Case Study of a 5 Year Old with School Refusal Behaviour

Mary, a five year old girl, had been attending her local nursery school successfully for several months. However, for the last four weeks she found it difficult to separate from her mother and refused to attend school so her case was referred to the school psychologist. Her mother and her nursery teacher agreed that her problem began when she had a disturbing dream during nap-time and became agitated when she woke up and realized her mother was not present. Everyday before going to school she began crying and requested not to attend.Subsequently, Mary was forced to attend school and when her mother dropped her to school her teacher had to hold on to her so her mother could leave the classroom.

Although she was calm at times through the day she very often started crying and asked for her mother. At home, Mary did not separate from her mother and did not sleep in her own bed. Mary was described by school staff as a quiet child who liked to play alone. She lived with her mother and her eleven year old brother.

Her parents had been separated for six months.Theoretical background When assessing treatment approaches for school refusal it is useful to consider whether the school refusal behaviour presents an acute onset or a chronic course, the degree of parental involvement, if other disorders are present as well as the number reasons behind the school refusal behaviour. Both cognitive-behavioural and behavioural interventions have been shown to successfully treat cases of school refusal with various degrees of severity and complexity.They usually achieve treatment success within three to six weeks with maintenance of treatment improvement showed up to five years (King & Bernstein, 2001; King & Ollendick, 1989). However, behavioural interventions are usually the treatment of choice since they are not as demanding on psychologist’s time (Kearney & Beasley, 1994). Various outcome studies have demonstrated the efficacy of child, parent, and family-based treatments for school refusers (King & Bernstein, 2001; Kearney & Silverman, 1999; Last, Hansen, & Franco, 1998).

Child-based treatments include: relaxation and breathing exercises to control physical anxiety symptoms, exposure-based techniques that gradually reintroduce children to school as they practice methods of controlling their anxiety and also, rapid return programs, which have been shown to produce the quickest treatment success (2. 5 weeks) (Blagg & Yule, 1984). Parent-based treatment methods include establishing regular morning, daytime, and evening routines. Parents are trained on procedures to reward attendance and punish non-attendance and reduce excessive reassurance-seeking behaviour.

Furthermore, family involvement has been shown to improve treatment outcome for both, behavioural and cognitive behavioural interventions, and should be included as part of the treatment for school refusal (King & Bernstein, 2001; Blagg & Yule, 1984). Diagnosis and treatment Mary, her parents and her teacher were interviewed by the pshychologist. Mary’s social and emotional functioning was assessed using the Devereux Behaviour rating Scales-School Form (Naglieri, LeBuffe & Pfeiffer, 1993), which was completed by her mother.This scale includes sub-scales for depression, physical symptoms or fears, interpersonal problems and inappropriate behaviours or feelings. Mary’s Total Scale Score was in the “Very Significant” range.

Mary was diagnosed with Separation Anxiety Disorder (SAD). She met the criteria for SAD described by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). The school psychologist made the diagnosis based on data collected from interviews with the mother and the school teacher.In addition, the data collected suggested that Mary’s school refusal behaviour was motivated by attention-seeking purposes.

Shaping, positive reinforcement and extinction were the selected approaches to treat Mary’s school refusing behaviour associated with SAD. Mary’s mother was taught a muscle relaxation technique with deep breathing that was to be practiced by Mary at bedtime to help her sleep and also to relax when she felt distressed during the day. They were also shown how to separate at the classroom door using adequate phrasing.The mother was advised to ignore crying and to verbally encourage Mary to attend school using praise but not to be forced to attend.

If Mary was excessively distressed, she was allowed to stay at home and to do schoolwork instead. In addition, the teacher was shown how to take Mary into the classroom holding her hand and using praise when she complied. Her teacher was also instructed to ignore her crying or asking for her mother. In case of Mary becoming excessively distressed at school her teacher was encouraged to soothe Mary by reassuring her that her mother would soon come to pick her up.In order to help Mary build new relationships with other children, for every successful school attendance, she was rewarded with ten minutes of free play with a child chosen by the teacher. An additional aim of the treatment was to increase the time Mary was apart from her mother in the home.

Mary was to practice being away from her mother five times a day on non-school days and twice a day on school days at a starting time interval of two minutes. For each successful trial Mary received a chocolate treat. The interval of separation was increased gradually by two minutes after four successful consecutive trials.Each increase in the time interval was accompanied by an increase in the value of the reward for the first trial. Assessment Mary’s successful school attendances were recorded over a baseline period of three weeks before the treatment started, during treatment and followed up four and twelve months after treatment.

A successful school attendance was defined in terms of Mary attending and remaining at school the whole day without excessive crying, clinging to her mother or showing other school refusing behaviours that require significant adult time, such as the teacher having to spend time apart from the class soothing Mary.The mother reported during weekly phone calls the greatest time intervals that Mary could be apart from her during the treatment period. The shaping procedure was considered successful when Mary was able to remain separated from her mother for intervals of twenty minutes as the perception of being away from a parent during this time was comparable to being away for longer periods for a five year old child. The treatment finished after three weeks of successful school attendance.

Interviews with the mother and the teacher were conducted for the follow up at four months and twelve months after treatment.The mother reported that Mary was no longer shadowing her or becoming distress when separating at school and that she was also sleeping in her own bed. The teacher confirmed Mary was successfully attending school and was no longer asking for her mother or becoming distressed through the day. She also confirmed Mary and her mother separated in the way reported above. The mother also completed the DSF scale at four and twelve month follow-up and Mary obtain a Total Scale Score in the “normal” range.

In addition, Mary did not meet the DSM criteria for SAD at both follow-up points.