The right to refuse treatment: What the research reveals

This review encompasses all published and many unpublished studies of refusal of antipsychotic medication by psychiatric inpatients. Many of the extant studies in this area have methodologic flaws in the means employed to gather or analyze data; where relevant to the points being considered, these flaws are noted. The review is broken down into five sections: frequency of refusal, characteristics of medication refusers, reasons for refusal, the natural history of medication refusal, and responses to refusal. A final section summarizes the extent of our knowledge today and points to future areas of investigation.     

On refusal

Traditionally, all efforts to counter psychotherapeutic work have been captured under the umbrella term, "resistance." However, it is useful to distinguish a concept of refusal. Resistance entails therapeutically a gradual elaboration of unconscious, preconscious, and partially conscious experience. Refusal manifests as a willful nonparticipation in offering or responding to material that can be symbolized. All communication has an element of refusal, which occurs at various levels of persistence, intensity, and legitimacy. Clinical examples are provided to discriminate refusal from resistance proper, and to describe three categories of mental and group experience, (a) refusal to perceive external experience; (b) refusal to think about what one knows, and (c) refusal to think about what one does not know. Therapeutic impasses may relate to limitations of the therapist's creativity and flexibility in thinking about and dealing with refusals, including one's own.     

日本拒绝上学概念的演变和原因探讨

拒绝上学指学生不是由于家庭贫困或生病,而是由于某种心理、情绪、身体或社会的原因而不去学校的现象。欧美最早进行研究,日本进行了五十多年的研究。该文介绍日本此现象的称呼从“学校恐怖症”、“拒绝上学”到“不去上学”的演变;日本学者从家庭、学校、社会方面对此现象进行的归因;拒绝上学的行为机制,如分离焦虑、情绪障碍、家庭关系不良;还介绍了日本教育部使用的小泉英二的分类。最后提示该现象在我国发展的可能性     

Use of the high-probability instructional sequence and escape extinction in a child with food refusal

We used the high-probability (high-p) instructional sequence with and without escape extinction in the treatment of food refusal. Acceptance increased and refusal decreased only with the introduction of escape extinction. These results raise important questions about the high-p sequence in the treatment of food refusal.     

„Pervasive refusal syndrome“

Pervasive refusal syndrome (PRS), as a new psychiatric disorder among children and adolescents, was first described 1991 by Lask et al. It is characterized by a determined refusal of the child to eat, talk, walk, care for themselves or participate in daily activities. An organic explanation for the symptoms is absent. The observed refusal of functions can be either active or passive. Children also demonstrate a clear resistance to help or treatment. This paper presents a case study that depicts PRS from the therapists’ and the patients’ viewpoint and helpful elements in therapy are evinced from both points of view.     

Studies involving fathers: Subject refusal, attrition and sampling bias

The reported rates of subject refusal and attrition are reviewed in those studies where data were collected directly from fathers. Only 34 per cent of such studies report on subject refusal rates and 36 per cent on attrition rates. Few studies comment on or give information that would allow an assessment to be made of sampling bias arising from subject refusal and attrition. Nevertheless, studies reporting subject refusal and attrition suggest that fathers are no more difficult to recruit than mothers and that a variety of factors, individually and in combination, may have some impact on recruitment. These include the type of commitment required, the techniques of recruitment used and whether studies are hospital, home or laboratory based. However, if biases due to subject refusal and attrition are to be identified and avoided, studies need to be more open in providing information about the characteristics of refusing and participating subjects. To encourage this, some new data are presented, suggesting a number of trends: (1) extended personal contacts with potential subjects may minimize subject refusal and attrition; (2) attrition may be somewhat higher in middle-class families and families with sons.     

Time Perception in Boys With Attention-Deficit/Hyperactivity Disorder According to Time Duration,Distraction and Mode of Presentation

The present study describes the incidence of test refusal at neuropsychological assessment, investigates its correlates, and its stability. The participants were 124 children aged 3.5 years whose development has been followed from birth in the Jyväskylä Longitudinal Study of Dyslexia (JLD). The frequency of test refusal on the Finnish version of the NEPSY was analyzed with respect to the children's concurrent and earlier cognitive and language skills, assessed using tests and parental ratings. Refusal during test-taking was found to be relatively common at this age, and high frequency of refusal at an earlier age was associated with similar tendency at a later age. High test refusal was associated with compromised neuropsychological and linguistic test scores. Missing data due to refusal were more common in neuropsychological tasks requiring verbal production. It is concluded that test refusals reflect a child's poor underlying skills and an attempt to avoid failure, rather than noncompliant or oppositional behavior.     

Early food refusal: Infant and family characteristics

This study compared infants who developed food refusal during the first year of life with a healthy control group concerning feeding, growth pattern, family situation, and infant behavioral characteristics. Infants with food refusal had a lower relative weight at inclusion in the study and at follow-up at the age of 2 years. Food refusal was also associated with weaning problems, parental reports of lower food consumption, a higher incidence of breast-feeding, a higher frequency of meals, psychosocial problems in the family, less positive perceptions of parenting, infant difficultness, and problematic behaviors. The findings have implications for identification and understanding of factors related to early food refusal.     

Clinical significance of test refusal among young children.

The present study describes the incidence of test refusal at neuropsychological assessment, investigates its correlates, and its stability. The participants were 124 children aged 3.5 years whose development has been followed from birth in the Jyv?skyl? Longitudinal Study of Dyslexia (JLD). The frequency of test refusal on the Finnish version of the NEPSY was analyzed with respect to the children's concurrent and earlier cognitive and language skills, assessed using tests and parental ratings. Refusal during test-taking was found to be relatively common at this age, and high frequency of refusal at an earlier age was associated with similar tendency at a later age. High test refusal was associated with compromised neuropsychological and linguistic test scores. Missing data due to refusal were more common in neuropsychological tasks requiring verbal production. It is concluded that test refusals reflect a child's poor underlying skills and an attempt to avoid failure, rather than noncompliant or oppositional behavior.     

Infant food refusal and parental social support

The purpose of this study was to examine the relations between various aspects of social support and maternal and infant outcome variables in a group of families having infants showing food refusal compared to a control group. In the case of early food refusal, the results indicated that access to emotional support and satisfaction with support were related to maternal psychosomatic health. The relationships were interpreted as showing that social support has moderating effects on negative outcomes of food refusal.     

Antidepressant Medication: Is It a Viable and Valuable Adjunct to Cognitive-Behavioral Therapy for School Refusal?

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for school refusal. However, some youth do not respond to CBT. The serious risks associated with school nonattendance call for novel approaches to help those who do not respond to CBT. Because school refusal is commonly associated with anxiety disorders, and the combination of CBT and antidepressant medication enhances outcomes in the treatment of anxiety disorders, combined treatment may be effective for school refusal. This narrative review evaluates the current evidence base for adding antidepressant treatment to CBT for school refusal. Six randomized controlled trials (RCTs), two open trials, six case studies/series, and one observational study were identified and reviewed. There is support for combined CBT and imipramine, but this medication is not typically used due to the risk of concerning side effects. Two recent RCTs failed to provide evidence for the superiority of combined CBT and fluoxetine. Further research in this area is required because the extant studies have a number of methodological limitations. Recommendations are provided for clinicians who consider prescribing antidepressant medication or referring for adjunctive antidepressant treatment for school refusal.     

Metadehumanization and Self-dehumanization are Linked to Reduced Drinking Refusal Self-Efficacy and Increased Anxiety and Depression Symptoms in Patients with Severe Alcohol Use Disorder

Metadehumanization, the perception of being treated as less than a human by others, is a pervasive phenomenon in intergroup relations. It is dissociated from stigmatization or stereotypes, and it has been recently identified as a critical process in severe alcohol use disorders (SAUD). Metadehumanization is associated with a wide array of negative consequences for the victim, including negative emotions, aversive self-awareness, cognitive deconstruction, and psychosomatic strains, which are related to anxiety and depression. This study aims to investigate if metadehumanization occurring among patients with SAUD is associated with clinical factors involved in the maintenance of the disease, namely symptoms of depression or anxiety and drinking refusal self-efficacy. A cross-sectional study was conducted among 120 patients with SAUD. Self-reported questionnaires measured metadehumanization, self-dehumanization (i.e., the feeling of being less than a human), anxiety, depression, drinking refusal self-efficacy, and demographics. Metadehumanization was significantly associated with self-dehumanization, anxiety, depression, and drinking refusal self-efficacy. Additionally, path analyses showed that self-dehumanization mediated the links between metadehumanization and clinical variables. These results indicate that metadehumanization and self-dehumanization could be essential factors to consider during SAUD treatment, as they are associated with increased psychiatric symptoms and reduced drinking refusal self-efficacy.     

A Beta Unfolding Model for Continuous Bounded Responses

An unfolding model for continuous bounded responses is proposed, derived both from a hypothetical interpolation response mechanism and from the hypothesis of two opposite sources of item refusal being collapsed. These two sources of refusal are made explicit in a three-component Dirichlet response model and then collapsed to obtain a (two-component) beta response model. The two natural parameters of the beta are interpreted as acceptance and refusal parameters and expressed as functions of person-item distances on a latent continuum. The potentially bimodal shape of the beta is exploited to model chaotic response choices among ambivalent subjects.     

ILLOCUTION,SILENCING AND THE ACT OF REFUSAL

Rae Langton and Jennifer Hornsby argue that there may be a free‐speech argument against pornography, if pornographic speech has the power to illocutionarily silence women: women's locution ‘No!’ that aims to refuse unwanted sex may misfire because pornography creates communicative conditions where the locution does not count as a refusal. Central to this is the view that women's speech lacks uptake, which is necessary for illocutionary acts like that of refusal. Alexander Bird has critiqued this view by arguing that uptake is not necessary for the illocutionary act of refusal. The Hornsby‐Langton view, then, is philosophically indefensible. Here I defend the philosophical cogency of the Hornsby‐Langton approach.     

Evaluation of a finger prompt variation in the treatment of pediatric feeding disorders

Children with feeding disorders often engage in refusal behavior to escape or avoid eating. Escape extinction combined with reinforcement is a well-established intervention to treat food refusal. Physical guidance procedures (e.g., jaw prompt, finger prompt) have been shown to increase food acceptance and decrease inappropriate mealtime behavior when more commonly employed escape extinction (e.g., nonremoval of the spoon) procedures are ineffective. The finger prompt, however, has not been extensively evaluated as a treatment adjunct to target food refusal, thus necessitating further examination. The purpose of this prospective study was to assess a variation of a finger prompt procedure to treat food refusal and to assess caregivers' acceptability of the procedure. Three children age 1 to 4 years admitted to an intensive feeding disorders program and their caregivers participated. The finger prompt was effective in increasing bite acceptance across all participants and decreasing or maintaining low levels of inappropriate behavior for 2 participants. The procedure was also acceptable to all caregivers.     

Evaluation of two physical guidance procedures in the treatment of pediatric feeding disorder

Children with pediatric feeding disorder may refuse to consume an adequate variety and/or volume of food to maintain expected growth. They can consume food but may actively or passively refuse, resulting in escape or avoidance of eating. Behavioral interventions like positive reinforcement with escape extinction can increase consumption. However, sometimes these interventions are insufficient, especially in treating passive refusal. In these cases, physical guidance may be used to prompt an open mouth to deposit food. Research indicates open-mouth prompts are effective and rated as acceptable. This study replicated an existing physical guidance procedure, the finger prompt, and compared its efficacy and acceptability with that of a spoon prompt. This study extended research by defining and measuring passive refusal as a dependent variable and assessing social validity among different stakeholders and times. Both prompts were effective in treating food refusal, and caregivers rated the finger prompt as more preferred.     

ACCEPTABILITY OF ALTERNATIVE TREATMENTS FOR SCHOOL REFUSAL: EVALUATIONS BY STUDENTS,CAREGIVERS, AND PROFESSIONALS

Summary . School refusal is a debilitating condition that may be treated in various ways. This study examined the acceptability and perceived effectiveness of alternative treatments for school refusal. A total of 376 people comprising students, parents, and professionals, were required to evaluate several treatment options in relation to a vignette. Despite its potential aversiveness, behavioural management was the most acceptable treatment approach followed, in order, by home tuition with psychotherapy, hospitalisation, and medication. A strong positive relationship was found between acceptability and perceived effectiveness.     

Examining extinction bursts in the treatment of pediatric food refusal

Escape extinction has been shown to be highly effective in the treatment of food refusal; however, unpleasant side effects such as extinction bursts may accompany extinction procedures. Bursting has been reported to occur in 24% to 39% of all cases for which extinction was used as a component during treatment of problem behavior. Although commonly used in treatments, the occurrence of extinction bursts in the treatment of pediatric food refusal has not been studied. This study measured the frequency of bursting in 10 children for whom escape extinction was used to treat food refusal. Results showed that extinction bursts were observed in 30% of the children included in the study, although they were relatively brief and resolved quickly. Considerations for using escape extinction in interventions will be discussed.     

Psychometric Properties and Clinical Utility of the School Refusal Assessment Scale in a Multiethnic Sample

Kearney and Silverman (1993) developed the School Refusal Assessment Scale (SRAS) to assess the function of and to prescribe treatment for school refusal behavior. The present investigation examined the psychometric properties and clinical utility of the SRAS in a multiethnic sample. Participants were 30 children and their mothers who were identified as school refusers after an initial screening. Results indicated that scales measuring negatively reinforced school refusal were intercorrelated, whereas scales measuring positively reinforced school refusal were not. Concurrent validity of dimensional and categorical scoring algorithms was examined. Although parent–child agreement was relatively low, validity analyses suggested that each reporter contributed important information. Clinical implications and areas for future research were discussed.