School-based Anxiety Research Articles

Des critères de repérage aux stratégies de prise en charge du refus scolaire : une revue de littérature internationale systématique

This article provides a systematic review of school refusal from 2007 until 2014. The goal of this study is to bring to light the latest advances in research and the actual issues on school refusal. A systematic review was conducted using: PubMed/Medline, ScienceDirect, Cochrane, PsycINFO and PsycARTICLES. Keywords used were “school refusal”, “school refusal behavior”, “school phobia” and “anxiety-based school refusal”. The literature review provides information on definitions used, diagnosis criteria, psychometrics, etiological and comorbidities aspects, as well as on the cognitive functioning, emotion regulation and intervention of youth with school refusal.

Child, Teacher and Parent Perceptions of the FRIENDS Classroom-Based Universal Anxiety Prevention Programme: A Qualitative Study.

School-based mental health prevention programmes can be effective but their adoption within schools will depend on their social acceptability. We report a qualitative evaluation summarising the views of children (115), parents (20) and school staff (47) about a universal school-based anxiety prevention programme FRIENDS. This study was conducted as part of a large scale randomised controlled trial (n = 1362) involving 40 schools in the UK providing primary education to children aged 7–11. Reported overall experience of the programme was very positive, with all three major components of the cognitive behaviour therapy programme (emotional, cognitive, and behavioural) being accepted well and understood by children. The programme was considered to be enjoyable and valuable in teaching children important skills, particularly emotional regulation and coping. Children provided examples of using the skills learned during FRIENDS to manage their emotions and solve problems. However, teachers were concerned that the programme overlapped with the current school curriculum, required additional time and almost half were unable to identify any tangible changes in the children’s behaviour. Whilst this paper provides evidence to support the social validity of the FRIENDS anxiety prevention programme, the concerns raised by teachers question the longer-term sustainability of the programme.

The parents' experience of school refusal in adolescence

While today's society places considerable importance on schooling and performances, school absenteeism is currently very high. One of the causes is anxiety-based school refusal. This phenomenon affects the adolescent but also has an impact on their family. Exploring the experience of the parents of teenagers presenting anxiety-based school refusal enables these families to be given better support.

School-Based Intervention for Test Anxiety

With children today being tested at younger ages, test anxiety has an earlier onset age. There is relatively limited research on test anxiety management programs with elementary school children. The theoretical basis for this nonrandomized pre-post intervention study is grounded in cognitive and behavioral interventions for test anxiety found to be efficacious with children. The purpose is to examine the impact of a school-based test anxiety prevention program on a sample of Singaporean fourth grade students relative to their levels of academic achievement and to identify active treatment components. 115 children aged 9–12 were assigned to group-based cognitive-behavioral treatment (n = 58) or control condition (n = 57). They completed the Children’s Test Anxiety Scale and Cognitive-Behavioral Skills Checklist at pre-, post-treatment, and 2 months’ follow-up. Anxiety ratings were hypothesized to be lower for the intervention than the control group at post-treatment. Skills that contributed to treatment outcomes were identified. A mixed-design analysis of variance revealed significant test anxiety reduction with medium treatment effect that was maintained for the intervention group across time. There was no change in the control group. Behavioral skills (e.g., relaxation exercises, study skills) contributed to treatment outcomes. Cognitive skills such as calming self-talk did not. The study provided preliminary evidence on the utility of brief, school-based anxiety interventions in test anxiety prevention for children. It added credence to adopting behavioral over cognitive strategies in treating test anxious children. Children with severe test anxiety at baseline benefited particularly from treatment.

Cognitive Mediation of Cognitive-Behavioural Therapy Outcomes for Anxiety-Based School Refusal

Cognitive-behavioural therapy (CBT) has proven to be effective for anxiety-based school refusal, but it is still unknown how CBT for school refusal works, or through which mechanisms. Innovative statistical approaches for analyzing small uncontrolled samples were used to investigate the role of self-efficacy in mediating CBT outcomes for anxiety-based school refusal. Participants were 19 adolescents (12 to 17 years) who completed a manual-based cognitive-behavioural treatment. Primary outcomes (school attendance; school-related fear; anxiety) and secondary outcomes (depression; internalizing problems) were assessed at post-treatment and 2-month follow-up. Post-treatment increases in school attendance and decreases in fear about attending school the next day were found to be mediated by self-efficacy. Mediating effects were not observed at 2-month follow-up. These findings provide partial support for the role of self-efficacy in mediating the outcome of CBT for school refusal. They contribute to a small body of literature suggesting that cognitive change enhances CBT outcomes for young people with internalizing problems. Regarding methodology, the product of coefficient test appears to be a valuable way to study mediation in outcome studies involving small samples.

School-based anxiety treatments for children and adolescents.

Anxiety disorders are the most common class of psychopathology among youth, yet many of these youngsters do not receive treatment. This is particularly concerning given the chronic course of anxiety disorders, which often lead to mood disorders, substance abuse, and serious impairment. Schools are an optimal venue for identifying anxious students and delivering mental health treatment given access to youth and ability to overcome various barriers to treatment. This article reviews four school-based treatments for anxiety disorders that have been evaluated in controlled trials. Discussion centers on feasibility, challenges to school-based implementation, and future research directions for this critical area.

Doll Play Narratives About Starting School in Children of Socially Anxious Mothers, and Their Relation to Subsequent Child School-Based Anxiety

Child social anxiety is common, and predicts later emotional and academic impairment. Offspring of socially anxious mothers are at increased risk. It is important to establish whether individual vulnerability to disorder can be identified in young children. The responses of 4.5 year-old children of mothers with social phobia (N = 62) and non-anxious mothers (N = 60) were compared, two months before school entry, using a Doll Play (DP) procedure focused on the social challenge of starting school. DP responses were examined in relation to teacher reports of anxious-depressed symptoms and social worries at the end of the child's first school term. The role of earlier child behavioral inhibition and attachment, assessed at 14 months, was also considered. Compared to children of non-anxious mothers, children of mothers with social phobia were significantly more likely to give anxiously negative responses in their school DP (OR = 2.57). In turn, negative DP predicted teacher reported anxious-depressed and social worry problems. There were no effects of infant behavioral inhibition or attachment. Vulnerability in young children at risk of anxiety can be identified using Doll Play narratives.

Treating Childhood Anxiety in Schools: Service Delivery in a Response to Intervention Paradigm

Millions of youth who attend schools in the United States suffer from clinically significant anxiety. Left untreated, these students often experience significant disruptions in their academic, social, and family functioning. Fortunately, promising treatments exist for childhood anxiety that are amenable for delivery in school settings. However, educational law and new service delivery paradigms such as response-to-intervention (RtI) affect the delivery of anxiety interventions. In light of extant laws and practices that govern education, this article discusses the provision of supportive services to address childhood anxiety. Specifically, this article reviews how RtI, the Individuals with Disabilities Education Improvement Act, and Section 504 of the Rehabilitation Act guide service delivery and subsequently impact school-based anxiety treatments. Suggestions are provided to address childhood anxiety within a framework that allows for graduated and fluid service delivery.

The Role of Cognition in School Refusal: An Investigation of Automatic Thoughts and Cognitive Errors

The purpose of this study was to investigate the cognitions of anxious school refusers. The cognitive constructs under investigation included negative cognition commonly linked to youth anxiety (i.e. negative automatic thoughts and cognitive errors) and positive automatic thoughts. The cognition of school refusers (n = 50) and youth from a community sample (n = 181) was assessed with the Children's Automatic Thoughts Scale-Negative/Positive and the Children's Negative Cognitive Error Questionnaire-Revised. When controlling for anxiety, school refusers were found to report more negative automatic thoughts concerning personal failure, fewer negative automatic thoughts concerning hostility, and fewer positive automatic thoughts. Negative automatic thoughts concerning personal failure and hostility, and the negative cognitive error of overgeneralizing were found to independently predict school refusal. The findings underscore the importance of further researching the role of cognition in the development, maintenance, and treatment of anxiety-based school refusal.

School refusal and anxiety in adolescence: Non-randomized trial of a developmentally sensitive cognitive behavioral therapy

The main objectives were to evaluate efficacy and acceptability of a developmentally sensitive cognitive behavioral therapy for anxiety-based school refusal in adolescence. Twenty school-refusing adolescents meeting DSM-IV anxiety disorder criteria participated in a non-randomized trial, together with parents and school staff. Outcome was assessed at post-treatment and 2-month follow-up. Treated adolescents showed significant and maintained improvements across primary outcome variables (school attendance; school-related fear; anxiety), with medium to large effect sizes. Half of the adolescents were free of any anxiety disorder at follow-up. Additional improvements were observed across secondary outcome variables (depression; overall functioning; adolescent and parent self-efficacy). The treatment was rated as acceptable by adolescents, parents, and school staff, which may help explain the very low attrition rate. Social anxiety disorder was the most common disorder among adolescents still meeting anxiety disorder criteria at follow-up. Treatment modifications to improve efficacy for school-refusing adolescents presenting with social anxiety disorder are suggested.

Urban African American Youth Exposed to Community Violence: A School-Based Anxiety Preventive Intervention Efficacy Study

This study evaluated the efficacy of a school-based anxiety prevention program among urban children exposed to community violence. Students who attended Title 1 public elementary schools were screened. Ninety-eight 3rd–5th-grade students (ages 8–12; 48% female; 92% African American) were randomized into preventive intervention versus waitlist comparison groups. Students attended 13 biweekly one-hour group sessions of a modified version of FRIENDS, a cognitive-behavioral anxiety intervention program. Results indicated that both intervention and control groups manifested significant reductions in anxiety symptomatology and total exposure to community violence, along with improved standardized reading achievement scores. Additional gains observed only in the intervention group were increased standardized mathematics achievement scores, decreased life stressors, and reduced victimization by community violence. The intervention was equally efficacious for both genders and for children exposed to higher, compared to lower, levels of community violence. Implications for comprehensive, culturally and contextually relevant prevention programs and research are discussed.

Mental health prevention in UK classrooms: the FRIENDS anxiety prevention programme

Childhood anxiety is a common condition which, if untreated, can cause considerable distress and impairment and increase the likelihood of mental health problems in adulthood. Developing good emotional health in children is therefore an important objective which has been emphasised in recent governmental initiatives and policies. In particular, schools have been identified as having an important role in promoting positive mental health in children. This paper summarises the different approaches, outcomes and shortfalls of school-based anxiety prevention programmes. One particularly encouraging programme based upon cognitive behaviour therapy, the FRIENDS for Life programme, is described. Outcomes from UK-based studies evaluating FRIENDS are summarised and the way the programme can be integrated within schools to complement other initiatives discussed. Finally, limitations of the current research are discussed and issues about the practical implementation of FRIENDS in schools highlighted.

Effects of Cognitive-Behavioral Intervention on the School Performance of Students with Emotional or Behavioral Disorders and Anxiety

Despite widespread treatment success in clinical settings, anxiety disorders are rarely targeted for intervention in students with emotional or behavioral disorders (EBD) who exhibit them. This study examined the effects of a school-based anxiety intervention on the performance of 3 students attending school in a self-contained EBD setting. Using a single-subject, multiple-baseline design across students, this study examined changes in anxiety, maladaptive behavior, and academic engagement as functions of participation in the cognitive-behavioral anxiety intervention, FRIENDS for Life. All 3 participants showed improvement across all measures. Implications for the implementation of a school-based intervention for EBD students who experience high degrees of anxiety, as well as study limitations and directions for future research, are discussed.

Outcome of Patients Attending a Specialist Educational and Mental Health Service for Social Anxiety Disorders

The purpose of this study was to evaluate the outcome of adolescents with anxiety-based school attendance problems enrolled in a specialist adolescent educational and mental health program that provides educational assistance and social skills development, and to suggest key elements that may account for its apparent effectiveness. Young people attending the Sulman Program in Sydney, Australia, between March 2003 and December 2004 were identified. Baseline information was gathered from the medical records, pre and postintervention personal development questionnaires were given to students, and pre and postratings of function were made. Those attending the program showed improvement in their general level of functioning indicated by completion of a year-long course of study (17 of 24), preparation for employment (17), increased independent travel (5), and self-rated improvement in social skills, stress tolerance and emotional literacy. Pre and poststaff ratings on the Health of the Nation Outcomes Scales Child and Adolescent (HoNOSCA), Children's Global Assessment Scale (CGAS) and Global Assessment of Functioning (GAF) indicated improvement in personal and social functioning. Parental satisfaction was rated as high. The findings confirm the effectiveness of, and need for, flexible programs to support adolescents with social anxiety disorder and other longer-term mental health problems to offset the adverse consequences of early withdrawal from educational and social environments. Several elements may help to explain the program's effectiveness and provide guidance for similar programs elsewhere.

The functional assessment of school refusal behavior.

School refusal behavior refers to child-motivated refusal to attend school and/or difficulty attending classes for an entire day (Kearney & Silverman, 1996). As such, the term represents an umbrella construct for many historical ones that have been used to describe youths with problematic absenteeism, including truancy, psychoneurotic truancy, school phobia, separation anxiety, and anxiety-based school refusal. School refusal behavior refers to a spectrum of problematic, illegitimate absenteeism that includes youths who miss school for extended periods of time, youths who miss school sporadically, youths who skip certain classes or who are tardy to school, youths with severe morning misbehaviors to attempt to miss school, and youths who attend school with great anxiety and somatic complaints that precipitate ongoing pleas to miss school in the future (Kearney, 2003). Keywords: School refusal behavior; truancy; school phobia. ********** School refusal behavior affects about 5-28% of school-aged youths at one time or another and is present fairly equally across gender, racial, and income groups (Kearney, 2001). The behavior is more common among students entering a certain school building for the first time. As such, youths entering kindergarten/first grade, middle school, and high school are particulary at risk. Attendance problems in this population generally occur for 1-2 years before treatment, but a large percentage of youths with school refusal behavior have attendance problems that last longer than two years (Bernstein, Svingen, & Garfinkel, 1990; Hansen, Sanders, Massero, & Last, 1998). A key characteristic of this population is its heterogeneity, as youths with school refusal behavior generally show a confluence of many internalizing and externalizing behavior problems. Common internalizing problems include general and social anxiety, fear, fatigue, depression and suicidality, and somatic complaints. Common externalizing problems include noncompliance to parents and teacher commands, defiance and aggression, running away from school or home, clinging, and temper tantrums (Kearney, 2001). Indeed, school refusal behavior is highly comorbid with many different mental disorders, particularly separation anxiety disorder, generalized anxiety disorder, oppositional defiant disorder, and depression (Kearney & Albano, 2004). School refusal behavior is often triggered by specific stimuli such as family and marital conflict and transitions, illness, school-based changes and threats, and traumatic experiences (e.g., Torma & Halsti, 1975). However, many cases of school refusal behavior are not triggered by any clear stimuli (Timberlake, 1984). School refusal behavior can be markedly debilitating for a child and family, and common consequences include distress, conflict, and problems with academics, legal standing, and finances (Kearney, 2001). Of course, extensive school refusal behavior is linked to potential dropout as well, which may lead to severe long-term economic, psychiatric, and interpersonal difficulties (e.g., Berg & Jackson, 1985; Hibbett & Fogelman, 1990). Because school refusal behavior is a serious and debilitating problem, proper assessment and treatment of these youths is critical. Unfortunately, the field has been fractured by a lack of theoretical focus as well as various terms and clinical strategies that apply to some but not all youths of this population. For example, many researchers have developed assessment and treatment procedures for youths with anxiety-based school refusal, but these procedures do not apply well to the many youths who refuse school without anxiety. In addition, the heterogeneous nature of this population presents obstacles to those who wish to categorize and assess these youths based on some stable form of school refusal behavior. A functional model of school refusal behavior To address these problems, a functional model of school refusal behavior has been developed that focuses more on the function or maintaining variables of the behavior rather than its myriad forms (Kearney & Silverman, 1996). …

Evaluation of Child Therapy and Caregiver Training in the Treatment of School Refusal

To evaluate the relative efficacy of (1) child therapy, (2) parent/teacher training, and (3) the combination of child therapy and parent/teacher training in the treatment of anxiety-based school refusal. Sixty-one school-refusing children (aged 7-14 years) from throughout Melbourne, Australia, were randomized to a child therapy program, a parent and teacher training program, or a combination of the two. Children were assessed before and after treatment, and at 4.5-month follow-up, by means of attendance records, self-report of emotional distress and self-efficacy, parent and teacher reports of emotional distress, and clinician ratings of overall functioning. Statistically and clinically significant pretreatment-posttreatment change occurred for each group. Immediately posttreatment, child therapy appeared to be the least effective in increasing attendance. By follow-up, the attendance and adjustment of those in the child therapy group equalled that of children whose parents and teachers were involved in treatment, whether on their own (parent/teacher training) or together with their children (combined child therapy and parent/teacher training). Contrary to expectations, combined child therapy and parent/teacher training did not produce better outcomes at posttreatment or follow-up.

Predictors of severity of absenteeism in children with anxiety-based school refusal

Examined possible relations among sociodemographic, clinical, and familial variables and level of school absenteeism in children with anxiety-based school refusal. These children exhibit a great deal of variability in the severity of school refusal, with some youngsters missing only an occasional day of school, whereas others exhibit pervasive school absenteeism. Participants were 76 children referred for treatment of anxiety-based school refusal. Children and a parent completed a structured clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children) and self-report measures that assess children's levels of fear (Fear Survey Schedule for Children-Revised), trait and somatic anxiety (Modified State-Trait Anxiety Inventory for Children), and depressive symptomatology (Children's Depression Inventory), as well as family environment characteristics (Family Environment Scale). Regression analyses revealed that older age, lower levels of fear, and less active families were primary predictors of greater levels of school absenteeism.

School Refusal in Anxiety-Disordered Children and Adolescents

The characteristics of anxiety-based school refusal were examined in 63 school refusing children and adolescents referred to an outpatient anxiety disorder clinic. Patients were assessed on sociodemographic, diagnostic, and personality variables, as well as familial history of school refusal. Results suggest that there are two primary diagnostic "subgroups" of school refusers--separation anxious and phobic. Phobic school refusers had a later age of onset and showed more pervasive (severe) school refusal than separation anxious school refusers. By contrast, separation anxious school refusers were more likely than phobic school refusers to have mothers who had a history of school refusal problems. The implications of these findings are discussed.