Applying a Multicomponent Framework to Manage School Refusal: A Case Report

Abstract Introduction: This paper presents the rationale of applying a combined cognitive behavioral and dialectical approach with parent management strategies to a case of anxiety-based school refusal. School refusal is a serious concern that causes much subjective distress to the child, placing his/her parents under tremendous stress. It negatively impacts the child’s self-worth and psychological well-being, and also interferes with social and educational development. The condition is frequently co-morbid with emotional difficulties including depression and anxiety in children and adolescents. Method: The client in this study is a 17-year-old boy with an above average intelligence level presented with school refusal, along with symptoms of anxiety, obsessive worry and excessive reassurance seeking behaviors. Initial assessments using the Children’s Global Assessment Scale (CGAS) revealed moderate impairment in the social area and severe impairment in the academic area. The client showed clear difficulties in emotion regulation, in terms of a higher use of expressive suppression and lesser use of cognitive reappraisal, which were identified on the Emotion Regulation Questionnaire (ERQ). Psychotherapy involved weekly sessions of Cognitive Behavior Therapy (CBT) and Dialectical Behavior Therapy (DBT) techniques including facilitating exposure, cognitive restructuring, distress tolerance, effective goal setting, and interpersonal effectiveness skills in the family context. Changes were assessed at 6 months, 12 months and 18 months follow-up. Results: Results showed reductions in subjective anxiety and reassurance seeking behaviors, and an increase in distress tolerance, with a higher use of cognitive reappraisal. Improvements in interpersonal effectiveness in the family context were noted. The CGAS and ERQ ratings at 6 months, 12 months and 18 months follow-up showed steady improvement, with the client resuming regular schooling. Conclusion: A combined cognitive behavioral and dialectical behavioral approach can be useful in managing school refusal. This case report emphasizes the need for further research to understand the effectiveness of multicomponent approaches to school refusal.