This article describes a successful intervention for a nine year old boy presenting emerging test anxiety and extreme blushing. The treatment consisted of a group-based cognitive therapy (CBT) in the school setting. This case-study illustrates how CBT can be applied within primary school addressing test anxiety when the concern is not only on the level of an emerging mental health problem, but also on a specific symptom. Mental health problems are a major concern in primary education because they negatively affect socio-emotional as well as academic school functioning. Within the ecological context perspective of Bronfenbrenner schools represent a key component of the child’s microsystem: they are one of the most proximal influences on a child, and understandably, represent the primary setting where children show impairment due to mental health problems 1. Research demonstrates that school-based cognitive-behavioral interventions that focus on small groups or individual students yield improvements in emotional, behavioral, social, and academic functioning 2. Nevertheless, within the field of school psychology there is a gap between research and practice that seems to be caused by difficulties in translating the programs from research to the realities of the school setting 3. Illustrations of real-life cases may help school psychologists gain insight into the application of interventions.

Test anxiety refers to feeling tense, fearful, and worried in evaluative situations4. It has formally been defined by Dusek as an “unpleasant feeling or emotional state that has physiological and behavioral concomitants and that is experienced in formal testing or other evaluative situations” (p.88) 5. It has been estimated that between 10% to 40% of all students suffer from various levels of test anxiety 6. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; 7), test anxiety is included indirectly as: “Individuals with Social Phobia often underachieve in school due to test anxiety(…)”. Bögels et al. argue that pervasive test anxiety is a form of social phobia (or social anxiety disorder), if fear of negative evaluation by others is the core issue, as was true for the current case 8. Test anxiety poses students at risk for underperformance on achievement tests, poor grades, repeating a grade and school drop-out 9101112. As such, it is important for schools to reduce test anxiety in their students effectively 13.

Blushing can be one of the symptoms of test anxiety 7. According to the communicative account of blushing, blushing has a remedial function. It communicates to observers that one is sensitive to their judgment 14. Experimental research shows that blushing causes others to make more favorable appraisals. A blushing person is considered to be more trustworthy, less responsible for violating a norm and more friendly compared to a person that does not blush, but for example only shows shame 15. Despite these positive effects, blushing is involuntary and uncontrollable and signals to others the presence of emotions that a person perhaps would like to suppress. The social blushing theory states that blushing occurs when a person receives undesired social attention 16. Particularly in young people, blushing is a bodily symptom that can occur in situations of increased self-consciousness 17, and these situations are common for children with test anxiety. Further, it is important to note that blushing is not only an especially salient physiological reaction (feeling warm cheeks), it is also clearly observable to others. As blushing often occurs in situations where one would rather not increase the attention of others, blushing can be highly aversive and for anxious individuals it can become a source of shame and anxiety in its own right 18.

In the case presented in this article, a nine year old boy was referred to the school psychologist because the teacher noticed that his learning was impaired by a fear of failure. Whereas the teacher felt it was important for him to be able to concentrate on learning; the boy and his family concentrated on the experienced worries, fears, nervousness and extreme blushing. In other words, the important outcomes were: reduction of test anxiety, blushing and the more indirect outcome of school achievement. An important question of the case study was whether the blushing would be reduced by a CBT that was focused on test anxiety. This was the expectation because, not only is CBT one of the interventions that is recommended for treating test anxiety 1319; Drummond and Su argue that anxiety management strategies in clinical settings reduce fear of blushing and blushing itself 20. They demonstrated that social anxiety rather than expected or perceived blushing can increase facial blood flow during embarrassment. Therefore, reduction of anxiety should also lead to subsiding of the blushing.

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

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

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

Tim and his parents were interviewed separately from each other using a semi-structured interview. Tim explained that he was very nervous at school before and during tests, and when speaking in front of the class or several classmates. His major concern was that he blushed frequently. According to Tim: “It happens all the time and I get really embarrassed”. Tim said that he would like to show more initiative in certain situations, such as playing a game, but that his shyness and nervousness withheld him from doing so. With concern to his school work, Tim often felt unable to concentrate and had many worries (“I think I will fail”, “I feel uncertain about the task”, “I think I might not be smart enough”).

Tim’s parents showed great involvement and his mother recognized some of the anxiety symptoms from her own youth. The parents confirmed that Tim was bothered frequently by his anxiety and felt helpless in not being able to reassure him. Tim’s parents knew that he blushed a lot at school whereas at home he was much more relaxed. The parents were discussing repetition of the fourth grade with the CC because of the little progress that Tim made during the school year. They thought that their son was “a sweet, open and bright boy”, but that his fears interfered with his ability to learn. They thought that Tim not only had low test scores, but also had actually learned less than he would have done when he had not been anxious. The symptoms seemed to have developed over a period of one year. The onset of test anxiety at this age falls within the normal range.

Tim completed two self-confidence subscales of the School Attitudes Questionnaire (SAQ; 21): expressive skills and self-confidence in examinations. The SAQ is a psychometrically sound and well-accepted diagnostic tool in the Dutch educational system. Each of the SAQ items consisted of a proposition, and the participant is asked to judge if the proposition is applicable to himself or herself on a short Likert-type response scale that has three options: that is the case, I don’t know, and that is not the case. Construct validity and reliability of these scales are good 21. In comparison to the norm scores, Tim showed confidence well below the average (stanine 3) on the self-confidence in examinations scale (an example of an item is: During a school test I am usually calm and able to work with concentration) and extremely low (stanine 1) on the expression scale (an example of an item is: I get shy when everyone in the classroom suddenly looks at me).

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

In this study, it was investigated what the effects of a small group CBT were for a case of test anxiety with extreme blushing. The current paper described the improvements of Tim during a program that was given in weekly sessions. Multiple informants and methods provided information that supported that the program was sufficient for both the anxiety as well as the blushing. The positive effect on the school achievement was also supported. The findings therefore confirmed our hypotheses.

With respect to the blushing, it was found that no adjustments to the program needed to be made. The blushing was, however, given attention to in response to initiatives of Tim to share his feelings on this topic. Within the small group CBT there it was possible for all children to share their thoughts and feelings and specific concerns. This may be a factor that is essential to meet the specific needs of all children in a group based program. For this purpose, it seems essential to create a therapeutic environment that feels safe and secure 23. The relationship with the psychologist 24, but also feelings of safety and friendship between the children should be fostered as these aspects are an important precondition for emotional disclosure in school-aged children 25. Making positive rules together with the children (e.g., ‘We listen to each other’) and verbally reinforcing prosocial behavior are concrete examples of how this can be established.

The improvement in Tim’s confidence in expressing himself in the presence of others showed a ‘sleeper effect’ (i.e., a delayed effect of treatment) 26. This effect might have occurred because Tim needed more practice and positive experiences before an increase in confidence could be achieved. During the treatment, Tim already showed great improvement in the exposure exercise, but there are many different situations in which expression oneself for an audience is needed (e.g., getting a turn in class or being invited for a social event). What is interesting is that Tim already expressed self-assurance in using the learned techniques in order to become more confident directly after the program. When the results of an intervention seem to be disappointing, it therefore might be informative to ask children about their faith in further improvement and to monitor this.

In conclusion, this case study is an illustrative example of how small group CBT can be applied in the school setting. The gap between research and practice needs to be narrowed because the school setting can have a great impact on a child and is also an important setting where children present mental health problems. The current problem of test anxiety is a clear example of this. The success of the intervention supports the possibilities of schools in fostering a healthy socio-emotional development in children.