What is Back2School?
Back2School (B2S) (M Thastum et al., 2020) is a manualized modular CBT program aimed at helping youths with school absenteeism increase their school attendance, by involving the youths, their parents, and the schools in the treatment. Originally, (in the randomized controlled trial; RCT) (M. Thastum et al., 2019) the B2S program was used together with the trans-diagnostic MMM manual (Jeppesen, 2017). In the new and revised B2S manual evidence based methods for treating anxiety, depression and behavioral problems had been integrated in the manual, which therefore now stands alone. Compared to the original RCT manual additional important changes has been made: There is an increased focus on parent management training. Methods for treating anxiety, depression and behavior problems has been integrated in the first 6 sessions – first from session 7 there are separate moduls for the different problems. The number of sessions has been increased from 10 to 11 sessions. The assessment interview is now a part of the manual, and now also includes a focus on motivation. There has been added several chapters e.g. on use of roleplay and rewards.
The B2S manual is specifically developed for treating school absenteeism. Intervention is determined via a descriptive functional analysis obtained via the School Refusal Assessment Scale (SRAS) (24) together with a case formulation approach to planning CBT for attendance problems. In the development of the intervention we adapted aspects of the @SCHOOL intervention (Heyne, Sauter, Ollendick, Van Widenfelt, & Westenberg, 2014) and the When Children Refuse School intervention (Kearney & Albano, 2007).
Status on Back2School
The Back2School program has now been implemented as a standard offer to youth with absenteeism in the municipality of Aarhus, Denmark. In addition 11 municipalities in Denmark are in 2022 testing the effectiveness of the program. Also, it is tested in a pilot study in Helsinki, Finland, and it is going to be tested in several municipalities in a pilot study in Norway in 2022. It has been translated into Finnish, Swedish and Norwegian.
The following publications has been published on the program (Johnsen et al., 2022; Lomholt et al., 2020; M. Thastum et al., 2019). The randomized controlled study has been published and can be read here.
Intervention structure
The intervention consists of a 3.5-hour clinical interview with the youth and parents aimed at designing a case-formulation and a treatment plan and preparing the family for the first therapy session; eleven 1-hour sessions with the child and parents together (except for session 2, 3 and 7 which is only with the parents); a 1-hour booster session with the child and parents together; and four school meetings. With the aim of installing hope for change in the family, to speed up the change process, and to show the family that the school attendance problem is taken seriously, the first two weeks of the intervention involve two sessions per week. For the following 6 sessions there is the option to schedule them weekly or once each two weeks as decided appropriate by the therapist and the family together. The implementation of the booster session is flexible regarding the timing and will be held within 3 months after the last session. An important part of the B2S intervention is to collaborate with the school. In addition to the sessions with the child and parents, four meetings with participation of teachers from the youth’s school, the therapists, and the parents are conducted. The meetings will take place at the child’s school at the beginning, the middle, and the end of the treatment period, and shortly after the booster session. For a detailed overview of the intervention, see Table 1.
Table 1. Overview of the Back2School sessions
| Session | Participants | Content |
| 0 | Parents and child Therapist | Structured assessment interview with the family including motivational work. The family receive handouts on psychoeducation and SMART goals as homework for session 1. Before session 1, the therapists are summarizing all relevant information, including the questionnaires, into a case formulation. Therapists are discussing the case formulation, choice of treatment modules, and treatment goals on a clinical conference |
| 1 | Parents and child | Presenting and discussing the case-formulation (a common understanding) with the family. Psychoeducation regarding school absence Development of SMART goals |
| 2 | Parents | Clarify and solve questions/problems regarding school placement, somatic symptoms in child, and parental motivation for change. Planning better routines at home. Working with sleep problems. Introduce the parents for rewards and praise as motivation for the child |
| 3 | Parents | Rehearse with roleplaying to give instructions in a clear and kind way Reinforcing positive behavior Introduce ignoring |
| 4 | Parents and child | Psykoeducation on exposure Planning a graduated exposure plan for returning to school Planning the first school meeting |
| School meeting 1 | School staff and parents | Presenting and discussing the case formulation with the school. Planning the role of the school in the youth’s return to school. Informing the school about the B2S and CBT approach. |
| 5 | Parents and child | Introduction to cognitive restructuring If relevant psychoeducation regarding the youth primary problem related to school absence (anxiety, depression, or behavioral problems). Continuing work with the gradual exposure plan for returning to school. |
| 6 | Parents and child | Cognitive restructuring Continuing work with the gradual exposure plan for returning to school. Problem solving. How can the parents help Introduction to positive child/parent interactions |
| 7 | Parents and child | Separate methods for anxiety, depression and behavior problems. For all: Continue with the school stepladder Anxiety: Anxiety stepladders/exposure Depression: Avoidance behavior and consequences. Behavior activation Behavior: Family rules. Token system |
| School meeting 2 | School staff and parents | Follow up on the youth’s progress in the school setting. Discussing potential academic difficulties. Discussing problems regarding bullying or other problems. |
| 8 | Parents | Parental behavior Anxiety (e.g. overprotection) Depression (how to react as parents) Behaviour (negative consequences) |
| 9 | Parents and child | Optional sessions Continue to work with the relevant methods. Continue to focus on school stepladder |
| 10 | Parents and child | Optional sessions Continue to work with the relevant methods. Continue to focus on school stepladder |
| 11 | Parents and child | Focusing on maintaining and continuing the progress Relapse prevention Planning school meeting 3 |
| School meeting 3 | School staff and parents | Planning how the school can continue to help and support the youth. Discussing relapse prevention |
| Booster session | Parents and child | Maintaining and continuing the progress. Problem solving regarding relevant problems. Relapse prevention. Advise possible further help. |
| Booster school meeting | School staff and parents | Planning how the school can continue to help and support the youth. Discussing relapse prevention |
Principle investigator
References
- Thastum, M., Arendt, K. B., & Kjerholt, C. (2020). Back2School. Manual til behandling af børn med bekymrende fravær: Psykologisk Institut, Aarhus Universitet.
- Thastum, M., Johnsen, D. B., Silverman, W. K., Jeppesen, P., Heyne, D. A., & Lomholt, J. J. (2019). The Back2School modular cognitive behavioral intervention for youths with problematic school absenteeism: study protocol for a randomized controlled trial. Trials, 20(1), 29.
- Lomholt, J. J., Johnsen, D. B., Silverman, W. K., Heyne, D., Jeppesen, P., & Thastum, M. (2020). Feasibility Study of Back2School, a Modular Cognitive Behavioral Intervention for Youth With School Attendance Problems. Frontiers in Psychology, 11.
- Johnsen, D. B., Lomholt, J. J., Heyne, D., Jeppesen, P., Jensen, M. B., Silverman, W. K., & Thastum, M. (2022). Sociodemographic and clinical characteristics of youths and parents seeking psychological treatment for school attendance problems. Plos One, 17(1).
- Heyne, D., Sauter, F. M., Ollendick, T. H., Van Widenfelt, B. M., & Westenberg, P. M. (2014). Developmentally sensitive cognitive behavioral therapy for adolescent school refusal: rationale and case illustration. Clin Child Fam Psychol Rev, 17(2), 191-215.
- Jeppesen, P. (2017). NCT03535805 (Transdiagnostic, Cognitive and Behavioural Intervention for school-aged Child With Emotional and Behavioural Disturbances).