Coping Cat Intervention for Anxiety-Based School Refusal
Absenteeism is a serious physical and mental health concern for a significant number of adolescents. Absenteeism places students at increased risk for suicide attempt, pregnancy, substance abuse, violence, school dropout, and risky sexual behavior (Kearney, C., 2008). Truancy, school refusal, and school phobia are terms that are often used interchangeably and defined inconsistently (Brand & O’Conner, 2004; Kearney, 2008), therefore it is difficult to determine the prevalence of students who miss school solely due to anxiety.
Truancy vs. School Refusal
A number of studies categorize absenteeism into two groups: school refusal and truancy (Kearney, 2008; Wilkins, 2008). Truancy is often defined as non-attendance without parental knowledge and is associated with delinquency and oppositional behaviors (Wilkins, 2008; Wimmer, 2008). School refusal generally refers to the students missing school with parental knowledge and the absence is due to an anxiety or other mood disorders (Brand & O’Conner, 2004; McShane, Walter, & Rey, 2001; Wimmer, 2008).
Kearney (2001) reports that 5 to 28 percent of children and adolescents experience school refusal behaviors. Tolin et al. (2009) report that school refusal behaviors peak during transition periods between elementary, junior high, and high school. In high school students, Guare & Cooper (2003) found no gender difference in rates of absenteeism, however found greater prevalence in Eurpoean-Americans (48.4%), students with poor to fair academic achievement (52.4%), 12th grade students (55%), and non-English-speaking families (65%).
Types of Anxiety Disorders
The most common anxiety disorders related to school refusal include separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder (Brand & O’Conner, 2004; Kearney, 2008; Wimmer, 2008). Community prevalence estimates indicate the lifetime prevalence of any anxiety disorder in children and adolescents is 15% to 20% (Beesdo, Knappe, & Pine, 2009). The child and adolescent prevalence of separation anxiety disorder is 2.8% to 8%, 7% for social phobia, and 4.3% for generalized anxiety disorder (Beesdo, Knappe, & Pine, 2009). Separation anxiety disorder generally manifests in early childhood, followed by social phobia in late childhood to adolescence, with first onset of generalized anxiety disorder typically occurring in late adolescence through early adulthood (Beesdo, Knappe, & Pine, 2009). Anxiety disorders are more prevalence in females (Connolly & Bernstein, 2007), with ratios ranging from 2:1 to 3:1 in adolescents (Beesdo, Knappe, & Pine, 2009).
Function of Behavior
Assessing the function of the school refusal behavior can help school providers understand the behavior and target the areas of intervention (Kearney, 2008; Tolin et al., 2009). Kearney (2008) proses that there are four different functions for school refusal:
- (a) avoidance of anxiety-provoking stimuli or situations related to a school setting;
- (b) escape from aversive, social or evaluative situations;
- (c) attention-getting behavior;
- (d) positive tangible reinforcement.
Function A is associated generalized anxiety disorder, function B with generalized and social anxiety disorder, function C with separation anxiety disorder and oppositional defiant disorder, and function D is associated with oppositional defiant disorder and conduct disorder (Kearney, 2008). The School Refusal Assessment Scale – Revised (parent and child versions) is a valid measure for determining the function the refusal behavior (Kearney, 2007).
Research indicates the cognitive-behavioral interventions are the most efficacious in addressing anxiety-based school refusal behavior (Kearney, 2008; Kearney & Bates, 2005; Last, Hansen, & Franco, 2008; Pina, Zerr, Gonzalez, & Ortiz, 2009; Tolin et al., 2009; Wimmer, 2008). The components of CBT used in treating school refusal include:
- psychoeducation regarding anxiety,
- relaxation training,
- cognitive restructuring,
- exposure techniques,
- reinforcement for attending school,
- parent training in effective commands and contingency reinforcement
- (Kearney, 2008; Kearney & Bates, 2005; Last, Hansen, & Franco, 2008; Pina, Zerr, Gonzalez, & Ortiz, 2009; Tolin et al., 2009; Wimmer, 2008).
While all these techniques are utilized with separation, social, and generalized anxiety disorders, certain elements may be accentuated depending on the function of the behavior. For example, Kearney (2008) recommends stressing parent training components when the function is attention seeking behavior, exposure techniques for avoidance of anxiety provoking stimuli, and cognitive restructuring when the function is to escape from social or evaluative situations.
Coping Cat/C.A.T Project
A literature review was conducted to identify a manualized intervention that incorporated the aforementioned CBT components, demonstrated empirical effectiveness in addressing anxiety-based school refusal, could be used in a school environment, and allowed for the flexibility in tailoring the intervention as recommended by Kearney (2008). While a number of CBT-based interventions were discovered (Silverman, Pina, & Viswesvaran, 2008; Warner, Fisher, Shrout, Rathor, & Klein, 2007), only the Coping Cat/C.A.T project (Kendall, Choudhury, Hudson, & Webb, 2002) met all of the criteria.
The Coping Cat program consist of 14-18, 60-minute sessions, which are completed over the course of 12-16 weeks (Comacho & Hunter, 2006). Albano and Kendall (2002) report that the first 8 sessions focus on psychoeducation and skill building. The remaining sessions are exposure-based, focusing on applying the skills in session and in vivo. The Coping Cat program also calls for parent training sessions and parental involvement in the exposures, when appropriate. The C.A.T. project is a modified version of the Coping Cat program (Kendall, 2006) that is tailored to be developmentally appropriate with adolescents ages 13 to 17 (Beidas, Benjamin, Puleo, Edmunds, & Kendall, 2010).
The Coping Cat program has been shown to be effective in treating anxiety-based school refusal (Beidas, Crawley, Mychailyszyn, Comer, & Kendall, 2010; King et al., 1998; King et al, 2001; Silverman et al., 2008). Using a brief, 4-week version of the Coping Cat program, King et al. (1998) found a significant improvement in school attendance and a decrease in negative affectivity. In a 3 to 5 year follow-up, King et al. (2001) discovered that 13 of the 16 available youth demonstrated normal and voluntary school attendance, were free from any new psychological problems, and demonstrated average academic performance. Another study by Beidas et al. (2010) documented the effectiveness of the Coping Cat program in reducing anxiety and school refusal behaviors in students with social phobia, generalized anxiety disorder, and separation anxiety disorder.
As previously mentioned, an effective intervention needs to be able to be individualized to the functions and needs of the student. The C.A.T. project and Coping Cat programs allow for flexibility without compromising the fidelity (Beidas et al., 2010). The effectiveness of the King study (1998) further attest to the programs flexibility. The manuals for the interventions also offer suggestions to therapists for flexible implementation (Beidas et al., 2010).
Implementation in Schools
In order to implement the C.A.T. program in a school setting, certain modifications need to be made.
- First, the 12-16 week may need to be shortened to fit the material within the school year. Comacho and Hunter (2006) propose a 12-week version of the intervention for school applications. In order for this to be successful the School Refusal Assessment Scale – Revised (Kearney, 2007) could be used to identify and target the functions of the refusing behavior.
- The order of exposure sessions following psychoeducation may need to be modified in order to have the student be able to come to the school building for sessions. Beidas et al. (2010) assert that exposure sessions may need to start right away for school refusal populations.
- As mentioned earlier, the C.A.T. project calls for parent sessions. Due to the potential difficulty in having parents attend sessions during school hours, it may be necessary to involve parents over the telephone rather than in-person sessions (Comacho & Hunter, 2006).
- Lastly, the 60 minute sessions would need to be modified to fit into a 45 to 50 minute school period.
Implementing the C.A.T. program requires proper training and supervision (Comacho & Hunter, 2006). While there is not a stringent protocol for training, clinicians should read the therapist manual, attend workshops, and obtain supervision (Comacho & Hunter, 2006). The publishers of the curriculum also offer training software and videos.
The therapist manual and treatment workbook are the bare essentials that would need to be purchased. All of the therapist manuals, workbooks, and training materials can be purchased from the publishers at the following website: http://www.workbookpublishing.com.
Albano, A. M., & Kendall, P. C. (2002). Cognitive behavioural therapy for children and adolescents with anxiety disorders: Clinical research advances. International Review of Psychiatry, 14(2), 129-134.
Beesdo, K., Knappe, S., & Pine, D. S. (2009). Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. The Psychiatric Clinics of North America, 32(3), 483.
Beidas, R. S., Benjamin, C. L., Puleo, C. M., Edmunds, J. M., & Kendall, P. C. (2010). Flexible applications of the coping cat program for anxious youth. Cognitive and Behavioral Practice, 17(2), 142-153.
Beidas, R.S., Crawley, S. A., & Mychailyszn, M. P. (2010). Cognitive-behavioral treatment of anxious youth with comorbid school refusal: Clinical presentation and treatment response. Psychological Topics, 19(2), 255-271.
Brand, C., & O’Conner, L. (2004). School refusal: It takes a team. Children & Schools, 26(1), 54-64.
Comacho, M., & Hunter, L. (2006). Effective interventions for students with separation anxiety disorder. In C. Franklin, M.B. Harris, & P. Allen-Meares (Eds.), The school services sourcebook: A guide for school-based professionals (pp. 69-87). New York: Oxford University Press, Inc.
Connolly, S. D., & Bernstein, G. A. (2007). Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46(2), 267.
Guare, R. E., & Cooper, B. S. (2003). Truancy revisited: Students as school consumers. Lanham, MD: Scarecrow. Kearney, C. A. (2001). School refusal behavior in youth: A functional approach to assessment and treatment. Washington, DC: American Psychological Association.
Kearney, C. A. (2007). Forms and functions of school refusal behavior in youth: An empirical analysis of absenteeism severity. Journal of Child Psychology and Psychiatry, 48(1), 53-61.
Kearney, C. A. (2008). School absenteeism and school refusal behavior in youth: A contemporary review. Clinical psychology review, 28(3), 451-471.
Kearney, C. A., & Bates, M. (2005). Addressing school refusal behavior: Suggestions for frontline professionals. Children & Schools, 27(4), 207-216.
Kendall, P. C. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual. Ardmore PA: Workbook Publishing.
Kendall, P. C., Choudhury, M., Hudson, J., & Webb, A. (2002). The CAT project therapist manual. Ardmore PA: Workbook Publishing.
King, N. J., Tonge, B. J., Heyne, D., Pritchard, M., Rollings, S., Young, D., … & Ollendick, T. H. (1998). Cognitive‐Behavioral Treatment of School‐Refusing Children: A Controlled Evaluation. Journal of the American Academy of Child & Adolescent Psychiatry, 37(4), 395-403.
King, N., Tonge, B. J., Heyne, D., Turner, S., Pritchard, M., Young, D., … & Ollendick, T. H. (2001). Cognitive-behavioural treatment of school-refusing children: maintenance of improvement at 3-to 5-year follow-up. Scandinavian Journal of Behaviour Therapy, 30(2), 85-89.
Last, C. G., Hansen, C., & Franco, N. (1998). Cognitive‐behavioral treatment of school phobia. Journal of the American Academy of Child & Adolescent Psychiatry, 37(4), 404-411.
McShane, G., Walter, G., & Rey, J. M. (2001). Characteristics of adolescents with school refusal. Australian and New Zealand Journal of Psychiatry, 35(6), 822-826.
Pina, A. A., Zerr, A. A., Gonzales, N. A., & Ortiz, C. D. (2009). Psychosocial interventions for school refusal behavior in children and adolescents. Child development perspectives, 3(1), 11-20.
Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child & Adolescent Psychology, 37(1), 105-130.
Tolin, D. F., Whiting, S., Maltby, N., Diefenbach, G. J., Lothstein, M. A., Hardcastle, S., … & Gray, K. (2009). Intensive (daily) behavior therapy for school refusal: A multiple baseline case series. Cognitive and Behavioral Practice, 16(3), 332-344.
Warner, C. M., Fisher, P. H., Shrout, P. E., Rathor, S., & Klein, R. G. (2007). Treating adolescents with social anxiety disorder in school: An attention control trial. Journal of Child Psychology and Psychiatry, 48(7), 676-686.
Wilkins, J. (2008). School characteristics that influence student attendance: Experiences of students in a school avoidance program. The High School Journal, 91(3), 12-24.
Wimmer, M. (2008). School Refusal. Principal Leadership, 8(8), 10-14.