may begin to practice extended conversations that are increasingly constructive. As before, this will involve role play and feedback where you first demonstrate an extended, constructive conversation with another family member. Along with watching for and addressing negative communications, the family may begin to focus more on increasing compliments and other pleasantries. For example, a statement such as “you barely finished your homework” may be translated into “I really like it when you finish your homework on time”.

Keep in mind things that prevent communication skills training from working. These include pessimism, punishment of one participant, and silence. As a result of several months [or more] of dispute over school refusal, there may be a lot of ‘emotional baggage’ that needs to be dealt with. One or more family members may need to have individual discussion with you to practice how to ‘unload’ without being emotional or negative.

Be aware that the family may not be able to completely change all hostile conversations in a short period of time. What you are doing is teaching a skill. Habitual usage of the skill may take extensive practice. The family should leave the process knowing what makes a positive exchange and what prevents a positive exchange. They should have ‘made public’ their own foibles in the process and learned words to say to each other to help them get back on track. Thus, having the language and concepts, along with a process of self monitoring should enable them, if they choose to do so, to continually improve the way they communicate. You must set the stage at the conclusion of the process by encouraging them to ‘check’ each other and to expect and welcome ‘checks’ from others in the future.

Peer Refusal Skills Training

A common reason for failure is peer pressure to skip school. In other words, the child may fully intend to go to school, but once s/he is there, is tempted or goaded by others into skipping school. As a result, you may find it useful to teach the child peer refusal skills that s/he can use to resist such pressure. Peer refusal skills training meshes nicely with communication skills training because the focus is on talking to others in a more constructive way. To start, ask the child to describe what his/her peers say at school to try to get him/her to skip school.

You and the child may then create different statements that can be used to firmly but appropriately refuse offers to skip school. Use role play and feedback in discussing different scenarios. Obviously, you must take into account a child’s anxiety about social rejection and build responses that will not let the child lose face. It is sometimes helpful for the child to blame their school attendance on their parents or you, thus absolving them [if only temporarily] of blame. In addition, a child can talk to peers about his/her interest in a particular class, the need to finish uncompleted work, potential rewards for school attendance or lack of desire to skip school. At this point, you may find it useful to outline suggested responses to peer pressures and ask the child to try them at school if the need arises.

Remember that peer refusal skills training will likely be most helpful if peer pressure is the main cause of interference with the school attendance contract. In addition, these skills may be helpful for refusing offers of drugs, which may be linked to school absence. However, if the contract is failing simply because the child is giving ‘lip service’ in sessions to you and his/her parents, then peer refusal skills will probably not be helpful.

Sleep Disorders

Another activity that interferes with school attendance is excessive sleeping in the morning or an inability to get up. This is sometimes worse for children who have been out of school for some time and who are not used to getting up early in the morning. For many adolescents, difficulty getting up is normal and temporary. In other cases, the child has a medical problem of a true sleep disorder that requires attention [If this is so, consult a medical doctor or sleep disorders clinic as appropriate for assessment and treatment.]. Common treatment for sleep disorders in children and adolescents include those listed in CBP#02-012 [from Durand, Mindell, Mapstone & Gernett-Dott, 1998].

In other cases, the child is simply staying up too late and not getting enough sleep, and/or feigning fatigue to avoid school. In these cases, you and the family members will need to design innovative ways of getting the child out of bed and ready for school. Try setting regular morning and evening routines and bedtimes, increasing rewards for rising at a certain time, setting the alarm clock earlier in the morning and having the parents constantly remind the child to get up, and allowing the child to get up later and then walk to school on his or her own. The latter option, however, usually requires some supervision and there is no guarantee the child will get up and go to school.

Escorting The Child To School

Despite the contract, you may find that the child still does not fulfill his/her end of the bargain. As a result, appropriate rewards are never given and the child continues to pursue inappropriate rewards outside of school.

In these cases, it may be necessary to have someone escort the child from class to class during the day. School officials are often unable to monitor children during the day, so one of the parents may need to do so. Obviously, this requires a lot of effort and time on someone’s part. However, the procedure is often effective because it ensures school attendance and allows a child to earn appropriate rewards. Sometimes, the mere mention of escorting prompts a child to adhere closer to the contract’s conditions because of the potential social embarrassment involved. If there is some valid urgency in getting the child back to school, the escorting may be implemented immediately.

Regaining and maintaining academic status

As a part of any reentry into school, the child, parents and school officials will need to be creative about finding strategies for making up past schoolwork and maintaining adequate academic performance. This may include after-school programs, extra tutoring, supervised homework time, daily report cards, weekly progress reports, rearrangements of class schedules, and/or teacher meetings to collect assignments. An excellent predictor of ongoing school attendance is often good academic performance. Children who do well in assigned work are more likely to stay in their classes. As the process progresses, encourage family members to define different academic problems and solutions and to incorporate these into a separate contract.

Homework

Continue family meeting – record conversations if desirable. Log aspects of contracting that are problematic or effective.
Continue communication skill practices. Log aspects that are problematic or effective.
Implement contracts and record experiences.
Think about problems and potential solutions for the next contract(s).
Continue Child Management Journal
Continue peer refusal skills as appropriate and record experiences.

CBP#02-010 Child Management Journal
CBP#02-011 Common Speaker/Listener Problems/Alternatives
CBP#02-012 Common Treatments For Sleep Disorder

CLOSURE

Slips & Relapse

A slip is a single error or some backsliding following intervention. In this case there is only minor regression toward old behaviors and only a minor amount of interference in a family’s daily routine. Slips may include such things as a missed school day, one or two days of high stress, short-term avoidance of a particular class, and/or intense but brief acting-out behaviors to stay home from school. Slips are not unusual after treatment and are especially common following long weekends, or extended vacations.

Relapse on the other hand, may be defined as a return to old problematic behaviors or substantial backsliding to nearly the point when the intervention started. In a school refusal population, relapse might involve things like missing school for several days or weeks, continued high levels of distress, avoidance of many social activities and/or evaluative situations at school, significant misbehaviors to get attention or tangible reinforcement, and or excessive family conflict over a child’s school refusal behavior.

Inoculation

One of the most important things that must be achieved in any school refusal protocol is that the parents and/or the child will need to know what to expect in the future and how to deal with expected future events. Part of inoculation against slips and/or relapse is to be able to project what might happen and to learn the skills necessary to deal with those situations. What you have been doing is teaching skills that will become the basis for change in the future as well as in the present.

Just as one takes ‘cue controlled’ relaxation techniques into in vivo exposure, there need to be specific techniques and/or procedures to deal with future events. But there is more to coping with fear than merely relaxing your body. The client also learns to create a private arsenal of coping thoughts. These are used to counteract habitual thoughts of danger and catastrophe that arise in phobic situations. Systematic desensitization teaches a client to master anxiety. The expectation is that s/he will feel little or no anxiety in situations s/he has desensitized him/herself to. This is simultaneously the strength and the weakness of the technique. The client feels a tremendous sense of accomplishment and freedom when they are relaxed in situations that formerly provoked anxiety. But what if anxiety begins to creep back in? What if you’re suddenly hit with a wave of the old panic? Systematic desensitization offers nothing to help you cope with this situation. You’re supposed to be anxiety free but you’re not. Technique #10 Stress Inoculation will provide you with the strategies to use to deal with anxiety and fear issues and Technique #16 Stress Inoculation for Anger will provide you with strategies to deal with anger.

In both of these processes, you are asking the clients to write down as many potential future problems as they can imagine and then helping them devise coping strategies to use if such a situation occurs. The family member can participate over the last week or two in developing a distressing situations list which will begin to identify ‘what ifs’ for school refusal. Since there are four different protocols to deal with the maintaining variables, there will be different types of things on the lists, but in each case, you should be able to help them identify skills they have already learned to apply to each case. Or you can work with them to develop the necessary coping strategies.

One of the coping strategies is to contact you, in time of crisis. However, this cannot become a crutch which is used indiscriminantly over time. Perhaps you should consider a contingency model, in that they have two consultations which they can use and only two. However, for each six months that the family is able to maintain order and have the child in school, they can earn an additional consultation. So during the first six months, they can call upon you twice, but after the first six month they would have another consultation, and so on. This sets up a model which suggests that if they are, in fact, coping, they will not need to use the consultation. But even if they go two or three years out, they have a consultation possibility.

Obviously, the parents would be unwise to use the consultations if the child ‘slips’. They will need to identify how deep the slip is and whether it is wise to use the consultation. It should be made clear that the child can implement the consultation as well. However, you want to keep the family involved. One way to do this is to suggest that the child must inform the family if s/he intends to use the consultation. Notice, this is not asking permission. However, it does give the family the opportunity to see if they can rectify the presenting problem for the child, before s/he implements the consultation. If they can, the child will have no need to proceed. If they can’t, this is probably a valid consultation need.

You should urge the family to continue the problem solving meetings, even if they reduce the number of times they meet. The family should ‘contract’ to renew the full process of meetings and recordings if problems occur and they have dropped these strategies. By doing the things they did with you, they may be able to identify and rectify the new problems which are causing the difficulties.

The Scrapbook

One method of relapse prevention involves taking photographs during in vivo exposure or desensitization practices. This can be especially effective for children who previously had a lot of distress or social anxiety about school, but my also be useful for children who refused school for positive tangible reinforcement and who may be in school for the first time on their own. Whatever the reason, photographs are a good way to reinforce the child for his or her accomplishments. Parents can then display the photographs in a prominent place in their home, much as they would a report card, drawing or another of their child’s personal accomplishments. In this way, the child can be continually reminded of his or her progress.

Another family oriented activity to further reinforce the child’s progress is the creation of a poster, journal or storybook of the child’s accomplishments using the photographs of the child’s exposure. Common photographs include the child sitting at his/her desk, talking with the teacher, interacting with friends, riding the school bus, and giving an oral report in front of the class. For each of the photographs, parents should help their child write a caption or paragraph description of the scene, including what s/he is thinking, feeling and doing in the picture. Combining the photographs with the child’s own written words serves as a creative and personal reminder and reinforcer of special moments in the child’s life.

Commercial [Kendall, 1992]

Another technique is the commercial. Specifically, you may ask the child’s help in producing a video ‘commercial’ aimed at teaching other children how to overcome the problem of school refusal behavior. In making the commercial, the clinician serves as the ‘director’ of the project, but the child is the expert on the subject and the star of the show. By enlisting the child as an expert in how to overcome school refusal, his/her self esteem and feelings of empowerment are boosted.

Guide the child’s performance, ensuring that all the key elements of the intervention are presented. For example, if the process involved relaxation techniques, demonstrations of these methods should be placed in the video. Coach the child to describe the three parts of anxiety [physical feelings, thoughts, behavior] and the ways in which these three components build upon each other during stressful situations. Cognitive methods [STOP; Silverman & Kurtines, 1996] should also be described with relevant examples presented by the child. If a portable camcorder is available, ask the parents to videotape their child conducting in vivo STIC tasks such as riding to school on the bus or eating in the cafeteria. Some children can devise creative scripts for these videos.

The child should get a copy of this video for his/her exclusive use. In this way, s/he can periodically play the video to remind of the progress and avoid setbacks in times of high stress or vulnerability [e.g., before the start of school, during standardized testing times, etc.].

Structured Activities

Encourage parents to keep their child on a regular ‘school’ schedule during holidays to ensure regular waking times and routines in the morning and regular bedtimes at night. This ensures sufficient amounts of sleep. During the summer, parents should try to start their child’s normal ‘school’ schedule about three weeks prior to the start of school. For children who refused school to pursue tangible reinforcement, gradual restrictions on curfew and time spent with friends may need to start at this time.

During summer vacation, parents should also try to have their child spend some portion of each weekday outside the home in an organized activity with other children and adults. For example, day camps, volunteer programs, sporting activities, youth groups and library programs can give children contact with people outside the family. This allows for the child to continue to practice and refine the anxiety management or peer refusal skills. In addition, more independent activity will help prevent backsliding to dependency on parents for moment to moment support for those attention seeking children. If there are no structured programs available, parents may wish to organize other parents in the community to form play groups or activity programs that can be rotated from house to house. This will gently influence the child to remain in contact with others and serve as a natural desensitization and exposure process. For children with separation anxiety, this will give them practice at leaving primary caretakers and functioning well on their own.

Introduction to a New School

Because many children have trouble coping with changing social and academic scenarios, especially when advancing to a new school [e.g., middle, high school], it is important to allow them to explore the new school building before classes begin. This can be done a few days before school starts and my be set up with cooperation from the child’s new school counselor. [Parents should be careful, however, that the child doesn’t view the counselor and his/her office as simply a safety signal.] Of special interest are the location of lockers, specific classrooms, cafeteria, libraries, gymnasiums, main and guidance offices, exits and settings for getting on and off the school bus. Because children with previous school refusal behavior often worry about getting lost and looking foolish, taking them on a tour of their new school building may serve to diminish anticipatory anxiety, increase self-efficacy and prevent relapse. Children should also receive information on school-based social and sporting groups that s/he is eligible to join. Parents may then gently encourage the child to become socially active in these groups.

A Final Word

Encourage the child and parents to understand that a return of some elements of the school refusal behaviors does not need to lead to full blown relapse. Anticipation of problems and ‘public disclosure’ to the family of such concerns should lead to a re-emphasis on the use of the skills they have learned, and such implementation should enable them to resolve these minor issues. Perseverance is often as important a quality in any of the techniques described. Help the family understand the skill they have gained and to affirm these skills as the strength to overcome both relapse and future experiences. They now have the skill to solve their own problems, At the same time, acknowledge that you will be available to help support these new skills, if that becomes necessary.

Appendix

Forms & Charts

CBP#02-001 Child’s Daily Log
CBP#02-002 Parent’s Daily Log
CBP#02-003 Anxiety Model
CBP#02-004 Anxiety & Avoidance Hierarchy
CBP#02-005 Feeling Thermometer
CBP#02-006 Relaxation Practice Log
CBP#02-007 Negative Emotions & Safety Signals
CBP#02-008 Interoceptive Exposure
CBP#02-009 Exposure Record Form
CBP#02-010 Child Management Journal
CBP#02-011 Common Speaker & Listener Behavior Problems
CBP#02-012 Sleep Disorder Interventions

Download Available | All Forms