Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study

CBPRA-00550; No of Pages 15: 4C

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ScienceDirect Cognitive and Behavioral Practice xx (2014) xxx-xxx www.elsevier.com/locate/cabp

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Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study Brian C. Chu, Lauren Hoffman, Alyssa Johns, Rutgers University Jazmin Reyes-Portillo, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute Amy Hansford, Medical University of South Carolina The majority of school-age youth experience some form of bullying, and the consequences can have significant impact on a child’s or adolescent’s social, emotional, and academic functioning. The majority of anti-bullying initiatives have focused on schoolwide prevention programs aimed to enhance school climate and a school’s response to bullying incidences. Few programs address the socio-emotional functioning of youth who are experiencing significant anxiety and mood problems following exposure to bullying. The current paper describes the development of a transdiagnostic behavioral activation and exposure program (Group Behavior Activation Therapy for Bullying) designed to address internalizing problems secondary to bullying. Case descriptions and clinical outcomes are reported from a pilot group of 5 youth (ages 12 to 13). Video clips of group demonstrations are included for illustrative purposes. Attendance was strong and group satisfaction ratings indicated the program was feasible and acceptable to conduct in school settings. Initial outcomes suggest that youth experienced benefits in anxiety and depression diagnoses, symptom outcomes, and functional impairment related to bullying. However, larger controlled evaluations are required to support any conclusions about treatment efficacy.

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prevalence and psychosocial impact of peer victimization in schools has rightly warranted significant attention in health care, education, and public policy (Merrell, Gueldner, Ross, & Isava, 2008). Up to 77% of students have reported an experience with bullying and 14% report significant negative reactions, including anxiety, depression, negative peer relationships, and lowered academic performance (Ericson, 2001; Hawker & Boulton, 2000; Haynie et al., 2001; Williams, Chambers, Logan, & Robinson, 1996). To address the large number of youth affected, nationwide initiatives are under way to identify and decrease bullying in schools. Consensus is still building around the term “bullying,” but most agree that bullying includes four types of aggressive behaviors: verbal (e.g., name-calling, teasing), psychological or relational (e.g., breaking up friendships, spreading rumors, social exclusion), physical (e.g., physical aggression, stealing belongings), and cyber (i.e., using the Internet, mobile phone, or other digital technology to harm others; New Jersey Department of Education, 2011). Bullying is commonly defined as “exposure, repeatedly and 1

HE

Video patients/clients are portrayed by actors.

Keywords: bullying; transdiagnostic behavior therapy; anxiety; depression

1077-7229/14/© 2014 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.

over time, to negative or aggressive acts on the part of one or more other students” (Olweus, 2010, p. 11). Bullying is thus differentiated from normative interpersonal conflict in that it entails an imbalance of power, an intent to cause harm, and evidence of repeated occurrence. The occasional “push” in the hallway or argument in the lunchroom would not necessarily be defined as bullying. Some state laws (e.g., New Jersey) have gone as far as to mandate that a victim be a part of a protected class (e.g., race, gender, sexuality, disability) for an incident to be classified as “bullying” (New Jersey Anti-Bullying Bill of Rights Act, 2011). These legal terms help clarify the responsibilities of the school administrators and the consequences for youth who bully. This will be discussed later.

Socio-Emotional Impact of Bullying Research has identified consistent impairment in social, emotional, and academic domains as a result of bullying. Victimization has been associated with school avoidance and lack of participation in class (Buhs, Ladd, & Herald, 2006; Juvonen, Nishina, & Graham, 2000); lower achievement and feeling unsafe in school (Glew, Fan, Katon, Rivara, & Kernic, 2005); somatic complaints, such as headaches, stomachaches, bed-wetting, and sleep problems (Williams et al., 1996); and social skills deficits (Egan & Perry, 1998; Rubin, Coplan, & Bowker, 2009; Schwartz, Dodge, & Coie, 1993). Bullying can also lead to further rejection and isolation as peers might be reluctant

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

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to befriend or defend targeted youth (Coie, Dodge, & Kupersmidt, 1990). As a result, emotional and behavioral problems are common in bullied youth. Meta-analysis has shown that bullying is significantly related to generalized anxiety and social anxiety. Victims are three times more likely than nonvictims to experience an anxiety disorder directly following the incident (Hawker & Boulton, 2000; Kumpulainen, Räsänen, & Puura, 2001) and are at heightened risk for future development of anxiety disorders in adolescence and adulthood (Gladstone, Parker, & Malhi, 2006; Hanish & Guerra, 2002; Sourander et al., 2007). A similar relationship has been found between bullying and depression. Victims are often lonely, isolated, and withdrawn (Hawker & Boulton, 2000), and an increase in depressed mood and suicidal ideation has been identified among victims (Klomek, Sourander, & Gould, 2010). Of course, the relationship between bullying and emotional distress is complex. Youth with primary anxiety and mood problems can be seen as easy targets for aggressive children as they are often inhibited, withdrawn, sensitive, and may lack the confidence to assert themselves in the face of bullying. Thus, anxiety and mood problems appear to be a consistent consequence of bullying, and internalizing disorders may be a significant predictor of future victimization (Cluver, Bowes, & Gardner, 2010; Fekkes, Pijpers, Fredriks, Vogels, & Verloove-Vanhorick, 2006).

Prevailing Models of Bullying Programs To address bullying in schools, all but a few states have passed anti-bullying legislation that requires school districts to develop and implement formal systems for identification and intervention of bullying. In New Jersey, for example, anti-bullying legislation mandates that each school identify an anti-bullying specialist who is responsible for preventing, identifying, and addressing harassment, intimidation, and bullying (HIB) incidents in the school. Anti-bullying laws differ across states, but most include statements prohibiting bullying behavior, procedures for reporting bullying events, and general guidelines for consequences (U.S. Department of Education, Office of Planning, Evaluation and Policy Development Policy and Program Studies Service, 2011). Some state guidelines have gone as far as imposing criminal sanctions for bullying behavior. In Georgia, a state with one of the most punitive sanctions for bullying behaviors, it is required that any student involved in bullying on three or more occasions be automatically transferred to an alternative school (Ga. Code Ann. §20-2-751.4). Several state statutes (e.g., Colorado, Maryland, Oklahoma, New Hampshire) encourage schools to implement bullying prevention programs. These legislative findings are noteworthy in that they reflect the seriousness with which policymakers consider the issue of bullying.

Many have expressed frustration that state legislation provides little guidance or financial assistance to develop bullying intervention programs. Some policies are vague, communicating the importance of schoolwide prevention efforts without outlining specific requirements to follow or allocating resources to support such programs. “Unfunded mandates” like these have placed substantial demands on school districts, individual schools, and school personnel to develop and implement programs individually, often without trained personnel who specialize in bullying. Despite these obstacles, a number of schoolwide anti-bullying prevention-intervention programs have been developed and implemented. These initiatives tend to focus on school climate factors, such as improving peer relations among the general student body, fostering awareness of bullying, and establishing a protocol for responding to bullying events. Research on the effectiveness of these programs, however, remains mixed (Smith, Sharp, Eslea, & Thompson, 2004; Vreeman & Carroll, 2007), highlighting the need for additional methods of intervention.

Focused Interventions for Victims of Bullying Few interventions focus specifically on youth who have been victims of bullying. Most existing programs target social skills deficits to decrease vulnerability to continued bullying. Fox and Boulton (2003) evaluated a social skills group program that used social learning and cognitive-behavioral strategies to teach victims prosocial behavior. Evaluation of this program revealed enhanced global self-esteem but no significant improvement in victimization, number of friends, peer acceptance, or symptoms of anxiety or depression. A similar social skills program developed by DeRosier (2004) yielded significant improvements in global self-esteem, peer acceptance, and social anxiety symptoms, though effect sizes were modest. Berry and Hunt (2009) developed an intervention that targeted victims of bullying who also reported elevated anxiety symptoms. In addition to social skills, the eightsession intervention incorporated anxiety management and self-esteem-building strategies (e.g., cognitive restructuring, graded exposure). Participants in this intervention reported reductions in bullying experiences and symptoms of anxiety and depression, though they did not report changes in aggressive or avoidant responses to bullying. The current paper describes a novel school-based group intervention that teaches victims protective strategies to minimize the impact of bullying and to build social skills that minimize risk for continued bullying. The program differs from prior models in that it is provided within the context of a behavioral activation and exposure program designed to help youth with anxiety and depression. In particular, the group aims to help victims

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

Transdiagnostic Behavior Therapy for Bullying combat the behavioral withdrawal, isolation, and inactivity that commonly develop as a consequence of bullying. The group behavioral activation therapy program (GBAT; Chu, Colognori, Weissman, & Bannon, 2009) is a 10-session group intervention adapted from adult behavioral activation (BA) programs that adds in-session exposure exercises (Addis & Martell, 2004; Dimidjian et al., 2006; Martell, Addis, & Jacobson, 2001). Core BA principles include (a) psychoeducation, (b) functional analysis, (c) problem solving, and (d) graded exposures/BA tasks. Individual functional analysis is taught using the acronym TRAP, which reminds youth to identify the trigger, emotional response, and avoidant patterns they use when they feel distressed. Youth are then taught to overcome avoidant and anhedonic cycles using the acronym TRAC, in which they replace avoidant patterns with adaptive coping (or active choices). Graded exposures/tasks are integrated throughout treatment to maximize participant experience of in-session in vivo exposure-based exercises. A recent randomized controlled trial comparing GBAT with a 15-week wait-list suggested that GBAT contributed to improvements in overall diagnostic impairment at posttreatment and in reductions in anxiety and depression symptoms in teens (ages 12 to 15) at 4-month follow-up (Chu et al., 2013). Although bullying victimization was not assessed in this trial, the GBAT program was chosen as the base intervention because of its focus on anxiety and mood problems, which are common among victims of bullying (Hawker & Boulton, 2000; Klomek et al., 2010), and its emphasis on behavioral activation and exposures, which target the common avoidance patterns (e.g., passive communication, limited involvement with peers) of this vulnerable group. The GBAT-bullying (GBAT-B) program includes 14 hour-long sessions but allows for flexibility to fit within class schedules. It starts with a general introduction session, and then teaches four bullying-specific modules. The final nine sessions cover the four core GBAT skills described above and integrates in vivo exposures (for further details, see Chu et al., 2009). Two individual sessions are also scheduled to provide individual feedback and check-in about progress. The novel four bullying-specific modules include psychoeducation, building one’s social network, assertiveness and decision-making skills, and making use of social resources. Module 1: Facts About School Life and Bullying The first bullying session provides definitions and psychoeducation around bullying. The aims of the session are to normalize the experience of being bullied, make students aware of the different types of bullying, and to assess fears and misperceptions of bullying perpetrators and victims. Using common legal definitions of bullying,

bullying is distinguished from age-typical teasing and isolated arguments. It is important for victims to make this distinction so that they can recognize when it is appropriate to seek help. Because youth culture often discourages “tattling,” information that helps victims distinguish chronic bullying from developmentally typical teasing may help encourage confidence in reporting future incidents. Different forms of bullying (physical, verbal, relational, cyber bullying) are described so that group members realize that bullying need not be physical to have serious implications and warrant attention. Group members are introduced to a “bullying thermometer” (see Figure 1) and group leaders ask members to identify different bullying events that lead to varying levels of distress (0 = not intense to 10 = the worst case of bullying). Each member generates individual anchors that reflect a different severity of bullying events to the individual. However, common themes will surface, and the group leaders highlight any conclusions that are surprising to the group (e.g., physical events may not always predict greater distress). Group leaders also help develop consensus around what kinds of situations ought to prompt differential help-seeking actions (e.g., when to seek help from a friend, parent, or school staff member). These norms are established so that youth begin to understand when it is important to seek help from an adult or seek official school action (e.g., threat of physical harm, widely distributed cyber bullying) and when it might be acceptable to seek support from a friend (e.g., managing upset triggered by teasing). Importantly, group members are exposed to helpful data on bullying across the United States. The goal is to de-stigmatize the fact that they were subjected to bullying and to emphasize that bullying often does not result from something they did. Group leaders then describe school-specific procedures for reporting bullying in the school to ensure that youth have concrete knowledge of the resources they have on school grounds and the formal reporting procedures. Module 2: Building Your Social Network Research suggests that victims are often targeted because others identify social skills deficits or traits that make them stand out (e.g., quirky interests, poor conversational skills, difficulty with social reciprocity, awkward behavior). At the same time, attempts to train youth in social skills or to make them “cool” can backfire. Such efforts can be perceived as “trying too hard,” and could set youth up for further targeting. Instead, a more controllable and effective strategy may be to help build a protective social buffer around the youth. Even one reliable friend has predicted reduced victimization, and it does not matter if this friend is “cool” (Fox & Boulton, 2006).

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

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Bullying Thermometer

How Intense? (0 “Not at all” 10 “the worst”)

What Kind?

What can you do?

Who can help?

Here’s the final step. For each situation, who can you go to for help when you feel targeted? It can be a friend, a group of friends, a family member, coach, teacher, or anyone you trust.

Figure 1. Bullying Thermometer emphasizing that different responses may be appropriate for different types of bullying events.

To help group members build their “social network” the leaders help members recognize the social contacts, friends, and supports they already have in their network

by introducing the social network, adapted from the “closeness circle” from interpersonal psychotherapy (Figure 2; Mufson, Moreau, & Weissman, 1994). This is

People I say hi to in class

People I chat with online Friends I text and call Family Me Best friends People I sit with at lunch

Friends from outside school

People I see on the bus

Figure 2. Building the youth's social network. Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

Transdiagnostic Behavior Therapy for Bullying a particularly important step because victimized youth often feel isolated and have difficulty identifying support sources (Boulton & Underwood, 1992). Group members are asked to think of people who might fit each category (e.g., “People I say ‘Hi’ to in class,” “People I sit with at lunch”) with the goal of identifying both the strengths and gaps in their social network. It also helps to broaden one’s understanding of social support. Social support can include emotional support (e.g., encouragement, caring), instrumental support (e.g., practical assistance, tutoring, learning a skill or practicing an activity together), informational support (e.g., advice, guidance), and companionship (e.g., giving a sense of belonging). Group leaders help members list the types of support they enjoy from each person in their social network. Group leaders highlight any surprises: Did they list individuals they did not expect? Do others give them support in surprising ways? Do some not give the support expected? Are there gaps in one or more kind of support? For example, can the student identify sufficient companionship but little emotional support? Alternatively, are they surprised by how much support they have? The remainder of the session focuses on brainstorming ways to build one’s social network, identifying potential barriers, and problem-solving solutions. If suitable, group members role-play scenarios representing social barriers. Members return to the bullying thermometer and identify which social supports they would approach if they were either directly targeted or were experiencing distress related to past bullying events. This helps members know who and when they would access each member of their social network. Members then commit to initiating three things they can do to build their social network over the week. Module 3: Standing Up for Yourself The third module aims to teach assertiveness skills and decision making that youth can use to help navigate potential bullying events. Bullied youth often do not know how to most effectively respond to aggression and do not feel comfortable exercising appropriate assertiveness, making them vulnerable to continued bullying (Schwartz et al., 1993). This can be even truer for youth with overlapping anxiety and mood problems. Youth are taught three main communication styles as described in Alberti and Emmons’s (1995) Your Perfect Right: aggressive (reactive aggression), passive (avoidant coping), and assertive (proactive–constructive). Youth are reminded that passivity and aggressiveness may inadvertently perpetuate bullying cycles or push potential support away. Members are taught the physical and verbal ways that they communicate assertiveness. Group leaders lead the group through a series of hypothetical situations that

represent varying degrees of bullying. Members identify aggressive, passive, and assertive ways to respond to the scenario and then role play to get an experiential feel for assertive behavior. Video 1 provides an example of a group leader describing the differences among the three response styles (all youth in videos were nominally paid actors).

Video 1. Teaching Assertiveness.

Importantly, group leaders make the point that there are times when escape is the preferred response. In situations where real physical harm is possible, or where there are multiple bullies present, the youth is encouraged to exit the scene without fear of looking weak. For example, if five youth converge on a targeted youth in the hallway and start hitting the youth, we would certainly recommend the youth flee the situation. If the five youth are taunting the targeted youth but not getting physical, we might recommend leaving the situation but try asserting himor her-self first (e.g., telling the bullies their taunts do not affect him or her). If it is a one-on-one situation in a relatively safe situation (e.g., classroom), we might encourage the targeted youth to fully practice assertiveness skills to see what impact assertiveness has. Group leaders help members evaluate in what situations it makes sense to stand up for oneself and which situations are “too hot to handle” on one’s own. The group returns to the bullying thermometer and adds solutions to the various bullying events so that youth feel prepared the next time such events occur. Module 4: Mobilizing Your Forces/Resources The fourth module leads group members through the process of accessing their social support when they have been a victim of bullying or realize they are “in over their head” after trying assertiveness skills. Students review their previous social network and discuss if anything has changed. Who have they called for advice? Who did they talk to for support or just to hang out? Who have they called when they were in trouble? Now that group

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

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members are familiar with the various types of support they can access (emotional, instrumental, informational, companionship), they may now have a refined notion of who is most helpful in which circumstances. The group leader can lead the group in a discussion of successes and challenges in accessing support over the past few weeks, helping each identify the most helpful members in their social network as well as the most useful strategies in accessing help. The leaders provide active shaping in the discussion. Milder forms of bullying may benefit from help from peers or siblings. More severe forms of bullying may necessitate help from adults. Members may be hesitant to access help from adults based on past disappointments, but group leaders should continue to encourage youth to access adult help when serious bullying occurs. The group then role-plays scenarios of different types of bullying and confrontations and enacts what would happen when they approach different people in their social network. Video 2 illustrates a discussion of using one’s social network to mobilize one’s forces.

referred youth who continued to exhibit mood and anxiety problems related to bullying. Interested youth and parents completed an IRB-approved assenting/ consenting process, and completed diagnostic interviews and self-report questionnaires (symptoms, impairment, group satisfaction) at pre- and posttreatment. Participants Five seventh-grade students (ages 12 to 13) participated in a 14-week GBAT-B group. The students were ethnically diverse (three White, one Hispanic, one biracial White and Hispanic) and from middle- to upper-middle-class families (total family income ranged from $20,000 to $100,000). They were drawn from a large, ethnically diverse, public middle school in a mid-Atlantic state. Clinical profiles are summarized in Table 1. There were no exclusion criteria. Therapists and Group Setting The group was co-led by two female advanced psychology doctoral students (ages 26 and 29; one Caucasian, one Hispanic) who were psychology doctoral students with experience in delivering CBT interventions for internalizing youth. Therapists received weekly supervision by a licensed clinical psychologist (the first author) utilizing videotape feedback. Group meetings were held in the guidance office at school and consisted of 14 weekly meetings confined to 38-minute class periods.

Video 2. Mobilizing Your Forces.

Students return to the bullying thermometer and list who they would approach in different circumstances. For homework, group members use the thermometer to track what bullying events they experienced, what communication style was most appropriate, who they approached for help, and how it worked. After this fourth bullying module, the group then resumes the traditional GBAT curriculum (Chu et al., 2009), which turns the focus on preventing depressed and anxious mood that comes from repeated experiences with bullying.

Descriptive Case Presentation To illustrate how GBAT-B can be applied in natural school settings, we describe findings from a pilot group of middle school students who were referred to the school’s counseling office for bullying-related distress. Each youth (or family) had reported a school incident that qualified for an HIB investigation. After completing the school’s mediation and intervention process, the HIB officer

Assessments Multidimensional assessments were collected pre- and posttreatment to assess diagnostic, symptom severity, and functional impairment. Diagnosis was assessed using the Anxiety Disorders Interview Schedule for DSM-IV–Child Interview (ADIS-IV-C; Silverman & Albano, 1996), conducted by independent evaluators trained to reliability (k ≥ .80 for all diagnoses). Clinician severity ratings (CSR) ranged from 0 (no impairment) to 8 (disabling impairment), with 4 indicating the threshold for clinical diagnosis. A bullying screener (i.e., ADIS-Bullying) was developed and added to assess type, frequency, intensity, and location of the child’s bullying experiences, and the level of impairment associated with bullying incidents using the same CSR scale. Anxiety symptoms were assessed with youth and parent report using the Screen for Childhood Anxiety Related Emotional Disorders (SCARED; Birmaher, Khetarpal, & Brent, 1997), a 41-item measure where symptoms are rated on a 3-point scale from 0 (not true or hardly ever true) to 2 (often true). Depressive symptoms were assessed using youth and parent report of the Center for Epidemiologic Studies–Depression Scale (CES-D; Radloff, 1977), a 20-item measure using a 4- point scale from 0 (rarely) to

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

Pre- and Posttreatment Clinical Outcomes Bullying Impairment

Pretreatment Anxiety/Depression

Post-Tx MBIS

SCARED-C

CESD-C

Youth

Sex

ADIS Diagnoses

Pre-Tx CSR

Post-Tx CSR

Pre-Tx MBIS

Mid-Tx MBIS

SCARED-P

1

M

11

44

38

9

23

17

8

26

15

3

M

34

25

23

31

4

M

4

7

3

5

F

(2) 0 0 6 0 0 (3) 0 0 (2) 0 0 6 0 (3)

6

M

5 (2) (2) 6 5 5 (3) (3) 4 (3) 6 6 4 4 4

33

2

SAD Bullying SAD Bullying GAD SAD SEP MDD Bullying ADHD Bullying MDD SAD GAD Bullying

12

6

25

Posttreatment Anxiety/Depression CESD-P

SCARED-C

CESD-C

SCARED-P

CESD- P

5

20**

14**

8

6

43

34

11*

6*

25**

9**

25

17

11

17

4**

6

6

0

3

4

7

0

3

–

–

33

25

10

11

23

17

–

–

Transdiagnostic Behavior Therapy for Bullying

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

Table 1

Note. * p b .05; ** p b .01. ADIS = Anxiety Disorders Interview Schedule; CSR = ADIS Clinician Severity Rating; MBIS = Multidimensional Bullying Impairment Scale; SCARED-C/P = Screen for Childhood Anxiety Related Emotional Disorders–Child/Parent; CESD-C/P = Center for Epidemiologic Studies–Depression Scale–Child/Parent; SAD = social anxiety disorder; GAD = generalized anxiety disorder; SEP = separation anxiety disorder; MDD = major depression disorder.

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Chu et al. 3 (most of the time). An 8-item (total range: 8–32) Group Satisfaction Questionnaire (GSQ; Chu et al., 2009) was used to assess negative and positive opinions of the program, including overall quality, helpfulness, and the degree to which youth learned skills. GSQ was administered posttreatment by a nontherapist research assistant. Finally, a novel measure created for this pilot was completed by youth. The Multidimensional Bullying Impairment Scale (MBIS) is a 20-item measure, rated 0 (not at all) to 3 (most of the time; total range: 0–60). Items begin with the clause “When I have been bullied, I . . .” and assesses the frequency that victimization negatively impacts family relations (e.g., “I argue with my family more often”), peer relations (e.g., “I would rather not see my friends”), academic performance and attendance (e.g., “I have a hard time completing my assignments,” “I stay home from school more”), and extracurricular participation (e.g., “I don’t go to after-school activities”). The MBIS was developed to assess the multidimensional impairment experienced by youth who have been bullied. Most existing measures are designed to assess bullying prevalence, youth attitudes toward bullies and victims, student perception of teacher responsiveness to bullying, and related constructs such as school climate, school culture, and typical peer relations (e.g., Rigby & Slee, 1993; Solberg & Olweus, 2003). No measure currently exists to assess the resultant socio-emotional consequences of being bullied and how that impairment changes over time. MBIS domains and items were based on a review of the literature and by adapting items from related impairment scales (e.g., Child Automatic Thoughts Scale [Schniering & Rapee, 2002]; Behavioral Activation for Depression Scale [Kanter, Mulick, Busch, Berlin, & Martell, 2007]; and Response to Stress Questionnaire [Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000]).

Overall Outcomes, Feasibility, and Acceptability Given the small sample and uncontrolled design of this pilot, demonstrating the efficacy of GBAT-B was not the primary aim. However, pre- to posttreatment assessments identified trends in the expected direction (Table 1). The three youth who met criteria for a pretreatment anxiety or mood disorder experienced remission in their principal diagnosis and remission in most comorbid disorders. Child five experienced a worsening in her comorbid social anxiety disorder (SAD), but improvement in her principal major depression disorder (MDD) and comorbid generalized anxiety disorder (GAD). Bullying impairment, as rated by the ADIS-B interview module, also demonstrated a decline in impairment for four of the five youth. Total scores on the self-reported MBIS decreased for three youth, was relatively stable for one youth, and increased for one. Of the four participants who reported significant anxiety and mood symptoms at pretreatment,

three demonstrated clinically significant change in the CES-D (reliable change index; Jacobson & Truax, 1991) and two in the SCARED, by youth report. Parent response to data collection was more limited, but the one parent who reported significant anxiety and depression symptoms at pretreatment also reported significant change by posttreatment. These findings provide very preliminary support for improvement in anxiety and mood symptoms, and in functional impairment associated with bullying. Attendance records and satisfaction ratings suggested that the group was both feasible and acceptable. Group attendance was strong (M = 13.2 sessions, SD = .45), with four of the five members missing one group session and one youth attending all 14 sessions. Satisfaction ratings suggested the group was well received by participating youth. Out of a possible range of 0–3, the mean GSQ score was 1.79 (SD = .89), indicating a mean rating approximately equating to “good.” The overall feedback was generally positive, although several group members reported important concerns and suggestions. When asked what they liked about the program, group members reported: “We talked about problems similar to mine,” “How we would do role plays to solve our problems,” and “I liked my group members, they were helpful along with group leaders.” One group member stated that he learned how to better cope with anger, while another member reported learning “new ways to deal with things.” In terms of what group members disliked, one member reported disliking fellow group members, another described frustration with the group having to stop to address problematic behaviors, and another disliked missing class. When asked what they would change about the group, group members suggested adding more role plays and making the activities more fun and active. Overall, three of the five youth rated the overall quality of the group as “good” or “excellent,” while two others rated it as “fair.”

Case Descriptions Youth 1 was a 13-year-old, multiracial (Hispanic and White) seventh-grade boy, living with both parents and one sibling. The father (graduate equivalency diploma) worked as a skilled laborer and his mother (college graduate) worked in industry, earning an annual $100,000–$150,000. Youth 1 had an individualized education plan to help manage an auditory processing disorder. At pretreatment, Youth 1 was diagnosed with SAD and reported that he did not have many friends. He reported that he was involved in several incidents of bullying in which a group of his peers teased him for being short, spread rumors about him, and called him names such as “Goody Two Shoes” and “Baby.” Youth 1 reported that bullying negatively impacted his mood,

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

Transdiagnostic Behavior Therapy for Bullying relationships with friends and family, and school performance. During group, Youth 1 was often quiet, but participated when prompted by one of the co-leaders. Youth 1 particularly benefited from the assertiveness module and actually practiced his assertiveness skills on behalf of Youth 4 in a bullying incident in the school cafeteria. In this incident, Youth 4 was approached by another student who often bullied him. The bully began to tease Youth 4 and threatened to beat him up. Youth 1 stepped in and told the bully to stop and that the bully should not hit Youth 4 because Youth 1 would back him up. Youth 1, Youth 4, and their friends then proceeded to walk away from the bully who did not end up hitting Youth 4. Youth 1 was very happy to have been able to intervene on behalf of Youth 4 and readily shared the incident at the subsequent group when reviewing assertiveness homework. This was also used as an example of “mobilizing your forces” for Youth 4, as it demonstrated that he could call on friends in situations where he previously felt isolated. Toward the end of the group, Youth 1 also began to participate in more role plays, suggesting a growing confidence and social efficacy. At posttreatment, Youth 1 reported a remission of his SAD diagnosis and did not report any recent bullying incidents. Overall, he had a better outlook on his ability to handle bullying and reported that bullying was only mildly impacting his mood, relationships with friends and family, and school performance. Video 3 illustrates a similar example where a youth is the target of cyber bullying. The youth calls on her brother for support and to brainstorm options. In Video 4, the girl describes the experience she had to the GBAT-B group. The group leader reminds the group of the TRAP/TRAC skills and illustrates how to brainstorm options and then select a helpful, active choice. Her TRAP acronym reveals a tendency to isolate and push others away: trigger (kids took her phone and falsely texted under her name), response (embarrassed, confused), avoidant pattern (go home and crash on bed, forget about it because I felt bad, ignore my

Video 3. Mobilizing Forces Vignette: Cyberbullying.

Video 4. TRAP-TRAC for Cyberbullying.

best friend because I didn’t want to talk to anyone). Her active choices each had pros and cons, but had the potential to move her in a positive direction: (a) finding the person who took the phone and tell him or her off, (b) leaning on friends instead of ignoring them, (c) telling an adult and (d) go for a run. Youth 2 of the group was a 12-year-old, Caucasian seventh-grade boy who had a preexisting diagnosis of Asperger’s disorder. His parents were divorced and his mother had full custody. The mother (high school graduate) was currently unemployed, and the father (college graduate) worked in the sciences, combining to earn between $20,000 and $30,000. At pretreatment, Youth 2 met criteria for subclinical SAD and self-reported anxiety symptoms. He reported a long history of bullying and described mostly name-calling, such as “Nerd,” “Four eyes,” and various homophobic slurs. Youth 2 endorsed difficulty maintaining friendships and attributed his social difficulties to bullying, stating that his classmates “constantly” made fun of him. Youth 2 was initially reserved, but he quickly started looking forward to each group and participated readily. Consistent with his Asperger’s disorder diagnosis, he had a difficult time with more abstract concepts, but excelled with the use of concrete, written materials. For example, the use of the social network circle allowed him to assess his support system in a visual way. The social nature of the group also provided important peer support and practice in sharing and engaging others. Youth 2 particularly benefited from the “Building Your Social Network” module. He initially endorsed having no friendships, but gradually added names of group members to his social network over the course of treatment. At the same time, the difficulties inherent in having an individual with an autism spectrum disorder in the group were apparent. As he became more comfortable in the group, he became very verbal and attention seeking with other members and was unable to recognize nonverbal social cues from group members and leaders. Toward the latter end of the group, his behavior required the group leaders to pull him aside

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

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Chu et al. often to explain why his behavior (e.g., butting in, taunting) was inappropriate (e.g., alienating others). At posttreatment, Youth 2 was still experiencing bullying on a daily basis, though he no longer reported any impairment from SAD. In regard to bullying, he stated, “The group didn’t change [the bullying] but it helped a bit on how to handle it.” By the end of group, Youth 2 was regularly visiting his school counselor to discuss his victimization. He reported that bullying only mildly impacted his mood, relationships with friends and family, or school performance. Youth 3 was a 12-year-old, Caucasian seventh-grade boy who lived with his father and older sister. The boy’s mother passed away several years ago. His father (college graduate) worked in retail sales, earning an annual $30,000–40,000. At pretreatment, Youth 3 met criteria for SAD and GAD, with subclinical diagnoses of MDD and separation anxiety disorder (SEP). Youth 3 had few friends and reported a significant bullying history involving being teased, excluded from groups, being called homophobic slurs, and being told that no one likes him. He had also been punched by older kids in his neighborhood, excluded from lunch tables at school, and left out of games in the neighborhood. He reported that bullying most strongly impacted his relationship with his family as he became easily annoyed by his father and sister, didn’t want to spend time with them, and felt he couldn’t confide to his family. Youth 3 found the structure of the group helpful, enabling him to speak with peers about his problems. The structured role plays and exposure component also engaged his more creative side, and prompted him to think about solutions to bullying in ways that he had not before considered. For example, during the course of a role play about making new friends, he was especially persistent when trying to ask a confederate peer to “hang out.” He later reported that he had been able to engage new friends because of the tactics he learned in group. Youth 3 also utilized his assertiveness skills outside of the group. Instead of responding passively when a friend returned a broken video game to him, he confronted his friend about the game in an appropriate manner, which did not result in conflict. Youth 3’s sad mood was problematic in that he would present as moderately withdrawn if group occurred when he felt negatively. In addition, Youth 3 and Youth 2 were often in conflict, and Youth 3 had little tolerance for Youth 2’s comments (perceived as insensitive) and frequent interruptions. Youth 3 would withdraw from group and choose not to participate in activities. The group leaders used this as an opportunity to model communication skills and to appropriately communicate the expression of emotion and boundaries to a peer. Youth 3 rated the overall quality of the group as “good” and noted that he learned “new ways to deal with things.”

At posttreatment, Youth 3 no longer met criteria for SAD or GAD and no longer had subclinical diagnoses of MDD or SEP. Youth 3 reported that he was still teased about once a week, but he was better equipped to deal with the bullying. He reported that being teased “messed up [his] mood,” but only for a short period of time as he was now able to “let it go” more easily. Youth 3 also reported a decrease in overall negative impact of bullying and noted an increase in his perceived ability to handle bullying. Youth 4 was a 12-year-old, Caucasian seventh-grade boy who was an only child and lived with his adoptive father. His mother had passed away when the youth was 11 years old. Both parents had graduated from college, and his father currently held a professional job, earning between $50,000 and $60,000 annually. Youth 4 had an individualized education plan to help manage a previous diagnosis of attention deficit/hyperactivity disorder (ADHD). At intake, Youth 4 did not meet criteria for any anxiety or mood disorder, though his father reported that the youth was previously in treatment for problems related to anxiety and depression and had received in-home therapy following the loss of his mother. Youth 4 reported being bullied on several occasions during the present school year in connection to his ADHD classification and death of his mother. A small group of kids would say that his mother died because she was “weak” and “an idiot,” and they would call him mean names for receiving special services in school. Youth 4 also reported that students had spread rumors about his sexuality and that he had been physically bullied on the playground (i.e., hit in the eye). While Youth 4 reported that he was able to handle bullying, he did admit that he wished it wasn’t happening. Youth 4 was one of the most outspoken group members, and was always happy to volunteer for role plays. Youth 4 experienced the most bullying incidents throughout the course of the group, and had difficulty not responding through equivalent aggressive gestures. During assertiveness training, Youth 4 worked with group leaders to find a middle ground between passive and aggressive responses to being bullied, which would not leave him continually vulnerable. For example, when an argument occurred outside of group with another group member, the co-leaders helped the youth conduct an individualized functional analysis using the TRAP acronym, identifying where he would ordinarily let avoidance interfere with maintaining the friendship. In this case, trigger (seeing the other member at lunch sitting with Youth 1 and 2), response (feeling betrayed by friends), and avoidance pattern (sitting by himself). With guidance from the leaders, he was able to incorporate assertiveness skills (speaking to the other member in a calm and assertive way, while stating his feelings). In this case, employing approach-oriented assertiveness skills was his adaptive coping response (TRAC) that helped directly

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

Transdiagnostic Behavior Therapy for Bullying address the problem. The other group member was receptive to his viewpoint, and the two were able to find a resolution. At posttreatment, Youth 4 did not endorse symptoms of anxiety or depression. He did endorse being bullied within the last month, stating that it occurred at least a couple of times per week. Nevertheless, Youth 4 reported that bullying was only mildly impacting his mood, relationships with friends and family, or school performance. Based on his report, the group helped him deal more effectively with these problems, although he wished there were more role plays incorporated into the program. Youth 5 was a 12-year-old, Hispanic seventh-grade girl who lived with both parents, four siblings, and eight other family members. Her mother (high school graduate) and father (some high school) both worked as skilled laborers, earning a combined $30,000–40,000. At pretreatment, Youth 5 met criteria for MDD, GAD, and SAD. Youth 5 walked with a limp due to a congenital disability and reported being teased often because of her gait. Youth 5 was often reprimanded by teachers for being late to class because she only used a particular, farther away, staircase to avoid bullies. She reported that bullying most strongly impacted her ability to succeed in school and that she had a hard time completing assignments, was distracted in class, and noticed a drop in her grades due to her worry about being teased. During the group, Youth 5 was mostly reserved, but participated when called upon by one of the co-leaders. The fact that Youth 5 was the only female in a group of sometimes-rambunctious males may have contributed to her quiet presentation. Youth 5 often did not complete homework and frequently forgot her workbook. Youth 5 recognized the value of mobilizing her forces and the need to rely on different people depending on the context and severity of a bullying incident. She was able to use her bullying thermometer to determine in what circumstances it was best to rely on peer support (e.g., teasing) versus telling her parents or a school administrator (e.g., cyber bullying). Her use of this skill was further brought to life during a role play in which she helped another youth determine who was the best person to access after a bullying incident. Over the course of the group, Youth 5 became closer to Youth 3 and became more assertive. She often stood up for Youth 3 when other members interrupted him (e.g., “Please let him finish speaking”). Overall, she seemed to enjoy group discussions and gained confidence in speaking up during the group. Youth 5 found the group helpful and liked that the group discussed problems relevant to her life. However, Youth 5 disliked that time was often taken away from the group for group leaders to address “fooling around.” At posttreatment, Youth 5 no longer met criteria for MDD or

GAD, but retained her SAD diagnosis. Symptoms of depression and anxiety also decreased by youth report. However, Youth 5 reported an increase in the negative impact of bullying. This reflects her feeling that there was too much horseplay that distracted from group content, which may have led her not to benefit as much from the group. For Youth 5, much of the work came through in vivo exposures. One of the unique additions that GBAT-B adds to the traditional BA program (Jacobson, Martell, & Dimidjian, 2001) is its focus on in-session in vivo exposures. In school, many of these exposures took the form of group role plays, though the group was encouraged to make full use of the school environment (e.g., administration offices, approaching teachers, peers, lunchroom) when possible. Video 5 demonstrates using the TRAP acronym to set up a social exposure for a shy girl who has been invited to a party. This is not identical to exposures conducted with Youth 5, but reflects similar themes. The girl identifies how the party (trigger) antecedes anxiety (response) and leads her to procrastinate or stay by herself at the party (avoidance responses). Figure 3 is a worksheet used to help structure the exposure set-up. Video 6 illustrates a first attempt to role play a party experience and Video 7 demonstrates a second trial. These videos are presented to remind

Video 5. Social Exposure Setup: TRAP.

Video 6. Social Exposure Trial 1.

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

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identify strengths and weaknesses that the client brings to the situation.

Discussion

Video 7. Social Exposure Trial 2.

therapists that repeated trials are essential to practicing skills. Viewing multiple trials also enables the therapist to

This paper introduced a novel bullying-specific adaptation to a transdiagnostic behavioral therapy using case studies and video illustrations. GBAT-B appeared feasible to implement in at least one school setting and was received well by participating youth. Satisfaction ratings were high and no incidents of stigma were reported. This was important as there could be an increased risk associated with identifying and labeling youth who are already targeted by their peers. To minimize this risk, we used traditional methods for maintaining privacy, such as discussing privacy and confidentiality at the beginning of the group and holding the group in the guidance office where the student body came for numerous academic activities. Additionally,

Figure 3. Exposure Worksheet. Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

Transdiagnostic Behavior Therapy for Bullying treatment materials (e.g., workbooks) focused on coping “skills” rather than using pathologizing terminology. Within the group we communicated an atmosphere where any bullying was unacceptable. For example, in one session, two of the members were talking about a third youth they did not like who was not in the group. When they began to mock the child, the group leader reminded them that rules about teasing and bullying extended to everyone. We felt this type of communication conveyed a zero-tolerance culture, even for youth who have been bullied themselves. Using BA and exposure as the basis for this adaptation seemed appropriate. The proactive nature of the skills focused on approach solutions within a strength-based framework. The focus was not to eliminate symptoms so much as to help students identify goals and work toward them. The BA framework promoted attending to the reinforcing events and experiences that occurred from “putting oneself out there.” Role plays and in vivo exposures reinforced the lessons that challenging tasks and situations become easier over time. These principles were consonant with the bullying modules that emphasized mobilizing one’s internal and social resources in proactive ways. Implementing any anti-bullying programs requires familiarity with state and district laws and regulations. For example, in New Jersey, where this program was implemented, bullying is defined legally as violence perpetrated on a “protected class” whereby a victim is targeted because of race, gender, sexuality, or disability (New Jersey Anti-Bullying Bill of Rights Act, 2011). Further, it is required that the perpetrator be of a dissimilar class as the bullying victim. For the purpose of this study, we had to negotiate with the school administration and counseling staff to include a broader set of victims beyond those who met the legally specific criteria. The school was similarly interested in expanding services, but we needed to keep in mind that youth who fit the state’s legal definition of bullying victims required additional services, such as participating in formal mediation and monitoring. Such idiosyncrasies across states and school districts may impact attempts to identify and intervene broadly. Program developers and implementers will want to be aware of such differences. A second goal was to develop a multidimensional bullying impairment scale. The MBIS was designed to assess functional outcomes related to friends, family, academic performance, school attendance, and participation in extracurricular activities. Youth reported a range of scores on the MBIS with two youth reporting pretreatment MBIS scores under 12 and three youth reporting scores over 23 (out of a total possible score of 60). The lower-scoring youth experienced most forms of impairment “sometimes,” while the youth with the higher scores experienced most kinds of impairment “sometimes” to “often.” These impairment scores were generally lower

than we expected for the types of bullying each reported. It may have been that youth were confusing the degree of impairment with frequency of bullying events and impairment. To ensure that youth are using the full range of scores, it might be necessary to provide reminders to respondents that they should be thinking about the degree of impairment (once a bullying event has occurred) rather than an averaged amount of impairment over a fixed period of time. The MBIS also appeared sensitive to change as the three youth with more favorable diagnostic and symptom outcomes also reported lower posttreatment MBIS scores. The one youth with poorer outcomes reported an increase in bullying impairment. Future research will want to recruit larger samples and conduct formal psychometric evaluation (e.g., reliability, validity testing), but the MBIS may be a promising tool to evaluate functional impairment experienced from bullying. One important area for future development would be to enhance how a group like GBAT-B addresses bullying in sexual-minority youth (e.g., lesbian, gay, bisexual, transgender). In our pretreatment interviews, two of the five youth reported being teased with homophobic slurs. It was unclear to us if either of these students identified as a sexual minority or was questioning his sexual identity. In deciding whether to introduce this topic explicitly in the group, we struggled with several considerations. First, research shows that lesbian, gay, bisexual, and transgender youth experience higher levels of victimization and report more emotional and behavioral adjustment difficulties than heterosexual youth (Williams, Connolly, Pepler, & Craig, 2004). We recognized the strong impact that such attacks could have on any student, even if these youth did not identify as sexual minorities. Second, the authors’ interest in developing this program was directly tied to related contemporaneous social-political issues. In 2010, Tyler Clementi, an undergraduate student at Rutgers University in New Jersey, committed suicide after he was bullied because of his sexual orientation. Clementi’s death brought local and national attention to the special needs of sexual-minority youth and helped galvanize support for amendments to the New Jersey Anti-Bullying Bill of Rights Act in 2011. The group leaders and supervisor weighed the pros and cons of various ways to incorporate the topic of homophobic slurs. We decided not to introduce information into the group that was reported in intake interviews unless the group members introduced the topics themselves. We felt this was important to protect each member’s privacy and to enable each student to “introduce” themselves without past labels. Neither boy ever introduced the topic of homophobic slurs to the group. However, a more proactive approach that protected privacy might have been to create a specific module on coping with attacks about one’s sexuality. Such

Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

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Chu et al. a module could have normalized the topic and decreased barriers to discussing individual experiences. Such a module could also be expanded to address concerns of other protected groups (e.g., race, religion, sex). Of course, it is not clear that such a module would be relevant to all youth, and so, a compromise might be to administer such a module if some members identify such concerns during intake interviews. Alternatively, a separate group could be created for youth who identify as a sexual minority. The same skills could be used, but the initial framing could focus on sexual-minority issues. Such a plan would want to weigh the positives that come with providing a supportive forum for youth with a specialized need with the potential risks of marginalizing a specific group of youth. Youth who have not yet self-identified as a sexual minority, or who are being bullied as a sexual minority, might also be hesitant to join a specialized group. A simpler solution might be to privately discuss any of these issues in an individual meeting with any youth reporting such experiences. Each alternative deserves further exploration. There may be additional reasons to develop specialty groups for bullying interventions. Youth who have been victims of bullying and who also bully others (i.e., bully victims) might be better served in a separate group. Such a group could introduce additional skills to build anger management skills and social problem solving. Further, a separate group might be warranted for victims with prominent social skills deficits. While the anxious and depressed youth in our group displayed withdrawn, inhibited behaviors that interfered with social interactions, most had age-appropriate social skills. Youth 2 who had been diagnosed previously with Asperger’s disorder demonstrated a need for more specific social skills instruction. A separate group that focuses on communication skills, perspective taking, and social reciprocity might be called for with such youth. Practice sessions might then shift from a focus on assertiveness to an emphasis on initiating and maintaining friendships. Overall, initial development of the GBAT-B program appears promising. In this small pilot group, clinical and functional outcomes were encouraging, where many diagnoses remitted from pre- to posttreatment, and symptom severity declined. Importantly, perceived impairment related to bullying decreased for most group members. GBAT-B uniquely addresses emotional distress associated with bullying by building skills where victims of bullying may have deficits: awareness of their social network, optimally utilizing their social supports, and assertiveness/decision making in times of threat. In addition, GBAT-B uses behavioral activation and exposure strategies that teach an approach-oriented coping style where withdrawal and isolation may seem the natural response. Replication with larger samples sizes, in controlled trials, is required to determine the efficacy and value

of GBAT-B. However, with continued development, GBAT-B could provide an important resource to schools.

Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.cbpra.2014.06.007.

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Please cite this article as: Chu et al., Transdiagnostic Behavior Therapy for Bullying-Related Anxiety and Depression: Initial Development and Pilot Study, Cognitive and Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.007

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