A Case Study of a School Child with Emotional and

Behavior Problems treated using Cognitive

Behavioral Therapy
Fatima Sana (  fatima.sana@umt.edu.pk )
School of Professional Psychology https://orcid.org/0000-0002-4873-384X
Sara Subhan

Research Article

Keywords: School Child, Behavioral, Problems, Cognitive, Distortions

Posted Date: September 6th, 2022

DOI: https://doi.org/10.21203/rs.3.rs-1970357/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License
 Abstract
Feeling is something that makes one’s thought patterns. If the feelings are like I am not
good enough, I am not perfect, and I am tired of feeling inadequate, then it’s time to think
why someone is treating oneself like substandard and finds a way to modify this
unconstructive thinking. And for modification of thinking, Cognitive Behavioural Therapy
(CBT) has been effectively used by revolving around A-B-A design model. The current
case study of N.P. 12 years old girl with unconstructive thought patterns (such as felt
inferior among class fellows and aggravated of sarcastic comments of class teacher).
Counselling therapy consisted of 8 sessions. Psychological Assessment revealed that
revealed that the academic performance of the child was moderate, severe emotional and
behavior problems as well as overall counselling and interventional plan revealed that
reduction in the intensity of emotional and behavioral symptoms throughout the course of
counselling therapy. This case study exhibits the effectiveness of CBT for individual
treatment of unconstructive thought patterns.
Keywords: School Child, Behavioral, Problems, Cognitive, Distortions.
Introduction
Adolescence stage is known as the process of continual development. Adolescents
face many difficulties and challenges during this continual development and growth period
(Saleem & Mahmood, 2011) that includes physical growth changes, parental prospects,
role identification, and social growth (Amoah et al., 2021; Block & Robins, 1993; Saleem
& Mahmood, 2011). New challenges, constantly changing emotional and social demands
may possibly put children and adolescents at severe risk of developing behavioral and
emotional problem (Caspi et al., 2000; López-Bueno et al., 2021). Usually, many of these
problems and difficulties have a tendency to diminish with time; however, some if not
handled appropriately, perhaps cause severe and serious physical, behavioral, emotional,
social, or academic problems that can later in life cause stress for children, families,
schools, and society (Gelfand & Drew, 2003; Hong et al., 2018).
Students experience many adjustments related problems, when they get admitted in
new school. Since many years, there are transformations in school’s rules and procedures,
teaching, performance expectations, and peers. Mainly, the change of school and adjusting
in a new school is always challenging and create problems, specifically when a student is
not good enough to adjust according to change. Essentially, students perhaps encountered
problems while adjusting based on three prime areas, such as academic, social interaction,
and emotional reaction to their original atmosphere (Gebhard, 2012). Furthermore,
students in new school possibly be experienced lack of social support, language barriers,
unfamiliar and inaccessible resources (Smith & Khawaja, 2011; Sullivan & Kashubeck-
West, 2015) that may often exhibit loneliness, isolation, and depression (Wei et al., 2007).
Adjustment in school factually has been raised in terms of children’s
accomplishment and progress (Birch & Ladd, 1996; Furrer & Skinner, 2003). This
consequence is crucial; however, being limiting it actually causes exploration for
antecedents and events in children’s environment that perhaps affect adjustment in new
environment. Emotional and behavioral problems often result into deferred school
progress, adjustment problems, school refusal, dropping out of schools, social
 2

incompetence, low self-esteem and self-confidence, lack of happiness, feelings of being

isolated, intrapersonal and interpersonal problems (Allison et al., 2019; Asher et al., 1984;
Bernstein & Garfinkel, 1986; Bos et al., 2010; Byrd et al., 1997; Boulton & Smith, 1994;
Chansky & Kendall, 1997; Egger et al., 2003; Hickin et al., 2021; Konu et al., 2002;
LaGreca et al., 1988; McClelland et al., 2020; Orvaschel et al., 1997; Parker et al., 2006;
Sadia & Mehmood, 2011; Yang & Zhang, 2018; Zima et al., 2000). Therefore, evidently it
is suggested that emotional and behavioral problems in school children may perhaps have
serious impacts. Further, early and timely identification of these problems, then proper
interventional steps may be helpful in handling of them. So, in the present case study,
Cognitive Behavioral Therapy has been found very effectual in managing the emotional
and behavioral problems such as aggressive reactions, adjustment in school, lack of self-
confidence, self-criticism, and social incompetence.
Case Report
The child N.P., 12 years old girl was the student of 6th grade. The child was referred
by her class teacher for the purpose of psychological assessment and management of
presenting problems as lack of concentration in studies, adjustment problems in school,
low and sad mood, least interest in school activities, and unfriendly attitude with class
fellows (specifically with class monitors). She tried to challenge the role and
responsibilities of class monitors and always ended up with fight. The child was
interviewed by a counselor and she reported that eight months back she was newly admitted
to this school. Everyone was new to her and she faced difficulty in adjusting to new
environment and interacting with peers. In her old school, she was the class monitor
because of her excellence in final exams. She used to share her every single query with
teachers like academic queries, home queries, etc. She had a lot of friends with whom she
spent time and play; also, her friends liked her as a class monitor for her unbiasedness. She
enjoyed reading Urdu story books and loved to help others. The child reported that her old
friends used to help each other in home work difficulty if they needed to. After eight
months, she admitted to new school after the completion of fifth class. In initial days at
new school, she tried to make friends and wanted to create a bond with teachers, but they
all found her annoying, did not accept her and using previous reasons to put her down. She
had no interest in extracurricular activities. According to child, whenever, she tried to share
her problems with teachers regarding incomplete homework, since her mother was ill and
she had to do all the home chores; however, her teacher did not believe her.
The student belonged to a middle socio-economic family, having 6 family members
consisting of 2 brothers and 2 sisters. Her one brother amongst siblings was married and
lived his own. The child was the second born in the family and elder among sisters. The
father of the child had grocery shop and had primary education. The mother of the child
was not educated, but she always supported her in decisions, and she had always been a
beloved daughter of her mother. Further, the child shared a strong bond with her father and
mother because she reported that they both understood and encouraged her regarding
teachers and class fellows’ behavior. The child reported weak bonding with siblings. She
wanted to be affectionate and caring towards her siblings, but the incidents at school made
her angry and vulnerable that’s why she found her siblings annoying and irritating all the
time.
 3

During history taking, the child seemed anxious, sad, and tensed and she was not
maintaining an eye contact; also, sat on the edge of the chair and continuously fidgeting
with her hands. Her tone of voice was of low pitch. She was tidy and wearing neat uniform.
Her head was covered with scarf. The child had no idea about her problems. During initial
sessions, the counselor introduced herself and explained the role of counselor to make her
comfortable and nervous-free.
Provisional Formulation
Based on initial history, it was concluded that the child’s inherited traits throughout
her early years of education made her brilliant in every aspect of life like excelling in exams
to be a class monitor and sharing every single query with her old teachers and friends,
because she considered them as her helping hands perhaps have predisposed the problem
in adjusting in new school. Subsequent, when the school changed, she experienced new
environment and found new people around her that perhaps have created hurdles for her to
share and express herself, the reason could be higher expectations and higher level of
education precipitated the problem. Further, no friends, no badge of class monitor on her
slash, and no understanding from teacher are perpetuating the problem. The close bond
with parents might serve as protective factor and no bonding with younger siblings because
of displacement of anger on them perhaps have created risks factors that maintained the
problem.
Assessment
For psychological assessment, Behavioral Observation (Ivey et al., 2014),
Counselling Interview (Nelson-Jones, 2005) with the teacher and child, Subjective Unit
Distress Scale (SUDS; Wolpe, 1969) for the presenting problems, Functional Behavioral
Assessment (FBA, Arndorfer & Miltenberger, 1993) to collect and analyze the function of
behavior, and School Children Problems Scale (SCPS, Saleem & Mehmood, 2011) to
assess the emotional and behavioral problems along with interventional plan was done with
the child.
Behavior Observation
The student was observed (Ivey et al., 2014) during counselling interview, in class room
and in play-ground. During classroom, it was observed that she was a regular student and
active during class lectures, but her class mates were not interactive with her.
Counselling Interview
The counselling interview (Nelson-Jones, 2005) with the teacher and child was focused on
the development of problems as well as eliciting the predisposing, precipitating and
maintaining factors of the problems. It was revealed that in child’s perspective, her
previous school was more significant and contented, because she had no friends in new
school and lack of communication with class teacher was perhaps made the child
aggressive and more anxiousness during school time.
Subjective Unit Distress Scale (SUDS, Wolpe, 1969)
A 0-10 point’s scale was used to identify the intensity of the targeted problematic behaviors
of the child. These ratings were sorted at pre and post levels to have an idea about
 4

improvement in child’s condition and to assess about the effectiveness of therapeutic

intervention.
Table 1
Subjective ratings of child’s problems
Problem Rating
Problems with teachers 10
Problems with class fellows 10
School adjustment problem 10
Anger 10
The subjective ratings of child’s problems she had been experiencing in school
depicted lack of cooperation from teachers and class fellows were causing problems for
her in adjusting in new school due to which she was experiencing anger related symptoms
at severe level.
Functional Behavioral Assessment (FBA, Arndorfer & Miltenberger, 1993)
The FBA process was yielded according to the core elements that based on function of
problem, including intensity, frequency, duration, and variability, assessment of
antecedents, including triggering factors i.e., conditioned and unconditioned, and
identification of consequences including reinforcing and punishing consequences.
Table 2
Components of Functional Behavioral Assessment of Child
Antecedents/Triggers Behaviors Consequences
Because I didn’t listen
Recess time Senior girls hit her.
them.
For my previous
Going to washroom Class monitors hit her.
misbehaviors.
Class monitor hit her while I had already given my
conducting oral test and oral test to teacher, so I
During oral test
complaint wrongly to would not give you oral
teacher. test.
I didn’t give her then she
hit me and in reply I also
Class monitor asked her to hit her. She hit me again
Absence of class teacher
give me your sticker then I went to teacher, but
teacher punished both of
us.
I said no then they hit me
Class monitors asked me to
and accused me, in reply
Before the assembly clean the mess around my
I also hit them, but never
side
accused.
These incidents made the child felt angry, irritated, and embarrassed that stimulated
the desire to express anger and resultantly she displaced her anger on younger siblings.
Therefore, this displacement of anger served as a stimulator for the child, because his class
 5

monitors had authority to hit her. Also, the attitude of teachers and monitors towards her
made other class fellows against her and they started treating her wrongly. In resultant, she
isolated herself and started displacing her anger on younger siblings. On average, the
child’s anger stayed for whole day with the intensity of 10. Whenever she had an encounter
with class monitors regarding any activity in the class, she felt irritable, embarrassed, and
angry.
School Children Problem Scale (SCPS, Saleem & Mahmood, 2011)
School Children Problem Scale (SCPS, Saleem & Mahmood, 2011) was used to
assess emotional and behavioral problems of child. The SCPS measured six different types
of emotional and behavioral problems namely Anxiousness, Academic Problems,
Aggression, Social Withdrawal, Rejection, and Somatic Problems.
The child was asked to self-report her intensity on various emotional and behavioral
dimensions that she might be facing while interacting with others. Read each item carefully
and rate the items to the extent in which you experience these difficulties while relating
with other people”. The scoring options included (0) never, (1) rarely, (2), sometimes, (3)
often, which was then scored according to six factors and a total score was also yielded and
interpreted in accordance with the already established norms of SCPS.
Table 3
Obtained score, Range of SCPS, and Categories of the Child
Factor Obtained Score M(SD) Category
F1: Anxiousness 22 13.48(7.28) Severe
F2: Academic Problems 7 7.11(4.42) Moderate
F3: Aggression 11 7.05(4.35) Moderate
F4: Social Withdrawal 14 14 8.51(3.94) Severe
F5: Rejection 11 3.30(3.25) Very Severe
F6: Somatic Problems 8 4.03(2.54) Severe
Ft: Factor Total 73 42.45(19.17) Very Severe
The results on SCPS revealed that the child might feel pressure in school that might
bring out some of the emotional and behavioral problems like new school, new
environment, and new people that perhaps led to anxiousness and aggressive symptoms
like the incidents in school with class monitors, misbehavior of class mates, and disbelief
attitude from teacher made the child socially rejected and isolated. Probably, the reason of
severity on factors namely social withdrawal, rejection, and somatic problems might be
because she wanted to make friends and wanted appreciation from her class teacher. She
also perhaps tried to communicate in order to make friends, but unacceptable attitude made
all intolerable for the child.
Overall psychological assessment revealed that child had anger outbursts and
anxiousness that perhaps subsequently caused problems related to somatic, intrapersonal
and interpersonal problems.
Therapeutic Intervention
 6

The therapeutic intervention was done using eclectic approach. Rapport Building
(Jone, 2005) was done in order to better formulate the child’s problem and to increase the
adherence in therapy. As child seemed apprehensive during initial sessions and had
difficulty in opening up, so in order to make a comfortable connection and to provide some
secure base; general questions were discussed. Supportive therapy (Miltenberger, 1997;
O'Donohue, 2009) was done during the intervention to empathetically understand and
actively listen the child’s problems. Psychoeducation was with the purpose to provide the
insight to child about her problems and to empower her in dealing with these problems in
an optimal way.
Anger management
The child was psycho-educated about the anger is a normal human emotion and can range
from mild irritation to an intense rage, then asked her to identify the triggers and warning
signs that caused anger like encountering with class monitors, disregard from class teacher,
and misbehavior of class fellows made the child angry. After that, asked the child to notice
‘why am I angry’, about what is causing this emotion. When you notice yourself becoming
angry, there are a number of techniques which you can use to ‘take the heat out’ of your
anger.
ABC model. The child had somewhat insight regarding developmental course of
problem, but how the interconnection of thought, feelings, and consequences were
elaborated to the child using ABC model of Cognitive Behavior Therapy (CBT, Beck,
1995). The identified situations of the child in the functional assessment form were used to
effectively explain the ABC model to the child. Moreover, it was elaborated that ‘A’ can
never be changed but the ‘B’ is in control of individual that can make a substantial
difference ‘C’.
The child was also psycho-educated about fight or flight with the purpose to explain
the situation when one faced with a life-threatening danger, so it often makes sense to run
away or, of that is not possible, to fight. The fight-flight response is an automatic survival
mechanism which prepares the body to take these actions. All of the body sensations
produced are happening for good reasons- to prepare to run away or fight-but may be
experienced as uncomfortable when one does not know why this is happening.
Deep breathing. As whenever child encountered with class monitors and stressful
comments from teacher, she felt physically charged like racing heart, sweaty palms, flushed
face, and headache, so to soothe her physical symptoms, deep breathing was taught to the
child.
Distraction. Further, used the distraction techniques with the purpose to manage
the unfruitful situation, as if you cannot change the situation, it can help to distract yourself
from whatever is making you angry by counting to ten, listening to music, calling a friend
to chat about something else, or doing housework. For instance, if you go angry home and
you find every single person irritating then, indulge yourself in some activity, or displace
your anger on some stuff toy. Further included Time Out technique that means removing
yourself from the situation for a period of time, to give yourself a chance to ‘cool down’
and think things through before you act. For example, when you notice yourself becoming
 7

angry during an argument with class monitors, say “I need to take time out, let’s talk about
this calmly when I get back” and then go for a walk.
Identify Time Wasters and Solutions
To resolve her problem regarding time wasting and could not find time for home
work was done through time management techniques. This included the identification of
time wasters and solutions. The child created a map of her daily routine then with the help
of counselor picked up the time wasters to manage time for that. After that, counselor asked
the child what she would do or skip from her routine to manage these wasters. She
responded that she tried to skip some TV shows and also lessen the time to do home chores.
Identifying the Cognitive Distortions (Beck, 1995)
During counselling interview, it was observed and noted that the thinking of the child is
clouded with cognitive distortions. She identified as nobody loves me and I am a
disobedient and rebellious child. The reason was she thought negative events as a never-
ending pattern of defeat, because her teacher and class monitors humiliated her that was
why she was guessing this about herself. Then she was asked to identify which of the
pattern is used by her mostly taking into account her FBA form. Later on, she was asked
what can be a better optimal and more positive thought that can counter the negative
distorted thought of her mind, she answered by distracting oneself from the problem, or
one can think about the situation of another person before reacting and spoiling one’s
mood.
Defense Attorney (Beck, 1995)

The child reported that she had never been a self- criticizer. Currently, the encountering
with class monitor, disregard from teacher, no badge of monitor on her slash and
misbehavior of class fellows and younger siblings made her feel that she’s not lovable. For
that defense attorney technique was used and asked her, “If you were trying to act as your
attorney whose job was to defend yourself, what would you say in your defense? Try to be
the lawyer possible in defending yourself” (Leahy, 2003, p. 49). The counselor introduced
that technique to child as game and she enjoyed a lot and felt relaxed. At the end of the
session she was able to understand that the reasons of not having the badge of monitor and
disregard from teacher, because hard work, good manners, and consistency is very
important for gaining desirable rewards and for that she would definitely work hard.
improvement and excellence from her education and behavior.
Use of Coping Statement (Hayes Et Al., 1983)
Whenever the child faces a stressful situation, an automatic negative thought came on the
surface and induced anxiety that led to anger outburst in her. Therefore, coping statements
were used to put a stop and to replace those thoughts with realistic and rational thoughts.
She was informed that when these rational self-statements are practiced and learned, brain
took over and they automatically occurred.
Assertive Skills Training
 8

Assertive skills training was given to the child to psycho-educate her to say no to peers and
society in a humble and polite manner to handle the pressuring situations. She was also
educated about the difference between the passive, aggressive, and assertive
communication. Further, the fogging technique (Cangelosi & Peterson, 1998) was also
educated her through role playing. She was instructed rather than arguing back, aimed to
give a minimal, calmed response using terms that were placating but not defensive.
Problem-Focused Solution
Problem-solving techniques was involved a process by which child attempted to analyze a
problem, identify options for coping, evaluate the options, decide upon a plan, and develop
strategies for implementing the plan. After that the process was started by following the
‘SOLVED’ techniques and asked the child to open her mind to all possible solutions about
the problems through brainstorming. If she wanted to write she could. At the end asked her
to verify the best solution by examining the pros and cons of every possible solution.
The overall outcomes of counseling plan identified that she became able to analyze,
identify, and evaluate the problems related to her instability of emotions and behaviors.
She also started taking interest in class activities and she felt less sad, anxious, and angry.
The outcomes depicted effectiveness of cognitive behavior therapy for management of
emotional and behavioral problems. Total 8 sessions (1 session per week of 45 minutes)
were carried out with the child for the purpose of counselling and therapeutic intervention.
Discussion
The quality of student’s relationship, or involvement with teachers and peers
factually serve as a powerful motivator (Connell, 1991). Effective school learning enhances
student’s interaction with others (Ryan & Powelson, 1991) and ineffective learning,
isolation, and social dissatisfaction lead to weak school achievement (Galanaki & Kalantzi-
Azizi, 1999). Therefore, social acceptance and appreciation are crucial aspects in
enhancing student’s intrapersonal and interpersonal functioning. As in this child’s case, the
social support was significantly missing that was causing problems related to adjustment.
Friends normally influence each other through characteristics of attitudes, behaviors, and
quality of friendship. These influential characteristics further affect interpersonal
relationships that eventually support effective school adjustment (Berndt, 1999; Berndt &
Keefe, 1996).
Generally, a student who is new to environment has four motives for effective
adjustment in school with new peers such as need for approval, identification, self-
enhancement, and need to be corrected, because student wants to be liked, so they try to
involve in activities and try to please friends for social approval (Berndt & Keefe, 1996).
When one does not find these motives then one perhaps become aggressive, feel rejected,
socially isolated, and have somatic problems. As positive quality of friendship displays
significantly higher self-esteem, fewer emotional and behavioral problems, more prosocial
behavior, and high achievement in school (Berndt & Keefe, 1996); contrarily, negative
quality of friendship lead to social incompetence, isolation, and more disruptive behavior.
As this child wanted to establish a relationship with teachers and class fellows, but
resultantly the unacceptable and depreciative behavior of them triggering anger, anxiety,
and irritability in child.
 9

The child’s case report formulation was based on the biopsychosocial model, which further
includes, predisposing, precipitating, perpetuating, and protective factors of problems.
Table 4
Formulation of Case based on Biopsychosocial Model
Factor Predisposing Precipitating Perpetuating Protective
factors factors factors factors
Biological Age, Temperament,
factors Temperament, Reactivity to
Reactivity to Anxiety,
Anxiety Somatic
problems
Psychological Feeling Aggression, Affection from
factors Rejected Displacement parents,
of anger, Child’s
Anxiousness, compliance

Social factors Social Weak bond

Withdrawal, siblings,
Adjustment in Lack of
new assertiveness,
environment Lack of social
support from
friends,
Lack of
appreciation
from teacher
It indicates that predisposing factors in the early age leads to affect temperament
and stimulates the anxiety reaction. The child felt rejected during school hours, felt socially
isolated and finding it difficult to adjust in new environment that were actually precipitated
her problems. Lack of acceptance in new environment, lack of appreciation, and lack of
social support from peer leads the child towards aggression, anxiety, displacement of anger
(which resultantly weaker her bond with siblings), and somatic problems. While
perpetuating factors further stimulated her temperament and reactivity to anxiety.
However, protective factor; mainly, affection from parents significantly boosted her
compliance.
Conclusion
The therapeutic interventional plan was effectively designed that includes cognitive
behavioral experiments to assist her with anger management, assertiveness techniques, use
of coping statement to build confidence and problem-solving technique was used to find
solutions for her reported problems. The lack of motivation in the child, absence of
appreciation and continuous incidents of misbehavior during school time made the hurdles.
However, overall therapeutic interventional plan was effective as the child showed
consistency and compliance throughout counselling sessions.
 10

Recommendations
The case study recommended that motivation developing techniques would perhaps
be more helpful in dealing the child. Most importantly, the family guidance would perhaps
provide further support and boost her competence in handling challenging situations.
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