Curious Incident Podcast Episode 11: Understanding School Refusal Behavior
Updated: Dec 16, 2022
About This Episode
Curious Incident is a podcast for special needs families and your window into the world of special education hosted by NYC Special Education Attorney Adam Dayan. In this episode, Adam talks with Francyne Zeltser and Ariel Kornblum from the Manhattan Psychology Group, a center for comprehensive psychological, behavioral, and educational services in New York City for children, adolescents, and adults. Their discussion revolves around understanding school refusal behavior including:
defining school refusal, looking for early warning signs
undergoing a comprehensive assessment
creating a treatment plan
providing effective supports and interventions
(LISTEN) The Curious Incident Podcast Episode 11: Understanding School Refusal Behavior
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Do you have questions about your child's education? Call Special Education Attorney Adam Dayan at the Law Offices of Adam Dayan: (646) 866-7157 and request a consultation with our New York attorneys today.
Speaker 1: This is Curious Incident, a podcast for special needs families and your window into the world of special education. Special needs parenting can be challenging and we want to make it easier by providing you with the resources you need to help your child. Let's delve deep into the world of learning differently with your host special education attorney Adam Dayan. Adam Dayan: I am excited to present my next two guests on this podcast, Francyne Zeltser and Ariel Kornblum from the Manhattan Psychology Group, a center for comprehensive psychological, behavioral and educational services in New York City for children, adolescents and adults. This is the first time we're having multiple guests on an episode and it's sure to be a dynamic conversation. Francyne is a New York state licensed psychologist, certified school psychologist and adjunct professor. She is the Clinical Director of Psychology Training and Special Projects at Manhattan Psychology Group as well as child, adolescent and adult psychologist. Ariel is a New York State licensed psychologist, board certified behavior analyst and licensed behavior analyst. She's the Senior Director of Clinical Operations at Manhattan Psychology Group, as well as a child, adolescent and adult psychologist. Francyne and Ariel, thank you for joining me today. Francyne Zeltser: Of course. Thank you so much for having us. Ariel Kornblum: Happy to be here. Adam Dayan: Great to have you. Francyne, let's start with you. Tell me a little bit more about yourself. What makes your approach and outlook unique given your particular background, skills and experiences? Francyne Zeltser: So I'm a licensed psychologist and a school psychologist, and I spent the last decade working in the public schools as well as in private practice. Having both of these experiences has allowed me to work in a more comprehensive manner with families servicing them both in the school system with the supports that are in place, as well as providing those wraparound services that are often not available in the school system. Adam Dayan: So when you were in the public school system, was that in New York City or outside of New York City and what was your role? Francyne Zeltser: So I worked in the suburbs of New York and I worked as a school psychologist and as a CPSE, CSE Chairperson. Adam Dayan: Ariel, how about you? What makes your approach and outlook unique given your particular background, skills and experiences? Ariel Kornblum: I'm a dually licensed psychologist and licensed behavior analyst in New York State. And in my previous experience, I worked as a school psychologist in the New York City public schools, as well as a school psychologist in a non-public school in New York City. My approach is unique in that I am one of very few dually licensed clinicians in New York, and my passion is in bringing both disciplines together. So all my work is centered around the overlap between psychological services and behavioral analytic services. Adam Dayan: Great, and I'm sure we're going to speak a lot about that overlap during the course of this conversation. Thank you. So what is school refusal? How is that defined? Francyne Zeltser: School refusal is a pattern of behaviors that's rooted in social-emotional difficulties. Often that difficulty is anxiety and that anxiety causes a child to avoid or refuse or have difficulty attending school on a regular basis. Often a child who is refusing school doesn't have any physical illness or any kind of pain, they just have trouble finding the courage to attend school on a regular basis, whether it's going to school first thing in the morning or staying in school for the duration of the school day. And this pattern of behavior persists over a period of days, weeks, and sometimes even months. Adam Dayan: And I understand there's a continuum within the context of school refusal. Can you talk about what that continuum is? Francyne Zeltser: Yes. So often there is an underlying anxiety or fear or worry about school. Sometimes it might be socially rooted where a child might be fearful that they don't have somebody to sit with at lunch or that they're going to have an uncomfortable social interaction. Other time it's rooted in academics. Maybe the child's struggling or they don't feel equipped to handle the school expectations in terms of academics. And other times it's just difficult for the child to be in the school building. Sometimes it might be difficult for them to separate from their parents, they might worry about their parents, they might worry about themselves. And there could be a number of different reasons that a child might feel anxious or worried about attending school on a regular basis. So often a child might miss a day of school. Maybe they have a headache or maybe they have a doctor's appointment and by missing a day of school they feel a little bit less anxious. So then they stay home and then they ask to stay home the next day. And what often ends up happening is the missing or avoiding of school accommodates and feeds in to this school refusal behavior and actually exacerbates the problem. Adam Dayan: Sure. Okay, so it sounds like as far as the continuum, it could be anything from academics to social emotional to anything about the environment that is causing the school refusal. Francyne Zeltser: Right. So some children naturally have a more difficult time transitioning to school. These are the children who are more anxious at the beginning of the school year, have difficulty transitioning back after breaks. Other children might have changes in their home environment. Maybe there's a new sibling, maybe there's a divorce, maybe there's an illness. And that might be the cause of the school refusal behavior. Adam Dayan: So they stay home, that alleviates the anxiety they're feeling, whatever it may be related to, and that builds a, "I want to stay home more, I want to stay home more," to avoid that anxiety. Yes? Francyne Zeltser: Right. So staying home is actually escaping from the anxiety. So they are avoiding having to cope or deal with the anxiety that they're experiencing, and then the anxiety actually builds up because they didn't face it. And each day that they're out of school, it becomes more and more difficult for them to go back into school. Adam Dayan: What are the early signs that parents or teachers should be on the lookout for before the problem becomes a problem? Francyne Zeltser: Parents and teachers should make note of changes in the child's behavior. Most notable are the psychosomatic complaints that often occur in the morning. "My head hurts. My stomach hurts." These are often the same complaints that a child presents to the school nurse in order to get sent home from school. And then when you follow up with the pediatrician, there is actually nothing wrong with the child. Additionally, having a lot of resistance or conflict in the morning, getting up, getting ready for school, as well as overall negative affect and negative opinion about school. Especially when a child had previously enjoyed school or previously been doing pretty well. Ariel Kornblum: Parents should know their children's baseline normal. Anything that deviates from that for a period of a few days is something that is noteworthy and an early sign. So psychosomatic complaints, absolutely, but also changes in sleeping, eating, hygiene, particularly for older kids. All those things are really important, so parents really need to understand where is baseline for my child? Where might they go to if they're either feeling down or they're having a difficult day, but what is really categorically different? And to really take note of that and try to intervene sooner because you can. Adam Dayan: What are your initial thoughts or impressions when you see that happening? Francyne Zeltser: I try to empower parents because parenting is really hard, and as parents, we don't always know the answers and it's okay to ask for help. I encourage parents to reach out to the school right away. So if it's day two that a child is staying home and there's no fever and there's no reason for them to stay home, reach out to the school nurse, reach out to the classroom teacher, reach out to the school counselor, let them know that something's going on and see if they could even support you in some way. Because the sooner we intervene, the better. Adam Dayan: So I know in our previous conversations you mentioned to me that there seems to be a spike in kids who are having school refusal around mid-October. Can you talk a little bit more about that and explain why that's the case? Francyne Zeltser: Yeah. So very often exposure to a feared stimuli helps reduce the anxiety. So the more consistently a child attends school, the less likely they will avoid school or the fear will be reduced. What ends up happening often in a typical school year is that the first few weeks of school, often the first six weeks of school are somewhat of a honeymoon period. The routines are taught, the focus is on social emotional learning. There's a lot of teaching of transitions and a lot of review of the prior year, and the academic rigor isn't fully present. As the school year goes on, often around mid-October, the expectations increase, and that is when the students are given their first rounds of tests, they're getting more and more homework and they're able to see maybe there's some learning differences or they're just struggling to keep up and we see an increase in that anxiety. Adam Dayan: And do you see that more often with certain ages or grades or that's variable? Francyne Zeltser: It really varies. There are certain kids who will come into kindergarten and they have difficulty separating. Maybe they haven't gone to preschool or separated from their families before. Other times there could be a goodness of fit that plays into it. Maybe the teacher they had last year was very supportive and very warm. And this year we have a more structured teacher who's less warm and maybe it's just not as good of a fit. So there's not a specific age correlated with school refusal behavior, but rather it has to do with the individual differences of the kids and their responsiveness to the school and the supports that are in place. Adam Dayan: One thing I wanted to clarify, because this came up in our previous conversations as well, the difference between having a true aversion to school and skipping school for entertainment purposes. Can you speak to that? Francyne Zeltser: Sure. So school refusal isn't not going to school because there's something better to do. It makes complete sense that a child might prefer to stay home from school if they have family in town visiting or if there's an exciting activity happening at home. That's time limited. School refusal is a pattern of behavior that occurs over time where a child is fearful or avoidant of school, they go to great measures to avoid going to school. And even if they do go to school, they often try to get sent home from school because being in school is so aversive for them. Adam Dayan: So what kinds of programs are available for children experiencing a school refusal? Paint a picture of the type of supports or interventions they may receive. Francyne Zeltser: So it's really important when a child starts exhibiting this behavior that we conduct some type of assessment, especially if this is a student who has not previously been evaluated or hasn't already been receiving services. So we like to do what we call a school refusal assessment, which is similar to a psychological and an FBA, where we assess the underlying social-emotional components of the school refusal behavior that might flag some anxiety or some other social-emotional issues. And we do a series of observations to better understand the behavioral aspect of it. What are the antecedents? What's happening at home when it's time to get ready to school? What's happening at school when they first walk into the building? And what are the consequences of the child saying, "I don't want to go to school," or asking to go to the school nurse? How are the parents responding? How are the teachers responding? How are the peers responding? Adam Dayan: Okay, and once you've done that assessment and conducted that observation, what next? Francyne Zeltser: So then we would write a plan, a school refusal plan, that would be very comprehensive. It would involve the parents, the school team, and really, everyone in the school building from the aid that's greeting them in the doorway when they first get into the classroom, to the teacher, the administrators. And it would be very comprehensive in that everyone would have a role and a set response to help proactively support the child in getting into school and then help them maintain their ability to stay in school. Adam Dayan: And as far as interventions go, what might be some interventions that could be part of that plan? Francyne Zeltser: So there is a counseling piece that's absolutely integral. The child most likely would need individual counseling as well as parent counseling and training for the parents and for the family unit as a whole, so that the parents feel better equipped to support their child. Parents often have a really hard time seeing their child suffer, so they often accommodate this anxiety or this behavior to avoid seeing their child suffer. So by receiving this parent training, they're able to be empowered and educated in how to best support their child so that they don't give in to these anxious behaviors and then unintentionally make the problem worse. Ariel Kornblum: I just want to add that school refusal behavior has the highest rates of recidivism for treatment. So the treatment for it has to be extraordinarily comprehensive. There are multiple stakeholders. We're talking hours and hours of therapy, of collaboration, of consultation in different environments in order to prevent that slip back. Adam Dayan: And I guess you just clarified it with that last piece, but when we talk about recidivism, we're talking about repeat occurrences of the same issue. So if it's not a comprehensive, intensive, effective plan that it could repeat itself in the future. Yes? Ariel Kornblum: Absolutely. It's very actually, likely to repeat itself in the future. School refusal behavior tends to be a chronic condition that will extend over years. It might pop up in moments of extreme anxiety for a child or a moment of turmoil in the family. So the treatment for it is not just initially comprehensive, it really lasts for a while. Adam Dayan: Okay, and I know we're going to get into what constitutes a comprehensive plan. We'll talk about some more interventions in a little bit. Let's make sure we come back to this point about recidivism so that parents and listeners understand what a plan should include so that it doesn't repeat itself. Speaker 1: You're listening to Curious Incident, a podcast for special needs parents with your host special education lawyer, Adam Dayan. If you like what you are hearing, please like and subscribe. Adam Dayan: What makes a plan comprehensive and effective so that the school refusal does not repeat itself? Ariel Kornblum: So like Francyne said, there's obviously a very important counseling component here. We have a child who is struggling with social-emotional difficulties. They need to be in counseling at least once a week, maybe sometimes more than that. But in terms of the comprehensive nature of school refusal programming, you have school teams. That includes teachers, counselors, principals, support staff, aids, related service providers, if the child is receiving speech or OT or something like that. Then you have not just parents, but caregivers, babysitters, grandparents, you might have bus drivers. There are so many people who need to be aware of what is going on so that they can utilize similar language and they can remind the child of what the interventions they're working on. Adam Dayan: I'm just going to... So you just named a lot of people, a lot of roles. What are their respective roles on this team to make sure that it's done consistently and effectively? Ariel Kornblum: So the goal of school refusal treatment is really simply put, to get the child back in school. And that means back in school for the duration of the day, back in school learning, back in school thriving. The overall purpose of that plan is to break down what are the steps to get the child back to that level where they are in school on a daily basis, learning and thriving? So the role of all these people is to support the child in achieving whatever goal they are working on, on the day that they see that child. Adam Dayan: And who's communicating with these various individuals to make sure that they're all playing their parts and doing so consistently according to the plan? Francyne Zeltser: That's a great question. So the case manager is often the psychologist that's working with the child directly who drafted the school refusal plan. That person becomes the team lead and is responsible not only for working with the child and the family, but also making sure that all stakeholders are on the same page and that the plan is being followed with fidelity. Adam Dayan: So for example, would the case manager be somebody within your practice who is talking to these individuals or is it someone within the school setting who's doing that? Francyne Zeltser: So we often would suggest that a psychologist within the practice is the case manager, that is the point person for all the different individuals that are working with the child. And what makes our practice so unique is that we're able to use both psychological services, educational services, and behavioral services to support the child. So often we find that schools aren't equipped to provide the intensive intervention that's needed, especially at the beginning of the treatment plan. So that's when we bring in a BCBA to help support the plan so that it's done with integrity. Adam Dayan: Okay, so you've clarified the role of case manager. Now talk a little bit more about approach and methodology. What are some of the things that the team is going to be doing with the student to implement this plan? Francyne Zeltser: So in individual counseling, the therapist is going to work with the student on learning coping skills. Coping skills might include relaxation training, social skills training, so that the child knows how to interact, a self-advocacy training. They will also work on desensitization so that the child fears going to school less and is better able to cope with the anxiety of going in school. These skills are often referred to as replacement skills, which are the skills that will then train the school team to help the child engage in when they start experiencing that anxiety. So for example, if the child starts getting fearful in class and asks to go to the school nurse, a trained teacher might say, "Why don't you try your deep breathing? And then if you still feel like you need to go to the nurse after your deep breathing, we could send you down to the nurse." And just prompting the student to use a replacement skill sometimes is enough to stop that anxiety spiral. Adam Dayan: How long do they usually remain in these programs or for how long do these plans usually remain in effect and where do they transition to after? Francyne Zeltser: So it depends. There's not a one size fits all for school refusal, and very often it depends on how long this behavior has been going on for. Sometimes a school refusal plan can be effective in just a week or two, and other times it might take a few months for the child to be able to be in school independently throughout the school day. Adam Dayan: And what factors influence that? Francyne Zeltser: There are a lot of factors. Number one being the child's social emotional functioning. How anxious are they? What is the underlying cause of the school refusal behavior and how responsive are they to treatment? Then also, the parents' responsiveness and the school's responsiveness with consistency being the absolute most important part of the plan. Ariel Kornblum: I'll also mentioned that goodness of fit with the school comes up as being very important throughout this process. And particularly when you've made some behavioral progress and you're more in a flow and the child, let's say, is attending school more often, it gives a really great baseline in order to assess the goodness of fit in the school. So our goal is obviously always to keep kids in the least restrictive environment. So we need to make sure, are we putting them in a place that is going to support them, support this level of need, or do we need to consider other options? Adam Dayan: Mm-hmm, absolutely. So apart from what you mentioned earlier, what other suggestions do you have for parents whose children are exhibiting school refusal behavior, and what is their first step for getting help? Francyne Zeltser: Parents should be very transparent with the school as to what is going on and what they are struggling with. If the classroom teacher is not responsive or not helpful, reach out to the school nurse, reach out to the school psychologist and reach out to a building administrator. The more school professionals that are involved, the more support that will be received because the plan needs to be comprehensive. Adam Dayan: And can you describe a typical trajectory for a student struggling with these issues? Francyne Zeltser: Generally, the school will try to intervene and put a support plan in place. Unfortunately, what often happens is that a person, let's say, a school psychologist or a guidance counselor, will be designated as the point person or the check-in person for the student. And sometimes that works really well until that person is not available. Maybe they're in a meeting, maybe they're absent, and then there's nobody there to support the child and the plan tends to fall apart, which is why it's so important that we have a comprehensive team in place so that if person A is not available, the child knows to go to person B or person C, so that there's never a time that the child does not feel supported. Adam Dayan: It seems like a pretty intensive approach and I know many schools are not equipped to provide such an approach. So let's talk about how does something like this work? And Ariel, maybe you can talk about what is a BCBA and how does a BCBA differ from an ABA therapist and how do they interact with each other? Ariel Kornblum: Sure. A BCBA is a Board Certified Behavior Analyst, someone who has had specific education in the science of behavior analysis, completed supervised experience, past certification tests, and really, their expertise is in analyzing and understanding behavior. From there, they are the experts in creating plans that address the functions of behavior. So when we talk about the functions of behavior, we're talking about the why. Sure, I see this behavior happening, but why is it happening? And that is really applicable to school refusal behavior as well. As Francyne mentioned, there is often a social emotional aspect to it, but some of that underlying stuff really comes out in observable behavior. So the multidisciplinary nature of working with a psychologist and a BCBA together really can create the most comprehensive plan that's looking at really, every aspect that is involved in school refusal behavior. A BCBA is categorically different than an ABA therapist. An ABA therapist is a pretty vague term that is assigned to any therapist that works directly implementing a program that was designed by a BCBA. More often than not, you see ABA therapists in the commercial insurance world working with autistic children under the supervision of a BCBA. Adam Dayan: So I think one thing that you just clarified is that ABA, applied behavioral analysis is not just for students with autism, correct? That's a common misperception. Ariel Kornblum: Correct. This is one of my favorite questions. So ABA and the sciences of behavior analysis is widely applicable. In fact, it's applicable to any sort of behavior that we can observe. The science of behavior analysis is applicable to work with almost all diagnoses as well as in work with typically developing children, with adults in jobs and corporate programming. So BCBAs have been pigeonholed into work with the autistic population, but ABA actually extends far further than that. Adam Dayan: And if I understood your description correctly, you have an ABA therapist who's on the ground providing instruction and keeping data, then you have a BCBA who is overseeing that process and making sure that the plan developed by the psychologist is implemented with fidelity. Is that right? Ariel Kornblum: Yes. Francyne Zeltser: And I think this has been going on for so long, but now in this, dare I say it, post pandemic world, where students were not consistently attending school for two years, we're seeing peak levels of school refusal. Ariel Kornblum: Absolutely. Think of every kid or every adult rather, that struggles with social anxiety. I mean, I know tons of adults who, remote work was really the best thing that ever happened to them. I don't have to talk to people anymore. I don't have to see people. I can work from the comfort of my home. Kids feel the same way. So there is an entire group of kids who were asked to come back to school when working remotely and learning remotely was extraordinarily effective for them, particularly older students, high school aged students who actually can learn in a remote setting. Speaker 1: If you like what you are hearing, please let us know by subscribing to the Curious Incident Podcast and letting other special needs parents know about it too. If you have thoughts, questions, comments, or would like to suggest ideas for a future episode, we'd love to hear it. So email your feedback to firstname.lastname@example.org. Adam Dayan: So you have a higher incidence of students who are exhibiting school refusal, and the goal is to help them feel comfortable transitioning back to school. So from your perspective as a BCBA, what is a typical session look like for a student struggling with school refusal? Ariel Kornblum: So the role of a BCBA in a school refusal program is really to be the point person on the ground working with all the stakeholders and working with that child to make sure a few things are happening. The first, if the child is working on some sort of relaxation technique in therapy, so they have some deep breathing exercises. If they're working on, let's say, a deep breathing exercise, to have a BCBA on the ground there, who meets them at their car door, meets them at their bus stop, instructs them, "If you are feeling a little bit anxious, let's practice your deep breathing," now that is someone who has constant contact with the psychologist, who's also talking with all the stakeholders in the school and can really be there to facilitate the program on the ground. So BCBAs are uniquely suited for this kind of role because this is where they work. They work in the community, they work in schools, they work in individuals homes. Let's say, in an extreme example of school refusal behavior, you might need a BCBA in your home in the morning. Let's move through the morning routine. Let's get you out the door. In my experience, I have met plenty of parents outside of a school and transition children into the school building. Sometimes you're even talking about 10 feet from the sidewalk into the front door, having someone there who can really understand and can get your child into the school building is so valuable when you're doing a comprehensive program like this. Adam Dayan: So if they've at home because they're refusing to go to school, how many hours per day are the ABA therapists and BCBA working with the student? Ariel Kornblum: So the goal of any school refusal program is to get physically back into the building. So for psychologists, for BCBAs, for any stakeholder, it is preferable for a child to be in the school building. They could be sitting in a hallway for eight hours. That is preferable to them learning at home. And I say that because again, it's a short term intensive intervention. We cannot work on getting a child back into the classroom, back learning, back participating, if they are not physically in the building. So if a child is refusing to go to school, all of our energy is focused on getting them physically into the school building. So we would not be providing services for eight hours a day at home. Adam Dayan: That makes a lot of sense. Ariel, we've talked about rapport and relationship building, play time, work time. Can you talk about how that fits in? Ariel Kornblum: Sure. So rapport building is an essential foundational part of any sort of therapy, whether it's psychological therapy, if it's ABA therapy, if it's speech, if it's OT, if it's PT, you're nothing if you don't have a relationship with the child you're working with. So every discipline has its own name for that kind of a thing. In ABA, we refer to it as pairing. The idea is that you are pairing yourself with reinforcement. So the therapist should be reinforcing to the child. I tell parents who are engaged in ABA therapy all the time, if you have a therapist show up at your door, your child should be happy to see that therapist. That should be exciting for them. And if it's not, we have a real foundational problem. Francyne Zeltser: I also want to add that the Covid quarantine, unfortunately, unintentionally, reinforced school refusal behavior because children who were anxious were forced to stay home often for 10 days, 10 consecutive days, that they were out of school. And for 10 days they didn't have to cope with the anxiety that they felt going to school. So that accommodated the anxiety and unintentionally reinforced it. Adam Dayan: Yeah, I'm searching for the right words. I mean, all I can come up with is tragedy. Ariel Kornblum: It is. It is. It is, it's extraordinarily tragic. Francyne Zeltser: The perfect storm. Ariel Kornblum: Because kids thrive. If you've ever been into a kindergarten, first, second grade classroom, they do the same stuff every day. To an adult, it's very boring. The morning meeting, the let's look at the weather, we do the same work activities. I mean, you're learning new things, but for kids to have huge disruptions in their learning makes it so that every time they come back to that, it's new. Imagine learning the same thing, the same routine, 10 times during a year. Adam Dayan: Right. Francyne Zeltser: Right, and I want to add that yes, it's not only special needs children that have school refusal behavior, but when school refusal behavior is significant and it interferes with their day-to-day functioning, it becomes a special need. And that's a time when we want to get the Committee on Special Education involved and consider if the child does not already have an IEP, consider doing a comprehensive evaluation and getting an IEP in place, I would say, a child that requires this level of support for, let's say, an anxiety disorder, would absolutely qualify a child with an other health impairment because it impacts their educational opportunities. Adam Dayan: Right, and we could probably have a separate podcast on Covid 19 and the ramifications for students, special ed or not. But I think this definitely shines light on some of those ramifications and it's unfortunate, but thankfully, there are professionals like you both who are able to step in and provide plans and supports to help kids transition back to school. So let's talk a little bit more about that. And if you could go into some more of the techniques and methodologies that can be used in the context of ABA therapy for a student with school refusal issues, I think that would be helpful for our listeners. Ariel Kornblum: Sure. So like Francyne was saying before, the beginning of this kind of intervention is a comprehensive assessment where we're looking at those underlying psychological conditions, and we are treating them via counseling, but we're also looking to analyze the function of the behavior. So a behavior analyst would be able to look at the behavior and determine why it's happening. The why is what really informs the intervention. So for example, if a child is refusing school because there is something more rewarding at home. There's a new baby at home, they don't want to leave the home, they want to be around mom and dad and the baby, then we know there is a setting event here. The environment is making it so that being home is more reinforcing than being in school. This is just an example of a potential function of a school refusal behavior. But if we're going to look at, which is what behavior analysts do, at altering the environment in order to set a child up for success, that might look like making home a little bit less reinforcing for a little bit and making school more reinforcing. So if school is more reinforcing, maybe that looks like some sort of short-term behavior plan where if you go to school and you participate, depends on the kid, this could be walk into the building and sit in the hallway for the whole day, it could be enter your classroom, it could be participate in the class, you can earn X, Y, and Z reward. And we will constantly look at what makes a good reward, what makes it again, reinforcing and does that happen every day? Does it happen over a series of days? And can we wean it out over time? That is one example of an intervention. Adam Dayan: So I think one thing that might be on some parents and listeners' minds is you're altering the environment. You're modifying the workload. You're helping the student gradually transition back. And they're missing out on some stuff, some classroom instruction while that process is happening. How do they ever catch up? How do they get back to a place where they're working on the same work and at the same level as their peers are? Ariel Kornblum: It's a really good question, one that comes up all the time and this kind of work. I will say, simply put, if this is what is happening with your child and your home, your most important thing is to get your child back into school. That is more important than the academic workload in that exact moment in time. But it depends on how long the behavior has been going on for, how reinforced it has been, how we are able to make progress when a plan is put into place. There are some cases where it's indicated to maybe start a course of intensive tutoring or to work on the homework at home if that is something that a child can do in that moment. But the underlying social emotional difficulties are the most important in this moment because, let's say, for example, you allow the child to do all the work of the school day in a counselor's office. That could be so reinforcing to a specific kind of kid, one that doesn't like working in groups, one that maybe has some social anxiety, doesn't like to participate in class. We have now offered them basically the perfect out. So breaking that will become harder. So we want to be mindful when we're altering the environment, we're not actually taking steps back. Speaker 1: Your listening to Curious Incident, a podcast for special needs parents with your host special education lawyer, Adam Dayan. If you like what you are hearing, please like and subscribe. Adam Dayan: I know you both work in the same psychology practice. You talked about the role of the case manager. Talk a little bit more. As members of a child's care team, how do you typically work together for the benefit of a child? Ariel Kornblum: Yeah. So Francyne and I work together, but we actually went to the same graduate school too. So we are similarly trained, but in our office we are very, very, very collaborative. That is what we pride ourselves on. We are able to offer a service that is a real wraparound service, in office, in-home, in the community, and that is what is needed to address school refusal behavior. So if there's a psychologist in the office who is the point person for a plan, who has developed a plan and someone from my team, a BCBA is on the ground working with that child, those two are going to be in communication at least every day, if not multiple times a day. And then you'll also have the BCBA talking with the parent, giving feedback, the psychologist giving feedback. Every single day when you're doing this kind of work is critically important because you need to decide what do we need to change, if anything, for the next day? So time is of the essence. We don't have time to say, "Oh, we'll decide in session next week how we're going to move forward." So the constant collaboration is... And that doesn't even include working with the child directly. That's all the backend stuff, is really very, very, very important in these kinds of cases. Adam Dayan: Did you want to add anything Francyne? Francyne Zeltser: I just wanted to add that it's really important that we understand the why and sometimes the why has to do with a fear. Other times it has to do with a learning difference. So having the ability to refer to different disciplines within one office is very helpful. We often receive referrals from our neuropsych that says, I have a child who came in for a comprehensive evaluation and there were no learning differences found, but there's significant anxiety and he's not attending school. Or we might say, it seems like the anxiety is rooted in the child not understanding the work. Why don't we do a neuropsych evaluation to better understand why the child is struggling in the classroom? So having access to different professionals all within a practice is very helpful. Adam Dayan: Excellent, thank you. What kinds of students do you typically serve in your psychology practice? Francyne Zeltser: We work with a variety of patients. Our youngest patients could be as young as 18 months old, and we have patients through adulthood. They come for all different reasons, and often they come to us because we provide a variety of services that might not be available at another practice, so maybe they need some in-home support. We have therapists that go into the home, not just ABA therapists, but also mental health clinicians that go into the homes. We're able to do evaluations, we're able to do tutoring. So we really work with all different populations. Adam Dayan: What are some reasons that they might be coming to you? Francyne Zeltser: We specialize in working with children with disruptive behaviors, mood disorders, anxiety disorders, attentional disorders. We work on parent-child interactions. We work on parent management training. There's just endless reasons that people come for support. Adam Dayan: So personally, as somebody who struggled with OCD when I was a kid, I'm curious, do you see any overlap between students who have OCD and are exhibiting school refusal issues? Francyne Zeltser: Yes, it's definitely something that would contribute to some school refusal behavior, and especially with OCD and also children who are germ anxious, they will often refuse to go to school, especially in this post Covid era where they're very fearful of getting sick. Adam Dayan: Sure, yep, makes sense. In my world, it's all about appropriateness. We litigate cases based on whether an educational program is appropriate or not. And so what I'm asking is from your standpoint, both of you, what makes an educational program appropriate? Francyne Zeltser: So the program needs to have the ability to provide the intensive supports that are needed at the beginning of the intervention and then modify the intervention as the child makes progress so that the supports can be pulled back to promote independence. Ariel Kornblum: So I think it's the same for really, any kid in terms of the appropriateness of an educational setting. It's one where the kid can learn, where they can thrive, where they feel empowered to self-advocate. And I think that what's really important about that kind of appropriateness when you talk about school refusal is again, the supports. Can the school provide the supports when needed? Can they pull them back when that's indicated? Can they identify the correct amount of scaffolding? At a certain point, a child who is struggling with this level of school refusal behavior will likely be referred for some sort of comprehensive evaluation. And at that point, we're really looking to see are there learning differences or social emotional difficulties that are so significant that maybe this is not the right environment? So constantly asking that question is super important when you're thinking about the appropriateness of fit. Adam Dayan: Sure, and I think that's a good segue. As I was saying before, our job as special education lawyers is to help families look at a proposed program from the school district and determine in collaboration with the experts, the psychologists and the BCBAs and the other experts, is this appropriate for this student, let's say, in this case, who's exhibiting school refusal? So I ask you, what has your experience been with the New York City Department of Education and the extent to which it's able or not able to effectively help students with school refusal or ABA needs? Ariel Kornblum: Simply put, the New York City Department of Education is not able to accommodate a high support need student with school refusal behavior. That is mostly because likely this is a student that may not have an IEP, may not be receiving related service provision already, and therefore not on the radar of school support staff. School psychologists in the New York City Department of Education are responsible for chairing CSEs, doing initial evaluations, and triennial evaluations. They do not readily see students for counseling, nor are they available to do so. Most buildings do not have a school psychologist on site five days a week. There are guidance counselors and social workers, but often there is so much going on that even finding that one point person is going to be extraordinarily difficult. As for the provision of ABA, New York City Department of Education does not provide ABA. In fact, they explicitly say that they do not practice any specific methodology, ABA being included. So typically, if they are using any sort of approach that includes behavioral science, it's not labeled ABA, it's usually not being delivered by someone who has a lot of experience, may have received a training here and there, but overall the New York City DOE is certainly not set up for this kind of intervention. Adam Dayan: Francyne? Francyne Zeltser: It's important to also note that it's not a question of whether or not the New York City Department of Education can provide it. It's can they provide this support consistently over a period of time, as long as it is needed. And often the answer is no. They simply don't have the bandwidth needed to provide this intensive support. And even if they can provide it once or twice, perhaps for a day or two, they're not equipped. They're not staffed to support a child who needs this level of support. Ariel Kornblum: I would mention that most schools are not. The level of intensity required for a school refusal program really involves a professional being on the ground, solely dedicated to this one child for the full school day, for days on end. I have never worked with a school private, public, New York City, outside of New York City, that was really able to do that without collaborating with an outside source. Adam Dayan: Just curious, I know we talked about the short end of the spectrum. It could be a week or two of interventions before the student is ready to transition back. In your experience, you guys have been doing this for years, what's the longest period that you saw it take for a student to be able to transition back? Francyne Zeltser: It would really depend on the time of the school year. So often when the school refusal behavior emerges around the holiday time, when there are a lot of breaks from school, it becomes more difficult because the child makes progress and then school is closed, and then they need a lot of support to transition back from the school break. And then there's another break. So when the behavior emerges around now, around Thanksgiving, it becomes very difficult and sometimes it might take them through February break to consistently return to school without some support needed, but they might show some regression, but with the support that is in place, they're able to transition back more readily than the first time that they transition back. Adam Dayan: So it could be months if it's an extreme case, and if the interventions weren't done effectively, then there could be a relapse or recidivism, as you said earlier. Ariel Kornblum: Yes, and I think all of these things are assuming goodness of fit also because if the goodness of fit is not there, at a certain point, the team will say it's not worth it. You can't put a kid back in a school that can't support the child. It's not fair. It's not fair to the child. So I think anywhere from two weeks to six weeks is probably the average amount of time, assuming goodness of fit, assuming that the child is receiving comprehensive service provision outside of school as well. But sure, yeah, it could take a while depending on school breaks and if the student needs to go to another school, then we're talking more time away from school buildings in general. Francyne Zeltser: Right, and it also depends what has been done prior to us being called in. So often the parents are asked to come into the school building and they end up sitting in the school building for the duration of the school day. And it takes even more work for us to get the parents out of the school before we're able to intervene. So that's why it's so critical to involve a professional right away. Adam Dayan: Sure. What skills do you help your students develop? Ariel Kornblum: Coping skills, frustration tolerance for things that may be hard or challenging, self-advocacy is a really, really big one, particularly when you're talking about students who are struggling with underlying social emotional challenges. For them to be able to self-advocate, "This is what I need and this is how I need it," is really the ultimate skill because eventually those students will turn into college students and turn into adults where they will have to self-advocate in order to get their needs met. Francyne Zeltser: Also, emotional regulation skills, their ability to feel upset or distressed, and then express that in an appropriate manner. And social skills, how can they interact with their peers and communicate appropriately. Adam Dayan: We've talked about how your practice works and the different people on the childcare team. Talk a little bit more about the interaction between your practice, for example, and the psychologist within the school, because there are people within that school building who need to be on the same page. So how does that piece work? Francyne Zeltser: So it depends on the plan that's in place, but often a provider from our practice, whether it be the psychologist or a BCBA, is in the building and part of their role is doing school training. So they're working directly with the psychologist in teaching them how to respond to the child, how to best support the child and how to implement the plan with the goal being that that school professional is going to eventually be the point person of the plan as we pull back our supports. Adam Dayan: What words of encouragement do you give to families who are worried if their children will never go to school and be able to learn? And do you have any anecdotes you can share to make this journey more concrete for our listeners? Ariel Kornblum: One day at a time. Thinking in the long term is really not useful when you are doing this kind of work. Every day is a new day. It's about little victories, not about sweeping changes that happen overnight. When I'm working with parents all the time, and particularly with this kind of work, I often tell them, you have to jump in with two feet. You have to do it in the way that I'm saying to do it in the way that the school is saying to do it. And you need to really, really, really commit to it, and it will be one of the hardest things you do as a parent, but it is very, very important. Francyne Zeltser: Parents should know that they are not alone and that help is available for them throughout the process. It might feel really difficult, it might even be embarrassing or shameful at times, but there is no shame behind supporting your child and advocating for your child and getting the support that is needed for your child and your family to be successful and to thrive. Adam Dayan: Are there other kinds of behavioral or emotional issues that you typically see alongside school refusal? Ariel Kornblum: Yes. So I also think it's very important to mention the degree of comorbidity between anxiety disorders and other behavioral conditions. So in particular, autism spectrum disorder has a very, very high rate of comorbidity with anxiety, and that's for individuals diagnosed with level one, two, or three autism, something that all parents need to be aware of. If their child is non-vocal, they're not able to communicate how they're feeling, parents need to be experts in their children's day-to-day behavior. So school refusal will look drastically different for a 15 year old with anxiety versus a seven year old who has level three autism and perhaps comorbid anxiety. We might not know that there's comorbid anxiety there, but it is our job as the adult and as caregivers to be keenly aware of what day-to-day behavior looks like so that we know something's up, something's going on here and we need to investigate it more. Adam Dayan: Right. Francyne Zeltser: And also, attentional disorders like ADHD, it's often which came first, the chicken or the egg? Was the child struggling to stay focused and on task in class, and then they fell behind and then they started to feel nervous that they couldn't keep up, so they started to avoid school or were they avoiding school and then it looked like they weren't paying attention? It's really hard to tease that apart. And often children struggle with both anxiety and attention. So providing the appropriate supports for both, which there are overlaps with the interventions is integral for the treatment to be effective. Adam Dayan: Sure. What advice would you give teachers who are educating students with school refusal or related behavior issues? Francyne Zeltser: It's really important for teachers to make time and space to check in with their students. Often we are very curriculum driven and we focus on the end goal of ensuring that our students learn this content in this particular day, and it doesn't always allow for the time to focus on that social emotional learning. Children who are not in a good social emotional place are not able to learn to their full capacity. So it's important that we address the social emotional piece first before we jump into the curriculum because the curriculum won't be able to be met until the child's ready to learn. Adam Dayan: I'm just going to give a shout out to Jerry Pavlon-Blum, who is a previous guest on this podcast. He talked about this. He talked about teachers being driven to get through the curriculum at the expense of not focusing on what's going on with the child, and he calls it getting under the table to understand what happened to you? Why are you on the floor? What's going on socially and emotionally? Because as you said, those drive behavior. Ariel Kornblum: Absolutely. Those drive a lot of things. I think for teachers also to constantly be working on understanding neuro divergence in general, how that plays for children in their classrooms. I think outside of schools in recent years, we've made a whole lot of progress in understanding neuro divergence and in working with individuals to self-advocate, to feel empowered to get their needs met in this world. We haven't exactly done the same inside schools, so children are often expected to conform, sit in their seats, be quiet, make eye contact. Outside of schools, we hardly push these things anymore. So I think also for teachers to understand not just what drives behavior or how to analyze behavior or how to intervene with behavior, but also just to broaden their horizons about what it means to be neuro divergent and how they can support those students. Adam Dayan: Yeah, that makes a lot of sense. All right, before we conclude, I have to ask, Francyne, I'll start with you. What fuels your passion? Why do you do what you do? What drives you to get out of bed and go into the office every day or work remotely every day? Francyne Zeltser: I'm so motivated to bridge the theory practice gap. When you are in graduate school, you learn about these great treatments, these great interventions that are evidence-based and they work. And then you get into the real world and it's not happening, and you ask yourself why. And it's often because there's misinformation out there. There's not enough education, there's not enough training, and there's not enough support. So it really motivates me to be able to put those supports in place and bring this to life to bridge that gap. Adam Dayan: That's wonderful. Ariel, how about you? Ariel Kornblum: So for me, my passion is in educating people and empowering people. So that's not just the families I work with. We have an enormous team of home-based therapists working at our practice, and my role there is to really supervise and lead the next generation of clinicians in how to deliver high quality service that really enhances people's lives. So like I was saying before, we are in an era of progress. There's a lot of new research, there's a lot of acceptance of neuro divergence that was not accepted previously. So my passion is really in rewriting that narrative in terms of how we can support people, how we can empower them rather than fix them. Adam Dayan: That's great. All right, real quick, one interesting fact about each of you. Ariel Kornblum: It's not terribly interesting, but the way that I got started in this field was, I was in college and I thought that I really wanted to work with kids and I didn't know what I wanted to do, and I somehow landed myself in a job of an ABA therapist. So I think the interesting thing about my career trajectory is I've always felt really passionate about enhancing the on the ground service provision, and I haven't been in this field for so many years, and in that time, things have just changed drastically. So continuing to include those people who are on the ground, who are doing the work in the conversations that we're having is really important. Adam Dayan: Nice. Francyne Zeltser: My fun fact is that I've been to all 50 states in the United States. The reason for that is because while I was in graduate school, I used to direct teen tours, which are traveling summer camps. So I used to travel across the United States and also throughout Europe with 40 or more teens. So that was my first experience working with adolescents and their families and supporting them, and it really motivated a lot of the work that I do today. Adam Dayan: That's amazing. Ariel Kornblum: Oh, it's way better than mine. Adam Dayan: Awesome. I love that. All right, where can our listeners get more information about Manhattan Psychology Group? Ariel Kornblum: The easiest place is our website. It's very comprehensive. There are tons of resources on there. There are blogs on there. Our contact information is on there. So it's just manhattanpsychologygroup.com. I will mention that if you do reach out for some kind of service, someone will get back to you in 24 hours. It's not like you put an inquiry into a black hole. Francyne Zeltser: You can also follow our posts on LinkedIn and on Twitter and on Instagram. Ariel Kornblum: Yes. Adam Dayan: Excellent. Francyne, Ariel, I want to thank you so much for coming on this podcast. School Refusal is such an important issue. It always has been, and it's only become more important and relevant in light of Covid 19 and the increased incidents of school refusal issues that you both spoke about on this episode. So thank you so much for coming on, and I think you gave such important nuggets to parents, including the fact that they're not alone in this process. There are experts out there like yourselves who can help them, and if they act early, they can make all the difference in the world for their children. So thank you both very much. Francyne Zeltser: Thank you. Ariel Kornblum: Thanks for having us. Speaker 1: Thanks for listening to Curious Incident, a podcast for special needs families. Don't forget to subscribe for a new episode every month. For more resources and helpful information, check out our website and blog at dayanlawfirm.com.
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