SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2019/Day 1

= Day 1 =

Evidence-Based Engagement Interventions for Disruptive Behavior: Looking Through a Microscope and Telescope
Presenter: Anil Chacko, Ph.D., Associate Professor, Department of Applied Psychology, New York University

Powerpoint: OSF

Learning Objectives:

 * Never Attend vs Drop Out vs Complete BPT
 * Those families who never attended had negative child attribution, the parents believed the child was never going to change, and had low expectations about the intervention
 * Therefore, the level of engagement was influenced by their thoughts about their child or the intervention
 * Those families that drop out of the treatment after several sessions believed the intervention was less and less relevant for their particular situation, which caused their discontinuation of the treatment
 * Things that were unrelated to time in treatment were parental stress, maternal depressive symptoms, and child symptom severity
 * Conclusion: we need to pay attention to the parents’ attitudes towards parenting, their child, and the intervention and how relevant treatment is for a particular family
 * Extending Barriers Model
 * In this model and its outcomes, engagement is measured by attendance, adherence, and dropout levels
 * Found that families who had low expectations in the beginning of treatment had higher overall engagement because when they started seeing the outcomes occur when they weren’t expected, they were more motivated to get engaged
 * It was found that growth in motivation was the predictor of engagement, not the baseline level of motivation
 * Credibility impacted adherence and dropout levels.


 * Barriers to treatment protocol (Mary McKay)
 * 2 prong approach: first contact via phone call and psychoeducation
 * The phone call was trying to elicit why the families were seeking treatment
 * The psychoeducation component served to educate the families on the services and resources the clinic/setting can provide
 * Clinic Level
 * Maximize caregiver investment and efficacy in help seeking
 * Phone call before increased engagement or people showing up
 * Parent training engagement intervention (Chacko)
 * Integrated into group BPT
 * Utilized group peer support by collaborating with one another
 * Small groups versus large groups
 * Peer support in interventions
 * Used problem solving skills
 * Psychoeducation
 * Participation enhancement intervention (Matthew Nock)
 * Integrated into individual BPT
 * Questionnaires about practical barriers to treatment, parent’s belief about their own parenting
 * Select motivation enhancement approaches: listening and adhering to treatment
 * Address practical barriers to treatment
 * Parent & caregiver active participation toolkit most recent of packages (Haine-Schlagel)
 * Focuses on alliance, empowerment, collaboration strategies for the clinicians and the parents
 * Incorporates a workbook and dvd that helps parents prepare for clinic engagement
 * Addresses practical barriers to treatment
 * Psychoeducation
 * Motivation Enhancements
 * Parent Empowerment skills


 * Barriers to Treatment Protocol (McKay):
 * Those families in the enhanced contact group (via a phone call) were more likely to keep their initial appointment
 * Families in the enhanced contact + initial intake group were more engaged in the intervention
 * Parent Training Engagement Intervention (Chacko)
 * Families in the parent training group had higher retention rates
 * Found that if you focus on working at the intake level and make engagement an important part of the process, drop rates will decrease
 * Families in the subgroup collaborative + problem solving group felt that they have greater social support, better quality of social support, more diversity in discussion, larger relevance of the treatment. These subgroups helped the families engage with people who were similar to themselves, which increased their engagement and overall adherence to treatment
 * Participation Enhancement Intervention (Nock)
 * Families in the intervention group had a larger average attendance adherence quantity at session 8. They were also more likely to complete the treatment than families in the standard participant motivation group
 * Parent and Caregiver Participation Toolkit
 * Families who used the toolkit had higher attendance, better treatment outcomes reported by the parents, and had more treatment engagement reported by the therapist.

Structural Stigma and LGBT Mental Health
Presenter: Mark L. Hatzenbuehler, Ph.D., Associate Professor, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health

Powerpoint:

Learning Objectives:

 * Sexual orientation is a person’s sexual and affectional preferences for people of the same or different sexes or genders
 * Multi-dimensional construct: refers to sexual attraction, sexual behavior, and sexual identity
 * Gender identity is a person’s perception of themselves as male, female, both, or neither
 * Cisgender individuals are people for whom biological sex and gender identity, expression, or behavior are in alignment are referred to a cisgender
 * Transgender individuals are people for whom gender identity, expression, or behavior does not conform to the biological sex to which one was assigned at birth
 * There are multiple levels of sigma: structural, interpersonal, and individual
 * Structural sigma refers to state policies and institutional policies. Stigma imposed by society
 * “Societal-level conditions, cultural norms, and institutional policies and practices that constrain the opportunities, resources, and wellbeing of the stigmatized”
 * Interpersonal stigma is related to abuse, discrimination, and rejection while individual stigma refers to self-stigma and concealing
 * The different approaches to studying structural stigma and LGBT health
 * Measures of structural sigma include: social policies, social attitudes, and composite indicators
 * Methods: observational, cross-national comparison, quasi-experimental, and lab-based
 * Outcomes: psychiatric morbidity, suicide attempts, premature mortality, physiological stress reactivity, health behaviors, bullying and identity concealment


 * Hidden from Health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey
 * Structural stigma is associated with greater odds of concealment
 * 2-3x more likely to conceal in an environment with high structural stigma
 * Structural stigma -> Concealment (AOR: 2.47, 95% CI: 2.10 - 2.91)
 * State-Level Policies and Psychiatric Morbidity in Lesbian, Gay, and Bisexual Populations
 * Sexual orientation disparity in psychiatric morbidity is higher in states with structural forms of stigma (having no protective policies)
 * Homosexuals are 1-2x more likely to be diagnosed with General Anxiety Disorder (GAD) and Dysthymia than heterosexuals
 * Homosexuals are 2-3x more likely to be diagnosed with Post-traumatic stress disorder (PTSD) than heterosexuals
 * They are 3-4x more likely to be diagnosed with more than one psychiatric disorder than heterosexuals
 * Neighborhood-Level LGBT Hate Crimes and Bullying Among Sexual Minority Youths
 * Found that there were higher rates of bullying among sexual minority youth in neighborhoods with a greater prevalence of LGBT assault hate crimes
 * There was no association between LGBT assault hate crimes and bullying among heterosexual youth and there was no association between bullying and overall violent and property crimes among sexual minority youth
 * The Impact of Institutional discrimination on psychiatric disorders in Lesbian, Gay, and Bisexual Populations
 * Study that investigated the effect of same-sex marriage ban in states on psychiatric disorders in LGB adults
 * Found that LGB adults living in states where same-sex marriage was banned had an increase in mood disorder diagnoses
 * Association of State Laws Permitting Denial of Services to Same-Sex Couples With Mental Distress in Sexual Minority Adults
 * Found that there was about a 50% increase in sexual minority adults experiencing marital distress in states that passed laws denying services to same-sex couples
 * Structural Stigma and Hypothalamic-Pituitary-Adrenocortical Axis Reactivity in Lesbian, Gay, and Bisexual Young Adults
 * Structural Stigma Associated with Blunted Cortisol Reactivity to Trier Social Stress Test
 * Stress of growing up in high structural stigma environments may exert biological consequences that are similar to other chronic life stressors
 * Overall findings suggest strong relationship between structural stigma and LGBT health
 * Triangulating evidence across multiple methods, measures, outcomes
 * Documenting specificity of findings to the stigmatized group (e.g., LGBT populations) and not the non-stigmatized group
 * Controlling for potential individual- and structural-level confounders to rule out spurious associations
 * Conducting falsification tests to show structural stigma does not predict outcomes it shouldn’t theoretically influence
 * Addressing plausible alternative explanations (e.g., selection into low stigma communities by healthy respondents)


 * Implications for Clinicians
 * Structural stigma affects the mental health of LGB populations across the life course
 * Structural stigma shapes biopsychosocial processes that may adversely impact treatment utilization and/or response to mental health interventions among LGB populations
 * Concealment
 * Sensitivity to status-based rejection
 * Physiological stress reactivity
 * Structural stigma may directly undermine the efficacy of psychological interventions
 * Recommendations for Clinicians
 * Assess clients’ exposure to stigma across levels of analysis (individual, interpersonal, structural)
 * Be attentive to stigma exposure across development, not just in current moment
 * Facilitate clients’ understanding of how stigma exposure affects their mental health
 * Support clients (and their families) in efforts to cope with, but also change, stigmatizing contexts
 * Consider the flexible adaptation of treatments, particularly in high stigma contexts
 * Implications for Preventive Interventions
 * Structural Stigma moderates intervention efficacy

Transdiagnostic Treatments for Youth Emotional Disorders: How Can We Get "what works" to More Children and Adolescents?
Presenter: Jill Ehrenreich-May, Ph.D., Associate Professor, Department of Psychology, University of Miami.

Dr. Ehrenreich-May is the first author of the therapist guide and workbooks for the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents  (UP-C and UP-A). Funding for research on the UP-C and UP-A comes from the National Institutes of Health, Queensland Children’s Hospital Foundation, American Red Cross, and other agencies.

Powerpoint:


 * The Unified Protocols
 * For which emotional disorders?
 * All anxiety disorders
 * Obsessive-compulsive disorder (e.g., OCD)
 * Adjustment disorder with depressed mood or anxiety

Depressive disorders


 * Emerging evidence for: PTSD (Gallagher, 2017; Varkovitzky et al., 2018), eating disorders (Thompson-Brenner et al., 2018; Eckhardt et al., under review), borderline personality features and disorder (Sauer-Zavala, Bentley, & Wilner, 2016; Tonarely et al., in preparation), bipolar disorder II (Ellard, Deckersbach, et al., 2012), anger and irritability in youth (Malmberg, Kennedy & Ehrenreich-May, in press; Grossman & Ehrenreich-May, in press), early onset serious mental illness (Weintraub et al., under review), etc.
 * Although they may look different, these disorders may be maintained by similar processes
 * Namely how the individual responds to intense negative (and to a lesser degree positive) emotions

Learning Objectives:

 * Youth Emotional Disorders are a Huge Problem
 * Anxiety and depressive disorders are the most prevalent mental health disorders.
 * They start during childhood and adolescence (onset in the middle childhood age).
 * They impair youth – at home, at school, with peers.
 * Like impairing relationships with families, friends, themselves, etc.
 * May not be able to see the level of impairment, but still very impairing.
 * They persist into adulthood and predict negative outcomes –future illness, poorer education, substance use, suicidal behavior.
 * Might morph and change over time, but without effective treatment, they last.


 * Youth Emotional Disorders are a global crisis
 * Close to 10% of the world’s population is affected by depression and anxiety.
 * Cost 1 trillion dollars annually
 * Becoming more common.
 * These problems increased in frequency between 1990 and 2013 nearly 50% from 416 million to 615 million people.
 * Every $1 invested in scaling up treatment for depression and anxiety leads to a return of $4 in better health and occupational outcomes.
 * Using brief, evidence-based strategies to address anxiety and depression in youth seems like an obvious solution to this crisis.
 * Things that work for OCD, anger, anxiety, and depression.
 * Many interventions have shown positive effects.


 * The Evidence Base for Treatment of Youth Anxiety, Depression, OCD and Anger is Pretty Good
 * CBT for anxiety disorders and CBT/IPT for adolescent depression are well-established treatments with strong effect sizes (Walkup et al., 2008; Weersing et al., 2017).
 * Combine with SSI the effect goes up to 80%.
 * Children were able to keep their gain.
 * Family-based and individually directed CBT for pediatric OCD are probably efficacious treatments (Franklin et al., 2014).
 * Parent-management training and CBT are effective in reducing anger and aggression in youth (Sukhodolsky et al., 2016).
 * We need to consider where and with whom
 * Within research institutions with certain populations.


 * Practitioner Barriers to Evidence-Based Treatment (EBT) Use
 * Few providers are trained in EBTs
 * Variable or no training in some degree programs
 * Limited time for training post-degree program
 * Very burdensome for clinicians to get trained in a new intervention
 * Limited availability of supervision/support in new EBTs
 * Costs of new training
 * Logistical barriers (competing work demands, child care, transportation)
 * Financial barriers (workshops, videos, etc. are costly)
 * The stress of doing something “new” (e.g., doing CBT/ACT/DBT when mostly trained in Family Therapy)
 * Very uncomfortable - not sure
 * Need a lot of support
 * Too many manuals of EBA
 * Embarrassment of riches
 * There are a lot of treatments that work for youth which is an unexpected barrier to Evidence Based Practice Use.
 * How does your institution choose?
 * Techniques in EBT Manuals May Not Differ that Much
 * There are a lot disorder or problem-specific EBT Manuals out there but majority contain similar effective strategies.
 * Lack flexibility in treatment targets and delivery models.


 * Shared Psychosocial Treatment Components for Youth Emotional Disorders
 * Focus on emotion identification and affective labeling
 * Psychoeducation of how emotions impact behaviors
 * Fundamental technique that you are going over is very similar
 * Education about how emotions impact behavior, prompting avoidance, escape, aggressions, compulsions, etc.
 * Cognitive strategies: restructuring, mindful awareness, behavioral experiments
 * Reappraisal
 * Mindfulness
 * Behavioral experiments to test a belief
 * Opposite action strategies: behavioral activation, problem-solving, exposure
 * Parenting strategies: psychoeducation, strategies for adjusting parenting behaviors that impact child emotional disorders
 * But, Multi-Problem Youth are the Norm
 * Up to 75% of children with an emotional disorder diagnosis have concurrent comorbid diagnosis (Costello et al. 2003; Beesdo, Knappe & Pine, 2009; Lavigne et al., 2015; Storch et al., 2016).
 * Problems also co-occur over time (Garber & Weersing, 2010)
 * True both within (multiple anxiety disorders) and between types of problem (e.g., co-occurring anger problems and major depressive disorder).
 * Makes matching problems to most existent EBTs an issue
 * The norm is comorbidity - shift and change over time
 * True for both Within and between classes of disorders (within - GAD and social anxiety), between (depression and anxiety)
 * Comorbidity and Emotional Disorders
 * Shared symptoms across different problems or disorders
 * Problem with our systems of classification (e.g., the DSM, ICD, etc.)
 * There is a lot of item overlap
 * Shared determinants of emotional disorders
 * Anxiety and depression share genetic, neurobiological and environmental factors
 * Negative Affect Syndrome (Barlow, Allen & Choate, 2004; Norton & Paulus, 2016)
 * More people are prone to experience a high level of negative affect
 * Transdiagnostic mechanisms underlying emotional disorders like rumination, intolerance of uncertainty, anxiety sensitivity common to many disorders.
 * Treatment Flexibility
 * Benefit from more targeted treatments for youth emotional disorders may be more modest or limited when applied in real-world clinical care settings (Weisz et al., 2017; Weisz, Jensen-Doss, & Hawley, 2006).
 * Replicate approaches in the community -> they are limited or modest effects
 * They are not outperforming treatment as usual (TAU)
 * Problems also shift or change in intensity during treatment for emotional disorders in youth (Marchette & Weisz, 2017)
 * Shifting focus from like anxiety to depression when not ready
 * Increased flexibility in the way we deliver our evidence-based treatments may be needed to address these challenges.
 * Advantages of a Transdiagnostic Approach to Treatment (Marchette & Weisz, 2017)
 * Increased efficiency of training in and dissemination of evidence based practices
 * Reduced training costs for practice organizations and practitioners
 * Improved fit to the way practitioners function in everyday practice
 * Improved fit to client characteristics in real-world settings
 * Increased clinician and client satisfaction with treatment
 * Three Main Approaches to Transdiagnostic Treatment
 * Common Elements Approach – Addressing multiple forms of psychopathology by bringing together therapeutic procedures commonly (e.g., Chorpita & Weisz, 2009).
 * 2. Principle-Guided Approaches
 * Addressing multiple forms of psychopathology by combining mechanisms of therapeutic change that can be applied to each (e.g., Weisz, Bearman, Santucci & Jensen-Doss, 2017).
 * Providing a set of therapeutic principles that we like can work
 * Addressing common mechanisms without too much detail for therapists to follow. What is the principle and how you can apply it very broadly
 * Core Dysfunction Approach –
 * Addressing multiple forms of psychopathology by addressing a hypothesized common higher order or underlying form of dysfunction (e.g., Ehrenreich-May et al., 2018).
 * Unified protocols
 * The Unified Protocols for Treatments of Emotional Disorders in Children and Adolescents
 * A core dysfunction approach that also features a modular structure (UP-A) and core or common treatment principles that may be flexibly applied to a range of emotional disorder conditions by focusing on excess fear, anxiety, sadness and/or anger in youth during treatment delivery.
 * Modular structure. Flexible container of skills that you can fit to a particular client needs
 * Came from her own clinical work
 * What is this Core Dysfunction believed to cut across emotional disorder presentations?
 * Neuroticism: The trait-like tendency to experience negative emotions and the intensity of that experience. Heightened Negative Affect, →Distress Aversion or Low Distress and Tolerance, and Experiential Avoidance.
 * This child is responding to the same stimuli with heightened emotion and experiencing a lot of aversion (what to get rid of as quickly as possible)
 * Want to avoid the experience completely
 * The Unified Protocols
 * For which emotional disorders? (recruited children with these..)
 * All anxiety disorders
 * Obsessive-compulsive disorder (e.g., OCD)
 * Adjustment disorder with depressed mood or anxiety
 * Depressive disorders
 * Did not want to eliminate comorbidity
 * Emerging evidence for: PTSD (Gallagher, 2017; Varkovitzky et al., 2018), eating disorders (Thompson- Brenner et al., 2018; Eckhardt et al., under review), borderline personality features and disorder (Sauer-Zavala, Bentley, & Wilner, 2016; Tonarely et al., in preparation), bipolar disorder II (Ellard, Deckersbach, et al., 2012), anger and irritability in youth (Malmberg, Kennedy & Ehrenreich-May, in press; Grossman & Ehrenreich-May, in press), early onset serious mental illness (Weintraub et al., under review), etc.
 * § Although they may look different, these disorders may be maintained by similar processes
 * § Namely how the individual responds to intense negative (and to a lesser
 * degree positive) emotions
 * Unified protocol case conceptualization model
 * Those with any emotional disorder/significant symptoms may experience
 * Frequent and intense experience of emotions


 * Parenting practices and behaviors associated with emotional disorders
 * Parents of youth with emotional disorders may also fall into patterns of behavior that reinforce the youth’s intense experience of strong emotion or unhelpful coping strategies.
 * Therefore, core emotional parenting behaviors are also targeted in the UP-A and the UP-C:
 * Excessive criticism
 * Overcontrol/overprotection
 * Modeling of distress and avoidance
 * Inconsistent reinforcement and discipline patterns


 * Target parenting behaviors called opposite parenting behaviors
 * Differs between early and adolescent
 * Helicopter parenting - evoked when seen in child is in distress
 * Some parents have psychopathology themselves
 * Kids with emotional disorders - parents will evoke inconsistent parenting practices
 * Parenting practices and behaviors associated with emotional disorders
 * Parents of youth with emotional disorders may also fall into patterns of behavior that reinforce the youth’s intense experience of strong emotion or unhelpful coping strategies.
 * Therefore, core emotional parenting behaviors are also targeted in the UP-A and the UP-C:
 * Excessive criticism
 * Overcontrol/overprotection
 * Modeling of distress and avoidance
 * Inconsistent reinforcement and discipline patterns
 * Target parenting behaviors called opposite parenting behaviors
 * Differs between early and adolescent
 * Helicopter parenting - evoked when seen in child is in distress
 * Some parents have psychopathology themselves
 * Kids with emotional disorders - parents will evoke inconsistent parenting practices



Evidence-Based Engagement Interventions for Disruptive Behavior: Practical Strategies to Integrate Into Routine Care
Presenter: Anil Chacko, Ph.D., Associate Professor, Department of Applied Psychology, New York University

Powerpoint:

Learning Objectives:

 * Initial Contact (McKay Telephone Strategy)
 * Intake Process (McKay Initial Clinical Interview ; Chacko Parent Preparation Protocol )
 * Ongoing Engagement (Nock Participation Enhancement Intervention ; Kazantzis Homework Process)


 * Initial Intake
 * Help parents clarify the need for mental health care.
 * Increase caregiver investment and efficacy by validating their attempts to seek help.
 * Identify attitudes about previous experiences with mental health care and institutions, as well as expectations for this experience.
 * Problem-solve around concrete obstacles to care.
 * Tell parents what to expect for the first appointment and answer any questions
 * Intake Process
 * Discuss the helping process with families, including family expectations, attitudes, attributions and concerns.
 * Include families as equal partners in treatment planning and decision making.
 * Start with issues that are most urgent to the family.
 * Talk with families about barriers to care and help identify resources to overcome barriers.
 * Integrate your assessment findings into how the family sees their situation
 * Ongoing Engagement
 * Validate families and take the time to understand each member’s perspective.
 * Establish and review SMART goals
 * Integrate progress monitoring
 * Idiographic (SMART)
 * Nomothetic
 * Engagement related
 * Remind families of their appointments.
 * Identify barriers to ongoing involvement.
 * Identify barriers to implementing change.
 * Empower parents to attempt new strategies and problem solving skills
 * Case of JD: J.D. is a 10-year-old patient referred by his general practitioner for help with his oppositional behavior. J.D. is accompanied by his mother, his father, and his father’s fiancée. His mother and father divorced 2 years ago, and the mother blames J.D.’s father for focusing more on his fiancée than his own son. J.D.’s father feels that the mother is overreacting (just as he feels she is overbearing) and that she does not see the utility of mental health treatment, stating, “There’s nothing wrong with J.D. He’s a kid. He’ll grow out of his oppositional behavior sooner or later.” J.D., however, has a history of oppositional behavior, which has only increased in severity at school and home over the past few years.
 * How do you approach the intake process with J.D. and his parents? How do you validate each parent’s perspective while doing what’s best for J.D.?
 * Removing the stigma of mental health; identifying that their child is having issues with defiance
 * Recognizing that people will have different perspectives (normalizing) and realizing that different kids will have different problems
 * What are the practical and perceptual barriers in this case?
 * The father has a different perspective on the severity of the problem and what needs to be done
 * Mom is viewing the time commitment (with finance) as a barrier
 * Transportation
 * How do you engage J.D.’s father, given his resistance to mental health treatment?
 * Appreciate what parents bring to this dynamic that they will always know their kid more than we do
 * What kind of assessment and psychoeducation is important for this family?
 * Standardized checklist - compare his behavior to standard norms


 * What obstacles or challenges do families have in engaging with your setting?
 * Think about problem the concrete barriers that families may have with your setting such as transportation, child care, scheduling/time issues, cultural barriers, stigma, lack of support from families/friends, competing priorities
 * Engagement Interactions. Ask yourself:
 * 1) What is going on?
 * 2) How does it affect domains of engagement:
 * Relationship: Relationship quality with the provider
 * Expectancy: Expectations about outcome; readiness and motivation to participate
 * Attendance: Presence and timeliness at a session
 * Clarity: Understanding approach/rationale, structure and goals of treatment, roles of each person
 * Homework: Active participation in collaboratively determined activities
 * 3) What do I do?
 * Style and Strategy

An Introduction to the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents
Presenter: Jill Ehrenreich-May, Ph.D., Associate Professor, Department of Psychology, University of Miami

Powerpoint:

Learning Objectives:






Treating Shy, Inhibited, and Socially Anxious Youth in Early Childhood
Presenter: Jami Furr, Ph.D., Senior Psychologist, Mental Health Interventions and Technology (MINT) Program, Center for Children and Families at Florida International University

Powerpoint:

Learning Objectives:
Anxiety
 * Anxiety keeps you safe, gets you to places on time, triggers fight or flight - normal emotion
 * Long-term - when you don’t like feeling anxiety you engage in avoidant behavior
 * Untreated anxiety can lead to poor academics and social development, chronic mental health problems
 * 10-20% of children have an anxiety disorder
 * Those with internalizing difficulties are harder to detect as they are not typically “bad kids”
 * Comorbidity - the norm is to have 2 or more anxiety disorders
 * Ebbing/flowing of fear, nightmares, separation anxiety can still be normal until it interferes with daily functioning
 * CBT is among the best treatments for the big 3 anxiety disorders (social, generalized, separation)

Social anxiety disorder
 * Persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others
 * Individual fears that they will act in a way that is embarrassing or humiliating or show anxiety
 * Must be excessive enough to cause interference w/ educational, occupational, and/or social achievements

Selective mutism
 * Consistent failure to speak in specific social situations when speaking is expected
 * Able to speak comfortably in other settings
 * Parents feel almost as if they have 2 personalities due to difference at home
 * Failure to speak causes interference w/ educational, occupational, and/or social achievements
 * Symptoms must last for at least 1 month (excluding 1st month of school) in order to be given an official diagnosis
 * Closely related to social anxiety disorder/phobia but not entirely overlapping
 * Rarely secondary to a traumatic event and is stable (not episodic or phasic)
 * Known trajectories of anxious youth into adolescence and adulthood
 * More common in girls than boys (<1% of elementary school children)
 * Bilingual children are over-represented in SM

SM Evaluation
 * Diagnostic interview w/ parents
 * Semi-structured clinical interview
 * Anxiety Disorder Interview Schedule (ADIS-IV-P)
 * Social Communication Anxiety Inventory (SCAI)
 * identify levels of verbalization in different contexts
 * Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS)
 * Selective Mutism Questionnaire (SMQ)
 * measure lack of speech and SM-related impairment
 * Screen for Child Anxiety Related Disorders (SCARED)
 * Parent, teacher, and/or self-report forms
 * BASC, CBCL/TRF, ECBI, RCMAS, RCADS, SNAP (for ADHD/ODD)
 * Observation w/in school or an office/clinic
 * School Speech Questionnaire (SSQ)
 * Verbal Output in Classroom Environments (VOICE)
 * Evaluation of child through structured observation
 * Selective Mutism Interaction Coding System (SMICS-ER)
 * observe both child and parent behavior
 * S/L evaluation
 * PPVT (TVIP in Spanish), EVT, TNL-2, CELF-5, OWLS-II, CASL, TAPS-4
 * Cognitive evaluation

Psychoeducation
 * Cycle of negative reinforcement
 * Child is prompted to talk or engage in conversation
 * Child gets overly anxious
 * Child avoids
 * Adult rescues
 * Child’s and adult’s anxiety are lowered
 * Accommodation leads to SM being very quickly and easily learned
 * Negative reinforcement
 * Contamination
 * School and others in their lives are associated with prior histories of not talking, making those individuals “contaminated”
 * New school & the therapist are not associated w/ any history of not talking - not contaminated!
 * Important to not ask any questions at all when first meeting the child
 * Education about how fear and anxiety work and that they are natural
 * Habituation
 * “Riding the wave” of anxiety until anxiety decreases on its own after experiencing stressor
 * Each successive time the wave gets easier

Treatment
 * Main procedures
 * Adaptation of Parent-Child Interaction Therapy (PCIT)
 * Stimulus fading, shaping, exposure
 * Cognitive-behavioral strategies for older children
 * Immediate reinforcement for “brave talking” and other participation behaviors
 * Individualized reinforcement plans using laminated boards
 * Token economy system
 * Bonus tokens
 * Treasure chest of rewards
 * Child Directed Interaction (CDI)
 * Encourages positive relationship building over time
 * Skills
 * Labeled praise
 * a positive statement regarding what the child is doing in the moment
 * ex: Great job using your voice to answer my question!
 * Reflection
 * a statement that repeats back to the child their verbalization
 * ex: if the child asks “Where is the bathroom?” you could reflect by saying “You want to know where the bathroom is”
 * Description
 * a statement about the child’s moment-to-moment behavior
 * ex: if you see the child coloring, you could say “You are coloring a flower with the red crayon”
 * General rules for CDI
 * Allow child to lead the play
 * Avoid commands
 * Avoid questions
 * Do not criticize child or use negative talk
 * Ignore minor misbehavior
 * Do not interpret but rather describe behavior
 * Be enthusiastic and enjoy your time with the child!
 * Verbal Directed Interaction (VDI)
 * Types of questions
 * Forced-choice
 * a question in which two or more possible responses are given within the question
 * ex: Do you want pizza or chicken?
 * Open-ended
 * a question in which a possible answer is not suggested within the question (5 W’s)
 * ex: What did you learn today at school?
 * Yes/No (to be avoided)
 * a question in which a possible or expected response is either “yes or “no” (not very effective)
 * ex: Did you do your homework?
 * this can be made into force choice by asking “Did you do your homework or not yet?”
 * General rules for VDI
 * Avoid yes/no questions
 * Do you want to eat this, yes or no?
 * Allow 5-10 seconds to respond
 * Describe their non-verbal behavior, do not interpret it
 * I see you’re shaking your head. Does that mean you’re hungry or you’re not hungry?
 * Repeat questions up to 3 times
 * What is your favorite color? (5 seconds) Is your favorite color blue or something else? (5 seconds) Is your favorite color blue, yes or no?
 * Practice in a separate space
 * Return to previous situation where child was successful
 * I know you were able to tell Sabrina your favorite color a few minutes ago. Go practice with her and I will be ask you this question after
 * Revisit the question later
 * That’s okay, think about the answer and I will ask you that question later.
 * Always use CDI skills
 * I really like how you are making eye contact with me. What is your name?
 * VDI Skills
 * Modeling
 * have a child observe another child or adult interacting adaptively with the feared situation (live or filmed)
 * ex: Ordering food at a restaurant
 * Coping Strategies
 * relaxation techniques used to aid in dealing with a stressful situation
 * ex: coping thoughts like “I am brave” or “When this is over, I’ll be glad I did it”
 * Pizza breaths - take deep breaths mimicking cooling a hot pizza
 * Squeezing lemons - reduce tension in hands by pretending to squeeze lemons
 * Practice
 * repeated performance of a structured exercise for the purpose if acquiring a skill and habituating them to a feared stimulus
 * ex: Practicing introducing themselves to strangers
 * Contingency Management
 * rewards for brave behaviors
 * ex: checks on a chart, stickers, tokens
 * Characteristics of a Good Reward System
 * Rewards increase the frequency of a behavior
 * Needs to be consistent and predictable
 * Must follow through
 * Only give rewards when they are earned
 * Different than a bribe
 * Should be faded out over time
 * Incorporate rewards into your existing system
 * Fade-in
 * gradually introducing a new individual into the child’s speaking circle
 * new individual gets closer in proximity to the child as an old individual with whom they’re already comfortable moves further away
 * Shaping
 * rewarding successive approximations to a desired behavior
 * ex: Trying to get the child to tell a new person their favorite color
 * Have the child tell the parent
 * Have the child tell the parent while the new person approaches
 * Tell parent with the new person side-by-side
 * Tell parent while looking at new person
 * Tell the new person
 * Exposure
 * have child interact with a feared stimulus (live or recorded)
 * ex: initiating a conversation with a peer

Cycle of Positive Reinforcement - Brave Talking
 * Disrupting the cycle of negative reinforcement
 * Instead of the adult rescuing, the adult gives the child the opportunity to respond
 * Adult shapes verbal behavior
 * Child answers question and is rewarded with a labeled-praise
 * Positive reinforcement for brave talking

Additional Tips for Teachers
 * Conduct fade-in procedure with the parent and child as soon as possible
 * If the child whispers only to the teacher, reflect what they said aloud to others
 * Use contingency management within the classroom to reinforce brave talking
 * When assigning classroom jobs, give the child a job that involves speaking
 * Appropriately reward brave talking without overwhelming the child with too much praise, especially in front of other classmates
 * May help to read a book about SM to the class, or any book that talks about how all kids feel scared sometimes
 * Child could create audio recording to present to the teacher and/or class
 * Communicate with parents any difficulties the child may have at school

Impact of Culture and Language
 * Case example: Maria
 * 6 year old bilingual in Spanish and English, mother only speaks Spanish
 * Spanish primary at home, English primary at school
 * Teacher would try to speak to her in Spanish but Maria would still not speak
 * Treatment modifications
 * Therapist conducted shaping hierarchy in Spanish using si/no
 * Then started saying those Spanish words in English
 * Fade-in with teacher in Spanish only with just si/no
 * Quickly transitioned to English within the same session
 * Went straight to English wiith peers
 * Follow-up: speaking to peers, teachers, community in English
 * Case example: Martin
 * 7 year old spoke Italian w/ mother and English w/ father
 * Would speak Italian and demonstrated much less SM behavior when in Italy
 * Did not want to come to treatment
 * Treatment modifications
 * Mother was more accommodating and had a harder time implementing treatment skills
 * Brought in Italian-speaking clinician but was less proficient
 * Changed to slow shaping procedure from Italian words to English words
 * Parents reported that their culture does not encourage rewards and felt they should just “do” things
 * Staying with culture of origin in terms of language in the beginning of treatment and then transition to including more English into the treatment (both at school and home)
 * Recommend English speaking practice at home, in community, and with peers
 * Recognize that youth learning multiple languages may have slower processing and expression - translating and back-translating occurring quickly

Building Social, Emotional and Behavioral Competencies in the Elementary School Setting Using a Multi-Tiered System of Supports
Presenter: Erika Coles, Ph.D., Clinical Director, Center for Children and Families at Florida International University

Powerpoint:

Learning Objectives:

 * 1) Recognize how multi-tiered behavioral strategies contribute to social and emotional learning in children
 * 2) Define trauma-informed schools and how using a trauma-informed framework can build social and behavioral competencies in the school setting
 * 3) Implement evidence-based strategies for building social and behavioral competencies

Other 2019 Days

 * SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2019/Day 2
 * SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2019/Day 3