Cognitive-Behavioral Interventions in Educational Settings

A Handbook for Practice

Ray W. Christner, Rosemary B. Mennuti, Rosemary B. Mennuti, Ray W. Christner, Arthur Freeman

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136486975
• Edition: 2
• Topic: Education
• Subtopic: Education Counseling

Schools and school staff play a critical role in the cognitive, behavioral, emotional, social, and interpersonal development of children and adolescents. This second edition of Cognitive-Behavioral Interventions in Educational Settings teaches readers to think strategically about the individual and plan for effective and specific interventions based on the student's age, developmental level, and presenting problems. It is written by forward-thinking, established professionals whose writing represents the state-of-the-art in cognitive behavioral interventions in educational settings, and presents evidence-based interventions for a variety of issues commonly seen in schools. Including both innovative and well-established approaches, they offer assessment methods and interventions for a variety of issues and concerns faced by school-aged youth. The use of case studies and session outlines, as well as the balance of theoretical and clinical concerns, enhances this book's value as a reference for both clinicians and students. New to this edition are topics on cyber-bullying, parent and school consultation, school-wide positive behavioral support, and bipolar disorder. This is the ideal reference for those who wish to select and utilize precise interventions in school settings.

II

APPLICATION OF CBT INTERVENTIONS WITH SPECIFIC DISORDERS

Five

Anxiety Disorders: School-Based Cognitive-Behavioral Interventions

ELIZABETH A. GOSCH, ELLEN FLANNERY-SCHROEDER AND ROBERT J. BRECHER

Although anxiety disorders are the most prevalent mental-health problem experienced by youth, it is often children with disruptive externalizing problems such as attention deficit hyperactivity disorder (ADHD) who come to the attention of school personnel. Children with anxiety disorders may be overlooked due to difficulty recognizing their internalizing symptoms, unfamiliarity with diagnostic criteria, and misconceptions regarding the negative consequences of these problems. Most school personnel are surprised to learn that approximately one in ten children suffers from an anxiety disorder, with epidemiological studies estimating prevalence rates between 12% to 20% in youth (Achenbach, Howell, McConaughy, & Stanger, 1995; Gurley, Cohen, Pin, & Brook, 1996; Shaffer et al., 1996). Left untreated, these disorders tend to have long-term effects on social and emotional development. Negative consequences associated with anxiety disorders in youth include academic underachievement, underemployment, substance use, lower levels of social support, and high comorbidity with other psychiatric disorders (Velting, Setzer, & Albano, 2004). Moreover, evidence suggests that these disorders demonstrate a chronic course, often persisting into adulthood (Rapee & Barlow, 2001).

Take the example of Chris, an 11-year-old boy who is painfully shy, avoids answering questions in class, never asks his teacher for clarification when confused about assignments, accepts a failing grade rather than risk presenting in class, and does not talk much with other children. Without intervention, his grades will suffer, he will miss out on the mentorship his teacher could provide, and he will be isolated from his peers. Such a child is at risk for failing to achieve important developmental milestones. Research suggests that Chris is also at risk for becoming depressed (Biederman, Faraone, Mick, & Lelon, 1995; Brady & Kendall, 1992) or abusing alcohol and drugs to cope with his anxiety (Compton, Burns, Egger, & Robertson, 2002; Deas-Nesmith, Brady, & Campbell, 1998). However, if children like Chris could be identified early in their school years and receive appropriate interventions, this negative trajectory may be avoided. It is the purpose of this chapter to provide information to school personnel to aid them in identifying and intervening with children at risk for anxiety disorders.

UNDERSTANDING ANXIETY DISORDERS

There are eight types of anxiety disorders described in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). For the purposes of this chapter, we are limiting our discussion to three of the most common anxiety disorders—generalized anxiety disorder (GAD), social phobia (SP), and separation anxiety disorder (SAD). These disorders tend to co-occur, and cognitive-behavioral treatments for these disorders follow similar protocols that are amenable to implementation in the school setting. Other anxiety disorders in youth such as panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder require unique treatment components (e.g., March, 1995).

The hallmark feature of GAD is at least six months of excessive anxiety and worry about a number of events or activities (such as school performance or safety concerns) that the child finds difficult to control (American Psychiatric Association, 2000). These worries are more pervasive, distressing, and of longer duration than typical everyday worries. Often, the worrying occurs without a significant precipitant. Moreover, the worry usually interferes significantly with day-to-day living and is accompanied by physical symptoms such as restlessness, feeling keyed up or on edge, being easily fatigued, difficulty concentrating, mind going blank, irritability, muscle tension, or trouble sleeping.

Social phobia differs from GAD in that the child exhibits marked and persistent fear of specific situations—social or performance situations in which embarrassment may occur (American Psychiatric Association, 2000). When faced with such a situation, these children experience a strong anxiety response that may resemble a panic attack (e.g., experiencing heart pounding, sweating, depersonalization). These children tend to avoid social or performance situations, although some may endure such symptoms while experiencing intense distress. Adolescents may recognize that their fear is unreasonable but children may not. The avoidance, fear, or anxious anticipation of these situations interferes significantly with the youth’s functioning and/or causes marked distress. Youth with social phobia may refuse to do presentations in class, write on the board, eat in public, interact with their peers, or talk with teachers due to their anxiety.

Separation anxiety disorder is characterized by at least 4 weeks of excessive anxiety concerning separation from the home or from those to whom the individual is attached (American Psychiatric Association, 2000). This anxiety is beyond that which is expected for the child’s developmental level with an onset before 18 years of age and causes significant distress or impairment. Children with this disorder may experience recurrent excessive distress when separation is anticipated or occurs, worry about harm befalling others, or worry that an untoward event will result in separation. They may refuse to go to school or elsewhere. They may demonstrate a fear or reluctance to be alone at home or in other settings and refuse to sleep away from attachment figures. Many of these youth experience repeated nightmares about separation and physical symptoms (e.g., headaches, nausea) when separation occurs or is anticipated.

Numerous clinical trials have demonstrated the efficacy of cognitive-behavioral therapy (CBT) for treating anxiety disorders in children (Dadds, Spence, Holland, Barrett, & Laurens, 1997; Kendall, 1994; Kendall et al., 1997; Short, Barrett, & Fox, 2001; Silverman et al., 1999). The CBT approach tends to be short-term and multifaceted, incorporating a variety of cognitive and behavioral techniques. Although early efforts focused primarily on the child in treatment, more recent studies support incorporating the anxious child’s social context, particularly the parents and school, into CBT treatment. A number of treatment manuals that share many common elements have been developed for this population, perhaps best known being the Coping Cat program (Kendall, 2000).

EMPIRICAL SUPPORT

Individual and Family Clinic-Based CBT Treatments

Kendall (1994) conducted a randomized clinical trial including 47 anxiety-disordered children randomly assigned to either a cognitive-behavioral treatment or a wait-list control condition. Results indicated that 64% of treated children no longer had their primary anxiety disorder at post-treatment. In addition, improvements were noted on self-report, parent-and teacher-report measures of child behavior. A one-year follow-up (Kendall, 1994) and a three-year follow-up (Kendall & Southam-Gerow, 1996) demonstrated maintenance of treatment gains. Kendall and colleagues completed a second randomized clinical trial in which 94 anxiety-disordered children were randomly assigned to a cognitive-behavioral treatment or a wait-list. Seventy-one percent of treated cases no longer had their primary diagnoses at post-treatment (Kendall et al., 1997), and treated children evidenced significantly greater gains on self- and parent-reported ratings of anxiety. Maintenance of treatment gains was evident at one-year and seven-year follow-ups (Kendall et al., 1997; Kendall, Safford, Flannery-Schroeder, & Webb, 2004). Barrett, Dadds, Rapee, and Ryan (1996), using a modification of Kendall’s Coping Cat program for use with Australian youth, added a family management component to the cognitive-behavioral treatment with good effects. Seventy-nine anxiety-disordered children were randomly assigned to one of three conditions: cognitive-behavioral treatment (CBT), cognitive-behavioral treatment plus family management (FAM), and a wait-list control. Approximately 70% of treated children, versus 26% of wait-list children, did not meet criteria for an anxiety disorder at post-treatment. Results suggested that younger children had better outcomes in the CBT versus FAM condition, while no differential effects were found between the two active treatments for older children. One-year and six-year follow-ups demonstrated maintenance of treatment effects (Barrett, et al., 1996; Barrett, Duffy, Dadds, & Rapee, 2001). In a comparative study performed by Kendall, Hudson, Gosch, Flannery-Schroeder, and Suveg (2008), individual cognitive-behavioral treatment and family cognitive-behavioral treatment outperformed a treatment composed of family-based education, support, and attention (FESA). Kendall et al. (2008) also identified parental anxiety as a potential moderator influencing how children responded to treatment, such that children with parents who have anxiety disorders did not experience remission of symptoms as frequently as children with parents who do not have anxiety disorders. Several other researchers have also documented the efficacy of cognitive-behavioral interventions for childhood anxiety (e.g., Silverman et al., 1999; Spence, Donovan, & Brechman-Toussaint, 2000).

Research further supports the efficacy of treatments based on Kendall’s Coping Cat program but modified for specific populations. Hirshfeld-Becker et al. (2008) developed the Being Brave program, a modification of Kendall’s Coping Cat program for younger children between four and seven years of age. Being Brave is composed of 20 sessions. The first six sessions are dedicated to psychoeducation for the parents only, focusing on anxiety management principles and how to coach anxious children in feared situations. The following sessions are for both child and at least one parent. During these sessions, the child is taught basic coping strategies for managing his or her anxiety, such as age-appropriate relaxation training and self-instructive strategies. Children are also provided the opportunity to practice these skills through graduated exposure. Immediate positive reinforcement is integrated into each coping strategy and exercise. The final session with the child concludes by reinforcing all that the child learned and celebrating the child’s success. The final session of the program is reserved for the parents only, focusing on maintaining the gains achieved during treatment and relapse prevention. Results of Hirshfeld-Becker et al. (2008)’s pilot study of nine children demonstrated that at post-treatment there was a decrease in the number of children treated who met DSM-IV criteria for anxiety disorder and reported symptoms of anxiety. At two-year follow-up, 67% of the children treated still did not meet criteria for an anxiety disorder (Hirshfeld-Becker et al., 2008).

Wood, McLeod, Piacentini, and Sigman (2009) compared Kendall’s Coping Cat program to their own program, Building Confidence, to explore the relative efficacy of child-focused CBT (CCBT) compared to family-focused CBT (FCBT). Wood et al. (2009) recruited 35 children aged 6 to 13 to participate in the study. Participants were randomly divided into either CCBT or FCBT conditions. The FCBT condition was composed of 16, 75-minute sessions. Each session of Building Confidence is divided into three parts. The first half-hour of each session is spent with the child and follows Kendall’s Coping Cat program. The second half-hour focuses on teaching the parents strategies to increase the child’s autonomy and reduce parental intrusiveness. Additionally, parents are taught the principles of selective attention as to reduce reinforcing the child’s anxious behaviors. The final 15 minutes of each session is reserved for a family meeting time. At one-year follow up, the majority of children from both CCBT and FCBT conditions did not meet diagnostic criteria for anxiety disorders. In regards to comparing the two treatments, however, no differences were observed on child report measures. FCBT was observed to have an advantage in outcome over CCBT on diagnostician and parent-report measures, supporting the researcher’s hypotheses that parenting style may influence child anxiety and leading the authors to conclude that modifying this parenting style is an additional route to treating children with anxiety (Wood et al., 2009).

Clinic-Based Group CBT Treatments

Several researchers have adapted Kendall’s protocol for use in treating clinic-based groups of anxiety-disordered children (e.g., Barrett, 1998; Flannery-Schroeder & Kendall, 2000; Mendlowitz, et al., 1999; Silverman, et al., 1999). Silverman et al. (1999) and Barrett (1998) compared a cognitive-behavioral treatment to a wait-list control. Results demonstrated that 64% and 75%, respectively, of participants no longer met criteria for their primary anxiety disorder. Self-report measures also demonstrated differential gains for treated versus control conditions, and results were maintained at one-year follow up. Flannery-Schroeder and Kendall (2000) compared individual and group formats to a wait-list control condition. Analyses revealed that 73% of children in individual and 50% of those in group formats (versus 8% of wait-list controls) failed to meet diagnostic criteria for their primary anxiety disorder at post-treatment. Self-report measures of adaptive functioning also demonstrated the superiority of the treatment conditions. Treatment gains were maintained at three-month follow up. Similarly, Mendlowitz et al. (1999) found cognitive-behavioral group interventions to reduce symptoms of anxiety and depression in a sample of anxiety-disordered children. Monga, Young, and Owens (2009) performed a pilot study testing a group treatment for young children, aged five to seven and their parents. Monga et al. (2009) were not only concerned with demonstrating the effectiveness of their protocol, but also challenging the belief that children below the age of seven cannot be treated through group cognitive-behavioral treatments. Results indicated that children in this age group can benefit from group CBT treatment when interventions are developmentally appropri...