Cognitive Behavior Therapy in Educational Settings as a Method to Treat Child Refugees
Heather L. Chester
Cancer InCytes Magazine
Volume 7, Issue 1, Summer 2020
June 7, 2020
Managing Editor: Barbara Recine, M.A.
There are over 12 million children refugees in the world, forced to flee their homeland due to war, conflicts and potential persecution. These traumatic experiences often cause children to suffer from symptoms of Post-Traumatic Stress Disorder (PTSD). Using cognitive behavior therapy (CBT) in educational settings decreases symptoms of PTSD. This literature review evaluates and compares three empirical studies in which CBT was used in an educational environment. Based upon the findings of this research, it was found that the use of CBT was effective in reducing PTSD symptoms, especially in settings where educators facilitated group CBT.
The global number of refugees in 2018 exceeded 25.9 million; over half of these refugees are children (1). According the United Nations High Commission of Refugees (UNHCR), a refugee is a person forced to “flee their country because of conflict, war, or persecution” (1). The impact of the trauma induced by these experiences is demonstrated by research linking refugees to the exhibition of symptoms of post-traumatic stress disorder (PTSD), anxiety disorder, depression and other emotional and behavioral problems (2). The use of cognitive behavior therapy (CBT) reduces the symptoms of depression, anxiety and PTSD amongst refugee populations and is an effective treatment for children (2). However, the lack of available mental health professionals proficient in the languages spoken by refugees, as well as cultural stigma associated with mental health services, make access to effective CBT challenging (3). These factors often deter refugee parents from seeking mental health assistance for their children. A potential solution to this problem is to implement task-shifting with teachers in a school or educational setting. This review summarizes research about the adaptation of CBT in educational settings in order to decrease adverse mental health symptoms among refugee children.
Cognitive Behavior Therapy in Educational Settings
The implementation of CBT or other mental health services in an educational center or school is an opportunity for refugee children with emotional or behavioral problems to receive treatment in a natural environment. A study conducted by Ehntholt, Smith and Yule (2005) found that within schools, communities of traumatized refugee children naturally formed (4). Using these natural groups, the study provided six group sessions of CBT for 1 hour a week facilitated by a teacher or other member of school staff trained in Children and War: Teaching Recovery Technique materials. Children were assessed before and after treatment for depression and behavioral symptoms using a variety of scales, one in which teachers assessed children using the Strengths and Difficulties Questionnaire (SDQ) (4).
In a second study conducted by Gormez, Kılıç, Orengul, Demir, Mert, Makhlouta, and Semerci (2017), CBT group therapy was delivered to refugee children by teachers who had received a two-day intensive training program (5). The teachers facilitated the CBT in groups of 8-10 students for 70-90 minutes weekly for a total of eight weeks. Children were assessed pre and post intervention using the Spence Children’s Anxiety Scale (SCAS), a self-diagnostic questionnaire, and by teachers using the SDQ (5).
In a third study conducted by Fazel, Doll and Stein (2009), mental health professionals worked with teachers to identify refugee children not receiving services and paired these children with mental health professionals (2). The participants met with the mental health professional to have CBT sessions two to five times weekly for the majority of the school year. Teachers assessed students using the SDQ before and after treatment and had weekly consultations with the mental health professionals about each student to optimize and reinforce assistance given (2).
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After six weeks in the Ehntholt et al. (2005) study, participants had lower anxiety levels and fewer behavioral difficulties (4). After treatment, there was no significant difference on the depression score, but the CBT group exhibited a significant improvement in the average SDQ score (9.20 before treatment; 5.40 after). The study concluded that the use of therapy groups had other positive results “of decreasing the children’s sense of hopelessness and loneliness, as well as normalizing their reactions” (4,p. 245). However, after a 2 month follow-up, a self-reported survey completed by participants did not detect further significant changes (4).
Gormez et al. (2017) showed compelling evidence of improvement in emotional and trauma-related symptoms (5). Post-treatment anxiety scores of the participants were statistically lower than initial diagnostic scores (40.38% versus 53.28% ), indicating that participants exhibited fewer symptoms found in anxiety-related disorders post treatment. According to the initial SDQ, 90.6% of participants showed symptoms of behavior difficulties, with an average score of 18.77, compared to 56.3% post-intervention, with an average score of 16.81 (5). After a school year in the study conducted by Fazel et al. (2009), the participants had lower SDQ scores, from the baseline average of 12.3 to a post-intervention average of 10.6 (2).
The three studies used CBT interventions within educational settings in different ways with different results. The first study conveyed the most drastic change of the SDQ averages in the shortest amount of time (43). The first and second interventions produced results better or on par with the third study in a shorter amount of time (2,4,5). Perhaps the reason for this is the fact that CBT therapy sessions were conducted in groups, normalizing the trauma and reactions to trauma and creating a supportive cohort within the community of the school (4,5). However, in the third study, students received one-on-one assistance and did not form a peer support system (2). One limitation to this conclusion is that since the educators were also the facilitators for CBT, they might have been biased in scoring students on the SDQ.
Since most refugee children spend large amounts of time in educational settings, training teachers in CBT can benefit vulnerable children (2). Teachers have existing knowledge and hands-on experience with their students and thus and are better able to screen and identify refugee children in need of mental health care (2). It was noted in the third study that using mental health professionals took strain off of educators (2). However, the results showed that one-on-one therapy was less successful in lowering the SDQ scores than group therapy conducted by a teacher. In addition, one-on-one therapy is less accessible due to the lack of mental health professionals, especially those fluent in the children’s native language, and the large demand for assistance. Perhaps a more sustainable solution is the training of educators to use CBT techniques. The first study found that, once trained, teachers were able to implement CBT techniques and were well-suited to group therapy (4). Likewise, the second study found that using a school-based, teacher-led psychological intervention was a sustainable way to improve symptoms of PTSD amongst refugee children (5).
In cases where parents may be afraid of the stigma of mental health care, the school-based intervention can provide a non-stigmatizing, convenient-access opportunity (4). “School-based health services offered an alternative to traditional clinic-based services for meeting the needs of minority children” (2, p. 298).
In the future, more direct research is needed to compare the efficacy of group CBT and one-on-one CBT in educational settings. It would also be interesting to compare the efficacy of using mental health professionals versus trained educators in CBT. CBT in school settings is a promising means to assist refugee children suffering from symptoms of trauma, anxiety and emotional disturbances.
Angelica, Eulirio, Warao, Delta Amacuro, & Warao. (n.d.). Global Trends - Forced Displacement in 2018 - UNHCR. Retrieved from https://www.unhcr.org/globaltrends2018/.
Fazel, M., Doll, H., & Stein, A. “A School-Based Mental Health Intervention for Refugee Children: An Exploratory Study.” Clinical Child Psychology and Psychiatry, vol 14, no. 2, 2009, pp. 297–309., doi: 10.1177/1359104508100128
Kien, Christina, Isolde Sommer, Anna Faustmann, Lacey Gibson, Martha Schneider, Eva Krczal, Robert Jank, et al. “Prevalence of Mental Disorders in Young Refugees and Asylum Seekers in European Countries: A Systematic Review.” European Child & Adolescent Psychiatry, vol. 28, no. 10, 2019, pp. 1295–1310., https://doi.org/10.1007/s00787-018-1215-z.
Ehntholt, K. A., Smith, P. A., & Yule, W. “School-based Cognitive-Behavioural Therapy Group Intervention for Refugee Children who have Experienced War-related Trauma.” Clinical Child Psychology and Psychiatry, vol. 10, no. 2, 2005, pp. 235–250., doi: 10.1177/1359104505051214
Gormez, V., Kılıç, H. N., Orengul, A. C., Demir, M. N., Mert, E. B., Makhlouta, B., … Semerci, B. “Evaluation of a School-Based, Teacher-Delivered Psychological Intervention Group Program for Trauma-Affected Syrian Refugee Children in Istanbul, Turkey.” Psychiatry and Clinical Psychopharmacology, vol. 27, no. 2, 2017, pp. 125–131., doi:10.1080/24750573.2017.1304748.