Download Session 6: Anxiety and Schools - DC Map – Mental Health Access in

Managing Anxiety &
Working Collaboratively
With Schools
Barbara Parks, LICSW D.C. Department of Behavioral
Health
Aaron Rakow, PhD, Georgetown University Hospital
Christopher Raczynski, MD, D.C. Department of
Behavioral Health
Accreditation
The George Washington University School of Medicine and Health
Sciences is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for
physicians.
The George Washington University School of Medicine and Health
Sciences designates this live activity for a maximum of 1.0 AMA PRA
Category 1 Credit(s)™. Physicians should claim only the credit
commensurate with the extent of their participation in the activity.
Instructions for Obtaining Credit
At the end of this webinar, you will receive an email for completing the
online course evaluation. Your certificate of credit will be available
immediately after you complete the evaluation.
Disclosure
In accordance with the Accreditation Council for Continuing Medical
Education's Standards for Commercial Support, The George Washington
University Office of Continuing Education in the Health Professions (CEHP)
requires that all individuals involved in the development and presentation of
CME activity content disclose any relevant financial relationships with
commercial interest(s). CEHP identifies and resolves all conflicts of interest
prior to an individual’s participation in an educational activity.
The following faculty, planners, and staff report that they have no relevant
financial relationships with commercial interest(s):
Chris Raczynski, MD (Speaker)
Barbara Parks, LICSW (Speaker)
Aaron Rakow, PhD (Speaker)
Mark Weissman, MD (Course Director)
Tamara John, MPH (Staff Planner)
Leticia Hall-Salam (Staff)
Commercial Support: This activity received no support from a
commercial interest.
General Information
Release Date:
March 25, 2014
Termination Date: March 25, 2014
Contact Information
Tamara John
Ph: (202)476-5781
Em: [email protected]
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Part 1: Learning Objectives
• Overview of epidemiology of anxiety
disorders
• Screening for anxiety disorders
• Review of common anxiety diagnoses
• Review of treatment methods
Anxiety Disorders:
Epidemiology
• Most frequent type of mental health
disorder
• Often suffer silently
• 10-15% of children suffer from some form
of anxiety disorder
• GAD, Social Anxiety, Separation Anxiety
• More common among girls (4x)
Assessment and Diagnosis
Normal vs. Clinical Anxiety
• Functional impairment (school, social,
family)
• Situations that trigger anxiety
• Length of impairment
• If patient is distressed by anxiety
Assessment and Diagnosis
Differential Diagnosis
Nature, duration, severity of syx.
“Panic-like symptoms”
“Fear of embarrassment”
“Obsesses about things”
“Disobedient adolescent in class”
Comorbidity
Principal dx: most problematic
Assess multiple points of view
Treat systematically not concurrently
Assessment and Diagnosis
Self-Report Measures
• To be used in conjunction with
structured clinical interview to make
a diangosis
• Adequate test-retest reliability, quick,
easy to administer
Self-Report Measures
Measure
Time to
Admin
Age
Range
Primary Focus
Structure
Revised
Children’s
Manifest
Anxiety Scale2 (RCMAS-2)
10-15 min.
6-19 years
Chronic Anxiety
37 yes/no
items
State-Trait
Anxiety
Inventory for
Children
(STAIC)
20 min.
8-14 years
Chronic Anxiety
20 items on 3pt. scale
Fear Survey
Schedule for
Children
Revised (FSS
C)
20 min.
7-16 years
Specific Fears
80 items on 3pt. scale
Self-Report Measures
Measure
Time to
Admin
Age Range
Primary
Focus
Structure
Social Phobia
and Anxiety
Inventory for
Children
(SPAI-C)
20-30 min.
8-14 years
Social
Anxiety
26 items on
3-point scale
Multidimensio
nal Anxiety
Scale for
Children-2
(MASC-2)
15 min.
8-19 years
Specific
Symptoms
39 items on a
4-point scale
Screen for
Child Anxiety
Related
Emotional
Disorders
(SCARED)
10 min.
8-18 years
Specific
Symptoms
38 items on a
3-pt. scale
Self-Report Measures
Measure
Time to Admin
Age Range
Reference
Child Depression
Inventory (CDI)
10 min.
6-18 years
Kovacs
Child Behavior
Checklist (CBCL)
35 min.
4-18 years
Achenbach
Youth Self Report
(YSR)
35 min.
11-18 years
Achenbach
Teacher Report
Form (TRF)
35 min.
4-18 years
Achenbach
Common Diagnoses
Generalized Anxiety Disorder
• “Worriers;” Worry excessively
about multiple areas of life
• More days than not for > 6 months
• Difficulty controlling worry, need
for reassurance
Common Diagnoses
Social Phobia
• Highly fearful of social or
performance situations
• Fear will be negatively evaluated by
others
• Typically recognize fear as
unrealistic; Will avoid at all costs
Common Diagnoses
Separation Anxiety Disorder
• Excessive anxiety about separation
from those to whom they are
emotionally attached
• Fear tragedy will occur to them or to
caregiver leading to separation
• Less common in adolescents
Common Diagnoses
Specific Phobia
• Excessive fear of particular
objects/situations
• Avoid fear stimuli
• Causes marked impairment to
routine
Common Diagnoses
Obsessive-Compulsive Disorder
• Obsessions: recurrent thoughts,
images, or urges - distressing and
intrusive
• Compulsions: repetitive behaviors
preformed in response to
obsessions aimed at preventing
negative event
Common Diagnoses
Panic Disorder with/w/o Agoraphobia
• Recurrent, unexpected episodes of
intense anxiety
• Short bursts of anxiety involved several
bodily symptoms (e.g., sweating, heart
racing, shortness of breath, etc.)
• Peak within 10 minutes
Common Diagnoses
Post-Traumatic Stress Disorder
• Re-experiencing event (distressing
recollections, dreams, etc.)
• Increased arousal when reminded
of traumatic event
• Avoidance of event or reminders
• Acute Stress Disorder <1mo
Treatment
Recognizing Feelings, Thoughts, and
Behaviors
•
•
•
Feelings: recognition of nuances between
varying emotional states (rating 0-10)
Thoughts: recognition that different
thoughts associated with different feelings
Behaviors: recognition of physical
manifestations of anxiety
Cognitive Restructuring
Working to change lens that world is an unsafe place
Modifying unrealistic thought patterns to “realistic
thinking” and/or “calm thinking” not necessarily
positive thinking
Start with ambiguous scenario (e.g., late arrival)
Most common anxious negative thought patterns:
Overestimation of how likely it is that unpleasant
events will occur
Overestimation of how bad consequences will be if
event does happen
Cognitive Restructuring
STEP 1
• Identify thought behind emotion “what is making me feel scared”
• Change to statement
“I am going to fail this math test”
• Avoid having negative emotion as
theme of prediction
“Why will you be scared/nervous?”
Cognitive Restructuring
STEP 2
Looking for evidence for a thought
• Past experiences
• Alternative possibilities
• General knowledge (observe
environments)
• Taking a different perspective
Cognitive Restructuring
STEP 3
Evaluating the thought based on
evidence
•“Having evaluated all the evidence,
how likely will the worrisome event
occur?”
•Repeating this with visuals to support
Cognitive Restructuring
STEP 4
Examining the consequences of feared
event
•Aim to address typical overestimation
of cost of negative event
•“What is the worst that can happen?”
Relaxation
Progressive muscle relaxation
Guided imagery
Meditation
• Good effects @ 6 mos
• No significant differences between
techniques
Relaxation
STEP 1
Outline purpose and benefits for relaxation
Relatively short exercises (15 minutes)
Tension vs. relaxation (as needed)
Minimize distractions
STEP 2
Guide: tense, isolate, concentrate, relax (arms, face,
stomach, legs)
STEP 3
Practice: consistent and repeated (10-15 min. each
day)
Exposure
• Fears are faced gradually
• Slightly difficult > most difficult
• Hierarchy
• Patient must stay in feared situation long
enough to learn that feared scenario will not
occur
• Practice and repetition are key to success
• Sufficient practice to demonstrate situation
is non-threatening
Exposure
Develop list of specific situations that child
finds difficult or actively avoids
• Ensure they are realistic and
achievable
• Cover entire range of anxiety
provoking scenarios within general
domain
• Lists feared scenarios in order of
difficulty
Contact Information
Aaron Rakow, PhD
[email protected]
202-650-7634
Children and Disasters
30
Children and “Disasters”
Christopher Raczynski, M.D.
Associate Chief Medical Officer
District of Columbia
Department of Behavioral Health
Learning Objectives
• Understand the reactions children typically
experience/demonstrate following a disaster/trauma
• Understand how to help parents help their children
following a disaster/trauma
Children and Disasters
32
Important Developmental Stages to Consider
• Infancy: 0 – 2 years old
• Toddlerhood: 3 – 5 years old
• Latency: 6 – 11 years old
• Adolescence: 12 – 18 years old
Children and Disasters
33
Reactions Common to All Ages
•
•
•
•
Regression to previously mastered stages of development
Behavioral changes
Emotional changes
Over/under reaction to stimuli
– Physical contact, sudden movements
– Bright lights, loud sounds
• Re-creation/re-experience of the traumatic event
Children and Disasters
34
Behavioral Changes
• E.g., withdrawing
– Infancy
• Withdrawing from caretakers
• Not playing with toys
– Latency
• Withdrawing from family/peers or activities
• Absenteeism
– NB: school refusal can become a psychiatry
“emergency”
Children and Disasters
35
Emotional Changes
• Infancy
– Fussiness, crying for no reason
– May show same emotions as caregivers
• Toddlerhood – Latency
– Unusually whinny, irritable or “moody”
• Latency
– Angry outbursts or aggression
• Adolescence
– Discomfort with feelings
• e.g., troubling thoughts of revenge
Children and Disasters
36
Over/under-reaction to Stimuli
• Infancy
– Easily started
• Think Moro
• Latency – adolescence
– Hyper-arousal
• +/- hyper-vigilence
Children and Disasters
37
Re-creation/re-experience of event
• Toddlerhood – Latency
– Art
– Play
• Latency < Adolescence
– Discussion of events
– Reviewing details
– Internet searches
Children and Disasters
38
Reactions Typically Unique to Infancy
• May not know trauma is happening
– But know caregiver(s) is/are upset
• May show same emotions as caregivers
– Modeling
Children and Disasters
39
Reactions Common in Infancy – Toddlerhood
• Separation anxiety
• Problems with:
– Feeding/eating
– Sleeping
• Naptime
• Bedtime routines
Children and Disasters
40
Reactions Common in Toddlerhood – Latency
• Worry about things getting lost
– Toys
• cannot underestimate importance of this for toddlers
– Favorite stuffed animal
– Special blanket
– Activities
• E.g., videogames or even pets
• Somatic complaints
– Headaches
– “Tummy aches”
Children and Disasters
41
Reactions Common in Toddlerhood – Adolescence
• Worry about recurrence of event
– Potentially more pronounced in latency
• New understanding of cause  effect not always
helpful
• Fears about safety
– Self
– Others
• Latency: family > peers
• Adolescence: peers > family (potentially)
Children and Disasters
42
Reactions Common in Latency – Adolescence
• Pre-PTSD-like symptoms
– Re-experience of the trauma
– Emotional numbing
– Decreased concentration
– Avoidance of places that remind them of the event
• Statements and questions about death and dying
• Difficulty with authority, redirection, or criticism
• Negative impact on issues of trust and perceptions
of others
– E.g., change in reading social cues
Children and Disasters
43
Reactions Typically Unique to Adolescence
• Increase in impulsivity and risk-taking behavior
– May be defensive
• Increased risk for substance use/abuse
– Suboptimal coping vs. self-medicating
• Writing and artwork featuring violent or morbid themes
– Not necessarily related to the trauma/disaster
Children and Disasters
44
Suggested Actions for Parents
•
•
•
•
Reassure their children that they are safe (now)
Provide extra attention and consideration
Stick to regular family routines
Model self-care
– Participation in physical activities/exercise
– Adequate sleep and nutrition
• Help shift focus from trauma to recovery
• Limit media exposure
– As much as possible
Children and Disasters
45
Reassurance
• Latency
– Rehearse family safety measures for future incident
• “Drills!”
• Adolescence
– Involve them in the development of safety protocols
Children and Disasters
46
Extra Attention/Consideration
• Infancy – Toddlerhood
– Avoid unnecessary separations
– Temporarily permit sleeping in bed of parents or siblings
• Infancy – Latency
– Let them know they are not to blame
• Latency
– Check in with them often to ask how they’re doing
Children and Disasters
47
Stick to Regular Family Routines
• Latency
– Home chores that structured, but not too demanding
– Set gentle, but firm limits for acting-out behavior
• Adolescence
– Encourage resumption of regular activities
• E.g., extracurriculars
Children and Disasters
48
Help Shift Attention from Trauma to Recovery
• Latency
– Point out kind deeds and the ways in which people
helped one another during the disaster
• Latency – Adolescence
– Don’t try to change feelings
– Teach coping skills
• Adolescence
– Promote involvement with community recovery work
Children and Disasters
49
Limit Media Exposure
• Infancy – Latency
– Protect them from excessive reminders
• Wolf Blizer
• Adolescence
– Watch news coverage with them
– Make self available to discuss
Children and Disasters
50
Pearls for Talking with Children about Disasters
1) Provide opportunity to talk about and make sense of the
event in a safe and accepting environment
- Don’t avoid the topic when a child brings it up
- Be honest, but not too graphic
- Check in to make sure they understand you, and you
understand them
- Gently correct inaccurate information
- Be prepared to discus the details again and again
- Especially with latency aged youth
Children and Disasters
51
Pearls (continued)
2) With toddlers…
- Get down to their eye level
- Speak in a calm, gently voice
- Talk about what happened in simple terms they can
understand
- Focus on more the child’s reaction than the trauma
- Tell them you (still) love/care for them and are working
to keep them safe
Children and Disasters
52
Pearls (continued)
3) Be there to listen, but do not force them to talk about
their feelings and emotions
- Let them know you are interested in what they are
thinking and how they are doing
- Talk about normal reactions to trauma
- Closely observe the child’s emotional status
 Do they seem actively afraid or withdrawn ?
- Ask what they might be worried about
 Ask what might help them cope
 Carefully make suggests, if necessary
Children and Disasters
53
Pearls (continued)
4) Encourage expression of feelings and emotions based on
developmental level
- Infancy – Toddlerhood
- Play, drawing, puppet shows, storytelling
- Latency
- Conversation and play
- Adolescence
- Writing and art
- Discussion of traumatic experience among peers
Children and Disasters
54
Helping Children Cope With Disasters
• Ask about challenging situations that they handled well
• Promote supports
– Spending time with friends
– Resuming recreational activities
• Promote relaxing activities and positive coping
Video: Color breathing
Gurwitch, R.H. (2012). Healing After Trauma Skills: A manual for professionals,
teachers, and families working with children after
trauma/disaster. Available at www.nctsn.org (Note: First edition, 1995
with special editions in 2001, 2009, and 2010)
Children and Disasters
55
Helping Children Cope With Disasters
• Ask about challenging situations that they handled well
• Promote supports
– Spending time with friends
– Resuming recreational activities
• Promote relaxing activities and positive coping
Video: Color breathing
• National Child Traumatic Stress Network Site:
• http://mediasite.nctsn.org/NCTSN/Viewer/?peid=18c1f8c4
243e489aa8a90da867a7644c
Children and Disasters
56
Thank you all!
• Live questions: shoot
• Offline questions:
– Christopher Raczynski, MD
– [email protected]
– 202-673-2160
Children and Disasters
57
Anxiety in School
Barbara J. Parks, LICSW
Clinical Program Administrator
DC Dept. of Behavioral Health
Academic Impact of Anxiety
•
•
•
•
•
•
Anxiety leads to poor academic performance and
underachievement
Highly anxious children in grade 1 are 10x more likely to be
in bottom 1/3 of class by grade 5
Highly anxious students score lower than peers on
measures of IQ and achievement tests (e.g. basic skills)
Anxiety leads to poor engagement in class
Highly anxious students avoid tasks that require
communication or that involve potential peer or teacher
evaluation
They consequently miss the benefit of interactive learning
experiences
Nature of Anxiety
•
Anxiety Disorders exist when…..
•
There is a fear or worry about a particular event or
multiple areas of life
•
Fear is excessive compared to peers or age
appropriate
•
The fear/worry causes significant distress and/or
significant interference (often avoidance) in daily
activities
How does anxiety impact at school?
Learning
-Attention
-Interpretation
-Concentration
-Memory
•Social Interaction
•Beliefs/Expectations
•Health
Signs of Anxiety in School
•
Reassurance seeking
•
Overly well behaved/bossy
•
Mistakes, routine changes and new situations cause
distress
•
Physical symptoms (frequent) stomachaches, headaches
•
Perfectionism
•
Procrastination- last minute or late
School Mental Health Supports in DC Schools
•
•
•
•
•
•
•
DBH School Mental Health Program-offered currently in 70
DC/DC Public Charter Schools
DCPS Social Workers- in all DCPS schools, serve Special
Education students and offer some evidence based
programs
Evidence Based approaches
-Cognitive Behavioral Therapy (CBT) is the treatment of
choice for anxiety
Can be individual or group therapy
Parental involvement encouraged
Treatment is skills-based where anxiety management skills
are taught in session and then applied between sessions in
real life
DC DBH School Mental Health Program
Reducing Barriers to Learning
•
Levels of Intervention
Primary Prevention: Intervention strategies for all students to PREVENT mental
health, behavioral, and social issues before they occur. Services include school-wide
interventions, classroom-based interventions, and mental health promotion activities
for example, prevention of substance abuse, sexual abuse, and violence.
•
Early Intervention Services: These services are provided at the first occurrence of
emotional, behavioral, or social concerns (e.g., Primary Project).
•
Treatment Services: Treatment is provided for students with a variety of problems,
including depression, substance abuse, disruptive behavior, anxiety, peer relational
problems, grief and loss, trauma, and family issues. Services include individual, family,
and group counseling.
•
Crisis Services: Interventions are provided for urgent situations and needs. Services
include crisis debriefing, grief counseling, and psychiatric referrals.
•
Parent/Family Support: Educational, supportive, and treatment services are provided
for families.
School Mental Health Program Model
•
•
•
•
•
Follow Public Health Model
Provides an individualized plan for each school of
Prevention, Early intervention and Intervention
services - gen educ.
Places one DBH mental health professional in each
school (can be full-time or part-time based on
criteria)
Evidence-based programs include programs that
address both anxiety and trauma in students.
Referrals for students who require medication
evaluation or more intensive treatment.
Contact Information
Barbara Parks, LICSW
[email protected]
202-698-1871