What is the effect of working with the school and the broad, social context of the child? - Chapter 9

What is this chapter about?

The CBT has its roots in social learning theory and is a framework in which the relationship between the cognitions, emotions and behaviours of an individual is investigated within a specific context. Children live in multiple environmental systems: family, school, sports clubs, neighbourhood children, etc. Parents and their schools play a big role in the child's life. Working with the school can therefore help to improve the effectiveness of the treatment.

The impact of the social environment is greater in CBT in children than in adults, because children are still very dependent on others. It is a great challenge for the therapist to understand all the social environments of the child. If a therapist works within a school setting or from the child's home environment, it is easier to observe important factors (such as dealing with peers at school, or family dynamics at home). It is also easier to connect with the most important people in the child's life.

How can we achieve therapeutic support?

According to Kadzin and colleagues (1997), there are several practical barriers that prevent the child and the family from attending the sessions, such as the distance to the clinic. Offering CBT in a more familiar and accessible setting increases the likelihood that the appropriate intervention will also be properly transmitted to the child and their parents.

20% of young people experience significant stress at some point in their school career, and over 11% experience significant mental health problems in high school. It is often the parents who turn to the school when they observe emotional problems in their children. Because of the strong relationship between the school, the children and their families, school is a good and easy place to deliver CBT. By offering CBT interventions in school settings, the therapy is more accessible and a larger proportion of children with stress will receive the appropriate guidance. CBT can also be delivered from the child's home, although working from a setting in which the therapist is "the guest" can come with some problems. Think of a high level of distraction (TV, passing neighbours, ringing phones, children running around). There is also a good chance that the child with problems does not see the "home" as a safe and objective place to have conversations.

How does CBT work in schools?

Schools play an important role in identifying and supporting children with psychological problems. However, teachers are not very good at noticing the early symptoms of children with mental health problems. However, they have a lot of knowledge about the learning skills.

A positive school climate with strong leadership, good quality relationships, and a cosy atmosphere is important for preventing mental problems. Factors that hinder the effective use of CBT treatment in schools include problems with available space and overlapping schedules, insufficient support within the school, and problems with staff (teachers who do not know about mental health problems and who do not want to be involved). According to Suldo and colleagues (2010), factors that do support the treatment are mainly the support of the staff at school and the competence of the therapist him/herself. When the resources are limited, practitioners should evaluate the school setting and see if involving the school would be beneficial or not.

What are the levels at which service is provided?

Although traditional CBT is delivered on an individual basis, there is increasing attention paid to a cascading model for giving treatments. This would be efficient and cost-effective. In principle, there are three steps in such a model (triangular form).

• Universal interventions: screening allows children who are at risk for mental problems to receive a universal CBT intervention in large groups. If the child does not progress within a certain period of time, he or she will move to the following step:
• Selected intervention: delivered to small groups of children in which the progress is carefully monitored. If the child has not benefited from both 1) and 2), he or she will receive a targeted intervention.
• Targeted intervention: the most intensive form in which the individual is focused on the individual in 6 to 16 individual sessions.

Due to the increasing demand for CBT for children and the shortage of trained CBT practitioners, there is more and more interest in such group-oriented approaches in schools. In such group forms, the practitioner will be given the opportunity, among other things, to observe 1) social interactions and otherwise obtain valuable information, 2) to test the skills to be learned in a safe setting, and 3) to normalize aspects of the problem. Ideally, the group size should be between 5 and 8 children and balanced in such a way that there is no risk of exposure to negative thinking models. Questionnaires and other tools can help to create such groups. Group-oriented CBT has proven effective in multiple areas, such as treating anxiety and training social skills.

How does an integrated, coherent CBT treatment in schools work for young people?

Unlike CBT for adults, CBT treatment for young people should always integrate three elements: psychosocial development, school, and the family life. This can be integrated through a case conceptualisation. The case conceptualisation should focus on both the systematic and the individual formulation, thus forming a bridge between the systems, without unnecessarily complicating the formulation.

What is meant by the art of collaboration?

Explicit agreements should be made prior to treatment, for example: who will be provided information and who will not? Imagine if there was a case of domestic violence. On the one hand, the safety of the child is central, but on the other hand this is also confidential information, which can lead to ethically complex issues. Therefore, make sure that you receive explicit permission from the child to share information. Teachers can provide very useful information about how a child functions in a group and how the child deals with formal learning processes. Although teachers quickly overlook internalizing disorders, their vision can be very helpful and can play a major role in achieving successful treatment. In this way, they can help with behavioural experiments, or stimulate positive interactions with peers. It is important that the teacher is engaged and does this in a time-efficient, easy, controllable and consistent way. Neither the teacher nor the parent should have the idea that therapy is "separate" from school and at home, i.e., as if it were something that stands on its own. For both parents and teachers, it can therefore be useful to regularly exchange feedback on the child's behaviour and experiences both at home and at school. It is important that such a feedback system is simple and efficient. The essence of trust between home and school is based on regular, high-quality communication. The importance of good quality communication (preferably face-to-face) between all the groups involved (therapist, teacher, parents, child) cannot be stressed enough. Finally, it is the therapist's job to stimulate the relationship between the teacher and the child. The art of collaboration is therefore about principles such as information sharing, the teacher's involvement, actively involving all parties (school, home and therapy), the use of simple and effective feedback methods, the importance of quality communication, and supporting the relationship between the child and the teacher.

What are the criteria for determining whether or not a child would benefit from CBT?

Sometimes it is difficult to determine whether CBT is an appropriate intervention for the child. According to the authors, the child must in any case meet the following conditions:

• Have the necessary linguistic, cognitive attention and memory skills.
• The problems prevent the child from being able to lead a "normal" life.
• The child wants to have a better life.
• The idea that improvement can come when the child behaves/feels differently.
• There is an expectation that the child will show up at appointments.

For the therapist, there are also skills that he or she needs to have within this specific CBT context. In addition to the fact that the therapist must of course have knowledge, competent therapists will have to be able to apply CBT in a different way within the context of the school, taking into account the level of development. They also need to know how schools function and how best to mobilise the child's help within this setting.

The CBT has its roots in social learning theory and is a framework in which the relationship between the cognitions, emotions and behaviours of an individual is investigated within a specific context. Children live in multiple environmental systems: family, school, sports clubs, neighbourhood children, etc. Parents and their schools play a big role in the child's life. Working with the school can therefore help to improve the effectiveness of the treatment.