Clinical Child and Family Psychology Review

, Volume 17, Issue 2, pp 191–215 | Cite as

Developmentally Sensitive Cognitive Behavioral Therapy for Adolescent School Refusal: Rationale and Case Illustration

  • David Heyne
  • Floor M. Sauter
  • Thomas H. Ollendick
  • Brigit M. Van Widenfelt
  • P. Michiel Westenberg


School refusal can be difficult to treat and the poorest treatment response is observed among older school refusers. This poor response may be explained, in part, by the impact of developmental transitions and tasks upon the young person, their family, and the treatment process. This paper describes and illustrates the @school program, a cognitive behavioral therapy (CBT) designed to promote developmental sensitivity when planning and delivering treatment for adolescent school refusal. Treatment is modularized and it incorporates progress reviews, fostering a planned yet flexible approach to CBT. The treatment is illustrated in the case of Allison, a 16-year-old female presenting with major depressive disorder and generalized anxiety disorder. A case formulation guided the selection, sequencing, and pacing of modules targeting predisposing, precipitating, perpetuating, and protective factors. Treatment comprised 16 sessions with Allison (interventions addressing depression, anxiety, and school attendance) and 15 concurrent sessions with her mother (strategies to facilitate an adolescent’s school attendance), including two sessions with Allison and mother together (family communication and problem solving to reduce parent–adolescent conflict). Two treatment-related consultations were also conducted with Allison’s homeroom teacher. Allison’s school attendance improved during the course of treatment. By post-treatment, there was a decrease in internalizing behavior, an increase in self-efficacy, and remission of depressive disorder and anxiety disorder. Clinically significant treatment gains were maintained at 2-month follow-up. Factors influencing outcome may include those inherent to the @school program together with less specific factors. Special consideration is given to parents’ use of both authoritative and autonomy-granting approaches when helping an adolescent to attend school.


School refusal Anxiety Depression Adolescence Cognitive behavioral therapy Modular therapy 



The authors wish to thank the following for their support of the @school Project: Professor Philip D.A. Treffers, Professor R. Vermeiren, Mr. Bart Siebelink, Ms. Rita Snel, Ms. Babette van Spijker, Ms. Marieke Schimmel, Ms. Lisa Duizer, Ms. Ilja Dekker—van Halderen, Dr. Marija Maric, and Ms. Rachel van Hout. We also thank Ms. Marjolein Vlaming for reviewing the manuscript.

Conflict of interest

The authors declare they have no conflict of interest.


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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • David Heyne
    • 1
  • Floor M. Sauter
    • 1
  • Thomas H. Ollendick
    • 2
  • Brigit M. Van Widenfelt
    • 3
  • P. Michiel Westenberg
    • 1
  1. 1.Developmental Psychology UnitLeiden University Institute of PsychologyLeidenThe Netherlands
  2. 2.Child Study CenterVirginia Polytechnic Institute and State UniversityBlacksburgUSA
  3. 3.Department of Child and Adolescent PsychiatryCurium-LUMC/Leiden University Medical CenterLeidenThe Netherlands

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