When Children Refuse School

--

David H. Barlow, PhD


 

Anne Marie Albano, PhD

Jack M. Gorman, MD

Peter E. Nathan, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

When Children
Refuse School
A COGNITIVE-BEHAVIORAL THERAPY APPROACH

SECOND EDITION

P a r e n t W o r k b o o k

Christopher A. Kearney • Anne Marie Albano

1

1
Oxford University Press, Inc., publishes works that further
Oxford University’s objective of excellence
in research, scholarship, and education.

Oxford New York

Auckland Cape Town Dar es Salaam Hong Kong Karachi
Kuala Lumpur Madrid Melbourne Mexico City Nairobi
New Delhi Shanghai Taipei Toronto
With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
Guatemala Hungary Italy Japan Poland Portugal Singapore
South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright ©  by Oxford University Press, Inc.

Published by Oxford University Press, Inc.

 Madison Avenue, New York, New York 
www.oup.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
ISBN: ----

        

Printed in the United States of America

on acid-free paper
About TreatmentsThatWork™

One of the most difficult problems confronting patients with various dis-
orders and diseases is finding the best help available. Everyone is aware of
friends or family who have sought treatment from a seemingly reputable
practitioner, only to find out later from another doctor that the original di-
agnosis was wrong or the treatments recommended were inappropriate or
perhaps even harmful. Most patients, or family members, address this prob-
lem by reading everything they can about their symptoms, seeking out in-
formation on the Internet, or aggressively “asking around” to tap knowledge
from friends and acquaintances. Governments and healthcare policymakers
are also aware that people in need don’t always get the best treatments—
something they refer to as “variability in healthcare practices.”

Now healthcare systems around the world are attempting to correct this
variability by introducing “evidence-based practice.” This simply means
that it is in everyone’s interest that patients get the most up-to-date and
effective care for a particular problem. Healthcare policymakers have also
recognized that it is very useful to give consumers of healthcare as much
information as possible, so that they can make intelligent decisions in a col-
laborative effort to improve health and mental health. This series, “Treat-
mentsThatWork™,” is designed to accomplish just that. Only the latest
and most effective interventions for particular problems are described in
user-friendly language. To be included in this series, each treatment pro-
gram must pass the highest standards of evidence available, as determined
by a scientific advisory board. Thus, when individuals suffering from these
problems or their family members seek out an expert clinician who is fa-
miliar with these interventions and decides that they are appropriate, they
will have confidence that they are receiving the best care available. Of course,
only your healthcare professional can decide on the right mix of treatments
for you.

This particular program is designed to treat children and teenagers who re-
fuse school and teaches parents how to help their children overcome a broad
range of school refusal behavior. School refusal is a widespread problem,
with up to % of American school-aged youths refusing school at some
 time. Many parents realize the severe consequences school refusal can have
for children and families but are uncertain about the best way to address
the problem. Unlike traditional treatments that are appropriate for only
some children, cognitive-behavioral therapy (CBT ) is applicable to differ-
ent groups of children. This workbook outlines individual treatment pack-
ages tailored to the particular reasons that children refuse school. There are
four main reasons that children typically refuse school: to relieve school-
related distress, to avoid negative social or evaluative situations at school,
to receive attention from a parent or a significant other, and to obtain tan-
gible rewards outside of school that make skipping school more fun than
staying in school. By undertaking this program with the support of a skilled
clinician, parents can help their children successfully return to school.

David H. Barlow, Editor-in-Chief,

TreatmentsThatWork™
Boston, Massachusetts

vi
Contents

Chapter  Introduction 

Chapter  Assessment 

Chapter  Consultation Session and General Treatment Session

Procedures 

Chapter  Children Refusing School to Avoid Objects or Situations

that Cause General Distress 

Chapter  Children Refusing School to Escape Painful Social

and/or Evaluative Situations 

Chapter  Children Refusing School for Attention 

Chapter  Children Refusing School for Tangible Rewards

Outside of School 

Chapter  Preventing Slips and Relapse 

About the Authors 

This page intentionally left blank
Chapter 1 Introduction

About This Parent Manual

This parent manual is designed to help you work with a therapist to help
your child who is currently refusing to go to school. This manual defines
school refusal behavior, describes how your situation might be evaluated,
and shows what you and a therapist can do to get your child back into
school without distress. You should use this manual with a qualified thera-
pist who is concurrently using the therapist guide to treat your child’s school
refusal behavior.

What Is School Refusal Behavior?

School refusal behavior refers to children aged  to  years who refuse to

attend school and/or have trouble remaining in classes for an entire day.
This is a common problem that many parents face, so do not feel alone.
School refusal behavior is a difficult and widespread problem, and can de-
velop into a more serious one if left untreated. Specifically, your child may
show school refusal behavior if he or she:

■ is completely absent from school, and/or

■ goes to school but then leaves school during the course of the
day, and/or

■ goes to school but only after behavior problems in the morning,

such as throwing temper tantrums or refusing to move, and/or

■ has unusual distress about going to school and begs you or your
spouse not to make him or her go back to school.

School refusal behavior is thus pertinent to many different children, includ-

ing those who always miss school as well as those who rarely miss school
but attend with great distress. School refusal behavior is also defined by the
length of time the problem has lasted. Acute school refusal behavior refers to
cases lasting  weeks to  calendar year. Chronic school refusal behavior refers

1
 to cases lasting longer than  calendar year, or across  academic years, hav-
ing been a problem for a majority of that time.

School refusal behavior, as defined in this manual, may not include cases that
involve:

■ legitimate physical illness (e.g., asthma) that makes school atten-

dance difficult, and/or

■ school withdrawal, when a parent deliberately keeps a child

home from school, and/or

■ social or familial conditions that predominate a child’s life (e.g.,

homelessness, running away to avoid abuse), and/or

■ other difficulties that are more substantial than school refusal

behavior (e.g., poor schoolwork, depression, overactivity, aggres-
sion, general lack of motivation).

If these circumstances are present, then the procedures described in this man-
ual may not apply to your child.

Frequency and Major Features of School Refusal Behavior

School refusal behavior is a common problem among children and adoles-

cents, affecting as many as %. The problem occurs equally among boys
and girls. Most children with school refusal behavior are age  to  years,
but the problem also peaks at ages  to  and  to  years as children enter
new schools. However, children may show school refusal behavior anytime
between ages  and  years.

Many different behaviors are shown by children with school refusal beha-
vior. These behaviors fall into two groups. The first group of school refusal
behaviors is those that are less obvious. Common examples include general
anxiety, social anxiety and withdrawal, depression, fear, and physical symp-
toms (especially stomachaches, headaches, nausea, and tremors). The sec-
ond group of school refusal behaviors is those that are more obvious. Com-
mon examples include tantrums (including crying, screaming, flailing of
limbs), verbal and physical aggression, reassurance-seeking, clinging, refusal
to move, noncompliance, and running away from school or home.

If nothing is done about school refusal behavior, serious problems could

develop. In the short term, a child could experience more trouble with

2
 schoolwork, poor grades, and alienation from friends. In addition, the
child’s family might experience conflict, disruption in their daily routine,
and legal problems. In the long term, a child with school refusal behavior
might have trouble getting into college, have occupational and marital
problems, and show alcohol abuse, criminal behavior, and anxiety and de-
pression. Of course, not all children will experience these problems, but
the chances of these problems developing are greater as a child misses more
and more school.

Reasons for School Refusal Behavior

Although children show many different school refusal behaviors, the rea-
sons for these behaviors may be few. Clinical research indicates that chil-
dren tend to refuse school for one or more of the following reasons:

■ to stay away from objects or situations at school that make the

child feel unpleasant physical symptoms or general distress
(negative affect)

■ to stay away from social or evaluative situations at school that are

painful to the child

■ to receive attention from a parent or a significant other

■ to obtain tangible rewards outside of school that make skipping

school more fun than staying in school

The first two reasons refer to children who refuse school to get away from
something negative at school. Common examples of school-related objects
that children sometimes avoid are buses, fire alarms, gymnasia, playgrounds,
hallways, and classroom items. Common examples of school-related people
that children sometimes avoid are teachers, principals, and children who
are verbally or physically aggressive. Common examples of school-related
performance situations that children sometimes avoid are tests, recitals, ath-
letic competitions, and speaking or writing in front of others. Remember
that children often refuse school for both of these first two reasons.

The latter two reasons refer to youth who refuse school to get something
positive outside of school. For example, younger children sometimes refuse
school so their parents will stay close and give them extra attention. In ad-
dition, older children and adolescents sometimes refuse school for specific

3
 things, such as watching television at home, engaging in social parties with
friends, and using alcohol or other drugs.

Children sometimes refuse school as well for two or more of the reasons
listed above. For example, some children are initially upset about school ac-
tivities and try to remain home to stay away from them. These children may
then discover the many positive things they can do at home. Therefore, they
refuse school to stay away from something at school and to pursue something
at home. In addition, some children miss school for long periods of time to
be with their friends, but are then faced with the difficult prospect of having
to go back to school and face new classes, teachers, and peers.

Children who refuse school for two or more reasons will probably need
more than one treatment and treatment for a longer period of time, com-
pared to children who refuse school for one reason. In addition, children
who have been out of school for long periods of time will probably need
longer and more intense treatment than children who have been out of
school for shorter periods of time. Because children often refuse school for
more than one reason, you should read all the parts of this manual that are rele-
vant to your family.

Traditional Treatments for School Refusal Behavior

Because school refusal behavior is a serious problem, mental health profes-

sionals and educators have tried to treat it in different ways. Some common
ways include:

■ increasing distance between a parent and child to reduce separa-

tion problems

■ increasing the child’s self-esteem in the classroom

■ teaching children to relax so they can cope with an object or

situation at school that makes them upset

■ forcing the child to go to school

■ negotiating a solution to the school refusal problem among fam-

ily members

■ medicating the child using antidepressant or antianxiety drugs

■ placing the child in an inpatient residential program

4
 In general, these treatments work well for some, but not all, children with
school refusal behavior. For example, increasing parent–child distance or
forcing a child to attend school may work well for young children but not
adolescents. Other procedures, such as family therapy, require more verbal
input that might be difficult for young children. In addition, teaching a
child to relax may work well for those who are fearful but less so for those
who are not fearful during school. Also, medication works well for some
children but not others, and side effects are sometimes a problem. Finally,
inpatient treatment is sometimes recommended for chronic, but not acute,
cases of school refusal behavior.

A New Model for Addressing Children With School Refusal Behavior

Because traditional treatments do not work for all children, this manual
presents a new model that divides school refusal behavior into different
groups. These groups are based on the four reasons why children refuse
school. Specific treatments are then given on the basis of the group most
relevant to a child. This model has been shown to be more effective than
using just one treatment for all youth with school refusal behavior.

Chapter  of this manual describes how a child with school refusal beha-
vior is assigned to one of these four groups. After this assignment, a speci-
fic treatment is given. A different treatment is used for each group. If a
child’s behavior falls into more than one group, then more than one treat-
ment is used. Overall, this may the best way of changing different school
refusal behaviors. The specific treatments are outlined in detail in chapter .

Specific Information for a Particular Case of School Refusal Behavior

Does This Manual Fit Your Child?

Because school refusal behavior is often made up of various problems, it

may be difficult for you to know whether this manual is appropriate for
your child. This section provides some sample questions that a therapist
may ask you when you first speak with him or her. Your answers should tell
you and the therapist if this manual will be useful.

5
Has Your Child Just Started Refusing to Go to School?

Your answer to this question may be important in deciding whether to go

any further in assessment or treatment. If your child’s school refusal beha-
vior has lasted less than  weeks, there is still an excellent chance it will end
on its own. In this case, the therapist may suggest that you call back in 
week if the problem persists or schedule an appointment for  week later.
In many cases, this appointment will turn out to be unnecessary because
the child has returned to school on his or her own.

On the other hand, the therapist may recommend that you come in for as-
sessment if your child’s school refusal behavior has been occurring every
day for at least  week and is severe enough that it leads to serious family
fighting or disruption in the family’s daily routine. In this case, or if your
child has been refusing school for more than  weeks, an assessment session
would probably be appropriate.

What Is Your Child’s Most Serious Behavior Problem?

Although this question is difficult to answer, try to think about whether

your child has behaviors that are more severe than his or her school refusal
behavior. Ask yourself, for example, whether your child:

■ is afraid to leave you or the house for any reason, not just to go
to school

■ is sad or unmotivated in many situations, not just those involv-

ing school

■ has expressed recent thoughts about harming himself or herself

■ is more overactive in all situations compared to most children his

or her age

■ is failing school, but not because of school refusal behavior

■ refuses to do what you ask in all situations, not just those related
to school

■ uses alcohol or other drugs on a regular basis

■ steals or destroys property on a regular basis

■ is frequently aggressive toward others

6
 If you think that these or other behaviors are more serious than school re-
fusal, then this manual may be only partially useful. It may be partially use-
ful because changing school refusal behavior can be the first step toward re-
solving other problems. For example, a parent may have a child who does not
listen to commands and is “out of control.” Although these behaviors are real
problems, many parents want to focus first on school refusal behavior be-
cause it is more urgent and because it can lead to improvement in other areas.
In cases where the first step in treating different problems is returning a child
to school, the treatments described in this manual may be helpful.

However, you may feel “in the dark” or confused and upset by your child’s
problems. As a result, you may not know which of your child’s behaviors
is the most serious. Try to give the therapist as much information as pos-
sible about your child’s different behaviors. When doing so, try to avoid a
common mistake that some parents make. Some parents pay more atten-
tion to obvious behaviors, such as breaking curfew or not doing home-
work, and pay less attention to signs of anxiety or depression. Try to give
your therapist information about all relevant behaviors, even those that are
harder to identify. It may be helpful to contact others, such as your child’s
teachers, who might provide additional information.

What Extenuating Circumstances Might Be Causing Your Child’s School Refusal Behavior?

In many cases of school refusal behavior, extenuating circumstances may

explain the problem. For example, the therapist may want to know about
your child’s medical problems. Often, school refusal behavior is related to
problems such as asthma, pain, insomnia, diabetes, infection, or physical
handicap. If you think this is possible, then your child should first see a pe-
diatrician for a medical examination. In addition, you and the therapist
(with your permission) should consult a medical doctor as necessary and
appropriate throughout therapy.

Another example of extenuating circumstances is when parents keep a

child home from school for economic reasons, as a safety person to help them
with the parent’s own anxiety problem, or out of fear that the child will be
kidnapped. In other cases, more serious family problems, such as sexual
abuse, may apply. If circumstances such as these exist, then discuss them
with the therapist. Many families hold back important information out of
embarrassment or fear. However, it is important for the therapist to have
this information so that he or she can develop the best treatment plan for
you and your child.

7
What Is Your Child’s Age?

The therapist will likely ask your child’s age. This information is important
because the treatments described in this manual have been designed for
children aged  to  years. They were not specifically designed for children
younger than  years who may be refusing to attend preschool or daycare.
Also, knowing your child’s age will give the therapist an early idea about the
best ways of assessing and treating your child. For example, treatments that
rely heavily on verbal discussion may be more appropriate for adolescents
than young children. On the other hand, physically bringing a -year-old
child to school is much easier than bringing a -year-old adolescent.

Is Your Child’s School Refusal Behavior Extremely Severe?

The treatments described in this manual may not fit severe cases of school
refusal behavior. Severe cases show extreme levels of distress, substantial
delinquent behavior, school absence longer than  years, and other behav-
iors. In these cases, other treatments will probably be necessary before, or
in addition to, the ones described here. Examples of other treatments in-
clude drug therapy for extreme anxiety, residential or inpatient treatment
for substantial delinquent behavior, or alternative school programs for ex-
tended absence. Be sure to talk with the therapist about alternative treat-
ments that may be best for your child.

What If This Workbook Does Not Seem Appropriate for Your Child?

If you are not sure whether this manual fits your child, then discuss your
situation with a knowledgeable therapist. The therapist should be able to
tell you if the procedures described here and in the therapist guide will be
helpful. If necessary, the therapist can refer you to another therapist who
specializes in your child’s problem. Remember, the procedures described in
this manual are designed specifically for children whose school refusal be-
havior is their major problem.

What Benefits Will You Receive From Reading This Workbook?

This parent workbook is designed to help you work with a qualified therapist
to resolve your child’s school refusal behavior. A corresponding Therapist
Guide is also available and should be used by your therapist as you progress

8
 through treatment. This workbook will help you understand the proce-
dures that may take place during assessment and treatment of your child.
It also provides answers to questions that you may have about the process.
By increasing your understanding of these procedures, you will become an
active participant in your child’s assessment and treatment. The procedures
described in this workbook are effective if parents and family members follow
through with what needs to be done. This parent workbook describes a clear,
step-by-step process to help you work with the therapist.

As you use this parent workbook with a therapist, thoroughly reread each
section (e.g., treatment session ) before each individual session. Become fa-
miliar with the main points of each section and write down a list of the
major themes or points that will be covered in the session. Write down any
questions or concerns you have at this time or in the future. Review these
with the therapist whenever possible.

The procedures described in this workbook are based on clinical experi-

ence and have been tested for various problems. However, these procedures
are meant for typical cases of school refusal behavior. As a result, you may
find that some changes will have to be made for your particular child. Un-
foreseen circumstances always arise; therefore, the treatment procedures
are flexible. You will also need to be flexible when working with your child’s
therapist. For example, some cases of school refusal behavior take less time to
resolve than what is described in this workbook; other cases take more time.
This workbook is a guide only.

The Structure of This Parent Workbook

This workbook provides you with an outline of what to expect if a thera-

pist uses these procedures to treat your child’s school refusal behavior. You
should work with a qualified therapist before using these procedures. Chap-
ter  describes what to expect in an assessment session and how you can
help the therapist monitor your child’s behavior. Chapter  describes what
to expect in consultation and treatment sessions. Chapters  through  de-
scribe treatments for each type of school refusal behavior and include
sample dialogues and troubleshooting recommendations. Finally, chapter
 describes how to prevent problems in the future.

9
This page intentionally left blank
Chapter 2 Assessment

This chapter covers the assessment process for children with school refusal
behavior. This includes the purpose and methods of assessment, monitor-
ing daily progress, contacting school officials, and other information. A
brief sample case is also provided.

What Is Assessment and What Is Its Purpose?

Assessment refers to the ways in which the therapist will gather information
about your child. The therapist sets up an assessment session to better
understand you, your child, and the school refusal behavior. At the begin-
ning of the session, the therapist will inform you and your child that most
information you give is confidential (the therapist will outline exceptions
for you). That means the therapist will not give the information to anyone
else unless you give permission. You may be asked to read and sign a con-
sent form that describes the upcoming procedures. The consent form also
allows the therapist to speak with others who can help, such as school offi-
cials. The therapist will probably want to see you and your child separately
during the assessment session. This will allow each of you to talk more
freely.

Although some things you talk about will be sensitive, you, your spouse or
partner (if you have one), and your child should be as honest as possible
so the therapist can learn answers to three basic questions:

■ What is your child’s major behavior problem?

■ What is maintaining his or her school refusal behavior?

■ What is the best treatment for your child?

To answer these questions, the therapist will need to know exactly which
school refusal behaviors your child presents. For example, he or she might
ask about your child’s school avoidance, ways of thinking, or physical symp-
toms. The therapist will need to know how often your child is attending

11
 school and his or her history of school refusal behavior over the past days,
weeks, and months. The therapist will also try to understand why your
child is continuing to refuse school. To do this, he or she may ask questions
about how your child is rewarded for being out of school, how school re-
fusal might be influenced by you or other family members, and how you
or your spouse or partner respond when your child refuses school.

During assessment, the therapist will also want to understand your family’s
ways of interacting, your parenting style, and your child’s personality, so-
cial relationships, school achievement, and related problems. The therapist
may also ask about other things and will gather information about other
concerns you may have. These discussions with the therapist may some-
times be uncomfortable, but they will help the therapist better understand
your situation and design a good treatment plan. These assessment discus-
sions will also help you and your child develop a positive relationship with
the therapist that is crucial for later therapy.

What Will Happen During Assessment?

None of the assessment procedures is threatening, but some sensitive areas

may be covered. The therapist will use basic procedures, including inter-
views and questionnaires. The therapist may also want to observe your
child as he or she attempts to go to school. Remember that you can choose
to decline to answer any question or to participate in any procedure. You are
free to ask any questions during assessment as well.

The Interview

When assessing a behavior problem, most therapists use some type of inter-
view. Different therapists use different interviews and interviewing styles.
The questions they ask will vary, depending on the case they are assessing.
However, to prepare you for what might be asked, some likely and pertinent
questions are presented here:

■ How often does your child refuse school specifically because

he or she is distressed about something at school? The thera-
pist might also ask some follow-up questions:

Is your child more upset about school than most children his or
her age?

12
 Are there any school-related objects, places, or people that he or
she wants to avoid?
Has your child told you of recent negative life events, or have
you noticed that he or she has suddenly changed his or her
behavior in any way?
Has your child expressed to you or have you noticed any specific
emotions or physical symptoms about going to school?
What are they?
Do these problems occur every day or primarily on school days?

■ How often does your child refuse school specifically because

he or she wants to avoid unpleasant social or performance
situations at school? Follow-up questions:

Does your child try to avoid these situations more than most
children his or her age?
Are there social or performance situations that he or she prefers
to stay away from (especially writing or speaking in front of
others, meeting new people, interacting with aggressive
peers, performing during recitals, tests, or athletic contests,
or being in or approaching large groups of people)?
Has your child told you of recent negative social or performance
events, or have you noticed that he or she has suddenly
changed his or her social behavior in any way?
Has your child expressed to you or have you noticed any specific
emotions or physical symptoms about interacting in social
or performance situations? What are they?
Do these problems occur primarily in all social or performance
situations or primarily in those situations related to school?

■ How often does your child refuse school specifically because

he or she wants to get attention from you or a significant
other? Follow-up questions:

Does your child show this attention-seeking more than most

children his or her age?
Are there specific behaviors that he or she engages in to get at-
tention from you (especially clinging, reassurance-seeking,
refusal to move, tantrums, telephone calls, protests, verbal
demands for attention, guilt-inducing behavior, or running
away from school to get to you)?

13
 Has your child told you of recent negative life events or have you
noticed that he or she has suddenly changed his or her beha-
vior toward you in any way?
Has your child expressed to you or have you noticed any specific
emotions or physical symptoms about interacting with you
or being away from you? What are they?
Do these problems occur in most daily life situations or prima-
rily in those situations related to school?

■ How often does your child refuse school specifically because

he or she wants to get tangible rewards from some source
outside of school? Follow-up questions:

Does your child pursue rewards outside of school more than

most children his or her age?
Are there specific rewards that your child leaves school to pursue
(especially spending time with friends, alcohol/drug use,
watching television or playing games at home, riding a
bicycle, sleeping, or attending shopping centers or casinos)?
Has your child told you of recent negative life or school events
or have you noticed that he or she has suddenly changed his
or her behavior in any way?
Has your child expressed to you or have you noticed any specific
emotions or physical symptoms about being in or leaving
school? What are they?
Does your child pursue rewards in many daily life situations or
primarily when school is in session?

■ Does your child refuse school for a combination of reasons

just discussed? If so, which ones do you feel are most important?

Remember that these questions will not be the only ones asked by the
therapist. Other behaviors may need to be assessed and different types of
information may be needed. Also, remember that you may add as much
information to the interview as you like. In general, the more information
you give, the better. In addition, if the therapist does not ask some of the
questions listed here, feel free to raise them yourself and provide answers if
possible during the assessment session.

14
Questionnaires

The therapist may also ask you and your child to fill out some question-
naires. Questionnaires are often used to gather additional and more speci-
fic kinds of information than what the therapist gathered during the inter-
view. For example, some questionnaires your child completes might evaluate
his or her levels of general and social anxiety, depression, fear, self-esteem,
and enjoyment of school. Other questionnaires might examine your child’s
acting-out behavior.

The therapist might ask you to complete some questionnaires as well. Par-
ent questionnaires, for example, might focus on your child’s behavior, your
marital relationship, and family interactions. The therapist may also ob-
tain, with your permission, a questionnaire from your child’s teacher about
social, academic, and behavioral problems that your child may be having
at school. Read the questionnaires before agreeing to fill them out.

A key questionnaire that your therapist may ask you to complete is the
School Refusal Assessment Scale-Revised (SRAS-R). The SRAS-R helps
identify the major reasons why a child is missing school. There are two ver-
sions of the questionnaire, one for the child and one for the parents. Both
are included at the end of this chapter. Please be as honest as you can when
completing these questionnaires.

Observation

If possible, the therapist will directly observe your child’s and family’s
morning activities. This observation might give the therapist additional in-
formation and help him or her better understand why your child is con-
tinuing to refuse school. The therapist will want to observe your child’s and
family’s behaviors under different circumstances.

What if you think your child refuses school to stay away from things that
lead to general distress? In this case, it may be useful for the therapist to
compare your child’s behavior when asked to attend school under regular
circumstances with your child’s behavior:

■ when asked to attend school under different circumstances (e.g.,

no full-day attendance, physical education class, lunch with
peers, playground), or

15
 ■ when asked to go with you to an equally large building that re-
sembles a school (e.g., an office building with similar busy activity)

What if you think your child refuses school to stay away from unpleasant
social or evaluative situations? In this case, it may be useful for the thera-
pist to compare your child’s behavior when asked to attend school under
regular circumstances with your child’s behavior:

■ when asked to attend school under different circumstances (e.g.,

no recitals, oral presentations, athletic performances, intense so-
cial interactions), or

■ when asked to attend school with no one or just a few people

present

What if you think your child refuses school for attention? In this case, it
may be useful for the therapist to compare your child’s behavior when
asked to attend school under regular circumstances with your child’s beha-
vior when:

■ you go with your child to school and/or the classroom, or

■ your child is allowed to contact you at any time during the

school day and be picked up from school by you (or your
spouse)

What if you think your child refuses school because it is more fun to be out
of school? In this case, it may be useful for your therapist to compare your
child’s behavior when asked to attend school under regular circumstances
with your child’s behavior when:

■ more rewards are made available for attending school, or

■ your child’s fun activities are reduced when he or she misses

school

The therapist will look to see if your child changes his or her behavior under
different circumstances. Specifically, the therapist will watch for:

■ clinging, refusal to move, running away, and/or not listening to

parent requests or commands

■ physical reactions such as stomachaches, headaches, abdominal

pain, tremors, and nausea/vomiting

16
 ■ complaints about discomfort related to school

■ sudden changes in behavior

■ pleas to end the observation and return home

■ your reactions and family member reactions to your child’s behavior

■ teacher reports of your child’s behavior at school

What Is the Best Treatment for Your Child?

By the end of assessment, you and the therapist should understand your
child’s major school refusal behaviors and why they continue to occur.
Based on this assessment, the therapist will form a treatment plan for your
case. In this model of school refusal behavior, different treatments are
based on why a child refuses school:

■ If your child refuses school to stay away from things at school

that lead to general distress, recommended treatment focuses on
reducing physical symptoms and avoidance of school.

■ If your child refuses school to stay away from unpleasant social

or performance situations, recommended treatment focuses on
building social/coping skills and reducing social anxiety.

■ If your child refuses school for attention, recommended treat-

ment focuses on improving parent commands, routines, and
methods of discipline. This is done to shift attention toward
school attendance and away from school refusal.

■ If your child refuses school because it is more fun to be out of

school, recommended treatment focuses on improving the fam-
ily’s ability to negotiate solutions to problems, increasing rewards
for attending school, and decreasing rewards for missing school.

If your child refuses school for two or more of these reasons, a combina-
tion of these treatments is recommended. These treatments are described
in detail in other chapters of this workbook.

17
Monitoring School Refusal Behavior on a Daily Basis

The therapist may also ask you and your child to keep track of school re-
fusal behavior and school attendance on a daily basis. This will help you
and your child better understand changes in your child’s behavior over
time. Also, you and your child will not need to rely so much on memory
when you talk to the therapist. The information you give will also help
your therapist understand your current situation and adjust treatment as
necessary. In addition, changes in behavior over time may be used to chart
improvement.

The therapist may also ask you and your child to give ratings in daily log-
books. Daily logbooks are included here. You may photocopy them from
the book or download multiple copies from the TreatmentsThatWork™
Web site at www.oup.com/us/ttw.

Child and parent logbooks should be kept separately. Be careful not to influ-
ence your child’s ratings, but remind him or her to complete the forms each
day. If your child has a question about what rating to give, have him or her
contact the therapist as soon as possible.

Ratings are made on a -to- scale where  is none and  is an extreme

amount. Ratings may be made about your child’s anxiety (nervousness, ten-
sion), depression (sadness, unhappiness), and overall distress (general feelings
of dread or being upset). In addition, you may rate your child’s noncom-
pliance (not listening to parent commands) and disruption to your family’s
daily routine. You might also chart your child’s behavior problems and
time missed from school. Finally, if you think that any event is important for
the therapist to know, write it down on the front or back of the logbook.

The therapist will show you and your child how to complete the logbooks.
He or she may show you a sample of a completed logbook to explain how
it is scored. You and your child should complete the logbooks in the evening,
after most of the day has passed. Be sure to ask the therapist any questions
you or your child have about the logbooks before you leave the assessment
session. Also, contact the therapist should any questions arise over the next
few days.

These logbooks are vital for the therapist to get a clear picture of what is
happening at home and school. They are also vital for you to better under-
stand the patterns of your child’s behavior. It is extremely important that you

18
 and your child complete these logbooks daily and bring them to each session.
This includes the next session, called the consultation session, which is usu-
ally scheduled  to  days after the formal assessment session.

Contacting School Officials

It will be helpful if you let the therapist contact school officials for addi-
tional information (you do not have to, however). Helpful school officials
may be teachers (including specialized ones such as physical education
teachers), school psychologists, counselors, principals, nurses, librarians, or
other staff members. You and your therapist should maintain contact with
these officials during the course of treatment. Important information from
school officials might include:

■ Course schedules, grades, written work, and required make-up

work

■ Goals and attitudes of school officials and peers regarding your

child

■ Procedures and timelines for getting your child back into school

■ Potential obstacles to getting your child back into school

■ Past school refusal behavior

■ General social or other behaviors of your child in school

■ Outline of the school (e.g., lockers, cafeteria, library)

■ Feedback about the effectiveness of the treatment procedures

■ Disciplinary and related procedures

■ Rules about absenteeism, conduct, or leaving school areas

■ Alternative school programs

■ Advice that school officials have previously given you regarding

your child’s school refusal behavior (e.g., forcibly bring your
child to school; place him or her in home schooling or on drug
therapy)

19
Child’s Daily Logbook

Your Name:

Please rate the following every day on a – scale where 
none, 
mild, 
moderate, 
marked,

severe, and 
extreme (for younger children: – scale where 
none, ‒ is a little,  is some,
‒ is much, and  is very much).

Date Anxiety Depression Distress

Please list any problems you have had at home or school since the last session:

20
Parent’s Daily Logbook

Your child’s name:

Please rate your child’s behaviors every day on a – scale where 
none, 
mild, 
moderate, 
marked,

severe, and 
extreme.

Date Anxiety Depression Distress Noncompliance Disruption

Please list any specific problems your child has had at home or school since the last session:

Please list the amount of school time your child has missed since the last session:

21
 If you have experienced a lot of conflict with school officials, be sure to tell
the therapist. Although such conflict is not unusual, keep in mind that co-
operation from school officials is often crucial for changing a child’s school
refusal behavior. For example, helpful school officials are often essential for
reintegrating a child into school and for keeping him or her there. You
should allow the therapist to act as a mediator between yourself and school
officials if necessary. In addition, you should work to repair your relation-
ships with school officials now and during the course of therapy.

Contacting Medical Professionals

The therapist may also ask your permission to speak with your child’s pedi-
atrician or other medical professionals who are currently treating your child
or who have done so in the past. The procedures described in this manual
may need to be altered if your child has certain kinds of medical conditions
(e.g., asthma, pain). Be sure to have a thorough discussion with the thera-
pist about all of the pertinent medical conditions that affect your child.

A Sample Case of Assessment and Assigning Treatment

Here is a brief sample case of a -year-old boy with difficulties going to

school for  months. His behaviors included crying, clinging, pleas for
nonattendance, and running out of the classroom. These problems became
worse over time, and the child had not been in school for  weeks. His par-
ents referred him for treatment and were afraid to force him to go to
school. In the meantime, during the day, the boy played games with his
mother, watched television, and rode his bicycle around the neighborhood.

An assessment using an interview, questionnaires, and therapist observa-

tion showed that the boy was refusing school for both attention and be-
cause it was more fun to be out of school. The child said he was willing to
attend school if he knew his mother was sitting in the main office and if he
could contact her whenever he wanted. This was not the case if the thera-
pist was at school instead of his mother. In addition, the child increased his
tantrums when not allowed to continue his daily fun activities. Therefore,
two treatments were recommended: parent training to reduce attention for
school refusal behavior and contracting between the child and parents to
increase rewards for going to school and decrease rewards for missing school.

22
School Refusal Assessment Scale-Revised (C)

Children sometimes have different reasons for not going to school. Some children feel badly at school, some have
trouble with other people, some just want to be with their family, and others like to do things that are more fun
outside of school.

This form asks questions about why you don’t want to go to school. For each question, pick one number that de-
scribes you best for the last few days. After you answer one question, go on to the next. Don’t skip any questions.

There are no right or wrong answers. Just pick the number that best fits the way you feel about going to school.
Circle the number.

Here is an example of how it works. Try it. Circle the number that describes you best.

Example:
How often do you like to go shopping?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

Now go to the next page and begin to answer the questions.

School Refusal Assessment Scale-Revised (C)

Name:
Age:
Date:
Please circle the answer that best fits the following questions:

. How often do you have bad feelings about going to school because you are afraid of something related to
school (for example, tests, school bus, teacher, fire alarm)?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you stay away from school because it is hard to speak with the other kids at school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you feel you would rather be with your parents than go to school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

23
School Refusal Assessment Scale-Revised (C) continued

. When you are not in school during the week (Monday to Friday), how often do you leave the house and do
something fun?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you stay away from school because you will feel sad or depressed if you go?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you stay away from school because you feel embarrassed in front of other people at school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you think about your parents or family when in school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. When you are not in school during the week (Monday to Friday), how often do you talk to or see other people
(other than your family)?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you feel worse at school (for example, scared, nervous, or sad) compared to how you feel at
home with friends?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you stay away from school because you do not have many friends there?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How much would you rather be with your family than go to school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

24
School Refusal Assessment Scale-Revised (C) continued

. When you are not in school during the week (Monday to Friday), how much do you enjoy doing different
things (for example, being with friends, going places)?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you have bad feelings about school (for example, scared, nervous, or sad) when you think about
school on Saturday and Sunday?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you stay away from certain places in school (e.g., hallways, places where certain groups of
people are) where you would have to talk to someone?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How much would you rather be taught by your parents at home than by your teacher at school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you refuse to go to school because you want to have fun outside of school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. If you had less bad feelings (for example, scared, nervous, sad) about school, would it be easier for you to go to
school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. If it were easier for you to make new friends, would it be easier for you to go to school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. Would it be easier for you to go to school if your parents went with you?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

25
School Refusal Assessment Scale-Revised (C) continued

. Would it be easier for you to go to school if you could do more things you like to do after school hours (for
example, being with friends)?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How much more do you have bad feelings about school (for example, scared, nervous, or sad) compared to
other kids your age?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often do you stay away from people at school compared to other kids your age?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. Would you like to be home with your parents more than other kids your age would?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. Would you rather be doing fun things outside of school more than most kids your age?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

Do not write below this line

. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
Total Score =
Mean Score =
Relative Ranking =

26
School Refusal Assessment Scale-Revised (P)

Name:
Date:

Please circle the answer that best fits the following questions:

. How often does your child have bad feelings about going to school because he/she is afraid of something re-
lated to school (for example, tests, school bus, teacher, fire alarm)?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child stay away from school because it is hard for him/her to speak with the other kids at
school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child feel he/she would rather be with you or your spouse than go to school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. When your child is not in school during the week (Monday to Friday), how often does he/she leave the house
and do something fun?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child stay away from school because he/she will feel sad or depressed if he/she goes?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child stay away from school because he/she feels embarrassed in front of other people at
school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child think about you or your spouse or family when in school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

27
School Refusal Assessment Scale-Revised (P) continued

. When your child is not in school during the week (Monday to Friday), how often does he/she talk to or see
other people (other than his/her family)?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child feel worse at school (for example, scared, nervous, or sad) compared to how he/she
feels at home with friends?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child stay away from school because he/she does not have many friends there?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How much would your child rather be with his/her family than go to school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. When your child is not in school during the week (Monday to Friday), how much does he/she enjoy doing
different things (for example, being with friends, going places)?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child have bad feelings about school (for example, scared, nervous, or sad) when he/she
thinks about school on Saturday and Sunday?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child stay away from certain places in school (e.g., hallways, places where certain groups
of people are) where he/she would have to talk to someone?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

28
School Refusal Assessment Scale-Revised (P) continued

. How much would your child rather be taught by you or your spouse at home than by his/her teacher at
school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How often does your child refuse to go to school because he/she wants to have fun outside of school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. If your child had less bad feelings (for example, scared, nervous, sad) about school, would it be easier for
him/her to go to school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. If it were easier for your child to make new friends, would it be easier for him/her to go to school?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. Would it be easier for your child to go to school if you or your spouse went with him/her?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. Would it be easier for your child to go to school if he/she could do more things he/she likes to do after school
hours (for example, being with friends)?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. How much more does your child have bad feelings about school (for example, scared, nervous, or sad) com-
pared to other kids his/her age?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

29
School Refusal Assessment Scale-Revised (P) continued

. How often does your child stay away from people at school compared to other kids his/her age?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. Would your child like to be home with you or your spouse more than other kids his/her age would?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

. Would your child rather be doing fun things outside of school more than most kids his/her age?
Half the Almost
Never Seldom Sometimes Time Usually Always Always
      

Do not write below this line

. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
Total Score =
Mean Score =
Relative Ranking =

30
Chapter 3 Consultation Session and General
Treatment Session Procedures

In this chapter you will learn about what may happen during a consulta-
tion session. In a consultation session, the therapist usually summarizes as-
sessment results and provides recommendations to the family about treat-
ment. In addition, some general points are presented regarding treatment
sessions.

The Consultation Session

Discussion of the Past Week

The therapist will probably want to speak with you and your child sepa-
rately for at least part of the time. He or she will remind everyone about
confidentiality and ask about family life since the last session. Be sure to
give your therapist any new information about sudden changes in beha-
vior. Be specific about how much time your child missed from school, his
or her distress and acting-out behaviors, how you responded to your child’s
school refusal behavior, important school and home activities, and family
interactions.

If much has changed since the last session, then the therapist may re-
interview you or your child and/or re-administer some questionnaires or
other procedures. This will be done to see whether any changes in the treat-
ment plan are needed. If little change occurred in school refusal behavior
since the last session, then the therapist will move on to the next step.

Discussion of Daily Logbooks

The therapist will examine the daily logbook ratings for two main reasons.
The first reason is to see whether the logbooks were brought in and com-
pleted properly. If you had problems, the therapist will discuss these with
you and your child. Common problems include forgetfulness, lack of mo-
tivation, or confusion about how to complete the logbooks. These issues

31
 must be resolved immediately. If you or your child had any problems com-
pleting the logbooks, discuss these problems with the therapist now.

Second, the therapist will be interested in any trends in anxiety, depression,

distress, noncompliance, or disruption of the family. For example, some
children with school refusal behavior show particularly severe anxiety rat-
ings on Sunday and Monday nights as the new school week starts. This
may indicate where treatment will have to be focused at some point. The
therapist will also note any discrepancies in the logbooks, read written
comments made on the logbooks, and check for sudden changes in beha-
vior during the week.

Discussion of Assessment Results

Following a discussion of the logbooks, the therapist will discuss the assess-
ment results with you and your child. The following areas may be covered:

■ Information from interviews and information regarding diagnosis

■ Information from questionnaires or formal tests

■ Information from observations

■ Differences in child and parent reports

■ Teacher or school official/academic reports

■ Other information obtained from other sources (e.g., medical

doctor)

■ Other information deemed relevant by the clinician that may

have an impact upon your case (e.g., crises, family members, in-
dividual perspectives, history, environment, interpersonal rela-
tionships, current stressors and resources)

Following this discussion, the therapist will provide answers to your ques-
tions and describe:

■ What he or she feels are your child’s major school refusal behaviors

■ What he or she believes is maintaining school refusal behavior

■ A general outline of treatment goals, expected outcome, and

timeline

32
 As the therapist discusses these things, be sure to add information or raise
any disagreements you may have. Feel free to ask questions and take notes
if you like. Most importantly, try to be open-minded about what the therapist
is saying. Some parents and children find it difficult to accept that they will
have to change some of their behavior. However, you or other family mem-
bers may need to be a major focus of treatment. As a result, the therapist
will try to explain why a specific treatment plan was chosen.

Providing a Rationale for Treatment

After summarizing the assessment results, the therapist will discuss why he
or she is recommending a certain treatment for your family. In addition,
the therapist will describe each aspect of recommended treatment.

If your child is refusing school to stay away from objects and situations that
lead to general distress, the therapist may indicate that relaxation training,
breathing retraining, and gradual re-exposure to the school setting will
help to:

■ Reduce unpleasant physical symptoms

■ Provide a way of coping with uncomfortable situations

■ Ease re-entry into school

If your child is refusing school to stay away from painful social or evalua-
tive situations, the therapist may indicate that role-playing, practice in real-
life situations, and cognitive therapy will help to:

■ Build skills so that your child will master social situations

■ Decrease social anxiety that interferes with performance

■ Reduce negative thinking that hampers school attendance

If your child is refusing school for attention, your therapist may indicate
that parent training in contingency management will help to:

■ Give you skills to improve your child’s compliance to your

commands

■ Shift your attention to positive behaviors such as going to school

■ Put you more in charge of what is happening at home

33
 If your child is refusing school to get tangible rewards outside of school,
the therapist may indicate that contracting among family members will
help to:

■ Reduce family conflict by providing a method for problem-solving

■ Increase rewards when your child attends school

■ Decrease rewards when your child misses school

If your child is refusing school for two or more of these reasons, then two
or more of these treatment plans will be needed. Other treatment compo-
nents may be added as appropriate. Ask the therapist specific questions
about his or her suggested treatment program. Remember that you, as the
client, can veto or change any treatment program that is suggested.

Pretreatment Considerations

In addition to summarizing the assessment results and suggesting a treat-

ment plan, the therapist will talk about things that may affect treatment.
Such things about your child might include:

■ Temperament/personality (e.g., hostility, sensitivity, motivation

or reaction to change, introversion versus extroversion)

■ Degree of self-esteem, self-efficacy, and self-discipline (e.g., will-

ingness to delay gratification, persistence in treatment)

■ Social status (e.g., popular, neglected, rejected) and degree of

racial/ethnic dissonance from peers at school

■ Verbal ability, intelligence, and academic status (e.g., high versus

low grades)

■ Physical status (e.g., overweight, tall, athletic)

■ Other problems (e.g., hyperactivity, aggression, learning disabil-

ity, running away from school)

■ Birth order and presence of siblings

■ Presence of traumatic life events

■ Attitude toward treatment and the therapist (e.g., willingness to

talk)

34
■ Willingness to sabotage treatment procedures between sessions
(e.g., refusing to complete homework assignments, becoming in-
creasingly secretive about school refusal behavior over time)

Things about you or your family that may affect treatment include:

■ Your methods of discipline and your relationship with your child

■ Single- versus dual-parent family

■ Conflict between you and your spouse or within the family

■ General family dynamics

■ Parent anxiety, depression, or other problems

■ Your family’s financial and time resources

■ Expectations and level of optimism versus pessimism regarding

the treatment plan (including degree of commitment to the plan)

■ Your family’s level of communication and problem-solving skills

■ Cultural variables (e.g., different levels of acculturation, language

differences, ethnic identity, mistrust of the therapist)

In addition, other things that may affect treatment include:

■ Degree of cooperation from school officials and other school

variables

■ Pressure from school officials to convince you to implement a

quicker treatment or a treatment other than the one described in
this manual

■ Cases referred by the family versus an external agency (e.g.,

court)

■ Restraints on the therapist’s time and resources

■ School victimization

The last item refers to children who feel they will be victimized in some
way if they attend school. Many children, for example, are victims of theft,
property damage, threat, and/or injury. Others are troubled by unpleasant
teachers or unfair rules. In addition, the violence and shootings that some-
times take place in American schools concern many parents and children.

35
 Such incidents may induce or affect school refusal behavior in different
ways. For example, a child may miss school because he or she is worried
about genuine potential harm or a threatening situation there. In addition,
a child may exaggerate claims of school victimization to manipulate par-
ents into letting him or her stay home. Finally, a school’s victimization rate
may induce a parent to withdraw his or her child from school whether or
not the child feels affected.

If school victimization or another pretreatment consideration is pertinent,

the therapist may suggest a change in the treatment plan. In cases of po-
tential school victimization, for example, the therapist may investigate
whether a change of school is appropriate or if another intervention is war-
ranted. If school officials are unwilling to help ease a child back into a class-
room setting, then more responsibility for treatment may rest on you. It
may be necessary to contact other people to help out with treatment if your
time and resources are limited. Be flexible as different circumstances arise,
and remember that the procedures in this workbook may change at any time
depending on your situation.

Other Considerations

Scheduling Future Sessions

In addition to outlining the treatment plan, the therapist will describe how
long treatment may last. This manual assumes an average timeline of eight
sessions in  to  weeks; however, your case may require less or more time.
During treatment, talk with the therapist on a regular basis about the struc-
ture and scheduling of future sessions. Also, it is a good idea to talk to the
therapist at this time about what to do in case of missed sessions or if other
agencies (e.g., insurance company, your job) limit the time you have avail-
able for therapy. Because the successful treatment of school refusal beha-
vior is often an intense process, missed sessions can be disruptive. It is ex-
tremely important to make every effort to attend each therapy session and/or to
make up missed sessions as soon as possible.

Work Between Therapy Sessions

Much of the treatment success that you and your child get from using this
workbook will come from the effort that you give between therapy ses-

36
 sions. Although the therapist can lay the groundwork for successful treat-
ment, you and your child will have to do the hard work to make treatment
pay off. Much of this hard work will come in the form of homework that
the therapist will give to you and your child. Don’t assume that the thera-
pist is the cure-all for your situation. He or she can accomplish only what
you and your child are willing to accomplish. However, if sufficient effort
is put forth, your chances for treatment success are very good. If you find
during treatment that you or another family member cannot carry out a
homework assignment, or if someone is deliberately sabotaging treatment,
then discuss this with the therapist immediately.

Review of the Past Week and Feedback

At the beginning of each treatment session, the therapist will want to talk
with you about events since the previous session. He or she will want to
know of any changes in the family’s situation or your child’s school refusal
behavior, as well as anything else you deem important. Be sure to use this
time to let the therapist know of any concerns or questions that you or
your child may have. The therapist will also want to see how you and your
child carried out the homework assignments from the previous session. If
there were problems, discuss them. Be sure to emphasize your child’s suc-
cesses as much as his or her difficulties.

In each treatment session, the therapist may also want to give you some
feedback about your or your child’s performance during the past few days.
It is very important at this stage to listen carefully to the therapist and try
to correct any problems that may have occurred. Remember, however, that
you have a right to disagree with anything regarding the progress and struc-
ture of therapy. If you do disagree, be open with the therapist about this
and propose some new ideas that might help remedy any current problems.

Discussion of Daily Logbooks

At the beginning of each session, the therapist will also want to review the
daily logbooks that you and your child are completing. Special attention
will be paid to sudden changes in ratings, patterns in the ratings, differ-
ences between your ratings and your child’s ratings, written comments, or
missing ratings. It is extremely important that you bring your and your child’s
completed logbooks to each session. The therapist must have this information

37
 to track treatment progress and help you implement the best course of ac-
tion regarding treatment. If you or your child are having any problems
with the logbooks, be sure to discuss these problems with the therapist.

General Points Regarding Specific Treatment Sessions

Treatment Session 2

In each treatment program, the second treatment session is often very im-
portant because many of your child’s school refusal behaviors will be dealt
with directly. Therefore, your motivation and effort in therapy will be as im-
portant as ever. The therapist will continue to check your child’s progress as
indicated in your logbooks, and should by this point have a good under-
standing of the trends in your child’s behavior. Likewise, you should have
a good relationship with the therapist at this point and feel comfortable
asking questions. Remember, it is important that you and your child parti-
cipate in, and follow through with, the treatment plan as much as possible.

Treatment Sessions 3 and 4

By sessions  and , the treatment process should be starting to mature as

you become more comfortable with the therapist and the procedures that
he or she is recommending. In addition, you should have a good idea
where therapy is headed and what will be asked of you and/or your child.
If you are uncertain, be sure to raise any questions with the therapist.

Sessions  and  often represent the “heavy lifting” portion of therapy.

During these sessions, your child’s school attendance will start, increase, or
be tied more closely to rewards and punishments. As a result, you will
spend more daily effort on the school refusal problem. Many family mem-
bers have trouble with treatment at this stage because of the increased
effort that is needed. Stick with the treatment program as long as possible
and rely on the therapist for support and feedback. Often, the longer ther-
apy continues, the greater the chances for success. In addition, continue to
develop a close working relationship with school officials.

38
Treatment Sessions 5 and 6

By sessions  and , treatment should be quite intense and focused. Al-

though different issues can be discussed at this time, you and the therapist
should spend much of the time in session addressing your child’s specific
school refusal behaviors.

The procedures in sessions  and  should be used only if things are going
fairly well up to now. If your child has started going to school or is going
with more regularity, then the procedures discussed for sessions  and 
may apply. However, if your child or family has so far seen less improve-
ment, then the therapist may want to spend more time covering material
from previous sessions. In many cases of school refusal behavior, “back-
tracking” to correct new or stubborn problems or relapses is not unusual.
Remember that the procedures described in this manual are meant to be
flexible enough to fit your particular case. Some cases take more time and
others take less time to resolve. Do not be too concerned if your therapy
schedule does not exactly match the one described here.

Treatment Sessions 7 and 8

By sessions  and , your child’s school refusal problems should be nearly

resolved. As a result, these sessions may focus on tying up loose ends, com-
pleting full-time school attendance, branching out into other areas of con-
cern, going over key themes from therapy, setting up long-term follow-up
procedures, and/or preparing for the end of therapy. If treatment does ex-
tend longer than eight sessions, then you and the therapist may continue
to rely on the principles and techniques described in this manual. Ex-
tended treatment is often necessary for stubborn cases of school refusal be-
havior or if other behavior problems need to be addressed.

Treatment success is sometimes defined as full-time school attendance for

some period of time and/or a substantial reduction in the child’s daily
stress regarding school. However, each case is different, and so you and the
therapist may define treatment success differently. In some cases, for ex-
ample, full-time school attendance for several weeks or a complete lack of
child anxiety regarding school is needed to define treatment success. In
other cases, especially those of adolescents with chronic absenteeism, even
part-time school attendance is a good definition of success. Whatever your

39
 definition of success, do not leave therapy until you have had a thorough dis-
cussion of all relevant issues with the therapist.

Stepping Down the Therapy Program

The latter sessions of therapy may be spaced apart to give you and your
child time to test new skills and uncover less obvious anxieties and worries
about school. Homework assignments may be given as appropriate and
will likely mirror those given in earlier sessions. Sessions may be scheduled
every other week or monthly through the end of the school year. This ta-
pering of treatment sessions will give you and your child a sense of support
and convey the message that your child is doing well and can handle any
anxious situations. In addition, this tapering of treatment sessions will
allow you and/or your family to refine the treatment procedures discussed
in this manual.

The final steps of treatment will be ensured as your self-confidence and

your child’s self-confidence improve and you and your child gain more ex-
perience handling a wide range of situations. Although the therapist will
work with you and your child to eventually terminate treatment, it is im-
portant for both of you to end therapy systematically, say goodbye to the
therapist, and discuss plans for the future.

The End of Treatment

When should treatment end? Ultimately, this is a question best answered fol-
lowing a thorough discussion with the therapist. Some parents and children
prefer to end treatment as soon as the child is back in school, but this ap-
proach is discouraged. In many cases, residual problems and questions re-
main, or the child “tests” the parents by refusing school one day a couple
of weeks later. An appropriate analogy to consider is what happens when
you are prescribed an antibiotic medication. This medicine usually must be
taken for  full days, long after the symptoms dissipate. If you stop the
medication once the symptoms disappear, you may place yourself at risk
of relapse due to an incomplete course of treatment. Similarly, the thera-
pist, you, and your child need to fully wrap up work together before it
ends. This may involve tapered sessions and relapse prevention training.

40
 Chapter  describes specific techniques used by therapists to ensure that
children stay on course and avoid relapse or setbacks.

In other cases, families have problems that go beyond the child’s school re-
fusal behavior. Treatments regarding these other problems should therefore
continue even if the child is back in school. Common examples of such
problems in a school refusal population include general family conflict,
anxiety, depression, lack of motivation, delinquent and oppositional beha-
vior, learning disability, and hyperactivity, among others. In complex cases
such as these, extended treatment is often appropriate and desirable to make
sure the child stays in school and to address these other problems.

Reading This Workbook

Chapters  through  in this workbook discuss the different treatments for

school refusal behavior. If your child is refusing school only to avoid ob-
jects or situations that cause general distress, then proceed to chapter . If
your child is refusing school only to escape painful social and/or evaluative
situations, then proceed to chapter . If your child is refusing school only
for attention, then proceed to chapter . If your child is refusing school
only for tangible rewards outside of school, then proceed to chapter . If
your child is refusing school for multiple reasons, then proceed to those
treatment chapters that are most relevant.

Note that some material in this manual may apply to different reasons why
children refuse school. Examples include escorting a child to school and
downplaying excessive reassurance-seeking. Therefore, you should read
each section in this manual in case it is necessary and in case you find a par-
ticular point relevant to your situation. In addition, it is essential that you
to discuss any new treatment technique with the therapist before trying it
on your own.

41
This page intentionally left blank
Chapter 4 Children Refusing School to Avoid Objects or
Situations that Cause General Distress

SESSION 1 Starting Treatment

School refusal behavior is often motivated by a desire to avoid emotions

such as fear, dread, anxiety, panic, or depression that can become associated
with certain school-related objects or situations. For children who avoid
objects or situations provoking such negative affect, the main goal of treat-
ment is to change the child’s avoidance behavior and build coping and ac-
tive school attendance behaviors. Treatment for this condition will involve:

■ Building an anxiety and avoidance hierarchy of objects and situ-

ations

■ Developing somatic management skills to decrease negative

emotional arousal

■ Systematic exposure to anxiety cues identified on a hierarchy in a

step-by-step fashion

■ Accessing self-reinforcement for coping with transient negative

emotions

Treatment involves training your child to use self-control procedures. Dur-

ing this treatment program, your child will learn to () identify personally
relevant situations and activities that provoke anxiety, and () use specific
somatic skills to prevent himself or herself from experiencing a full-blown
anxiety reaction. Gradually, your child will enter those situations that are
most anxiety-provoking while using these somatic management skills.

The therapist will spend the majority of each session with your child, but
will invite you to the last part of each session to give your input and review
the material covered in that session. The therapist may enlist your assis-
tance with your child’s homework assignments, and it will be helpful if you
set aside uninterrupted time for these practices and make them a family
activity.

43
Psychoeducation

Initial treatment will involve helping your child understand the nature and
process of anxiety. As your child’s understanding of anxiety progresses, the
therapist will help her observe her own anxiety reactions, identify where
anxiety reactions occur, and use specific skills or tools to cope with nega-
tive emotions. The following is an example of how a therapist might ex-
plain the process of anxiety to a child:

When you say that you’re scared (anxious, upset), it sounds like and feels like
there’s one big ball of bad stuff rolling over you, and there’s nothing you can
do to stop it. It’s like a train is going to run you over! If we think of feeling
scared in that way, then we stay upset, and feel like we can’t handle the situa-
tion. But, being scared (anxious) is really made up of three parts. First is
what you feel. All those feelings in your body that let you know you’re scared.
Things like your heart beating fast, shaking, your hands feeling sweaty, and
butterflies in your stomach are all signals that you’re scared. The second part
to being scared is what you say to yourself. Usually, you say something like
“Get me out of here,” “I’m afraid! I can’t do this,” “I want to go home,” or
“I need Mom or someone to help me.” And, finally, the third part to being
scared is what you do when you’re scared. This is usually something like leav-
ing a place, or avoiding going someplace, or always wanting to be near some-
one who can help you feel better.

The therapist will ask your child to provide personally relevant responses
to each of the three components of anxiety: physical (“What I feel”), cog-
nitive (“What I think”), and behavioral (“What I do”). The therapist may
draw three circles, each depicting a component of anxiety, and ask your
child to identify her own physical feelings, thoughts, and behaviors when
confronting an anxious school situation. The therapist may use cartoons or
pictures from magazines depicting youth in school situations, and your
child will be asked to describe what the child in the picture may be feeling,
thinking, and doing. In this way, the therapist and your child can build
rapport, understand what provokes anxiety, and understand how your
child interprets various situations. The therapist can illustrate to your child
the process of escalating anxiety, and the opposite process of calming or
de-escalation.

In this way, the therapist can identify targets for change within each com-
ponent. The therapist will then describe to the child the way in which these

44
 three components interact, each adding to the other to spiral into over-
whelming feelings of anxiety. The therapist will emphasize the physical
sensations of anxiety, how these sensations spiral to uncomfortable levels,
and the resulting avoidance behavior that occurs. The therapist will explain
to your child that she (the child) will use specific skills to address each com-
ponent. Your child will use relaxation and deep breathing to manage her
physical feelings of anxiety; step-by-step practices of entering anxious
situations to change avoidance and escape behaviors; and self-reinforce-
ment and pride and praise to change the negative thoughts that accompany
her anxiety.

Building an Anxiety and Avoidance Hierarchy

Using information gathered from the assessment interviews and logbooks,

the therapist will help your child build her Anxiety and Avoidance Hierar-
chy (AAH). The therapist may also ask for your input when building the
AAH. A blank copy has been provided for this purpose. You may photo-
copy the AAH from this workbook or download a copy from the Treatments
ThatWork™ Web site at www.oup.com/us/ttw. The AAH lists the objects
and situations that the therapist and your child will target for change over the
course of treatment. Using a Feelings Thermometer (Figure .) or other
measurement scale, your child will rate her anxiety and avoidance of these
objects and situations at each session.

Figure . shows a sample AAH from a -year-old girl who refused to at-
tend school due to separation anxiety concerns. As you can see, steps on
the AAH are gradual so your child can begin with the easiest (or lowest)
item and then progress up to the most difficult (highest) hierarchy item.
This is how your child’s treatment will proceed.

Relaxation Training and Breathing Retraining Exercises

The therapist will next begin to teach your child methods of relaxation and
deep breathing. Ideally, the therapist will audiotape this segment for your
child to use at home. If a tape recorder is not available, use the relaxation
and deep-breathing scripts included at the end of this section. Your child
will be asked to find a comfortable position in a chair or couch and to ei-

45
Anxiety and Avoidance Hierarchy

Problem:

Anxiety Avoidance
Situations or Places That Scare Me! Rating Rating

.

.

.

.

.

.

.

.

.

.

46
 0 2 4 6 8
Not at all A little bit Some A lot Very, very much

Figure 4.1
Feelings Thermometer

Problem: School refusal due to anxiety about being away from home and from her parents

Anxiety Avoidance
Situations or Places That Scare Me! Rating Rating

1. Staying in school all day without calling Mom and Dad 8 8

2. Staying in school all morning, and not calling Mom or Dad, or going to the nurse 8 8

3. Riding the school bus all by myself 7 8

4. Waiting for Mom, and she’s late to pick me up 6 7

5. Staying with the babysitter, and Mom doesn’t call home to check on us 5 5

6. Getting my school clothes ready the night before school 5 3

7. Having tutoring at the school, without Mom there 4 2

8. Going to school to get my homework, and visiting with my teacher 3 2

9. Going to lunch at school 3 2

10. Meeting with the tutor while Mom goes shopping 3 2

Figure 4.2
Sandy’s Anxiety and Avoidance Hierarchy

47
 ther close her eyes or let her gaze settle and focus on one spot in the room.
The therapist will then talk your child through a series of muscle tension
and relaxation exercises. These exercises are designed to teach your child to
discriminate between the physical sensations of tension and calmness. The
therapist will focus your child on “letting go” of tension and feeling calm
and relaxed. It will be important for your child to isolate each muscle group
one at a time, and so the therapist will direct your child to tense only a par-
ticular muscle (this step can be difficult for younger children). The thera-
pist will emphasize deep breathing (into the stomach or diaphragm) as a
way to prolong the relaxation and make it more complete. The therapist
will use imagery to help younger children follow these exercises. The entire
process of relaxation takes about  minutes. Following this process, the
therapist may call you in for a discussion and summary of this first session.

Homework

Homework assignments after session  may include the following:

✎ Practice the relaxation and breathing procedure at home every day,

twice a day if possible, between sessions. Record each practice on the
relaxation log provided. You may photocopy this form from the work-
book or download multiple copies from the TreatmentsThatWork™
Web site at www.oup.com/us/ttw. Note any particular difficulties en-
countered during the practice (e.g., inability to concentrate, falling
asleep during practice).

✎ Continue to complete the daily logbooks (see chapter  for blank

logbooks). Note any specific situations or experiences that arise dur-
ing the week.

Relaxation Script

Have the child recline in a comfortable position and either close her eyes
or focus on one spot on the wall or ceiling. Legs and arms should not be
crossed; have the child take off shoes and loosen any tight clothing (e.g.,
belts).

48
Relaxation Practice Log

Name:

Practice 1 Practice 2
Day
Time How did you feel? Time How did you feel?

49
 I would like you to sit as comfortably as possible in your chair. During the
next few minutes, I am going to give you some instructions about tensing and
releasing different muscle groups. I want you to listen carefully and do what I
ask you to do. Be sure not to anticipate what I say; just relax and concentrate
on my voice. Any questions? (Answer questions as they occur.)

Okay, put your feet on the floor, and put your arms on the arms of the chair.
(Focus or close eyes as desired.) Try to relax as much as possible.

Using this tension-release relaxation protocol, tensed muscles are to be held

in place for approximately  seconds.

Hands and Arms

Make a fist with your left hand. Squeeze it hard. Feel the tightness in your
hand and arm as you squeeze. Now let your hand go and relax. See how
much better your hand and arm feel when they are relaxed. Once again,
make a fist with your left hand and squeeze hard. Good. Now relax and let
your hand go. (Repeat the process for the right hand and arm.)

Arms and Shoulders

Stretch your arms out in front of you. Raise them up high over your head.
Way back. Feel the pull in your shoulders. Stretch higher. Now just let your
arms drop back to your side. Okay, let’s stretch again. Stretch your arms out
in front of you. Raise them over your head. Pull them back, way back. Pull
hard. Now let them drop quickly. Good. Notice how your shoulders feel more
relaxed. This time let’s have a great big stretch. Try to touch the ceiling.
Stretch your arms out in front of you. Raise them way up over your head.
Push them way, way back. Notice the tension and pull in your arms and
shoulders. Hold tight, now. Great. Let them drop very quickly and feel how
good it is to be relaxed. It feels good and warm and lazy.

Shoulders and Neck

Try to pull your shoulders up to your ears and push your head down into your
shoulders. Hold in tight. Okay, now relax and feel the warmth. Again, pull
your shoulders up to your ears and push your head down into your shoulders.
Do it tightly. Okay, you can relax now. Bring your head out and let your
shoulders relax. Notice how much better it feels to be relaxed than to be all

50
 tight. One more time now. Push your head down and your shoulders way up
to your ears. Hold it. Feel the tenseness in your neck and shoulders. Okay. You
can relax now and feel comfortable. You feel good.

Jaw

Put your teeth together real hard. Let your neck muscles help you. Now relax.
Just let your jaw hang loose. Notice how good it feels just to let your jaw drop.
Okay, bite down hard. That’s good. Now relax again. Just let your jaw drop.
It feels so good just to let go. Okay, one more time. Bite down. Hard as you
can. Harder. Oh, you really are working hard. Good. Now relax. Try to relax
your whole body. Let yourself get as loose as you can.

Face and Nose

Wrinkle up your nose. Make as many wrinkles in your nose as you can.
Scrunch up your nose real hard. Good. Now relax your nose. Now wrinkle up
your nose again. Wrinkle it up hard. Hold it just as tight as you can. Okay.
You can relax your face. Notice that when you scrunch up your nose your
cheeks and your mouth and your forehead all help you and they get tight, too.
So when you relax your nose, your whole face relaxes too, and that feels good.
Now make lots of wrinkles on your forehead. Hold it tight, now. Okay, you
can let go. Now you can just relax. Let your face go smooth. No wrinkles any-
where. Your face feels nice and smooth and relaxed.

Stomach

Now tighten up your stomach muscles real tight. Make your stomach real
hard. Do not move. Hold it. You can relax now. Let your stomach go soft. Let
it be as relaxed as you can. That feels so much better. Okay, again. Tighten
your stomach real hard. Good. You can relax now. Settle down, get comfort-
able and relax. Notice the difference between a tight stomach and a relaxed
one. That’s how we want to feel. Nice and loose and relaxed. Okay. Once
more. Tighten up. Tighten hard. Good. Now you can relax completely. You
feel nice and relaxed.

This time, try to pull your stomach in. Try to squeeze it against your back-
bone. Try to be as skinny as you can. Now relax. You do not have to be skinny
now. Just relax and feel your stomach being warm and loose. Okay, squeeze

51
 in your stomach again. Make it touch your backbone. Get it real small and
tight. Get as skinny as you can. Hold tight now. You can relax now. Settle
back and let your stomach come back out where it belongs. You can feel really
good now. You’ve done fine.

Legs and Feet

Push your toes down on the floor real hard. You’ll probably need your legs to
help you push. Push down; spread your toes apart. Now relax your feet. Let
your toes go loose and feel how nice that is. It feels good to be relaxed. Okay.
Now push your toes down. Let your leg muscles help you put your feet down.
Push your feet. Hard. Okay. Relax your feet, relax your legs, relax your toes. It
feels so good to be relaxed. No tenseness anywhere. You kind of feel warm and
tingly.

Conclusion

Stay as relaxed as you can. Let your whole body go limp and feel all your
muscles relaxed. In a few minutes it will be the end of the relaxation exercise.
Today is a good day. You’ve worked hard in here and it feels good to work
hard. Okay, shake your arms. Now shake your legs. Move your head around.
Open your eyes slowly (if they were closed). Very good. You’ve done a good job.
You’re going to be a super relaxer.

Breathing Retraining Script

Ask the child to imagine going on a hot-air balloon ride. As long as the
hot-air balloon has fuel supplied by the child’s breathing, destinations are
unlimited. Ask the child to breathe in through her nose and out through
her mouth with a SSSSSSSSS....... sound. You may encourage this process
through imagery, such as having a picture of a hot-air balloon nearby. If
necessary, have the child count to herself slowly when breathing out.

The following is an example:

Imagine going on a ride in a hot-air balloon. Your breathing will give the
balloon its power. As long as you breathe deeply, the balloon can go anywhere.
Breathe in through your nose like this (demonstrate). Breathe slowly and
deeply. Try to breathe in a lot of air. Now breathe out slowly through your

52
 mouth, making a hissing sound like this (demonstrate). If you want, you can
count to yourself when you breathe in and out.

SESSION 2 Intensifying Treatment

In this session, the therapist will begin to present to your child those ob-
jects or situations that provoke her anxiety. This process will occur through
a procedure called “systematic desensitization.” First through imagination
(“imaginal exposure”), then using real-life situations (in vivo exposure),
your child will confront her anxieties in a step-by-step fashion. Between
sessions, your child will practice imaginal and real-life exposures, or Show
That I Can (STIC) tasks. The therapist will enlist your help in setting up
and conducting these STIC tasks.

Preparing your Child for the Systematic Desensitization Process

The term “systematic desensitization” will be explained to your child if she

is an older adolescent and can understand more complex concepts. Other-
wise, the therapist will provide your child with an explanation such as the
following (T stands for Therapist; C stands for Child):

T: Let me ask you something. Do you know how to ride a bike? Or

swim? Or do you ski or ride horses? (Probe until you find some ac-
tivity the child can perform with some skill.)

C: Yes, I can ride a bicycle. I learned that when I was  or .

T: Okay, tell me about what you do when you want to go (biking, ski-
ing, horseback riding).

C: Well, I get my bike out of the garage, and I ride it up the street or to
my friend’s house.

T: Okay, you have to get the bike out of the garage. What do you
think about when you’re riding your bike?

C: Nothing. I mean, I think about what me and my friend are going to

do. Like maybe we’ll play video games.

53
 T: Are you riding your bike in the street or on the sidewalk?

C: Well, I have to ride on the sidewalk. But sometimes I have to cross

the street, so I look both ways.

T: And what are you doing with your hands, feet, and eyes when you
ride?

C: Nothing. I just pedal and hold the handlebars. And I have to look
where I’m going.

T: Okay. So, what you’re telling me is that you get on the bike, ride
along the sidewalks and street, pedal along, and watch where you’re
going, and you don’t think about those things. Instead, you think
about what you’re going to do with your friend. Right?

C: Yeah, I guess.

T: Sure, it’s automatic that you ride now, and watch out for where
you’re going. You’ve learned how to do these things, haven’t you?
(Child nods.) And you don’t even think about how you’re doing
these things anymore. But, do you remember when you first went
out on the bike? Do you remember that it used to be scary?

The therapist will question your child and prompt him or her to recall the
first time riding a bike or doing some similar activity that requires skill. The
therapist will ask your child to identify the physical feelings, thoughts, and
behaviors of a child who is learning to ride for the first time. The therapist
will then ask your child about her initial learning experiences—how initial
steps were small, but with practice your child developed skill and mastery.
At this point, the therapist will focus your child on how continued practice
and over-learning has made the situation easy and automatic. The thera-
pist will ask your child about what happened to her initial anxieties:

T: Why aren’t you scared of falling off the bike now?

C: Because I don’t fall anymore. And if I do, I may get scraped, but it
gets better.

T: So, even if you do fall, you know you’re going to be okay. Right?

C: Yeah, I’ve fallen. I just have to get on the bike again. That way I
don’t get scared again.

54
 T: Right! That’s exactly right! You have practiced riding your bike, and
you started out in steps. Someone helped you, and you used train-
ing wheels. Then you took them off when you started feeling more
comfortable and less nervous. Right? So you did this step by step
and, as you developed more skill, you became less nervous. Now
you don’t even think about how you were once nervous.

The therapist will then introduce your child to the concept of taking steps
one at a time and mastering each step until very little or no anxiety is felt.
This will be accomplished through the imaginal desensitization process,
which may be presented to your child as “practicing thinking about the
troubling situations.” The therapist will describe and alternate relaxing
scenes with anxiety-provoking scenes from your child’s AAH. Your child
will be instructed to raise her hand when she becomes uncomfortable.

Constructing the Anxiety Scenario

The therapist will choose one of the easier steps from your child’s AAH.
This will be the first situation to confront imaginally. The therapist will ask
your child about what she thinks will happen in the situation, and develop
a script or scenario about that situation based on what your child thinks and
is anxious about. The therapist may embellish these scenes to some degree.
Often, parents are surprised at the graphic nature and intensity of the
child’s anxieties. However, it is important to note that these are your child’s
anxieties and, left to her imagination, they can continue to develop
unchecked. The therapist will help your child think about these anxieties,
mix in relaxing scenes so the thoughts themselves are no longer scary, and
then discuss what is realistic for any given situation. The goals of desensi-
tization are to gradually get your child to listen to an entire anxiety scenario
“as if watching a movie” and realize that the scene is not that scary itself.
Another goal is to have your child recognize that she can cope with just
about any scenario in a positive, proactive way. A sample scenario, using
situation  from Sandy’s AAH (Figure .), follows:

It’s after  o’clock, and you and your mother are driving to school to see your
teacher. You have to go in and get your own homework. You haven’t been in
school for  weeks, and haven’t really seen any of the other kids or the teacher.
The last time you were there you felt real funny in your stomach, and you felt
like throwing up. As you get closer to school, you start to feel a bit dizzy, and

55
 start to sweat a bit. You look up at Mom, and want her to turn the car
around, but she says you have to get the work. Mom has to stay in the car, be-
cause there’s no place to park, so you have to go in alone. Mom drives up to
the front door of the school. Some kids are there, and some teachers, but not
anyone you know. You open the car door, and feel really dizzy now, and your
stomach feels like you’re on a roller coaster. You start to walk up to the door,
and you feel really shaky and sweaty. These are the feelings that you get some-
times that scare you. What if you get sick? You look back, and Mom is mov-
ing the car, and is now pulling out of the school driveway. You walk in
through the door, and feel so dizzy that you have to hold on to the wall to
stay standing. Some kids walk by and laugh. You’re really feeling scared now,
and it’s getting harder to breathe. What if you faint, and no one comes to get
you and help you? What if Mom just stays in the car? You start walking down
the long hall to the classroom, and when you get there, several kids are in line
to see the teacher. So, you have to wait. It’s really hot in the classroom, and
you feel like you might throw up. You’re so dizzy now, and can taste real sour
stuff coming up in your throat. You feel dizzy and faint, and wish that the
teacher would look at you and help you, but she’s talking to someone else. You
can feel it coming now, it’s at the top of your throat. You yell out for help,
and when you do, you get sick all over the place. The teacher and all the kids
are looking at you now, with wide eyes. You feel really sick, and really embar-
rassed. If only your mother had come in with you.

Tracking Anxiety During Desensitization

Throughout the systematic desensitization process, the therapist will ask

your child to rate her anxiety levels using the Feelings Thermometer (see
Figure .) or other measurement scale. The therapist will record your child’s
ratings. This way, the therapist can illustrate, using charts or graphs, what
happened to your child’s anxiety during the systematic desensitization.
These charts or graphs will show how your child gradually mastered her
anxiety over the course of treatment.

Some children are able to track their own anxiety levels. Recording their
own ratings gives children instant information about how they handled
certain situations. The ratings can illustrate how they coped with panic
symptoms, separation concerns, fears of specific objects or situations, or
any other situation where anxiety ratings can be taken and recorded. You

56
 may wish to keep your child’s ratings in a log or notebook to remind your
child of progress made during therapy.

Conducting the Imaginal Desensitization

The therapist will likely audiotape the following desensitization procedure

for later processing and for home use. The desensitization begins with the
therapist instructing your child to raise her hand whenever anxiety makes
her uncomfortable. This is indicated by a level of  or above on the Feel-
ings Thermometer. The therapist will explain that he or she will first have
the child relax, and will then begin presenting the troubling scene. Your
child is to listen to the therapist and imagine the scene in her mind as if it
is actually happening. When anxiety becomes uncomfortable, she should
raise a hand. At that point, the therapist will ask your child to “switch” to
thinking about something pleasant, such as being on a beach, in the park,
or in some other place that is relaxing and pleasing for your child. Once
the anxiety falls back to a level of  or , the therapist will again begin to
present the troubling scene. This switching back and forth will continue
until your child is able to tolerate listening to the scene all the way through
without increasing levels of anxiety.

As your child begins to progress through each scene, the therapist will ask
her to raise a hand when the anxiety reaches a level of  or . This allows
your child to develop increased tolerance and eventually habituate (get
used) to the sensations and feelings of anxiety. As tolerance increases, these
feelings will lose their ability to signal your child to escape or avoid, and
will allow her to try new situations while tolerating normal levels of arousal.
If necessary, the therapist will divide the anxiety scenario into smaller steps
or less volatile scenes. The imaginal desensitization process always ends
with a relaxation scene.

Processing the Imaginal Desensitization

Once the imaginal desensitization is completed, the therapist may call you
in to the session to discuss your child’s progress. The therapist may play
some of the tape for you and ask your child to explain and demonstrate the
process to you. The therapist will then question your child: “What hap-

57
 8 8
Feelings Thermometer Scale

Feelings Thermometer Scale

4 4

0 0
Time in Minutes Time in Minutes

Figure 4.3
Sandy’s Anxiety Ratings

pened to your anxiety while we did this practice?” The therapist may illus-
trate the habituation of anxiety by drawing graphs or diagrams of your
child’s anxiety ratings throughout the desensitization process. This will
show how the anxiety dissipated with each succeeding presentation. For ex-
ample, compare Sandy’s anxiety about riding the school bus in her first
imaginal desensitization session with her anxiety in a later in vivo, or real-
life, desensitization practice (Figure .).

The therapist can show Sandy on the first graph how she was initially very
anxious about riding the bus, given that her anxiety ratings began near 
and very quickly reached their worst level of . Furthermore, the therapist
can emphasize that this simply involved Sandy’s imagination. However, by
showing Sandy her second graph, she can clearly see that, during a real-life
(in vivo) ride on a school bus, her anxiety started on a lower level, peaked
at a lower level, and went away much faster than before. Sandy therefore
learned that what she imagines is often worse than what will actually occur,
and that she can handle the situation despite her anxiety.

Even if your child did not habituate, the therapist will praise your child for
any effort or degree of participation and process what may have been par-
ticularly difficult for your child. In such cases, which are not unusual, the
anxiety scenario can be broken down into smaller steps or less volatile scenes.

58
 It is important that your child be given praise and encouragement for mak-
ing any step, no matter how small. Typically, desensitization begins slowly,
and the pace quickens over time. This may occur in one session or across
two or more sessions if necessary.

If your child’s anxiety ratings do not readily habituate (go down), the thera-
pist may process with your child what thoughts she may be having during
the exposure. For particularly troublesome or negative thoughts, the thera-
pist may use cognitive restructuring procedures (see chapter ). These pro-
cedures will enhance your child’s ability to identify and change negative
thoughts.

Homework

Homework assignments after session  may require more assistance on

your part and may include the following:

✎ Continue to practice the relaxation procedure, using the tape just be-
fore bedtime each night.

✎ At least once daily, your child should listen to the desensitization

tape and go through an imaginal procedure (STIC task). You may
assist your child by asking for anxiety ratings, or by keeping other
children who are at home from interrupting the procedure. You
should talk with your child after each practice, much like the thera-
pist did during the session. Focus your child on how her anxiety dis-
sipated, and offer praise and encouragement for attempting and/or
completing each practice.

✎ Beginning with the next school day after this session, wake your
child about  to  minutes before school is scheduled to start and
implement the normal school-day routine. Follow this routine as
closely as possible. Your child should do schoolwork and read school-
related books when at home during the day.

✎ Continue to complete the daily logbooks, noting any specific issues

or situations that may arise during the week.

59
SESSIONS 3 AND 4 Maturing Treatment

Sessions  and  will continue to focus on systematic desensitization, with

an introduction to in vivo desensitization. In vivo desensitization involves
having your child gradually enter the anxious situation and use her relax-
ation techniques to manage anxiety. Your help will be crucial to the success
of this process, as you will be expected to arrange the time and place of the
in vivo desensitization and help your child engage the situation.

Continuing the Systematic Desensitization

The therapist will review your child’s progress in listening to the home-
based imaginal desensitization tapes (STIC task) and discuss any problems
encountered during the week. If your child was noncompliant with the
STIC task, the therapist will address the reasons why this occurred. Some
children avoid doing the homework to avoid any rising feelings of anxiety.
It may be that the anxiety scenario needs to be divided into smaller steps,
or the therapist may program “coping scenes” during the desensitization. If
your child is having a particularly difficult time listening to the scene and
is unable to habituate to the anxiety, then the therapist can present images
of your child and a favorite superhero or athlete confronting and coping
with the situation. Example:

You are waiting for your mother to pick you up after school, but she is late! As
you stand out front, the other kids are all being picked up, and the teachers
have gone back into the school or driven home. It is really getting late, and
you are worried that something may have happened to Mom. What if some-
thing bad happens to you? You notice that the sky is getting dark, and big
thunderclouds are coming. It starts to thunder, and flashes of lightning are
happening. You try to go back into the school, but now the door is locked!
Where is Mom? You are really scared now, and feel like crying. You think
something terrible must have happened to Mom, and now you could get
caught in the lightning! But, wait! You start to think, “What would (name of
child’s famous role model) do in this situation?” There must have been times
when he had to wait for his parents, and probably he was alone and outside
too. Would he cry if he were here? What would he tell you to do? Picture
(name of child’s famous role model) standing next to you. He says, “Okay,
you’re afraid that something bad happened to Mom, but why else could she

60
 be late?” You answer, “Well, maybe she’s in traffic, and there are a lot of cars.
Or, maybe she had to run an errand and it’s taking a bit longer than she
thought.” (Name of famous role model) tells you, “Yeah! Good thought! She
could just be running late. Now, what should you do about the weather
here?” Now picture yourself telling (name of famous role model), “Well, I
suppose I could stand under the awning, and wait by the door. That way I
can see Mom when she comes, and I’ll be out of the storm.” “Great job,” says
(name of famous role model). “Take some deep breaths, and wait by the door
for her. She’ll be here soon.” (Name of famous role model) gives you a high-
five, and you feel so proud! Now, picture yourself going to the door, standing
under the awning, and waiting calmly for Mom.

Some children will avoid doing their STIC tasks because they anticipate
that getting better means getting back into school more quickly. If this is
happening with your child, the therapist will focus your child on the goals
of the program and examine whether additional factors (e.g., attention-
getting, tangible rewards for staying home) need to be addressed more di-
rectly in treatment.

The therapist will continue to develop scenarios for each item on your
child’s AAH, and progress to more challenging items sequentially. Progress
will be evident when your child listens to an entire AAH scene, does not
have to switch to a neutral, relaxing scene, and reports minimal anxiety
ratings.

Introducing Your Child to the In Vivo Desensitization

In vivo desensitization involves entering and confronting real-life situa-

tions or activities. For this part of treatment, the therapist must help your
child make a link between imaginal confrontation of anxious situations
and actually entering these situations. See the following example:

T: Let’s think about something. Remember when we talked about how

you learned to ride a bicycle?

C: Yes, from practice.

T: Right. And you’ve been doing a great job here, practicing here and
at home imagining doing these things that make you upset.

C: Yes, I “Show That I Can” all the time. I do my practice every day!

61
 T: Yep. 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?

C: Yes, I remember.

T: 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 to just get on a bike and ride?

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

T: Right! So, watching the movie may help you to know what it looks
like to ride. And, it may show you some 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.

C: Right. You have to get on the bicycle to learn how to ride it.

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

C: So, I have to ride the school bus?

T: Well, eventually, yes. But first, we’ll only practice for real the situa-
tions we’ve done in here and on tape. And we’ll 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. We’ll first do it in your
imagination, and then we’ll do it for real. Taking it easy, going one
step at a time, and we’ll get Mom and Dad to help out here and
there.

Conducting the First In Vivo Desensitization

The therapist will role-play with your child one of the easier items from the
AAH. This role-play, made as close to reality as possible, will involve your
child “acting out” and confronting an anxious situation. For example, if

62
your child is anxious about being alone either at school or home, then the
therapist will construct a situation where your child waits in a therapy room
by herself for a period of time. Initially, the situation will be set up to be
minimally anxiety-provoking and your child will be encouraged to use the
relaxation and deep-breathing skills to manage anxiety. As your child de-
velops tolerance of the situation, the therapist will slowly make these situa-
tions more challenging and encourage your child to refrain from using any
safety behaviors to make herself “feel better.” Following are examples of a
graduated in vivo desensitization for a child who is afraid to be left waiting
alone:

. Sitting alone in the therapy room for  and then  minutes, knowing
that the therapist is in the hall

. Sitting alone in the therapy room for  and then  minutes, know-
ing that the therapist may not be in the hall

. Sitting alone in the therapy room for  minutes, with the lights
dimmed, and knowing that the therapist is not in the hall

. Sitting alone in the therapy room, not knowing how long it will be,
with lights dimmed, the therapist not in the hall, and Mom or Dad
told not to be in the waiting room

Desensitization trials begin with assistance from the therapist and with
relatively easier situations, and demands increase with each successive trial.
Your child’s expectations are also addressed, as she first knows what to ex-
pect in the situation (e.g., trial , knowing the therapist is in the hall), but
is later exposed to unknowns (e.g., trial , not knowing how long it will be).
This process is designed to build up your child’s ability to cope with am-
biguous, challenging, and often uncontrollable situations. Anxiety often
results from feeling unable to control a situation or predict what could hap-
pen in any situation, along with concern that something very negative will
occur. These desensitization procedures teach your child that, even when
she doesn’t have total control in a situation, she can still cope effectively
and that the worst scenario is not likely to occur. Your child learns to tol-
erate normal levels of arousal while gathering information about her cop-
ing resources and skills.

The therapist will invite you in to review progress with your child. Your
child will tell you about the in vivo desensitization, and the therapist will
review with you how the daily routine has been progressing. There will be

63
 specific instructions on what steps to take next in getting your child more
used to, and involved with, the school routine. For example, the next STIC
task may involve a trip to the school library or meeting after school hours
with the teacher to pick up homework. These tasks combine the in vivo de-
sensitization process with the STIC tasks. The therapist will discuss any
potential problems with adherence to the school schedule, and make rec-
ommendations as needed.

Setting the Pace of, and Assistance With, the In Vivo Practices

There are several ways to set the pace of in vivo exposures. A slower pace is
preferred for younger children, those with special needs, and those with ex-
ceptionally high levels of anxiety. This allows the child to fully habituate to
the anxiety, over-learn the plan of confronting the stressor, and build trust
that she will not be forced into something overwhelming by the therapist.

In assisted in vivo exposure, either you or the therapist performs the expo-
sure with your child. This allows your child to receive support from a
trusted individual and observe a model who manages the situation. A care-
ful balance must be struck between modeling, where you show the child
how to manage the situation, and rescuing, where you take over and do the
situation for your child. Modeling and assisted exposure keep the focus on
your child, with the goal of having her confront the stressor and manage
the situation herself. Typically, the therapist first models for your child how
to deal with the situation while the child observes. Next, the therapist helps
your child manage the situation. Your child and the therapist (or you) then
engage in the situation as a team. Next, your child manages the situation
on her own, with words of encouragement from the team. Finally, your
child engages the situation on her own while verbalizing self-reinforcement
for performing the in vivo desensitization.

In massed exposure or flooding, your child confronts a stressor at a high

intensity. Rather than gradually progressing up the AAH, the therapist
chooses a higher-rated situation and begins there. Relaxation procedures
are typically downplayed, so the advantage of flooding is that it takes less
time. Your child simply enters the anxious situation and stays with it until
anxiety naturally dissipates. Flooding is not often used with young chil-
dren, when anxiety is extreme, at the beginning of therapy, for children

64
 with chronic school refusal behavior, or for children with social/evaluative
anxieties. Deciding to use more rapid flooding procedures depends on your
child’s progress to this point and whether she understands the reason for
this process.

Homework

Homework assignments after sessions  and  may include the following:

✎ Continue to practice the relaxation tape at bedtime.

✎ At least once daily, listen to and conduct a tape (imaginal) desensiti-
zation procedure.

✎ An additional STIC task, which will involve a minimum of  differ-

ent days of in vivo desensitization practice. This task will be agreed
upon by the therapist, your child, and yourself. The in vivo desensiti-
zation may involve any of the following: practice at home, such as
practicing staying alone in a room or the house for various periods of
time; allowing you to leave the house and staying with a sitter for
various periods or time; visiting the school bus stop in the morning;
visiting the school or some room at the school; or similar situations.
You will have to agree to make the time to assist your child with
these in vivo practices. The therapist will give you and your child
specific instructions for conducting the practice.

✎ Continue to follow a regular school-day schedule, with early waken-

ing, typical dressing and preparing for school, and completing school
assignments. It is important to avoid inadvertently reinforcing your
child for not going to school. For example, it may be easier for you
to take your child to the store or on errands; however, these types of
outings serve to reinforce your child’s avoidance of school, increase
dependence on you, and give a message that it’s okay to be home.
Arranging for a sitter or, in the case of responsible older children,
leaving your child alone for specified periods is preferred to taking
her with you on such excursions.

65
SESSIONS 5 AND 6 Advanced Maturing of Treatment

Sessions  and  involve helping your child move more swiftly and aggres-
sively through the AAH. It is imperative that you and your child make
every effort to arrange and complete the assigned in vivo desensitization
practices (STIC tasks) so that your child builds her experience confronting
and coping with stress. The therapist may also want to arrange therapy ses-
sions at your child’s school or in places other than the office to conduct as-
sisted in vivo practices. Over time, your child will learn to construct and
carry out her own exposures and turn anxiety-provoking situations into
positive opportunities to take on challenges. The key goal is to train your
child to recognize when negative emotions occur, and then to immediately
set up an exposure and take coping action rather than avoiding or escap-
ing. This coping process is termed “transfer of control.” In the transfer of
control model, the therapist is the expert who assumes responsibility dur-
ing treatment to transfer his or her knowledge of coping with negative
emotions to you and your child. The therapist does this by modeling for
and training you to conduct in vivo desensitization at home, and helping
your child practice anxiety management skills. Through systematic home-
work assignments, you become an active and crucial part of the transfer
process by fostering your child’s sense of control and mastery of negative
emotions.

Review of Assigned In Vivo Desensitization and STIC Tasks

Each session will begin with a review of the assigned homework and an ex-
amination of your child’s progress during in vivo desensitization practices.
Examples of assigned tasks include visiting the school and/or teacher, stay-
ing alone for increasingly longer periods, and approaching and remaining
in other situations. The therapist will help your child “troubleshoot” any
difficulties during these in vivo practices. The therapist will emphasize the
importance of using deep-breathing and relaxation techniques to remain
calm during difficult situations and to stay in a situation rather than avoid-
ing or escaping. In addition, the therapist will review your child’s progress
in adhering to a school schedule and her initial attempts at attending
classes or school functions.

66
Stepping up the STIC Tasks: Eliminating Safety Signals

As treatment continues, your child will confront more challenging situa-

tions for in vivo desensitization both within and between sessions. One
focus of your child’s desensitization practices should be to enter 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 situa-
tion. Although a safety signal may lessen your child’s anxiety in the short
term, the long-term use of safety signals maintains anxiety and prevents
your child from learning that she can manage the situation.

When your child is worried, fearful, anxious, or sad, she may become more
“clingy” or needy of attention and reassurance. Children who refuse to at-
tend school or other activities due to these negative emotions can often be
“bribed” into entering these situations with assistance. For example, some
anxious children will ride the school bus only if a certain sibling or friend
accompanies them. If the “safety” child is absent, the anxious child more
strongly resists riding the bus. Similarly, youths with panic attacks may re-
quire elaborate safety measures such as carrying a cellular telephone in case
they need to call for help. Youths with panic disorder find it very difficult
to be away from home or their primary caretaker for fear that no one else
will understand or be able to help them if a panic attack occurs.

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. Table . lists some common safety signals for chil-
dren who refuse school. The therapist will help your child construct in vivo
practices to confront and challenge these negative emotions. As each prac-
tice progresses, accompanying safety signals will be systematically taken
away so that your child has the opportunity to learn how to manage the
situation alone.

In Vivo Practices

Increasing the challenge of the STIC tasks, along with decreasing the use
of safety signals, will give your child experience with managing difficult
situations. The therapist may begin with an imaginal desensitization so
that your child is prepared for the real-life practice situation. The imaginal

67
Table 4.1. Negative Emotions and Behaviors and Accompanying Safety Signals
Negative Emotions and Behaviors Safety Signals

Worry: “What if ” thinking; reassurance-seeking; Repeated questioning; needing to know every detail
anxiety in new or changing situations; perfectionism. and plan; carrying everything in the book bag (fear
of leaving something behind); rewriting and erasing
to get a paper “perfect.”
Panic: “Fear of the sudden rush of certain body sensa- Having someone always close by “just in case” (e.g.,
tions, such as a racing heart, sweating, dizziness, friend, parent); carrying certain objects to feel better
shortness of breath, or shaking. (e.g., water, medicine, cellular telephones or beep-
ers); checking heartbeat or pulse; dropping out of
sports or gym activities.
Anxiety about specific objects or situations: Anxiety Watching a weather report and anticipating a storm;
about fire drills, riding the bus, insects or animals, sleeping with the lights on or needing someone to
thunderstorms, a ringing bell, small places like class- sleep with the child; earplugs (most children with
rooms, doctors, needles, or the dark. these types of fears avoid the situation at all cost!).
Separation anxiety concerns: Anxiety that something “Shadowing” or clinging to Mom or Dad; always being
terrible will happen when separated from home or in sight of Mom or Dad; never being alone; needing
loved ones, and then two people will never see each lots of reassurance if a separation is going to occur.
other again.
Sadness, the “blues,” or depression: Being down more Clinging; not wanting to be alone; having someone else
days than non; feeling hopeless or that things will (parent, friend) solve or handle one’s problems due
never work out; feelings of worthlessness or guilt; to beliefs that “I can’t ever get things right” or “I
loss of interest in usual activities; irritability; crying; don’t deserve this.”
thoughts of death or harming self.

desensitization will describe your child confronting a stressful or anxious

situation and not engaging in a safety behavior. If your child progresses
fairly rapidly, then in vivo desensitization may begin quickly. Following are
examples of in vivo desensitization plans for three of the most common
forms of negative distress in a school refusal population.

Example 1: The Clinging Child—“Don’t Leave Me Alone!”

Problem Focus

School refusal due to fears that something terrible will happen to Mom or
Dad, or of being kidnapped or killed, or of getting lost and not being able
to find the way home.

68
Safety Behaviors and Signals

Needing to call home every hour during the school day; needing Mom and
Dad to call home every hour when they go out without the children; hav-
ing Mom or Dad always arrive early to pick up child from school; having
Mom or Dad drive down the same streets to prevent getting lost.

In Vivo Desensitization Plans

The child practices going for increasingly longer periods of time without
talking to Mom or Dad, and gradually works up to not knowing their where-
abouts. Telephone calls initially can be stretched to every  minutes, then
to twice in the morning and once in the afternoon, then to once only in the
morning, and then to no calls at all. A similar schedule would apply when
the parents go out without the children: Call home every  minutes, then
every  hours, then once during any -hour period, and then not at all.

In vivo practice for anxieties about not being picked up on time would
have a parent arrive  minutes late and give a plausible excuse (e.g., stuck
in traffic), then  minutes late with an excuse, then  minutes late with-
out an excuse, and then  minutes late (working up to  minutes). To in-
crease the challenge in this situation, the therapist may employ “confeder-
ates,” or assistants who are unknown to the child, who will walk by or ask
for directions. Concurrently with this type of exposure, the therapist will
instruct the child about what to do to stay safe if a parent is running late:
wait inside the school building and inform the office staff that you are
there; stay outside and inform a teacher or an adult who is well known that
you are waiting for your parents; do not approach strangers; if a stranger
approaches you, walk quickly toward a group of kids, an adult who you
know, or someone in authority such as a police officer or crossing guard.
The goal of this type of exposure is to enhance the child’s tolerance for nor-
mal inconveniences and to develop the necessary skills to manage and re-
main safe in an ambiguous situation.

To desensitize anxiety about getting lost, the therapist and parent may
blindfold a child (using a mask or scarf ) and, without talking, take the child
on a walk around the office building or outside area. Although the child
would be led by the hand, the absence of conversation and being able to
see the surroundings will arouse anxiety and worry. By increasing the prac-
tice time, the child will again learn to tolerate an ambiguous situation. In the

69
 next step, the parents drive on unfamiliar roads and occasionally mumble,
“Oh boy, where are we?” The parents are instructed not to give any reas-
surance to the child and stay “lost” for increasing periods. The parent then
verbalizes his or her plan for finding the correct street while remaining
calm and in control: “Okay, let’s see where we are. Breathe slowly; relax.
This is Hylan Boulevard, and I know that it runs into New Dorp Lane at
some point. Take it easy; stay calm and relaxed. I’ll keep driving in this di-
rection for another mile. Okay! There’s New Dorp Lane! I knew I could
find it if I just remained calm!”

Example 2: Pushing the Panic Button—“I Feel Sick and I Need Help!”

Problem Focus

Panic attacks occur in a variety of situations or places, and may cause nau-
sea, dizziness, shortness of breath, heart palpitations, sweating, shaking,
numbing or tingling sensations, and feelings of unreality. These attacks
may have come “from out of the blue” or may have happened to the child
in school, on the bus, in public places such as malls and movie theaters,
and/or in crowds.

Safety Behaviors and Signals

Carrying a paper bag in case of hyperventilation, a bottle of water to keep

the throat “open,” and a cellular telephone to call for help; needing to have
Mom available by telephone at all times; parents rearranging their work
schedules to drive the child to and from school to avoid the bus that “trig-
gers my panic attacks”; attending school only for half days because panic is
more likely to occur in the afternoon; staying home to rest in bed each af-
ternoon to stave off panic; being given an open pass by the teacher to go to
the school nurse at any time during class in case of panic symptoms (on av-
erage, spends at least  hour each morning with the nurse), and then lying
on a cot.

In Vivo Desensitization Plans

For a person with panic attacks, interoceptive exposure exercises help de-
sensitize her to the physical sensations that accompany panic. Interocep-
tive conditioning is the process of learning to be afraid of physical sensa-

70
Table 4.2. Interoceptive Exposure Exercises for Target Sensations
Exercise Target Sensation

Spinning in a chair Dizziness, lightheadedness

Running in place or up stairs Shortness of breath, racing/pounding
heart
Breathing through a straw Shortness of breath, chest tightness
Staring at a light and then reading Visual disturbances, unreality
Shaking head from side to side Lightheadedness
Tensing all muscles, and holding them Muscle tension, tingling sensations
very tight
Hyperventilation Shortness of breath, pounding heart,
lightheadedness, tingling sensations
Putting head down below the knees, Lightheadedness, dizziness, unreality
and then “popping” up very quickly

tions. Individuals with panic begin to feel a change in their physical state
and become very vigilant about the change and scared of its implications.
Individuals with panic thus typically avoid running up stairs, aerobic ac-
tivity, drinking caffeinated beverages, or other situations or activities that
may cause physical changes. One key to overcoming panic is to learn to tol-
erate normal physical arousal and changes without becoming scared and
distressed. Interoceptive exposure involves the systematic provocation of
these sensations over repeated trials to reduce anxiety. A hierarchy of sen-
sations that scare the child is constructed and, beginning with the least
anxiety-provoking sensation, the child engages in exercises designed to elicit
the sensation at higher and higher intensities. Typical exercises and their
targets are listed in Table ..

The goal of having the child engage in these exercises is to teach her that
these sensations are temporary, predictable, and controllable. Most impor-
tantly, the child learns that changes in physical states are normal and harm-
less. Parents should be forewarned that the child will be somewhat uncom-
fortable, but only temporarily. The sensations of a panic attack are harmless
and will eventually go away even if the child does nothing at all. Most im-
portantly, the child will learn that normal functioning does not have to be
changed because she experiences panic attacks.

The child should also be entering situations that she avoids and gradually
leave safety signals (e.g., paper bags, cellular telephones, water bottles) at

71
 home. School attendance should be gradually increased and visits to the
nurse more limited. These steps involve cooperation with the teacher and
school nurse, so the therapist must be able to communicate how they may
coach the child to comply with the desensitization. Similarly, practice at
home will involve spending less time in bed and increasing the amount of
time spent engaging in physical activities (e.g., bike riding) that arouse
physical sensations. The child should use deep breathing whenever anxiety
is aroused, and should remain in the situation despite feeling panic-like
sensations.

Example 3: The Worrier—“What If, What If, What If?”

Problem Focus

Excessive worry about new situations, changes in routine, doing things per-
fectly or to an unrealistic standard; difficulty with concentration, resting and
sleeping well; complaints of muscle tension or aches; and repeatedly ask-
ing the same question in the same manner again and again.

Safety Behaviors and Signals

Constantly seeking reassurance from parents, teachers, and peers; teacher

reporting that the child is “always at my desk”; child needing to know what
the family’s plan is for every day of the week and has difficulty if plans are
changed or unexpected events occur.

In Vivo Desensitization Plans

The child will be taught to experience less-than-perfect or less-than-desired

circumstances, and accept the consequences without asking for reassur-
ance. For example, a child who is overly perfectionistic and puts undue
pressure on herself may be asked to purposely make mistakes on home-
work papers or in sporting activities (e.g., strike out in baseball). Similarly,
a child who is overly preoccupied with looking perfect may be asked to
wear something wrinkled, have messed-up hair, and not use the mirror to
check on her appearance. Reassurance should not be given. Parents must
refrain from responding to the child when she repeatedly asks, “Do you
think this is okay?” When the in vivo desensitization involves making mis-

72
 takes on schoolwork, we often ask the teacher to expect a change in the
child’s work, and possibly to prepare some worksheets that will not enter
into the child’s official grade. The child will be taught that, even if mistakes
occur, there are usually no long-term consequences and most mistakes can
be remedied.

For a child overly concerned with details of plans and activities, we teach
her to confront unknown and changing experiences. Schedule an outing
that involves several planned stops (e.g., first to the mall, then to Grandma’s
house, then to the library). Typically, children who worry excessively will
want to know all of the details of each stop, such as how long they will be
there, what will happen, and who else may be involved. Parents should
change the order of the plans (e.g., go to Grandma’s first) and length of
time that the child expects to be in each place (e.g., leaving ahead of sched-
ule or staying longer in one place). As the child begins to adjust, parents
should advance desensitization by confronting established expectations
(e.g., Grandma is not at home, the library is closed) and canceling an in-
dividual element of the plan. Lastly, parents should cancel an entire sched-
uled outing at the last minute without giving notice to the child.

The Ups and Downs of Providing Reassurance

As a parent, your natural tendency is to comfort your child when she is

upset, protect your child from harm and stress, and give your child experi-
ences that enhance her self-esteem and development. It is perfectly natural
and normal for you to respond to tears and fears with hugs and comfort-
ing words. It is also normal for your child to ask questions about events and
daily life situations, especially as she grows and gains more experience with
the larger world.

Children who are prone to experience anxiety or distress, however, can

push your limits. This is not the child’s fault, nor is it yours. Some people
are more inclined to respond to stress with depression, anxiety, and fear.
For example, if you take a moment to think about different relatives or
friends, imagine how each would respond to hearing that they may be laid
off from their jobs. Some may react with anger and punch the wall. Some
may react with depression and withdraw. Some may start worrying and
thinking about all the terrible things that could result from the layoff. Fi-
nally, some may start planning for the layoff and evaluating how they could

73
 deal with the situation. Each person reacts with some degree of guidance
from his or her “temperament.” Every person is born with a temperament
that guides him or her toward being more angry, depressed, anxious, fear-
ful, excitable, low-key, or “even-keeled.”

Individuals born with anxious and depressive temperaments may learn

over time to respond to situations with increasing distress. This is where
your child’s anxious or depressive temperament can interact in a negative
way with your parenting practices. When your child is upset, you want to
provide comfort. Parents of anxious or depressed children find that they
provide much more comfort and reassurance than they do for their chil-
dren with more “even” temperaments. They also notice differences be-
tween how they react to their distressed child and how other parents react
to their children. Moreover, parents of distressed children learn over time
that they never seem able to provide enough reassurance or comfort for their
child. The distress continues, the questioning doesn’t seem to end, and the
parent’s frustration level is reached faster and faster with every life event.
This is a paradox: as a parent, you want to comfort your child; because of
your child’s distressed temperament, however, you may never have enough
comfort to satisfy her needs. As a result, you may become resentful or frus-
trated with your child, and you dread the confrontations that result from
her unending or unrealistic needs. Finally, you may feel guilty or inade-
quate as a parent.

You have done nothing wrong. Your child’s school refusal behavior and ac-
companying distress is a result of her temperament interacting with her life
experiences and your desire to be a good parent. In plain terms, there is no
one to blame and no reason to look for blame. Your child has learned over
time to react in certain ways, and you have learned to react to your child
with increasing levels of reassurance and comfort. The key to helping your
child cope with and manage her distress, however, is to stop providing re-
assurance and comfort beyond what you would give to the average child.

Through this program of relaxation training and desensitization, your child

will learn to accept the ups and downs of everyday life. Also, your child will
learn to comfort herself when feeling normal levels of arousal or distress
and to use appropriate coping skills to enter and deal with various situa-
tions at school and home. For your child to succeed in this program, you
should follow the therapist’s feedback. You will learn to provide reassurance
when it is appropriate, and ignore complaints and tears when there is noth-

74
ing real to be upset over or if the distress is excessive. The in vivo desensi-
tization plans are designed to expose your child to what she fears or dreads
and teach your child that she can handle the situation. Your child may be-
come somewhat upset when entering school situations that she has avoided
for a period of time. If you provide too much reassurance, however, and
allow your child to escape or avoid the in vivo desensitization practices,
then she will receive the message that she can’t handle the situation. Only
with experience will your child learn to master these negative emotions.
You have to be prepared to let your child feel some distress until she learns
that nothing is going to happen that she can’t deal with in some way.

Some guidelines for providing reassurance follow.

If your child asks a question, answer one time. If she asks again, remind
her that she knows the answer, but remind her calmly and only once. If
asked again, turn away from your child. Example:

CHILD: When do I have to start going to school?

PARENT: You’ll start on Monday, with social studies class.

(Ten minutes or so pass)

CHILD: Do I have to start going to school on Monday?

PARENT: You know the answer to that question.

CHILD: But, is it this coming Monday, is that when?

(Parent turns away from child. When the child begins to speak about other
topics, or continues on a more appropriate discussion regarding school, the
parent turns back to the child and continues to give attention.)

If your child is going to attempt an in vivo desensitization task that is new or

particularly challenging, direct her to use the relaxation and deep-breathing
skills learned in therapy. Remind your child once about her accomplish-
ments up to this point. Do not dwell on the issue, and do not get into a long
discussion where you are providing too much comfort and reassurance.

CHILD: I don’t think I can stay in school all day. What if I don’t feel
well and want to come home?

PARENT: Why don’t you look over your logbooks and notes from
therapy? Think about all the things you’ve been doing that
you couldn’t do before.

75
 CHILD: Yeah, I know. But that’s different. Dr. Eisen was always
there. Now I have to go all day by myself.

PARENT: It sounds to me as though you should practice your deep

breathing and relaxation some more.

CHILD: But what if I forget to do this in school? What will happen

if I get really sick or something? I don’t know if I should go
on Monday.

PARENT: The plan is set for Monday, and you’re going to go to

school. You know what to do to help yourself, and it’s time
to do it. (Parent turns away)

Give your child attention for appropriate behavior, positive coping, and
practicing the skills learned in therapy. The key is to reinforce your child
when she is sticking with the program and to ignore negative behaviors.

PARENT: Hey, I heard you playing your STIC tape just now. What’s up?

CHILD: Dr. Eisen said I should practice each day, and imagine my-
self going to school for longer and longer times.

PARENT: I’m very proud of you for following what Dr. Eisen says to
do. I know it hasn’t been easy for you. You should feel really
good about yourself, for making yourself to go to school
and do all this work. What are the things that are easier for
you to do now?

(Parent and child continue to discuss progress, and the positive ways the
child has coped with distressing situations. The child gains attention for
talking about her efforts at coping.)

The therapist may ask you to join the sessions to practice ignoring inap-
propriate behavior and to give positive attention for appropriate behavior.
The therapist will also discuss ways you can help your child with the in vivo
desensitization plans.

Homework

Homework assignments after sessions  and  may include the following:

✎ Continue to practice the relaxation tape at bedtime and complete
logbooks.

76
 ✎ Complete STIC tasks that will involve various in vivo desensitization
plans, in addition to imaginal desensitization as needed.

✎ Increase attendance in school over the course of these sessions, with

the goal of having your child attend most of the day, every day.

SESSIONS 7 AND 8 Completing Treatment

By this point in your child’s program, she will be expected to attend school
on a full-time basis. The therapist may have helped your child return to
school by actually going in with her the first few times. It is important that
children who are sensitive to general distress continue to use the relaxation
and deep-breathing skills they learned early in the program. These skills
will prove invaluable when your child confronts a stressor or anxious situ-
ation in real life. The purpose of the in vivo desensitization and exposure
STIC tasks has been to prepare your child for confrontations and to give
her practice in managing emotions during these times. Most importantly,
the STIC tasks have been designed to gradually bring your child to full-
time school attendance and tapered support from the therapist. Your child
is now in the end stages of the transfer of control approach. She should be
taking most of the responsibility for the treatment process and applying
what was learned in real-life situations. If necessary, the therapist will con-
tinue to implement techniques from previous sessions to help your child
achieve this goal.

77
This page intentionally left blank
Chapter 5 Children Refusing School to Escape Painful
Social and/or Evaluative Situations

SESSION 1 Starting Treatment

Many adults can recall when being in a social situation, being the focus of
attention, or being tested or evaluated was accompanied by butterflies,
shaking, or some other indication of anxiety. For most people, these initial
feelings of anxiety disappear quickly, and their ability to perform in the so-
cial or evaluative situation is not impaired. Many people can also recall
times during their school years when being called on in class to give an oral
report, being teased by others, or taking a test would trigger those physical
sensations that signal anxiety. For some children, anxiety in social, per-
formance, and evaluative situations is so distressing that they cannot toler-
ate these situations. Instead, avoidance behavior takes over. If your child
refuses school to escape painful social and evaluative situations, treatment
will involve:

■ Identifying what your child tells himself in anxiety-provoking

situations

■ Changing negative thoughts to coping, helpful statements

■ Graduated exposure to anxiety-provoking social situations in session

■ Practicing skills in real-life social situations

The therapist will spend the majority of each session with your child, but
will invite you to the last part of each session to give your input, review ma-
terial covered, and plan homework. If your child has been avoiding situa-
tions involving other people, such as attending parties, initiating or join-
ing conversations, or talking on the telephone, your therapist will show
you how to help your child enter those situations. Similarly, if your child
has had difficulty with performance or evaluative situations, he will learn
to engage in those situations in a graduated and structured manner. It will
be your task to facilitate your child’s contact with these situations, with the
guidance of the therapist.

79
Psychoeducation

The therapist will begin treatment by explaining to your child the nature
and process of social and evaluative anxiety. Anxiety is divided into three
components: physical (“What I feel”), cognitive (“What I think”), and
behavioral (“What I do”). The following is an example of how a therapist
will explain to a child how the interaction of these components maintains
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. Were you
able to just jump on it and ride away, or did you feel shaky and think you
might fall? Remember how it was to have someone hold on to the seat, to help
you be steady? What did you think would happen if they let go of the seat
and left you to go on your own? Well, with practice, again and again, you
learned to feel comfortable and ride that bike straight and steady. 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. Do you think you would’ve wanted to jump back onto that bike again?
No way! If you tell yourself that something is scary, and that you can’t do
something, then it really feels scary and it keeps you from wanting to try
again. This is the same thing that happens to some people when they have to
give an oral report, or play an instrument in front of other people, or take a
test in school, or even when they try to start conversations. Because they tell
themselves it’s a scary situation, and that they can 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.

Typically, the therapist will draw three circles, each depicting a component
of anxiety, and ask your child to identify his or her own physical feelings,
thoughts, and behaviors when confronted with a social anxiety situation.
The therapist will use cartoons or pictures from magazines depicting youth
in various situations (e.g., standing near a group of children, talking with
an adult), and your child will be asked to describe what the child in the pic-

80
 ture may be feeling, thinking, and doing. In this way, the therapist and
your child can build rapport, understand what provokes anxiety, and under-
stand how your child interprets various situations. The therapist can illus-
trate to your child the process of escalating anxiety, and the opposite pro-
cess of calming or de-escalation.

Building an Anxiety and Avoidance Hierarchy

Using information gathered from the assessment interviews and logbooks,

the therapist will help your child build his Anxiety and Avoidance Hierar-
chy (AAH). The therapist may also ask for your input when building the
AAH. A blank copy is provided in chapter  (page ) for this purpose.
You may photocopy the AAH from this workbook or download multiple
copies from the TreatmentsThatWork™ Web site at www.oup.com/us/ttw.
The AAH lists the objects and situations that the therapist and your child
will target for change over the course of treatment. These are the situations
that the therapist and your child will cover during treatment. Using a Feel-
ings Thermometer (see Figure ., page ) or other measurement scale,
your child will rate his anxiety and avoidance of these situations at each
session.

Figure . shows a sample AAH for a -year-old boy who refused to attend
school due to anxiety about social and evaluative situations. As you can see,
steps on the AAH are gradual so your child can begin with the easiest (or
lowest) item and then progress up to the most difficult (highest) hierarchy
item. This is how your child’s treatment will proceed.

Identifying and Changing Negative Thoughts

Anxiety about social and evaluative situations is largely a result of negative

thoughts or “self-talk.” When anticipating a social or evaluative situation,
your child is likely to focus on what could go wrong, how bad he may look,
or the belief that others will laugh or think badly of him. During these
situations, your child may focus on these negative thoughts instead of how
the situation is really progressing. As a result, anxiety increases and can
overwhelm your child. The therapist will help your child develop a plan to
identify and change these negative thoughts.

81
Problem: School refusal due to anxiety about social or evaluative situations

Anxiety Avoidance
Situations or Places That Scare Me! Rating Rating

1. Starting a conversation with two kids I don’t know well 8 8

2. Going to the lunch room, and sitting with some kids I don’t know too well 8 7

3. Volunteering to read out loud or write on the blackboard 7 7

4. Calling up someone from class and asking about the homework 7 7

5. Raising my hand to answer a question 6 7

6. Giving an oral report 6 6

7. Answering and talking on the telephone when it rings at home 5 4

8. Asking the teacher for help or to explain something 4 4

9. Ordering my own food in the cafeteria or a restaurant 4 4

10. Starting a conversation with someone I know 3 3

Figure 5.1
Mark’s Anxiety and Avoidance Hierarchy

For a younger child, the therapist may use the letters S-T-O-P to help change
thoughts:

S stands for “Are you feeling SCARED?”

T stands for “What are you THINKING?”

O points you toward “OTHER HELPFUL THOUGHTS?”

P is to PRAISE yourself for using these steps, and PLAN for the
next time

Depending on your child’s age and developmental level, the therapist may
rehearse these steps sequentially with your child, focusing on using the
steps in different social situations that may trigger anxious thoughts. How-
ever, it is not critical that your 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 think” when con-
fronting a feared situation.

82
 Figure 5.2
Stop Sign

For an older child or adolescent, the therapist will help him identify “auto-
matic thoughts” (ATs). ATs are negative, unhelpful, anxious thoughts that
seem to happen automatically and focus on what is dangerous or scary
about a situation. In fact, ATs can make a benign situation seem very
frightening. Examples of common ATs are:

All-or-None Thinking: “It must be perfect.” “I can’t do this at all.”

Catastrophizing: “This is the worst thing that can happen to me.”

Can’ts or Shoulds: “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’m going to fail this test.” “Nobody will talk to me.”

Cancelling the positive: (This usually occurs when someone gives a

compliment) “I should have done better.” “This wasn’t my best work.”

In Session , your child will learn to identify his thoughts in those situa-
tions that trigger anxiety. Step  will be to teach your child to recognize the
cues or triggers for his anxiety (focus is on the “S” step). Younger children
will be asked to draw pictures of those things that cause anxiety. Older chil-
dren will be asked to keep a logbook or list of situations that cause anxiety.
You can help the therapist identify these cues by keeping a logbook of
situations where you notice that your child’s avoidance or other behavior is
signaling anxiety. You should keep your list separate from your child’s, and
it is best to not prompt your child or compare lists. The therapist will ask
older children to keep a list of their thoughts that occur when they en-
counter anxiety-provoking situations. The therapist will use this list to help
your child identify how he anticipates and predicts negative events.

83
The Coaching Team

When you are invited into the session, the therapist will have your child re-
view the day’s progress. It will be helpful for you to follow the child through
the process of challenging and changing thoughts so that you can “coach”
your child during tough situations.

A sports team analogy illustrates how to assist your child. Children are told
that they are the “key player” of the team. The therapist is the “head coach”
and the parent(s) is/are the “sideline coaches.” At first, the head coach calls
all the plays. The head coach lays out the STOP plan for changing and
challenging thoughts and sets up the initial role-play exposures to practice
managing anxiety. The sideline coaches (parents) will help the child set up
home-based practices. Also, the sideline coaches will study the plays (STOP
plan) and assist the child as needed. The therapist will instruct you to
prompt your child to use the STOP steps. As the “game” (treatment) pro-
gresses session by session, the head coach will let the “key player” call some
of his own plays. The whole team will assist at first, but as the key player
gets to really understand the plays, he can begin to call them alone. This il-
lustrates the process of helping your child learn the anxiety management
skills and exposure plans, and setting up the initial exposures. However,
with time and practice, your child will assume greater responsibility for his
own therapy.

Homework

Homework assignments after session  may include the following:

✎ You and your child should keep a log of situations that cause your
child anxiety.

✎ Continue to complete the daily logbooks (see chapter  for blank

logbooks). Note any specific situations or experiences that arise dur-
ing the week.

84
SESSION 2 Intensifying Treatment

In this session, the therapist will begin with a continued focus on your
child’s self-talk. Specifically, he or she will teach your child to identify and
dispute negative, unhelpful thoughts. The therapist will use behavioral ex-
posures to prompt your child’s anxiety reactions and then his use of cop-
ing self-talk skills. In a behavioral exposure, the therapist and your child
will role-play an anxiety-producing situation, such as starting a conversa-
tion with someone in the cafeteria. The purpose of this role-play is to prompt
your child to experience anxiety and to identify his negative thoughts that
perpetuate the anxiety. The therapist will then help your child dispute
these thoughts. Moreover, behavioral exposure will allow your child to
practice gradually entering those situations that cause anxiety; therefore, he
can gain experience with approach and mastery of these situations. Real-
life (in vivo) practice in entering these situations will occur between ses-
sions, with your assistance. These home-based practices are called “Show
That I Can” or STIC tasks. The therapist will help you set up and conduct
these STIC tasks.

Challenging and Changing Negative Thoughts

The therapist will review the past week with your child and focus on iden-
tifying the triggers of his anxiety, as well as corresponding negative
thoughts and images. Using a chalkboard or flip chart, the therapist will help
your child identify his specific patterns of arousal and negative thoughts.
The following is an example of dialogue that may accompany this exercise
(T stands for Therapist; C stands for Child):

T: So, one of the things that happened last week was that you walked
out to the playground, and a bunch of kids were already playing a
game. This made you nervous?

C: Yeah, I was upset.

T: Okay, so the “trigger” was seeing a group of kids playing a game.

Let’s write that up here on the board, and call it the trigger. Okay,
so think about what was going on right before you saw the kids.
You were walking out of the school, headed toward the playground.
What were you thinking?

85
 C: I don’t know. I wanted to go out and play.

T: Okay, so you wanted to go play. Did you think about what game
you wanted to play, or who you might play with?

C: Yeah, I thought I’d play tag with my friend Bethany. I was looking
for her.

T: Okay, and how were you feeling right then, before you got out onto
the playground?

C: I wanted to play, and was glad that it was recess. I felt happy.

T: Then you saw the kids playing together. What did you notice then?

C: Bethany was out there with a bunch of kids. I got nervous.

T: All right, that’s the “S” in STOP. Let’s put that on the board. When
you say that you saw Bethany with a bunch of kids, that’s when you
first noticed you were scared. Now, what were you thinking?

C: I don’t ever really play with those kids. Bethany may not want to
play with me. What if they don’t want to play with me? (The thera-
pist writes these thoughts on the board under “T.”)

T: Okay, let’s look at these thoughts that you are having. One at a time
we’ll look at each. Start with “I don’t ever play with those kids.” Do
you remember back before you used to play with Bethany? Before
you knew her?

C: Yes, in first grade.

T: Were you afraid to go and play with her, when you first saw her?

C: A little. But we started playing together. And it was okay.

T: So once you started playing together, you were less and less scared?

C: Yeah, I wasn’t scared of her anymore. We became friends then.

T: Right! There’s always a time when we haven’t done something, but

once we do it, it gets easier. So, what other things can you say to
yourself instead of “I never play with those kids”?

C: Well, I haven’t played with them before, but I could get to play with
them and know them. (The therapist writes these thoughts on the
board under “O.”)

86
 Other, helpful
Trigger Scared? Thoughts? thoughts? Praise!

Recess Seeing Bethany I don’t ever play I haven’t played This is a good plan
playing with a with them. Bethany with them before, for me!
bunch of kids may not want to but I could try and
play with me. get to know them!

What if they
don’t want to play
with me?

Figure 5.3
STOP Example

T: Great! That’s a really helpful thought, and gives you a good plan for
what to do.

The therapist will lead your child through each negative thought and ask
about his experience with similar situations. This process will teach your
child to examine the evidence for these thoughts and to dispute the
thoughts with rational, realistic thinking. The following questions (termed
“dispute handles”) are commonly used to refute anxious thoughts:

■ Am I % 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?

The therapist and your child will go through several examples of “STOP”
to practice challenging and changing these negative thoughts. This will
prepare your child for the next section of the session, behavioral exposure.

87
Tracking Anxiety During Behavioral Exposure

Prior to the start of your child’s role-play, the therapist will ask for a rating
of anxiety. This is your child’s best estimate of how nervous or anxious he
feels. The therapist will ask your child to rate his level of anxiety using the
Feelings Thermometer or other measurement scale. Anxiety ratings will
then be taken every minute during the behavioral exposure role-play. Most
behavioral exposures last  to  minutes. The therapist will record your
child’s ratings throughout treatment. Also, prior to the exposure, the thera-
pist will ask your child to define several very specific goals for the exposure.
These goals will be concrete, observable, and attainable behaviors or ac-
tions that your child will work toward performing. For example, in an
exposure focused on starting and maintaining conversations, a child may
have the following goals:

■ I will introduce myself and say hello.

■ I will ask two questions.

■ I will look up and make good eye contact during the conversation.

The therapist will also keep track of whether your child meets these goals
during the exposure role-play. After the role-play, the therapist will discuss
with your child how he feels, and whether he thinks the goals were met.
Using graphics on a flip chart or board, the therapist will present your
child’s anxiety ratings and put up the “score” for each goal. At this point,
the therapist will process the exposure with your child, focusing on his be-
havior, whether the anxiety interfered with performance, and whether your
child was able to use the STOP procedures to change any negative thoughts.
They will then discuss strategies for building on the successes and over-
coming any trouble encountered during the exposure. The main lesson in
this process is that practice helps and that anxiety will naturally go away as
your child learns to focus on the situation instead of his feelings.

Initial Behavioral Exposures

The therapist will help your child choose a relatively easy situation from his
AAH. Through role-playing, the therapist and your child will create the
situation in the session, allowing your child to practice the STOP proce-

88
dures. Behavioral exposures serve several purposes in your child’s treatment.
They allow him to practice anxiety management skills while approaching
and engaging in situations he normally avoids. Instead of responding to
normal levels of anxiety and trying to escape or avoid, your child will learn
to tolerate normal rises in anxiety and allow these feelings to go away natu-
rally while remaining in the situation. Behavioral exposures allow your child
to gain mastery and control over his anxiety reactions.

Another way of understanding the therapeutic process involved in behav-

ioral exposures is to think about a social situation that would cause anyone
to feel anxious. For example, if you imagine yourself back in school, think
about the thoughts that might go through your mind as you wait for the
teacher to call on you to give an oral report. Anyone who has given an oral
report can recall butterflies in the stomach, sweaty hands, shaky voice, and
sweating. As the teacher calls each of your classmates to talk, you wait for
your turn, look at the clock, and think, “I hope I don’t have to go today;
Hurry up and ring the bell; What if I don’t know what to say?” If the bell
rings and class ends before your turn, recall what happens to the feelings
and thoughts of anxiety. They typically go away immediately. This imme-
diate relief serves to reinforce anxiety in the long run, and for those indi-
viduals who are prone to being anxious, the pattern of escape or avoiding
anxiety can begin. For these people, at the next initial sign of anxiety (e.g.,
butterflies or a “What if ” thought), they are more likely to want to avoid
the situation (e.g., stay home with complaints of being sick) or escape (e.g.,
leave school sick). However, those people who attend the next class and sit
waiting for their turn are likely to gain experience with the situation and
learn a different lesson.

Recall what actually happens when giving an oral report. Although anxious
at first, over time people learn that the initial rise of sensations goes away
by itself. These are temporary feelings that anyone can experience when an-
ticipating something or getting “psyched up” to do an activity. Moreover,
with repeated experience and talking with peers and family members,
people learn that everyone feels these things at times, that these thoughts
and feelings are normal, and that, in spite of these feelings, they can still
perform and master the task.

89
Processing Exposures

Throughout the course of treatment, the therapist will give your child feed-
back about what happened to his anxiety during the exposure practices.
The therapist will illustrate the process of mastering anxiety and negative
feelings by drawing graphs or diagrams of the child’s anxiety ratings over
the course of each practice. This will show how the anxiety dissipated with
each succeeding exposure.

If your child’s anxiety ratings do not readily habituate (go down), the
therapist will process with your child what thoughts he may be having dur-
ing the exposure. For especially troublesome or negative thoughts, cogni-
tive restructuring procedures will continue to be used. These procedures
will increase your child’s ability to identify and change negative thoughts.

Setting the Pace of, and Assistance With, Exposures

There are several ways to conduct practices to set the pace of role play (and
later in vivo) exposures. Gradual exposure occurs at a relatively slow pace
set by the therapist and your child. The therapist will set a slower pace for
younger children, those with special needs, and those with exceptionally
high levels of anxiety. The rationale for moving slower is to allow the child
to fully handle anxiety, over-learn the plan of confronting the stressor,
and build the child’s trust that he will not be forced into something over-
whelming.

In assisted exposure, either you or the therapist performs the exposure with
your child. Your child can learn by example and feel supported when over-
coming his anxieties. A careful balance must be struck between modeling,
where you show the child how to manage the situation, and rescuing, where
you take over and manage the situation for your child. Modeling and as-
sisted exposure keep the focus on your child. The goal is for your child to
confront the stressor and manage the situation himself. Typically, the thera-
pist first models for your child how to deal with the situation while your
child observes. Next, the therapist helps the child manage the situation.
The child and therapist (or you) then engage in the situation as a team.
Next, the child manages the situation on his own, with words of encour-
agement from the therapist or parent. Finally, the child engages the situa-

90
 tion on his own while verbalizing self-reinforcement for performing the
exposure.

Homework

Homework assignments after session  may involve the following:

✎ Continue to complete the daily logbooks and have your child write
down his thoughts during anxiety-provoking situations. Following
the STOP model, your child will be required to identify and change
his negative thoughts.

✎ The therapist will ask your child to practice in real life the situation
role-played during this session (STIC task). Your child will be re-
quired to practice at least three times prior to the next session. For
example, if his difficulty involves calling a classmate on the tele-
phone, the assignment will be to call a classmate three times during
the week. Your child will also be asked to record an anxiety rating
immediately prior to, and immediately after, this exercise. You are
encouraged to talk with your child after each practice, much like the
therapist would during a session, and focus your child on what really
occurred during the practice and what happened to the anxiety.
Praise and encourage each attempted and completed practice.

✎ Beginning with the next school day after this session, wake your
child about  to  minutes before school is scheduled to start and
follow the normal school-day routine. Follow this routine as closely
as possible. Your child should do schoolwork and read school-related
books if he stays home.

SESSIONS 3 AND 4 Maturing Treatment

In Session , the therapist continued to help your child examine and change
negative thoughts. In addition, your child practiced role-plays (behavioral
exposures) of troublesome situations. Sessions  and  will begin with a re-
view of your child’s STIC tasks and a discussion of any difficulties in con-
ducting and following through with the homework. The therapist may de-

91
 cide to role-play any difficulties encountered by your child since the last
session, including any troubles that may have occurred during the STIC
exposures. The main focus of these sessions will be to prompt your child
to confront more challenging social situations. Again, this will be enhanced
by role-playing these situations with the therapist. To facilitate your child’s
examination and alteration of negative thoughts, and to reinforce coping
with difficult situations, the therapist will make these role-plays more diffi-
cult for your child. In other words, rather than role-playing “perfect”
scenarios, your child will be challenged with situations where the outcome
is less than desirable, and where he will have to cope with rising levels of
anxiety.

Review of the Past Week

The therapist will review your child’s progress in conducting the previously
assigned STIC tasks. In particular, the therapist will look for any signs of
avoidance, escape, or otherwise inappropriate management of these situa-
tions. If your child did not complete any of the assigned tasks, the thera-
pist will ask your child to recall and discuss the thoughts that were going
through his mind. Using the STOP procedure, the therapist will help your
child examine which “thinking traps” may have interfered with carrying
out the STIC task.

If your child did not complete any of the assigned STIC tasks, the thera-
pist will help your child process his avoidance of the tasks. The therapist
will continue to help your child challenge the negative thoughts that pre-
vent him from confronting these fears. The therapist will review the dis-
pute handles used to question your child’s thoughts, and your child will
practice questioning and changing negative thoughts. If your child has
completed the STIC assignments, the therapist will examine any difficul-
ties, successes, or other issues with the goal to reinforce compliance with
the homework. In doing so, the therapist will focus your child on what it
feels like to actually complete the STIC task, what actually happened, and
how the child coped with the situation.

92
Stepping Up the Behavioral Exposures

The therapist and your child will continue to focus on practicing entering
anxious social situations. New and more challenging items from your child’s
AAH will be constructed in these sessions. The therapist will begin to pre-
sent your child with more difficult and anxiety-provoking situations as ap-
propriate. For example, on Mark’s AAH (see Figure .), item  is giving an
oral report in front of the class. The therapist is likely to uncover a variety
of negative thoughts for this situation:

■ What if I stutter?

■ What if someone starts laughing at me?

■ I may not know what to say.

■ Suppose I can’t read a word?

■ Suppose I mispronounce a word? I’ll look stupid.

For this behavioral exposure, the therapist will want Mark to give an oral
report and actually experience some of these anxious scenarios. The pur-
pose of doing a less-than-perfect job, or having the situation go wrong in
some way, is to help your child tolerate undesirable consequences. After all,
no one can control what other people think or do, or always be in control
of everything. Anyone may stutter, shake, mispronounce a word, forget or
lose his or her place, or otherwise “mess up” during a presentation. Through
practice, your child will learn that things are usually less than perfect, and
that it is normal for situations to go this way.

For Mark’s behavioral exposure, the therapist will likely set up the follow-
ing situations to challenge his negative thoughts and provide him with ex-
perience in coping:

What if I stutter? What if someone starts laughing at me?

Mark will be asked to give an oral report in front of the therapist and pos-
sibly some assistants. During the talk, he will be prompted by the therapist
to stutter several times. Each time, an assistant will laugh, look away, roll
his or her eyes, lean over and talk to another person, or otherwise do some-
thing each time he stutters. Mark’s goal for this situation will be to con-
tinue to read the report, no matter what the audience does. Following the
exposure, the therapist will help Mark process the exposure in various

93
 ways, focusing on how anxious he felt and how he actually performed; how
bad the outcomes really were; what other possibilities could account for the
audience behavior (e.g., people were laughing at something they read; they
were tired; they weren’t being nice).

I may not know what to say. Suppose I can’t read a word? Suppose I mispro-
nounce a word?

During another practice, Mark will be given a report to read that contains
difficult words (probably technical or scientific words). The goal of this ex-
posure will be to have Mark actually “mess up” and be unable to pronounce
some words. The audience will initially pay attention and listen to the talk.
However, with repeated exposures, the audience will again act disinter-
ested, snicker, or otherwise display various behaviors indicating that they
are not following Mark’s talk. The therapist will help Mark cope with and
master this situation.

Processing the More Challenging Exposures

The therapist will spend considerable time with your child examining the
thoughts and behaviors that occurred during these behavioral exposures.
Many children quickly come to understand that it is normal to make mis-
takes or to be embarrassed or uncomfortable, or for other people to be less
than nice at various times. These children recognize that their discomfort
is momentary and that, in spite of being anxious or slightly embarrassed,
in the long run they will be fine. However, some children can be hard on
themselves. These children push for situations to turn out perfectly, and it
is much more difficult for them to tolerate anything less than perfect. They
are anxious about embarrassment, rejection, or humiliation, and their over-
riding thought is that “No one will like me or want to be around me.”

To process the exposure, the therapist will take your child through a sce-
nario step by step. At each point, the therapist analyzes your child’s thoughts,
anxiety ratings, and actual performance behaviors. For example, imagine
an exposure where a young girl is to start and carry on a conversation with
a peer. The child reports feeling anxious because “I may not know what to
say; she may not like me; what if I say something stupid?” During this ex-
posure, the child meets all of her goals: She introduces herself, asks three
questions, maintains eye contact, and smiles. However, her anxiety ratings

94
remain high throughout the exposure. This indicates continued high anxi-
ety. Following this exposure, the therapist processes the situation:

T: Okay, Stacy, look at your goals. Seems that you met every one. In
fact, instead of asking three questions, you actually asked five. What
do you think about that?

C: Well, I guess I did okay on that, but I just didn’t feel good.

T: What were you thinking about while you were doing this practice?

C: I just kept thinking I was messing up. I thought I looked stupid.

T: Take a look at these goals. How did you mess up? What did you do
that was so bad?

C: I don’t know. I thought I wasn’t talking enough.

T: But you actually asked more questions than you had hoped. And I
counted that you answered all five of the questions that were asked
of you.

C: I did? I didn’t realize that.

T: The point is that even though you felt nervous, you were doing fine.
You were asking and answering questions, and having a real conver-
sation. Can you see that?

C: I kept telling myself I wasn’t doing well.

T: A-ha! So, even though you were doing everything you wanted to,
you kept those negative thoughts coming. Do you realize what kind
of negative thought that is?

C: Canceling out the positive. Even though I was doing okay, I was
telling myself I was doing bad.

T: That’s it. You’ve got to let yourself focus on what you’re doing, and
feel better about that. Let’s try it again.

For children who are particularly hard on themselves, a “role-reversal” prac-

tice may prove helpful. In this situation, the therapist probes for what the
child is most anxious about in a social situation. A typical example is a
child who is anxious about eating in front of others because he is afraid of
being watched and laughed at if food spills, or of being asked a question

95
 while having food in his mouth. Usually, the therapist begins by asking the
child if he has ever noticed any other child in this situation.

T: So, you’re concerned that if you spill your drink on your shirt, the
other kids will laugh and make fun of you.

C: Yeah, I’ll look stupid.

T: And if you look stupid, then what will happen?

C: Kids may start to tease me, and I’ll feel terrible. Then I won’t want
to go to school anymore.

T: Let me ask you something. Have you ever seen anyone else spill a
drink?

C: I don’t know. I guess so.

T: Now really, think hard. Who was the last kid you saw spill some-
thing?

C: I don’t remember.

T: Okay, let’s try this. Have you ever seen another kid in school
throw up?

C: Yes. Yuck.

T: Okay, so throwing up is really yucky, worse than spilling a drink,

right?

C: Yes.

T: Okay, so who was the kid that threw up?

C: The last one was Maggie. She threw up in the hallway.

T: Okay, anyone else that you remember throwing up?

C: Michael did it once. In second grade.

T: Okay. Do you ever play with Maggie or Michael?

C: Yes.

T: Why do you play with them?

C: Because they’re nice. They’re my friends.

96
 T: But, these two THREW UP! Yuck! Don’t you think they’re gross
now?

C: No, they’re my friends. They’re nice. So what if they threw up? It

happens to a lot of kids.

T: Yeah, I guess it does. But, why do you still like them? What they did
is worse than spilling stuff.

C: Well, just because they were sick and threw up is no big deal. They
couldn’t help it. They’re still really nice and fun.

T: So, if you went to the cafeteria, and spilled some milk, wouldn’t you
STILL be fun? And still be nice? Wouldn’t it be just like if some
other kid did something, no big deal?

C: What?

T: You seem to be really hard on yourself, but you’re okay with your
friends making mistakes, or getting sick, or throwing up or spilling
things. If you still like other kids who do things, don’t you think
they would still like you if you spilled something?

C: Oh, yeah. You’re right. I guess that’s right.

The therapist may then construct an exposure where the child interacts
with those who have spills on their shirts, and carries on conversations
while someone spills more drinks or food. The child may even be encour-
aged to spill on himself to gain the experience of making mistakes in front
of others. The point of these exposures is to illustrate that discomfort is
temporary, and that most people’s reactions are also temporary.

Homework

Homework assignments after sessions  and  may involve the following:

✎ Continue to complete the daily logbooks and have your child write
down his thoughts during anxiety-provoking situations. Following
the STOP model, your child will be required to identify and change
negative thoughts.

✎ The therapist will ask your child to practice in real life the situation
role-played during this session. Your child will be required to practice

97
 at least three times prior to the next session. Your child will also be
asked to record an anxiety rating immediately prior to, and immedi-
ately after, this exercise. Talk with your child after each practice,
much like the therapist would during session, and focus your child
on what really occurred during the practice and what happened to
the anxiety. Offer praise and encouragement for attempting and/or
completing each practice.

✎ Continue to implement the normal school-day routine and adhere to

it as closely as possible. Your child should do schoolwork and read
school-related books when at home during the day.

SESSIONS 5 AND 6 Advanced Maturing of Treatment

Sessions  and  will involve helping your child progress through the main
portion of his AAH. Through role-playing and new real-life exposures, the
therapist will help your child enter and stay in those social and/or evalua-
tive situations that he is anxious about and avoids. A major focus of these
exposures will be to elicit your child’s negative self-talk and help your child
challenge and change these thoughts. In these sessions, your child will con-
tinue to practice changing thoughts to a coping focus. The therapist will
spend time role-playing and modeling for your child the process of cogni-
tive restructuring (changing thoughts). You may be invited to attend these
sessions to observe the therapist and become better at coaching your child
in using these cognitive strategies. The degree of your involvement will
likely depend on a combination of factors, including the severity of your
child’s school refusal problem, his age and developmental level, and any
special needs that he may have. Moreover, if your child’s motivation is not
strong, the therapist may enlist your help in finding appropriate incentives
to reward your child for doing the therapy work.

Because your child has been refusing school due to anxiety in social and
evaluative situations, it will be necessary to involve other people if the
treatment is to be successful. For example, you may have your child’s peers
come to your home for a play date. This will give your child an opportu-
nity to practice conversation and related social skills. For the most part,
other children or adults don’t need to know that your child is testing his
new coping skills or working on a personal problem. However, you may

98
 need to inform your child’s teacher about certain exposures or situations
that your child will be facing. Examples include speaking up more in class
or asking the teacher for help.

If your child has been shy or quiet, it is possible that other people have
come to expect less interaction with him. Therefore, the therapist will in-
form you what to tell the teacher to facilitate your child’s progress in try-
ing new social behaviors. Also, your child will need to be gradually exposed
to various social/evaluative situations outside of school. If you have been
speaking for your child in public places, such as restaurants or stores, the
therapist will help you “step back” and coach your child to speak for him-
self. It is not unusual for parents of adolescents with social or evaluative
anxiety to comment on typical teenage things that their children are not
doing (e.g., ordering food in a restaurant, answering or talking on the tele-
phone, paying for their own purchases at the mall). The involvement of
other people and a variety of social situations will be the focus of your
child’s STIC tasks throughout the remainder of treatment.

Realistic Thinking

The therapist will begin each session discussing your child’s progress in fol-
lowing through with the weekly STIC tasks. This will allow the therapist
to evaluate your child’s ability to identify and challenge negative thoughts.
As your child’s skill in using cognitive change techniques improves, he will
develop greater tolerance for approaching and staying in challenging social
or evaluative situations.

In the s, the popular press and pop psychology movement promoted
the concept of “positive thinking” as a way to overcome negative and dis-
tressing emotions. Positive thinking entails repeating thoughts to oneself
such as “I can do this,” “I’m smart,” and “I’m a good person” to neutralize
negative thoughts. Research and clinical experience explain why some
people never get better through the use of positive thinking. Positive think-
ing has been shown to actually interfere with focusing on and accomplish-
ing a task. In fact, children who are anxious about tests actually do just as
bad or worse when given positive statements such as “I’m smart, I can do
this.” Positive thoughts don’t provide any real information or coping solu-
tions for the child to rely on and use in a given situation. During a test, for
example, a child can become so focused on trying to convince himself that

99
 “I am smart” that concentration on the actual task is disrupted. As the
child recognizes that the task is not getting completed, his levels of frus-
tration and physical tension increase. This sets into motion the cycle of dis-
ruptive physical sensations, thoughts, and behaviors, each reinforcing the
other and making the situation worse. In this case, “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 think-

ing is the predominant style of thought used by well-adjusted individuals.
Healthy thinking is characterized by realistically examining the situation
and the resources available to manage a given situation. Healthy thinking
is reality-based, focused on problem-solving and task management, and
characterized by adaptive thoughts. By this point in your child’s program,
the therapist has helped your child use the STOP program or similar cog-
nitive restructuring techniques to uncover irrational or negative beliefs (the
“S” and “T” steps). Your child has practiced changing these negative
thoughts to more realistic and adaptive coping statements (the “O” step
that involves the use of dispute handles). Role-plays and behavioral expo-
sures give your child opportunities to test his thoughts and gather evidence
that he can cope with anxious situations. Continued exposure to challeng-
ing situations will give your child evidence to refute and change negative
thinking.

Trials of Childhood: Examples of Social/Evaluative Exposures and Restructuring

Children and adolescents with social anxiety may be anxious about a wide
range of situations involving other people, tests, oral presentations, or
sports or musical performances. If your child’s social anxiety is focused on
only one type of social situation, it is considered “non-generalized.” This is
the case with individuals who are otherwise fine but become extremely
anxious when having to give a talk in front of others. Many children and
adolescents, however, are anxious about many social situations. This is
called “generalized” social anxiety. It is normal for social anxiety to increase
as a child enters adolescence. However, for children more prone to experi-
encing this type of anxiety, adolescence can be an even more difficult and
distressing stage of life. The therapist will construct more challenging ex-

100
 posures during this phase of treatment so that your child will be encour-
aged to use his cognitive restructuring skills more readily. Preparation for
each exposure is the same: your child defines several concrete goals, identi-
fies his negative or automatic thoughts, and provides a rational alternative
thought for each using dispute handles. Following each exposure, the
therapist will help your child develop a healthy thinking style. Below are
examples of exposures and cognitive restructuring procedures for different
social anxieties.

Example 1: Tackling Test Anxiety

In exposures conducted for test anxiety, the therapist will administer tests and
quizzes to your child. The therapist may request sample tests from your child’s
teacher or develop tests based on your child’s current schoolwork. The exposure
will manipulate a number of situations that your child is likely to encounter,
such as being timed, having multiple-choice or essay questions, and being sur-
prised with a “pop” quiz in therapy as opposed to a planned quiz. A typical post-
exposure processing follows:

T: Okay, so what happened during this test?

C: I got only  out of . I knew I’d bomb that test.

T: You do well in math; tell me the percentage that you got on this
quiz.

C: Eighty. I only got an .

T: What is the worst thing that could happen with an  on a test?

C: I could fail the subject, and then I’d fail in my other subjects too.

T: Let’s take one thing at a time. Tell me, is  percent a failure?

C: No, but it’s only a B.

T: Wow, what kind of thought is that, “it’s only a B?”

C: (Looks at list of thought labels) Oh, I just disqualified a positive.

Okay, I did better than a C.

T: So, rephrase that thought. What’s really going on with a B?

C: Okay, I got a B, and that’s a passing grade.

101
 T: Okay, and tell me, have you ever failed a test before?

C: No, but I did get a C once.

T: And?

C: A C is still passing.

T: Okay, so have you ever failed a subject before, because you got a C
or a B?

C: No.

T: So, how likely is it you would fail the test and then fail the subject?

C: Well, it could happen.

T: Do you study for your tests?

C: Yes.

T: What else do you do to prepare for your tests?

C: I do my homework.

T: Okay, so tell me realistically, how likely is it you would fail the test
and then fail the subject?

C: Okay, it’s really not likely I’d fail the test.

T: Why, what is the evidence saying you wouldn’t fail? Put it all
together.

C: It’s not likely I’d fail, because I do study and I do all my homework.

T: Give me a percentage for how likely it is from  to  percent.

C: Well, it’s really only maybe a % chance.

T: What’s really the worst thing that could happen?

C: I could get a B in the class, but that’s not failing.

The therapist will give repeated test simulations to your child, each fol-
lowed by the cognitive restructuring steps outlined in STOP. The therapist
will emphasize examining the evidence for your child’s anxiety and looking
realistically at potential outcomes and their consequences. Some children
are anxious about tests because of certain learning disabilities or because
they do not do well on tests. The focus of this treatment is on managing

102
 anxiety that can develop due to a history of poor performance. In cases of
true learning problems, a therapist may coordinate treatment with a tutor
or special education teacher so the child with special needs can manage
anxiety and then benefit most from appropriate academic services available
to him.

Example 2: Standing Up to Shyness

Some shy or quiet children who worry about what other people think may
be at risk for developing clinical levels of social/evaluative anxiety. Shyness
is generally accepted in our culture as a normal variant of one’s personality.
By itself, it is not a problem. However, for the child who shrinks away from
making friends, is unable to speak up for his own needs, or is otherwise un-
able to warm up to people, shyness is so extreme that it is problematic. It
is also unfortunate that shy or quiet children are often overlooked as teach-
ers struggle to teach in overcrowded classrooms. Children with extreme
shyness often suffer with overwhelming anxiety before others recognize the
need to help them. The focus of a shy child’s exposures will not be to re-
make that child’s personality. This is important to understand: Your child
will not become someone he doesn’t want to be. There will be no radical
change in your child’s temperament or personality. Instead, by addressing
social anxiety in treatment, your child will be more relaxed in social situa-
tions. Your child will be able to make decisions about what he wants to do
based on his preferences, and not because of overriding anxiety about re-
jection, embarrassment, or incompetence.

Exposures for shy children and adolescents will involve interactions with
different people in different situations: starting conversations in the cafete-
ria, calling a classmate for missed homework, asking a question in class,
joining a group of kids who are already playing together, asking someone
to stop doing something annoying, saying “no” when desired. The follow-
ing is an example of helping a child question the evidence for anxiety about
what other people think of him:

T: What is the hardest thing about school for you?

C: I guess the other kids.

T: What is it about the other kids that bothers you?

103
 C: I don’t know. I don’t think they really like me.

T: Why do you think that? What happens with the other kids?

C: No one really talks to me. I have no friends, and I don’t have anyone
to sit with in the cafeteria or at recess.

T: Have you ever tried to talk to the other kids?

C: Yes.

T: When was the last time you tried?

C: I don’t know . . . it was a while ago. Maybe last year.

T: Well, then it sounds like you’ve given up trying to talk to others.

C: It’s no use. I’m afraid of them not liking me, I know they already
don’t like me.

T: Wait, let’s look at what’s really going on. You may have tried last
year. But this year you haven’t at all, have you?

C: No.

T: What are some of the reasons why the other kids don’t talk to you?

C: Because they don’t like me, I told you that. They all know each
other and they’re all friends.

T: First, tell me what kind of a thought is, “Because they don’t like me”?

C: It’s mind reading, or maybe fortune telling. I know, I’m predicting

that they don’t like me, but I really can’t know what they think.

T: That’s right! What evidence do you have, besides the fact no one has
tried to talk to you recently, that they don’t like you?

C: Well, none really.

T: So, what other reasons may there be for the kids not talking to you?

C: I don’t know, I guess because I don’t try to talk to them.

T: Maybe. Where do you usually hang out during lunch or recess?

C: I just stay in the classroom, or go to the library.

T: So, is it fair to say you don’t even go near the other kids?

104
C: Yeah.

T: So, what evidence is there they don’t like you?

C: None.

T: And what else may be going on?

C: Well, maybe because I don’t hang around the other kids, and don’t
go talk to them, that’s why they don’t talk to me. But it’s so hard!
What if I don’t know what to say?

T: Okay, right. One thing at a time. Remember, slow down that tape
of automatic thoughts in your mind, and dispute one thought at a
time. Maybe the other kids don’t talk to you because you’re not
hanging around the cafeteria or recess area. Maybe they don’t have
a chance to talk with you.

C: Yeah, I can see that.

T: Okay, and, because you haven’t done this in a while, it’ll be hard.
Trying to talk with someone is hard if you’re out of practice. But,
you also said, “What if I don’t know what to say?”

C: Yeah, then there will be some stupid silence, and I’ll look like a jerk.

T: Oh, but if the other kid doesn’t talk, will he look stupid?

C: What? No . . .

T: So, why would you look stupid if you were quiet for a moment? Let
me ask you something. How many people does it take to have a
conversation?

C: I guess at least two.

T: Yes. So, in a conversation with two people, and you being one of
them, how much of the conversation are you responsible for?

C: Um, just half of it.

T: That’s right. You’re only responsible for  percent of the conversa-

tion. The other person is also responsible. So, if there’s silence, it’s
not just because of you, but also because of the other person. Right?

C: Yeah, that’s right.

105
 T: So, what can you do to prepare yourself to start a conversation with
someone?

C: Well, I guess I’m only responsible for half of the conversation. And,
if I haven’t talked with this person, it may be hard at first. I guess I
have to try it, and make myself hang around where the other kids are.

T: Good going.

Shy children need repeated experience with conversations and placing

themselves around other people. The therapist will focus on increasing
your child’s ability to physically place himself closer to peers, as well as on
improving conversational and social skills. The therapist will continuously
challenge your child’s dysfunctional attitudes and beliefs as your child
gathers new information about social situations and about being the focus
of attention.

Example 3: Overcoming Gym Jitters

Performance-based subjects or activities are likely to cause jitters for many

children and even adults. The child prone to social anxiety, however, may
be even more anxious about performance-based activities and develop a
strategy of avoidance to inappropriately manage this problem. If you have
noticed your child complaining of stomachaches or illness on gym days, or
if his guitar suddenly snaps all its strings right before the annual recital, you
may suspect high levels of social anxiety. Children who refuse to attend
school due to performance-based anxieties will try to avoid these situations
at all costs. Or, they may endure the situation with great distress and then
drop out of the activity or class at their first chance. The following dialogue
illustrates the main concerns of an adolescent who refused to attend school
due to performance anxiety:

C: Going to gym was the main problem. I just couldn’t stand it when
everyone laughed at me. I can’t do sports. I’m always picked last for
everything. It stinks.

T: Tell me more about gym class. I want to know who’s in your class
and the activities you have to do.

C: All the guys from my homeroom are there. They’re all jocks, every
one of them. We started out doing basketball. What a joke. I never

106
 played before. Then we had to play football. I was so bad in basket-
ball that no one picked me for football. The coach had to put me on
a team.

T: Let’s break this down. All the guys in your gym class were jocks?
That means that every single one of them played on a team sport at
your school?

C: No, not everyone. Most of them.

T: How many kids are in that class, and how many are on teams?

C: All right, so there’s  guys in the class, and maybe  play on the
school teams. But that’s a lot.

T: Okay, and of those  guys who were not on the teams, they were all
total jocks too. Is that what you’re telling me?

C: No. My friend Brian wasn’t too good at anything either. But every-
one likes him. He got picked before I did for the teams.

T: So, Joey, tell me this, when you go to gym, what do you do? When
you first get to gym class, what are you likely to do?

C: I have to change. And I hate to change in front of those guys. So I

go into the bathroom to change.

T: What are the other guys doing?

C: They’re hanging out and fooling around with each other, waiting for
the coach. They all get along. It’s hard to go back in there.

T: Tell me about changing in front of the other guys. What bothers

you about that?

C: Well, it’s hard to say. I don’t want to be laughed at. I don’t lift
weights or anything. They tease the skinny guys and the guys who
are fat, and I don’t want to be teased for being a runt.

T: It’s not fun getting teased, if it’s intended to hurt you. Teasing can
also be just for fun and joking around, like among friends. Is it re-
ally hurtful, or just joking?

C: I don’t know. Maybe a little of both. The guys who get teased seem
to handle it okay. I just don’t want to blush and make it worse.

107
 T: Okay, so here’s a few things to think about. You worry about look-
ing different than others, because you don’t lift weights. And you
worry about blushing if you’re teased. Ask yourself, how many of
those  guys lift weights, look perfect, and don’t blush at times
when they are teased?

C: Well, okay, not everyone’s a jock. They aren’t perfect either.

T: What makes the difference between those guys and you?

C: They let it happen. They go in and change in front of the jocks, and
get called names.

T: And then what happens?

C: I don’t know. Not much, I guess.

T: Do these guys get left out of the games? Are they great athletes, de-
spite their size and shapes?

C: No. It’s over pretty quickly. They don’t really seem to be bothered.
And they play everything, even the ones who aren’t so good at
sports.

T: Okay, so these guys stay with the situation. You’re going into the
bathroom, so you separate yourself from the beginning. When you
come out changed, then what do you do? Do you go and hang
around the guys?

C: No. I usually read a book until the coach tells me I have to do some-
thing. I try not to talk to anyone.

T: Oh. Hmmm. Why do you do that?

C: So no one will talk to me. So maybe they’ll forget about me and I

won’t have to play the sport.

T: Then, is it possible that the other guys pick you last because you’re
sitting on the side, reading or trying to not be noticed?

C: Yeah, it’s possible.

T: And, is it possible that if you tried to hang around a little more, that
the other guys might start picking you sooner?

C: Sure, anything is possible.

108
T: Let me ask you this. You don’t like all sports, right?

C: No, I like to play tennis. I just don’t like basketball and football.

T: Oh. Do you get to play tennis in gym class?

C: Yeah, but not until the spring, and only for  weeks.

T: Oh. And are these jocks good at tennis, too?

C: No, especially the bigger guys.

T: So, is it fair to say not everyone can be good at everything?

C: Yeah.

T: And when those big jocks mess up on the tennis court, does anyone
tease them?

C: Yeah, their friends laugh about it.

T: Okay. So, let’s sum this up. Not everyone has a great body, but other
kids still change together. And, not everyone is good at everything,
and even the jocks get teased. And, if you sit by yourself with read-
ing, you may be overlooked by the others, but not excluded on pur-
pose. Right?

In this example, the therapist uncovered faulty beliefs and helped the child
examine what he could do. Joey did play tennis, but he discounted this fact
and focused on his misery in the moment. Joey also compared himself to
the jocks, and not all the other kids, thus making himself feel all the more
different and awkward. The therapist will help your child change “all-or-
none” thinking to more realistic appraisals of the situation and his abilities.
In vivo exposures for this child would involve leaving his book (a safety sig-
nal) behind and going up to the boys he is familiar with during gym class.

Children in this situation may benefit from some basic social skills train-
ing in making and keeping eye contact, starting and joining conversations,
and being assertive. If the child is teased in a mean way, the therapist trains
him to ignore teasing and not respond to the teasers. This is accomplished
through teasing exposures, where the therapist role-plays with the child.
The therapist teaches children to focus on what they are doing, to take
deep diaphragmatic breaths, and to refrain from giving any attention to the
teasers. In such situations, teasers usually quit if they are not reinforced. If
a child is bullied or touched physically by a teaser, the therapist instructs

109
 him to report this to an adult who will listen and who has authority over
the other children (e.g., coach, principal). Most often, children who are
teased attempt to tease back. Some are able to do this successfully and the
teasing either becomes good-natured or stops altogether. Other children
are unable to tease or fight back verbally, and by trying to do so they draw
more negative attention to themselves. That is why we prefer to train chil-
dren not to respond to the provocation.

Homework

Homework assignments after sessions  and  may include the following:

✎ Your child will be given in vivo exposure STIC tasks to complete be-
tween sessions, along with appropriate cognitive restructuring exer-
cises for each task. Remember to coach your child through these
tasks according to the guidance from the therapist. The dialogues in
chapters  and  give you practical examples for coaching your child
to examine the realistic evidence for his faulty beliefs.

✎ STIC tasks are likely to be assigned for school-related situations.

Your child should be attending at least part of the school day by the
end of sessions  and . These STIC tasks will increasingly involve
your child interacting with both children and adults; be sure to help
your child follow through with these exposures. This may require some
adjustment on your part. If you are used to a child who has a quiet
schedule or does not invite other children to your house, this will
temporarily change. It is important to schedule your time so that you
can get your child to school or to social situations involving different
people. Although it may seem excessive to have your 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 during later treatment.

✎ Continue to complete the daily logbooks.

110
SESSIONS 7 AND 8 Completing Treatment

By this point in your child’s treatment, he will be expected to attend school

on a full-time basis. The therapist may have helped your child return to
school by actually going in with him the first few times. These assisted ex-
posures will be invaluable when your child confronts an anxious situation
in real life. The purpose of the STIC tasks has been to prepare your child
for confrontations and to give him practice in managing emotions during
these times. Most importantly, the STIC tasks have been designed to gradu-
ally bring your child to full-time school attendance and tapered support
from the therapist. He should be taking most of the responsibility for the
treatment process and applying what was learned in real-life situations. If
necessary, the therapist will continue to implement techniques from previ-
ous sessions to help your child achieve this goal.

111
This page intentionally left blank
Chapter 6 Children Refusing School for Attention

SESSION 1 Starting Treatment

If your child is refusing school for attention, then she may be refusing par-
ent and/or teacher commands and showing overall disruptive behavior.
Other behaviors may include clinging, refusal to move, tantrums, running
away, constant telephoning, and guilt-inducing behaviors. Up to now, the
action that you have taken to reduce these problems may have been marked
by conflict, confusion, or ignoring or giving in to the situation. You have
probably noticed that giving in to your child’s misbehavior has reduced
stress in the short run but is worsening the problem in the long run. In ad-
dition, you have probably noticed that your family behaves in ways you
don’t like. In fact, these family conflicts likely lead to your child’s contin-
ued school refusal behavior.

You may have developed a way of responding to your child’s noncompli-

ance and other problems in school-related situations. This chapter will show
you a different way of handling these problems. It will teach you skills that
will help you change your child’s misbehavior and cope with difficult situa-
tions. At first, the things you learn may cause even more problems than be-
fore. For your family to make progress, however, it is important that every-
one work hard and work through the difficult situations.

The focus of treatment is you (and your spouse or partner, if you have
one). Treatment will thus be different from treatments described in other
chapters of this manual. The major goal is to shift your attention away
from your child’s school refusal behaviors and toward her school atten-
dance. This will involve:

■ Changing the way you tell your child to do something

■ Setting up daily routines

■ Setting up punishments for your child’s school refusal behavior

■ Setting up rewards for your child’s school attendance

113
 Although the therapist will spend much of his or her time with you, you
should bring your child to the treatment sessions so the therapist can tell
your child what is going to happen. This will give your child the opportu-
nity to ask questions about the treatment plan and think about the pun-
ishments and rewards that you may give. The therapist will explain that
your child’s behavior determines whether you give punishments or rewards.

The therapist may invite your child to tell what she thinks of the treatment
plan. In some cases, the therapist may make minor changes based on valid
reasons your child gives. However, in most cases, the therapist will not
allow your child to “negotiate” the procedures that have been set. Often,
an attention-seeking child who sets the family agenda is the very problem
that parents had in the first place. One goal of therapy is to modify the
child’s controlling, attention-seeking behavior and put parents in charge of
what is happening at home.

The therapist may recommend that you tell your other children about the
treatment plan to get their support and assure them that they will not
be neglected during treatment. Siblings sometimes misbehave when they
realize that one child is getting extra attention for bad behavior. Watch for
and deal with this as soon as it happens. One solution is to use the treat-
ment techniques for all your children. Feel free to discuss any new child
problems with the therapist during treatment.

Changing Parent Commands

The first step is to change the way you give commands. In many families
with an attention-seeking child, the child successfully negotiates what she
wants and often draws her parent(s) into a long discussion. A goal of treat-
ment is to shorten these discussions into a simple parent command, a simple
child response, and a simple parent response.

The therapist may start by asking you to list  commands you have given
your child in the past few days. Be honest in telling the therapist exactly
what you said to your child. Include commands about chores, interactions
with siblings, finding things, stopping behavior, or other matters that you
think are appropriate. Next, the therapist may ask you to list  typical
commands you have given your child about school attendance. Use the
Commands List Form included here to create your lists. You may photo-
copy this form from the workbook or download multiple copies from the

114
Commands List Form

Commands from the past week:

.

.

.

.

.

.

.

.

.

.

School-related commands:

.

.

.

.

.

.

.

.

.

.

115
 TreatmentsThatWork™ Web site at www.oup.com/us/ttw. Be sure to tell
your therapist about any extenuating circumstances or other reasons for why
and how you gave certain commands.

The therapist will compare the two lists of commands to decide whether
treatment should be narrow or broad. For example, if your child listens to
you most of the time except for going to school, then treatment can focus
narrowly on school refusal behavior. If your child does not listen to you
most of the time, then the therapist will broaden treatment to include
these other times.

The therapist will look for patterns in your commands. For example, he or
she may look for commands you give in the form of questions, commands
that are vague or incomplete, commands that are interrupted or carried out
by someone else, commands that are too difficult for your child, or com-
mands given in the form of lectures. The therapist may give you feedback
about some of the things he or she notices about these commands. Be open
to this feedback and ask questions.

Setting Up Regular Routines

The therapist may ask you to give a detailed description of a typical school-
day morning in your house. Be specific about this routine. Describe it in
-minute increments if necessary. If your family has no morning routine,
mention this as well as any general routine that you follow. If your routine
differs depending on the day of the week, describe the routine for each day.
If you expect changes in your routine over the next  to  weeks (e.g., due
to vacations, holidays, changes in work schedules, school breaks), mention
these as well. You may use the form provided here to provide a description
of your morning routine. You may photocopy this form from the work-
book or download multiple copies from the TreatmentsThatWork™ Web
site at www.oup.com/us/ttw.

In describing your routine, pay special attention to the times your children
rise from bed, wash and get dressed, eat, brush their teeth, do extra activi-
ties 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, describe
each one but especially the one for your child with school refusal behavior.
In addition, let the therapist know what your typical routine is during the
morning (as well as any differences between your routine and your spouse’s).

116
Our Morning Routine

Time to complete this step

What I want my child to do (e.g., :–: a.m.)

This is especially important in cases where a child takes advantage of one

parent’s absence to force the other parent to keep her home from school.

The therapist will also ask how you respond to your child’s behavior in the
morning. Pay special attention to your behavior toward your child’s refusal
to go to school. Focus on your behaviors such as ignoring, calming your
child, yelling, physical interactions, or lecturing, among others. Be honest.
Many parents are embarrassed that their lives revolve around a controlling
-year-old, but describing your interactions with your child is important
for treatment. For example, when your child throws a tantrum or clings to
the banister to refuse school, what exactly do you do? Do you eventually
give in to your child because of other important matters? What happens
during the day when your child is home from school? What do you say to
each other and what is the emotional atmosphere like?

The therapist will note how you respond to your child’s behavior and give
you feedback. Remember that a central theme of treatment is to reward
school attendance and punish school refusal. Therefore, you should prac-
tice downplaying or ignoring school refusal behaviors (e.g., excessive physi-
cal complaints, clinging, tantrums) as much as possible and giving atten-
tion to appropriate behaviors (e.g., getting out of bed, eating breakfast on
time). If you have gotten used to paying attention to your child only when

117
 he or she shows “bad” behavior, it is important to start practicing your shift
in attention to positive behavior.

Setting Up Punishments for School Refusal Behavior

The therapist will ask you to list any punishments you have used in the past
to discipline your children. Examples include lectures, spankings, ground-
ings, restriction of privileges, loss of valued items, and fines, among oth-
ers. It is possible that you have used very few punishments in the past or
that you wait until your child’s behavior is severe before giving punish-
ment. Be sure to tell this to the therapist. In addition, some parents don’t
believe in punishment. This is not necessarily wrong, but it can affect treat-
ment and you should tell the therapist if this is your position. You may list
the punishments on the form provided here.

Tell the therapist if you use different punishments for your children. For
example, you may punish your child with school refusal behavior much
more than your other children. In addition, your therapist may ask you to
describe whether each punishment was effective and whether you still use
it. Identify your uses of each punishment over the past few days and how
your child responded.

Your therapist will also want to know how you used these punishments in the
past few weeks or months. For example, have you tried time-out? If so, what
procedures did you use? How long did you try it? Did both parents imple-
ment time-out? Did your child know the house rules before being placed in
time-out? Have you tried grounding? If so, did your child leave the house
anyway? Did she tear up the bedroom? Did she say, “I don’t care”? All past
punishments must be discussed in depth. The therapist will also want to
know how effective you think punishment will be in changing your child’s
current behavior. The therapist may discuss with you some possible new
rules and punishments and get your feedback. Be sure to give your input.

Setting Up Rewards for School Attendance

The therapist may ask you to list rewards you have given recently for your
child’s good behavior. Examples include verbal praise, attention, play or
reading time with your child, food, toys, money, or an easing of responsi-

118
Punishments List Form

.

.

.

.

.

.

.

.

.

.

bilities, among others. Let the therapist know if these rewards differ from
child to child. As with punishments, the therapist will ask you to describe
whether each reward was effective and whether you still use it. You may list
rewards on the form included here.

The therapist will also explore how you used rewards in the past. For ex-
ample, what system of reward did you set up for your child? The therapist
will want to know how effective you think rewards will be in changing your
child’s current behavior. In doing so, the therapist may suggest some new
rewards. Be sure to give your input. Finally, the therapist will talk to you
about your time and other resources that may affect what rewards and pun-
ishments can be used in treatment.

Homework

Homework assignments after session  may include the following:

✎ Keep a list of the commands you give to each child between this ses-
sion and the next one. Write the command in the exact wording you
used.

119
Rewards for School Attendance

.

.

.

.

.

.

.

.

.

.

✎ Keep a daily record of your family’s morning routine between this

session and the next one.

✎ Think about changes in the morning routine that may help your
child go to school.

✎ Think about other punishments and rewards you have used in the
past and possible new ones that you could use in the future.

✎ Continue to complete the daily logbooks (see chapter  for blank

logbooks). Note any specific situations or experiences that arise dur-
ing the week.

SESSION 2 Intensifying Treatment

This section describes how a therapist may intensify treatment for a child
refusing school for attention. Again, the major focus is you and your spouse
and the major goal of treatment is to shift attention away from school re-
fusal behaviors and toward school attendance. This will involve changing

120
 your commands, setting up daily routines, setting up punishments for
school refusal behavior, and setting up rewards for school attendance.

Changing Parent Commands

The therapist may begin this session by reviewing the list of commands
you gave to your children over the past few days. The therapist will pay par-
ticular attention to commands you gave your child who is refusing school.
In the following example, T represents the therapist, F represents the child’s
father, and M represents the child’s mother:

T: I see one command you gave yesterday was “Clean your room.” Can
you tell me about that?

F: Yeah, I told her she should clean her room. She didn’t get around to
it, of course.

T: When you told her to clean her room, what was she doing at the
time?

F: Watching television. She always seems to find something to do

when we ask her to do something.

T: I see another command was more urgent and about school.

M: Yes, I asked her this morning to stop hanging on to me.

T: Okay, what does “hanging on” mean?

M: She was all over me, whining and complaining about having to go
to school. She didn’t want to go and was bugging me to let her stay
home.

T: Okay, you say that she was “all over” you. What exactly does that
mean?

M: Well, it’s hard to describe. She comes over to me, sometimes grabs
my leg or lies at my feet when I’m trying to do something, like
make the kids’ lunches.

The therapist will begin to change some of the statements you make to
your child. He or she will check your list of commands for errors. Listen
carefully and be open to what he or she suggests. The therapist may point
out specific ways to make your commands more effective. For example:

121
 ■ Say exactly when the command is to be carried out. In the ex-
ample commands above, no timelines were set for starting the task.
When you give a command, give a time limit. Give a -minute
limit for starting chores such as cleaning a room or washing
dishes. If the command needs to be carried out immediately, as
was the case with the mother’s command, then give a -second
limit. The therapist will help you decide which commands need
to be obeyed within the -second limit. These will be many of
the commands you give when trying to get your child to school.

■ Say exactly what you require of your child and keep it simple.
The command “Clean your room,” for example, has different
possible meanings. Does this include dusting, vacuuming, mak-
ing the bed, and straightening the dresser? Does it mean more
than that? Instead of this vague command, try something more
specific such as, “Pick up your clothes from the bedroom floor
and hang them up on hangers in the closet. Start within  min-
utes.” Instead of “Stop hanging on to me,” try, “Take your hands
off of me. You have  seconds.”

■ Be sure that your child is physically capable of carrying out the

command. For example, if your -year-old can’t hang up clothes
in the closet, don’t ask her to do it. Your child should also be able
to understand all parts of the command. Stick with simple one-
step commands first. Ask your child to repeat the command if
necessary to be sure she understands it.

■ Be sure that nothing competes with your child’s attention (e.g.,

watching television, talking with friends) when giving a com-
mand. Although some children are capable of “not hearing” or
“forgetting” a command, make sure that there is no possibility of
this. In particular, make direct eye contact with your child when
you give a command.

■ Be sure the command is a command and not an option or ques-

tion. In the above example, the father indicated that the child
“should” clean her room. In addition, the mother asked her child
to “stop hanging on to me.” These words suggest that the child
has a choice. Eliminate this choice by giving short, direct com-
mands in sentence form.

122
 ■ Eliminate sarcastic criticism of your child. Sarcasm is often
noted by children, who may think that they will get no rein-
forcement even when they do comply. Stay neutral in your tone
when you give a command. This neutrality will be especially im-
portant later when dealing with your attention-seeking child.

■ Cut down on extra speech during a command (e.g., don’t give

lectures) and be sure you do not reward your child by having
someone else carry out the command (e.g., having a sibling do
the dishes) for her.

■ Engage in a task with your child after giving a command (e.g.,

pick up toys in a room with your child; prepare for work as the
child prepares for school).

■ Always provide some reward for obeying a command (compli-

ance) and some punishment for failing to obey a command
(noncompliance).

The therapist will go through all the commands on your list and help you
change them as necessary. Try to come up with good changes yourself so you
can learn to build effective commands on your own. Focus especially on
commands you give in the morning for school attendance. In addition, if ex-
cessive reassurance-seeking by your child is a problem now, talk to the thera-
pist about the possibility of starting procedures to address this behavior.

Setting Up Regular Routines

The therapist will also review your description of a typical school-day morn-
ing in your house. He or she will pay special attention to the times the chil-
dren 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. In addition, the therapist will review your typical routine
during the morning, including your behaviors toward your children.

The therapist will then give you feedback about changes that are necessary
to regulate your morning routine and improve your responses to your chil-
dren. Be open to these changes and give your input. For example, the thera-
pist may want you to set up a stricter morning routine. He or she may rec-
ommend that you have your child rise from bed about  to  minutes

123
 Table 6.1. Sample Morning Schedule
Time Action

: a.m. Wake the child (child required to be out of bed by : a.m.).
:–: a.m. Child goes to the bathroom and washes as necessary.
:–: a.m. Child dresses and accessorizes as necessary.
:–: a.m. Child eats breakfast and discusses her day with parent(s).
:–: a.m. Child makes final preparations for school (e.g., books, jacket).
:–: a.m. Child goes to school with parent(s) or rides the bus.
: a.m. Child enters school and classroom.

before school starts. Do this even if your child is not currently attending
school. Allow your child only  minutes between waking up and rising
from bed.

In addition, the therapist will help you set times for your other morning
activities. Your schedule should be flexible but strict enough to allow for a
smooth transition to school. The schedule in Table . may be used as a
rough guide.

Setting Up Punishments for School Refusal Behavior

The therapist will review the list of punishments you used in the past to
discipline your children, looking specifically at the effectiveness of each
and how it was used. You will discuss your attitudes toward each punish-
ment as well. Be sure to discuss any new rules or punishments that you
think are important. The therapist will probably want to focus on reduc-
ing five specific school refusal behaviors. These can be chosen from infor-
mation gathered during assessment, and you should rate them from most
problematic to least problematic. Example:

. Refusal to move (most problematic)

. Aggression/hitting sister or parent

. Crying

. Excessive reassurance-seeking (asking the same question more than

twice in  hour)

. Screaming (least problematic)

124
 The therapist will then ask you to choose a specific punishment that you
could use for your child’s two least problematic behaviors. It is important
at this point to focus on less problematic behaviors. That way, you can
practice what to do with less effort and experience some success with the
process. However, if you feel comfortable addressing more of your child’s
behaviors at this time, let the therapist know. Punishments may also be set
for noncompliance to commands.

The punishment should be practical and be given both in the morning and
after school. Your child should know that school refusal behavior is serious
and will be addressed at all times of the day, not just in the morning. Ex-
amples of punishment for an attention-seeking child include ignoring,
time-out, working through misbehavior without extra attention, and going
to bed early. In some cases, however, stronger or more tangible punishments
are needed.

In addition, the therapist will go over all possible scenarios that could occur
in the next few mornings and form a plan with you to deal with them. Al-
though this may take some time, knowing how to respond to any behavior
is important for putting you in charge of your home life. As much as pos-
sible, work toward the goal of getting your child to school.

Note that some children will behave worse to get their parents to give in. This
is known as an “extinction burst” and can damage the therapy process. If
your child forces you to give up now, then he or she will misbehave even
more later when you try to assert yourself again. Be aware of this possibil-
ity and try hard to follow through on commands and punishments. Be sure
you know exactly what to do during the next few mornings when trying to
get your child to school. In addition, stay in regular contact with the thera-
pist during the next few days.

Setting Up Rewards for School Attendance

The therapist will also review the list of rewards you used in the past for
good behavior. He or she will review the effectiveness and desirability of
each reward, as well as your attitudes about each and how you used them
in the past. Talk about new rewards you think are important.

The therapist will first ask you to choose a reward for two good behaviors.
Try to make the reward attention-based. For example, if your child does

125
 not scream or ask a question multiple times, then give a lot of verbal praise
in the morning and schedule a time at night when you and your child can
do something together (e.g., read, play a game). In some cases, however,
stronger or more tangible rewards are needed.

Your therapist will instruct your child about the expected routine, appro-
priate behaviors, and punishments and rewards. Your child will be reminded
that it is her behavior that determines whether you give punishments or re-
wards. You should, after the therapist, repeat this to your child in session
and at home to reinforce your role in taking charge.

Homework

Homework assignments after session  may include the following:

✎ Continue to keep a list of commands you give to each child. Change

your commands according to the session  discussion. If you have a
spouse, meet with him or her each night to discuss changes you
should make for the next day.

✎ Beginning with the next school day after this session, wake your
child  to  minutes before school starts and implement the new
school-day routine. Follow this routine as closely as possible. Your
child should do schoolwork and read school-related books if she
stays home.

✎ Use the punishments for the two behaviors you have chosen.
✎ Use the rewards for the absence of the two behaviors you have chosen.
✎ Contact the therapist if any problems arise.
✎ Continue to complete the daily logbooks. Note any specific situations
or experiences that arise during the week.

SESSIONS 3 AND 4 Maturing Treatment

This section describes the “maturing” of treatment of children who refuse

school for attention by revisiting procedures from sessions  and . At this
point in treating your child, the therapist will help you focus more on your

126
 morning and evening routines and on changing your child’s school refusal
behaviors. This may include ignoring inappropriate behaviors, physically
taking your child to school, and dealing with your child during the day-
time if she stays home following misbehaviors. Ideally, you will begin to see
less school refusal behavior and learn important skills that will help you
solve other problems in the future. In addition, many parents learn skills
in therapy that are helpful in dealing with their other children.

Changing Parent Commands

The therapist will review the list of commands you give to your children.
The therapist will check for problems in these commands and give you
constructive feedback. Be open to this feedback. The therapist will also ask
you about nonverbal gestures and parent disagreements that could hurt the
effectiveness of your commands. For example, some parents give commands
without firmness of tone or eye contact, and other parents may undercut
their spouses by inadvertently or deliberately giving in to a child. The thera-
pist will want you to address these problems immediately.

The therapist will focus on recent commands you have given to your child
with school refusal behavior, and those you have given in the morning be-
fore school. The therapist will review each command and note important
things that you are not saying or doing. For example:

T: It seems you had two good days and two bad days since the last ses-
sion. Can you tell me what the major difference was between these
two sets of days?

M: On Monday and Wednesday, John (child’s father) and I seemed re-

ally to be in “sync.” We were working together to get the kids up
and going to school, and we backed each other up as we talked
about last time. (To husband:) Don’t you think so?

F: Yeah, I do. I guess it broke down a bit on the other days.

T: Let’s talk about that. What exactly “broke down”?

F: There was a lot more resistance to going to school on both those

days, and he (child) had a lot of tantrums. We started yelling and
nothing much got accomplished. I had to go to work, and I guess
he wore her (mother) down.

127
 In this sample case, a therapist would explore what led to the breakdown
of the treatment procedures. The most likely reasons for breakdown in-
clude parent disagreements, one parent leaving the situation, and increased
child misbehaviors. When these things happen, parents are more likely to
give unclear commands (e.g., “Will you please be quiet?” and “I just wish
you would go to school”). You and the therapist should find out what is
breaking down your commands and correct any problems as soon as pos-
sible. It may be necessary to change your work schedules or ask other
people to help you bring your child to school.

If your child has clearly increased her misbehavior to force you to abandon
your commands or to give up on the set routines and rewards and punish-
ments, be sure to tell the therapist. He or she will help you develop ways of
working through your child’s behavior problem to accomplish your goals. To
back up your commands, for example, you may have to physically dress
your child and bring her downstairs while she is throwing a tantrum or is
becoming “dead weight.” By session , you should know what makes a
good command. If you are uncertain or if extenuating circumstances (e.g.,
spouse leaving home early) continue to interfere with your commands, talk
to the therapist.

The therapist may raise the issue of ignoring inappropriate behaviors. Many
parents adjust to a child who is always demanding attention by simply re-
sponding to the child whenever she acts up. For example, some parents
have a tendency, over time, to leave a child alone when he or she is playing
quietly (“Don’t disturb him”), but to react immediately when he or she is
disruptive (“Stop that now”). As the child grows older, however, she learns
that the best way to get parental attention is to misbehave.

Among children who refuse school, a common way of getting attention is

to exaggerate physical complaints. This applies especially to vague com-
plaints like headaches, stomachaches, and nausea. Attention-seeking chil-
dren rarely complain of specific, identifiable symptoms like fever or vom-
iting (although it is possible). If you and the therapist are sure that your
child is exaggerating physical symptoms for attention and not because of a
medical condition, then you may want to ignore these complaints. How-
ever, you should first rule out any possible medical conditions.

To ignore exaggerated physical complaints, the therapist may ask you to do

different things in the morning. Examples include stopping eye contact
with your child (i.e., looking away when he or she complains), using time-

128
 out, working through tantrums or excess verbal behavior, paying attention
to well-behaved siblings, and talking to your spouse. When engaging in these
behaviors, be sure that your child does not play one parent against the
other to get what he or she wants. In two-parent families, is not uncom-
mon for one parent to ignore a child’s inappropriate behavior only to have
the other parent attend to it. Consistency between you and your spouse is ex-
tremely important to present a united front to your child. Your child must
learn that misbehavior, including exaggerated physical complaints, will not
be tolerated by anyone. Conversely, be sure to praise and otherwise reward
your child when he or she is not complaining of exaggerated symptoms.

Ignoring some of your child’s behavior, especially complaints of physical

symptoms, will be hard. Some parents feel guilty about being overly stern
with their child. Some are concerned that something might actually be
wrong with their child, or that they will cause long-term psychological
harm to their child. Some worry that their child will no longer trust them
with personal information. If you do feel guilty or have other concerns
about ignoring misbehavior, tell the therapist about it. He or she may give
you more information about differences between parental firmness and
over-restrictiveness. The therapist may also refer your child for a medical
evaluation to ensure that nothing is actually physically wrong. Ignoring ex-
aggerated complaints will not cause psychological harm to your child. In
fact, as children learn that their parents will attend only to realistic and
nonexaggerated concerns, their respect for their parents often grows and
they may be more likely to confide in their parents in the future. When you
are in doubt about downplaying child misbehaviors or exaggerated physi-
cal complaints, remember that the key goals of this treatment are to shift
your attention to more positive child behaviors and to put you more in
charge of the home life.

Setting Up Fixed Routines

The therapist will review the routine you set up with your family and dis-
cuss any changes that you made. If you have made changes to the daily rou-
tine to make it work better, or want to suggest changes, be sure to tell the
therapist. He or she will emphasize structured, consistent routines so that
your child becomes used to what is happening (or is going to happen) in
the morning. The therapist may work with you on the nighttime routine

129
 as well. In general, children should have set times for coming home from
school, completing homework, eating dinner, playing, and preparing for
bed. The order of these activities may change, of course, depending on
your family’s situation. In addition, you and your therapist may agree to
limit playtime or increase homework time as necessary. If your child is not
in school at all, you should obtain schoolwork from the teacher and have
your child work on it at home during the day and/or evening.

By session , you should know what makes up an efficient routine. If you

are uncertain, talk to the therapist. Also, review with the therapist the pre-
vious mornings and evenings and indicate what could be improved. Talk
about extenuating circumstances that interfered with the routines. Com-
mon problems include dawdling siblings, lack of energy, increased child mis-
behavior, constant changes in work and other schedules, and having other
priorities. Talk to the therapist about the advantages and disadvantages of
suspending your child’s social activities at night and on the weekends (e.g.,
Scouts, soccer practice, dance lessons) until she is attending school full-time.

Forced School Attendance

If your child is not attending school at all or is missing most of school, start
thinking about physically bringing her into the classroom. For many chil-
dren who refuse school for attention, forced school attendance is effective.
However, it must be used with caution. You should physically take your child
to school only under certain circumstances. These circumstances include:

■ A child refusing school only for attention and without any sig-
nificant distress or anxiety

■ Parents who are willing to take the child to school and school
officials who are willing to meet the child at the door of the
school building and escort the child to class

■ The presence of two parents or one parent and another adult

who can take the child to school

■ A child who understands what will happen if she refuses school

■ A child who is currently missing most school days

■ A child who is under age  years

130
By session , the therapist may raise this issue with you and discuss how the
process works. However, if there is some urgency in getting your child back
to school, you may pursue forced school attendance now. Thoroughly discuss
this procedure with the therapist before attempting it. Think about whether
you have the energy, ability, and desire to follow through with forced school
attendance.

By session , start thinking about physically bringing your child into school
if the circumstances for using this procedure are met. The first step is to
discuss with the therapist how you feel about the procedure. If you feel you
are willing and able to put forth the effort that is required, then you may
proceed. However, if you have any hesitation or guilt, you should talk to
the therapist before moving ahead. Remember that hesitation on your part
may be exploited by your child and may make future attempts at school at-
tendance much harder. If you are hesitant, wait before using this procedure
or use other techniques recommended by the therapist.

Forced school attendance usually involves some physical contact with the
child. In most cases, this means getting the child into the car or into the
school building. Most children stop their attention-getting behavior once in
school, so forced school attendance usually refers to morning behaviors that
are the parents’ responsibility. In most cases, the necessary physical force is
simply picking the child up and carrying her. The treatment described in
this manual does not, of course, sanction any contact that could harm the
child.

Forced school attendance typically starts at the end of the morning rou-
tine. The parent tells the child to get into the car/bus and/or to enter the
school building once there. If the child does not obey these commands, the
parent gives a warning. The warning should be short and clear (e.g., “Go
now or we will take you there”). If the child obeys, the parent gives verbal
praise. If the child does not obey, the parents should pick the child up and
carry her into the car or school. School officials should be forewarned and be
ready to help. If there are two parents, both should carry the child and ig-
nore or work through the child’s tantrums. One parent should drive the car
while the other parent sits in the back seat with the child to prevent escape.
The parents should stay neutral or “matter-of-fact” in their tone and give
the child very little verbal attention.

You should stop forced school attendance if your child is overanxious or if

the situation becomes unbearable for you. The danger in stopping, how-

131
 ever, is that your child will learn that you will give in if her misbehavior is
severe enough. Forced school attendance must be used only under the right cir-
cumstances and with strong follow-through. Be sure to thoroughly discuss forced
school attendance with the therapist if you think it is a reasonable option.

Setting Up Punishments for School Refusal Behavior

The therapist will talk with you about any past or present punishments you
have given for school refusal behavior. Discuss how you prefer to discipline
your child, your feelings about punishment, and any extenuating circum-
stances. In addition, the therapist will review your child’s school refusal be-
havior since the last session and how you used punishment. In particular, the
therapist will review how you punished the two lowest-severity behaviors.

If you had problems with the punishments since the last session or found
they didn’t work, the therapist will want to discuss how and what punish-
ments were given. If the punishments had some effect on your child’s be-
havior, then the therapist will ask you to punish the next-highest-severity
school refusal behavior. Refer to session  and your established hierarchy of
problematic school refusal behaviors. Go over all relevant scenarios with
the therapist and discuss any important issues that you think might come
up in the next few days.

By session , you should know which punishments are most effective. If

you do not, then talk to the therapist. Also, review the previous mornings
and evenings and indicate what could be improved. Talk about circum-
stances (e.g., inconsistency between parents) that interfered with your use
of punishment.

Daytime Procedures

At this stage in treatment, if your child is still missing most days of school,
then you and the therapist can set up daytime procedures. If your child is
missing school during the day, she should sit in a chair under your super-
vision during school hours. You could do this at home or at work if neces-
sary. You should avoid verbal or physical attention beyond what is absolutely
necessary. In addition, your child’s setting should be as dull as possible. At
the end of school hours, you should give the normal punishments (e.g.,

132
 grounded in room doing homework). If school refusal behavior continues
for the majority of the week, then give appropriate punishments for the
weekend. Be sure to thoroughly discuss daytime procedures with the therapist
if you think that they are a reasonable option.

Setting Up Rewards for School Attendance

Discuss with the therapist any past or present information about rewards
for school attendance, including their effectiveness, your feelings about the
rewards, and any extenuating circumstances. In particular, the therapist will
want to review how successful the rewards were in changing your child’s
behavior since the previous session. Feel free to suggest changes where nec-
essary. Choose a reward for the next appropriate behavior on your list.

By session , you should know which rewards are most effective. If you do
not, then talk to the therapist. Also, review the previous mornings and
evenings and indicate what could be improved. Talk about circumstances
(e.g., inconsistency between you and your spouse) that interfered with
your use of rewards.

Homework

Homework assignments after sessions  and  may include the following:

✎ Adjust as necessary the list of commands you give to each child.

✎ Implement changes to the morning and evening routines and follow
the routines closely.

✎ Implement the punishments for the next-highest-severity behavior

when it occurs.

✎ Implement the rewards for the absence of the next-highest-severity

behavior.

✎ Engage in forced school attendance and daytime procedures if neces-

sary and according to the therapist’s recommendations.

✎ Continue to complete the daily logbooks, noting any specific issues

or situations that may arise during the week.

133
SESSIONS 5 AND 6 Advanced Maturing of Treatment

This section describes advanced maturing of treatment. This means taking

a hard look into what is currently happening in your home and what re-
mains to be done. By this time, all the daily procedures (i.e., routines, con-
sequences, forced attendance) should be “up and running” and finely tuned
to your family’s situation. At this point, you and the therapist should have an
open discussion of what remains to be done and change what may be block-
ing treatment success. These later sessions sometimes call for more creativ-
ity, and you and the therapist may need to come up with innovative modi-
fications of the techniques described here. For example, you may need to
be creative about bringing your child to school, leaving your child’s class-
room, dealing with tantrums in public places, or giving rewards for atten-
dance after school.

The basic techniques discussed earlier—commands, routines, and conse-

quences—will continue to be addressed in these sessions. Other proce-
dures such as forced school attendance and daytime consequences may be
broadened as well. Remember that for children who are progressing slowly,
repetition of previous procedures might be appropriate.

Changing Parent Commands

The therapist will continue to review the commands you are giving to your
child. Be sure to talk about things that interfere with clear commands. If
you have a spouse, discuss things that interfere with a united front that you
can present to your child. If necessary, examine what may be interfering
with your commands (e.g., distractions) and/or ask your child to repeat what
you have said to her. Use your child’s feedback to make changes if neces-
sary. Example:

M: Matthew, turn off the television and get ready for school. I want
you to put your jacket on and pick up your books now.

C: What? In a minute.

M: Look at me. (Mother establishes eye contact with the child). Thank
you. What did I say?

C: Come here?

134
M: Listen to me. Shut off the television now. (Child does so) Thank
you. Look at me. Put on your jacket and pick up your books now.
What did I say?

C: Put on my jacket and get my books.

M: Thank you for listening. Go ahead.

You should also note special circumstances that break down the effective-
ness of parent commands. For example, many children who refuse school
for attention are members of single-parent families. Therefore, another
parent is not there to back up the single parent or help deal with other chil-
dren as the single parent focuses on the child who refuses school. If this is
the case, using others such as siblings, the ex-spouse, or even school officials
to give commands or bring the child to school may be helpful. This may
be difficult, and you should not do anything that makes you uncomfort-
able (e.g., contact an estranged ex-spouse). However, parent commands
are often more effective if they are backed up with valid promises of con-
sequences (e.g., punishments, forced school attendance) from two parents/
adults.

In addition, parent commands sometimes break down when several chil-

dren in a household refuse school at once. For example, a -year-old may
start refusing school after seeing his -year-old brother refuse school and get
a lot of parent attention as a result. It may be useful to address the oldest
child first. The older child may be the one with the most severe behavior
and may be the leader of the household rebellion. In such a case, parents
may need to concentrate their best efforts on issuing appropriate com-
mands to the older child. A reduction of the older child’s school refusal be-
havior may serve as a model for younger children. However, parents should
be careful not to completely ignore younger siblings who refuse to go to
school. If you have this situation in your household, be sure to discuss with
the therapist all the relevant family dynamics that may influence treatment
(e.g., a younger child idolizing and imitating an older one).

Finally, parent commands will be ineffective, of course, if a parent chooses

not to give them. If this is the case, your therapist may look at family com-
munications and parent moods and attitudes that break down treatment. In
some cases, for example, family/parent problems need to be solved first. Such
problems might include marital dissatisfaction, family conflict, alcohol/drug
use, financial pressures, or other stressors. In other cases, a parent may de-

135
 liberately sabotage the treatment process or otherwise fail to follow through
with treatment. If any of these problems apply to you or your family, be
honest with the therapist and address them right away.

At this point in treatment, you should be constantly reviewing what you

are saying to your child. In particular, you should review your commands
at different points of the day to see if they are clear, consistent, and effec-
tive. Compare the commands you give in the morning with those you give
in the late afternoon and evening. In particular, you should be able and
willing to identify “bad” commands and discuss how to change them. Search
for anything that breaks down the effectiveness of your commands. Ideally,
this review process should occur in evening conversations about the day
(and/or before the next morning). If you have a spouse, you should also
concentrate on supporting one another during this difficult process. The
therapist may discuss how you and your spouse communicate, if you wish.

By this time in treatment, you should be clear and brief in the commands
you give to your child. Commands should be few in number and be given
in a neutral manner. Rewards and punishments, already set up by this point,
should immediately follow obedience and disobedience to these commands,
respectively. For example, if your child appropriately complies with a com-
mand, you and your spouse should praise the child quickly but not too
extensively. Your child should come to realize that attention will be paid to
compliance, but it is important not to dilute the value of the attention by
giving too much of it. If your child does not comply with a command, then
give appropriate negative consequences (e.g., time-out, working through
misbehavior, ignoring).

At this point in treatment, it may also be helpful to explore with the thera-
pist how your child’s teacher interacts with your child at school. If the
teacher or other school officials seem to interact with your child effectively,
then no intervention is necessary. However, if your child is defiant in the
school setting, then it may be helpful to include your child’s teacher in the
therapy process. Of course, this decision ultimately rests with you, and all
ramifications should be considered. For example, including the teacher
may embarrass a family member and interfere with treatment. An alterna-
tive strategy is to have the therapist meet with the teacher separately (with
your permission). In this way, basic elements of treatment can be trans-
ferred to the school setting to reduce your child’s behavior problems there.
For example, the teacher may be instructed to give your child short, clear

136
 commands and send a daily report home to you. You may then give posi-
tive and negative consequences based on this report.

Establishing Fixed Routines

As in prior sessions, the therapist will continue to work with you to struc-
ture the morning and evening routines for your child. By this time, the
routines should be predictable to your child, and you should be providing
immediate consequences for any substantial deviations from the routine.
You may wish to ask your child what she thinks of the daily routines, but
keep this conversation to a minimum. Use your child’s feedback to make
changes if necessary, but don’t allow your child to dominate this process
or negotiate changes. Remember that you are in charge of the routines
at home.

Morning Routine

At this point in treatment, your child should be rising at a specific time in

the morning and getting ready for school. This should be done even if she
is not currently going to school. Specific times for each task in the morn-
ing should also be set. If your child is sticking to the morning routine, then
you should praise her in the morning and evening. If your child is not
sticking to the morning routine, then you should be giving punishments.
This may be an immediate punishment (e.g., verbal reprimand in the morn-
ing) and/or a delayed punishment (e.g., grounding in room after school
and at night).

During the morning routine, you should be paying attention to positive

behaviors and ignoring or working through negative behaviors. If your child
throws a temper tantrum, for example, you should try to dress the child
and complete other morning tasks as much as possible. If this takes most
of the morning, including school time, that is fine. You should try to bring
your child to school in mid-morning or even mid-afternoon if necessary.
The key is to give your child the clear message that school attendance is manda-
tory and will be pursued even after school has started that day. This will re-
quire a lot of effort on your part and may need to be coordinated with school
personnel.

137
 At this point in treatment, you should expect your child to go to school
after the morning routine. School attendance may be part-time or in an al-
ternative classroom setting (e.g., library), but your child should be spend-
ing at least part of the day at school. If your child was acting out in the
morning before going to school at the start of treatment, then attendance
should continue. By this point in treatment, you may use forced school at-
tendance if appropriate.

If your child complains of physical symptoms early in the day, it may be

hard to tell whether the symptoms are real. If you haven’t done so, have
your child checked by a medical doctor. If you have been ignoring your
child’s exaggerated complaints, you may have noticed that one of two things
is happening. First, your child may have stopped or at least decreased her
excessive complaints of physical symptoms. In this case, maintain what
you have been doing. Second, your child may have increased her behavior
or started complaining of more serious symptoms to elicit your sympathy.
In this case, you may have to set more definitive rules. Be sure to consult
the therapist and medical doctor before implementing any procedure.

It is useful to require school attendance unless your child has a fever of at

least  degrees and/or obviously has a physical condition that precludes
school attendance (e.g., vomiting, bleeding, severe diarrhea or cough, lice).
Of course, your situation may be unique and call for a different approach.
Inform your child of these rules and adhere to them closely. Don’t be sur-
prised if she tests the limits of these rules. If your child is legitimately sick
and must stay home from school, be sure that she is restricted to bed (not
just the bedroom, but bed ) for the entire school day. You should give very
little extra verbal or physical attention and you should tell your child that
you expect her to attend school the next day (if appropriate). If your child
has to miss school for some other reason (e.g., family funeral), she should
be told the same thing and attend school as soon as possible.

Daytime Routine

If school attendance is not possible at this point, then daytime routines and
consequences should be used. You should make arrangements for your
child during the day if the school refusal situation is unchanged and nei-
ther one of you can be at home. In this case, bring your child to work and
assign her boring tasks or make her sit in a chair all day (with little verbal

138
 or physical attention from others), or to a friend, relative, or neighbor who
can do the same thing.

In other cases, at least one parent or adult will need to supervise the child
while at home during the day. During this time, you should give your child
no extra verbal or physical attention. In addition, you should require her
to sit alone, do boring chores, or complete homework sent home from
school. The goal is to deprive children of attention for refusing school but,
at the same time, make them expend some effort for their disruptive beha-
vior and/or maintain their schoolwork. If possible, you should try to get
your child to attend school each day if only for an hour or two. Repeat the
“Go to school” command each hour, and follow with appropriate school
attendance/rewards or negative consequences.

Evening Routine

If your child stayed home for the entire day, do not allow her to enjoy fun
activities at night. Some parents allow their children to go out and play
after the normal school period is ended, but this may give the child the im-
pression that all she has to do is “wait it out” to enjoy fun activities. Instead,
get your child’s schoolwork from the teacher and have your child work on
it at night. Suspend activities such as television, videogames, or other so-
cial engagements as appropriate. Consult the therapist about what to do in
your case.

Whether or not your child attends school that day, her routine should also
be set after school hours and at night. After-school activities, homework,
and recreational activities should be set to a specific time and tied to school
attendance. For example, if your child eventually attended school but re-
fused to move in the morning for  minutes to avoid school, she may be
grounded for the evening, required to do additional homework, and/or
sent to bed early. You can ground your child or make her sit on the stairs
or in a corner at night for twice the amount of time she refused school that
morning (e.g., -minute morning tantrum
 minutes of grounding
that evening). Conversely, if your child attended school with no problems,
then you may give a lot of verbal attention and spend extra time with her.
You should make it clear to your child that school attendance is an impor-
tant part of life. Any missed time will have consequences not just for that
morning, but also during the day, night, and even the weekend. For ex-
ample, some children end up owing their parents a large “debt” of ground-

139
 ing time during the week. This debt can then be paid in grounding or extra
chores on the weekend.

When implementing routines and administering punishments for a child

with persistent school refusal behavior, some family members feel guilt and
frustration and find that their home resembles a battlefield. Other family
members may feel that the treatment procedures are too mechanical for
their family. Although you should maintain pressure on your school-refusing
child during the week, you also need to maintain family cohesion and child-
hood fun. In some persistent cases, it may be necessary for families to set
aside treatment procedures on the weekend and enjoy some fun activities
together. Because the therapist knows your situation well by this point,
consult with him or her.

Forced School Attendance

If you are physically bringing your child to school, continue to follow the
procedures for sessions  and . If the situation is not improving or is be-
coming unbearable for you, then speak to the therapist about changing or
ending the procedure. Remember, however, that ending the procedure at
this point may convey to your child that her extreme misbehavior is enough
to force you to give in. This will damage any future attempts to bring your
child to school.

In some cases, parents find it emotionally difficult to force a child to attend

school for an entire day. In other cases, it is simply impossible to get the
child to attend full-time. In still other cases, the child has some anxiety
about attending school all day but the anxiety is not severe enough to jus-
tify a full day’s absence. If any of these cases describes your situation, it may
be useful to bring your child to school during the afternoon and let her fin-
ish the school day. On subsequent days, bring your child to school at ear-
lier and earlier times (e.g., a half-hour earlier each day until the normal be-
ginning time is reached). An advantage of this approach is that your child
may have an easier time going to school at lunchtime or recess when she
can be with friends and separating from you is not as difficult. In addition,
your child knows that she has to attend school for only a couple of hours
before coming home.

140
 The disadvantage of this approach is that others may wonder why your
child is starting school in the middle of the day and ask your child intru-
sive questions. Your child may need some strategies to cope with this situ-
ation. Examples include deflecting the questions by changing the topic or
laughing with peers, declining to answer on the basis of privacy (i.e., it’s
none of their business), straightforwardly answering the questions, or re-
ferring the questions to someone else.

Another strategy is to have your child stay in a library or other area of

school before physically bringing her into the classroom. This requires co-
operation with school officials, who must be consulted beforehand. For ex-
ample, your child could stay at the library and complete schoolwork or
chores (e.g., re-shelving books) for the entire day. Subsequently, she could
be reintegrated into the classroom for an initially short (e.g.,  hour) and
then a gradually longer period of time. Any behavior problems on your
child’s part should be conveyed to you for appropriate consequences in the
evening.

Another problem with forced school attendance is that some school district
personnel are unable or unwilling to help parents bring a child into school
or check the child’s school attendance throughout the day. In these cases,
it may be good for parents to get to know teachers, counselors, attendance
officers, and others who can help to some extent. If absolutely necessary,
parents can bring their child into the classroom and monitor her themselves.
Parents can then gradually reduce the amount of time they are in the class-
room. Keep in mind, however, that parent attendance at school is exactly what
many attention-seeking children want, so the procedure must be used with
great care. Do not use this procedure unless the therapist recommends it
and you are confident that you can leave your child’s classroom at a pace
set with the therapist. If at all possible, however, avoid this procedure.

Excessive Reassurance-Seeking

In many cases, excessive reassurance-seeking continues to be a problem.

Excessive reassurance-seeking may come in several forms, including ()
constantly asking the same questions over and over, () attending school
but constantly telephoning parents at home or work, and/or () attending
school but constantly demanding attention from the teacher or deliber-
ately becoming disruptive to be sent home.

141
 Children will sometimes repeat statements or ask the same questions over
and over about the following topics:

■ Pleas for home schooling or to change teachers, schools, or

classes

■ Proposed deals to delay school attendance or to stop the therapy

process (e.g., “I’ll go to school next week if you let me go to
work with you this week” or “I’ll go to school tomorrow if we
don’t have to go to the clinic anymore”)

■ Physical complaints and fatigue

■ Scheduling of dropoffs and pickups during the day

■ Difficulty and scheduling of schoolwork

If your child asks the same questions over and over, try the following plan.
When your child asks the question, answer it once. If your child asks again,
calmly remind her only once that she knows the answer. If your child asks
the question again, turn away. Example:

CHILD: Mom, are you going to make me go to school on Monday?

PARENT: Yes, we talked about that in therapy. (Ten minutes or so pass)

CHILD: Are you sure I have to go on Monday? Can’t I just start on

Tuesday?

PARENT: You know the answer to that question.

CHILD: How about if I do work at home on Monday and then start

Tuesday?

(Parent turns away from child. When the child begins to speak about other
topics, or continues on a more appropriate discussion regarding school, the
parent turns back to the child and continues to give attention.)

The therapist may set a limit on the number of times your child can ask a
particular question. One rule for young children with excessive reassur-
ance-seeking behavior is to allow one question about school per hour. Fol-
lowing this question and your answer, ignore your child’s school-related
questions until the following hour. Gradually increase this period of time
(e.g., to , ,  hours). Keep in mind, however, that this sometimes requires
a lot of stamina and selective “deafness.”

142
 Another form of excessive reassurance-seeking is when children attend
school but constantly call home or work to get comfort about what wor-
ries them. Sometimes this is the original school refusal problem, and some-
times it develops after a child resumes school attendance. Either way, it is
an inappropriate way to get attention. In most of these cases, the child
should be allowed one telephone call per day to a parent and only as a re-
ward for good classroom behavior. In severe cases, this may start with more
calls and then be gradually cut back. Of course, telephone calls would have
to be set up with the cooperation of school officials. You should punish ex-
cess calls at night. In addition, reassurance-seeking children should not
have access to cellular telephones.

Finally, a child who attends school may seek constant attention from a
teacher to be sent to the nurse’s office, to be sent home from school, or to
contact her parents. In other cases, a child will engage in disruptive beha-
vior to be suspended from school or be otherwise sent home. In these cases,
the therapist will work with you and the teacher to set up rewards and pun-
ishments in the classroom for your child’s behavior. For example, a card
system may be set up so that each violation of the rules (including inap-
propriately bothering the teacher) results in a card change from green (ac-
ceptable) to yellow (warning) to orange (last warning) to red. Upon re-
ceiving a red card, the child would be sent to the principal’s office for
discipline or to complete homework. In cases of older children or adoles-
cents, more age-appropriate methods should be used (e.g., token economy,
verbal feedback and reprimands, detention). A key aspect of this plan,
however, is to prevent the child from leaving school, which would only serve
to reinforce the child’s misbehavior. Therefore, close cooperation with school
officials is essential. In addition, a daily report card may be sent home so
that you can administer appropriate rewards or punishments at night.

Setting Up Punishments for School Refusal Behavior

The therapist will continue to review your punishments and make changes
where necessary. If appropriate, get feedback from your child about the
effectiveness of the punishments and use this feedback to make changes if
necessary. Talk with the therapist about any daytime restrictions on your
child’s activities and your attention toward her. Extend punishments to the
second-highest-severity behavior if appropriate.

143
Setting Up Rewards for School Attendance

The therapist will continue to review your rewards and make changes
where necessary. If appropriate, get feedback from your child about the
effectiveness of the rewards and use this feedback to make changes if nec-
essary. Extend rewards to the absence of the second-highest-severity beha-
vior if appropriate. Be sure your child knows of all rewards and punish-
ments beforehand.

Homework

Homework assignments after sessions  and  may include the following:

✎ Adjust the list of commands you give to each child.

✎ Continue to implement the morning, daytime, and night routines.
✎ Implement punishments for the next-highest-severity behavior if it
occurs.

✎ Implement rewards for the absence of the next-highest-severity

behavior.

✎ Continue to complete the daily logbooks.

SESSIONS 7 AND 8 Completing Treatment

In treatment sessions  and , treatment may begin to change in some key

ways. First, as your family nears the end of therapy, it is important that the
treatment procedures closely resemble what should be occurring naturally.
For example, your child should be entering school on her own without
much extra help. In addition, any rewards you give to your child should be
based more on verbal praise. Also, you may ease the strictness of morning
and evening routines if necessary and appropriate. However, be careful not
to stray too much from treatment procedures that helped your child return to
school.

Second, you and the therapist may extend treatment to related problems if
your child’s school refusal behavior is fully or nearly resolved. For example,

144
 the therapist may want to concentrate on commands you give your child
at other times (e.g., weekends) or for other behavior problems. You and the
therapist should not extend these treatment practices, however, until your
child’s school refusal behavior is under control.

As you move toward session , treatment can be finalized and you can dis-
cuss the end of therapy. Also, the therapist will want to give you recom-
mendations for handling your child’s behavior in the near and distant future.
The therapist may develop lists of problems to avoid and, if necessary,
schedule long-term follow-up contact and booster sessions (see chapter ).

Changing Parent Commands

The therapist will continue to review the commands that you give to your
child. If your child continues to have trouble going to school or under-
standing what you say, the therapist may help you make changes in your
commands. For some children, for example, parent commands must be
kept simple and compliance must be rewarded one command at a time. To
see if you have a firm grasp of good commands, the therapist may give you
a hypothetical example of a child behavior and ask you to respond to it. If
problems arise, the therapist will review material from previous sessions to
help you adjust your commands.

If your child is attending school on a near-regular basis, your morning

commands should not change. If you have other concerns, then talk to
your therapist now. For example, some children will start to attend school
and show excellent morning behaviors because their parent(s) focused so
much attention on challenging their bad behaviors. However, problems
may remain at night or on the weekends, and you should address them
now. In addition, some children will start to attend school but continue to
show attention-getting behaviors (e.g., excessive questions) in other places
(e.g., supermarket). The therapist may focus on your commands and re-
sponses in these places as well. Remember that the chances of relapse are
lower if you consistently use the treatment procedures for behaviors in dif-
ferent places and times. Finally, the therapist may help you extend treat-
ment to other children in the family if you wish.

By session , the therapist may help you finalize your commands. He or she
will give you a summary of the commands that are best for your child. The
therapist will show how certain commands helped your child return to

145
 school. Use these as much as possible. Remember some basics about com-
mands: simplicity, clarity, consistency, and immediate responses to listen-
ing or not listening. If desirable, develop with the therapist a written list of
good commands and types of comments to avoid.

Keep in mind that some families return to old patterns of behavior after
treatment ends. For example, some parents don’t practice their new com-
mand skills once their child is back in school. Some parents will “give their
all” during treatment but give up after treatment ends. In addition, some
children increase their school refusal behavior after treatment ends to test
their parents and force them to abandon firm commands. You should main-
tain contact with the therapist for some time after treatment ends. His or
her support and feedback about good commands will help cut down on the
chances of relapse.

Establishing Fixed Routines

The therapist will continue to work with you about morning and evening
routines for your child. By now, these routines should be quite predictable
to your child, and you should deal with any deviations immediately. If
your child continues to have problems attending school, the therapist will
help you change these routines as necessary. For example, some children re-
spond better to routines that involve just a few steps.

If your child is attending school on a near-regular basis, your morning rou-

tine should stay the same. If you have other concerns, then talk to your
therapist now. For example, some children will attend school but still need
a lot of structure at school or home or at night and on the weekends. Let
the therapist know of any differences between the morning routine and
routines for other times of the day. For any additional routines, consider
your child’s preferences but don’t let her dominate discussions. You have
the final say about routines.

By session , the therapist may help you finalize routines for morning and
evening (if your child is back in school, midday routines should be un-
necessary). The therapist will give you a summary of what routines are best
for your child. Remember some basics about routines: regularity, pre-
dictability, and immediate responses to breaking the routine. If desirable,
develop with the therapist a written summary of current routines and pit-

146
 falls to avoid (e.g., too much child influence, inflexibility, failure to give
punishments and rewards).

Keep in mind that some families return to old patterns of behavior after
treatment ends. For example, some parents become lax about enforcing
routines once their child is back in school. This sometimes happens when
parents want to give their child a break or the benefit of the doubt when
minor troubles start again. Unfortunately, this often leads to a child getting
more attention for inappropriate behavior (the original problem that re-
quired treatment). Remember that a basic goal of treatment has been to ac-
tively attend to positive behavior and ignore negative behavior at all times.
You should continue to adhere closely to the routines, respond neutrally to
your child during these routines, and work through problem behaviors.
Also, be sure to downplay excessive physical complaints and work to bring
your child to school at least part-time on days when she refuses to attend.
You should maintain contact with the therapist for some time after treat-
ment ends to prevent recurring problems.

Setting Up Punishments for School Refusal Behavior

The therapist will continue to review the punishments you give for school
refusal behavior. By now, these punishments should be quite predictable to
your child and should be given consistently. If your child continues to have
problems attending school, the therapist will help you make changes. For
example, some children will respond only to punishments that are stronger,
applied more immediately, or applied more consistently. If you are using
daytime punishments, the therapist will also want to know their effect and
help you make any necessary changes. The therapist may give you a hypo-
thetical example of a child behavior and ask how you might respond to it
using punishments and rewards. If problems arise, the therapist will review
material from previous sessions to help you adjust punishments and rewards.

If your child is going to school on a near-regular basis, then the punish-

ments should stay the same. If you have other concerns, then talk to the
therapist now. For example, some children will attend school but still re-
quire punishments for related behaviors such as aggression, noncompliance
in other settings, failure to complete homework, bedwetting and/or sleep-
ing with parents, tantrums, general disruptive behavior at home or in class,
and yelling, among others. If behaviors such as these remain a problem,

147
 then you should deal with them now. The chances of relapse will be less if
you understand how to use punishments consistently for different behaviors.

By session , the therapist may help you finalize the punishments you give
for school refusal behaviors and make changes where necessary (by this
time, daytime punishments should no longer be needed). He or she will give
you a summary of what punishments are best for your child. The therapist
will show how specific punishments helped your child’s return to school.
Remember some basics about punishments: fairness, predictability, consis-
tency, and immediate administration when needed. If desirable, develop
with the therapist a written summary of the useful punishments and pit-
falls to avoid (e.g., giving punishments too long after a specific behavior).

Keep in mind the danger of not giving punishments in the future. For ex-
ample, some parents stop giving punishments because of guilt, shame, de-
tachment, or nonchalance. Any current problems in this area should be ad-
dressed now. In addition, some parents differ in their responses to a child
or to children across different behaviors. Remember that consistency is es-
sential in giving rewards and punishments to children. Finally, some par-
ents fall into the habit of giving severe punishment every once in a while
instead of moderate, consistent, and predetermined punishments when-
ever they are appropriate. Some parents wait until a behavior problem is
very severe before giving punishment. Be sure to use appropriate punish-
ment every time your child misbehaves. If necessary, discuss with the thera-
pist the use of physical punishment and its pitfalls. Keep in mind that physi-
cal punishment may increase aggression in children. Stick to the treatment
procedures that the therapist outlined for you.

Setting Up Rewards for School Attendance

The therapist will continue to review the rewards you give for school at-
tendance. By now, the rewards should be quite predictable to your child
and should be given consistently. If your child continues to have problems
going to school, the therapist will help you change these rewards. Some
children respond to rewards that are stronger, applied more immediately,
or applied more consistently. If your child is attending school on a near-
regular basis, then the rewards should stay the same. If you have other con-
cerns, then talk to the therapist now. For example, rewards may be set up
for the absence of the behaviors mentioned above.

148
 By session , the therapist may help you finalize the rewards given for
school attendance and make changes where necessary. Be careful not to be-
come complacent about giving rewards in the future. Some parents stop
giving rewards once their child is back in school, but this often leads to fu-
ture relapse. In addition, some parents start to take school attendance for
granted, become busy and “forget” to recognize their child’s behavior, or
give big but infrequent rewards. All of these practices may lead to relapse,
however, and should be avoided.

Keep in mind that your child should know of any changes you decide to make
in future treatment. Children should not be punished for behaviors they
don’t know are wrong. Remember, if you need to punish, you don’t need
to explain, and if you need to explain, you don’t need to punish. In other
words, all rules, punishments, rewards, and unwanted behaviors should be
explained to your child beforehand, and she should know them by heart.

Homework

Homework assignments after sessions  and  may include the following:

✎ Continue to use appropriate commands. Periodically review the list

of pitfalls regarding commands given by the therapist.

✎ Continue to use the morning and evening routines. Periodically re-

view the list of pitfalls regarding routines given by the therapist.

✎ Use the punishments and rewards for the most severe school refusal
behaviors and related behaviors if applicable. Periodically review the
list of pitfalls given by your therapist.

✎ Contact the therapist as needed for support, feedback, answers to

questions, long-term follow-up, and booster sessions if necessary.

149
This page intentionally left blank
Chapter 7 Children Refusing School for Tangible
Rewards Outside of School

SESSION 1 Starting Treatment

If your child is refusing school for tangible rewards outside of school, then
he may be hiding school absences, displaying verbal and physical aggres-
sion, running away, spending an excessive amount of time with friends, and
acting disruptively to stay out of school. Your child’s behaviors may also in-
clude a hostile attitude, refusal to talk, drug use, gambling, or excessive sleep.
Up to now, the action your family has taken to reduce these problems may
have been marked by conflict, bribery, severe punishment, and confusion
about what to do next. In addition, you’ve probably noticed that family
conflict often leads to your child’s continued school refusal behavior.

You may have developed a certain way of responding to your child’s dis-
ruptive behavior and other problems that affect school attendance. This
treatment will teach your family a different way of coping with these prob-
lems. It will teach you skills that are alternatives to arguing and confusion.
Your family will practice problem-solving techniques. At first, the things
you learn may cause even more problems than before. For your family to
make progress, however, it is important that everyone work hard and
through difficult situations. The more everyone cooperates in therapy, the
faster your family will progress in treatment.

The focus of treatment is your entire family, but especially you, your
spouse or partner (if you have one), and your child who refuses school.
The major goal is to change the way your family solves problems, deals
with conflict, increases rewards for school attendance, and decreases rewards
for school absence. Specifically, this will involve:

■ Setting up times and places for negotiating solutions to problems

■ Defining behavior problems

■ Designing written contracts between you and your child to

tackle the problem

■ Implementing contracts

151
 The therapist will probably split the treatment time equally between you/
your spouse and your child. The therapist should speak with your child
first. The therapist should also mediate the first few contracts by negotiat-
ing separately with you and with your child. Speaking with the child first
is sometimes key to getting him “on board” the treatment program. It is im-
portant for the child to know that the therapist is considering his view as
much as the parent’s view.

A key element in contracting is that everyone negotiates in good faith. This means
that you and your child should give a reasonable account of what you are
willing to do and what you feel is unfair or unworkable. If there is anything
you feel uneasy about, say so. The therapist will ask about each line of each
contract to make sure it is satisfactory to you and your child. If it isn’t, you
and your child should speak up and ask for changes. Siblings should be
told about the treatment procedures so they know what to expect. In many
cases, it is preferable to include other children in the contract process so
they don’t feel left out and so they can help monitor compliance.

Establishing Times and Places to Negotiate Problem Solutions

At this time, the therapist will probably conduct the problem-solving/con-

tracting process entirely during the therapy session. In this way, the thera-
pist can see how you and your child design the contract, can provide detailed
suggestions, and can address any problems. In particular, the therapist will
note any communication problems your family may have, as well as other
behaviors (e.g., sabotage, refusal to participate) that interfere with good
problem-solving. If these interfering behaviors are minor, the therapist
may address them now. For example, if one family member has trouble ex-
pressing what he or she wants, the therapist can give some suggestions for
responding. However, if these interfering behaviors are major (e.g., fight-
ing), the therapist may want to assess them further and address them over
several sessions.

Although much of the problem-solving/contracting process will initially

take place in session, you and your child should think about times and
places that your family can talk about problems at home during the week.
In later treatment sessions, contracting should take place during these times

152
 at home. Think about times when everyone is home, when other matters
are not too urgent, when family members are relaxed, and when there are
no immediate distractions. This is often a difficult, if not impossible, task.
However, making time for problem-solving is essential if your family’s con-
flict and your child’s school refusal behavior are to be reduced. If you have
problems finding such a time, be sure to inform the therapist so that he or
she can address this in session. A common problem is when a family mem-
ber doesn’t want to participate in family meetings because he or she fears
that other family members will “gang up” on him or her.

Defining the Behavior Problem

When designing the first contract for your family, the therapist will want
to focus on a problem other than your child’s school refusal behavior. Al-
though this may seem counterintuitive, it is essential that family members
practice appropriate problem-solving on a simpler level at least once. This
will help the therapist gauge how fast or slow further treatment needs to
be. Setting aside school refusal behavior for the moment may also lessen
immediate family tension and pressure on your child.

The therapist may choose a minor problem that has recently occurred. Ex-
amples include not doing chores, not going to bed on time, not checking
in with a parent, or not completing a homework assignment. The therapist
will ask your family to tackle only one problem. Try to avoid problems that
are unsolvable, long-standing, or overly complicated. For example, don’t
focus on your child’s trouble with the law a year ago (now unsolvable),
your family’s conflict (which may be long-standing), or your family’s fi-
nances (too complicated). Keep it simple.

When defining a problem, each family member should participate. Differ-

ent family members may define a problem differently, but this is normal.
For example, you might define a problem as “He never takes out the garbage
when I ask him.” Your child might define the problem as “I have to take
out the garbage all the time.” Each definition is vague, however, and points
to a communication problem. As a compromise, your therapist might de-
scribe the problem simply as “The garbage is not being taken out on a regu-
lar basis.” In this case, no one is blamed and the problem is clearly defined.

153
Designing a Contract

As mentioned above, the therapist should mediate the first contract by ne-
gotiating separately with you and with your child. In this way, the thera-
pist can engage in “shuttle diplomacy” by working his or her way back and
forth between you and your child. After the behavior problem has been
well defined, the therapist will ask your child to describe as many potential
solutions to the problem as possible. Even humorous ones such as “Hiring
a maid to take out the garbage” should be included. The therapist will ask
your child to come up with  to  proposed solutions and rank them in
order of desirability. Desirability depends on whether the solution is prac-
tical, realistic, specific, and agreeable to everyone. After completing this
process with your child, the therapist will ask you to come up with your
own solutions and rank them in order of desirability.

The therapist will then propose one solution that is most desirable. All of
you should bargain in good faith and let the therapist know if the solution
is acceptable or not. Focus on compromise. For example, a good solution
to the problem presented here might be: “(Child) will be asked to take out
the garbage only on Wednesday and Saturday, but must take out the garbage
when asked on those days.” If you and your child agree to this solution, then
the therapist will move to the next step.

The next step is to develop rewards and punishments for completing or

not completing the contract. As before, the therapist will speak with you and
your child separately and focus on rewards and punishments that are desir-
able and agreeable to everyone. The first contract will be simple. For example:

(Child ) agrees to take out the garbage on Wednesday and Saturday if

asked. If (child ) completes this chore correctly, then (child ) will re-
ceive an extra half-hour of curfew on Saturday night. If (child ) does
not complete the chore, then (child ) will be required to be in the
house  hour earlier than usual.

As mentioned earlier, you may wish to add other children to the contract
as appropriate. The therapist will then close any loopholes that might exist
in the contract. In this contract, for example, it may be necessary to define
exactly when the child will take out the garbage, what the chore involves,
who will decide the chore was carried out correctly, and what time curfew
is supposed to be. In closing the loopholes, the therapist will give more say
to the parent(s). In addition, the finished contract should be time-limited—

154
 no more than a few days at most. In this way, if problems arise, the thera-
pist can address them quickly.

Implementing the Contract

Once the first contract has been designed, you and your child should read
it and say whether you agree to it. If not, then the therapist will renegoti-
ate the contract. If you reach agreement, then all of you will sign the con-
tract and get a copy. You should display the contract in some part of the
house where it can be read, referred to, and initialed daily by everyone. The
door of the refrigerator is a good place. You should ask final questions at
this point. Because this is the first contract, the therapist may contact your
family several times in the days following this session to help you address
any problems. In the meantime, reflect on what you have just accom-
plished. You and your child have agreed without fighting to solve a prob-
lem. If this contract is successful, you should be able to solve more difficult
problems.

Homework

Homework assignments after session  may include the following:

✎ Think about times and places where you can work on problem-
solving in the future.

✎ Think about problems and potential solutions for the next contract.
✎ Implement the current contract and contact the therapist if necessary.
✎ Continue to complete the daily logbooks. Note any specific situations
or experiences that arise during the week.

SESSION 2 Intensifying Treatment

This section describes how the therapist may intensify treatment for a child
refusing school for positive tangible rewards outside of school. As discussed
before, the major focus of treatment here will be you, your spouse, and
your child, although other children may be included as appropriate.

155
Establishing Times and Places to Negotiate Problem Solutions

At this time, it is still best to conduct most of the problem-solving/

contracting process in the therapy session. However, your family should
begin to meet at regular times at home to talk about the current contract
and what changes might be made at the next therapy session. As men-
tioned before, these times should have little distraction and full family par-
ticipation. This will allow your family to practice discussing important is-
sues, and will help the therapy process. In later treatment, contracting will
be taking place during these times at home.

For now, the therapist may ask you to schedule one or two home sessions
between sessions  and . During the home sessions, everyone should sit at
a table and talk about the contract or other issues. At first, this may be awk-
ward, and some children may call the process “stupid.” To ease tension,
limit the meeting to  to  minutes. Also, make sure that everyone has an
equal amount of time to speak. If there are four people in the family, for
example, give everyone  minutes to talk about whatever they want. Keep
time if necessary. Some other basic rules for the family meeting are:

■ Agree ahead of time about who will call the meeting to order.
Rotate this job among family members if possible and as appro-
priate.

■ As much as possible, limit the family discussion to the contract

and any complaints or problems each family member may have.
Try to stick to simple statements and avoid going off on tan-
gents. Avoid hurtful comments as much as possible.

■ Allow each person to speak without interruption. A person who

wants to respond to another must wait his or her turn. Try to
minimize questioning.

■ Do not allow the meeting to be dominated by one family mem-

ber, especially a parent. If someone is given  minutes to talk and
only  minute is used, then think about that person’s statement
in silence for  minutes.

■ Encourage family members to stay at the meeting for its entire

duration; if a family member does not wish to talk, he or she can
simply sit and listen to the others.

156
 ■ Praise everyone for attending the meeting.

■ If the meeting does not go well, end it and schedule another at a

later time. Examples of problems include insults and verbal and
physical fighting. In extreme cases where family members cannot
get along, then inform the therapist and discuss these issues in
session.

■ If the meeting goes well and a healthy discussion is taking place,

feel free to extend it. However, if one person thinks the meeting
is not going well, then it is not going well. You should then re-
schedule this session. An exception may occur if one family
member is deliberately sabotaging or disrupting the meeting. In
this case, family members should tolerate or include the disrup-
tive person as much as possible but ask him to leave if necessary.
The therapist should be made aware of this disruption to address
it as soon as possible. As a general rule, exclusions of this sort
should be kept to an absolute minimum.

■ Contact the therapist during the meeting if you have questions.

Defining the Behavior Problem

The therapist will review with your family whether the first contract was
successful. If you had problems, then the therapist will explore the reasons
why. Be honest about why the contract may have been unsuccessful. Talk
about even sensitive topics such as fighting among family members, low
motivation, or deliberate failure. The therapist will spend a lot of time talk-
ing about these issues and may want to re-implement the contract. Keep in
mind that some cases take longer than others to resolve. Additional prac-
tice with simpler contracts is often necessary before moving on to more
complicated ones.

If the first contract was successful, then the therapist may want to move on
to a second contract. This second contract may involve more complicated
problems that have nothing to do with your child’s school refusal behavior,
or some limited aspect of school refusal behavior. The more severe a child’s
school refusal behavior, the greater the chance a therapist will suggest the
first approach. In this way, the family has another opportunity to practice
problem-solving before tackling school refusal behavior.

157
 If the therapist believes it is appropriate to move to the next step, then the
next contract may contain some aspect of school attendance behavior (e.g.,
morning preparation). In addition, you should talk with the therapist
about other behaviors that could be in the contract. It is a good idea to in-
clude chores because later contracts may include paying youths for chores if they
attend school. In the meantime, however, talk about the chores, behaviors,
or problems on which you and your family would like to focus. Again,
avoid problems that are unsolvable, long-standing, or overly complicated.

You, your child, and the therapist will define each part of a new contract
and come up with compromises. For example, the contract may be ex-
tended to include () the garbage chore from before, () preparing for school
in the morning, and () obeying curfew (assuming that the latter two are
not currently being done). Be sure to define each part specifically. For ex-
ample, “preparing for school in the morning” might mean dressing and
eating by a certain time and “obeying curfew” might mean coming home
at a certain time at night. Specific times should always be set.

Designing the Contract

As before, the therapist will negotiate the new contract separately with you
and your child. Each of you should describe as many solutions to the prob-
lems as possible. Again, focus on solutions that are practical, realistic, spe-
cific, and potentially agreeable to everyone. Choose the one proposed so-
lution that is most desirable for each problem. For getting ready in the
morning, for example, a good solution might be to arrange the times at
which your child will do different things (e.g., eating, dressing). With re-
spect to curfew, a good solution might be to choose a time that is reason-
able to you and your child.

If each family member agrees to the definitions, then the therapist will help
you come up with rewards and punishments for completing or not com-
pleting the contract. As before, focus on those rewards and punishments
that are most appropriate and agreed upon by everyone. In addition, the
therapist will close any loopholes in the contract and make sure that the con-
tract is time-limited. You should also add a general statement to the con-
tract to declare your family’s commitment to the therapy process. A sample
contract based on the issues discussed here is presented in Figure .. A
blank contract form is also provided. You may photocopy this contract or

158
Sample Contract
Privileges Responsibilities

General

In exchange for decreased family conflict and a agree to try as hard as possible to maintain this
resolution to school refusal behavior, all family members contract and fully participate in therapy.

Specific

In exchange for an extra half-hour of curfew on take out the garbage on Wednesday and Saturday if
weekend nights, (child) agrees to asked.

Should (child) not complete this responsibility, he or she will be required to be in the house one hour
earlier than usual.

In exchange for the privilege of possessing a radio and rise in the morning at :, dress and eat by :,
television in his or her room, (child) agrees to wash and brush teeth by :, and finalize prepara-
tions for school by :

Should (child) not complete this responsibility, he or she will lose the radio and television and be
grounded for one day.

In exchange for the privilege of possessing a compact obey : p.m. curfew on school nights and :
disc player in his or her room, (child) agrees to curfew on weekend nights.

Should (child) not complete this responsibility, he or she will lose the compact disc player and be
grounded for one day.

(Child) and his or her parents agree to uphold the conditions of this contract and read and initial the contract
each day.

Signature of (child) and parents:

Date:
Figure 7.1
Sample Contract

159
Contract

Privileges Responsibilities

General

Specific

(Child) and his or her parents agree to uphold the conditions of this contract and read and initial the contract
each day.

Signature of (child) and parents:

Date:

160
 download multiple copies from the TreatmentsThatWork™ Web site at
www.oup.com/us/ttw.

Implementing the Contract

Remember that this new contract is appropriate only if your family suc-
cessfully completed the first contract, your family is getting along fairly
well, and you are reasonably sure that your family can handle all the parts
of this contract. If your family’s situation is different in some way (e.g., the
first contract was unsuccessful), then the therapist may proceed more
slowly and develop a simpler contract or ask you to re-implement the first
one. For moderate to severe cases of school refusal behavior, this new con-
tract may be appropriate because actual school attendance is not yet re-
quired. In many cases, a gradual buildup to school attendance is more
effective than immediately requiring the child to attend school. For milder
cases of school refusal behavior, where the child is missing school only part
of the time (e.g., certain classes), this new contract or a more complicated
one may be appropriate.

Once the contract has been designed, each family member should read it
and state whether he or she agrees to it. If not, then the contract will be
renegotiated. If everyone does agree to the contract, then everyone should
sign it and receive a copy. Everyone should ask final questions at this point.
Be sure to contact the therapist between sessions should any problems arise
or if a family member wants to talk about important issues concerning the
contract or your family. A common problem that arises is when a child agrees
to the contract because he feels pressured to do so or because he is frustrated
and wants to get out of the therapy session as soon as possible. It is a good
idea for the therapist to contact the child that night or the next day to see
if the child wants to make any changes in the contract or make known any
concerns he has about the therapy process.

Homework

Homework assignments after session  may include the following:

✎ Set up a time and place when a family discussion can occur. Meet
one or two times between sessions for these informal conversations.

161
 Follow the rules and record the conversation for the therapist if all
family members agree.

✎ Think about problems and potential solutions for the next contract.
✎ Implement the current contract and contact the therapist as necessary.
✎ Continue to complete the daily logbooks. Note any specific situa-
tions or experiences that arise during the week.

SESSIONS 3 AND 4 Maturing Treatment

In maturing of treatment, you and your child may revisit procedures from
sessions  and . In addition, you will learn about communication skills train-
ing, peer refusal skills training, alternative contract ideas, and what can be
done if your child continues to miss several classes during the school day.
At this point in treatment, contracting should focus more specifically on
your child’s particular school refusal behaviors. You may also work on deal-
ing with your child during the day if he skips school or remains home fol-
lowing tantrums or other problems. In doing so, you should begin to see
an effect on your child’s school refusal behavior and learn important skills
that may be useful for tackling other problems in the future. Many parents
learn skills that are useful in dealing with their other children as well.

Establishing Times and Places to Negotiate Problem Solutions

Your family should continue to meet at a regular time at home to discuss

the current contract and what changes might be made at the next therapy
session. At this point, you should meet about twice a week. The therapist
will ask you about these informal sessions. He or she will be interested in
whether the meetings have been actually scheduled and held, discussions
during the meeting, conflicts, points of agreement and disagreement, com-
pliments and insults, silence among certain family members, and areas that
need improvement. If you have numerous problems, the therapist may lis-
ten to an audiotape of the meetings, ask you to change or stop the meet-
ings, and/or conduct more in-depth family therapy in session. If the meet-
ings are progressing fairly well, your family should continue them during

162
 the week. By session , your family should practice negotiating with one
another just like you do in the therapy session. This will enhance problem-
solving and communication skills training.

Communication Skills Training

In communication skills training, family members are taught to have con-

versations without verbal abuse, hostility, negative thinking, interruptions,
or dismissals of each other’s statements. At this point in treatment, the thera-
pist may teach these skills if your family fights frequently and/or if mis-
communication is interfering with the contracting process.

Communication skills training initially involves having one family mem-

ber make a statement to, or ask a question of, another family member who
listens quietly. Following the first person’s statement, the second person is
asked to repeat or paraphrase what was said to make sure the message was
correctly heard and understood. For example:

CHILD: I feel like I can’t do anything with my friends.

FATHER: It sounds like you feel you want more time with your
friends.

During this first step, the therapist will concentrate on basic problems in
communication. Examples of such problems include interruptions, incor-
rect paraphrasing, refusal to do the task, silence, and hostile words (e.g., in-
sults). The therapist will stop a conversation as soon as a problem develops,
give feedback, and ask you to try again.

At this stage, your family should simply concentrate on giving short, clear
messages; listening; and paraphrasing correctly. Your family can practice
these steps in the therapy session and later during family conversations and
meetings. If possible, keep a list of problems that come up during family
discussions.

Defining the Behavior Problem

The therapist will review with your family the success or failure of the pre-
vious contract. If the contract failed, he or she will explore why. Be sure to
mention any family fights, motivation problems, or other factors that pre-

163
 vented the success of the contract. The therapist will want to spend time
dealing with these issues and re-implement the contract if possible.

If the previous contract was successful, your family should be proud. Re-
member that problems can be peacefully and effectively solved. Depend-
ing on your situation, the next contract could involve either more complex
problems that have nothing to do with school refusal behavior, or the in-
troduction of school refusal behavior as one key part. The more severe your
child’s school refusal behavior or your family’s fighting, the more likely the
therapist will use the first approach.

If your family is progressing well, then the next contract may focus more
on your child’s school attendance. One of the best ways to do this is to link
house chores, money, and school attendance. This must be done with cau-
tion and is subject to your approval, your family’s financial situation, and
whether the extra work and rewards are acceptable to you and your child.
The therapist will help your family develop a list of appropriate chores and
behaviors and then use this list to set conditions of the new contract. If you
object to using chores or money, then you will need to explore other re-
wards and punishments with the therapist.

During session , the therapist will review the success or failure of this con-
tract. Because this contract was the first to deal specifically with school atten-
dance, the therapist will explore at length any problems that prevented the
contract from succeeding. Many children fulfill their end of a contract
until school attendance is required. At this point, many children begin to
say one thing and do another. For example, it is not unusual for a child to
agree to school attendance in the therapy session but miss school the next
day. In this case, the therapist will look for the cause of such failure.

Peer Refusal Skills Training

A common reason for such failure is peer pressure to skip school. Your
child may fully intend to go to school, but once he is there, others tempt
or goad him into skipping school. The therapist may find it useful to teach
your child to use peer refusal skills to resist such pressure. Peer refusal skills
training meshes nicely with communication skills training because the thera-
pist focuses on talking to others in a more constructive way. To start, the
therapist may ask your child to describe what his peers say to try to get him
to skip school. For example:

164
T: Okay, Justin, you’re saying that you meant to go to school, but that
your friends kind of pressured you to skip yesterday afternoon?

C: Yeah, they found me in the hallway and kept after me to join them
off-campus for lunch. Then we just hung out and blew off the after-
noon.

T: What did your friends say to you to get you to skip school?

C: I don’t know; they just ragged on me. They kept saying we’d have
fun and that we’d do our work later. They said we’d just have lunch
for a couple of hours, but then it turned into the whole day.

The therapist and your child may then create statements that your child
can use to firmly but appropriately refuse offers to skip school. The thera-
pist will take into account your child’s fear of social rejection and build re-
sponses that will not let your child lose face. It is helpful sometimes for
youths to blame their school attendance on their parents or therapist, thus
absolving them (temporarily only) of blame. In addition, a child can talk
to peers about his interest in a particular class, the need to finish uncom-
pleted work, potential rewards for school attendance, or a lack of desire to
skip school. At this point in therapy, the therapist may find it useful to out-
line suggested responses to peer pressures and ask your child to try them at
school if the need arises. For example:

T: Okay, Justin, we’ve talked about some ways you can avoid being in
situations where your friends can pressure you into leaving school.
We’ll also work, as you agreed, on changing your lunch schedule so
you’ll eat earlier and see them less. But let’s assume that your friends
do track you down during the day and get after you to skip school.
What can you say to them?

C: I don’t know; maybe I don’t want to or maybe I can’t?

T: Okay, you could say that, but you’re not giving a definite reason. I’m
afraid that if you say “I don’t want to,” they’ll think you’re thinking
about it and keep after you. What are some specific reasons you can
give, like focusing on your parents or talking about your schoolwork?

C: I guess I could say my parents are really on my case about school

and I should go. Or I could say I have to finish my science project
that’s due. I guess I could even just say, “Some other time” and walk
away.

165
 T: Great! Let’s try those in case you do run into friends who ask you to
skip school. Let’s see how it works over the next few days, and I’ll
call you to see how it goes.

Remember that peer refusal skills training will likely be most helpful if peer
pressure is the main cause of interference with the school attendance con-
tract. 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 your child is giving “lip service” in session to you or the
therapist, then peer refusal skills may not be helpful and a more intensive
treatment alternative may be necessary.

Designing the Contract

As before, your therapist will focus on negotiation, compromise, and as-

surances that the contract is acceptable to everyone. In addition, he or she
will emphasize clear solutions, effective rewards and punishments, closed
loopholes, and a short timeline. This new contract should closely mirror
the previous contract but with necessary changes. In addition, the thera-
pist may tie communication skills training to the contracting procedure.
For example, he or she may bring your family together to form the contract
and practice listening and paraphrasing. A sample contract based on issues
discussed earlier (see “Defining the Behavior Problem”) is presented in
Figure .. Keep in mind that full-time school attendance does not neces-
sarily have to be pursued at this point. Sometimes asking the child to
simply attend a few of his favorite classes per day is a good start.

If your family does not approve of linking money to chores and school at-
tendance, then alternative contract ideas may be proposed. Examples of al-
ternative tangible rewards include extension of curfew, more time with
friends, fewer required chores, eating by oneself or with friends, videogames
and movies, car rides to school, and certain foods, among others.

Implementing the Contract

This contract is appropriate only if your family has done well to this point.
If your family struggled with this contract, then the therapist will repeat
procedures from sessions  and . The timeline for this contract should be

166
Sample Contract
Privileges Responsibilities

General

In exchange for decreased family conflict and a try as hard as possible to maintain this contract and
resolution to school refusal behavior, all family fully participate in therapy.
members agree to

Specific

In exchange for the privilege of being paid to complete attend school full-time between now and the next
household chores between now and the next therapy therapy session.
session, (child) agrees to:

Should (child) not complete this responsibility, he or she will be required to complete the household
chores without being paid.

In exchange for the privilege of possessing a radio and rise in the morning at :, dress and eat by :,
television in his or her room, (child) agrees to wash and brush teeth by :, and finalize prepara-
tions for school by :.

Should (child) not complete this responsibility, he or she will lose the radio and television and be
grounded for one day.

In exchange for compensation of five dollars, (child) vacuum the living room and clean the bathroom be-
agrees to: tween now and the next therapy session.

Should (child) not complete this responsibility, or he or she will not be paid.
complete the responsibility in an insufficient manner
(to be determined by parents),

(Child) and his or her parents agree to uphold the conditions of this contract and read and initial the contract
each day.

Signature of (child) and parents:

Date:
Figure 7.2
Sample Contract

167
 short and the next therapy session should be scheduled within  to  days.
This will give your family time to implement the contract and allow the
therapist to suggest changes if problems arise. In many cases, the first con-
tract dealing specifically with school refusal behavior is the most difficult to im-
plement. Therefore, be sure to rely on the therapist for support and feed-
back. Parts of previous contracts (e.g., curfew) may also be added to this
contract if you like.

Escorting Your Child to School

Despite the contract, your child may still not fulfill his part. Many children
will agree to school attendance but skip school during the day anyway with-
out peer pressure. As a result, appropriate rewards are never given and the
child continues to pursue inappropriate rewards outside of school.

If this is your situation, it may be necessary to walk your child from class
to class during the day. School officials are often unable to monitor children
during the day, so you (or your spouse or another adult you trust) may need
to do so. This requires a lot of effort and time on someone’s part. However,
the procedure is often effective because it ensures school attendance and al-
lows a child to earn appropriate rewards. In addition, the potential embar-
rassment is sometimes enough to prompt school attendance. At this stage
in treatment, the therapist may simply suggest this procedure as an option
for your family (including your child) to consider if the next few school
attendance contracts do not succeed. However, if there is some urgency in
getting your child back to school, you may use escorting now. Be sure to
discuss this procedure with the therapist before starting.

Homework

Homework assignments after sessions  and  may include the following:

✎ Continue to meet informally as a family once or twice between now

and the next session. Discuss the parts of the current contract that
remain a problem and those that are most effective. Also discuss how
family members communicate and what should change. Record the
conversation for the therapist if desirable. Practice communication
skills as appropriate.

168
 ✎ Think about problems and potential solutions for the next contract.
✎ Implement the current contract and contact the therapist if necessary.
✎ Begin to use peer refusal skills and escorting as appropriate.
✎ Continue to complete the daily logbooks, noting any specific issues
or situations that may arise during the week.

SESSIONS 5 AND 6 Advanced Maturing of Treatment

In treatment sessions  and , advanced maturing of treatment should take

place. The basic elements of contracting—defining problems and negoti-
ating solutions—will continue to be the focus of these sessions. However,
other procedures such as communication skills training and peer refusal
skills training may be broadened as well. Remember that for children who
are progressing more slowly, repetition of previous procedures might be ap-
propriate. You should take a hard look into what is happening in your
home and what remains to be done. By this time, all the daily procedures
(i.e., family meetings, contracts, refusal skills) should be “up and running”
and finely tuned to your family’s situation. At this point, you and the thera-
pist should have an open discussion of what remains to be done and change
what may be blocking treatment success. In addition, these later sessions
sometimes call for more creativity, and you and the therapist should try to
create innovative modifications of the techniques described here. For ex-
ample, you may need to be inventive about certain parts of a contract, in-
creasing or enhancing family communication, or helping a child refuse
offers to skip school.

Establishing Times and Places to Negotiate Problem Solutions

The therapist will review your family meetings that have been taking place
at home. In particular, he or she will explore how well your family negoti-
ated solutions to problems and will analyze audiotapes of the meetings if
necessary. The therapist will check to see if family members were able to
listen to one another and correctly repeat or paraphrase each other’s mes-
sages. The therapist will check for interruptions, incorrect paraphrasing,

169
 insults, and silence, among other behaviors. If you made a list of commu-
nication problems, discuss it with the therapist. If your family had problems
with the first step in communication skills training, then the therapist will
continue to build listening and paraphrasing skills. Keep in mind that if
your family is having extreme problems communicating, then more ex-
tensive family therapy and exploration of other issues might be appropri-
ate and can supplement the procedures described here.

Advanced Communication Skills Training

Techniques

If your family did listen and paraphrase well over the past few days or ses-
sions, then you may go on to the next step in communication skills train-
ing. This might involve practicing conversations without hostility. To start,
the therapist may suggest certain rules about what you should avoid in a
conversation. He or she will encourage family members to avoid name-
calling, insults, sarcasm, inappropriate suggestions, and screaming, among
other behaviors. If these behaviors are not a problem, then the therapist
may address less serious problems (e.g., lack of eye contact, articulation).

Conversations between family members should first be short, involve two

family members only, and be closely monitored by the therapist. He or she
will use a role-play and feedback procedure that will be explained to each
family member. This might first involve a conversation between one fam-
ily member and the therapist in front of other family members. In the fol-
lowing example, the therapist 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 haven’t
done so in a long time. The intention is to have the other party (in this case,
the father) and other family members model an appropriate conversation.

C: I just don’t understand why I have to go to school. I’m almost 

years old and everybody keeps treating me like a little kid.

T: (Acting as father and looking directly at the child) It sounds like

you’re kind of angry.

C: Yeah, I am. Why can’t you just leave me alone to do my own

thing?

170
T/F: Can you be more specific? I’m not sure what you mean.

C: I want to spend more time with my friends. I should be able to go

out if I want to.

T/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?

C: 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, the therapist will point out to everyone the appro-
priate behavior that was demonstrated: calmness of tone, lack of interrup-
tions, acknowledging another person’s viewpoint, correct paraphrasing, and
lack of insults or other derogatory remarks. In this example, the therapist/
father gathered information from the teenager without judgment or de-
fensiveness. The problem (i.e., time with friends) was identified and de-
fined accurately and negative emotions were vented appropriately.

During this role-play process, be sure to raise any questions you may have.
The therapist may practice a one-on-one conversation with your child to
reinforce some important points (e.g., listening). Later, two family mem-
bers (e.g., father, son) may be asked to speak directly to one another in a
short conversation. The therapist will monitor this conversation closely
and interrupt and give feedback if problems develop. Example:

C: Well, 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.

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

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

T: Good. Let’s find out exactly what concerns your son. (Motions to
do so)

F: Okay. What exactly concerns you?

C: 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.

171
 F: Okay, how much time do you feel you need to spend with your
friends? (Therapist nods to approve of this statement)

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

T: Okay, John, let’s stick to answering the question. Try to leave out
statements or questions that are sarcastic or too negative.

C: Okay. I’d like to spend at least a couple of hours a night with my

friends. Maybe some more time on the weekends. (Therapist nods)

F: Okay, so  hours a night on a school night after chores and home-

work and dinner are done? Does that sound about right?

C: Yeah.

The therapist will introduce different issues in these dialogues between two
family members to help you practice appropriate communications. The
therapist will make a recommendation about how long to practice these brief
conversations before taking the next step. The next step could be other
one-on-one conversations (e.g., mother–child) or adding more people to
the conversation. Once a particular parent–child dialogue is progressing
well, for example, the other parent may be added. You should be careful,
however, to avoid overly strict alliances (e.g., two parents versus one child)
that could damage the communication process. Should problems occur,
the therapist will again step in and give feedback. For example:

C: When I’m with my friends, I should be able to do what I want.

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

C: Yeah, I guess so. I’m almost an adult.

F: Well, you’re getting there . . .

M: (To father) Frank, he’s not an adult.

F: I realize that, but John seems to feel he’s becoming an adult. (To
child) Right?

C: 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.

172
 T: 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? (Therapist nods)

If your family has done well listening, paraphrasing, and having short con-
versations without many problems, then communication skills training
may advance even further. This might involve practicing extended conver-
sations that are increasingly constructive in nature. As before, this will in-
clude role-play and feedback in which the therapist first demonstrates an
extended, constructive conversation with another family member. As the
family practices these extended conversations, the therapist will closely watch
for negative communication. In addition, your family may focus more on
increasing compliments and other pleasantries. The therapist may also spend
time helping family members reframe comments in a positive way. For ex-
ample, a statement such as, “You barely finished your homework” may be
translated into, “I really like it when you finish your schoolwork on time.”

Potential Problems

Several things may prevent communication skills training from working

quickly or at all. These include pessimism, punishment of one converser,
and silence. In many cases of severe school refusal behavior, family mem-
bers have been fighting for several months or years. As a result, they have
set negative patterns of talking and are pessimistic about change. It is im-
portant for family members to see that they can learn to interact well at a
simple level and that this signals hope for future change. Therefore, ex-
tended practice at this stage may be necessary, and simple positive conver-
sations may be a realistic final goal. A second problem occurs when one
family member continually criticizes another during a conversation. In this
situation, the therapist may act as a mediator by allowing one person to
speak, paraphrasing the message himself or herself, and then presenting it
to the second person. Be sure to raise any unresolved family issues that
cause hostile conversations between family members. Finally, if silence is
an issue, the therapist may focus on those family members who are willing
to talk and allow the silent member to watch these conversations. In a one-
on-one meeting with the silent member, the therapist may try to convince
that person to participate in therapy as much as possible.

173
 Be aware that your family may not be able to change all hostile conversa-
tions in a short period of time. By this time in treatment, however, you and
your family should know what makes a good conversation and what pre-
vents a good conversation. Your family should become skilled at listening
to one another and accurately paraphrasing what is said. In addition, your
family should be using these new ways of communicating in your home
meetings and when designing new contracts. If your family has not yet
reached this point, the therapist will repeat the procedures practiced in
previous sessions. Also, the therapist will continue to explore other issues
and family dynamics that prevent family members from having positive
conversations.

Defining the Behavior Problem

The therapist will review with your family the success or failure of the pre-
vious contract. He or she will explore at length any problems that prevented
the contract from succeeding. One thing that often blocks a successful con-
tract is a child’s activities with his friends outside of school. These activities,
which are sometimes powerful enough to overwhelm a contract, may range
from those that are minor (e.g., eating lunch in a fast-food restaurant for a
short period of time) to mid-range (e.g., hanging out in a shopping mall for
an afternoon) to major (e.g., day parties, drug use, sexual activity, gambling
for extended periods of time). By this time in treatment, you should know
where your child is during each school day and what he is doing.

If problems continue to interfere with the school attendance contracts,

then you may need to take more serious steps. These could involve adding
stronger rewards for school attendance and stricter punishments for non-
attendance (if all parties agree), increasing parent supervision of the youth
during the day, and/or legal intervention (e.g., contacting police to break
up an illegal drug party). Any legal intervention must be used with caution
and you should consider all consequences, including effects on the therapy
process. Be sure to consult the therapist.

Another child activity that interferes with school attendance contracts is

excessive sleeping in the morning or an inability to get up. This is some-
times worse for youths who have been out of school for some time and who
are not used to getting up in the morning. For many adolescents, difficulty
getting up is normal and temporary. In other cases, the child has a medical

174
 problem or a true sleep disorder that requires attention (if this is so, then
be sure to consult with a medical doctor or sleep disorders clinic for as-
sessment and treatment). In still other cases, the child has simply stayed up
too late and not gotten enough sleep. In a few other cases, the child is feign-
ing fatigue to avoid school.

In the latter two cases, you and the therapist will need to design innovative
ways of getting your child out of bed and ready for school. Try setting regu-
lar morning and evening routines and bedtimes (see chapter ), increasing
rewards for rising by a certain time, setting the alarm clock earlier in the
morning and constantly reminding your child to get up, and allowing your
child to get up later and then walk to school on his own. This usually re-
quires some supervision, and there is no guarantee the child will get up.
Some parents try more drastic measures, but coercive procedures are not
recommended. Try to negotiate a solution to the problem with your child
and incorporate the solution into the next contract.

At this stage in treatment, your family should be able to define behavior

problems. Each family member should be giving his or her opinion about
how to define a behavior problem as well as appropriate contract rewards
and punishments. If this is not the case, the therapist will repeat procedures
described in previous sessions.

Finally, you and your child should have strategies for making up past school-
work and maintaining academic performance. These strategies may include
after-school programs, extra tutoring, supervised homework time, daily re-
port cards, weekly progress reports, rearrangements of class schedules, and/or
teacher meetings to collect assignments. Children who like assigned school-
work and/or do well in school are more likely to stay in their classes. As ther-
apy progresses, you and your child may consider defining different academic
problems and solutions and incorporating these into a separate contract.

Peer Refusal Skills Training

By this time in treatment, your child should know how to respond to peers
who try to get him to skip school. In particular, your child should know
specific phrases and conversational techniques that enable him to refuse
peer pressure without being ridiculed or rejected. In addition, your child
should be able to recognize and avoid situations that produce temptations
to leave school.

175
 If peer pressure continues to be an issue, however, then the therapist will
check your child’s refusal skills. If necessary and possible, the therapist will
suggest other coping skills such as avoiding certain places at school, not
talking to certain peers, and completing homework in the library. In addi-
tion, the therapist may use cognitive restructuring procedures to modify
any erroneous thoughts your child has about his peers and about refusing
offers to skip school. For example, children commonly worry that after
turning down offers to skip school, they will lose friends, appear ridiculous,
or feel humiliated. If these things are possible, then cognitive restructuring
may not be helpful. However, if your child is clearly worried for no legiti-
mate reason when refusing offers to skip school, then cognitive procedures
may be helpful (see chapter ).

Designing the Contract

If the previous contract involving school attendance was unsuccessful, the

therapist will explore any outstanding issues that block the design of an
effective contract. If the contract was successful, the therapist will likely
ask family members to renew it. However, you may make changes in the
contract if everyone agrees. In addition, your family may design a second
contract to address other concerns, such as time and activities with friends
(Figure .), oversleeping, and academic problems. In doing so, remember
to define each issue specifically and create solutions that are acceptable to
everyone.

By this point in treatment, you and your family should be able to design a
good contract for a particular problem. You and your family should prac-
tice good communication skills during the contract design process. For ex-
ample, family members could have short one-on-one conversations about
possible changes in the upcoming contract. Involve as many family mem-
bers in this process as possible.

Implementing the Contract

The therapist will ask you to implement the school attendance and/or an-
other contract by following the procedures described previously. By the
end of session , you and your family should be able to recognize problems

176
Sample Contract
Privileges Responsibilities

In exchange for the privilege of spending two hours adhere to all aspects of the school attendance contract
per school night (:–: P.M.) and three hours per and inform his or her parent(s) where he or she will be
weekend night (:–: P.M.) with friends between before leaving the house as well as any changes in
now and the next therapy session, (child) agrees to: where he or she will be when with his or her friends.

Should (child) not complete this responsibility, he or she will be required to stay in the house for the
next two evenings.

(Child) agrees not to engage in any illegal activity this contract is terminated and (child) will be required
during time spent with friends. Should (child) not to stay in the house during the evening until the next
complete this responsibility, therapy session.

(Child) and his or her parents agree to uphold the conditions of this contract and read and initial the contract
each day.

Signature of (child) and parents:

Date:
Figure 7.3
Sample Contract

sticking to a contract and fix them accordingly. If not, you should discuss

this in the therapy session, because problems in this area now may lead to
problems in the future. Talk about anything (e.g., low motivation) that
seems to break down a contract.

Escorting Your Child to School

If you have found it necessary to walk your child from class to class during
the school day, be sure that he is rewarded for school attendance. In addi-
tion, find out whom you should contact if your child leaves school, and how
you can gradually withdraw from the escorting situation. Try to rely more
on school personnel (e.g., teachers, guidance counselors, attendance offic-
ers, hall monitors) to monitor your child and/or give you daily reports about
your child. In this way, your child will come to expect that his school atten-

177
 dance is always being checked. As much as possible, provide rewards or pun-
ishments for school attendance or refusal immediately after the behavior.

In some cases of very persistent school refusal behavior, parents find it

quite difficult to constantly follow through on implementing contracts, ad-
ministering punishments, and/or escorting a child to school and classes. In
these cases, some family members feel guilt and frustration and find that
their home resembles a battlefield. You should continue to focus on re-
solving school refusal behavior during the week. However, you also need
to maintain family cohesion and fun. In some persistent school refusal
cases, for example, it may be necessary for families to set aside treatment
procedures on the weekend and enjoy some fun activities together. Because
the therapist knows your situation well by this point, consult with him or
her about this.

Homework

Homework assignments after sessions  and  may include the following:

✎ Continue to meet informally as a family one or two times between

now and the next session. Record your conversations for the therapist
if desirable. Discuss aspects of the current contract that are problem-
atic and effective. Practice communication skills as appropriate and
desirable.

✎ Think about problems and potential solutions for the next contract(s).
Follow through on procedures to reduce any barriers to contract success.

✎ Continue to use refusal skills as appropriate.

✎ Implement the current contract and contact the therapist if necessary.
✎ Continue to complete the daily logbooks.

SESSIONS 7 AND 8 Completing Treatment

In sessions  and , treatment may begin to change in some key ways. First,
as your family nears the end of therapy, it is important that the treatment
procedures more closely resemble what should be occurring naturally for

178
 your child. For example, your child should be going to school on his own.
In addition, any rewards you give to your child should be made more natu-
ral if possible. Also, your family should be setting up contracts more inde-
pendently of your therapist. Be careful, though, not to stray too much from
treatment procedures that led to your child’s return to school.

Second, treatment procedures may be extended to related problem areas if

your child’s school refusal behavior is fully or nearly resolved. For example,
you may develop contracts for other time periods (e.g., weekends) or be-
havior problems (e.g., arguing). You and the therapist should not extend
these treatment practices, however, until your child’s school refusal beha-
vior is well under control.

In sessions  and , treatment procedures can be finalized and you may

wish to talk about ending therapy with the therapist. Also, the therapist
may make recommendations to your family about handling child behavior
problems and other issues in the near and distant future. The therapist may
develop lists of potential pitfalls to avoid, and schedule long-term follow-
up contact and booster sessions (see chapter ).

Establishing Times and Places to Negotiate Problem Solutions

The therapist will review the family meetings that have been taking place
at home, especially how family members practiced negotiation and com-
munication. Review your family’s list of major problems in this area. If
your family continues to fight or have trouble developing contracts, then
the therapist will review material from previous sessions to help you im-
prove negotiation or communication.

To ensure that your family has a firm grasp of negotiation and communi-
cation skills, the therapist may give you a hypothetical example of a family
problem and ask family members to discuss it. The therapist will check the
conversations for communication problems and address them as necessary.

If your child is going to school on a near-regular basis, then the family

meeting/negotiation/communication process should stay the same. If you
have other concerns, then talk to the therapist now. For example, some fami-
lies become good at talking about school refusal behavior but not other
areas. Fighting often continues about marital issues, the child’s other be-
havior problems, activities outside of the family, finances, and sibling be-

179
 haviors. If desirable, the therapist will extend negotiation and communi-
cation skills training to these other problems. Remember that the chances
of relapse will be lower if your family deals with all problems appropriately.

By session , the therapist may finalize his or her review of the family meet-
ings that have been taking place at home, and of details about how your
family negotiates and communicates with one another. Also, the therapist
will give your family a summary of guidelines about speaking with one an-
other appropriately. In doing so, he or she will point out how certain ways
of negotiating and communicating helped your child return to school. Re-
member some basic themes regarding negotiation and communication:
simplicity, clarity, respect, and two-way interactions.

Remember that it is easy to slip back into old patterns of communicating

once a relatively calm household has been restored. Family members some-
times go back to silence or yelling to make their point. Also, parents some-
times start to take good child behaviors for granted and give punishment
(and no rewards) only after severe problems occur. To help counteract this,
families should continue to meet regularly and practice the negotiation and
communication skills learned in therapy.

Defining the Behavior Problem

The therapist will review with your family the success or failure of the pre-
vious contract. As before, he or she will explore any problems that pre-
vented the contract from succeeding. If peer pressure continues to be an
issue, then the therapist will check the progress of your child’s refusal skills
and see if and how they were used. If your family continues to have trouble
resolving problems, then the therapist will help your family redefine beha-
vior problems, rewards, and punishments. If necessary, he or she will go
back to the point where contracts were simpler and more time-limited. To
ensure that your family has a firm grasp of how to define a problem, the
therapist may give you a hypothetical example of a vague problem and ask
family members to define it. He or she will watch for problems and address
them as necessary.

If your child is going to school on a near-regular basis, then your con-

tracting process should stay the same. If you have other concerns, then talk
to the therapist now. For example, some families have other problems that

180
are less well defined than school refusal behavior. Dealing with such prob-
lems now will give your family good practice at defining even vague be-
haviors. List additional problems for the therapist. Examples of behaviors
related to school refusal include aggression, noncompliance in other set-
tings, failure to complete homework, social withdrawal, tantrums, refusal to
move, general disruptive behavior at home or in class, arguing, and yelling,
among others. If these behaviors are a problem, work with the therapist to
develop specific definitions now in case you want to use them in the future.

In addition, some parents continue to have vague complaints about their

child such as, “Joshua lacks self-confidence in school,” “Sarah shows a lack
of respect for others,” or “Andrew’s just a bad kid.” Family members should
stay away from statements that may be insulting in nature, and restate sen-
tences in a positive and clear manner. In the sentences presented here, for
example, the following restatements could be made: “Joshua needs to raise
his grades to a ‘B’ level,” “Sarah and her parents need to interact by speak-
ing in a normal tone of voice,” and “Andrew needs to get more involved in
positive extracurricular activities.” Remember that specific, positive state-
ments have more therapeutic value than vague, punishing ones.

By session , the therapist and your family may finalize the last set of be-
havior problem definitions. The therapist will give the family a summary
of examples and guidelines about defining key behavior problems. Be sure
to make up some sample definitions of common problems in case your fam-
ily needs them later. Also, the therapist may point out how defining prob-
lems in a specific way helped your child’s return to school. Remember some
basics regarding problem definition: be simple and specific, handle one
issue at a time, and allow all members to contribute their own definitions.

Remember as well that it is easy to slip back into old ways of defining prob-
lems once a relatively calm household has been restored. In particular, fam-
ily members sometimes develop a tendency to define a behavior problem
specifically (e.g., child needs to be in school) but not completely (for how
long?). Be sure to cover all the bases. In addition, keep in mind that your
child may need ongoing support to resist peer pressure to skip school. You
may go over ways of doing this with the therapist. Finally, remember that
a key to stopping school refusal in the future is to help your child maintain
his academic performance. This may require ongoing contact between you
and school officials, who can supply daily or weekly report cards.

181
Designing the Contract

The therapist will ask you to design a new contract to fit your family’s cur-
rent situation. Try to extend the contract timeline (e.g., to  to  weeks) if
appropriate, and practice communication skills with as many family mem-
bers as possible during this process. If your family continues to have prob-
lems designing contracts, then the therapist will review material from pre-
vious sessions to help you.

To ensure that your family has a firm grasp of how to design a contract and
communicate appropriately, the therapist may give you a hypothetical ex-
ample of a vague problem and ask you to design a contract for it. For ex-
ample, the therapist may give your family a scenario in which the child has
recently started to eat in his room to stay away from family members. In
this example, the therapist may add that increased family fighting makes
the child want to eat alone. The therapist will keep the sample problem
somewhat vague to get your family to deal with an unclear situation. Re-
member, you may be dealing with similar unclear situations in the future.

Following this description, your family should start the problem-solving

steps taught in the last few sessions. The therapist will observe how you de-
fine the problem, communicate with one another, and design a contract.
He or she will see if one or a few family members dominate the process, and
will step in if your family has problems. Following this “practice time,” the
therapist will give your family feedback about areas of success and areas
that need improvement. Be sure to raise and resolve any remaining issues
that might break down effective contracts in the future.

If your child is going to school on a near-regular basis, then the contract

design process should stay the same. If you have other concerns, then talk
to the therapist now. In addition, draw up sample contracts for related
problems in case you want to use them in the future.

By session , your family and the therapist may finalize the last set of con-
tracts. The therapist will give your family a summary of examples and
guidelines about designing contracts. Remember some basics regarding
contract design: agreement by all members, specific and tightly defined
conditions, strong reinforcers and punishers, limited timeline, signatures,
and daily checking by all members. The therapist may point out how spe-
cific contracts helped your child return to school.

182
 Remember that because the contracting process requires time and effort,
families sometimes stop using the process once therapy has ended. In par-
ticular, families may start to use “oral contracts” where there is general
agreement that if the child does “A,” the parents will do “B.” This method
has two main problems. First, families often do not take enough time to
carefully design the contract, thus leading to possible loopholes, misinter-
pretation, and forgetfulness. Second, parents are willing to bribe their child
for some good behavior (e.g., school attendance) and not give punish-
ments for some bad behavior (e.g., school refusal). Try to follow the formal
contract process that you learned in therapy.

Implementing the Contract

The therapist will ask you to implement this contract following the proce-
dures used previously. If your family continues to have problems imple-
menting contracts, the therapist will review material from previous sessions
to help your family follow through. Also, if possible, start to gradually
withdraw from going to school with your child if you are currently doing
so. Rely more on school officials to monitor your child and/or give you
daily reports about him.

If your child is going to school on a near-regular basis, then implement the

contract in the same way as before. If you have other concerns, then talk
to the therapist now. For example, some family members may want to add
other behaviors and conditions to the current contract. Be sure not to add
too many. If necessary, draw up several small contracts.

By session , your family should be implementing the final contracts de-

signed in session with the therapist. Implement these contracts using the
procedures described previously. Discuss any remaining problems that in-
terfere with the use of contracts. In particular, the therapist will discuss po-
tential problems that often trouble families once they leave therapy. For ex-
ample, some families change the contract midway between the start point
and end point. If the purpose of this is to close loopholes, that is fine.
However, youths often pester their parents to ease up on restrictions and
make the contract more favorable to them. Be careful to avoid this. In ad-
dition, families sometimes extend a contract indefinitely without dis-
cussing it further. This may not consider changes in the child’s life, for ex-

183
 ample, that might make the contract obsolete. Instead, discuss contracts at
length at least once a week.

Homework

Homework assignments after sessions  and  may include the following:

✎ Meet formally as a family to discuss issues and problems at least

twice per week. Practice communication skills. If a family member
wishes to raise a problem, have each family member define it as spe-
cifically as possible.

✎ During these meetings, formulate a contract for a defined problem if

appropriate. Implement the contract for a limited time. Discuss as-
pects of the current contract that are problematic and effective. Try
to reduce problems that block contract success.

✎ Continue to use peer refusal skills and make up schoolwork as

appropriate.

✎ Periodically review lists of pitfalls regarding each of these treatment

components given by the therapist.

✎ Contact the therapist as needed for support, feedback, answers to

questions, long-term follow-up, and booster sessions if necessary.

184
Chapter 8 Preventing Slips and Relapse

This chapter defines slips and relapse and gives you a brief overview of how
the therapist may help your family prevent your child from returning to
school refusal behavior. As mentioned in chapter , long-term school re-
fusal behavior may lead to long-term problems as your child ages. As a re-
sult, you must work to prevent any backsliding and to address any new
problems that do occur as soon as possible. The therapist will likely make
more specific recommendations based on your particular case.

Slips Versus Relapse

A slip is a single error or some backsliding following treatment. A slip might

be a missed school day,  or  days of high stress, short-term avoidance of
a particular class, and/or intense but brief acting-out behaviors to stay home
from school. Minor slips are not unusual after treatment and are common
following long weekends, extended vacations, or, in the case of year-round
schools, track breaks.

Relapse, on the other hand, may be defined as a return to old problematic

behaviors or substantial backsliding almost to the point when therapy
started. Therefore, relapse might involve 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 at-
tention or positive tangible rewards, and/or excessive family conflict over a
child’s school refusal behavior.

If Slips Occur

If slips happen, and they probably will as your child tests your resolve, then
return to the therapeutic assignments described in this manual. In addi-
tion, remember the key aspects of the skills that you and your child have
learned (see chapters  through ). If necessary, review with the therapist
some of the key aspects of exposures, relaxation and appropriate breathing,

185
 dispute handles and cognitive restructuring exercises, parent commands,
forced school attendance, parental firmness and consistency regarding school
attendance and refusal, contracts, communication skills, and other tech-
niques in this manual. It is a good idea to design, with the therapist, “re-
lapse prevention sheets” that contain key reminders of what to do in a given
situation. You and your child can then refer to these sheets periodically.

Some general sample reminders for each treatment package are listed in
Table .. Keep in mind that this is not an exhaustive or even a necessarily
pertinent list. The therapist will help you design certain relapse prevention
reminders in accordance with your family’s particular history and con-
cerns. Specifically, these relapse prevention sheets often involve child-based
strategies to cope with certain anxiety-provoking situations, procedures for
getting homework and attendance records, house rules, contracts, and ap-
propriate family responses to different child behaviors (e.g., what the fam-
ily should do if the child runs away from school or avoids class).

Don’t be discouraged when slips happen. Some family members make the
mistake of thinking that if the child refuses school again or becomes some-
what more anxious, then the entire therapy process was wasted. This is not
true. Slips are usually the result of relaxed efforts and not incompetence on
your part or your child’s part. Instead, try to view the situation as a challeng-
ing one that will help you and your child practice the skills learned in therapy.

If slips continue for a while, or if you and your child are becoming in-
creasingly frustrated about renewed school refusal behavior, then contact
the therapist. In fact, the therapist may recommend that you stay in occa-
sional telephone contact as needed after your family ends formal treatment.
This is a way of discussing progress as well as any new issues that arise that
contribute to slips (e.g., changes in class schedule, academic problems, other
stressors). However, try not to become too dependent on the therapist for
feedback. Instead, try initially to solve any new problems or slips based on
skills that you and your child learned in therapy.

If Relapse Occurs

If slips are becoming too frequent, however, and your child seems to be re-
lapsing into regular school refusal behavior, then be sure to discuss this with
the therapist. He or she may be able to provide some feedback on what to
do or schedule you and/or your family for additional treatment sessions.

186
Table 8.1. Sample Relapse Prevention Reminders For Families

For children who refused school to avoid objects or situations that cause general distress/negative affectivity
. Practice relaxation and breathing exercises when needed and once per week.
. Record stressful parts of the day and review them with parents at night.
. Put aside a safety signal and approach and complete one stressful activity per day.
. Practice self-reinforcement when appropriate exposure occurs.

For children who refused school to escape aversive social and/or evaluative situations
. Keep a journal of automatic thoughts during stressful times of the day.
. Practice changing thoughts to coping, helpful ones when necessary.
. Approach and have a five-minute conversation with three people per day.
. Participate in one extracurricular activity per semester.

For children who refused school for attention

. Review commands given to the child daily.
. Administer consequences for misbehaviors as soon as they occur in different settings and at different times; work
through tantrums in preparing the child for school.
. Maintain the regularity and predictability of the child’s morning routine.
. Allow the child to ask one question on one topic per hour.

For children who refused school to pursue tangible reinforcement outside of school
. Monitor the child’s school attendance on a daily basis.
. Contact teachers or other school officials once per week regarding the child’s academic work.
. Schedule one family problem-solving meeting per week.
. Develop and implement a contract twice per month.

Do not wait until the following school year to address relapse. Some parents,
if their child starts refusing school again in the late spring, become dis-
couraged and simply wait out the school year or believe there is no point
in addressing school refusal behavior at so late a time. However, if the child
successfully refuses school during the late spring, this may mean that she
will be out of school for several months (i.e., during spring and summer).
This will make getting the child back to school in the fall a much harder
task. A better strategy would be to reintegrate your child back into school
in the late spring (with, perhaps, the therapist’s help) and then pursue sum-
mer classes or other strategies to keep your child active and knowing that
you will react to school refusal behavior whenever it occurs.

If relapse happens, don’t be discouraged. Relapses do happen, especially in

more severe cases of school refusal behavior. However, perseverance is often
as important a quality as any of the techniques described in this manual.

187
 In other words, the more you and your child keep trying to resolve the
problem, the more long-term success you and your child are likely to see.

Preventing Slips and Relapse

There are techniques that you, your child, and the therapist may engage in
to try to prevent slips and relapse even before they begin. Some of these
techniques can take place as therapy is ending, and others may take place
at some time in the future.

Photographs and the Return-to-School Storybook

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 may also be useful for children who refused school for atten-
tion or positive tangible rewards and who may be in school for the first time
on their own. Whatever the reason, photographs are a way to reinforce your
child for her accomplishments. You can display the pictures in a prominent
place in your home (e.g., refrigerator, bedroom door), much as you would
your child’s report card, drawing, or other personal accomplishment. In
this way, your child can be continually reminded of her progress.

Another family-oriented activity to reinforce your child’s progress is the

creation of a poster, journal, or storybook of your child’s accomplishments
using the photographs of your child’s exposures. Helpful photographs in-
clude the child sitting at her school desk, talking with the teacher, inter-
acting with friends, riding the school bus, and giving an oral report in front
of the class. For each of the photographs, help your child write a caption
or description of the scene, including what she is thinking, feeling, and
doing in the photograph. Combining the photographs with your child’s
own written words serves as a creative and personal reminder and rein-
forcer of special moments in your child’s therapy program.

Commercial

Another relapse prevention technique is the commercial. Specifically, the

therapist may ask your child’s help in producing a video “commercial”
aimed at teaching other kids how to overcome the problem of school re-

188
 fusal behavior. This is often done toward the end of treatment. Dr. Philip
Kendall is the originator of this unique and highly successful idea for pre-
venting slips and relapse. In making the commercial, the therapist will
serve as the “director” of the project, but your child is the expert on the
subject and star of the show. By enlisting your child as an expert in how to
overcome school refusal, your child’s self-esteem and feelings of empower-
ment are boosted.

The therapist will guide your child’s performance, ensuring that all the key
elements of her treatment are presented in the video. For example, if your
child’s treatment involved relaxation or breathing techniques, demonstra-
tions of these methods will be placed in the video. Your child will be
coached to describe the three parts of an anxious feeling (physical feelings,
thoughts, behavior) and the ways in which these three components build
upon each other during stressful situations. Cognitive methods (STOP)
might also be described, with relevant examples presented by your child. If
a portable camcorder is available, the therapist will ask you to videotape
your child conducting key in vivo STIC tasks such as riding on the school
bus or eating in the cafeteria.

Some children devise very creative scripts for these videos. For example,
one child acted as the “game show host” as he quizzed family members and
the therapist on various techniques for overcoming negative emotions. An-
other child acted as a “Dateline NBC” reporter and spliced the Dateline
opening into her video. During her video, she “investigated” the problem
of school refusal in which she uncovered negative thoughts and the “ag-
gravations from avoidance.” Even though the video is developed as a way
to teach other children how to overcome their problem, your child keeps
the video for her exclusive use. In this way, you can periodically play the
video to remind your child of the program and to prevent setbacks during
times of high stress or vulnerability (e.g., before the start of school, during
standardized testing times).

Structured Activities Outside the Home

Long breaks from school, such as summer vacation or the December holi-
days, can provide enough time for a child to slip backwards to inappropri-
ate habits and fears. Children who relapse may have greater tendencies to
experience negative emotions and anxiety. Typically, the plans and proce-
dures taught in therapy are forgotten or put aside during this time. There

189
 is the tendency to want to “leave well enough alone” and not continue to
practice the procedures and skills learned in therapy. To prevent relapse,
keep your child as much as possible on a regular “school” schedule during
holidays. This means regular waking times and routines in the morning
and a regular bedtime at night. This ensures that your child’s sleep–wake
cycle stays within normal limits and that she gets a sufficient amount of
sleep. During the summer, try to start your child’s normal “school” sched-
ule about  weeks prior to the start of school. For children who refused
school in the past for tangible rewards, gradual restrictions on curfew and
time spent with friends may need to start at this time. In this way, your
child’s day can start to mimic what will need to happen when school soon
starts.

During summer vacation, try to have your child spend some portion of
each weekday outside the home in an organized activity with other chil-
dren and adults. For example, day camps, volunteer programs, sporting ac-
tivities, youth groups, and library programs can give your child much con-
tact with people outside the family. This will allow your child to continue to
practice and refine her anxiety management skills. In addition, especially
for attention-seeking children, more independent activities will help pre-
vent backsliding to dependency on you for moment-to-moment support.
If there are no structured programs available in your area, organize other
parents in your community to form play groups or activity programs that
can be rotated from house to house. Again, this will gently “force” your
child to remain in contact with others and will serve as a natural desensiti-
zation and exposure process. This will give children with separation anxi-
ety practice at leaving primary caretakers and functioning well on their own.

Booster Sessions

Some therapists and schools will provide “booster” programs for children
who had previously refused to attend school. Booster sessions may be pro-
vided in individual or group format. These sessions are usually scheduled
at high-pressure times of the year, such as early August before the start of
school, during a mid-semester break, or during exam periods. The purpose
of the booster program is to review skills and discuss any potential prob-
lems that your child fears may occur. By anticipating these problems and
intervening before they occur, your child is more likely to successfully re-
enter school and engage in school life. Booster programs may be particu-

190
 larly important for children making a transition from elementary to middle
school or from middle school to high school. Transition times are difficult
for children who have had a history of school refusal, anxiety, or depres-
sion. Booster programs are usually structured, short-term, and highly in-
dividualized to meet the child’s needs.

Introduction to a New School

Because many youths have trouble coping with changing social and aca-
demic scenarios, especially when advancing to a new (e.g., middle, high)
school, it is important to allow them to explore the new school building
before classes begin. You can do this a few days before school starts with co-
operation from the child’s new school counselor. Be careful, however, that
your child doesn’t view the counselor and his or her office as simply a safety
signal. Of special interest are the location of lockers, specific classrooms,
cafeteria, libraries, gymnasia, main and guidance offices, exits, and settings
for getting on and off the school bus. Maps are also helpful, but encourage
your child to be as independent as possible. Because children with previ-
ous school refusal behavior often fear getting lost and looking foolish, tak-
ing them on a tour of their new school building may serve to diminish an-
ticipatory anxiety, increase self-efficacy, and prevent relapse. Your child
should also receive information on school-based social and sporting groups
that she is eligible to join that semester. Gently encourage your child to be-
come socially active in these groups.

Children with Chronic School Refusal Behavior

For children with chronic or severe school refusal behavior, relapse preven-
tion is quite challenging. Follow-up in these cases will generally need to be
more frequent and intensive than follow-up for cases involving acute
school refusal behavior. Relapse prevention in chronic cases is likely to de-
pend more on reduced family conflict, reduced child noncompliance and
disruptive behavior, changes in parent attitudes, the child’s participation in
extracurricular activities and development of appropriate social contacts,
continued motivation to attend school, and ongoing medical interven-
tions, if applicable. As a result, you may need to be vigilant about slips in
many more different areas than just those specifically related to school re-
fusal. You and the therapist may also remain in close contact following the
end of formal treatment.

191
 Keep in mind as well that because children with chronic school refusal be-
havior are often placed in alternative or part-time curricular programs, you
should be aware of any upcoming changes that could interrupt attendance.
For example, a school district with financial difficulties may be forced to
eliminate an after-school program that your child was attending. In this
case, you may have to make alternative arrangements for attending classes
during the day, evening, or summer. In addition, you may find that your
child is showing new behaviors (e.g., substance abuse, depression) that
could interfere with school attendance. In this case, contacting the thera-
pist for feedback, scheduling therapy sessions, or pursuing treatment with
another specialist are possible options.

Overall, relapse prevention for youths with chronic school refusal behavior will
depend on a close monitoring of attendance and related behaviors for at least
several months. As a result, you should maintain a healthy relationship with
the therapist and school officials (e.g., teachers, attendance officers) who
can help you identify and address problems as early as possible. In this way,
you can lower the chances of relapse to school refusal behavior.

Some Final Comments

Dealing with school refusal behavior can often be a trying experience for
both parents and children. Because of this sometimes debilitating prob-
lem, this manual tries to provide some guidelines for identifying key school
refusal behaviors and for addressing them in a timely fashion. We hope you
have found many or most of the techniques in this manual useful, and we
invite any comments you may have about these procedures. We have found,
in working with this population for several years, that some of the best ex-
perts are often the children and parents themselves.

192
About the Authors

Christopher A. Kearney, PhD, is professor of psychology and Director of the

UNLV Child School Refusal and Anxiety Disorders Clinic at the University of
Nevada, Las Vegas. He is the author of numerous journal articles, book chap-
ters, and books related to school refusal behavior and anxiety disorders in youth,
including School refusal behavior in youth: A functional approach to assessment and
treatment; Getting your child to say “yes” to school: A guide for parents of youth with
school refusal behavior (Oxford); Social anxiety and social phobia in youth: Char-
acteristics, assessment, and psychological treatment; Casebook in childhood beha-
vior disorders; and Practitioner’s guide to treating fear and anxiety in children and
adolescents: A cognitive-behavioral approach. He is also an author for two forth-
coming books from Oxford: Helping school refusing children and their parents: A
guide for school-based professionals and Silence is not golden: Strategies for helping
the shy child. Dr. Kearney is on the editorial boards of Behavior Therapy, Jour-
nal of Clinical Child and Adolescent Psychology, Journal of Abnormal Psychology,
Journal of Psychopathology and Behavioral Assessment, Journal of Anxiety Disor-
ders, and Journal of Gambling Studies. In addition to his clinical and research
endeavors, Dr. Kearney works closely with school districts around the country
to improve strategies for helping children attend school with less distress.

Anne Marie Albano, PhD, ABPP, is Associate Professor of Clinical Psy-

chology in Psychiatry at Columbia University/New York State Psychiatric
Institute, and Director of the Columbia University Clinic for Anxiety and
Related Disorders. Dr. Albano received her doctorate in clinical psychology
from the University of Mississippi in  and completed a postdoctoral
fellowship at the Phobia and Anxiety Disorders Clinic at the State Uni-
versity of New York at Albany. She is board certified in clinical child and
adolescent psychology and a Founding Fellow of the Academy of Cogni-
tive Therapy. She is the President-Elect of the Association for Behavioral
and Cognitive Therapies. Dr. Albano is a Principal Investigator for an
NIMH multicenter clinical trial entitled “Child/Adolescent Anxiety Multi-
modal Treatment Study” (CAMS) and was a PI for the landmark NIMH-
sponsored Treatments for Adolescents with Depression Study (TADS). Both
trials examine the relative efficacy of CBT, medication, combination treat-
ment, and pill placebo in youth. In addition to the CBGT-A program for
adolescents with social phobia, Dr. Albano is the co-author with Dr. Patri-

193
 cia DiBartolo of a treatment manual and parent guide for school refusal
behavior and she is the co-author with Dr. Wendy Silverman of the Anxi-
ety Disorders Interview Schedule for Children, all published in the Treatments
That Work™ series. Dr. Albano conducts clinical research, supervises the
research and clinical development of postdoctoral fellows in psychology
and psychiatry, and is involved in advanced training of senior level clini-
cians in the application of cognitive behavioral approaches to diagnosis
and treatment.

194