Managing Anxiety & Working Collaboratively With Schools Barbara Parks, LICSW D. C. Department of Behavioral Health Aaron Rakow, Ph. D, 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, Ph. D (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: tjohn@childrensnational. org Hardware/Software Requirements PC Microsoft Windows 2000 SE or above. Internet Explorer (v 5. 5 or greater), or Firefox Flash Player Plug-in (9. 0 or later) Check your version here. Policy on Privacy & Confidentiality Sound Card & Speakers 800 x 600 Minimum Monitor Resolution (1024 x 768 Recommended) http: //www. gwu. edu/privacy-policy Adobe Acrobat Reader* Copyright MAC OS 10. 2. 8 http: //www. gwu. edu/copyright Safari or Firefox Flash Player Plug-in (9. 0 or later) Check your version here. Sound Card & Speakers 800 x 600 Minimum Monitor Resolution (1024 x 768 Recommended) Adobe Acrobat Reader* Internet Explorer is not supported on the Macintosh. * Required to view printable (PDF) version of the lesson.
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 (4 x)
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 Scale 2 (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 3 pt. scale Fear Survey Schedule for Children Revised (FSS C) 20 min. 7 -16 years Specific Fears 80 items on 3 pt. scale
Self-Report Measures Measure Time to Admin Age Range Primary Focus Structure Social Phobia 20 -30 min. and Anxiety Inventory for Children (SPAI-C) 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 35 min. (YSR) 11 -18 years Achenbach Teacher Report Form (TRF) 4 -18 years Achenbach 35 min.
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 <1 mo
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, Ph. D aaron. v. rakow@gunet. georgetown. edu 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=18 c 1 f 8 c 4 243 e 489 aa 8 a 90 da 867 a 7644 c Children and Disasters 56
Thank you all! • Live questions: shoot • Offline questions: – Christopher Raczynski, MD – Chris. raczynski@dc. gov – 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 10 x 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 barbara. parks@dc. gov 202 -698 -1871
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