Cognitive behavior therapy in the school setting : A case study of a nine year old anxious boy with extreme blushing

Within the field of school psychology there is a gap between research and practice, caused by difficulties in translating the programs from research to the realities of the school setting. Illustrations of real-life cases may help school psychologists gain insight into the application of interventions. The purpose of this study was to describe an example of small group cognitive behavior therapy in the school setting. It concerned test anxiety with extreme blushing. A single subject case study of a nine year old Dutch boy was described. Interviews, observations and questionnaires were used for evaluation, as well as a standard national achievement test. The results indicate that the test anxiety and blushing decreased and on the achievement test three years later, performance was good. As it concerns a case study, the results are discussed tentatively. It was concluded that the intervention was successful without alterations to the program. This study provides an illustration of research put into practice. DOI : 10.14302/issn.2476-1710.JDT-16-1317 Corresponding author: Francine C. Jellesma, Research Institute Child Development and Education, University of Amsterdam, Email: F.C.Jellesma@uva.nl


Introduction
This article describes a successful intervention for a nine year old boy presenting emerging test anxiety and extreme blushing. The treatment consisted of a group-based cognitive therapy (CBT) in the school setting. This case-study illustrates how CBT can be applied within primary school addressing test anxiety when the concern is not only on the level of an emerging mental health problem, but also on a specific symptom. Mental health problems are a major concern in primary education because they negatively affect socio-emotional as well as academic school functioning. impairment due to mental health problems [1]. Research demonstrates that school-based cognitive-behavioral interventions that focus on small groups or individual students yield improvements in emotional, behavioral, social, and academic functioning [2]. Nevertheless, within the field of school psychology there is a gap between research and practice that seems to be caused by difficulties in translating the programs from research to the realities of the school setting [3]. Illustrations of real-life cases may help school psychologists gain insight into the application of interventions.
Test anxiety refers to feeling tense, fearful, and worried in evaluative situations [4]. It has formally been defined by Dusek as an "unpleasant feeling or emotional state that has physiological and behavioral concomitants and that is experienced in formal testing or other evaluative situations" (p.88) [5]. It has been estimated that between 10% to 40% of all students suffer from various levels of test anxiety [6]. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; [7]), test anxiety is included indirectly as: "Individuals with Social Phobia often underachieve in school due to test anxiety(…)". Bögels et al. argue that pervasive test anxiety is a form of social phobia (or social anxiety disorder), if fear of negative evaluation by others is the core issue, as was true for the current case [8]. Test anxiety poses students at risk for underperformance on achievement tests, poor grades, repeating a grade and school drop-out [9][10][11][12]. As such, it is important for schools to reduce test anxiety in their students effectively [13].
Blushing can be one of the symptoms of test anxiety [7]. According to the communicative account of blushing, blushing has a remedial function. It communicates to observers that one is sensitive to their judgment [14]. Experimental research shows that blushing causes others to make more favorable appraisals. A blushing person is considered to be more trustworthy, less responsible for violating a norm and more friendly compared to a person that does not blush, but for example only shows shame [15]. Despite these positive effects, blushing is involuntary and uncontrollable and signals to others the presence of emotions that a person perhaps would like to suppress.
The social blushing theory states that blushing occurs when a person receives undesired social attention [16].
Particularly in young people, blushing is a bodily symptom that can occur in situations of increased selfconsciousness [17], and these situations are common for children with test anxiety. Further, it is important to note that blushing is not only an especially salient physiological reaction (feeling warm cheeks), it is also clearly observable to others. As blushing often occurs in situations where one would rather not increase the attention of others, blushing can be highly aversive and for anxious individuals it can become a source of shame and anxiety in its own right [18].  [20]. They demonstrated that social anxiety rather than expected or perceived blushing can increase facial blood flow during embarrassment. Therefore, reduction of anxiety should also lead to subsiding of the blushing.

Importance of this Study
In general, case studies are important because they help make something being discussed more realistic for teachers, school boards, and others. Case studies help people to see that what they have learned or read about a subject is not purely theoretical but instead can serve to create practical solutions to real dilemmas. With respect to interventions in schools, there is discussion about the use of existing programs because people sometimes reason that those problems are unlikely to be successful for a specific case or child [3]. The thought is that the child is an individual that in some aspects departs from the population of children for which the program was developed. Protocols and programs are seen as cookie-cutter approaches that in practice are unfit. With the current study, an example of a program put into practice for a specific child that departs from peers with test anxiety because of the extreme blushing, provides a clear example that CBT can be followed effectively and can meet specific individual needs.

Case Representation
Tim was a nine year old boy from a two-parent family of average social economic status. He lived with his parents and younger brother near his school in a small town in the Netherlands. Tim had entered school at age 4, which is common in the Netherlands where kindergarten and primary school are integrated.

Referral Information
The fourth grade teacher referred Tim to the care coordinator (CC) of the school because she noticed that he displayed clear signs of distress (frequent, visible blushing and expressions of worry) and that his learning progress was unexpectedly low. The CC discussed the referral with Tim's parents who confirmed that Tim seemed to be bothered a lot by fear of failure and associated distress. The parents agreed for Tim to be seen by the school psychologist (i.e., author of the paper). In order to remain objectively, all assessments and observations were discussed with a second person, a social worker, who also co-observed the second last session of the therapy.

Assessment
Tim and his parents were interviewed separately from each other using a semi-structured interview. Tim explained that he was very nervous at school before and during tests, and when speaking in front of the class or several classmates. His major concern was that he blushed frequently. According to Tim: "It happens all the time and I get really embarrassed". Tim said that he would like to show more initiative in certain situations, such as playing a game, but that his shyness and nervousness withheld him from doing so. With concern to his school work, Tim often felt unable to concentrate and had many worries ("I think I will fail", "I feel uncertain about the task", "I think I might not be smart enough").
Tim's parents showed great involvement and his mother recognized some of the anxiety symptoms from her own youth. expressive skills and self-confidence in examinations.
The SAQ is a psychometrically sound and well-accepted diagnostic tool in the Dutch educational system. Each of the SAQ items consisted of a proposition, and the participant is asked to judge if the proposition is applicable to himself or herself on a short Likert-type response scale that has three options: that is the case, I don't know, and that is not the case. Construct validity and reliability of these scales are good [21]. In comparison to the norm scores, Tim showed confidence well below the average (stanine 3) on the selfconfidence in examinations scale (an example of an item is: During a school test I am usually calm and able to work with concentration) and extremely low (stanine 1) on the expression scale (an example of an item is: I get shy when everyone in the classroom suddenly looks at me).

Treatment Plan
In this study, a Dutch program was used

Session 2
The children had to introduce themselves with a collage that they had made as a homework assignment.
Tim was clearly nervous when doing so, but the positive responses of the other children seemed to reassure him.
The breathing exercise went really well. The exposure exercise was more difficult. Tim choose to present himself, and used two sentences. He was blushing.
Afterwards a game with different types of moving (e.g., running, jumping) was played. Tim anxiously observed the behavior of the others, but during the game did become a bit more brave in his behavioral expression.
He complimented himself on doing all the exercises.

Session 3
Tim had successfully worked with the homework assignment (repeating the relaxation exercised). The He had to smile when one of the others told him that he did, but that it was cute.

Session 7
The children learned that it is OK to make mistakes. Tim had also heard this message before by his parents and teacher and was very willing to share experiences with the other children. In the game children had to move objects in a circle without using their hands. The exposure went really well. Tim took several minutes. During the relaxation exercise, Tim was laughing with one of the girls. Tim had not blushed during this session. He complimented himself for helping others.

Session 8
The topic was finding solutions for problems.
Tim participated well. In the game the children worked together in two teams getting across the room in different ways and Tim showed some initiative, that he later complimented himself on. The exposure exercise went as well as the previous session. Tim felt sorry that it was the last session. Tim had not blushed.

End of Program
After the eight sessions, the parents were given information about Tim's progress. They also received advice on how to help Tim with relaxation and changing negative thoughts into helpful thoughts. In the booster session, the children received a reminder of all the techniques that they had learned. Tim enjoyed this session and made a relaxed impression.

Observations
Observations during the sessions revealed decreases in Tim's anxiety and blushing. The parents were interviewed after the eight sessions and they felt that there was a significant decrease in Tim's fear of failure. They still agreed that it would be best for Tim to repeat the fourth grade and had more faith that he would make progression now.

Interview with Tim
On

Interview with the Teacher
For the long term evaluation of Tim's success, Tim's sixth grade teacher was interviewed three years later. This is the last grade of primary school in the Netherlands. Tim's teacher said that she knew Tim as a very gentle and kind boy. He did not seem anxious and there were no signs of test anxiety or social inhibition.
According to the teacher: "Tim can sometimes feel a bit shy in new, social situations, but then he is able to discuss this." The teacher did not notice any blushing in Tim anymore.

School advice
For the final outcome, Tim's academic success, we looked at his performance on the official national test that children take in the sixth and that is used to inform the parents and the school about the child's appropriate high school level (in combination with the impression that the school has formed). On this test, Tim received advice to go to senior general secondary education (HAVO) , which qualifies students to enter higher professional education (HBO).

Discussion
In this study, it was investigated what the effects of a small group CBT were for a case of test anxiety with extreme blushing. The current paper described the improvements of Tim during a program that was given in weekly sessions. Multiple informants and methods provided information that supported that the program was sufficient for both the anxiety as well as the blushing. The positive effect on the school achievement was also supported. The findings therefore confirmed our hypotheses.
With respect to the blushing, it was found that no adjustments to the program needed to be made. The blushing was, however, given attention to in response to initiatives of Tim to share his feelings on this topic.
Within the small group CBT there it was possible for all children to share their thoughts and feelings and specific concerns. This may be a factor that is essential to meet the specific needs of all children in a group based program. For this purpose, it seems essential to create a therapeutic environment that feels safe and secure [23].
The relationship with the psychologist [24], but also feelings of safety and friendship between the children should be fostered as these aspects are an important precondition for emotional disclosure in school-aged children [25]. In conclusion, this case study is an illustrative example of how small group CBT can be applied in the school setting. The gap between research and practice needs to be narrowed because the school setting can have a great impact on a child and is also an important setting where children present mental health problems.
The current problem of test anxiety is a clear example of this. The success of the intervention supports the possibilities of schools in fostering a healthy socioemotional development in children.