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...