School Phobia and School Refusal

Generally, all psychosocial treatment approaches stress the importance of getting the child back to school, and thus in parents taking an active approach in returning the child to school (Wicks-Nelson and Israel 1997). Controlled clinical trials provide empirical evidence for the efficacy of this approach. Nigel Blagg and William Yule (1984), in a study comparing behavioral treatment condition, in-patient condition, and home schooling-psychotherapy condition with sixty-six youths (ages eleven to sixteen years) with SRB, found that more youth in the behavioral treatment condition returned to school (93.3%) compared with youth in the in-patient (37.5%) and home schooling-psychotherapy groups (10%). Blagg and Yule concluded that behavior therapy produced rapid and successful outcomes for most of the cases. More recently, Neville King and his colleagues (1998) randomly assigned thirty-four children (mean age=11.0 years) with SRB to two groups: cognitive-behavioral treatment and a wait-list control condition. Results indicated that youth in the cognitive-behavioral treatment group improved significantly more with respect to school attendance, fear, anxiety, depression, general internalizing behavior, and global clinician ratings.

Two studies have compared exposure-based cognitive-behavioral treatment to an attention-placebo control condition. Specifically, Cynthia G. Last, Cheri Hansen, and Nathalie Franco (1998) assigned fifty-six youths (age six to seventeen years) with school phobia to one of two groups: cognitive-behavioral treatment and an education support condition that did not involve therapist prescription for child exposure to school stimuli. Although children in the cognitive-behavioral treatment showed significant improvement, including increased school attendance, children in the education support condition showed similar improvement. A similar pattern of findings was found by Silverman and her colleagues (1999) in a treatment study for child phobic disorders (n=104; age six to sixteen years), including SRB. In this study education support also was used and contained no therapist prescription for child exposure to phobic stimuli. The two experimental conditions were a behavioral condition (i.e., contingency management) and a cognitive condition (i.e., self-control). Although some exceptions were found, overall, on most of the main outcome measures, similar patterns of improvements were found across conditions, including the education-support condition. Taking the findings of Last and her colleagues and Silverman and her colleagues together, the implications are that further psychosocial intervention research is needed for use with children with SRB that moves beyond wait-list control design, and that focuses particularly on investigating mediators or mechanisms of change.

In addition to cognitive behavioral interventions, family-based psychosocial intervention approaches are widely used by practitioners, including structural, strategic, experiential, and behavioral (Kearney 2000). Unfortunately, we are not aware of randomized controlled trials that have investigated the efficacy of treating SRB using family-based psychosocial therapy.

Using Kearney and Silverman's (1993) functional motivational approach to SRB, described earlier, in which SRB is conceptualized as maintained by positive and/or negative reinforcement, Kearney and Silverman (1999) used single case study design methodology in which children and their parents were assigned to either prescriptive treatment, based on the functional motivational condition as measured by the School Refusal Assessment Scale (Kearney and Silverman 1993) or nonprescriptive treatment, not based on the functional motivational approach youth. For youth who refused school for the functional motivational condition relating to attention-getting behavior, for example, parent training in contingency management was used to establish clear parent commands, regular evening and morning routines, and consequences for compliance and noncompliance. In contrast, youth who were assigned a nonprescriptive treatment (i.e., received a treatment based on their lowest-rated functional condition), these children showed worsened percentage of time out of school and daily ratings of anxiety and depression. Prescriptive treatment immediately following the nonprescriptive treatment was found to be effective, however. In summary, there is a need for further psychosocial intervention research for children who display SRB. Of particular importance will be examining the role of family factors in terms of both development/maintenance of SRB as well as SRB's treatment.