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Cognitive-behavioural Intervention with a Depressed Adolescent Experiencing School Attendance Difculties Stephanie Rollings, Neville King, Bruce Tonge, David Heyne and Dawn Young Behaviour Change / Volume 15 / Issue 02 / June 1998, pp 87 - 97 DOI: 10.1017/S081348390000320X, Published online: 06 October 2014

Link to this article: http://journals.cambridge.org/abstract_S081348390000320X How to cite this article: Stephanie Rollings, Neville King, Bruce Tonge, David Heyne and Dawn Young (1998). Cognitivebehavioural Intervention with a Depressed Adolescent Experiencing School Attendance Difculties. Behaviour Change, 15, pp 87-97 doi:10.1017/S081348390000320X Request Permissions : Click here

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Cognitive-behavioural Intervention with a Depressed Adolescent Experiencing School Attendance Difficulties Stephanie Rollings, Neville King, Bruce Tonge, David Heyne, and Dawn Young Monash University

This article describes a cognitive-behavioural intervention implemented over 10 sessions with an adolescent girl experiencing school refusal and depression. Treatment focused on the learning of various coping skills to deal with stressful situations at home and school. Following a decision to change schools, a rapid school return was employed. A multimethod, multisource evaluation was used at pretreatment, posttreatment, and follow-up assessments. The data indicated positive treatment outcomes: the adolescent returned to full-time attendance at school and exhibited decreased levels of emotional distress. The treatment gains were maintained at a 3-month follow-up.

A

lthough school refusal can occur through the entire range of school years, it appears that school refusal in adolescence is a particularly challenging problem for mental health professionals. Adolescent school refusers generally display more psychiatric disturbance than younger school refusers (Atkinson, Quarrington, & Cyr, 1985; Coolidge, Hahn, & Peck, 1957). For instance, school refusers often receive a diagnosis of one or more anxiety disorders, but the adolescent school refuser may be more likely to also meet criteria for a depressive disorder or dysthymia (King et al., in press). Levenson (1961) suggested that school refusal in adolescence "augurs a severe and therapeutically resistive emotional disturbance" (p. 539). Many authors have noted that the prognosis for adolescent school refusers is poorer than for their younger counterparts (e.g., Hersov, 1977; R o d r i g u e z , R o d r i g u e z , & Eisenberg, 1959; Valles & Oddy, 1984). A number of uncontrolled case studies suggest the utility of cognitive and behavioural procedures with school-refusing children and adolescents. These interventions have focused on providing the young person with the coping

skills necessary for school attendance. For instance, Bornstein and Knapp (1981) successfully employed self-control desensitisation in the treatment of a 12-year-old boy with multiple phobias and school refusal. McNamara (1988) taught self-management strategies to a 12-yearold girl to help her overcome her fear of school. The girl was encouraged to monitor her own school attendance, lesson attendance, and selfconfidence. This resulted in an increase in her school and lesson attendance. Croghan (1981) used imaginal desensitisation and refraining of a 17-year-old boy's misinterpretation of an earlier event to successfully treat his anxiety about school. Mansdorf and Lukens (1987) incorporated cognitive restructuring into the treatment of two school-refusing children with separation anxiety. The children were taught how to use coping self-statements to dispute inappropriate behaviour and guide positive behaviour. Following this cognitive preparation, a graduated return to school was implemented via contingency management by the parents. Both children achieved regular school attendance within 4 weeks, and this was maintained at a 3month follow-up.

Address for correspondence: Stephanie Rollings, Centre for Developmental Psychiatry, Monash Medical Centre, 246 Clayton Road, Clayton VIC 3168, Australia. E-mail: [email protected]

BEHAVIOUR CHANGE Vol. IS, No. 2 1998 pp. 87-97

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STEPHANIE ROLLINGS, NEVILLE KING, BRUCE TONGE, DAVID HEYNE, AND DAWN YOUNG

Few case reports address the challenges for therapists in dealing with school-refusing adolescents who present with the more complex clinical picture of comorbid anxiety, depression, and oppositional/defiant behaviour. The present study describes and evaluates an intervention that involved the use of behavioural and cognitive procedures with an adolescent school refuser who was depressed and extremely resistant to returning to school. A multimethod assessment procedure was used. A comprehensive psychological test battery was administered to the adolescent, and clinical interviews were conducted with the adolescent, her parents, and teachers. Parent and teacher reports of the adolescent's behaviour were also obtained via questionnaire. The intervention aimed to help the adolescent cope with the stressors associated with school return and regular school attendance. Method Subject Jane was a 13-year, 8-month-old female in Year 8. She had been referred by the school's student welfare coordinator to the school refusal clinic, an outpatient clinical research facility at Monash Medical Centre, Melbourne. At the time of referral, Jane had been experiencing intermittent school attendance problems for 2 years, and had completely refused to attend school for the past 3 weeks. An assessment was conducted with Jane and her parents over two sessions. It consisted of semistructured and diagnostic interviews together with the administration of standardised questionnaires. Jane was interviewed separately from her parents. The clinicians also visited Jane's school and interviewed school staff about their perceptions of Jane's difficulties at school. At the first assessment, Jane arrived with red and swollen eyes from crying. She initially refused to enter the interview room but eventually agreed to do so, under the condition that she could be in a separate room from her father. Jane sat with her head bowed, scowling and avoiding eye contact. She was extremely reluctant to answer questions, and when she did so, Jane spoke in a childish tone. She repeatedly stated "I hate school. Horrible

school". Over the course of the two assessment sessions, Jane gradually relaxed and began to offer more information about herself and school. When asked what aspects of school she disliked, Jane stated that she disliked teachers, there was "too much work", and some work was "hard". Jane indicated that she would like to do school by correspondence but that her parents had refused to allow this because they felt Jane would become "even more of a hermit". According to Jane, she had a number of friends at school and was satisfied with her social relationships. Jane initially stated that she did not feel scared about school but later admitted that she sometimes felt nervous or sick when faced with having to attend school. Jane's parents described her as a child who had never cared much for school and who had a high level of absenteeism in previous school years. According to her parents, Jane's refusal to attend school in the current term began after she had a week off school due to physical illness. Mr and Mrs A. reported that they had tried unsuccessfully to enforce Jane's attendance at school and that they then gave up. They explained that when they tried to make Jane attend school she would cry and refuse to get out of bed. Mr and Mrs A. asserted that Jane did not like teachers and that she had had some negative experiences with her teachers that year. They reported that Jane was very secretive about school, frequently avoided submitting homework, and had hidden her report card from them the previous term. Mr and Mrs A. reported that Jane had some friends at school but did not often mix with them outside school hours. Jane's father admitted that he and Jane did not have a good relationship and that he had a better relationship with Jane's sister, Sally. According to Mr A., Jane tended to avoid him at home. Jane described her father as "mean" and said that her father allowed her sister many privileges but denied Jane her requests. In the parent interview, it was revealed that Jane's older sister was a high achiever academically. According to Mr and Mrs A., Jane had always been in her sister's shadow and could not do things as easily as Sally. Teachers at Jane's school described Jane as a bright and capable student without any apparent

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INTERVENTION WITH A DEPRESSED ADOLESCENT

learning difficulties. However, she did seem unmotivated to complete work. One teacher suspected that pressure was brought to bear on Jane to achieve good results at school and that Jane felt anxious about her school performance. When this hypothesis was presented to Jane during the formulation session, she burst into tears, saying that everyone wanted her to be like Sally but she could not. The student welfare coordinator described Jane as "socially immature". She reported that Jane had a group of friends at school but often seemed sad and withdrawn. Assessment Procedure

School attendance was the most crucial of the outcome measures. Jane's school attendance record was examined to determine the extent and pattern of her nonattendance at school. Self-reports of fear, anxiety, depression, and coping were derived via the Fear Thermometer, the Revised Children's Manifest Anxiety Scale (R-CMAS; Reynolds & Richmond, 1978), the Children's Depression Inventory (CDI; Kovacs, 1981) and the Self-Efficacy Questionnaire for School Situations (SEQ-SS; Heyne et al., 1998). The Fear Thermometer is a visual analogue scale on which the young person is required to indicate how scared they would be about attending school tomorrow (cf. Walk, 1956). The RCMAS is a 37-item instrument which consists of three anxiety factors: physiological anxiety, worry/oversensitivity, and social concerns / concentration. There is strong empirical support for its reliability and validity (e.g., Reynolds & Paget, 1983). The CDI is widely used in the assessment of depressive symptomatology and possesses sound psychometric properties (Kendall, Cantwell, & Kazdin, 1989; Kovacs, 1981). The SEQ-SS allows the young person to estimate their ability to cope with 12 anxietyprovoking situations associated with school attendance. Items are rated on a 5-point Likert scale from really sure I couldn't cope to really sure I could cope. Preliminary research suggests that the instrument has good internal consistency and test-retest reliability (Heyne et al., 1998). Caregiver reports of Jane's internalising and externalising behaviour were assessed with the Child Behavior Checklist (CBCL; Achenbach

& Edelbrock, 1983) and Teacher Report Form (TRF; Achenbach & Edelbrock, 1986). Jane and her parents also underwent separate structured diagnostic interviews using the Anxiety Disorders Interview Schedule for Children (ADIS-C) and a parallel version for the parents (ADIS-P) (Silverman & Nelles, 1988). The ADIS-C/P is based on the classification of psychopathology presented in the Diagnostic and Statistical Manual of Mental Disorders (DSMIV; American Psychiatric Association, 1994). Jane was diagnosed with major depressive disorder and oppositional defiant disorder, according to DSM-IV criteria. According to Jane's reports she had been depressed for several months. Parent and teacher reports suggested that, although Jane had been very anxious about attending school for some time, her school refusal at the time of assessment was characterised more by oppositional behaviour than by anxiety. There was also evidence of significant problems in Jane's relationship with her father, warranting a Vcode of parent-child relational problem. Another important aspect of Jane's school refusal was the secondary gain for Jane associated with avoiding school. For instance, during the day, Jane was spending her time reading, watching television, and baking cakes. These factors were seen to be powerful in maintaining her school refusal. Intervention Procedure

Intervention involved 10 sessions of cognitivebehavioural therapy focused on helping Jane to resume voluntary, full-time attendance at school as soon as possible. The duration of treatment was 6 months. The intervention with Jane focused on cognitive restructuring, problemsolving, social skills training, exposure to school, and contingency contracting. The therapy sessions were facilitated by interactive discussion, written materials, behaviour rehearsal, social praise, and homework tasks. Table 1 summarises the major treatment components. Session 1 focused on continuing to build rapport with Jane, to engage her in the therapeutic process and to set some individual goals for treatment. Initially, Jane was asked to identify things in her life that she enjoyed. Jane nomi-

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TABlfl Outline of Treatment Program Session

Content

Session 1

Rapport building Goal-setting Affective education

Session 2

Cognitive restructuring: Recognising and assessing self-talk

Session 3

Planning for school return Discussing school placement Cognitive restructuring: School Relaxation training

Session 4

Planning for school return Social skills training

Session 5

Planning for school return Cognitive restructuring: Sibling rivalry

Session 6

Preparing for school return Contingency contracting

Session 7

Preparing for school return Cognitive restructuring: Returning to school

Session 8

Trouble-shooting Developing coping statements

Session 9

Positive reinforcement for school attendance

Session 10

Review of coping strategies

nated horse-riding, reading, cooking, and family holidays. The therapist responded enthusiastically to Jane's descriptions of her interests, which had a positive effect on rapport. It was then relatively easy to engage Jane in a goal-setting exercise. Jane identified things in her life which she would like to change, including: to find it easier to talk to other people, family members not yelling at each other, being allowed to go out more, to stop being compared to her sister, and to do more horse-riding. Jane also nominated school as something she would like to change. When asked to elaborate on what aspects of school she would change, Jane listed: some teachers, making work easier, doing different subjects, no reports, no spelling tests, and more field trips. To Jane's list of goals, the therapist added the overall goal of the treatment program: to help Jane return to school. Affective education (see Kendall, 1994) was also a focus of this first session. This was seen to be important in view of Jane's depressed mood. Jane and the therapist played a game with "feel-

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ings cards". On each card was printed a feeling. Each person took turns to describe what the emotion felt like and to describe a time when they had felt like that. Jane enjoyed this activity and participated fully. Many of Jane's responses related to school. For example, when describing panic, Jane said "When you have to go to school and you feel sick and your hands go all sweaty". For embarrassed, Jane said "When the teacher reads out your mark on a test". At the beginning of each of the following sessions, some time was spent with Jane discussing in detail her latest horse-riding experience. Jane also talked about her recent cooking efforts, and the therapist shared some of her recipes with Jane. This became an important rapport-building exercise, and created an alliance between Jane and the therapist. Session 2 focused on teaching Jane to recognise and assess self-talk during stressful situations. The notion that people can have helpful and unhelpful thoughts in situations was explained. A number of visual aids including


cognitive cartoons were used to instruct Jane in the connection between thoughts, feelings, and behaviours. On one worksheet, Jane was asked to think about how she might think, feel, and behave if she was offered the opportunity to go horse-riding. For as long as discussion focused on these general, nonthreatening situations, Jane willingly responded. However, when school-related questions were posed to Jane, she became teary and upset. She stated "I don't want to go back to school". Any attempts to engage Jane in a discussion about school were met with sulking and silence. The therapist responded empathically and stated that together she and Jane would develop a plan for school return. It was proposed that the plan might include a gradual return to school. Jane stated that she was never returning to school. On arrival at Session 3, Jane stated that she wished to change schools. The therapist engaged Jane in a problem-solving exercise. Jane was encouraged to identify and consider advantages and disadvantages of changing school. Table 2 shows the list of "pros and cons" for changing school that was developed in collaboration with Jane. On evaluation of this list, Jane agreed she would attempt to return to her old school. Again, Jane started crying as school was discussed. She was encouraged to identify reasons why it might be good to attend school. Jane initially resisted this, saying there was nothing good about school. Information gathered from Jane during the assessment was

used to remind her of aspects of school that she did enjoy, including being with friends, going on field trips, and doing wood-work and metalwork. Jane nominated "it helps you get a job" as another reason for attending school. The therapist added "it's the law to attend school" and suggested that if Jane returned to school soon, she might not have to repeat a grade. Jane indicated that she agreed with these reasons. Jane's career goals were discussed. Jane reported that she wanted to become a horse strapper and that she knew to do so she would have to complete Year 11. This information was used to further motivate Jane to consider a school return. Jane recorded the positive aspects of attending school that she had identified on a list entitled "Good Things about School." Jane was taught some simple relaxation techniques such as deep breathing. Progressive muscle relaxation training was also trialed. Jane was reluctant to try the relaxation exercises, and afterwards she reported that she did not enjoy them. Jane was crying on arrival at Session 4. She was adamant that she would not be returning to her old school because of worry about facing the kids and teachers and doing the work. Jane again stated that she wanted to change schools and, more specifically, she said she wanted to attend "a special school for kids who cannot cope with normal school". The pros and cons list from the previous session was reviewed. Jane now stated that she would rather repeat a grade at a new school than return to her old school. The remain-

TABLE2 Jane's Pros and Cons List for Changing Schools Pros

Cons

Teachers know me

Don't like the teachers

Old school Have friends

Teasing

Might not have to repeat a grade

Don't like the other kids

Make new friends

Teachers don't know me

New school Different teachers

Cost Might be hard to make friends Might have to repeat Might not be happy there

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der of the session focused on social problem-solving and social skills training. As Jane was particularly anxious about facing the other students on return to school, she was encouraged to think of possible responses to peers' questions about her absence. Jane rehearsed her responses through role-playing with the therapist, and feedback was given on her performance. The issue of Jane wanting to change school was discussed with Jane's mother at the conclusion of the session. It wasresolvedthat this matter be discussed by the family at home and that the therapist be informed of their decision regarding school placement. In Session 5, Jane explained that she had not talked to her parents about changing schools. However, she was very willing to discuss this issue with the therapist, and she asked a lot of questions about going to a new school. This was the first indication from Jane that she would definitely contemplate a return to school. She seemed accepting of the need to repeat a grade. She agreed that she would talk to her parents about changing schools. The issue of rivalry between Jane and her sister Sally was discussed in this session. Jane was encouraged to talk about good things about herself and the ways that she was different from Sally. She was helped to develop positive self-statements about herself in comparison to Sally, and Jane listed these "coping statements" on paper. Jane's parents telephoned the therapist a few days later to say that they would consider a change of school. However, they were concerned that perhaps Jane did not have the intellectual capacity to cope with the academic demands of the mainstream schooling system she had been attending. It was agreed that a psychoeducational assessment of Jane be conducted by one of the clinic's psychologists. The results indicated that Jane's overall intellectual ability was within the average range. Jane's parents then began making inquiries at prospective schools. Jane was extremely reluctant to be involved in this process, and she refused to visit any of the schools. The therapist offered to accompany Jane on one of the school visits and Jane accepted. Although Jane was initially positive at the enrolment interview, she became very anxious and started to cry when one of the teachers demanded an assurance

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from her that if accepted into the school she would attend everyday. The school staff were then even more reluctant to enrol Jane, but they did so after they were informed about the content of the school refusal clinic's treatment program for Jane. Given the amount of school that Jane had missed, it was agreed in collaboration with Jane that she should repeat Year 8. Moreover, given that there were only several weeks of the school year remaining, she would start at the new school at the beginning of the next school year. In Session 6, Jane's preparations for starting back at school were discussed. When talking about school, Jane became very sulky and sat with her head down, refusing to talk. The therapist said that when Jane was ready to talk, they could continue preparing for next week's return to school. As Jane continued to sulk for some time, the therapist attempted to re-engage her by stating that today they would discuss rewards for school attendance. Jane's mood improved immediately, and she responded with interest. The therapist suggested that an attendance plan be developed together, and if Jane adhered to the plan then they would have a celebration. The therapist suggested a reward menu, including afternoon tea at the cafeteria or the therapist baking a chocolate cake. Jane seemed very pleased with the latter idea and was then willing to discuss her attendance plan. It was suggested to Jane that, because she was starting at a new school at the beginning of the school year, it may be just as well for her to attend school for full days from the very first day. Jane agreed to this. A verbal contract was made between Jane and the therapist. When Jane attended for 4 days in a row, the therapist would bring a chocolate cake to the session for Jane. This was followed by a discussion of what needed to be done in order for Jane to get to school, including preparations the night before, what to pack, what time to go to bed, what time to get up in the morning, and who would take Jane to school. Social skills training continued in this session. The issue of friendship formation was discussed briefly with the aid of a handout ("Ways to Make Friends"). However, Jane indicated that, although she would return to school, she


was not interested in getting to know anyone. The therapist attempted to challenge some of Jane's negative thoughts about peer relations, but Jane remained silent. In the session before Jane returned to school (Session 7), the notion of helpful and unhelpful thoughts was revised. The therapist attempted to engage Jane in the process of developing some positive, coping statements. However, Jane seemed highly anxious about the impending school return and was reluctant to be involved in this activity. The therapist provided her with a list of coping statements to read at her leisure. The therapist emphasised to Jane that returning to school would help her to get her life back on track and to be doing what other 13-year-olds normally do. The preparations for Jane's first day at school were reviewed. Although Jane did not seem very confident about her return to school, the therapist communicated the clear expectation that Jane would attend. Jane's mother phoned the therapist after the first day of school. She explained that Jane had gone to school but had become very anxious and upset and she had refused to go to class. Staff at the school had phoned Jane's mother to come and collect Jane from school. The therapist rang Jane and communicated her pleasure at Jane's efforts to go to school. The following day Jane refused to go to school. In speaking to the therapist by phone, Jane explained that she had "cold feet" because of what happened the previous day. Jane said the hardest thing had been having to wait too long before going into class. The therapist suggested to Jane that her experience with her school return so far could be likened to falling off a horse; Jane had tried to go back to school and had a bad experience but the best way for her to deal with it was to try again, and each time she tried it would be easier. Jane responded with interest to this analogy and agreed to try to go to school the next day. The therapist arranged for Jane to be dropped off by her mother closer to the time of the school bell. Jane seemed happy on arrival at Session 8 two days later. She explained that she had attended school for two classes the previous day, and that her teacher had suggested that she

could go home at recess. Jane reported that although she had felt nervous, it had been easier than the first day. A new attendance plan was devised, whereby Jane was expected to attend until lunch-time the next day and then begin full-time attendance after that. Jane was happy and laughing as she described her impressions of the school. She said that she had already met a group of girls who were friendly and welcoming. Some time was spent developing some positive, coping statements for Jane. These included "I only have to stay until lunch on Monday", "I'll get to have chocolate cake on Friday", and "It gets easier every day". Prior to Session 9, Jane had informed the therapist by phone that she had been attending as per the attendance plan (every day for 5 days). Session 9 focused on positive reinforcement for Jane's efforts. This involved a party with chocolate cake, as agreed in the contract. Jane arrived at the session in school uniform and looking very happy. She explained that she was enjoying school, had made several friends, and that she had some nice teachers and some subjects that she enjoyed. Jane reported that she was coping well with the school work so far. Termination was discussed. In the final session (Session 10), Jane graphed her attendance over the past 3 weeks. This was useful in helping her to see the achievements she had made. The issue of homework was discussed. Jane admitted that she had not always been completing homework and that, in the past, she had sometimes stayed home if she had not finished homework that was due to be submitted. Jane said now she would go to school even if she had not done her homework because the teachers were very understanding. Jane said she did not worry a lot about work now because she had done a lot of it before and was finding it easy. In fact, Jane said she had been able to assist peers with their work. It seemed that this had given Jane a tremendous confidence boost. Jane indicated that she would like to do well with her work but would settle for B-grades and C-grades. Some time was spent reviewing the strategies that had helped Jane return to school. The therapist encouraged Jane to make a poster outlining some of these strategies. The aims of this exercise were to reinforce Jane for her success

93

r STEPHANIE ROLLINGS, NEVILLE KING, BRUCE TONGE, DAVID HEYNE, A N D D A W N YOUNG

and to bolster the maintenance of the treatment gains (see Kendall et al., 1991). It was also explained to Jane that it could be of help to other young people who see the poster to know how she had managed to overcome her school refusal problem. Jane seemed very pleased that her ideas might help others. It was interesting to note that many of the strategies that Jane cited as useful were those which she had resisted discussing or learning about during treatment.

Results Posttreatment and follow-up sessions were conducted 4 weeks and 12 weeks after treatment, respectively. These sessions involved clinical interviews with Jane, her parents, and her teachers, and the readministration of questionnaires. At posttreatment and follow-up, Jane stated that she was enjoying school and had made some friends. She said that there were still some times when she did not want to go to school but she would go anyway in order to see her friends. Jane said she was coping with school work and no longer felt nervous or worried about attending school. Her parents reported that Jane was still having some time off due to illness but seemed to be coping reasonably well and was happier in mood. The teachers at Jane's school said that although Jane was attending regularly she was often late to school and was sometimes away because she was supposedly ill. They reported that when at school, Jane seemed happy and

fitted in well socially. They said that Jane's academic performance was satisfactory but she seemed to become stressed about her workload. Attendance

Jane showed a pretreatment attendance rate of 0%. After Session 7, Jane returned to school and there was a marked increase in her school attendance from that time. At the posttreatment assessment, Jane was attending school 95% of the time and by 12-week follow-up her attendance had increased to 100%. Self-report Instruments

Table 3 presents pretreatment, posttreatment, and follow-up data from self-report instruments completed by Jane. Decreases in Jane's selfreported levels of fear associated with going to school, general anxiety, and depressive symptomatology following treatment are noted. Jane's score on the SEQ-SS increased following the intervention, indicating that her perceived level of ability to cope with school situations increased. As can be seen in Table 3, treatment gains on self-reported emotional adjustment were maintained at follow-up. Caregiver Reports

Table 4 presents parent and teacher ratings of Jane's behaviour at pretreatment, posttreatment, and follow-up. The ratings point to a decrease in CBCL internalising and externalising scores,

TABLE 3 Child Self-report at Pretreatment, Posttreatment, and Follow-up Instrument Fear Thermometer0

Pretreatment

Posttreatment

Follow-up

25

0

2

61°

41

44

12 13° 12

9 6 7

9 9 7

25b

1

3

55

56

R-CMAS |T scores) Total Physiological Worry/Oversensitivity Social Concerns / Concentration

CDI

41

SEQ-SS' b

c

° 0 = not scared, 100 = very scored. Clinical range. Total SEQ-SS scores range from 12-60, with higher scores indicating higher self-efficacy.

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INTERVENTION WITH A DEPRESSED ADOLESCENT TABLE 4 Parent and Teacher Reports at Pretreatment, Posttreatment, and Follow-up Pretreatment

Posttreatment

Follow-up

CBCL (mother) Internalising Externalising

66° 56

52 49

63° 44

CBCL (father) Internalising Externalising

68° 64°

49 49

58 45

TRF Internalising Externalising

80° 61°

57 49

51 49

Instrument

' Clinical range. ° Borderline range.

such that Jane's behaviour is rated as being within the normal range for her age following treatment. Similarly, there was a change in Jane's internalising and externalising behaviours at school: following the intervention, teachers at Jane's new school reported fewer internalising and externalising behaviours than had been reported by teachers at her previous school. Generally, these treatment gains are maintained at follow-up, although Jane's mother's ratings suggest a re-emergence of some internalising behaviours at follow-up. Diagnoses

Prior to treatment, Jane was diagnosed with major depressive disorder and oppositional defiant disorder, according to DSM-IV criteria. Following treatment, reports from Jane, her parents, and her teachers suggested that these diagnoses were no longer warranted. However, the V-code description of parent-child relational problem remained, given that the difficulties in Jane's relationship with her father were still evident following treatment. Discussion This study describes the application of cognitive and behavioural procedures with a 13 yearold girl to address her school refusal. The adolescent presented with comorbid depression and oppositional/defiant behaviour. The intervention was delivered over an unusually lengthy period in response to a number of fac-

tors: Jane's initial resistance to contemplate a return to school, followed by her desire to change schools; Jane's parents' uncertainty about which school would be appropriate for Jane; delays in enrolling Jane in a new school; school holidays; and the decision to delay Jane's transition to the new school to coincide with the start of a new school year, given that Jane was repeating a grade. In this way, the program was individualised according to the needs of the adolescent and her family (cf. Naylor, Staskowsi, Kenney, & King, 1994). Following the intervention, the adolescent showed improvements in school attendance, and reported increased ability to cope with school situations and reduced anxious and depressive symptoms. Reports by the adolescent's parents and teachers suggest that, after the intervention, Jane was displaying fewer internalising and externalising behaviours. Key factors in the success of this intervention were deemed to be (a) a change of school, as negotiated during treatment; (b) helping the adolescent to identify her thoughts about school and to challenge and modify her unhelpful cognitions; and (c) positive reinforcement for school attendance. Another important factor may have been the support and encouragement provided to the adolescent by the therapist. Bordin (1979) suggested that the development of a therapeutic alliance is essential for treatment effectiveness. Time spent developing this bond may be of particular importance when

95


working with oppositional adolescents who seem unmotivated to change. It is also interesting to note that, following her return to school, Jane no longer presented as depressed. Lewinsohn, Clarke, Hops, and Andrews (1990) developed a multicomponent, cognitive-behavioural treatment to successfully treat depressed adolescents. Some elements of Jane's treatment program were similar to the components of Lewinsohn and colleagues' intervention (e.g., controlling irrational and negative thoughts and increasing social skills). Although the focus of Jane's treatment was her school refusal and not her depression, Jane reported that she no longer experienced symptoms of depression following treatment. It may be argued that teaching Jane skills for identifying and modifying her negative thoughts had a positive effect on her mood. Another plausible explanation is that Jane's depression was closely connected to her irregular attendance at school. Tisher (1983) referred to the feelings of social "failure" that may be experienced by the student who has had a prolonged absence from school, and to the associated depression the young person may feel regarding this failure. It seems likely that, once Jane was helped to attend school regularly, thus restoring some normality to her life, she felt happier in her mood. Numerous studies have pointed to the important role that parents can play in the treatment of school refusal (e.g., Ayllon, Smith, & Rogers, 1970; Mansdorf & Lukens, 1987; Tahmisian & McReynolds, 1971). In the present case, treatment focused solely on the a d o l e s c e n t . J a n e ' s p a r e n t s w e r e not directly involved in treatment, nor were her teachers. Contact with the parents was limited to a few brief p h o n e c o n v e r s a t i o n s and administrative discussions following the sessions with Jane. The results suggest that change can be effected by focusing treatment on the adolescent school refuser. One possible advantage of this approach is that it encourages the adolescent to take responsibility for his/her own behaviour change, fitting with the adolescent's developmental tasks of increasing autonomy and responsibility. However, there are also several possible limitations of the approach. We suspect in this case that, had the parents and school received

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behaviour management training, Jane would have returned to school more rapidly. This may have prevented her needing to repeat a grade at school. Parents and teachers may also play an important role in the maintenance of treatment gains and the prevention of relapses. This may have been important for Jane, given that at follow-up her mother's reports suggested a reemergence of a number of internalising behaviours. It is also important to note that, at the follow-up assessment, Jane was still having problems in her relationship with her father. There are clear limitations of a treatment approach which is focused on only one party when such relationship problems exist.

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