SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2018/Day 2

Day 2

Keynotes

Recent Advances in the Development of Psychological Treatments for Adolescents with Panic Disorder

Presenter: Donna B. Pincus, Ph.D., Boston University

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/5gm2h/?action=download%26mode=render

Learning Objectives:

List the three common triggers for panic attacks that comprise the “cycle of panic”

School nurses on front lines because biggest trigger zone is school setting. Emotion of fear is human- fear from inside out, the scream, shaggy etc. Fascinated by the emotion of fear- horror movies, roller coasters, skydiving Also fascinated by bravery- Harry Potter, superman, Brave Panic is different because trying to escape something inside of you Afraid heart will stop or they’ll freak out and everyone will see Fear and anxiety are natural- adaptive, protective feeling Not an attack- just the fight or flight system (Sympathetic and parasympathetic nervous system) She doesn't call it a panic attack with patients, these are just internal feelings, boiling down the ANS with children and it is not going to * actually hurt you but it can help. Thinking it is dangerous rev the anxiety up. Ask kids how the ANS somatic symptoms can serve a purpose/adaptive. Break it down with them, tell them the reason why anxiety is like an annoying watchdog... Can improve performance or focus in appropriate amounts How can physical sensations of anxiety be adaptive? Sweaty- It cools you down, makes you slippery so if something tried to get you it’d slide off Stomach Ache/nausea- When we have a panic attack, we never usually throw up Dizziness- blood to legs to run Heart racing- body taking blood to legs Shortness of breath- ready to run Panic like a yappy watchdog that barks when it’s safe like the mailman Why is this important? Understudied and debilitating, significant interference with everyday life, tends to go into adulthood, many families don’t have good access to help One strategy to help Shake head side to side and try to feel anxious Run in place for a minute: 45 seconds to a minute to come down See how long it takes to go down See that we can observe the feeling Use spinny chair: watch how quickly it comes down, notice triggers and that anxiety does dissipate. Help them know the facts. Take small straw and break through it: 15-20 seconds to go back to homeostasis Crux of panic is fear of physical symptoms Interoceptive exposure- learning to learn how not to fear Hopeful message- 70% diagnosis free at post-treatment What is panic disorder- you don’t know trigger sometimes, it surprises you, you can have panic attacks in other anxiety disorders but in panic disorder it is where you start to avoid situations and fear having an attack. Discrete period of intense fear quickly brought on and intense physical symptoms Panic attacks can happen to anyone, but the disorder is the fear of having the attacks Panic attacks don't come out of the blue but there are triggers and some have a vulnerability to having panic attacks due to genetic or biological factors, environmental stressors, separation anxiety in early childhood Example- teen girl whose mom quits job to sit in school parking lot because that’s the only way that teen will go to school and mom rocks her and makes hot chocolate- inadvertently reinforced. Family relationships important but we don't want the anxiety to be the glue. They still have a role just not to be their anxiety banisher. Mom was sad when cured, so treatment has an aspect of what the relationship will be like after being cured. Prevalence of panic disorder 36-63% of kids have panic attacks, 5% have disorder Phenomenology- adolescence is peak time Associated functional impairments- depressed mood, social impairment, educational underachievement, substance use- “numb out to get rid of symptoms of panic, family disruption

List several places that adolescents commonly avoid due to fear of panic
Places- Gym, parties, mood restaurants, school

Observe evidence-based treatment for panic in adolescents

PCT-A (Panic control treatment for adolescents) 11 session panic control treatment - psychoeducation, cognitive restructuring, interoceptive exposures, graduated exposures and elimination of safety behaviors, review of skills and relapse prevention Examples of developmentally tailored components of treatment- like a stective, teen friendly analogies, drawing things Didn’t have therapist with them for exposures Study- patients getting PCT-A feel below clinical level on clinical severity rating (level 4 of 8) in anxiety as well as marked change in depression and avoidance But need a more intensive treatment option? Some parents can’t wait 3 months because needs to go to school soon or lives far away Potential benefits of exposure Expand access to treatment Provide more immediate relief How? More therapist/family involvement 8 Day intensive panic treatment Changes- simplified language, framing exposures as “riding the wave,” developed parent component, in vivo exposure with therapist One condition had family involvement and one did not Breakdown- Day 1 & 2- psychoeducation, cognitive restructuring, building motivation for exposure, teaching them cognitive techniques Day 3- hour in a half or so, interoceptive exposure and rationale for exposure Day 4 and 5- graduated in vivo exposre with therapist accompaniment Day 6 and 7- the therapist phases out, weight being lifted off their shoulders, self practice Day 8- review of self-practice, relapse prevention, plans for future in vivo exposure, launching pad to go out and use these skills, continue to practice in their natural environment, practice is hugely important. Three component model- physical sensations, thoughts, behaviors Myths - going crazy, losing control Parent training- don’t model anxiety; parents come to at least 30 minutes of each session and participate in some interoceptive exposures Parent and non parent groups did well 73% panic free at 12-month follow-up Limited by small and not as diverse as wanted sample Many forms of avoidance- refusing to try something new, numbing with substances, limiting choices

Summarize findings from randomized controlled trials of panic disorder

Utilize evidence based psychological treatment tools to treat panic disorder

Describe novel ways that evidence based treatments for panic disorder in adolescents can be disseminated more broadly to the public
Working with MA school district to see if treatment could be delivered in school Giving nurses iPads to do ecourse for kids to do while there for free based on “riding the wave,” live talk with therapist after certain modules Challenges- getting people on board

Special Issues in Clinical Child and Adolescent Assessment

Presenter: Andres De Los Reyes, Ph.D., University of Maryland at College Park; Director, Comprehensive Assessment and

Intervention Program (CAIP); Editor, Journal of Clinical Child and Adolescent

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/kz6rc/?action=download%26mode=render
Learning Objectives:

Understand the typical patterns of correspondence within multi-informant assessments of mental health

Often get different answers about mental health from different people and who needs care or are interventions making a lasting impact Why do people give you different answers? Children and adolescents lead complex lives Example- Adolescent experiencing great anxiety in any performance situation but no problem one on one Example- kid with no problem with audience, scared of one on one Example- knows what to do until no social expectation of what to say All 3 people probably act fine with friends Clients all unique- but want problem to look the same from all angles but hard to reconcile with diversity that comes into clinic How often do we see discrepancies? Achenbach meta analysis form 50’s to 80’s and correlated raters’ ratings and found correlation of .28 which is almost moderate De los Reyes meta analysis 2015 from 80’s to 2015 and got correlation of .28 Open science/replication crisis De los Reyes follow up in press to meta analysis- where is data coming from? Mostly Europe and U.S but broad from 33 countries and results consistent across countries

Learn about theories underlying why multi-informant assessments might yield discrepant outcomes

What do informant discrepancies mean? Maybe some informants are stressed or error Achenbach said it was context-specific differences- kids acts differently in different places. People agree more for easy to see stuff like aggression and less on like anxiety or depression. People agree more if they are viewing from the same context. When pairs of teachers, both parents, etc. see the same thing in the same place for internalizing and externalizing. Continuous measures better than discrete measures, so do continuous have better correlations? More bang for your buck if you measure things continuously more than discreetly. Discrepancies can become useful tools if you set yourself up to understand it. Not every measure you use is valid and reliable. Multi-informant discrepancies may occur because sometimes children behave differently in different settings or the clinician did not prep right for the assessment.

Learn approaches for integrating cross-informant data in clinical assessments

Operations triad model (OTM)- Just because discrepancies often occur doesn’t mean they always occur or mean the same thing when they do Converging operations Diverging operations Compensating operations- easy because you can average Know there’s need for care if anyone says there is Are informant discrepancies useful? Assessments of preschool disruptive behavior Chicago preschool project- 288 kids and parents, some with and without behavioral problems Collected data about destructive behavior from moms and teachers Developed destructive behavior diagnostic observation schedule (interview for destructive behaviors) Had been getting bad info because kid acting good so have different people assess and then ask kid to pick up toys and then assess further to see if there’s a pattern of disruptive behavior 8% display disruptive behavior all the time, some more in home setting, some in non-home disruptive Used late class analysis- using groups of people not items (like factor analysis) that produces a control group For disruptive behaviors when parent and teachers say different things it maps to different behaviors and settings in the lab 3 groups- anybody says yes then similar outcomes as adults 4 categories- teacher yes or no and parent yes or no Context and assessing child Autism spectrum disorder When parent and teacher information converges it indicates the severity. Context and assessing adult social anxiety disorder [1] (also see Achenbach 2005 meta-analysis for adults) Can find people who show social impairment across context shows convergence of client and clinician agreement is high versus people who show a few symptoms Take home- What should I do when I collect data from multiple informants? Discrepancies are predictable in terms of pattern and direction Understand clients’ spaces- home, school, peer relations Parent giving them scaffolding at home that’s making it only show up at school Construct hypotheses about what you expect to get from informants Test hypotheses about informant discrepancies- administer independent assessments and gather info from other sources to corroborate like academic record “Trust but verify” Not logical to chock it up to measurement error or someone’s bias or bad day What if I don’t have access to multiple informants or can’t get assessment from a particular area of child’s life? Social anxiety- lots of anxiety interacting with non friend peers De los Reyes collects peer report Is there a way to test discrepancy between adolescent and parents? Kid might be giving something like interaction with peers that parent doesn’t see Peer report usually given to whole school “who in your school hits people” or “is shy” Colleague had trained adults to act as peers and found young-looking undergrads to be a “peer” and change the measure wording to not say “my child” - peer confederate Trained them to carry out a few tasks that are structured and unstructured and then give speech- always find unstructured most stressful Social anxiety scale Thin slice judgements- social psych- get a bit of observation and make predictions, so can the peer see them 20 minutes and fill out things Adolescent-confederate correlations .4-.5 So has incremental usefulness Confederate can also predict well the adolescent’s felt social anxiety Does this triad of informants produce data that when combined makes increased power to detect effects

Integrating Behavioral Health Services into Primary Care

Presenter: Thomas J. Power, Ph.D., ABPP, Children's Hospital of Philadelphia

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/w39fg/?action=download%26mode=render
Learning Objectives:

Learn the opportunities and challenges of offering behavioral health services in primary care

Expanded role for primary care providers (PCPs) Training for developmental disabilities (m-CHAT) and mental health conditions Brief psychoeducation about what high score on scales mean Referral resources How to provide medication for things like ADHD or depression Education for how to implement common factors of effective psychotherapy Instilling hope, listening with hope, shared decision making, affirming families for help seeking Consultation for PCPs- need resources Telehealth provides supports in some states for PCPs so they can contact psychiatrist or similar person if a case is tricky for diagnostic or * medication questions or the need for referral Linking primary care and mental health services 3 levels- Coordinated care- services at different places with attempt to communicate Co-located care- mental health provider and PCP in same setting Integrated care- integration of MH and primary care in same setting Elements of integrated primary care Provided at same time in the same place PCP sees MH issue and calls in MH professional who talks briefly and then invites family back for follow-up care Shared electronic record so can see information and send information Done in educational context because providers are educating each other Exemplar of collaborative care Study- adolescents with depression Engaged in shared decision making with PCP- decide what primary problem is and set goals Therapy done with Effectiveness of behavioral health intervention in primary care Helped with children and adolescents with ADHD, DBD, anxiety, depression More collaborative model had significantly better results over co located care

Learn a multi-tier model of service delivery in primary care and strategies for providing universal, selective, and targeted services

Tiers Tier 1- web based practice support Tier 2- case manager to try to connect Tier 3- more integrated care ADHD as an exemplar PCPs generally feel comfortable providing care for children with ADHD Tier 1- Web based practice support One team has: Portals to assess ADHD and guide follow up care, collect info, scores it and gives good feedback Dr. Power’s tool- ADHD care assistant- portal linked to electronic health record, uses the Vanderbilt (in public domain) Promotes shared decision making- asks parents about preferences for treatments and goals Parents had intermediate preference for therapy, strong preference for medication Feasibility of the care assistant- some PCPs used (67%) some used a lot some a little Use of care assistant increased likelihood that scales would be sent and completed Parents could choose to share information with teachers or not, but only 16% of teachers looked at the information if it were given to them Tier 2- Care manager level Individual to help coordinate care- bachelor’s level Offers psychoeducation, calls school to find out what teachers think, monitor progress, coordinate services Now analyzing whether it’s more helpful than usual care and examining moderators Tier 3- Multimodal interventions Partnering to achieve school success (PASS) targeting low income urban K-4 children Components- engagement strategies, parent training, consultation between school and family Feasibility- Average of 9 sessions per participant, decent results Challenges to implementation of PASS Participants attended many schools so hard to establish relationship with all of them HIPPA and FERPA make it difficult to communicate between people for consultation In school consultation not covered by billing Competencies for IPC Psychologists- screening, interprofessional practice, brief intervention services, practice management, cultural competence Need for additional training- for engaging in interdisciplinary practice, quality improvement methods (using info in health record to improve care), IPC legal and ethical issues, supervision of trainees, therapy training for behavioral parent training and CBT for anxiety and depression Training opportunities- get relevant coursework and work in practice setting Funding for training/grant, offered through FIU for working with primary care- DHHS, HRSA for graduate psychology education and behavioral workforce education and training Careers in IPC- hospitals’ primary care

Learn strategies for overcoming barriers to integrating services in primary care and linking the health and school systems in providing care
Limitations of IPC Reimbursement - might be given certain amount of money to practice to help child and then it has to be distributed by the administrators of the institution Have to align services services with billing opportunities- hard to get insurance to pay for both people in the room Difficulty linking services in primary care and schools

Workshops

Helping Children Grow Up Brave: Evidence-Based Strategies for Helping Youth Overcome Fear, Stress, and Anxiety

Donna B. Pincus, Ph.D., Boston University

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/x5ukj/?action=download%26mode=render

Learning Objectives:

1. Describe the three component model of anxiety
2. Distinguish between normal and clinical levels of anxiety in youth throughout development
3. Describe several factors contributing to the etiology and maintenance of anxiety disorders in youth
4. Recognize differences between the DSM-5 anxiety disorders
5. Utilize evidence based treatment tools to treat anxiety disorders in youth
6. Apply information learned to three case vignettes
7. Summarize the benefits and drawbacks of intensive and weekly approaches to youth anxiety treatment

Parental Cognitions: Assessment and Treatment Implications

Charlotte Johnston, Ph.D., University of British Columbia

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/5sfz9/?action=download%26mode=render

Handout: Parental Cognitions: Relations to Parenting and Child Behavior

Learning Objectives:

1. Acquire knowledge of different types of parental cognitions, including perceptions, expectations and attributions for child behavior and understand how these cognitions are associated with parent and child functioning
2. Learn about how different parental cognitions may be assessed, including the advantages and disadvantages of different assessment tools
3. Recognize possible pathways through which parental cognitions may influence treatment engagement and outcome for families

Bridging the Gap: Understanding and Addressing Barriers to Treatment for Ethnic Minority Families

Erlanger A. Turner, Ph.D., University of Houston- Downtown

Learning Objectives:

1. Identify barriers to treatment for families
2. Articulate common strategies to engage families in treatment
3. Describe core factors associated with culturally responsive treatment

Evidence-Based Treatment for Youth with Mood and Comorbid Disorders

Mary Fristad, Ph.D., ABPP, The Ohio State University Wexner Medical Center

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/9a6wv/?action=download%26mode=render

Learning Objectives:

Describe critical aspects of diagnosing depressive and bipolar disorders in youth

Started working when kids couldn’t have depression because they didn’t have superegos and couldn’t have bipolar disorder Rule #1- Take a video not a snapshot- you only see kid when they come to office rarely in manic episodes during assessment (for bipolar disorder) Need to longitudinally understand child’s pattern of behavior in context Don’t think you can do bipolar assessment in one hour Usually lifetime condition that will wax and wane 2 pictures needed at end of evaluation- pregnancy labor delivery and list of things from birth to interview like # of schools, moves, child care, stressful life events, medial and psychological history, home/school/peer functioning How to diagnose BPSD Allergies, asthma, chronic illness, injuries (head trauma) Treatment of these problems Review previous lab findings and brain scans Low bar of suspiciousness of drug use Rule 2- What’s in and out Differential diagnosis- ADHD, ODD/CD, DMDD, PTSD, OCD, ASD etc. Comorbid disorders- anxiety, DBD, LD, ASD, etc. Rule 3- we diagnose children not families but families give good information Twin studies- 54% of identical twins for depression, 67-79% for bipolar disorder If one of two parents has a mood disorder there’s a 25% chance of a kid to have a mood disorder, if both parents then 75% chance Regularly make 4 generation genograph Parents will parent how their parents did unless a strong conscious effort is made otherwise Sometimes therapy is a lot of “putting fuel in mom’s tank Rule 4- Check progress ISBP review by Youngstrom- parents and caregiver have biggest effect size Best assessments PGBI 10M, CMRS-10, and MDQ good fro screeners and progress Depressive disorders- many in category Bipolar disorder- BP I and II and cyclothymia Now have to have increased goal related behaviors or energy Technically bipolar it doesn’t have to have a depressed episode Mania usually followed by depression- things can be mortifying and depress you that you did in mania, or just exhausting Rare to diagnose cyclothymia because kids don’t often come to clinic When will my child get better? MDD- Single episode length 7-9 months and common reoccurence PDD- single untreated episode 4 years, usually has MDD episode and heightens risk of BPSD or SUD Defining conditions- seasonal affective disorder- hibernating, rarely have reverse pattern- treated with a light box Psychotic symptoms- Hallucinations- hearing/seeing, might want brain scan for smell or feeling; delusions Occur when mood symptoms are severe Suicide risk High during or right after inpatient treatment, during crisis, life events, or a friend’s attempt Need to note that physical aspects change first so depressed person might start sleeping and eating but feel terrible so need to be told feelings will follow later Warnings signs- talking about death/suicide, saying goodbye, makings wills, giving away belongings Other factors- anger, depression, perfectionistic, drug abuse, abuse, runway, past attempt, self destructive, access to guns 5 main profile points- where to intervene Adolescent- can’t change Male- can’t just change it Mood disorders- need to treat, Drug abuse- get kids in prosocial activities Stressful life events- will happen Likelihood of suicide in males increases if gun and ammo in house Who’s at isk of bipolar disorder? ¼ to ½ of depressed youth with 2-5 years Risk factors- family history (of bipolar more, but any mood disorder), medication induced hypomania, symptoms of psychomotor retardation or psychosis Differential diagnosis/comorbidity Medical problems- temporal lobe epilepsy, and a host of others Medications that can increase cycling- anything for depression (antidepressants or even light box), allergy medicines, antibiotics, illicit drugs BPD vs ADHD Irritability, talking, distractibility, and energy all high for both BP has more- elated mood, grandiosity, psychotic symptoms Is it mania or something else Euphoria- Kids can have transient from special events Irritability- like fever of psychology- could be anything Grandiosity- might be true talent, imagination if peers unavailable- need to understand difference between life and fantasy Decreased need for sleep (different than just not sleeping because that could be anything like depression/anxiety poor sleep hygiene, excessive * environmental stimuli); BP truly full of energy Pressured speech- Racing thoughts- young, low IQ, or language disorder might need mom as interpreter to check if really racing thoughts Distractibility- needs a baseline and only for mania if departs from baseline and not medication wearing off Increased goal-directed activity- Psychomotor agitation is common across things Gifted kids- do things fast but makes accomplishments and gets things done Depressed/anxious/traumatized- may be agitated or demonstrate nervous habits Excessive involvement in pleasurable/risky activities Sexual abuse- acting out common but not only reason- Hypersexuality- erotic, pleasure-seeking excessive and violates social norms Psychosis- Everyone has perceptual distortions going to sleep or waking up Pathological usually hearing derogatory or commanding voice Suicidality Treating co occurring disorders- some treated by mood disorder treatment, but often needs special intervention

Explain a biopsychosocial model of understanding and treating mood disorders in youth

Types of treatment Biological- medications, lights, ECT, nutrition Psychological School based/social Medication Does not cure, but can manage Families need to be active partners Otherwise kid might not be taking it Partial responses common- lots of tinkering can be done by changing dose, time taken, type Full response (no symptoms left) not a reason to stop because could prevent future episodes If/when stopping medication do so with doctors advice Mood stabilizers are not addicting Ask for medication fact sheets and know side effects Know what to do if serious one occurs Make sure all doctors know what medications are being taken Have a good timetable- some medications take several weeks to work and improve physical stuff first Make a plan to remember to take medicine like a pill holder and have a plan for missed doses and plan not to run out Some need to be blood monitored Second generation antipsychotics outperform mood stabilizers but have serious side effects metabolically Lithium is good but underused and has limitations (salt so keep water intake other) Treating bipolar depression very important- but don’t have great treatments so therapy and lifestyle important Nutritional- need more study Treating comorbid disorders Guidelones mostly anecdotal Treat with psychosocial when needed and parents agree With ADHD- medication first line low and slow, and psychosocial ODD/CD- mood medications may help, parent training, or environmental changes may be necessary Anxiety- CBT is first, medications second SSRI’s with caution or maybe benzodiazepines Substance abuse- both immediately and simultaneously- Lithium might be helpful, but family based psychotherapy ASD- ASD programs Maintenance treatment- What gets you well often keeps you well, discontinuation leads to relapse but work slowly toward monotherapy (like over summer when lower stress for kids) Based on experience- stay on maintenance dose for 18 months post treatment Helping with side-effects Dizzy- stand up slowly Dry mouth- drink water Impaired sleep- have a routine you don’t deviate from much even on weekends of possible and wake up at same time even if tired, don’t have exercise or caffeine late in the evening Omega 3 fatty acids with psychotherapy- decreased symptoms in BPNOS and cyclothymia- EPA and DHA 1 gram of those together and can be combined with medication Family environment really matters to long-term outcomes and rate of recovery Family psychoeducation and skill building has well established evidence CBT and DBT are possibly efficacious, IPT Four common ingredients of therapy Education Family-based Emotion regulated Symptom management Multi-family psychoeducational psychotherapy (MF-PEP)- have families together in a gym 8 sessions Projects to do in between Parent/child pieces to be done Compared treatment and wait list group on mood severity index and significantly better Impact on service utilization and mood severity- parental attitudes toward treatment impacted quality of services sought Wanted to instill hope- don’t give up It worked in community too and behavioral symptoms also went down not just mood so should treat mood before behavioral disorders MF-PEP did not impact anxiety- obvious because there was no exposure-response prevention Variables that don’t predict treatment response- demographics, cogtive ability, which mood diagnosis, parental axis I diagnosis (except borderline PD) Individual family PEP (IF-PEP) Adjusted for not groups, worked Therapist needs to understand kids/families and mood disorders Treasure tower- if you do good you get a prize out of the machine at the end Focus on learning- Repetition matters- each session has review/preview Sequential- sessions build on each other Multi-sensory- words and pictures used Comprehension check- session ends with kid joining parents and demonstrating breathing of work, summarize lesson of day, explain homework project for week Goals of all child sessions- Emotion awareness- feelings chart Behavior regulation- reinforce and behavior Group rules, points, immediate reinforcers (candy) Social support- news of the week in MF PEP and peers Social skills- ongoing coaching and weekly game Develop and reinforce a universal coping strategy- deep breathing and imagery Improve parent-child communication- start and end sessions together Develop and accomplish realistic goals for fix-it list Provide scaffolding and modeling from therapists Session 1- Fix it list- things they want to be better turned to “I” language so kid can work toward goals Motto- It’s not your fault but it’s your challenge Session 2- naming the enemy- focus on positive attributes and openly talk with parents about symptoms- always use the real name for things- fear of a name only increases fear of a thing itself -Dumbledore for kids, for parents The beginning of wisdom is to call things by their right names- Chinese proverb Session 3- healthy habits- sleep and diet- pick one to monitor and pick a second one in session 7 Session 4- Identify trigger so increase emotional awareness, ID physiological cues, ID helpful/hurtful behaviors (B of CBT) so does it hurt anyone; * ID coping strategies; build toolkit at home (concrete and visual), and then monitor these things Tool kit needs to have big menu of coping strategies they can use something at any time Need to remember to use toolkit, and decide whether they want parent to remind them Session 5- C of CBT- emotions not bad but thoughts are and can be changed Get behavior, preceding thought, and what happens Session 6- problem solving What’s the trigger, how to calm down, think about what the problem is and how they can solve it, make a plan to do the best option, what did they do, did it work?, if yes do next time Session 7- communication- express what you need/want Verbal/nonverbal Nonverbal- posture, personal space, facial expression, gestures, tone of voice Kids tend to overinterpret anger in parents Session 8- verbal communication Kids get to request three things to have better verbal communication Session 9- review and graduate and provide very specific behavioral praise Goals across all sessions- Education Better support Skill building “Parents, you didn’t cause this but you can help.”- when they’re not defensive it gives them emotional capital to do constructive things The Phoenix Dance- for girls with BP; out of the darkened room for adults; an unquiet mind Kids need to know it’s not their job to manage a parent with mood disorders and need another trustworthy adult with whom to vent How to conceptualize family based intervention Blaming not useful, need to educate families, opposite can make families being skittish or defensive Moodychildtherapy.com for manuals Goals of PEP- build skills and hope

Use the Fix-It List throughout treatment to assist families in appropriate goal setting

Use the Naming the Enemy Exercise to assist families in differentiating the youth from his or her disorder

Utilize the Tool Kit to assist youth/parents in implementing emotion regulation strategies

Explain the basics of CBT to youth/parents utilizing the Thinking-Feeling-Doing exercise

Multi-Modal Assessment of Adolescent Social Anxiety

Andres De Los Reyes, Ph.D., University of Maryland at College Park; Director, Comprehensive Assessment and

Intervention Program (CAIP); Editor, Journal of Clinical Child and Adolescent

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/4ry5j/?action=download%26mode=render

Handouts:

• Manual for Administering Social Interactions with Unfamiliar Peer Confederates Comprehensive Assessment and Intervention Program
• Social Interaction Anxiety Scale (SIAS)

PDFs of Research Study:

• The Validity of the Multi-Informant Approach to Assessing Child and Adolescent Mental Health
• Informant Discrepancies in Adult Social Anxiety Disorder Assessments: Links With Contextual Variations in Observed Behavior

Learning Objectives:

1.) Learn how to administer behavioral tasks in the clinic to assess adolescent clients' social anxiety with unfamiliar peers

Multi-modal assessment from parents, adolescents and teachers are used to express concerns that clinicians aren't familiar with or observe in the scope of the clinic. Evidence-based assessments should serve the purpose of filling the gap between understanding concerns and facilitating treatment. Issue: Adolescents with social anxiety fear positive evaluation such as being center of attention and appraisal but clinicians tend to just focus on the adolescent’s fear of negative evaluation. These are factors that make clinicians question the accuracy and truth of the adolescent’s self report of social anxiety. Solution: Compare reports of the parent and the adolescent to see if social anxiety is great enough to need to provide care. One issue is that discrepancies between the informants reports are common. Sometimes discrepancies can cause uncertainty such as debating if the child has ADHD or social anxiety but based on parents you think ADHD but you need more information to make a decisions. Informant discrepancies may be caused by a manipulated mood causing a changed behavior before interactions. Discrepancies between reports might mean you are missing something when assessing social anxiety. Who else do you ask after receiving an informant discrepancy? You need to obtain reliable and valid information about adolescents’ concerns specifically in interactions with unfamiliar peers You need to get more information to confirm what adolescent said about peer interactions but you can’t ask friend because they're familiar to them. Some might suggest sending out a single item measure asking who is shy with a list of names of classmates on it but it is impractical to ask the whole school what they think about them. Naturalistic observation is one suggestion some may give to avoid confidentiality issues when it comes to gathering information about the patient’s interactions with unfamiliar peers instead of recruiting them for reports. The problem with naturalistic observation is that it is hard to standardize for each person and the dilemma of where to go observe them because adolescents interaction for different spaces varies. All of these issues have lead to the idea of making confederate peers. This study is important because social anxiety predicts externalizing behavior like substance use dependence and disorder. Adolescents as adults are at risk for self medicating with alcohol for “liquid of courage” in social settings. Social anxiety might have been precursor for risky behaviors and so treating social anxiety will prevent or buffer negative behavior as an adult. This is all theory and speculation and no longitudinal research has been done yet to back it.

2.) Learn how to administer survey measures to multiple informants to assess adolescent clients' social anxiety

For the  peer evaluation report it was the same one parent’s and adolescent’s filled out except “I” and “My child” on free assessment was changed to “The participant”. The research study’s task of recreating interactions with unfamiliar peers, was a mix of varying situations. The structure should vary in battery of tasks, to see if the adolescent could grasp normal and clear social rules in a situation, and then ambiguous social rules conditions. Collection for physiological data about the person's stress level had also been collected in some studies with polar electro, heart rate, flexibility and level of arousal to see which condition stressed the participant out more. The recruitment of socially anxious clients was a developmental extension off of Dr. Deborah Beidel's social anxiety studies on children. The plan to get unfamiliar peers for this study while getting the International Research Board to approve it was to train young looking undergraduates to be peer adolescent and to complete the same parent assessments to get thin slice judgements. Participants were never directly informed that the confederates were participants but if they asked the confederates if they were participants then the confederates were told to just say they were here for a part of a study. This kept the set up under the radar. This "unfamiliar peer" the study created is like the referee between the parent or teacher or adolescent's report on the adolescent's social anxiety. Their score on the report helps determine if the adolescent or parent's score is correct. Most confederates have no experience before enrolling as a volunteer in the study. In order to get them to look like a adolescent they dress them down just like a Narc or an actor playing a adolescent on a TV show or movie. These confederates come in with experience from working at hotlines, hospitals, clinics etc. Confederates are unpaid volunteers. Most confederates do it for next steps in a career in psychology and to learn how administer the task. To train confederates, the research lab uses the trainer-trainer approach by getting confederates to help and practice with other confederates on how to act in the set up scenarios. The unpaid volunteers do all of the one on one assessing and take multiple refresher courses to make sure they stay robust and ready. The confederate must learn word for word lines but they have no training with measures and how to fill out the survey because parents don't get trained on how to fill out the measure either. When parents and confederates say they do not know how to answer a particular question on the measure they are told that there is no right or wrong answer and that the study just wants to know what they think. Confederates on average work 10-12 hours per week. To maintain high retention rates for unfamiliar peers Dr. De Los Reyes writes them letters of recommendation and vouches for them for jobs/favors. About 300 confederate interns have contributed to this research study. The unfamiliar peers are trained to stay cool and neutral when faced with nonverbal awkward moments and uncertainty from the participants.

3.) Learn how to score and interpret freely available survey measures of adolescent social anxiety

When a participant comes in they take a baseline and quick physical assessment before being exposed to a condition. This is done to create a reference point for anxiety rating so they can infer points in between the beginning and after being exposed to the social conditions. Participants that were recruited from their parents seeing a flyer about free clinical shyness evaluation only know they are coming in for that shyness evaluation and that is it. This study is assessing using a source never used before, a created unfamiliar peer. Participants are informed to fill out the surveys after each social interaction set up based on feelings during interaction not the feelings they are having at that moment after finishing. The study tested for clustering effects with confederates and nothing significant was found. It was hypothesized that gender match up for the participant and confederate would scrub out confounding variables but they did not account for sexual orientation and so this might have a role in interaction. This study also had a flyer that did not say anything about shyness evaluation but just that a study was looking for adolescent volunteers in order to get a sample of adolescents who are not shy or adolescents who's parents aren't bringing them in because of a concern with their introvertedness. "Wranglers" in this study are graduate students in the lab who gave out the surveys, read out the scenarios and helped conduct the interactions. Confederates nor Wranglers had any idea beforehand if the participant was a recruited shy teen or regular teen. The word "shy" was used in advertising flyer because the research study wanted to recruit a wide enough net of teens to see if they could differentiate. There is a high confidence in reliability of scoring. The scores relates really well to behavior, closely approximated and cut offs are not the same for Social Interaction Anxiety Scale (SIAS) and SPAIC. Teen participants usually rate in 20s and unfamiliar peers usually rate in the 30s. Most sensitive point: that hits that cut off… too sensitive or too specific, 0-1 and consists of 2 curves. The values of scores and elevation of adolescent and parent evaluations were looked at to see if confederate peer pick up on blind spots between the parent and adolescent.

Other 2018 Resources

• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2018/Day 1
• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2018/Day 3