Group Cognitive Behavioral Therapy in Schools

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Running head: GROUP CBT IN SCHOOLS 1
Group Cognitive Behavioral Therapy in Schools
Jenna Paternostro
Paul J. Sullivan
Simone Behar
Maxwell Berlyant
Robert D. Friedberg1
Center for the Study and Treatment of Anxious Youth at Palo Alto University
1 Corresponding Author: Robert Friedberg, Ph.D. 5150 El Camino Real C-22, Los Altos,
CA 94022 Phone: 650-961-7503 Ext 17, Fax: 650-961-9310 rfriedberg@paloaltou.edu

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Introduction
Providing mental health services in schools is a promising initiative. (Herzig-Anderson,
Colognori, Fox, Stewart, & Masia-Warner, 2012). These programs address frequent barriers that
are often seen in usual care settings including high costs of services, waitlists, and transportation
requirements (Herzig-Anderson et al., 2012). Recently, research and development of school-
based group Cognitive Behavioral Therapy (CBT) skyrocketed (Daunic, Smith, Brank, &
Penfield, 2006). In addition, many school-based programs appear highly successful in reducing
anxiety, depression, and disruptive behaviors in children (Daunic et al., 2006). However, further
research is needed to identify the long-term effects of the school-based programming (Weist et
al., 2014).
In the following sections, school based programming is explored along with specific CBT
group programs that are currently being implemented. Next, indications and recommendations
are suggested for successful application of interventions. Additionally, transdiagnostic modular
CBT is reviewed and applied to group CBT in school-based settings. To conclude, clinical
applications are discussed.
School Based CBT Groups
School-based mental health services account for 70% of the mental health services
youth obtain (Herzig-Anderson et al., 2012). CBT spectrum approaches possess a long-standing
tradition of empirical support with youth. Within this section, current challenges in
dissemination and implementation of interventions in school-based settings are reviewed, and the
advantages of using group CBT-based programs in school are discussed.
CBT treatments for youth are broken into common “modules” that are individualized to
target transdiagnostic presenting problems (Friedberg, Gorman, Witt, Biuckians, & Murray,

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2011; Weisz & Chorpita, 2012). Modularized evidence-based practices are congruent with the
goals set forth of implementing effective care in school settings (Weist et al., 2014).
Modularized techniques, rooted in CBT, for children with internalizing and externalizing issues
in school settings have shown promising results. Modular CBT allows for flexible
implementation in school settings (Weist et al., 2014). These programs aptly respond to the
institutional difficulties school settings pose by utilizing innovative techniques to reach a greater
number of children.
Unique challenges of implementing school-based mental health programs include briefer
sessions due to class schedules, managing treatment around school vacations, and coordination
with school personnel (Weist et al., 2014). Ruffolo and Fischer (2009) examined these
complications when they instituted a CBT group program for depressed adolescent students in
middle and alternative high school settings. Group interventions are often the preferred modality
in school-based settings since a higher number of students can receive access to mental health
services (Ruffolo & Fischer, 2009). Their groups consisted of 45-minute sessions utilizing 9
CBT modules including: psychoeducation, self-monitoring, pleasant activity scheduling, and
cognitive restructuring. Involvement in the CBT group led to decreased depressive
symptomology, improved classroom attendance, and increased class participation. These results
showcase that CBT groups are flexible to the demands of the school day, while producing
positive results for the students involved.
School-based group CBT protocols are used with externalizing behaviors as well. In an
intervention targeting at-risk 4th and 5th grade students for disruptive and/or aggressive behavior,
Daunic and colleagues (2006) created the Tools for Getting Along (TFGA): Teaching Students to
Problem Solve program. TFGA is 20-lesson classroom-based intervention in which teachers are

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trained in the protocol to educate students about social and problem-solving skills. Students who
received TFGA increased their ability to engage in problem solving skills. These improvements
generalized to the classroom, as teachers rated these children having improved their management
of their expressions of anger (Daunic et al., 2006). Additional benefits of TFGA included
bolstering the executive functioning of students marked by inhibiting impulse behaviors, shifts in
thinking patterns, and monitoring behaviors (Daunic et al., 2012). Daunic and colleagues (2006,
2012) suggest the universal intervention TFGA assists at-risk students in learning social problem
solving skills and preventing costly referrals for children in need of services.
A common shortcoming of school-based CBT groups is the overreliance on costly,
specialized mental health clinicians to deliver school-based interventions (Herzig-Anderson et
al., 2012). Schools must be able to implement a cost effective protocol by training school
personnel to properly conduct CBT groups. However, empirical evidence is emerging that
shows trained school personnel can effectively implement school-based CBT groups (Kavanagh
et al., 2009). Barrett, Lawry-Webster, & Turner (2000) compared the outcomes of students who
received the FRIENDS program from psychologists and trained teachers. Results suggest that
both were equally successful in conducting the program. Studies examining the long-term the
effectiveness of universal programs led by school and professional personnel are underway.
Increasing the competency of school personnel in delivering sound mental health services in
schools is a crucial step in the sustainability of these programs.
In order to achieve successful implementation and dissemination of school-based CBT
services, school personnel will require training and consultation. Stronger training is a priority to
ensure high-quality evidence-based practice in schools (Weist et al., 2014). Masia-Warner and
colleagues (2013) assessed the competency and adherence of six school counselors to conduct a

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modular school-based group of an evidence-based social anxiety treatment. School counselors
received rigorous training as well as 12 weekly, 40-minute in-person consultations from post-
doctoral fellows. During the program, school counselors had difficulty with the more nuanced
aspects of CBT, such as cognitive reappraisal. However, according to the consultants’ ratings of
the school counselors, over half were deemed highly competent in delivering services. As the
program progressed, counselors reported becoming more comfortable with the skills taught,
which increased their fidelity to the protocol. Despite that hurdles that may exist currently,
sustainability and widespread dissemination of CBT group programs in school settings is an
achievable reality.
Specific CBT School Based Programming
Numerous CBT school-based programs are empirically supported. A brief overview of
program models as well as research determining their effectiveness is discussed. Group CBT
school-based programs that are reviewed include; Cool Kids Program, Skills for Academic and
Social Success, The Feelings Club, FRIENDS Program, and the Resourceful Adolescent
Program.
Cool Kids Program. The Cool Kids Program initially targeted anxious children and their
parents. Adaptations for community agency and school settings, adding sessions on coping with
bullying and social skills training, allow for greater ecological validity (Herzig-Anderson et al.,
2012). Cool Kids is comprised of eight group sessions for 8-10 children and two parent
information sessions. Modules covered in the program include psychoeducation, cognitive
restructuring, graduated exposure, assertiveness training, coping with bullies, and social skills.
School children ages 8 to 11 years old showed a significant decrease in symptoms of anxiety
upon program completion and at four-month follow up.

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Skills for Academic and Social Success. Skills for Academic and Social Success (SASS)
is a school-based program adapted from Social Effectiveness Therapy for Children (Fisher,
Masia-Warner, & Klein, 2004). Children attended twelve weekly group sessions, which are
bolstered by two individual sessions, two parent sessions, four social events, and two booster
sessions. SASS specifically targeted adolescents with social anxiety disorders and emphasized
in vivo exposure to social situations. Prosocial peers engaged in the program to provide age-
appropriate modeling and support during social events (Fisher et al., 2004). Over half of the
adolescents who participated in studies of SASS no longer met criteria for social anxiety disorder
after treatment (Masia-Warner, Fisher, Shrout, Rathor, & Klein, 2007). In sum, SASS is a
successful treatment for anxiety and is unique in its integration of socially adaptive peers and
group exposures.
The Feelings Club. The Feelings Club treated childhood anxiety by focusing on negative
feelings and maladaptive thoughts (Manassis, Wliansky-Traynow, Farzan, Kleiman, Parker, &
Sanford, 2010). Elementary school-aged children in The Feelings Club displayed consistent
improvement across age, gender, and ethnicity. Children in both the structured activity control
group and the Feelings Club program self-reported decreased levels of anxious and depressive
symptoms. However, at a one-year follow up, children in the program met fewer diagnostic
criteria for an anxiety disorder. Manassis and colleagues (2010) concluded that The Feelings
Club is a successful preventive program for children at risk for anxiety disorders.
FRIENDS. In a study of the FRIENDS program (Stallard, Simpson, Anderson, Hibbert,
& Osborn, 2007), children 9-10 years old exhibited improvements in overall anxiety, self-
esteem, separation anxiety, and obsessive-compulsive symptoms. Children who scored as
clinically anxious or as having very low self-esteem showed the most significant change.

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However, participants who did not demonstrate clinical levels of anxiety also improved. This
suggests that FRIENDS is successful as both a treatment and a preventative measure for anxiety
in school children. In contrast to studies of child treatment, the FRIENDS program was
delivered by trained school nurses instead of Ph.D. level therapists. Therefore, non-specialists
can provide effective care in school-based settings using the FRIENDS model.
Resourceful Adolescent Program. The Resourceful Adolescent Program (RAP; Rose,
Hawes, & Hunt, 2014) is a universal school-based protocol for prevention of depression in
adolescents. Participant retention rates are extremely high because the intervention is delivered
in the classroom. The program is manualized and includes student workbooks, which facilitates
group leadership by non-specialist providers. RAP can be administered to adolescents, parents,
and teachers either independently or in any combination of the three. Parents and teachers are
taught how to model and encourage open communication, conflict prevention, and promoting
connectedness. Adolescents learn coping skills to help all youth prevent the onset of depression.
Over eleven weeks, groups of about 15 students participated in discussions on how to build self-
esteem, emotionally regulate, restructure negative thoughts, problem solve, understand multiple
perspectives and seek help. Students who were interviewed after receiving RAP report that they
noticed improved interpersonal relationships, better self-regulation, and more helpful cognitions
(Shochet, Montague, Smith, & Dadds, 2014).
Research on school-based group CBT programs currently dominates the CBT with
school-aged children literature. The increased number of programs being developed paved the
next step in disseminating successful programs to schools in hopes of gathering a greater
understanding of the need and feasibility of implementation.
Indications and Recommendations

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This section distills the latest research on school-based CBT groups for children and
adolescents into key indications and recommendations for using CBT in a school context.
Implications regarding the use of such programs to reduce mental health symptomology, as well
as delivery and training of CBT group interventions are addressed. Moreover, specific gaps in
the literature are identified and future directions for CBT groups for child and adolescent
populations are discussed.
The current literature supports the utilization of school-based CBT groups to decrease
anxiety and depressive symptoms, as well as mitigate elevations in aggressive behaviors in
children and adolescents (Kavanagh et al., 2009). Nonetheless, there is still a dearth of evidence
regarding long-term evaluation of treatment gains for school-based CBT programs (Stallard et
al., 2007). More long-term research is needed to investigate the maintenance of treatment gains,
as well as the efficacy of booster sessions in a CBT school-based group setting (Kavanaugh et
al., 2009).
A majority of studies relied on demonstrating that school-based CBT groups reduce
symptomology (Gillham et al., 2012). Additionally, the symptom improvements identified in
CBT group programs are potentially accounted for by the passage of time (Stallard et al., 2007).
It is paramount for future studies to employ more robust experimental designs, which include a
non-intervention control group, as well as randomized group assignment (Stallard et al., 2007).
Another aspect that requires further assessment is the investigation of global academic
and social benefits precipitated by school-based CBT programs (Stallard et al., 2007). In
addition to the specific symptom reduction effects demonstrated, such programs boost children
and adolescent’s social and academic performance (Stallard et al., 2007). However, fewer
school-based CBT group interventions examined their impact using metrics that school

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performance hinges upon such as grades, test scores, school attendance, and participation in class
(Kavanagh et al., 2009; Ruffolo & Fischer, 2009). Without research measuring these potentially
global effects, studies only speculate as to the impact on comprehensive social and academic
functioning. Increasing the universal functioning of the students, over and above symptom
reduction, needs to be the goal of all School-Based Health Centers.
A variety of programs demonstrated that school and professional personnel are
adequately trained in the administration of manualized group CBT programs in school settings,
which produce clinically meaningful results with respect to symptom reduction (Kavanaugh et
al. 2009; Stallard et al. 2007). The literature suggests that future programs may effectively
utilize their existing recourses (i.e. teachers, nurses, other faculty members) to implement group
interventions (Kavanaugh et al. 2009; Stallard et al. 2007). For example, appointing a single
CBT specialist in charge of educating faculty on CBT framework and group treatment protocol
will allow institutions to further budget finances. School-based group CBT programs are already
limited by the scarce amount of financial recourses available, and hiring in-house faculty to
administer treatment mitigates some of the expenses incurred (Ruffolo & Fischer, 2009).
Moreover, the CBT specialist can oversee faculty adherence to the treatment manual through
regular fidelity checks, which are done over the course of training (Ruffolo & Fischer, 2009).
Overall, the group model is well tailored for a scholastic setting, allowing for greater access to
student mental health services, coupled by facilitating the destigmatization of mental healthcare
in schools (Ruffolo & Fischer, 2009).
Transdiagnostic Modular CBT
Transdiagnostic approaches revolutionize Cognitive Behavioral Therapy (CBT) treatment
for youth by devising treatments that address multiple problems within a single protocol.

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Patients that seek psychological services in everyday clinical practices present with pervasive
comorbid diagnoses that do not align well with single-disorder manuals (Weersing, Rozenman,
Mather-Bridge, & Campo, 2012). Recently, increasing empirical support suggests that
transdiagnostic approaches are effective in treating youth with a variety of disorders (Ehrenreich,
Goldstein, Wright, & Barlow, 2009; Santucci & Ehrenreich-May, 2012; Weisz et al., 2012).
When implementing disorder-specific manuals, it is often encouraged that the clinician uses their
clinical judgment to identify the individual’s needs in order to adapt treatment.
However, the current literature fails to provide operative guidelines for clinicians to help
determine flexibility within constraints of the manual. In usual care settings, where single-
disorder manuals are commonly misused without proper flexibility and supervision, the
effectiveness of evidenced-based interventions is significantly truncated (Chorpita, Bernstein, &
Daleiden, 2011).
Implementation of the CBT modules requires the clinician to identify transdiagnostic
factors that the individual is experiencing to guide the flow of treatment. Recent studies also
report transdiagnostic modular CBT as effective and efficient in treating children in individual
and group settings (Ehrenreich et al., 2009; Ehrenreich-May & Bilek, 2012; Weisz et al., 2012).
Modular Cognitive Behavioral Therapy (CBT) utilizes five core modules which targets
specific mechanisms that allow for individualization of treatment planning. The standard CBT
modular protocol for youth includes: psychoeducation, self-monitoring, basic behavioral tasks,
cognitive restructuring, and experiments/exposures (Friedberg & Brelsford, 2011; Friedberg,
McClure, & Garcia, 2009).
Learning theory postulates that as new experiences are practiced, the patient learns
different ways of reacting with behaviors and emotions. Basic behavioral tasks use learning

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theory to build upon the patient’s dispositional coping skills by applying action-based techniques
to create new learning (Friedberg & Brelsford, 2011; Friedberg et al., 2009). Cognitive
restructuring addresses inaccurate and distressing thoughts frequently present with childhood
psychological disorders. Cognitive restructuring techniques aim to reduce the child’s negative
beliefs and shift cognitions into more adaptive interpretations of events.
In the final, but requisite module, experiments and exposures, the patient faces the
emotionally evocative experiences they heretofore avoided in events that cause heightened
physiological arousal. Exposures and experiments are not limited to anxiety disorders but
address experiential avoidance across a multitude of disorders. Exposures should speak to the
patient’s cognitive, behavioral, physiological, interpersonal and emotional reactions. This
process begins with the patient and clinician collaboratively creating a hierarchy of avoided
activities that cause the patient distress. Once the hierarchy is created, the patient gradually
completes the tasks to develop greater performance attainment and mastery of experience
(Friedberg et al., 2011).
Transdiagnostic modular CBT answers many critical concerns present with single-
disorder manuals. The core modules are interchangeable making it an ideal process for
individualizing treatment for youth who display a of host mental health symptoms. Further, the
dissemination of modular CBT protocols to school-based settings are effective and transferable
to group therapy programs.
Clinical Applications
In this section, we move from research and theory to clinical applications. Processes and
procedures for the desk-side practice of CBT in schools are elaborated. More specifically, the
importance of maintaining the prototypical session structure while conducting group CBT is

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emphasized. Specific examples of modular CBT methods are explained and illustrated. Finally,
the section concludes with unique considerations for school-based CBT groups.
Session structure
The prototypical cognitive therapy session structure remains intact when doing group
CBT with children (Friedberg & Brelsford, 2011; Friedberg & McClure, In press). Accordingly,
group sessions begin with a mood check in, homework review, and agenda setting. After the
agenda is established, session processing ensues followed by homework assignment and
feedback. Session processing is guided by a modular format.
Application of Modules
The psychoeducational and self-monitoring modules for school based group CBT set the
stage for higher intensity interventions. A variety of psychoeducational materials and techniques
may be employed to orient children to treatment. There are a number of excellent resources that
are translated into multiple languages (Friedberg et al., 2009; Friedberg et al., 2011). In
particular, the NewYork University Child Study website offer many downloadable materials
which are available in multiple languages (www.aboutourkids.org).
We will describe two favorite psychoeducational techniques for use in school based
group CBT. Visual illusions are used as psychoeducational stimuli in the innovative Unified
Protocol for Youth (UP-Y) (Ehrenreich-May and Bilek, 2012; Ehrenreich et al., 2009). Studies
of visual perception in experimental psychology are replete with examples of stimuli which
generally involve reversals of figure and ground (Atkinson, Atkinson, Smith, and Bem, 1990). A
classic illustration is the Young Girl/Old Woman image (Boring, 1930). The illusion is
presented to the children and they are asked to write down what they see. After they share their
individual perceptions, therapists unpack the process. Therapists ask group members where they

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directed their attention and they explain that what they saw was based on the focus of their
attention. Subsequently, the group leaders teach the children that this is exactly the lesson of
cognitive behavioral therapy and they will learn to center their attention on the most accurate
sources of data.
The Volcano is a psychoeducational craft exercise that explains the way inhibiting and
exploding emotions work (Friedberg et al., 2009). The procedure is based on the classic
elementary school science project. Therapists can either purchase a science kit or simply use a
plastic cone, baking soda, and vinegar. The children and their therapists build their volcano by
pouring the baking soda into the cone. Therapists then explain that the baking soda represents
their thoughts and feelings and the vinegar is the stress associated with avoiding emotional
expression. When the stressor (e.g. vinegar) is added, the feelings simmer, bubble, and
overflow.
Symptom tracking or target monitoring is essential for initiated self-directed change and
evaluating treatment outcome. There are a variety of measures that are suitable for symptoms
tracking including the Children’s Depression Inventory-2 (Kovacs, 2011), Screen for Child
Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1997), Multidimensional
Anxiety Scale for Children-2 (MASC-2; March, 2013), SNAP-IV (Swanson, Sandman, Deutsch,
& Baren, 1983), and the Strengths and Difficulties Questionnaire (Goodman, 1999). Completing
Thought Diaries are also fundamental self-monitoring procedures. Many child friendly thought
records such as Catching Your Thoughts and Feelings (Friedberg, Friedberg, & Friedberg, 2001),
“What’s Buggin’ You” and “Your Brain Storm” (Friedberg et al., 2009) are quite suitable to
school-based CBT groups.

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Peterman, Read, Wei, and Kendall (In press) discussed several engaging and creative
ways to construct SUDS hierarchies. For instance, for a child who has difficulty scaling
distressing feelings on a 1-5 scale, a DisneyTM Princess/Villain scale might be constructed. More
specifically, one young girl scaled her emotions with Belle (1), Jasmine (2), Arielle (3), Cruella
de Ville (4), and Ursula the Sea Witch (5) representing points on her distress continuum.
Early group CBT interventions tend to focus on behavioral tasks. Social skills training is
a staple in school based groups. It is essential that the social skill training is done experientially.
Hands-on teaching is preferable to more abstract procedures. Bierman (2004) offered a number
of very creative social skills exercises that enable in vivo practice. For instance, she
recommended the group build a trail mix together. Each child is given an ingredient (e.g raisins,
chocolate pieces, nuts, granola, etc). However, each member must make a mix containing every
piece. Of course, therapists should check with children and parents regarding any potential food
allergies. They must share their individual item and appropriately ask a peer for their ingredient.
Group therapists process the way the children share and request the pieces.
A favorite cognitive restructuring procedure in school-based group therapy is Changing
Your Tune (Friedberg et al., 2001). Changing Your Tune is founded on the metaphor of song
lyrics that get stuck in one’s head. The lyrics are like automatic thoughts that keeping running
through children’s heads. The procedure begins with the therapist selecting a popular song with
repetitive lyrics. The children are instructed to listen to the song and raise their hand as soon as
they identify the repetitive lyric. Next, they listen to the song again and sing along with the
repetitive lyric. Therapists then ask the group what was required in order to successfully
complete the task (e.g. paying attention, looking for repetitive words). Therapists then explain

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the similarities between paying attention to repetitive meaningful thoughts and the song lyrics
they just heard.
The next phase of the procedure gives children practice in changing tunes. In the practice
phase, children are supplied with some negative automatic thoughts and they are invited to try to
change them. Finally, after the children are successful with their practice, they are challenged to
record their own “tunes” on the worksheet and try to change them.
Another cognitive restructuring technique was inspired by Child Recycling Therapy
(Caminha & Caminha, 2012). This procedure involves writing children’s inaccurate appraisals
on Silly PuttyTM. The thought is written on the Silly Putty with a water-based marker and then the
child is invited to pull the corners of the Silly Putty. This action literally encourages children to
“stretch” their thinking. Additionally, the more they stretch their thinking, the more their
distorted thinking loses clarity.
Thought Digger (Friedberg et al., 2001) is a more advanced rational analysis procedure
useful in school based CBT groups. Thought Digger teaches children to ask themselves Socratic
Questions. The exercise is presented in two phases. In part one, 11 sample questions (e.g. “what
good things about myself am I ignoring?”, “Am I confusing maybe with for sure?”, etc.) are
taught to the group members. In part two, children select a thought digger question to apply to
their distressing thoughts. Finally, in phase three, children construct a new conclusion based on
the thought digger questions.
The power of experiential learning cannot be overstated (Peterman et al., in press).
Accordingly, school based groups should include a strong experiment and exposure component.
Experiments and exposures are individually tailored to each group member’s presenting
problem.

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For instance, Ella was a 9 year old who was diagnosed with social anxiety disorder. Not
surprisingly, reading aloud in class was excruciating for her. After she acquired a number of
behavioral and cognitive coping skills, she was ready for exposure. The group was the ideal
setting for behavioral practice and several graduated exposures were crafted. In the initial stages,
Ella was invited to read in front of the group and the members gave her relatively positive
feedback. In later trials, group members were coached to give her negative feedback so Ella
gained practice dealing with her fears of negative evaluation.
Maurice presented with different problems. Maurice suffered from poor impulse control,
low frustration tolerance and difficulties managing his anger. Common triggers for him was not
winning at games and waiting for his turn. Accordingly, after Maurice navigated the preceding
modules, experiments were designed to test his ability to apply coping skills. For example, a
group game was played and Maurice was selected last for his turn. He was coached to manage
his rising anger level by applying his coping skills when he was “boiling hot” with mad feelings.
Considerations for Group Use
Friedberg and Crosby (2001) outlined some basic considerations for school based group
CBT. First, attention needs to be directed to group composition. In general, homogenous (e.g.
similar age, diagnoses) groups are preferable. However, real world complexities often
necessitate heterogeneous groups. Not surprisingly, more sophisticated group therapy skills are
required when conducting heterogeneous groups.
A second rudimentary issue is whether the group is on-going or time-limited. In time-
limited groups, there is a pre-determined number and sequence of interventions. An on-going
group does not limit the number of sessions. Time-limited groups have closed enrollments
meaning that all children enter and leave at the same time. No new members are added after the

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first group. Therefore, the group composition remains the same over the course of the group. In
open ended groups, new members are regularly added and accordingly the group composition
varies considerably over the course of treatment.
A third elementary consideration is setting and enforcing limits in group sessions. Clear
limit setting decreases children’s anxiety as well as increasing therapist credibility and
trustworthiness. A good strategy is to collaboratively develop group rules with the members and
post them in the room so children can readily see them. Once these rules are established, it is
incumbent on leaders to enforce them.
Friedberg et al. (2009) stated that CBT becomes more complicated when there is more
than one person other than the therapist in the room. In group therapy, clinicians need to divide
their attention between members. They must not only notice the child who is talking but also
those individuals who are responding. Since disclosure is public and occurs in a social context,
group members’ cognition, emotional, and behavioral expressions impact all those in the room.
Clinicians planning to conduct CBT groups in schools need to mindfully consider length
of group session time as well as when the group is scheduled during the day. Shorter groups are
more likely to be welcomed more by school personnel than longer sessions. Clinicians must
remember that when time is allocated to group CBT, it subtracts from academic classroom time.
Therefore, we recommend shorter, focused groups that can be delivered in a thirty minute time
period. Clinicians will also need to collaborate with school personnel on group scheduling. The
CBT groups should be located somewhere in the school day that does not interfere with
sequencing of academic topics or classes.
Clinicians are also well-advised to work with school districts to find proper space for
group work. Most schools are cramped for space and offer limited additional rooms for groups.

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It is important to find a room that afford privacy and produces a comfortable atmosphere
Conclusion
With current findings suggesting profound ineffectiveness of treatment in usual care
settings, shifting attention to providing services in schools is crucial (Garland et al., 2013).
School-based programs account for the significant barriers that often challenge community
mental health clinics. In addition, group programs increase access to resources and reach a
greater number of children when delivered in schools.
The proliferation of group based CBT programs in academic settings dominate recent
literature. Modularized CBT approaches allow for flexibility while maintaining effectiveness
and loyalty to treatment protocols. This ability for individualization permits programs to address
a multitude of mental health disorders in youth, including externalizing and internalizing
problems. Furthermore, several innovative group CBT programs are empirically supported and
well-equipped to meet the challenges of providing mental health services to children in schools.
Although there are exciting advances in group CBT for school-based programs, more
robust research is needed. Long-term treatment gains, effectiveness of school personnel
administering protocols, and academic benefits will ensure greater effective care for children in
school-based settings.

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References
Atkinson, R.L., Atkinson, R.C., Smith, E.E., & Bem, D.J. (1990). Introduction to psychology
(10th ed.). San Diego, CA: Harcourt, Brace, and Janovitch,
Barrett, P. M., Lowry-Webster, H., & Turner, C. (2000). FRIENDS program for children: Group
leaders manual. Brisbane: Australian Academic Press.
Bierman, K.L. (2004). Peer rejection: Developmental processes and intervention strategies. New
York: Guilford.
Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & Neer, S. M. (1997)
Screen for child anxiety related emotional disorders (SCARED): Scale construction and
psychometric characteristics. Journal American Academy of Child and Adolescent
Psychiatry, 36(4), 545-553. doi:10.1097/00004583-199704000-00018
Boring, E. G. (1930). A new ambiguous figure. The American Journal Of Psychology, 42, 444-
445. doi:10.2307/1415447
Caminha, R.M., & Caminha M.G. (2012). Baralho dos pensamentos:reciclando ideias,
promovendo conscience. Sinosys:Porto Alegre, BZ
Chorpita, B. F., Bernstein, A., & Daleiden, E. L. (2011). Empirically guided coordination of
multiple evidence-based treatments: An illustration of relevance mapping in children's
mental health services. Journal Of Consulting And Clinical Psychology, 79(4), 470-480.
doi:10.1037/a0023982
Daunic, A. P., Smith, S. W., Brank, E. M., & Penfield, R. D. (2006). Classroom-based
cognitive–behavioral intervention to prevent aggression: Efficacy and social validity.
Journal Of School Psychology, 44(2), 123-139. doi:10.1016/j.jsp.2006.01.005
Daunic, A., Smith, S., Garvan, C., Barber, B., Becker, M., Peters, C., & ... Naranjo, A. (2012).

GROUP CBT IN SCHOOLS
20
Reducing developmental risk for emotional/behavioral problems: a randomized
controlled trial examining the Tools for Getting Along curriculum. Journal Of School
Psychology, 50(2), 149-166. doi:10.1016/j.jsp.2011.09.003
Ehrenreich-May, J. & Bilek, E. L. (2012). The development of a transdiagnostic, cognitive
behavioral group intervention for childhood anxiety disorders and co-occurring
depression symptoms. Cognitive and Behavioral Practice, 19, 41 – 55.
doi:10.1016/j.cbpra.2011.02.003
Ehrenreich, J. T., Goldstein, C. M., Wright, L. R., & Barlow, D. H. (2009). Development of a
unified protocol for the treatment of emotional disorders in youth. Child and Family
Behavioral Therapy, 31(1), 20-37. doi:10.1080/07317100802701228
Fisher, P. H., Masia-Warner, C., & Klein, R. G. (2004). Skills for social and academic success:
A school-based intervention for social anxiety disorder in adolescents. Clinical Child and
Family Psychology Review, 7(4), 241-249. doi: 10.1007/s10567-004-6088-7
Friedberg, R. D. & Brelsford, G. M. (2011). Using cognitive behavioral interventions to help
children cope with parental military deployments. Journal of Contemporary
Psychotherapy, 41, 229-236. doi:10.1007/s10879-011-9175-3
Friedberg R. D., & Crosby, L.E. (2001). Therapeutic exercises for children: Professional guide.
Sarasota, FL; Professional Resource Press.
Friedberg R. D., Friedberg B. A., & Friedberg R. J. (2001). Therapeutic exercises for children.
Sarasota, FL; Professional Resource Press.
Friedberg, R. D., Gorman, A. A., Witt, L. H., Biuckians, A., & Murray, M. (2011). Cognitive
behavioral therapy for the busy child psychologist and other mental health professionals.
New York, NY: Rutledge.

GROUP CBT IN SCHOOLS
21
Friedberg, R. D., & McClure, J. M. (In press). Clinical practice of cognitive therapy with
children and adolescents: The nuts and bolts (2nd ed.). New York: Guildford Press.
Friedberg, R. D., McClure, J. M., & Garcia, J. H. (2009). Cognitive therapy techniques for
children and adolescents: Tools for enhancing practice. New York, NY: The Guilford
Press.
Garland, A. F., Haine-Schlagel, R., Brookman-Frazee, L., Baker-Ericzen, M., Trask, E., &
Fawley-King, K. (2013). Improving community-based mental health care for children:
Translating knowledge into action. Administration and Policy in Mental Health, 40, 6-22.
doi:10.1007/s10488-012-0450-8
Gillham, J. E., Reivich, K. J., Brunwasser, S. M., Freres, D. R., Chajon, N. D., Kash-MacDonald,
V., & ... Seligman, M. P. (2012). Evaluation of a Group Cognitive-Behavioral Depression
Prevention Program for Young Adolescents: A Randomized Effectiveness Trial. Journal
Of Clinical Child & Adolescent Psychology, 41(5), 621-639.
doi:10.1080/15374416.2012.706517
Goodman, R. (1999). The extended version of the Strengths and Difficulties Questionnaire as a
guide to child psychiatric caseness and consequent burden. Journal Of Child Psychology
And Psychiatry, 40(5), 791-799. doi:10.1111/1469-7610.00494
Herzig-Anderson, K., Colognori, D., Fox, J. K., Stewart, C. E., & Masia-Warner, C. (2012).
School-based anxiety treatments for children and adolescents. Child and Adolescent
Psychiatry of North America, 21(3), 655-668. doi: 1-/1016/j.chc.2012.05.006
Kavanagh, J., Oliver, S., Lorenc, T., Caird, J., Tucker, H., Harden, A., & ... Oakley, A. (2009).
School-based cognitive-behavioural interventions: A systematic review of effects and
inequalities. Health Sociology Review, 18(1), 61-78. doi:10.5172/hesr.18.1.61

GROUP CBT IN SCHOOLS
22
Kovacs, M. (2011). Children’s Depression Inventory-2 Manual. New York, NY: Multi-Health
Systems.
Manassis, K., Wilansky-Traynow, P., Farzan, N., Kleiman, V., Parker, K., & Sanford, M. (2010).
The feelings club: Randomized controlled evaluation of school-based CBT for anxious or
depressive symptoms. Depression and Anxiety, 27, 945-952. doi: 10.1002/da.20724
March, J. S. (2013). Multidimensional anxiety scale for children-2. North Tonawanda, NY:
Multi-Health Systems.
Masia-Warner, C., Brice, C., Esseling, P., Stewart, C., Mufson, L., & Herzig, K. (2013).
Consultants' perceptions of school counselors' ability to implement an empirically-based
intervention for adolescent social anxiety disorder. Administration And Policy In Mental
Health, 40(6), 541-554. doi:10.1007/s10488-013-0498-0
Masia-Warner, C., Fisher, P. H., Shrout, P. E., Rathor, S. and Klein, R. G. (2007), Treating
adolescents with social anxiety disorder in school: an attention control trial. Journal of
Child Psychology and Psychiatry, 48(7), 676–686. doi: 10.1111/j.1469-
7610.2007.01737.x
Peterman, J. S., Read, K.L., Wei, C., & Kendall, P. C. (In press). The art of exposure: Putting
science into practice. Cognitive and Behavioral Practice.
Rose, K., Hawes, D. J., Hunt, C. J. (2014). Randomized controlled trial of a friendship skills
intervention on adolescent depressive symptoms. Journal of Consulting and Clinical
Psychology, 82(3), 510-520. doi: 10.1037/a0035827
Ruffolo, M. C., & Fischer, D. (2009). Using an evidence-based CBT group intervention model
for adolescents with depressive symptoms: lessons learned from a school-based
adaptation. Child & Family Social Work, 14(2), 189-197. doi:10.1111/j.1365-

GROUP CBT IN SCHOOLS
23
2206.2009.00623.x
Santucci, L. C. & Ehrenreich -May, J. (2012). A randomized controlled trial of the child anxiety
multi-day program (CAMP) for separation anxiety disorder. Child Psychiatry and Human
Development, 44(3), 439 – 451. doi:10.1007/s10578-012-0338-6
Shochet, I., Montague, R., Smith, C., & Dadds, M. (2014). A qualitative investigation of
adolescents’ perceived mechanisms of change from a universal school-based depression
prevention program. International Journal of Environmental Research and Public
Health, 11, 5541-5554. doi: 10.3390/ijerph110505541
Stallard, P., Simpson, N., Anderson, S., Hibbert, S., & Osborn, C. (2007). The FRIENDS
emotional health programme: Initial findings from a school‐based project. Child and
Adolescent Mental Health, 12(1), 32-37. doi:10.1111/j.1475-3588.2006.00421.x.
Swanson, J. M., Sandman, C. A., Deutsch, C. K., & Baren, M. (1983). Methylphenidate
hydrochloride given with or before breakfast: I Behavioral, cognitive, and
electrophysiologic effects. Pediatrics, 72, 49-55.
Weersing, V. R., Rozenman, M. S., Mather-Bridge, M., & Campo, J. V. (2012). Anxiety,
depression, and somatic distress: Developing a transdiagnostic internalizing toolbox for
pediatric practice. Cognitive and Behavioral Practice, 19, 68-82. doi:
10.1016/j.cbpra.2011.06.002
Weist, M. D., Youngstrom, E. A., Stephan, S., Lever, N., Fowler, J., Taylor, L., & ... Hoagwood,
K. (2014). Challenges and ideas from a research program on high-quality, evidence-based
practice in school mental health. Journal Of Clinical Child & Adolescent Psychology,
43(2), 244-255. doi:10.1080/15374416.2013.833097
Weisz, J. R., & Chorpita, B. F. (2012). 'Mod squad' for youth psychotherapy: Restructuring

GROUP CBT IN SCHOOLS
24
evidence-based treatment for clinical practice. In P. C. Kendall (Ed.), Child and
adolescent therapy: Cognitive-behavioral procedures (4th ed.) (pp. 379-397). New York,
NY US: Guilford Press.
Weisz, J. R., Chorpita, B., Palinkas, L., Schoenwald, S., Miranda, J., Bearman, S., & ... Gibbons,
R. (2012). Testing standard and modular designs for psychotherapy treating depression,
anxiety, and conduct problems in youth: a randomized effectiveness trial. Archives Of
General Psychiatry, 69(3), 274-282. doi:10.1001/archgenpsychiatry.2011.147