(p. 1) CBT Applications in Schools
Within the United States, it is estimated that 20% of school-aged children will experience significant mental health needs at some time during their education (Kessler et al., 2005; Merikangas et al., 2010; U.S. Department of Health and Human Services [USDHHS], 2000). Among students ages 9 to 17, approximately 21% will exhibit symptoms of a diagnosable disorder during the year, 11% will have significant impairment due to symptoms, and 5% will exhibit extreme functional impairment. For students (ages 10–24) served in schools across all disabilities, nearly 50% are mental health related (Gore et al., 2011). In a review of epidemiology studies published between 1993 and 2005, Costello et al. (2005) rank ordered median estimates for the most common mental health disorders among 5- to 17-year-olds. They found the highest prevalence for anxiety-related disorders (8%), followed by disruptive behavioral disorders (7%), major depression (4.8%), substance use (4.75%), conduct disorder (3.8%), oppositional defiant disorder (3.5%), attention-deficit/hyperactivity disorder (ADHD; 3%), simple phobias (2.5%), social phobia (2%), and separation anxiety (1.8%). Researchers examining other samples have also found high prevalence rates for learning disorders (9.7%), ADHD (9.5%), and stuttering (6.1%; Karpiak & Zaboski, 2013).
Another study reviewed 15 years of adolescent prevalence data and found that the prevalence of separation anxiety and ADHD decreases from childhood to adolescence, whereas the prevalence of depression and substance use disorders increases (Costello et al., 2011). In reviewing 30 years of longitudinal data for rural Appalachian students (primarily American Indian and Anglo), researchers concluded that most mental health disorders manifest in childhood and can precipitate adverse outcomes through adulthood (Costello et al., 2016). They also noted that 6 out of 10 (60%) children with early psychiatric disorders had adverse adult outcomes, including multiple mental health problems, suicidality, life-threatening health concerns, incarceration or felony charges, being fired from multiple jobs, lack of family/peer support, and high school dropout. In contrast, (p. 2) only 1 out of 5 (20%) individuals without childhood mental health diagnoses experienced adverse adult outcomes. The correlates and predictors of adult psychiatric and substance use disorders included family/environment risks, trauma, genetic markers, epigenetics, and poverty (irrespective of race/ethnicity). Together these studies provide a snapshot of the mental health needs school personnel are likely to serve, and these findings argue for early intervention supports.
Unmet mental health needs can have a significant negative impact on students’ education and life opportunities. Nearly 44% will drop out before completing high school, and this statistic goes up to 50% for minority students (Greene & Winters, 2005). For secondary students, 46% of school failures are considered attributable to psychiatric disorders (Stoep et al., 2003). In considering the more serious consequences of acute mental health needs, suicide is the third leading cause of death for students ages 10 to 24 (Center for Disease and Prevention [CDCP], 2017). Overall, 16% of high schoolers have seriously considered suicide, 13% have made a plan, and 8% reported an attempt. Among youth completing suicide, 81% are males (CDCP, 2017). Given these outcomes, there is a need for early, high-quality mental health services for vulnerable youth.
Only 20% of children with diagnosable disorders receive mental health services, only 40% of those with serious emotional disorders receive care from a specialty mental health professional, and less than 10% receive treatment for more than 3 months (Costello et al., 2016). Most youth receiving services (70–80%) acquire intervention through their school district rather than clinics or private practitioners (American Academy of Pediatrics, 2004; Burns et al., 1995; Hoagwood & Erwin, 1997; Rones & Hoagman, 2000). Based on these findings, several national initiatives have advanced the role of schools in mental health service delivery for youth (President’s New Freedom Commission on Mental Health, 2003). Some of the benefits of school-based counseling interventions include a reduced risk of counseling no-shows, elimination of insurance treatment limitations, and fewer transportation barriers for families. Schools also provide a naturalistic setting for counseling with abundant opportunities for in vivo practice and generalization of new skills, offer sustainable resources located within schools, and facilitate opportunities to increase parent involvement (Atkins et al., 2010).
Efficacy of Cognitive Behavioral Therapy (CBT) in Schools
In considering best practices and evidence-based counseling treatments, the Task Force on Promotion and Dissemination of Psychological Procedures through the American Psychological Association has designated CBT as “well established” for use in children and adolescents (Silverman et al., 2008). CBT has been applied with success in school settings to address the most common childhood/adolescent mental health syndromes, including anxiety-related disorders, phobias, depression, obsessive-compulsive disorder, ADHD, and behavioral/conduct disorders (p. 3) (Ginsburg et al., 2008; Masia Warner et al., 2005, 2007; Mychailyszyn et al., 2011; Neil & Christensen, 2009; Parker et al., 2016).
For students with mental health needs, which may not include a formal diagnosis, there also are a range of validated counseling approaches, including psychoeducation, mindfulness, and scripted or modular cognitive behavioral curricula (Friedberg et al., 2009; Ginsburg et al., 2008; Masia Warner et al., 2005, 2007; Mychailyszyn et al., 2011; Neil & Christensen, 2009). A meta-analysis by Cuijpers et al. (2014) indicates that medication and counseling each independently exert moderate effects on improvement compared to placebo (g = 0.35, g = 0.37, respectively), suggesting that counseling can be an effective, viable, and side effect–free option compared to pharmacotherapy. Research also shows that CBT may have more long-term enduring results than medication alone (Canton et al., 2012; Carpenter et al., 2018; Cuijpers et al., 2013). Based on a review of 106 meta-analyses, some of the strongest CBT effects are for bulimia, anxiety and anger-related disorders (Hofmann et al., 2012), with even stronger effects when combined with exposure and response prevention (E/RP—discussed further in Chapter 7). When symptoms and impairment are acute or severe, studies indicate that medication outperforms counseling in the short term (Blanco et al., 2013; de Gage et al., 2012). However, augmenting medication with CBT increases intervention effects beyond medication alone (g = 0.43; Cuijpers et al., 2014). In addition to improving mental health status, school-based CBT has also resulted in secondary benefits including improved attendance, lower discipline referrals, and higher overall grade point average (GPA) (Michael et al., 2013). For these reasons, CBT remains an essential intervention choice for school-based practitioners (Zaboski et al., 2017).
As noted in this section, the level of mental health needs can be conceptualized in three categories: mild, moderate, and severe. It is also common in medicine to conceptualize patient care in a three-level paradigm: prevention, treatment, and rehabilitation (World Health Organization, 2001). In this medical framework, preventive actions interrupt the causes of illness, treatment recognizes emerging illness and stops symptoms from worsening, and rehabilitation tries to restore function to the greatest extent possible. Similar tiered models also have been developed for school systems’ intervention design.
Multi-tiered Systems of Support (MTSS)
MTSS is a comprehensive framework for providing levels of support for students based on their progress monitoring data and response to intervention (National Association of Directors of Special Education [NADSE], 2008a, 2008b). The MTSS framework is often conceptualized as a three-tier model, although variations exist (Figure 1.1). These tiers are based on students’ assessed needs, and progress monitoring assessments are utilized across all tiers to evaluate student success. The model was created to address academic achievement, and its application has resulted in considerable improvement in core skills (Grapin et al, (p. 4) 2019). This framework also has been applied to behavioral and social-emotional functioning (NADSE, 2008a, 2008b; Sulkowski et al., 2011).
Tier 1 focuses on all students. Supports at this level are universal and include evidence-based, high-quality classroom instruction, social-emotional learning curricula, and classroom-wide behavioral management practices. Ideally, the needs of approximately 80% to 90% of students across behavioral, social-emotional, and academic domains should be met by these universally available supports. Like the tiered medical model, this tier is preventive. Group data are reviewed three or four times a year to ensure that most students are meeting benchmarks (e.g., grade-level vocabulary acquisition, math skills, absences under the state mean, no discipline referrals or suspensions). When less than 80% of students are achieving expectations, it suggests that the curricula or the system’s infrastructure may need adjustment. The exercise of reviewing broad group data may also reveal patterns of need for specific groups (e.g., minority or homeless children) that the school infrastructure needs to address at Tier 1 (Sulkowski & Joyce-Beaulieu, 2014). If group patterns exist, it also may be unfair to isolate those children for Tier 2 or 3 services when there are systemic-level changes that could ameliorate difficulties (e.g., more culturally appropriate curricula for diverse students, bus pickup at homeless shelters, quick implementation of free lunch for temporary circumstances such as homelessness). Another approach to acquiring group social-emotional data is the use of universal screeners (Joyce-Beaulieu & (p. 5) Zaboski, in press). These instruments are typically brief rating scales and identify students at risk. Forms are often completed by teachers.
As an example, if greater than 20% of children are not meeting basic reading skills, perhaps a better curriculum, more instruction time, or different instructional methods are needed. Likewise, if 20% of students are receiving behavioral referrals or exhibiting high absenteeism, it suggests that classroom management strategies and attendance policies need review. Diligent review of a school’s whole-group data ensures accountability for maintaining high-quality pedagogy that is responsive to the needs of the population the school is serving (Benner et al., 2013). Monitoring the school’s ability to meet students’ needs while simultaneously identifying those students who require early intervention offers the additional benefit of closing the disparity in services for minority students (Benner et al., 2013). When the needs of 80% or more of the students are met, those whose scores remain low are provided Tier 2 interventions to quickly close the achievement or behavioral functioning gap (Fixsen et al., 2005).
The second tier provides supplemental, targeted interventions and supports for at-risk students. These interventions are short term and highly efficient and are considered a rapid response to emerging risk. Often a small-group format is utilized for children with common needs. For example, in elementary schools there are often clusters of students who could benefit from social skills development, test anxiety reduction, or self-regulation techniques. At Tier 2, CBT may be applied using treatment protocols or scripted or modular curricula. Counseling groups may address these needs, sometimes in tandem with classroom behavior incentive plans. Progress monitoring data are collected during small-group interventions and used to make decisions regarding whether interventions have been successful, need to be continued, or need to be changed. Assessments may include several options, such as observational data, naturally occurring school data (e.g., grades, attendance, frequency of nurse visits, behavioral referrals, suspensions), rating scales, and Subjective Units of Distress Scale (SUDS) measurement. Intervention frequency (how many sessions per week), intensity (length of sessions), and duration (total number of weeks) can all be adjusted. If a student’s progress is not adequate, additional interventions may be added, including progression to the Tier 3 level.
Tier 3 interventions are intensive, often multifaceted, and typically delivered individually (Eagle et al., 2014). Some Tier 3 interventions, however, may be delivered in groups, especially when the student’s symptoms or impairment, like social anxiety, could be remediated from social interaction (Zaboski et al., 2019). For (p. 6) mental health and social-emotional needs, Tier 3 may involve more formalized CBT techniques and sessions that are highly customized to the student (e.g., modified CBT for autism; Zaboski & Storch, 2018). Collaboration with outside care providers and pharmacological treatment may also be indicated depending on symptom severity (Wexler, 2017). Tier 3 interventions also require progress monitoring, so the use of pathology rating scales (e.g., anxiety, depression, conduct disorder, oppositional defiant disorder, and obsessive-compulsive disorder) in additional to school performance improvement measures (e.g., attendance, behavioral discipline referrals) is common.
Despite being provided high-quality core instruction and social-emotional supports as well as significant Tier 2 and 3 interventions, a small percentage of students will need additional supports on a sustained, long-term basis. For these students, schools may initiate eligibility for special education procedures and consideration for placement as emotional disturbance (ED), as well as refer them to providers outside of the school system for additional supports.
Section 504 Plans, Individuals with Disabilities Education Act (IDEA), and Individualized Education Programs (IEPs)
Section 504 Plans
Section 504 plans offer protections for individuals with disabilities and originated with the Rehabilitation Act of 1973 (1973). The broad legislation is a civil rights law passed by Congress and applies to individuals of all ages in a range of settings, including employment and schools. The Americans with Disabilities Act of 1990 (1990) and the Americans with Disabilities Act Amendment Act of 2008 (ADAAA, 2008) were subsequently passed to update the law’s provisions. These laws offer additional guidance on Section 504 plans as they apply to educational settings. The core principle ensures an equal opportunity for individuals with disabilities to access programs, activities, and advancement. For schools, this includes participation in all school-based activities (e.g., access to quality instruction/learning, including extracurricular activities such as sports or drama). Eligibility criteria require that:
1. The student has a physical or mental impairment that interferes with one or more daily life activities,
2. The student has a record of this impairment, or
3. The student is regarded as having the impairment.
School decisions on whether a student meets Section 504 criteria may be based on a range of information sources. Eligibility teams may review education data, attendance, discipline referrals, test score history, and documentation of diagnoses from healthcare providers and also may supplement this information (p. 7) with assessments to gather more information. However, qualifying for a 504 plan does not require a formalized assessment battery the way that qualifying for special education would. This is an important point, as it is one area of differentiation from the criteria for special education placement.
The Section 504 definition of a physical impairment includes those that are the result of a physical disorder or condition, cosmetic disfigurement, or anatomical loss that impact a physiological system, such as musculoskeletal, digestive, or neurological. Mental impairment is included and can be a diagnosed mental illness, emotional impairment, or a specific learning disability. Major life activities include care of oneself, breathing, speaking, or working. In the classroom, this can also include concentrating, thinking, or communicating (U.S. Department of Education, Office of Civil Rights, n.d.). Section 504 plans are written with school personnel and parental input and include accommodations and modifications to ensure students can access the curricula and school activities. At times, these plans may request supplemental counseling support services within the school. These plans are reviewed periodically but do not have measurable goals as would be required for special education placement plans.
IDEA and IEPs
Provisions through the IDEA and the IDEA Improvement Act of 2004 include 14 categories for special education services (IDEA, 1990, 2004): autism, deaf-blindness, deafness, developmental delay, ED, hearing impairment, intellectual disability, multiple disabilities, orthopedic impairment, other health impairment (OHI), specific learning disability, speech or language impairment, traumatic brain injury, and visual impairment including blindness. Across the United States approximately 7.1 million children receive special education services, which represents 14% of all students (National Center for Education Statistics, 2020).
Special education placement requires an eligibility assessment and development of an IEP, a plan that incorporates supportive accommodations and modifications tailored to the student’s needs (Office of Special Education and Rehabilitative Services, U.S. Department of Education, 2000). Goals and outcome measures are written into the plans and progress is monitored by the school’s problem-solving team so plans can be adapted as needed. The IEP differs from a Section 504 plan in that formalized annual review meetings are required (more often if parents request them) and reevaluation is required every 3 years. If the student’s disability is short term, the school-based eligibility team also may withdraw the special education designation once all goals are met. If the needs are related to social-emotional struggles, behavioral disorders, chronic health syndromes, or mental health diagnoses, designated services often include counseling. For students with mental health support needs, specific counseling goals, progress monitoring mechanisms, and frequency, intensity, and duration qualifiers may also be included. As noted in Chapter 3, these specified IEP requirements will need to be followed and documented when planning counseling sessions. Additionally, (p. 8) students in any IDEA category, even if it is not primarily mental health related, may have counseling as a supplemental support depending on their needs. As an example, a child who has suffered a sudden loss of vision may need long-term special education services under the category of visual impairment. This child also may need shorter-term counseling for emotional supports associated with depression and adjusting to this new life circumstance.
The IDEA categories that might be most amenable for counseling include ED and OHI when related to the stress of chronic health conditions. It is important to note that these categories do not necessarily align well with mental health diagnoses from the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013), although many diagnoses can be served within the broad IDEA designations. This may be a point of confusion for parents and outside service providers less familiar with school-based services, especially when a diagnosis is documented and needs are obvious. Part of the role of school personnel, making eligibility decisions, is to understand the overlap between DSM and educational taxonomies and ensure students are placed appropriately.
When significant social-emotional needs manifest, the ED category may be designated. Within special education, 5% of students have this designation (National Center for Education Statistics, 2020). The criteria for ED are defined in IDEA (2004, Sec. 300.8 (c) (4)):
Emotional Disturbance means a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance:
(A) An inability to learn that cannot be explained by intellectual, sensory, or health factors.
(B) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers.
(C) Inappropriate types of behavior or feelings under normal circumstances.
(D) A general pervasive mood of unhappiness or depression.
(E) A tendency to develop physical symptoms or fears associated with personal or school problems.
Eligibility requires a formal assessment establishing the criteria and a team decision. Students with ED are a heterogeneous group. Thus, the term may be viewed as an umbrella label encompassing a range of externalizing and internalizing difficulties. Externalizers often include conduct dysregulation difficulties (e.g., intermittent explosive disorder, oppositional defiant disorder, conduct disorders). Internalizers may include anxiety-related or mood disorders (e.g., phobias, social anxiety, generalized anxiety, bipolar disorder, depression). Depending on the (p. 9) severity, children with other syndromes may also receive special education services under ED (e.g., obsessive-compulsive disorder, eating disorders, schizophrenia).
It is important to note that although some DSM diagnoses are mentioned as examples in this text, having the diagnosis does not automatically qualify students for services; they would still need to meet criteria A to E as noted by IDEA (2004). Likewise, students may exhibit significant emotional disturbance without meeting criteria for a DSM diagnosis and still be eligible for special education ED services. As noted previously, this can be confusing to parents, especially if they have been referred by a private provider with a recommendation for special education and a documented diagnosis. If the mental health syndrome does not have the impairments noted in the criteria, the child may not qualify for special education. Individual states also have additional special education statutes and procedures to consider. Given the nature of ED, it is likely that IEPs will require counseling to address at least some portion of the youth’s functioning.
The designation of OHI is often utilized for students with chronic health illnesses. Examples include ADHD, heart conditions, tuberculosis, rheumatic fever, nephritis, asthma, sickle cell anemia, hemophilia, epilepsy, lead poisoning, leukemia, diabetes, or any other medical condition, such as Tourette syndrome (IDEA, 2004). The OHI criteria include limited strength, vitality, or alertness, including a heightened alertness with respect to the educational environment due to chronic or acute health problems that adversely affects a student’s educational performance. A medical assessment documenting the health problem is required (IDEA, 2004). OHI accounts for about 15% of all children receiving special education services (National Center for Education Statistics, 2020). For students receiving OHI services, counseling would most likely be supplemental rather than the primary intervention and would be related to the stressors and coping mechanisms for illness.
Chronic Health Conditions
Approximately 20% of youth are diagnosed with a chronic illness (e.g., diabetes, asthma, epilepsy), and of those children, 6.5% have illnesses that significantly interfere with normal school activities (Merikangas et al., 2015, 2010; USDHHS, 2007). More severe forms of illnesses may be related to discrete medical interventions (e.g., corrective spinal surgeries) or ongoing treatment (e.g., multiple rounds of chemotherapy for leukemia with episodes of remission and relapse, cardiovascular disorders). Chronic illness is defined as lasting at least 3 months, requiring extensive medical care, and negatively impacting the ability to participate in typical activities (Mokkink et al., 2008). For these students, Section 504 plans or IEPs under the special education category of OHI provisions may (p. 10) be implemented. However, a nationwide survey found that 504 plans are most often utilized for individuals with ADHD, chronic health conditions, and multiple diagnoses and impairments (Holler & Zirkel, 2008). Accommodations and modifications for students with chronic health struggles often include significant allowances for medical absences, additional time for making up class assignments or credits, streamlining curricula, additional breaks for fatigue, and counseling, and in more serious circumstances, a hospital-homebound provision may include sending a teacher to the child’s home for instruction. Adding to the complexity of service needs for these students, research has indicated that 70% of students with special medical needs have three or more comorbid conditions (Parasuraman et al., 2018).
Studies of youth with chronic health conditions indicate that they have a higher incidence of some behavioral, academic, cognitive, and social-emotional difficulties (Clark et al., 1999; Maslow et al., 2011; Reuben & Pastor, 2013; Shaw & McGabe, 2008; Shiu, 2001). Research has also suggested a link between poor physical health and a variety of mental health needs (Merikangas et al., 2015, 2010; USDHHS, 2007). But the area of impact may differ by the illness and the severity of impairment. In a meta-analysis, Boekaerts and Roder (1999) reviewed 200 studies and found that children with chronic illness exhibited more behavioral problems associated with depression and social withdrawal. A meta-analysis of 569 studies in 2010 (Pinquart & Shen, 2011) noted higher externalizing (g = 0.22), internalizing (g = 0.47), and total behavioral problems (g = 0.42) on the Child Behavioral Checklist (CBCL; Achenbach & Rescorla, 2001) for students with chronic illness as compared to students without chronic illness. Total effects were moderate for the teacher-report forms (g = 0.37) and small (g = 0.17) for the child self-report forms of the CBCL. Interestingly, the highest internalizing scores were for children with chronic fatigue syndrome (g = 1.42), while some of the highest externalizing scores were for students with epilepsy (g = 0.88 to g = 1.07). A national longitudinal survey of 22,831 children in Canada found those with chronic illness were more likely to have high absenteeism, learning disabilities, and mental health conditions (McDougall et al., 2004). Effects were most impairing for children with chronic illnesses that limited physical activity. A review of another large sample of students in California (N = 22,730, 2nd to 11th grades) found that chronic health problems increased the probability of low performance on a standardized English test by 55% and math scores by 56% (Crump et al., 2013).
When planning counseling for students with chronic illness, there are several unique considerations. For students without illness, counseling content is usually provided sequentially with a set schedule. However, for children with high absences due to medical procedures and who have fatigue, pain management, or reduced concentration factors, counseling will need to be highly flexible. Gaps in attendance may require reestablishing rapport, reviewing prior concepts and strategies, and taking frequent breaks during sessions. Counseling also may need to prioritize general encouragement and a nurturing stance for the child. Lastly, (p. 11) when notified that a child’s condition is terminal, the school and parents will likely advise changing the counseling focus to a palliative care model. This involves acknowledging the strengths the child has, facilitating their choices in how they will spend their remaining time with school friends and family, and supporting their psychological and social needs. Schools will withdraw counseling goals related to academic achievement, making up missed work, or preparing for high-stakes testing and follow the child and parents’ lead on when and if child wishes to continue attending school.
In summary, this chapter has provided an overview of the national prevalence trends for youth with mental health needs and supporting evidence for delivery of CBT in schools. The MTSS model and the ways in which tiered services are integrated within the context of school referral processes were reviewed. For more intensive needs, Section 504 and IDEA provisions also may offer formalized accommodation and modification supports that include counseling intervention. The students most likely to acquire longer-term services include those with ED, OHI, and chronic health conditions. Together, this information offers a context for school-based CBT.
Sample School-Based Counseling Report
The counseling case report provided here offers an overview of how increasing intervention intensity over time might be provided within a school utilizing an MTSS model for mild to moderate level of need. Later chapters will provide embedded counseling examples for more intensive needs as specific techniques are introduced, and by the end of this text readers will learn how conceptualize and apply CBT in cases like these and monitor the progress of students.
Tier 2 Counseling Intervention Summary
This report contains privileged and confidential information and may only
be released with written parental consent except as provided by law.
Child’s Name: Kaveh (pseudonym)
Date of Birth (DOB):
Date of Initial Contact: 2-7-2021
Chronological Age (CA): 11-2
Date of Final Contact: 3-30-2021
Reason for Referral
Kaveh was referred for counseling following an Individual Education Program (IEP) meeting. His teachers and mother specifically expressed behavioral concerns in regards to having exceptionally high personal performance expectations, self-derogatory comments, becoming easily frustrated, and being unable to cope adequately.
(p. 12) Background Information
Kaveh is an 11-year-old who resides with his biological parents. English is the only language spoken in the home. He attended the same elementary school from kindergarten through 5th grade and transitioned to 6th-grade middle school this year. In kindergarten, the school speech therapist identified a speech impairment for which Kaveh received 60 minutes of speech therapy each week. In 1st grade, Kaveh also qualified for gifted services and subsequently began receiving enrichment classes. He has maintained grades of A’s and B’s since kindergarten.
The counselor’s review of school records indicates Kaveh’s kindergarten teacher noted he was a quick learner and high achiever but had difficulty controlling frustration, rapidly becoming angry if things did not go as he expected. As a result, parents, teachers, and the school counselor met during a problem-solving team meeting and discussed the following intervention strategies: allowing Kaveh time to “cool down,” discussing and rehearsing ways to obtain desired items by raising his hand, offering alternative methods for expressing anger (e.g., asking teacher for help), and encouraging Kaveh to take a deep breathing break when upset. The counselor noted in his record that his behavior improved, with fewer outbursts. In 1st grade, Kaveh’s parents initiated outside counseling services through a local family behavioral support clinic. He learned a three-step program (ALERT) to calm himself and manage his aggression: thinking calming thoughts, breathing (“blow out the bad thought”), and making good choices. In collaboration with parents, the classroom teachers reminded Kaveh to use ALERT as needed. There were only minor outbursts throughout the year. In the spring of 3rd grade, Kaveh’s outbursts increased again and the problem-solving team, in collaboration with the speech/language therapist, added a weekly small-group social pragmatics intervention. Specifically, he was taught how to adaptively express his feelings and emotions and self-monitor his anger. Progress monitoring data in his record indicated that the intervention lowered outbursts to zero by the 9th week. In 4th grade, school team members reviewed Kaveh’s IEP and concluded that he had met all speech goals, behaviorally matured, and progressed with his appropriate peer interactions. He no longer met criteria for speech impaired, so his IEP for speech services was closed, exiting him from special education. No behavioral incidents were noted for 5th grade.
Description and Analysis of the Problem
Kaveh transferred from elementary to middle school in 6th grade. His current teachers note he is a hardworking student with exceptional math skills who places considerable stress on himself to achieve and never get a wrong answer. They also noted he has found middle school curricula challenging in some classes, including science and language arts. His teachers are concerned that he becomes easily upset when he does not understand a new concept the first time it is presented (p. 13) or when asked how he would find an answer. Specifically, they noted a variety of triggers leading to his frustrations, including missing needed items (e.g., pencil, journal) or forgetting something (e.g., lunch money); situations that challenge him (e.g., group work when he is not always right and wants to compete), time constraints (e.g., tests), and believing he should have done better (e.g., assignment, test); and social situations where he feels annoyed by other students. The teachers also mentioned that when Kaveh becomes frustrated he typically reacts with negative self-talk (e.g., curses; “I’m stupid”; “I should be able to do this easy”; “I’m never gonna pass this”).
At this time he has three behavioral referrals for directing his aggression to others when he becomes frustrated (e.g., verbal insults, physically pushing). Data indicate in the last 3 weeks he has had at least one outburst a day and one aggressive act every week. Teacher strategies have included asking him to take a time out for 3 minutes, discussing his behavior with him once he is calm, and ignoring his minor frustrations (e.g., mumbling, grimacing) if they are not interrupting other students. One teacher mentioned that most other students in the class react to Kaveh’s behavior by staying away from him, and she is worried about peer neglect as he adjusts to this new cohort. Teachers also indicated that Kaveh can be reasoned with when not angry and very apologetic to others for his behaviors once he calms down.
The counselor interviewed Kaveh’s mother regarding her concerns about his behavior. She indicated that Kaveh has unrealistic expectations and that they are leading to his frustration and meltdowns. She shared that he becomes frustrated easily at home, like when he did not perform a new stunt on his skateboard correctly the first time or when he had to study more than usual to keep up with classwork. She added that when he has a bad day, he talks “nonsense” (e.g., that he will never get into a good college, never get a great job, and just be a loser in life). Despite these challenges, he has several strengths, like his love of family, soccer, skateboarding, and video games. He has several close friends in the neighborhood who enjoy these activities with him. His mother’s goals are for him to more frequently ask for help, pause to get his composure before acting out, and think less self-critically.
During classroom observations, it was noted that Kaveh is on task about 80% of the time and polite to teachers. He also seems to have a few casual friends who he engages with between classes. His book bag and work folders are somewhat disheveled, making it difficult for him to locate things at times. When work is difficult his body tenses, he gently bangs his head on the desk or against the wall, or he puts his torso under the table to escape the situation. He also softly mutters some self-derogatory statements (“Can’t get this stupid stuff”; “My dumb brain lost the pencil again”; “This is hopeless”). If peers tell him to “chill out” or “be quiet,” he will sharply reply “shut up.”
(p. 14) Student Interview
A semistructured interview was conducted with Kaveh. He indicated that he becomes upset when he does not meet his own expectations. He labeled himself as a “perfectionist.” He said that he knows he overreacts and has expectations that are too high and that do not help. Kaveh said math comes easy to him but science and language arts frustrate him (especially grammar). When asked to describe how those subjects are frustrating, he mentioned that when he encounters a scientific theory or has to memorize grammar rules, he gets nervous, his mind shuts down, he thinks he will never get it, and he calls himself “stupid.” He likes facts in science but not theories because they are a “waste of time.” He does not understand why grammar rules are more important than his creative ideas. Kaveh thinks he is smarter than his peers and does not like to be corrected or redirected. As a result, other students annoy him in class (especially a couple of male students) when they continually interrupt him or do not listen when he tells them to stop talking. Kaveh noted he wants to be the best or not bother, and he is secretly afraid that he will disappoint his family and not get into a great college if he cannot get everything right in 6th grade.
Kaveh’s emotional and behavioral functioning was assessed using the Behavior Assessment System for Children, Third Edition—Teacher Rating Scale (BASC-3 TRS; Reynolds & Kamphaus, 2015) and Parent Rating Scale (BASC-3 PRS). The BASC-3 is an omnibus behavior rating scale designed to assess a broad range of children and adolescent behaviors and emotions. Preintervention, Kaveh’s mother and father rated Kaveh’s depression in the at-risk range, whereas his teacher rated it in the clinically significant range. Similarly, his teacher rated his anxiety in the clinically significant range, and his parents rated it in the at-risk range. All other clinical scales on the BASC-3 were average range. Kaveh preferred not to complete the self-report version of the BASC-3, noting he doesn’t like to answer so many questions about himself. To maintain rapport, Kaveh was gently encouraged, but the counselor also noted he has the right to assent. It also was felt that if he was unduly influenced to complete the form despite his objection, the data may be inaccurate.
Intervention Design and Implementation
Intervention efforts focused on Kaveh recognizing signs of anxious arousal, identifying anxious cognition, learning appropriate problem-solving strategies and coping skills to manage his frustration, and evaluating himself more positively when experiencing situations that could potentially lead to anxiousness. In reviewing interviews, observations, and assessment data, the counselor hypothesized that Kaveh was engaging in some all-or-nothing thinking, “should” thinking, and catastrophizing. Because Kaveh has a high opinion of himself and is an independent thinker, Socratic questioning techniques would be part of the counseling plan.
(p. 15) Counseling was conducted for 6 weeks, 1 hour per week. Sessions were semistructured such that specific exercises and activities were implemented in a specific sequence while still allowing flexibility to discuss any issues Kaveh presented to the counselor (an outline of each counseling session can be found at the end of this report). Kaveh appeared to be very responsive to working with the counselor and using various strategies discussed. Also, homework was assigned and reviewed each week that emphasized the material covered during each counseling session. The counselor adhered to a cognitive behavioral orientation and adapted sessions from both Kendall’s treatment program for youth with anxiety disorders (Coping Cat; Kendall & Hedtke, 2006) and Stark’s treatment program for adolescents with depression (ACTION; Stark et al., 2011).
Kaveh was first taught how to become more aware of his own experiences and recognize signs of anxious arousal. Specifically, Kaveh was taught the relationships between his thoughts, emotions, and behaviors and how changing his self-talk (the degree to which it is positive/negative) will impact how he feels and behaves through the use of both positive and negative examples and a thought/emotional charades activity. Kaveh also learned how to differentiate anxiety from other emotions and identified bodily symptoms (through a figure drawing) associated with his anxiety. Therefore, such physiological signs could be used as cues to engage his coping techniques. Additionally, Kaveh participated in exposure tasks that provoke anxiety to (a) help Kaveh realize that imperfection is manageable and (b) practice the skills he learned outside of session. In building a fear hierarchy, Kaveh indicated five fears: getting an answer wrong in front of others, falling off his skateboard at the park, having others know he does not understand some grammar rules, asking the teacher for help in front of peers, and admitting he forgot his lunch money or pencils. In collaboration with teachers, a series of exposures were established (e.g., asking to borrow a pencil because he forgot his, asking for peer and teacher help, letting others see his paper with grammar corrections after it was graded, trying a difficult new skateboard stunt when others were watching, and risking answering in class). Subjective Units of Distress Scale (SUDS) ratings from 1 (no anxiety) to 10 (maximally anxious) were taken during exposures to monitor level of discomfort.
The counselor also sought to identify Kaveh’s anxious cognitions and to change negative and self-derogatory thinking to more positive and realistic thoughts. The inflexible core belief at the center of Kaveh’s anxiety is that he has to be perfect in every situation; specifically, he notes, “I should do everything right all the time, and I should always be perfect.” The counselor worked with Kaveh to evaluate the evidence for that expectation. In doing so, Kaveh identified how his self-talk can include negative self-evaluations, perfect standards for performance, fear of failure, and concern about what others might think. Also, at times his thoughts can be catastrophizing and ruminate out of control. For example, in regard to doing poorly on an academic task, Kaveh indicated the following thoughts: “I’m stupid,” “I don’t deserve to be in this grade,” “I should be held back,” and “I feel horrible—my life’s never going to be good.” Therefore, the counselor worked (p. 16) with Kaveh to restructure his cognition through Socratic questioning to dispel the accuracy of many of his thoughts. Specifically, Kaveh was asked to provide supportive evidence for/against having a specific negative thought and how he could think about and interpret the situation differently (also, this was modeled for Kaveh by the counselor). This provided Kaveh the opportunity to generate alternative positive thoughts that are more realistic and less negative, thus changing his perceptions regarding the potential severity of a situation (e.g., doing poorly on an academic task).
Kaveh also learned how to evaluate himself more accurately and reasonably. Specifically, Kaveh was shown how he could rate himself based on his effort and not the outcome. Also, for challenging tasks, perfect execution should not be expected; therefore, he grew accustomed to rewarding himself for partial success. In addition, given that everyone makes mistakes/forgets, Kaveh learned to accept that he is no exception and should not hold himself to an impossible standard. Since situations will at times be challenging, Kaveh was provided modeling/practice in identifying the positive things he liked about how he handled a situation as well as discussing what he could do differently if the situation were to occur again. Also, Kaveh created a “self-map” indicating several positive attributes about himself that would remain stable regardless of his academic performance.
Another counseling goal was to help Kaveh use problem-solving skills to cope with novel anxiety-provoking situations. In doing so, he identified specific situations and was guided in generating a useable list of coping strategies (e.g., create an exposure or challenge his thoughts). Importantly, his ineffective coping mechanisms were also discussed (e.g., banging head on wall, crawling under the desk, negative self-talk) and replaced with more effective strategies (e.g., taking a break, seeking support, thinking about the situation differently). Lastly, two booster sessions were provided for Kaveh (at 2 and 4 months postintervention) to review strategies and his progress.
Evaluation and Outcome of the Intervention
Pre- and postintervention rating scale data were collected from Kaveh’s teacher and his parents. They rated Kaveh’s behavior using the anxiety and depression subscales of the BASC-3 at preintervention and 6 months postintervention. Overall, their ratings of both anxiety and depression were lower following the counseling intervention with booster sessions (Figure 1.2). Additionally, Kaveh practiced his exposures over a 3-week period and was able to bring the anxiety SUDS scores elicited by each of them down to a 5/10 or lower. He also reported less avoidance behavior in anxiety-provoking situations. Additionally, no classroom behavioral referrals were noted during the counseling intervention or 6 months postintervention.
Session 1: Affective Education/Recognize Signs of Anxious Arousal
• Confidentiality, assent, rapport building (Note: Guidelines are discussed in Chapter 3 of this text)
• Become more aware of own feelings before they escalate, physiological cues
• Relationship between thoughts, emotions, and behaviors (Note: The CBT triad is reviewed in Chapter 6 of this text)
• Differentiate anxiety from other emotions
• Identify negative self-talk statements (e.g., “I am stupid”)
• Homework: diary of feelings (antecedent, physiological cues, label feeling)
Session 2: Exposure Tasks (Note: The exposure/response prevention technique is discussed in Chapter 7 of this text)
• Build fear hierarchy
• In-vivo exposure (model, utilize coping skills) with SUDS ratings
• Normalize anxiety; it’s a manageable experience
• Homework: practice at-home exposures (e.g., new skate park feat in front of others)
• Practice exposures
• Identify inflexible core beliefs (i.e., distortions, all-or-nothing thinking, “should” thinking, catastrophizing)
• Challenging negative self-thought
• What’s another way to think about it?
• Where’s the evidence?
• Generate alternative positive thoughts
• Homework: list of anxious negative self-talk (generate positive coping self-talk); continue exposure practice at home
Session 4: Develop Coping Skills/Problem Solving
• Practice exposures
• Identify specific situations/settings that are problematic
• Teach problem-solving process (provide examples of situations, help generate alternatives, evaluate possibilities, choose solution)
• What is the problem?
• What are all the things I could do about it (brainstorm)?
• What will probably happen if I do those things?
• Which solution do I think will work best?
• After I tried it, how did I do?
• Homework: generate actions to cope from previous list of negative/positive self-talk; continue exposure practice at home
Session 5: Contingency Management/Build Positive Sense of Self
• Practice exposures
• Evaluate own actions more accurately, reasonably, positively
• Teach to rate himself based on effort and not outcome (give examples)
• For challenging tasks, perfect execution is not expected; reward partial success
• Learn to identify things he liked about how he handled the situation and what he would do differently
• Generate list of positive self-rewards
• Homework: interview others, asking how they would evaluate you if you . . .; diary: create list of behaviors that show it is OK not to be perfect
Session 6: Review and Closure (Note: Techniques for terminating therapy are discussed in Chapter 9 of this text)
• Review information from sessions 1 through 5
• Celebrate successes
(p. 19) • Rehearse go-to strategies when anxious
• Provide contact process for school if need more sessions
Chapter Discussion Questions
1. What mental health syndromes are most prevalent in youth?
2. How might counseling services fit within an MTSS model of service delivery?
3. What are some of the similarities and differences between Section 504 plans and IEPs?
4. What special considerations might be pertinent when counseling students with chronic health needs?
5. How do students qualify for special education?
6. What is the difference between ED and OHI classifications?
7. What are some of the benefits of school-based counseling?
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