- Studies
- Stars study
- Calm study
- TAPES study
- Do evidence-based practices work in settings such as schools with younger than college aged populations?
- Cartoon: parents talking about how carefree childhood is, child is outside racked with worry about global warming, exams, etc.
- Anxiety in students is underidentified and undertreated
- Perhaps people think its transient
- Parents and teachers begin to accommodate the child’s anxiety (basically let it go)
- Background: Why Anxiety?
- Anxiety disorders are most common pediatric disorders: 10-20% prevalence rate, 2 in 20 students affected (clinical criteria) but also likely 2 that don't technically meet clinical criteria
- Know that students have anxiety, but still don't get adequate help
- Causes significant impairment in many facets of life: social, academic, familial (parents don't know how to handle it- ignore it, accommodate it, etc), personal stress (somatic symptoms such as nausea, sleep problem)
- Anxiety has a chronic course: 6-10 years after treatment, ½ still meet diagnostic criteria for anxiety disorder
- Anxiety is a gateway illness: having anxiety as a child leads to greater chance of developing depression, substance use disorder, etc as an adult
- Most common in youth: GAD, social phobia, specific phobia, specialized anxiety disorder
- Why schools?
- What is treatment as usual (TAU) for anxiety diagnosis in schools?
- Is CBT better than TAU in schools?
- Expanding the network of school providers
- Children have valid concerns and worries during childhood. * Anxiety is underestimated and under treated in children
Why do they go unnoticed?
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- Not apparent and disruptive
- Anxiety in the classroom is avoided
- Try to adapt to the child and not put them in situations that cause discomfort
- Care providers believe they will grow out of it or it is not serious
Why is anxiety in children important to study?
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- Measurement of anxiety is getting better
- Anxiety disorder is the most common psychiatric disorder- and is on the rise!
- 10-20% lifetime prevalence rates
- 2 in 20 students affected
- 2 more will not meet criteria but will likely meet some of the items
Problems caused by Childhood anxiety
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- Social interactions
- Fewer friends
- Little to No extracurricular activities o Less likely to attend events like field trips
- Academic
- Preform lower
- Attendance is lower
- Familial
- Tough parenting causes tensions
- Babying- allowing them to avoid situations that cause distress
- Causes parental conflict
- Family distress
- “Gateway illness” more likely to develop other disorders
- Adult anxiety
- Suicidality
- Other diagnoses
Primary Diagnosis: Generalized Anxiety Disorder (GAD)
6-year-old boy
Key worries:
- Making mistakes/perfectionism/changes
- Hours getting ready looking just right
- Upset each morning afraid of missing the bus
- Upset by changes in plans
- Hours on homework re-does assignments tears up assignment if makes a mistake
- Seeks constant reassurance
- Sought school nurse because of stomach aches
- Missed school due to anxiety
Separation Anxiety 10-year-old girl
- Must be near mom at all times so begs to stay home
- Could not be alone in a room in the house
- Sleeps with mom
- Leaves bathroom door open
- Texts mom during day and asks to leave school
- Stomach aches each morning causing her to be often late to school
How are we doing currently?
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- Less than half of youth received services
- High impairment, less than half receive services they need.
- Likelihood of receiving treatment: 30% anxiety vs 70% ADHD
- Critical need to enhance access, bring services to school
Why School Interventions?
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- Takes away many barriers to seeking treatment (fees and transport)
- School setting can trigger anxiety, clinical advantage - student can get corrective feedback immediately unlike outpatient care
- Separation, performance, and social
- Better generalization of skills
- Treatment improves academic functioning
Evidence-based Treatments
- Cognitive Behavioral Therapy (CBT)
- Medication-SSRIs
CAMS: Response rates 60%-80%
- 60% is one treatment alone (independent)
- 80% is when both treatments are used (together)
- Are school clinicians using CBT?
Primary Aim: Compare the effectiveness of Modular CBT (more flexible for each child)(MCBT) to TAU
- Modular CBT takes the elements of CBT but gives more flexibility to the clinician
- Modules:
- start with psychoeducation (what is anxiety and how does CBT work)
- Exposure
- Relaxation
- Cognitive
- 6 year randomized control trial (RCT) in MD and CT: MCBT (n = 37) or TAU
- Clinicians were not trained in CBT so they had one day of training with optional supervision
- 12 weeks of treatment but the average was 9
- Evaluations at pre, post, 1 year follow up
- 216 students (6-18 year olds)
The CBT Modules
- Psychoeducation 1st session
- CBT Triangle
- Exposure 2nd session and throughout
- Relaxation strategies
- Cognitive restructuring “changing thoughts”
- Problem solving
- Relapse prevention
- Meditation
- Most children had more than one disorder
What is (Treatment as Usual (TAU)?
- Clinicians reported their primary therapeutic orientation and then after each session evaluated therapeautic strategies(n=25)
- Before clinicians were trained, clinicians reported
- Session by session summary forms data (n=475) clinicians reported:
- IE-report (n = 90 sessions) showed that only 14% were actually using CBT when evaluated
- TAU involved more relationship building like playing games together
- A lot fell into the category of other for example:
- Emotional support for feelings
- Making holiday cards
Conclusions & Limitations
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- Majority of clinicians report using CBT or CBT elements
- Evaluations reveal low CBT use
- School clinicians are thinking about CBT
- The sample was small may not be generalizable
- We need more training for school psychologists
- Highlight need for better training
Is MCBT Better than TAU in Schools?
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- Outcomes assessed by trained evaluators at post and 1 year follow up to assess anxiety severity, global functioning, and clinical improvement
- Using CGI-S
- Anxiety did go down over time and stay low over time, however no between group differences (CBT = TAU)
- Same with global functioning
- Clinically meaningful improvement no group differences
- Were expected to get 60% improvement (like CAMS) but only got 30%, showing school based CBT isn't as effective and isn't more effective than TAU
- Why lower MCBT response rate?
- Had a lower dose (only about 9 sessions)
- Poor training and supervision (only 1 day of training)
- Low MCBT quality
- CBT content missing (exposure)
- Did clinicians adhere to MCBT?
- Adherence is around 70-80%, bit quality is not great
- Clinicians reported they adhered to exposure, bit many actually did not when evaluated
- Could TAU be contaminated?
- A diagnostic report was provided
- Ongoing monitoring conducted
- Prescribed number of sessions
- Could have made TAU better than normal
Cams was more effective than stars but why?
- Lower dose (9 sessions for 20-30)
- Limited/poor training and supervision
- 1 day; optional supervision
- Low MCBT quality
- Key CBT element of exposure may have been missing
- Lower clinician adherence of exposure
- TAU- contaminated
- Diagnostic report provided
- Ongoing monitoring conducted
- Prescribed # of sessions
- CBT elements were used in TAU
Cochrane report (2013) data are “limited and inconclusive if CBT is more effective over TAU”
Implications and Solutions
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More training but there are limits because of funding and cooperation
- Must enhance training of school clinicians or outsource mental health professionals
- Explore alternative treatments? What in a session is best to help kids improve
Expanding School-Based Anxiety Treatment
- Expanding school based providers
Calm Study
- Why and Who
- School nurses could help
- Familiarity with kids because of somatic problems
- Less stigma and beloved by students
- Overview
- 3-year study
- Intervention 1: CBT
- 6 Calm modules based on CBT
- Intervention 2: Only using relaxation exercises
- Relaxation, meditations, and other strategies
- Results
- Anxiety went down
- Somatic symptoms were reduced
- Behavioral avoidance decreased
- Automatic thoughts significant reductions**
TAPES
- High need for anxiety treatment, but shortage of school clinicians
- Can task shift- use people not trained in mental health necessarily but teach them to work with kids with anxiety
- First was calm study (use school nurses)
- Kids with anxiety are frequent flyers in the nurse’s office, but the nurses were not trained to handle pediatric anxiety disorders
- Less stigma associated with going to see school nurse and also have better relationship with them
- CALM
- Developed two nurse intervention
- 6 modules
- CALM-R uses relaxation training only
- N = 30 (nurses) and 54 (kids)
- Nurses make a big difference, anxiety went from clinical to subclinical range
- Somatic symptoms also decreased
- Behavioral avoidance also decreased
- Anxious thoughts decreased
- Case study 1 boy had decreased symptoms (went 2 months without going to nurse)
- Case study 2 girl was able to try a sleepover, be alone in a room
- conclusion
- Progression in the right direction
- TAPES
- Uses teachers
- Can easily identify students with anxiety
- Published in TRIALS
- Meet with student and parent together
- Uses school home model (teachers and parents use same language)
- 5 30-minute teacher led meetings
- Teachers have increase in knowledge of CBT, decrease in accommodation of anxiety
- Students have reductions in anxiety as reported by parents and teachers
- Anxiety severity
- Anxiety did go down overtime and remained down
- Did not differ significantly between groups
- Global functions
- Improved over time
- No significant between group differences
Follow up of Case 1 and Case 2
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Many of the issues were resolved or reduced
- Who and why
- Teachers, can easily identify problems
- Overview
- Intervention development
- Open trails
- Randomized Control Trial (RCT)
- Why a school and home model
- Better communication between teachers and parents is associated with better outcomes
- Trial run
- Reduction of anxiety
- From parent, child, and teacher report
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