School-Based Behavioural Consultation for School-Refusal Behaviour

Through three case reports, the present study explores a school-based behavioural consultation for school-refusal behaviour. A two-part intervention was established in this study. The first part consisted of a school counsellor providing behavioural consultation for school-refusal behaviour to the parents and school staff and the second part used an attendance process which parents and school staff escorted children who are unwilling to engage in treatment process to school. Through a series of intervention, all participants were able to attend school from the first week of intervention, and a school-based behavioural consultation using escorting school attendance was effective in treating these children. In addition, this study found that all the parties involved in this process should spend most of their energy during the first crucial week of intervention.


Introduction
In recent years, school-refusal behaviour has become a common and serious problem in the Japanese school system, which requires six years of compulsory education in primary school (first to sixth grades) and three years in secondary school (seventh to ninth grades).Japan defines school-refusing children as those who are absent from or unable to attend school for over 30 days per year due to physical, psychological, social and/or emotional factors, with the exception of disease and economic reasons (Ministry of Education, Culture, Sports, Science, and Technology-Japan, 2009).Based on this definition, over 120.000Japanese children in primary and secondary schools (1.18%) are school refusers (Ministry of Education, Culture, Sports, Schience, and Technology-Japan, 2009).Moreover, with an increasing number of children attending "school nurse's offices", "adaptation classes", and "free schools", which are regarded as a legitimate substitute for a conventional school setting, the number of children regularly refusing the classroom environment is estimated to be far more than 120.000.
According to a survey done by the Ministry of Education, Culture, Sports, Science, and Technology-Japan (2000), more than 20% of children who refuse to attend school progress to social withdrawal.Without appropriate intervention, school-refusal behaviour may be prolonged and thus become more difficult to treat (Okuyama, Okada, Kuribayashi, & Kaneko, 1999).Prolonged school-refusal behaviour leads to academic problems and interferes with social development (Pina, Zerr, & Gonzales, 2009) and mental health (Blagg, 1987;Dube & Orpinas, 2009;Fremont, 2003;Kearney, Pursell, & Alvarez, 2001), and not surprisingly, the rapid increase in social withdrawal following school-refusal behaviour has become a profound social problem in Japanese society.Given this growing problem, the Japanese government has, over the past few years, allocated, in addition to the regular school staff, part-time school counsellors, school assistants and school social workers to secondary schools throughout the country.However, the situation is expected to worsen before it gets better.

General clinical interventions for school refusal have focused mainly on Cognitive Behavioural Therapy (CBT)
to increase attendance and reduce distress (Kearney & Bensaheb, 2006), and recent studies have provided clear evidence that systematic exposure-based CBT is clinically effective (Bernstein, Hektner, Borchardt, & McMillan, 2001;Doobay, 2008;Kearney, 2002;Last, Hansen, & Franco, 1998;Mofitt, Chorpita, & Fernandez, 2003;Ollendick & King, 1999;Wimmer, 2008).CBT for school-refusal behaviour employs psychoeducation, cognitive restructuring, contingency contracting, parental-management strategies and exposure on the basis of a detailed assessment and functional analysis of children and their parents (Kearney, 2003;King & Bernstein, 2001;Tolin et al., 2009).However, there are few specialised institutions that are able to provide a CBT programme for school-refusal behaviour in rural areas.Therefore, since school personnel everywhere find themselves facing what has become a common and universal problem, it makes sense for them to try a practical school-based approach (Kearney, Pursell, & Alvarez, 2001).
One problem with a school-based approach, however, is that most school refusers are reluctant to come to counselling in school, even if their parents ask them to attend (Maeda, Hatada, Sonoda, & Takayama, 2012), which makes it hard for school counsellors or psychologists to do their jobs.Some children may be able to attend school in some instances but choose to stay at home with the full knowledge that their parents are under scrutiny for their school refusal (Lauchlan, 2003).Kearney (2008) identified four reasons for school refusal: (1) avoidance of stimuli provoking negative affectivity; (2) escape from aversive social situations; (3) pursuit of attention from significant others; and (4) pursuit of tangible rewards outside of school.Moreover, school refusers commonly combine reasons 1 and 4. In other words, children distressed about school and allowed to stay at home by parents are likely to enjoy doing their favourite activities, which reinforces school-refusal behaviour.This tendency has been seen in a number of Japanese children who (a) refuse to go to school because of trivial issues; (b) are not diagnosed with any particular physical or mental disorders; (c) have no problem going out with family and friends outside of school hours; and (d) spend most of their time alone doing favourite things such as watching television, playing video games, surfing the Internet or reading comic books during the school day (Maeda, 2012).In such circumstances, only the parents (mostly mothers) actually visit the school counsellor or psychologist, who may then inevitably discuss indirect intervention without interviewing the children or conducting any direct assessments.Thus, school-based consultation for school refusers as an indirect intervention with parents and teachers can become a crucial option.
Although there are various approaches for school-refusal behaviour, early return to school is the essential aim of all treatments; otherwise, too long an absence sets in motion secondary factors that make treatment more difficult (Hersov, 1972).For this reason, a number of studies have pointed out the importance of involving parents as a part of the intervention process (Cerio, 1997;Nuttall & Woods, 2013;Epstein & Sheldon, 2002;Heyne, Sauter, Ollendick, Van Widenfelt, & Westenberg, 2014;Kearney & Bates, 2005;Kearney & Bensaheb, 2006;Lauchlan, 2003).Some studies emphasise that parents of school-refusing children should put a stop to this behaviour and escort children to school in a parental intervention process (Berg, 1985;Blagg & Yule, 1984;Doobay, 2008;Kearney & Graczyk, 2014).Heyne and Rollings (2002) suggested the importance of providing consultation to parents based on behavioural theory and instructing them in strategies for facilitating school attendance, such as (1) minimising secondary gain from school refusal; (2) establishing a smooth household routine; (3) clarifying the date and process for school return; (4) giving instructions; (5) planning to ignore behaviours that accompany school refusal; (6) modelling confidence; (7) escorting the child to school; (8) leaving the child at school; (9) dealing with running away and; (10) providing positive reinforcement.
Consultation with school staff is also essential in the treatment of school-refusal behaviour, especially in cases of adolescent school refusers (Heyne et al., 2014).Kearney and Bensaheb (2006) reported that school-based professionals encounter school-refusing children who (1) are anxious in the morning about school or parental separation; (2) engage in misbehaviours during the school day for the purpose of visiting the school nurse to escape the classroom or to be sent home; and (3) display high levels of somatic complaints.School staff should be encouraged to use planned ignoring of inappropriate behaviours, such as pleading to go home or tantrums, thus employing the same approach as recommended for parents (Heyne & King, 2004).If teachers and other school professionals recognise these features of school-refusal behaviour and provide appropriate supports, intervention can ensure the integration of these young people into the classroom.Thus, providing behavioural consultation for school-refusal behaviour to parents and school staff utilises CBT as an inevitable indirect intervention.Through three case reports, the present study explores the effectiveness of a school-based behavioural consultation with parents and school staff for school-refusal behaviour.A two-part intervention was established in this study.The first part consisted of a school counsellor providing behavioural consultation for school-refusal behaviour to the parents and school staff and the second part used an attendance process in which parents or school staff escorted children to school.The goal of the intervention was an early return to the classroom.

Participants
The intervention was done with three Japanese secondary school children exhibiting school-refusal behaviours.Their behaviour closely matched the criteria proposed by Blagg and Yule (1984), which included extreme difficulty in attending school with refusal and absence from school for at least three days; accompanying emotional upset marked by temper tantrums, sleep disturbances and psychosomatic complaints; remaining at home with the knowledge and permission of parents and the absence of significant antisocial problems such as persistent lying, wandering from home, stealing, destructiveness or inappropriate sexual activity.These behaviours were deemed as those that would best respond to an exposure-based approach.The parents of the participants visited a school counsellor (the author) to seek help, and according to the parents, all three children underwent medical and psychological examinations, and none were diagnosed with physical or psychological disorders.When the parents were initially interviewed at the school, the children were reluctant to attend, despite firm efforts by their parents to have them do so.Both the parents and school staff confirmed that none of the participants had issues with bullying in the classroom and no problem going out with family or friends after school hours.Moreover, they spent most of their time at home during school hours engaging in their favourite activities.

Procedure
The two-part intervention was implemented via school-based behavioural consultation.As already indicated, in the first part the school counsellor provided behavioural consultation to parents and school staff in a support meeting.Parents and staff were informed about basic behavioural theory, the process of the formation of school avoidance behaviour (two-factor theory of learning) and negative effects of prolonged school-refusal behaviour, which included academic underachievement, employment difficulties and increased risk of psychiatric illness.The counsellor also provided training on the mechanism and process of in-vivo exposure and coping skills for dealing with resistive responses.Moreover, somatic complaints (headache, stomach ache, nausea, backache, vomiting, fever, dizziness, diarrhoea, cardiac palpitations and reports of feeling unwell) and resistive behaviours (crying, temper tantrums, verbal abuse, violent behaviours, self-harming behaviours, threats to commit suicide and running away from home) during intervention were carefully explained to parents and school staff.The negative effects of prolonged school refusal were emphasised to encourage parental involvement.
The second part of the intervention was the escorting process conducted by the parents and school staff.As a typical intervention plan, adults were instructed to follow four principles.First, parents would clearly explain to the child how the escorting process would be implemented a few days prior to the intervention.Second, the parents would wake up the children, get them changed into their school uniforms and escort them by car to school at a fixed time.Third, when resistive behaviours occurred, the parents and school staff would physically escort the children to school.Fourth, the participants would be directly escorted to the classroom and would not be permitted to go home during school hours.
In these uncontrolled case studies, the rate of school attendance and time spent in the classroom were defined as the effect measure, and data on these measures were compared for before and after the intervention.School staff recorded the data for participants' school attendance and provided the data to the school counsellor every day.

Case Presentation
Child A was a 13-year-old (seventh grade) male student.He was enrolled in a local public secondary school with about 300 students.His family included his father, mother, two elder brothers, a younger brother and a younger sister.His father was a salaried worker and his mother was a full-time housewife.Child A's school-refusal behaviour first occurred when he was in the third grade; he refused to attend school either on Monday or when he refused to participate in a scheduled event.When he was in the sixth grade, he missed all his classes except for the graduation ceremony of primary school.After enrolling in secondary school (seventh grade), Child A attended all his classes for the first three days but refused to attend school from the fourth day onward.Although he prepared for school and told his mother the night before that he intended to go, he complained of stomach ache in the morning, and his mother allowed him to stay at home.His father was an easy-going, amiable character who left all the matters of his son's school refusal to his wife.Despite Child A's shy personality, he had a few close friends and enjoyed playing with them every weekend.The mother visited a child consultation office, where she was advised that parents needed to cooperate to help their child.However, specific programmes for school-refusal behaviour were not provided by the consultation office.As a result, Child A continued to avoid school for 19 consecutive months, and he spent his time surfing the Internet, watching animation DVDs and playing video games during school hours.

Case Conceptualisation
Child A's school-refusal behaviour was due to negative reinforcement in avoiding aversive stimuli related to school, such as attendance on Monday or a dislike of school subjects.In addition, his mother allowed him to engage in his favourite activities during school hours, which positively reinforced and maintained his school-refusal behaviour.Child A's morning stomach ache typically disappeared when he was allowed to stay home from school, and it was assessed as a minor stress response managed by school non-attendance.When the child tried to attend school at the beginning of a new school term, he failed after three days.This was considered to be the result of a deficiency in stress tolerance caused by classroom avoidance over several months.The parents never actively encouraged Child A to attend school once he started skipping, and this further reinforced and maintained his school-refusal behaviour for over 19 months.

Intervention Process
The school counsellor, parents, classroom teacher, nurse and year-head for the grade held a support meeting to address Child A's school-refusal behaviour.In the meeting, the parents insisted that their son would naturally return to school by blocking any stimuli from the school and respecting his desire for school non-attendance.Moreover, the mother wanted to know the cause of her son's school refusal.The school counsellor pointed out that the prolongation of Child A's school refusal was elicited by past support from his parents.The counsellor provided behavioural psychoeducation as described in the Procedures section.After receiving psychoeduation, the parents agreed to the proposed escorting intervention process.The intervention plan was as follows: (1) after the meeting the parents would clearly explain the behavioural intervention to their child; (2) they would wake him up at 6:30 a.m., get him changed into his school uniform and escort him to school at 8:00 a.m.; and (3) school staff would come to their house if the parents could not manage to escort the child to school on time because of resistive behaviour.The support meeting was held on Friday evening, with the intervention planned to commence in four days' time (the following Tuesday).

Escorting Phase (10 Weeks)
On the first day of the intervention, Child A showed minor resistive responses (complaining of stomach ache and stiffened resistance) as his parents tried to escort him to school.His mother phoned the school staff and told them that she wanted to keep her son out of school because of stomach ache.Following the intervention plan, the school staff advised against this and went to the child's house to offer support.The mother agreed and informed her son that the school staff would escort him.When the school staff arrived at their house, Child A was ready to attend school.After brief verbal persuasion by the school staff, he was escorted to school by his mother.The classroom teacher waited for Child A at the school entrance and escorted him to the classroom.He did not display any further resistance to being escorted from the entrance to the classroom.Then, Child A attended all his classes and communicated normally with his classmates during recesses.On the second and third day, Child A displayed similar behaviours regarding school attendance: he would be ready for school before the school staff arrived; the staff would verbally persuade him to attend school and he would be escorted to school by his mother.After arriving at the school, he would attend all his classes without any psychological problems.On the fourth day, his mother phoned the school staff and said that she would manage to escort him without a home visit because he had not complained of a stomach ache for the first time.After the phone call, the mother escorted him to school on time, and he attended all his classes.During the first week, Child A never required a physically escort from the school staff and attended all his classes after being escorted by his mother.
On the Monday of the second week, despite displaying school-refusal behaviour, Child A attended school after verbal persuasion by the school staff.Between Tuesday and Thursday, he attended school on time with his mother.However, Child A suddenly refused to attend school while getting ready on Friday.Although a phone call from the mother was delayed for 30 minutes, the school staff eventually arrived and persuaded him as usual.He attended in the middle of the first class without any problems.In the third week, he went to school with his mother from Monday through Thursday and managed to attend by himself on Friday.From the fourth week, although he needed to be escorted by his mother, he continued to attend school without the support of school staff.On the fourth day of the fifth week, the school staff visited Child A's house for the last time to encourage him to attend school.The mother reported that he showed no further somatic complaints from week 6 through week 10, and the intervention was terminated thereafter.
Over the 10 weeks of intervention (43 days), Child A never missed school.His attendance in school (classroom, nursing room and individual study room) and in the classroom was 99.7% and 99.2%, respectively.Moreover, he never needed to be physically escorted by the school staff despite their needing to visit his house for persuasion on six occasions.Child A's mother escorted him to school for 42 days.Child A continued to attend school for 10 weeks after the intervention commenced and began attending school by himself from week 11 without being escorted by his mother.The school staff reported that Child A attended all his classes without any problems, implying that his school attendance became completely normal.Between weeks 11 and 19, his school attendance was 100%, and he never missed a class.After week 19, his school attendance remained stable with no further absence from school, which confirmed a continuing benefit from the intervention.

Case Presentation
Child B was a 14-year-old (eighth grade), highly intelligent male student.He attended a local secondary school that enrolled about 400 students.His family includes a father (salaried worker), a mother (part-time worker) and an elder brother (unemployed).Child B had a cheerful personality and several friends from early childhood.He did not have any difficulties with interpersonal relationships and had good grades.He was not good at waking up in the morning and took a long time to get ready for school.Since early childhood, he occasionally refused to attend school on a Monday or when he did not want to participate in an event, especially long-distance running.During primary school, his mother and a classroom teacher escorted him to school because of his reluctance to attend.Just after enrolling in secondary school (seventh grade), Child B began refusing to attend school by not getting out of the bed (resistant response).Although his mother tried to wake him up, he would remain immobile in his bed and would refuse to get ready.His mother took him to a psychiatrist who found no clinical diagnosis and advised that he should not go to school for a while.In addition, both parents attended a public child consultation centre where they were advised that their child should attend school only when he wanted to do so, and that they should not compel him to attend.Afterwards, Child B went to an individual study room within the school when he wished, he would stay there for about two hours and then returns home without taking any classes.After skipping school, Child B enjoyed watching television, watching DVDs and surfing the Internet.Furthermore, he played with his friends every weekend and had no problem socialising with them.His school-refusal behaviour became progressively worse and his school attendance levels (individual study room only) were 57% and 28% in the seventh and eighth grades, respectively.During this year period, he never attended classes, and his parents consulted with the school staff and school counsellor.

Case Conceptualisation
Since early childhood, Child B had trouble waking in the morning and tended to avoid school events that he disliked, which triggered his school-refusal behaviour, which was shaped by the negative reinforcement of avoiding waking up at a certain time in the morning.In addition, the ensuing support that prompted him to enjoy his time without attending school acted as a positive reinforcement.The reinforcement of Child B's school-refusal behaviour prolonged his non-attendance and triggered additional school refusal behaviour.

Intervention Process
A support meeting was arranged just before the new term (ninth grade), which was attended by Child B's parents, school counsellor, vice-principal and guidance counsellor.The parents insisted that they would like to force their son to return to the classroom as soon as possible because of prolonged non-attendance.In addition, the parents stated that although Child B was willing to return to school, he was not able to get out of bed on time for school.In the meeting, the participants decided to implement an escorting intervention from the first day of the new semester.The following treatment plan was put into place: (1) the parents would clearly explain to the child how escorting would be implemented prior to the intervention; (2) they would wake him up, get him changed into his school uniform and escort him to school by car; and (3) the school staff would be ready to support the parents if they could not manage Child B's resistive responses.Three male school teachers were assigned to this case, given Child B's muscular build.

Intervention Phase 1 (10 Weeks)
On the first day of the intervention, the parents managed to wake up their child and get him ready but could not persuade him to leave the house.Following the support plan, the parents asked for support, and the school staff arrived to support them.Child B remained seated in protest against escort by his parents.For an hour the school staff and his parents attempted to persuade him to attend school.Despite their efforts, Child B remained immobile, so the parents and school staff stood him up and attempted to get him out of the house; however, he grabbed hold of the front door.When the school staff physically removed him from the door, Child B's resistive response rapidly declined, and he voluntarily got into the car.After arriving at school, Child B was escorted to the nursing room at first, where he stayed for half an hour before attending the first lesson, with his friends escorting him to the classroom.However, just before entering the classroom, he escaped from the school and went home.The school staff visited his house at lunchtime because his parents were at work and he was alone at home.They persuaded Child B to return to school, and he reluctantly agreed.Then, he entered the classroom and attended all his classes that afternoon.Child B entered the classroom for the first time in two years.
On the second day, Child B attended school with his mother.Although he entered the classroom and attended the first two lessons, he escaped during the break.The school staff went to his house, as they had done previously, but they did not manage to meet him because he was out of the house.On the third day, Child B came to school with his mother and attended all his classes without escaping from school.From that day onward, he regularly came to school with his mother escorting him and attended all his classes without escaping.On the third day of the third week, the school staff were asked to provide support for their son's school refusal behaviour.However, they were required to provide only a few minutes of verbal persuasion before Child B agreed to attend school without resisting.After that day, he resumed school attendance with his mother and continued until week 10.In the first 10 weeks (42 days), one school day was missed, and his school-attendance and class-attendance rates were 94.1% and 92.2%, respectively.Moreover, he needed to be physically escorted to school by his parents and school staff on only one day (2.3%).

Intervention Phase 2 (23 Weeks)
From week 11, Child B began attending school without the need to be escorted by his mother.However, he needed to be escorted after some holiday weekends, but on each occasion, he changed into his school uniform and got ready to attend school as soon as the school staff arrived at his house.Because his resistive responses disappeared when the school staff encouraged him to attend school, the number of school support staff was reduced from four to two.During this 107-day period, Child B had a school attendance rate of 99.2% and a class attendance rate of 98.8%.He needed home visits and verbal persuasion by the school staff on only five days (4.6%).

Intervention Phase 3 (10 Weeks)
From week 35, Child B's school attendance became slightly unstable.However, the school staff supported him and his parents on each occasion when he faltered, and he managed to continue with his school attendance.In week 40, he was accepted to his second-choice school after taking the entrance exam for senior high school.During this period (49 days), Child B missed two days of school, and his school attendance and class attendance rates were 92.6% and 90.8%, respectively.He needed home visits and verbal persuasion by school staff on eight days (16%).

Follow-Up (Post-Graduation)
The school counsellor remained in contact with Child B's mother after he graduated from secondary school.According to his mother, Child B lived in a dormitory of a boarding school and did not exhibit school-refusal behaviour.At age 17, Child B enjoyed his school life without any behavioural or psychological problems.

Case Presentation
Child C was a 14-year-old (ninth grade) male student with above average intelligence studying in a local secondary school that enrolled about 300 students.His family comprised a father who worked as a teacher away from home, a mother who worked part-time, an older brother studying in high school, and a younger brother enrolled in the seventh grade.Child C had several friends despite having an introverted personality, and he had no serious interpersonal problems to date.Although he sometimes refused to attend school after a weekend holiday when he was in primary school, he attended school normally for the first four months after enrolling in secondary school (seventh grade).However, after the summer holidays, his number of school absences gradually increased, and he missed all his classes in the first four months of eighth grade.His parents consulted with a public school board office, where they were advised to implement gradual school attendance and were offered the use of an adaptation class provided by the office as a first step of support for their child's school-refusal behaviour.
Although Child C agreed to attend the adaptation class from September, he was unable to attend the first two months.From November, Child C began attending the adaptation class without any absences and was able to continue until the end of the eighth grade (five months).Child C's tutor reported that he studied very hard in class and would have no academic problems in a normal class.At this point, Child C also expressed a preference to return to studying in a normal class; thus, a return to the classroom was decided from the beginning of the ninth grade.
Although Child C attended school on the first two days of the new semester, he left school on the third day just after reaching the school.From that day on, his school-refusal behaviour recurred, and he spent most of his school hours alone in his room playing video games and reading comic books.At the same time, he also began to refuse meeting friends who played with him during the weekends.Because of this change in his situation, his parents advised him to return to the adaptation class, but he refused to do so.Two months later, his parents visited the school counselling office to discuss their son's behaviour.

Case Conceptualisation
Since primary school, Child C had a tendency to refuse to attend school on a Monday or after a long holiday.This tendency was maintained after enrolling in secondary school, and school non-attendance increased after the seventh grade summer holidays.At first his parents decided to wait and see whether their son would naturally return to school without support.However, this strategy reinforced and maintained Child C's school-refusal behaviour; consequently, he completely missed school for eight months.Subsequently he attended the special adaptation class at the public school board for five months, during which the public school board staff provided no practical support (for example, social skills training, shaping, systematic desensitisation or gradual exposure) for returning to the school or classroom.Therefore, although Child C tried to attend school from the beginning of the ninth grade, his refusal behaviour promptly resurfaced after three days of the new semester.In addition, prolonged school-refusal behaviour increased Child C's stress response to meeting friends.

Intervention Process
The school counsellor, guidance counsellor, parents, classroom teacher, and assistant teacher held a support meeting to discuss Child C's school-refusal behaviour.In the meeting, the participants insisted that Child C's current behaviour had become more severe, as evidenced by his refusing to meet his friends after school.The parents were concerned about their son's recurring school refusal and requested practical support to return him to normal school attendance.In particular, they were concerned that their son had become socially withdrawn.The parents also reported that their son wanted to return to school because he was going to high school in a year.
The specific treatment plan included the following: (1) the parents would clearly explain to Child C prior to the intervention how the escorting process would be implemented; (2) the father would take three days off from living away from home to help, wake up Child C, get him changed into his school uniform, and escort him to school by car; (3) the mother would prepare the school uniform, textbooks and other necessities for school; and (4) the school staff would support the parents if they could not manage their child's resistive responses.

Intervention Phase 1 (Five Weeks)
Immediately after the support meeting, the father told Child C that he would be escorting him to school on two days.Although Child C showed a resistive response to his father's declaration, the parents ignored it as planned.The intervention commenced on Friday in consideration of the child's psychological burden.On the first day of the intervention, the parents called the school staff for support because of strong resistive responses to the escort.When the school staff arrived at Child C's house, he sat in protest in his room without changing clothes.Because he remained entirely unmoved by verbal persuasion, his father and the school staff physically escorted him to the car.Child C continued to display serious resistive responses in the car and his father sat next to him until he arrived at school.Child C's mother brought his school uniform, school bag and textbooks in her car.Child C's resistive responses slightly diminished when he arrived at the school, but he still needed to be physically escorted to the counselling office where the school staff tried to get him changed into his uniform.Despite minor resistive responses, he eventually put on the school uniform.Child C asked the school staff if he could wash his face, and he did so in a restroom with a member the staff.Afterwards, the classroom teacher visited Child C and escorted him to the classroom with the help of verbal persuasion, which he accomplished without any resistive responses.Subsequently, Child C attended all six classes that day without exhibiting any maladaptive behaviours.
The second day was similar because Child C again stayed in bed as a resistive response before the father and school staff physically escorted him, while his mother carried the school uniform and book bag.However, there were no resistive responses in the car or counselling office, and he entered the classroom just before the first class and attended all his classes that day.
On the third day, Child C attended school with his mother without the support of school staff.According to his mother, she and her husband managed to wake up their son, get him dressed and escort him to school with only slight resistive responses.After Child C arrived at school, he entered the classroom with his teacher and attended all the scheduled classes.This behavioural pattern continued for five consecutive days.During this period, the mother intensively persuaded her son to prepare for school despite his reluctance.
On the eighth day, the mother asked school staff for support.Since the third day, the father had returned to the workplace and was away from home, so three school staff members were required to escort Child C when he exhibited minor resistive responses to school attendance.From the next day, Child C attended school with his mother without any support from the school staff and this routine continued until the summer holidays (week five).In the first five weeks of the intervention (17 days), Child C's school attendance was 100%; he needed to be physically escorted to school by the school staff on four days, and there were 13 days when he was escorted by his mother.

Intervention Phase 2 (11 Weeks)
Although Child C was reluctant to attend school on the first day after the summer holidays, he eventually went after being persuaded by his mother.After attending the first two classes, Child C complained of feeling sick and had a break in the nursing room for two hours.However, his condition did not improve to allow school attendance, and ultimately he returned home early from school.However, from the following day, his school attendance returned to normal and continued for 11 consecutive days.
On the first day of the tenth week, Child C exhibited intense temper tantrums that required the school staff to physically escort him.His resistive response was particularly strong on this day, and the school staff, who did not have to escort him for three weeks, experienced difficulties that lasted an hour.Consequently, Child C attended from the second to the last class but did so without further maladaptive behaviours.His school-attendance behaviour became normal the following day and continued for 10 weeks.On the last day of week 16, the school staff arrived to support the mother, but Child C went to school with only verbal persuasion.Over these 10 weeks (44 days), Child C's school attendance was 95.7%; he needed to be physically escorted to school by the school staff on one day and by his mother on 43 days.

Intervention Phase 3 (19 Weeks)
From week 17, Child C's resistive responses were uncommon and his mother was able to encourage him to attend school.He maintained regular school attendance, and the school staff did not need to escort him until his graduation day.The mother reported that Child C attended his classes on time every day and never pleaded somatic complaints.In addition, his study workload and family communication increased considerably.Child C went to school by himself on the last day of the ninth grade.During weeks 17 through 35, his school and class attendance rates were both 100%, and he did not need to be escorted by the school staff.

Follow-Up (Post-Graduation)
After graduation from secondary school, Child C enrolled at his first choice of high school.In the first year, he was reluctant to attend the first days after summer and winter holidays.However, his parents escorted him to school on each occasion, and his school attendance returned to normal.Afterwards, he continued to regularly attend school, and his school refusal behaviours were not observed, including at the end of the second year of high school.

Discussion
As can be seen from the results of these three case studies, a school-based behavioural consultation and escorting process by parents and school staff was effective in supporting children with prolonged school-refusal behaviour who were unwilling to actively engage in intervention.School refusal occurred in these participants as an avoidance response to unpleasant stimuli in school; however, they were reinforced by several environmental factors.Each set of parents accessed either medical institutions or public consultation offices.None was able to provide practical treatment other than to advise them to wait for their children to spontaneously attend school.Such passive support not only deprived the children of opportunities to eradicate their school-avoidance responses but also prolonged their school-refusal behaviour.In addition, the participants were allowed to engage in activities they enjoyed during school non-attendance, which reinforced and maintained their school-refusal behaviour.
As in the cases of the children in the present study, when children in compulsory education refuse to engage in usual treatment (e.g., CBT), their parents, school counsellors and school officials must opt for indirect active interventions.In such cases, exposure-based school attendance may represent a practical treatment in which parental support is provided to block children's school-refusal behaviour and escort them to school.Given that the child with school refusal may then show a variety of resistive responses, such as somatic complaints or temper tantrums, appropriate responses by support persons are key factors for the success of this intervention.However, because there have been few case reports on this subject, little is known about resistive responses during interventions, appropriate parental responses to maladaptive behaviours or the detailed process of change in school-attendance behaviours.
Child A resumed his normal school life from the first day of the intervention despite being absent from school for 19 months.Although he pleaded a minor somatic complaint as a resistive response for the first four days of the intervention, he returned to school with little resistance after verbal persuasion from the school staff during a home visit.In this case, the mother almost accepted Child A's resistive response to keep him out of school on the first day, at variance with the treatment plan.Therefore, the school staff persuaded the mother not to accept his resistive response and supported her in escorting Child A to school.This sequence on the first day blocked Child A's prolonged school-avoidance behaviour and led him to attend school normally.By escorting him to attend all his classes from the first day, we may have reduced his discomfort about the classroom and increased his self-efficacy.
Contrary to expectations, Child A showed no serious resistive responses while he was escorted to the school or classroom and attended all his classes without any physical or psychological problems from the first day of the intervention.In addition, his intervention proceeded smoothly from the escort phase to the unassisted school-attendance phase.Thus, it is possible that Child A had few worries regarding attending school despite prolonged absence and simply needed a trigger to return to the school.In other words, for Child A, it was necessary to remove the reinforcers, such as parental behaviour in the morning, which were hindering his school attendance.This effectively led to a smooth return to school.
The intervention for Child B, who refused to enter the classroom for nearly two years, was more difficult.His parents and four school staff members were engaged in the escorting process because of his prolonged school-refusal behaviours and muscular build.Over the first three days of intervention, he displayed resistive responses such as crouching on the floor and temper tantrums and both his parents and school staff had to physically escort him to school.However, Child B showed no serious resistive responses from day four and attended school with only verbal persuasion.In addition, his school attendance returned to normal in the 11th week.In this case, four male staff members were continuously engaged in further intervention because of Child B's build and resistive responses.Consequently, his resistive responses were lower in intensity than anticipated, and the school staff managed to handle his resistive responses.Thus, six supporters (the parents and school staff) effectively blocked Child B's school avoidance behaviour, which may have taught him that resisting escort was in vain.An exposure-based approach for school-refusal behaviour could be a significant burden to children, parents and school staff (Maeda et al., 2012) but interventions that employ several supporters, similar to this case, may ease their physical and psychological burden during the intervention.
Although Child C attended a special adaptation class opened by the public school board as part of a gradual approach to school return, he was not provided with practical support to move forward, such as systematic desensitisation or shaping.Escorting by parents was employed to return Child C to the classroom.During the first two days of the intervention, he exhibited serious resistive responses (temper tantrums), and his father and four school staff members were required to block these responses by physically escorting him to school.Child C's resistive responses were extinguished by firm blocking actions for two days, and he was able to attend school with a verbal prompt by his mother.When Child C arrived at school, a close classmate waited for him at the entrance and escorted him to the classroom, which became a positive reinforcement for his class attendance behaviour.In addition to serious resistive response observed during the first two days, Child C showed school-refusal behaviour on three additional days over a 35-week period.However, on each occasion his parents and school staff blocked his school-refusal behaviour and escorted him to school.This interventional approach contributed to Child C's prompt school return and subsequent stable school attendance.
As these three case studies demonstrate, the focus of the escorting process should be the extinction of resistive responses, including somatic complaints, resistive behaviours or inappropriate behaviours that must be eliminated through effective physical blocking as far as possible.Then the parents and school staff can more easily escort the child to school.This case study found that the peak resistive response occurred during the first three or four days of intervention.In other words, most of the physical and psychological burdens faced by the child, his parents, and the school staff, as well as the demands of the escorting intervention, are issues during the first week.Therefore, parents and school staff who are provided with behavioural consultation should spend most of their energy during the first crucial week of intervention.In this study, allocating four or five staff members for intervention in the first week was sufficient to effectively eliminate resistive responses and to contribute to early school return.
All children in this case study returned to the classroom after the first week of intervention, possibly because the school counsellor advised parents and school staff not to provide an individual study room for school refusers.Consequently, they did not display any behavioural or psychological problems in the classroom despite their rapid return.Indeed, through the process of exposure, the children's stress from school non-attendance was quickly relieved.Such quick recovery from school-refusal behaviour suggests the major benefit of an exposure-based intervention.
Needless to say, the indirect behavioural intervention described in this study should be employed carefully, since the school counsellor does not have an opportunity to interview the children refusing school.However, all school refusers need to return to the classroom as quickly as possible to avoid missing key experiences with classmates and teachers.In particular, many children who refuse to attend school in Japan are in a socially withdrawn state and may lack practical support.In these cases, behavioural intervention done by parents and school staff who have been provided with behavioural consultation and training may represent the only effective approach to treatment for these children who refuse other types of treatment.Thus, as long as children with prolonged school-refusal behaviours continue to refuse standard therapy, indirect intervention by parents and school staff may be their only opportunity for help.

Figure 1 .
Figure 1.Rate of school attendance (Child A)

Figure 2 .
Figure 2. Rate of school attendance (Child B)

Figure 3 .
Figure 3. Rate of school attendance (Child C)