Cognitive Behavioral Therapy in Schools
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Cognitive Behavioral Therapy in Schools

A Tiered Approach to Youth Mental Health Services

Linda Raffaele Mendez

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eBook - ePub

Cognitive Behavioral Therapy in Schools

A Tiered Approach to Youth Mental Health Services

Linda Raffaele Mendez

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About This Book

In recent years, many U.S. schools have implemented tiered models of support to address a range of student needs, both academic and behavioral, while cognitive behavioral therapy (CBT) has simultaneously gained popularity as an effective means of supporting the mental health needs of students. Cognitive Behavioral Therapy in Schools provides school-based practitioners with the necessary skills to determine students' mental health needs; establish a tiered, CBT-based system of supports; select appropriate programs at Tiers 1, 2, and 3; deliver CBT using various formats to students who are at risk or demonstrating problems; progress monitor multiple tiers of service; and work collaboratively with teachers, administrators, and families.

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Section II

Tier 1

Universal Mental Health Supports for Students

5 Universal Supports for Social and Emotional Learning

Tiered systems of mental health begin with a foundation of universal support for all students at a school or within a school district. In this chapter, we describe universal supports for social and emotional learning (SEL) as the foundation for a cognitive behavioral therapy (CBT)-based tiered system of school-based mental health (SMH). We begin the chapter by describing how SEL is unique from but related to Positive Behavioral Interventions and Supports (PBIS; Sugai & Horner, 2006) and how the two can complement each other. We then summarize three lines of research that provide empirical support for the importance of universal SEL in schools. Subsequently, we offer online resources for identifying SEL programs and provide examples of several empirically supported SEL programs for use at the elementary and secondary levels. Of note, there are SEL programs that are solely based on CBT principles (e.g., Friends for Life!, Barrett, 2004) and other programs that incorporate CBT into some lessons but have a broader theoretical base (e.g., Strong Kids, Merrell, Carrizales, Feuerborn, Gueldner, & Tran, 2007). Because we believe it is important to have flexibility in choosing a specific universal program for your school, we include both types of programs in this chapter. We conclude the chapter by describing how to determine which SEL program is best suited for a particular school and various instruments/strategies available for universal screening and subsequent progress monitoring to determine whether the goals of the universal mental health initiative are being met.

A Comparison of PBIS and SEL

To begin, we want you to have a clear understanding of how support for behavior in schools differs from support for mental health. Many SMH providers are familiar with PBIS, a framework for designing and implementing procedures for promoting appropriate behavior in the school setting (Sugai & Horner, 2006). Both PBIS and SEL can be delivered within a multi-tiered framework as has been described in this book. In addition, both emphasize that skills related to adaptive behavior are learned and therefore must be taught. However, while PBIS is focused on teaching and reinforcing appropriate behavior (e.g., how to transition appropriately from one class to the next), SEL is focused on teaching skills related to the awareness and management of emotions and relationships (e.g., how to solve a problem with a friend). Osher, Bear, Sprague, and Doyle (2010) described PBIS as a teacher-centered approach focused on establishing extrinsic rules and teaching students to follow these rules through the use of positive reinforcement. In contrast, they described SEL as a student-centered approach focused on teaching students the skills they need to manage their own behaviors in relation to self and others.


Many schools have adopted PBIS in an effort to proactively address behavior management. This includes adapting environmental conditions so that problem behaviors are less likely to occur, setting school-wide expectations for students that are implemented consistently across classrooms and other school spaces, and putting procedures in place to teach and reinforce appropriate behavior (Florida’s Positive Behavior Support Project, 2011). Florida’s Positive Behavior Support Project (2011) recommends that school personnel select three to five clearly defined behavioral expectations to be taught to all students across all settings. By establishing a universal set of rules and expectations, a common language for discussing behavior is created, and school-wide expectations are made clear. Other recommendations from Florida’s Positive Behavior Support Project for implementing universal behavior supports include stating expectations in positive terms, providing teachers with scripts or lesson plans to teach expected behaviors and practice them with students, and establishing and delivering effective consequences to address both appropriate and inappropriate behaviors.
A critical component of PBIS is continuous collection of data for progress monitoring and decision making. Data are used to determine how well the current system is working, where problems continue to exist, and which students are in need of greater levels of support (Florida’s Positive Behavior Support Project, 2011). Students who do not show adequate response to universal programming (i.e., primary prevention) may receive secondary prevention supports, including increases in structure and predictability, more frequent adult feedback on behavior, and higher levels of home–school communication (Esler, Godber, & Christenson, 2008; Scott, Alter, Rosenberg, & Borgmeier, 2010; Shapiro, 2011). If individual student problems continue to persist despite secondary prevention, tertiary prevention may be indicated, with team-based assessment, including functional behavioral analysis (FBA), used to inform a student’s individualized intervention plan (Scott, Alter, & McQuillan, 2010).
Multiple randomized controlled trials have indicated that PBIS has a positive influence on students. Examples of this positive effect include a decrease in office discipline referrals and suspensions at the elementary level (Bradshaw, Mitchell, & Leaf, 2010) as well as a decrease in office discipline referrals and an increase in attendance at the high school level (Freeman et al., 2016). Decreases in internalizing problems also have been found at the high school level (Cheney et al., 2009). The Technical Assistance Center on Positive Behavioral Interventions and Supports ( and Florida’s Positive Behavior Support Project ( both provide excellent resources for learning more about PBIS.


Universal SEL programs implemented in schools also have been shown to result in a wide variety of positive outcomes for students (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). In contrast to PBIS, however, their focus is on social and emotional skill development rather than on behavior management. According to the Collaborative for Academic, Social, and Emotional Learning (2013), SEL includes five content areas: self-awareness, self-management, social awareness, responsible decision making, and relationships skills. Table 5.1 provides a definition and example of each of these skills.
Table 5.1 Domains of Social and Emotional Learning
Name Definition Example
The ability to recognize one’s own thoughts and emotions and the influence they have on behavior.
Recognizing anger cues in oneself and what may happen (e.g., yelling, hitting) if strategies are not employed to manage them.
The ability to regulate one’s thoughts, emotions, and behavior.
Taking action to manage angry feelings by walking away, taking a deep breath, or distracting oneself by thinking about something different.
Social awareness
The ability to take another person’s perspective.
Understanding how a friend would feel if you cancelled plans with him at the last minute.
Responsible decision making
The ability to make positive choices in regard to social interactions and personal behavior.
Making one’s best attempt to complete homework, even if it is boring or difficult.
Relationship skills
The ability to develop and maintain healthy and rewarding relationships with diverse individuals or groups.
Building mutually satisfying friendships with other students at a new school.
Source: Collaborative for Academic, Social, and Emotional Learning (2013)

Integrating PBIS and SEL

Although PBIS and SEL were developed and have been evaluated primarily as independent approaches to addressing student behavior and mental health in schools, researchers have suggested that integrating the two may offer synergistic effects (Domitrovich et al., 2010; Osher et al., 2010). Cook, Frye, Slemrod, Lyon, and Renshaw (2015) noted that integrating these two approaches makes logical sense for at least three reasons: (1) both are prevention focused, (2) both use positive rather than punitive methods for addressing behavior, and (3) both emphasize the importance of teaching skills to promote academic and social success. When Cook et al. (2015) compared (1) PBIS alone (the universal supports included in the BEST Behavior approach to PBIS; Sprague & Golly, 2004), (2) SEL alone (Strong Kids SEL curriculum; Merrell et al., 2007), (3) PBIS and SEL together, and (4) business as usual (neither intervention) in two low-income elementary schools, they found that the combination of PBIS and SEL together produced the best results. More specifically, post-hoc pairwise comparisons showed that the difference in pre-post teacher-rated internalizing and externalizing scores was greatest for those students who received the combination condition (vs. business as usual), with effect sizes of d = 1.12 for externalizing behavior and d = .74 for internalizing behavior. Students in the PBIS alone and SEL alone conditions performed similarly to each other, although they both performed significantly better than students in the business as usual condition. Compared to business as usual, pre-post effect sizes for externalizing behavior were d = .87 for PBIS alone and d = .72 for SEL alone. Effect sizes for internalizing behavior were d = .10 for PBIS alone and d = .33 for SEL alone. Overall, these results suggest that the integration of PBIS and SEL holds considerable promise for addressing both internalizing and externalizing behavior problems in schools. The findings of the Cook et al. (2015) study provide support for integrating tiered approaches to support students, recognizing the interconnections between behavior and mental health. Multi-Tiered System of Supports and the Interconnected Systems Framework (discussed in Chapter 2) each provide a model for this type of integration of student support across domains (e.g., social–emotional, behavior, academic).

The Importance of Universal SEL Programs

Despite the positive results reported in studies like Cook et al. (2015), it can be difficult to convince school personnel of the importance of universal mental health programming in schools. This is because there are many competing priorities in schools, and administrators may not recognize the importance of addressing mental health universally. Although several arguments can be made for the importance of mental health services for all students, a full discussion of this issue is beyond the scope of this book. Nonetheless, we want to share with you three lines of research that support the importance of universal mental health initiatives. The first is focused on adverse childhood experiences and their implications for individuals if left unaddressed. The second is focused on how well teachers are able to identify youth with mental health concerns. The third explores the influence of SEL programming on students in schools. We discuss each of these in further detail and how they support the need for universal mental health programming next.

Adverse Childhood Experiences

Although it has long been recognized that child abuse, neglect, and family dysfunction occur in the lives of children, research conducted by Kaiser-Permanente, a managed healthcare organization in California in the mid- to late 1990s provided much greater understanding of the extent of these experiences and their long-term implications (Felitti et al., 1998). In this study, a sample of more than 17,000 adults were asked to report if they had experienced any of 10 adverse childhood experiences (ACEs) prior to the age of 18. ACEs included the following: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) physical neglect, (5) emotional neglect, (6) parent or caregiver alcoholism or drug abuse, (7) witnessing domestic violence, (8) parent or caregiver mental illness, (9) parent or caregiver incarceration, and (10) parent or caregiver death, divorce, or abandonment. Study results showed that 28.3% of participants reported having experienced physical abuse, 26.9% reported having a parent or caregiver abuse substances, 23.3% reported their parents had separated or divorced, and 20.7% reported having experienced sexual abuse. Of the 10 ACEs about which they were asked, 26% reported at least one ACE, 15.9% reported two ACEs, 9.5% reported three ACEs, and 12.5% reported four or more ACEs (Felitti et al., 1998). These results alone were quite shocking given that this was a sample of middle-class adults, but there was more. The higher the ACE score, the worse the physical health outcomes over time. For example, a participant with an ACE score of 4 or more was 2.5 times more likely to have chronic obstructive pulmonary disease or hepatitis than an individual with an ACE score of 0. Individuals with an ACE score of 4 or more also were 4.5 times more likely to experience depression and 12 times more likely to experience suicidal thoughts than individuals with no ACEs. These findings led Felitti and colleagues (1998) to propose that ACEs lead to social–emotional and cognitive impairment, which then leads to engaging in health-risk behaviors (smoking, drinking, overeating, unprotected sex, etc.), putting the individual at risk of disease, disability, and social problems, leading to early death.
More recent research with a pediatric sample (Burke, Hellman, Scott, Weems, & Carrion, 2011) showed that, among 700 youth aged 0–21 in a low-income, urban population, 67.2% had experienced at least one ACE, and 12% had experienced four or more ACEs. This study also examined learning/behavior problems in relation to ACE scores. Among youth with no ACEs, 3% had learning/behavior problems; among youth with four or more ACEs, 51.2% had learning/behavior problems. In addition, 45.2% of youth with four or more ACEs had a body mass index score at the 85th percentile or higher (overweight or obese).
The take-away point from the Felitti et al. (1998) and Burke et al. (2011) studies is that ACEs, which are not uncommon, put youth on a path toward poor health outcomes, with social–emotional and cognitive impairments setting into motion other maladaptive behaviors and outcomes. Given these findings, it would appear that we have an excellent opportunity to interrupt this progression and change the life trajectories of a sizeable number of youth by including SEL programming in schools. It is this point that Paul Tough makes in his book How Children Succeed: Grit, Curiosity, and the Hidden Power of Character. In this easy-to-read paperback, Tough discusses the research on ACEs and notes that it is not intelligence that underlies success in life but rather skills like perseverance, optimism, curiosity, and self-control. Tough makes a strong argument that we must provide youth with opportunities to learn skills that will help them overcome adverse experiences. These are the types of skills taught ...

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