CLINICAL

Kearney / SCHOOL
CASE STUDIES
REFUSAL/ January
BEHAVIOR
2002

Case Study of the Assessment

and Treatment of a Youth With
Multifunction School
Refusal Behavior

CHRISTOPHER A. KEARNEY
University of Nevada, Las Vegas

Abstract: School refusal behavior is a common problem among children and adolescents
and can lead to serious short- and long-term consequences if not addressed. Although
recent treatment outcome studies have targeted youth who refuse to go to school for one
specific reason (e.g., anxiety, attention), very little information is available on youth who
refuse school for two reasons, and no information is available on youth who refuse school
for three reasons. This article reports on the successful treatment of a 12-year-old boy who
received prescriptive treatment for multifunction school refusal behavior. The treatment
was assigned in accordance with a set assessment strategy designed to identify the primary
reasons why a particular child refuses to attend school.

Keywords: school refusal behavior, assessment, treatment.

1 THEORETICAL AND RESEARCH BASIS

School refusal behavior refers to youth who have difficulties attending classes or
remaining in school for an entire day. The behavior covers children and adolescents
who are completely or partially absent from school, those who display morning
misbehaviors in an attempt to stay out of school, and those who experience great distress
about attending school and who issue pleas to miss school in the future (Kearney &
Silverman, 1996). School refusal behavior is present in about 5% to 28% of school-aged
children, is seen equally in boys and girls, and is prevalent in many types of families of
different incomes (Kearney, 2001). Serious short-term and long-term problems can develop
as a result of extended school refusal behavior, including distress, family conflict, social
alienation, academic problems, delinquency, and school dropout, among others.
A key aspect of school refusal behavior is its heterogeneity; youth with school
refusal behavior display a wide range of internalizing and externalizing behavior prob-

AUTHOR’S NOTE: Please address correspondence to Christopher A. Kearney, Department of Psychology, University
of Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas, NV 89154-5030.
CLINICAL CASE STUDIES, Vol. 1 No. 1, January 2002 67-80
© 2002 Sage Publications

67
68 CLINICAL CASE STUDIES / January 2002

lems. Common internalizing behavior problems include anxiety, depression, somatic

complaints, fear, fatigue, and withdrawal. Common externalizing behavior problems
include noncompliance, verbal and physical aggression, clinging, refusal to move, tan-
trums, and running away from home and school. In many cases of school refusal behav-
ior, a confluence of these symptoms is evident. Such confluence is often difficult to sort,
however, a fact that has led some researchers to develop assessment and treatment strate-
gies for this population based more on the function rather than the form of behavior.
Kearney and colleagues (Kearney & Albano, 2000; Kearney & Silverman, 1996)
have devised a functional classification, assessment, and treatment model for youth with
school refusal behavior. In this model, youth are hypothesized to refuse school for one or
more of the following reasons: (a) to avoid stimuli that provoke a sense of general nega-
tive affectivity (i.e., distress, anxiety, depression), (b) to escape aversive social and/or
evaluative situations (e.g., tests, recitals, peer interactions), (c) to obtain attention from
significant others (e.g., parents), and/or (d) to pursue tangible reinforcement outside of
school (e.g., sleeping, playing with friends). The first two conditions refer to youth who
refuse school for negative reinforcement or to avoid something aversive in the school
building. The latter two conditions refer to youth who refuse school for positive rein-
forcement or to obtain something positive outside of school.
Kearney and Silverman (1993) devised the School Refusal Assessment Scale to
measure the relative strength of these functional conditions for a particular case of school
refusal behavior. Parent and child versions were constructed, and ratings from both are
combined with other assessment data to determine the strongest function. Kearney and
Albano (2000) developed prescriptive treatment strategies for each function that are
assigned and tailored individually to a particular client.
For youth who refuse school to avoid stimuli that provoke negative affectivity,
prescriptive child-based treatment involves psychoeducation about anxiety, anxiety/
avoidance hierarchy development, somatic control strategies (e.g., relaxation,
rebreathing), and gradual reexposure to the school setting. For youth who refuse school
to escape aversive social and/or evaluative situations, prescriptive child-based treatment
includes psychoeducation, anxiety/avoidance hierarchy development, modeling and
role-play, cognitive restructuring, and gradual reexposure to the school setting. For youth
who refuse school for attention, prescriptive parent-based treatment includes contin-
gency management, establishment of routines, modification of parent commands, and,
in some cases, forced school attendance. For youth who refuse school for tangible rein-
forcement outside of school, prescriptive family-based treatment includes contingency
contracting, communication skills training, peer refusal skills training, and, in some
cases, escorting the child to school and classes.
Preliminary treatment studies have demonstrated that prescriptive treatment based
on function is effective for this population (Chorpita, Albano, Heimberg, & Barlow,
1996; Kearney & Silverman, 1990, 1999). However, these studies evaluated youth who
 Kearney / SCHOOL REFUSAL BEHAVIOR 69

were refusing to attend school for one particular function. Very little work has been done
to address youth who refuse school for multiple reasons. For example, it is not uncom-
mon for a child initially to refuse school due to something unpleasant at school but then
to enjoy the amenities of home life and refuse school to stay home as well. In addition,
many adolescents home from school for long periods of time become nervous about the
prospect of returning to new peers, teachers, and classes. In each case, the child is refus-
ing school for both negative and positive reinforcement.
The purpose of this article is to describe and discuss a recent case of school refusal
behavior that was motivated and maintained by several (three) functions. The present-
ing symptoms, assessment strategy, and treatment elements are covered in detail. In
doing so, an overall strategy for assessing and treating this population is made available. A
key aspect of this strategy is to engage in a thorough assessment of the functions of school
refusal behavior and prescribe treatment that specifically addresses each of the functions.

2 CASE INTRODUCTION

Jordan (not his real name) was a 12-year-old White male referred to a specialized
university-based clinic for youth with school refusal behavior and anxiety disorders. He
was referred in the first week of October of the academic year, with school having been in
session for 6 weeks. Jordan was referred by his parents and his school counselor, all of
whom had been increasingly exasperated with his behavior during the past month and
especially in the past 2 weeks. The initial assessment session was attended by Jordan and
his mother, “Mrs. J.” Jordan’s father was regularly out of town on business during the
week and did not attend the assessment or therapy sessions. He did, however, consult
with the therapist via telephone.
During the initial assessment process, Jordan appeared sullen and subdued. He
replied to all questions put to him but was guarded in his answers and not fully sure of
why he was at the clinic. He was polite and respectful but also eager to leave the interview
and begin work on his questionnaires (see Assessment section). During his work on the
self-report measures in another room, Jordan was much more animated as he spoke with
a female undergraduate student. He completed all of his questionnaires quickly and
spoke to the student about his friends, family, school, and life events.
Mrs. J. was also subdued but politely and efficiently answered the interview ques-
tions put to her. She was occasionally apologetic for her son’s behavior and also slightly
embarrassed at her inability to get Jordan to school. Moreover, she expressed a fear that
returning Jordan to school would cause him long-term harm and was confused about
what steps to take next. Consent was secured to speak with school officials, and Mrs. J.
indicated that she would be happy to know what they said. The assessment session lasted
about 90 minutes and was followed 1 week later with a consultation session.
70 CLINICAL CASE STUDIES / January 2002

3 PRESENTING COMPLAINTS

Jordan reported that he currently had a number of anxiety-based physical symp-

toms when attending school. Most prominent among these were shaking and nausea,
although other symptoms such as accelerated heart rate, muscle tension, crying, diffi-
culty breathing, and fidgeting would occur. These symptoms tended to begin early in the
morning and worsen in intensity up to the point where Jordan had to get on the bus. The
symptoms were so severe at this point (reportedly a 10 on a 0-10 scale) that Jordan was
forced to return home. On returning home, his anxiety symptoms quickly abated and
remained low until the following morning. This cycle would continue each school day
but not on Saturday or Sunday.
Jordan also reported several anxiety-based cognitive symptoms. Specifically, he
reported a strong fear of getting into trouble in class, making mistakes on homework, get-
ting poor grades, and being late to school or class. Jordan said he worried constantly in
the morning, and previously when at school, that he would somehow get into serious
trouble for various innocuous acts (e.g., talking at school, handing in work not according
to procedure). He also stated that he always tried to do his best and worried that he would
not always be able to do so (he was highly perfectionistic). Part of his worry stemmed
from the greater amount of homework he faced in his new middle school. Jordan was
concerned that he would not be able to finish his work and therefore would get into trou-
ble. This worry was unfounded, however, as Jordan was traditionally a fine student and
one who continued to carry A and B grades despite his absences.
During the past 2 weeks when not in school, Jordan also reported more difficulty
sleeping, paying attention to others, and concentrating on his work. Most of this was the
result of not going to school, a scenario that did bother Jordan because he knew the
importance of his education and because he felt guilty about the effects of his behavior
on his mother. He did report a desire to return to school but insisted that his anxiety pre-
cluded full-time attendance at this point. He was open, however, to an initial part-time
schedule combined with anxiety-reduction strategies.
Mrs. J. reported other symptoms that were present in Jordan, including occasional
vomiting of breakfast (medical conditions had already been ruled out). She also said she
had to pick up Jordan from school one day several weeks earlier because of his difficulty
breathing while there. She reported that Jordan often complained of his teachers and
amount of homework, particularly regarding his early morning classes in first, third, and
fourth periods. Mrs. J. also complained of Jordan’s behavior during the day while home.
After finishing his homework in the morning, following several prompts, Jordan would
talk to his mother, play with his dog, watch television, visit with younger friends, and play
on the computer. Mrs. J. expressed concern that Jordan was becoming quite accustomed
to the pleasurable activities available to him at home.
 Kearney / SCHOOL REFUSAL BEHAVIOR 71

4 HISTORY

Jordan stated that he attended classes without difficulty for the first 4 weeks of
school. At that point, however, he got into trouble for talking in one class. Specifically,
the teacher of that class singled him out and reprimanded him before his classmates.
The event was reportedly quite humiliating for Jordan, who had never gotten into any
trouble during elementary school. He said he felt extremely embarrassed and anxious
following the event and into that evening. The following day, Jordan prepared for school
as he normally would and strode to the bus stop. At that point, however, he was unable to
board the bus due to overwhelming feelings of anxiety. He then walked home and was
allowed to stay home during that day by his mother. On subsequent days, the same event
happened, and Mrs. J. acquiesced to her son’s strong demands that he not be sent to
school.
After several days of this scenario, Mrs. J. began to plead with her son to attend
school and discussed different ways of reintegrating him. Specifically, she warned him of
impending consequences (e.g., legal, academic, social) and gave comfort in an effort to
persuade Jordan to go back to school. These discussions were successful only in convinc-
ing Jordan to complete his schoolwork (retrieved by his mother) and to continue to prac-
tice a musical instrument he had just starting learning to play in band. Otherwise, he
steadfastly refused to attend school and had now been absent for 2 straight weeks. In addi-
tion, Mrs. J. reported that Jordan was dawdling more in the morning, reluctantly getting
dressed, and trying to sleep later. He also attended to his schoolwork in a slower fashion
each day and seemed to be growing accustomed to a lackadaisical schedule at home.

5 ASSESSMENT

Assessment consisted of structured diagnostic interviews, behavioral question-

naires, daily ratings, and discussions with school officials with Mrs. J.’s permission. Child-
based measures included the Anxiety Disorders Interview Schedule for Children (child
version) (Silverman & Albano, 1996), State-Trait Anxiety Inventory for Children
(Spielberger, 1973), Children’s Manifest Anxiety Scale (Reynolds & Paget, 1983), Fear
Survey Schedule for Children–Revised (Ollendick, 1983), Daily Life Stressors Scale
(Kearney, Drabman, & Beasley, 1993), Children’s Depression Inventory (Kovacs, 1992),
Social Anxiety Scale for Children–Revised (La Greca & Stone, 1993), Piers-Harris Self-
Concept Scale (Piers, 1984), Negative Affectivity Self-Statement Questionnaire
(Ronan, Kendall, & Rowe, 1994), and School Refusal Assessment Scale (child version)
(Kearney & Tillotson, 1998).
These child-based questionnaires were chosen and are commonly used to assess
youth with school refusal behavior because of the frequency of internalizing symptoms
72 CLINICAL CASE STUDIES / January 2002

in this population. The instruments are standardized and excellent measures of many
covert problems that may go undetected in an interview due to a youngster’s reluctance
to admit personal or potentially embarrassing information. The data can also be used in
comparison with reports from other parties (e.g., parents, teachers) to form an overall
impression about the function of school refusal behavior.
Parent-based measures included the Anxiety Disorders Interview Schedule for
Children (parent version) (Silverman & Albano, 1996), Child Behavior Checklist
(Achenbach, 1991), Family Environment Scale (Moos & Moos, 1986), and School
Refusal Assessment Scale (parent version) (Kearney & Tillotson, 1998). These instru-
ments were chosen to assess externalizing problems as well as family dynamics that are
commonly linked to specific functions of school refusal behavior (see Kearney, 2001;
Kearney & Silverman, 1995). The data are also used in combination with other reports
to derive an overall functional profile.
Data indicated that Jordan met criteria for no formal Diagnostic and Statistical
Manual of Mental Disorders, 4th edition (DSM-IV) diagnosis (American Psychiatric
Association, 1994), although he did meet criteria for subclinical generalized anxiety dis-
order. The only criterion that prevented a full diagnosis was time, as Jordan displayed the
requisite symptoms for less than 6 months. Data from the anxiety and negative affectivity
questionnaires indicated moderate but not severe levels of discomfort. This is not neces-
sarily unusual, however, in a child who has not been attending school for some time and
whose anxiety level is therefore low. Jordan’s endorsement of school-related items on the
Fear Survey Schedule for Children–Revised was also moderate (e.g., “some” fear of
“having to go to school”). Of particular fearfulness was “not being able to breathe,” an
anxiety symptom about which Jordan seemed most concerned. In addition, his level of
self-esteem was good and his level of depression low.
Mrs. J. reported moderate levels of internalizing and externalizing behavior prob-
lems, although these were tempered as well by Jordan’s nonattendance over the past few
days. Family Environment Scale data revealed elevated cohesion, achievement orienta-
tion, and active-recreational orientation scores in addition to low conflict and moral-
religious emphasis scores. The family was described by Mrs. J. and by school officials as
hard driving and achievement oriented, which may have contributed to Jordan’s
perfectionistic nature.
Data from the School Refusal Assessment Scale indicated that Jordan was primar-
ily refusing school for three reasons: avoidance of stimuli that provoke negative affec-
tivity, attention, and tangible reinforcement. His combined (child and parent) profile
scores for the four functions described earlier were 3.50, 0.80, 3.17, and 3.05. Only the
second function, escape from aversive social and/or evaluative situations, did not seem
relevant. In a recent treatment outcome study, profile scores within 0.50 points of one
another were considered equivalent (Kearney & Silverman, 1999). Therefore, Jordan’s
school refusal behavior was considered to be maintained by three functions. In essence,
 Kearney / SCHOOL REFUSAL BEHAVIOR 73

Jordan was refusing school because of the anxiety he faced while there but also to enjoy
the many amenities, tangible and intangible, available at home.
A discussion with school officials was not overly informative because the academic
year was young and Jordan was not yet well known. He was generally described as a good
student and a polite youth but also one who seemed overly conscientious at times. His
class schedule was obtained, and his counselor indicated that this could be changed if
necessary, albeit with changes in teachers and times. Jordan’s more demanding classes
(i.e., English, math, reading) were in the morning prior to lunch, whereas his more
enjoyable classes (i.e., computer, science, band) were in the afternoon. School officials
also agreed to participate in a part-time schedule whereby Jordan would be gradually
reintroduced to school and be allowed to attend at odd hours.

6 CASE CONCEPTUALIZATION

When addressing youth with school refusal behavior, it is best to digest all of the
available assessment information to form an opinion about what motivates or maintains
the behavior. This process may start by examining profiles from the School Refusal
Assessment Scale. As noted above, Jordan appeared from his profile to be refusing school
for multiple reasons. However, these ratings only provide an initial hypothesis about why
a child is refusing school. Case conceptualization must continue by examining data that
confirm or disconfirm this original hypothesis.
In Jordan’s case, several pieces of information supported the idea that he was refus-
ing school to avoid negative affectivity. Both he and his mother reported that Jordan had
physical and cognitive symptoms of worry, and his avoidance of getting on the bus was
clear. Still, other factors disputed this scenario. For example, Jordan had no prior history
of school refusal behavior and met no formal criteria for an anxiety disorder. In addition,
scores on his self-report measures of anxiety were only moderate. However, the therapist
decided that Jordan was indeed refusing school to avoid negative affectivity on the basis
of several facts. First, Jordan was clearly sincere in describing his anxiety symptoms and
had said that they had escalated so quickly because his father was no longer available dur-
ing the week to personally talk to him. Second, daily ratings of distress were high, indicat-
ing that Jordan was nervous about attending the clinic and the prospect of returning to
school.
Other data also supported the idea that Jordan was refusing school for attention and
for tangible reinforcement. He clearly enjoyed talking to his mother and spending time
with her during the day. In addition, he had access to, and enjoyed, various play options
at home and in his neighborhood. Some factors disputed this idea, such as the fact that
Jordan was generally compliant in other areas and had few externalizing behavior prob-
lems. Still, the therapist concluded that Jordan was indeed refusing school for attention
74 CLINICAL CASE STUDIES / January 2002

and tangible reinforcement on the basis of several facts. First, Jordan’s relationship with
his mother was close and somewhat overdependent. The two clearly spent a lot of time
together in the father’s absence and had grown accustomed to supporting each other. In
addition, Mrs. J. had essentially acquiesced to Jordan’s desire to play during school hours
once his schoolwork was completed.
Prescriptive treatment in a functional model of school refusal behavior is assigned
on the basis of the strongest maintaining variables of the behavior. Because Jordan’s
school refusal behavior was maintained by several (three) factors, a complex treatment
strategy was constructed. This consisted of (a) anxiety-reduction strategies with a particu-
lar focus on controlling Jordan’s hyperventilation, (b) gradual reexposure to the school
setting, (c) parent training in contingency management, and (d) restriction of activities
during school hours.

7 COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS

Treatment lasted four sessions, and assessment of progress was made via daily rat-
ings and actual school attendance. During Treatment Session 1, Jordan was educated
about the nature of anxiety, its three response systems (cognitive, physiological, behav-
ioral), and his individual pattern in the morning and at school. Jordan would typically
experience somatic anxiety symptoms first, which would then stimulate cognitive wor-
ries about getting into trouble or being late to class. These physiological and cognitive
symptoms would gradually increase and peak at the point of boarding the bus, at which
time behavioral avoidance was displayed. Other scenarios were covered with Jordan as
well, such as entering the school building, speaking to others in class, and moving from
class to class. Jordan was able to comprehend his pattern of anxiety and was able to pro-
vide more detailed examples of the scenario when it occurred during the day.
The next step was to stem the somatic anxiety symptoms, and this was done via
breathing retraining and tension-release relaxation of key muscle groups. Jordan prac-
ticed breathing in slowly through his nose and out through his mouth to control his
hyperventilation. In addition, to address his stomach, Jordan tensed this area, held it tight
for 5 seconds, and released it. The therapist and Jordan practiced this several times and
then worked on secondary muscle groups such as the face and legs. Jordan was instructed
to practice these techniques at least twice per day and during any stressful situations.
Jordan was also asked to choose three periods of school that were least problematic
for him. He indicated that his afternoon classes of computer and band were his favorites,
although they sandwiched science class, which was less preferred. Jordan was asked if he
could attend computer and band class but sit in the library during science class. He
agreed to try this part-time schedule and was encouraged to practice his somatic control
exercises when entering school.
 Kearney / SCHOOL REFUSAL BEHAVIOR 75

Session 1 also involved work with Mrs. J., who supported the part-time schedule
and was able to secure a relative to take Jordan to school midday. In addition, Mrs. J.
agreed to establish a consequence system to be implemented based on Jordan’s level of
compliance. If Jordan attended school during the mandated times without difficulty, he
would be allowed to play with friends and enjoy the amenities of home at night as if he
had attended a full day. If Jordan did not attend school as mandated, however, his privi-
leges would be revoked and he would have to spend time in his room completing school-
work or engaging in reading or some other academic activity. In addition, Jordan’s morn-
ing time at home was restricted to schoolwork and band practice.
The therapist also counseled Mrs. J. regarding her statements made to her son as
well as the morning routine. Specifically, Mrs. J. was to refrain from any attempts to com-
fort Jordan or persuade him to attend school. Instead, she was asked to allow the conse-
quences to work and abstain from any extra verbal or physical attention. Should Jordan
engage in any excessive reassurance-seeking behavior, such as asking the same questions
repeatedly, Mrs. J. was to ignore these and refocus her son toward schoolwork and atten-
dance. Mrs. J. was also educated about the anticipated positive effects of this therapy pro-
gram and that no long-term negative discomfort was expected. She was also encouraged
to allow the family relative to take Jordan to school and to downplay any farewell scenes
with her son. Finally, Mrs. J. was instructed to rigorously maintain the morning schedule
so that Jordan would arise and prepare for school as if he were starting first period on
time. Dawdling was linked to consequences as well.
Between Sessions 1 and 2, Jordan was reluctant to attend school, and school offi-
cials delayed the procedures for 2 days (see Complicating Factors section below). He did,
however, prior to Session 2, attend school for three periods on each of 3 days. The period
between computer and band was spent in the library. During Session 2, Mrs. J. reported
that the consequences had been administered accordingly. In addition, she was able to
modify her statements to nudge Jordan to school and maintain the morning routine. Jor-
dan reported enormous discomfort (rating of 9) on the first day back to school and was
primarily concerned that he would be late to class and get into trouble. He arrived at
school in plenty of time, however, reducing his anxiety considerably. In addition, Jordan
was able to control any physical symptoms of anxiety because they were at a manageable
level. He knew, for example, that the end of the school day was near and that the classes
he was attending were his most comfortable. Work in this session concentrated on his
worries, and these were allayed via basic cognitive restructuring. His next homework
assignment was to attend lunch and science class, thus keeping him in school from 10:54
a.m. to the end of the day.
At Treatment Session 3, Jordan reported that he was able to meet the homework
assignment and reported anxiety levels around 4 or 5. This was significant as it indicated
that Jordan was habituating to the school setting, thus driving his anxiety ratings down. As
part of his psychoeducation process, Jordan was informed that anxiety levels tend to
76 CLINICAL CASE STUDIES / January 2002

decline as one practices a situation more and gains mastery over it. Examples specific to
his life (e.g., learning a musical instrument) were raised to reinforce this point. Previous
procedures were implemented, and Jordan was instructed to add two more classes to his
schedule. He chose his first and third period classes and was allowed to stay in the library
during second period if he wished. Over the next week, Jordan was able to complete this
assignment. Treatment Session 4 consisted of reinforcing the procedures that had been
taking place, and Jordan was instructed to add his second period class and to ride the bus
to and from school. He was able to accomplish both goals, and daily ratings of distress
ranged from 0 to 1 each day. Treatment was terminated during a brief Session 5 as atten-
dance and anxiety remained at acceptable levels.

8 COMPLICATING FACTORS

One complicating factor in this case was Jordan’s very high anxiety on the first day
back to school. Even though Jordan was only required to attend three periods and two
classes, he called the therapist that morning to say that he was unsure he could go. It is
not unusual for the first scheduled time back to school to be the most difficult part of ther-
apy for a youth with school refusal behavior. Often, this difficulty is in the form of high
anxiety, but it can also mean the child is deliberately worsening his or her misbehavior to
gain further attention or tangible rewards. A key feature of treatment at this stage is to
adopt a general rule that no backsliding should be allowed. For example, if a child makes
it to school grounds but cannot bring himself or herself to enter the school building, par-
ents or others should remain with the child until anxiety dissipates. Although difficult, a
return home, or backsliding, should be avoided so as not to reinforce inappropriate
behavior. In some cases, this means staying with the child for several hours in the school
parking lot, but this option will facilitate treatment much more than a return home. In
similar fashion, once a child is attending two classes at school per day, this should be the
minimum attendance required each day until a more detailed schedule is implemented.
In Jordan’s case, encouragement from the therapist and his mother was sufficient
to impel him to attend school for two classes on the first day. In other cases, very gradual
exposure is needed. For example, it may take several hours or days for a child to enter a
school building, but small steps forward are key in this situation. Many times, including
Jordan’s case, these small steps lead to faster and more substantial gains later.
Events in Jordan’s case were further complicated by a delay in the treatment plan
by school officials. The school counselor who had originally agreed to the procedure
backtracked and said that a full conference with the dean and attendance officer would
be necessary prior to approval. This delayed treatment for 2 days and inadvertently rein-
forced Jordan’s absenteeism. This scenario reveals the importance of working closely
with all relevant school officials and being sure that any plan (e.g., partial reintegration,
 Kearney / SCHOOL REFUSAL BEHAVIOR 77

schoolwork sent home) be conducted with their full cooperation. In many cases, cooper-
ation from school officials is key to resolving a child’s school refusal behavior.

9 MANAGED CARE CONSIDERATIONS

Although no significant managed care considerations applied to Jordan’s case,

such considerations do apply to many cases of youth with anxiety disorders and school
refusal behavior. One such consideration is a focus on brief, solution-focused therapy.
Because of the emphasis on limited sessions in managed care, treatment of school refusal
behavior usually must be abridged and condensed. Short-term treatment manuals for
this population are available (Kearney & Albano, 2000), but clinicians should be aware
of the need to impart much information in a short period of time. Second, the era of
managed care has tended to create a greater reliance on drug therapy compared to psy-
chotherapy. In fact, treatment guidelines for youth with anxiety disorders tend to be phar-
macologically focused (American Academy of Child and Adolescent Psychiatry, 1993).
However, a close examination of drug treatment outcomes studies for youth with anxiety
and/or school refusal behavior has revealed mixed results or positive results if combined
with behavioral procedures (see Kearney & Silverman, 1998, for review). Clinicians are
encouraged to explore a full range of psychotherapeutic options, including those
described here, for this population.
Third, primary care providers may tend to downplay or fail to support reimburse-
ment for a behavioral problem (i.e., school absenteeism) that is not formally part of the
DSM-IV or in need of immediate medical attention. School refusal behavior is poten-
tially as debilitating a condition as any formal mental disorder, however, and this should
be conveyed to managed care administrators. Fourth, managed health care tends to
emphasize cheaper and more readily available resources than licensed psychologists.
This is unfortunate given that the treatment of school refusal behavior is often a delicate
issue that benefits most from substantial, intensive, and complex psychological treat-
ment. Finally, preventative care is sometimes trivialized in a managed health care sys-
tem, despite the fact that early detection and amelioration of school refusal behavior in
youth at risk for absenteeism would save enormous resources.

10 FOLLOW-UP

Follow-up with Jordan 1 month later indicated continued progress and no school
refusal behavior. In addition, duress at school was minimal. This is consistent with treat-
ment outcome data from other studies (Chorpita et al., 1996; Kearney & Silverman,
1990, 1999). Prescriptive treatment for school refusal behavior tends to be more effective
78 CLINICAL CASE STUDIES / January 2002

in the long run compared to a generic treatment approach that targets the entire popula-
tion. This is likely due to the individual attention given to a certain case and because fac-
tors other than anxiety (e.g., attention, tangible reinforcement) are considered and
addressed.

11 TREATMENT IMPLICATIONS OF THE CASE

Jordan’s case is the first in the literature that involves the assessment and treatment
of a youth whose school refusal behavior was maintained by three functions. His success-
ful treatment implies, at a very preliminary level, that a prescriptive therapy approach is
effective for detailed and complex cases of school refusal behavior. His case also indi-
cates that the concurrent use of multiple prescriptive treatments is feasible and perhaps
desirable in this situation. In particular, the combined prescriptive treatment approach
mandated that both Jordan and his mother be intimately involved in therapy, and this
combined effort appeared key to resolving the case. In many instances of school refusal
behavior, family participation in therapeutic homework assignments increases compli-
ance, supervision of the child, and easing of pressure from school officials. What remains
unclear, however, is which of Jordan’s treatment ingredients was most effective. Future
casework and research will need to determine which aspect of prescriptive treatment is
best for youth with multifunction school refusal behavior.

12 RECOMMENDATIONS TO CLINICIANS AND STUDENTS

When addressing cases of school refusal behavior maintained by multiple func-

tions, several things should be kept in mind. First, the behavior will be likely referred to
as an urgent one by parents and school officials, and many different hypotheses about the
cause of the problem will be offered. As a result, great care should be taken during the
screening and scheduling process to listen to all relevant parties and determine the true
urgency of the situation. In some cases, for example, an immediate return to school is
unnecessary.
In related fashion, a comprehensive assessment should be conducted regarding
not only the forms but also all the functions of the behavior. Knowing why a particular
child is refusing school will advance treatment of the case immeasurably, especially if
the functions are prioritized and addressed by strength. A common scenario in this popu-
lation is for children to report one main function and for parents to report another. In this
scenario, the clinician must weigh the statements made by each party, rely on his or her
own observations and third-party information, and consider several explanations. For
example, it is possible that two or more functions are truly influential to the case, and it is
possible that one or more parties is uninformed about the child’s school refusal behavior.
 Kearney / SCHOOL REFUSAL BEHAVIOR 79

A comprehensive assessment that relies on multiple methods and multiple sources of

information is usually critical in cases of school refusal behavior.
Clinicians should also keep in mind that treatment sessions for youth with
multifunction school refusal behavior will tend to be lengthy, intense, and frequent. In
addition, clinicians should be prepared to receive calls at different times of the day. In Jor-
dan’s case, for example, it was not unusual for him to contact the therapist via e-mail and
telephone calls early in the morning prior to school. Clinicians should be aware of the
often-dire nature of these cases and the severe disruption that it causes family members
who often want the problem resolved as quickly as possible.
Clinicians also have to carefully decide the timeline for returning a child with
multifunction school refusal behavior to school. In contrast to traditional dictates regard-
ing this population, an immediate return to full-time attendance is often not preferable.
This is especially the case for youth with high levels of anxiety as well as those with long
histories of school refusal behavior. In addition, educating children about their condi-
tion and soliciting their input regarding its resolution is important and should precede
any reintegration. In other cases, gradual work toward a part-time schedule as the final
goal may have to be considered. In very chronic cases, alternative methods of education
(e.g., night courses, vocational classes) may have to be pursued.
The treatment of youth with multifunction school refusal behavior is a challenging
one but one that can be successfully completed with a comprehensive assessment pro-
cess and a complex prescriptive treatment strategy. Clinicians are encouraged to be inno-
vative when treating this population and to be persistent in addressing extremely difficult
cases. In addition, therapists should remain aware of the rapid advances in this field with
respect to assessment and treatment.

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Christopher A. Kearney is an associate professor of clinical child psychology and director of the UNLV
Child School Refusal Clinic at the University of Nevada, Las Vegas.