What School Based Anxiety Interventions are Effective?
Making the Grade: School-based Interventions for Pediatric Anxiety Disorders: Primary data presented looking at which school-based anxiety interventions are most effective edit
Golda S. Ginsburg, Ph.D.
University of Connecticut
This talk was given at MICAMH at FIU in Miami, Florida.
Intro edit
• Background: Why Anxiety? Why schools?
• What is treatment as usual (TAU) for anxiety dx 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? edit
- 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? edit
- 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 edit
- 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 o 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
Case Example 1 edit
Primary Diagnosis: Generalized Anxiety
6-year-old boy
Key worries:
- Making mistakes/perfectionism/changes
- Hours getting ready looking just right
- Upset each morning afraid of missing the bus
- Hours on homework re-does assignments tears up assignment if makes a mistake
- Seeks reassurance
- Sought school nurse because of stomach aches
- Missed school due to anxiety
Case example 2 edit
Separation Anxiety 10 years old girl
- Must be near mom at all times beg to stay home
- 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? edit
- Less than half of youth received services
- Likelihood of receiving treatment: 30% anxiety vs 70% ADHD
- Critical need to enhance access, bring services to school
Why School Interventions? edit
- Takes away many barriers to seeking treatment
- School setting can trigger anxiety
- Separation, performance, social
- Better generalization of skills
- Treatment improves academic functioning
Results edit
Evidence-based Treatments
- Cognitive Behavioral Therapy (CBT)
- Medication-SSRIs
CAMS: Response rates 60%-80%
- 60% is one treatment alone
- 80% is when both treatments are used
STARS edit
Primary Aim: Compare the effectiveness of a modular CBT (MCBT) to TAU edit
Modular CBT takes the elements of CBT but gives more flexibility to the clinician
- 6 year RCT in MD and CT: MCBT (n = 37) or TAU
- One day training; optional supervision
- 12 weeks of tx
Evaluations at pre, post, 1 year follow up
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 TAU? edit
- Primary therapeutic orientation (n=25) CBT 68%
- Session summary forms (n=475) CBT 67%
- IE-report (n = 90 sessions) CBT 14%
A lot fell into the category of other for example:
- Emotional support for feelings
- Making holiday cards
Conclusions & Limitations edit
- School clinicians are thinking about CBT
- The sample was small may not be generalizable
- We need more training for school psychologists
Is MCBT Better than TAU in Schools? edit
- 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
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 edit
More training but there are limits because of funding and cooperation
Expanding School Based Anxiety treatment
Calm Study edit
- Why and Who
- School nurses could help
- Familiarity with kids because of somatic problems
- Less stigma and beloved by students
- School nurses could help
- 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
Follow up of Case 1 and Case 2 edit
Many of the issues were resolved or reduced
TAPES Study edit
- Who and why
- Teachers, can easily identify problems
- Overview
- Intervention development
- Open trails
- 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
- Reduction of anxiety