SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 3

= Day 3 =

Reactivity to Community Violence Exposure: Rethinking Desensitization in Youth of Color in Urban Communities
Presenter: Noni K. Gaylord-Harden, Ph.D., Associate Professor, Clinical Psychology, Loyola University Chicago

Notes:
Next steps:  Q&A 
 * The curvilinear relationship between ECV and depression but the linear effect for anxiety
 * Desensitization - a reduction in emotional or physical reactivity to stimuli
 * Hyper-vigilance and hyper-arousal appear to be protective against future ECV and victimization
 * Different observed effect in sample with older boys
 * Possible grief/loss response
 * Unique sample due to identity stress
 * Adaptive calibration model (conditional adaptation) - in contexts of high stress/adversity, young people exhibit behaviors that allow them to adapt to that setting that may not translate outside of that setting
 * Instead of viewing those symptoms as pathological, they may be conditional
 * Dangerous/unpredictable environments shape stress response system towards vigilant and unemotional patterns
 * Demonstrates the need for a public health approach as opposed to a criminal justice/delinquency perspective
 * 1) What are the age and gender effects on curvilinear association?
 * 2) What are the long-term effects of hyper-arousal
 * 3) Trauma-informed interventions - what post? grief/loss interventions, ADHD & Disruptive Behavior Disorders, substance use
 * Q: Conditional adaptation may be protective - maybe the only way of intervening is to make the environment safer
 * A: Yeah (laughing)


 * Q: I see some of these things daily in school - they can’t adapt to the school that may be adaptive outside. We need to teach the skill of adapting, but how do you go about that?
 * A: Emphasis on the fact that there aren’t always skill deficits


 * Q: When you found the mediation between high hyper-vigilance/high aggression related to low long term violence, what do you find in peer relations?
 * A: Question of peer endorsement - adolescents are sensitive to the evaluation of others. If their peers approve of their behaviors, they are more likely to engage in them.


 * Q: The studies deal with high-threat perceived environments - have you looked into their perception of violence? Some kids feel like they live in a world of violence and behave as such.
 * A: Social media and what’s available at any moment can have an exposure effect. Desmond Patton at Columbia - “internet banging” looking at how violence plays out on the internet. Kids can be exposed to violence through what they see online and on the news.


 * Q: Referring to the study of 18 to 25-year-olds, is there a correlation between hyper-vigilance in young men who live in conditional adaptation environments and those who work in those communities (i.e., what about the difference between seeing it as pathological or adaptive)?
 * A: The pathological perspective comes from researchers and outsiders and is not how the people in those communities actually see it.

A Storm of Innovations: Bringing the Best of the Free Mental Health Tools to the People Who Would Benefit
Presenter: Eric Youngstrom, Ph.D., Professor of Psychology and Neuroscience and Psychiatry, The University of North Carolina at Chapel Hill

Powerpoint: A Storm of Innovations: Using the Web to Work Together and Bring the Best Psychology Information to the People Who Would Benefit

Notes:

 * Updates since last time:
 * Assessment center and wiki
 * Keep everything free, problem- no marketing budget, people don't use tools because it is not advertised.
 * Use Wikipedia because anyone can edit, free, lots of people use it
 * Translations
 * Remixes:
 * Crisis response
 * Vignettes
 * What is HGAPS?
 * Started as a club at UNC, incorporated as a 501c3
 * Sister chapters at UCLA, App
 * Vision: bring best info about psych science to the people who would benefit (parents, clinicians, etc) for free
 * EBA Pages on Wiki
 * QR code leads to EBA on wikiveristy
 * Can use Wikiversity “to teach a class” and share info with people
 * If printed as a book- wiki info is 300 pages of material, all for free
 * Link can be shared with anyone
 * Goal: make easier for clinicians to use info
 * Wiki Impact
 * 173 new articles, edited 600 pages, 11000 edits, 150 mil views
 * How do we pay for this?
 * Started with grants from SCCAP for pizza
 * Assessment Center
 * Free measures that are easier to to find, connected to wiki
 * If electronic, we could score for you and give a summary of results
 * Most audacious idea: giving away everything!
 * QR code goes directly to assessment center- everyone sees what we have
 * Over 65 assessments on the assessment center
 * Each contains an intro, instructions, disclaimer, demographics, questionnaire, calculated scores, resources for general public, and tools for clinicians
 * Assessment batteries
 * Made in Qualtrics, for use for clinicians or parents
 * Several issues are assessed by the three batteries
 * Hard part of the assessment center: how to do it responsibly?
 * Have been live with a pilot version for more than a year now (rebuilt the DBSA) and it has been used 30000 times (only 9 assessments)
 * Current one is even more
 * Translations
 * All assessments are in English
 * 25 measures in at least 2 languages (usually Spanish)
 * A few measures in 25 languages
 * Today we plan on translating a lot of them in Spanish
 * Will be doing this with Open Science Framework (OSF)
 * If you know of a Spanish translation, can email it to us
 * Will add this to OSF (a free library)
 * Remixes
 * Crisis response
 * Grew out of parkland
 * Lead with resources to manage stress
 * Goals were to create EBA and repackage it in a way that was accessible to the public so that it could be disseminated to those who would benefit
 * Visuals look more accessible and attractive to public
 * Able to use resources and remake them for different situations (shootings in Pittsburgh and Orlando)
 * Have more than 30 infographics
 * Can use social media to disseminate resources
 * Can do targeting advertising for different audiences
 * Some infographics have been translated to Spanish (UNCC)
 * Can also be used in response to natural disasters (I.E. hurricanes) a lot of this came from Miami
 * After Hurricane, went to the Friday Center (red cross shelter) and gave qr codes to infographics
 * Outcomes of dissemination- posters
 * Vignettes
 * Not limited to clients
 * Hannah Baker from 13RW- show what a counselor could have done differently, what Hannah could have done differently
 * Talked with Dr. Helen Hsu who was a consultant for the show and said it was fine to do
 * Trying to take hard information and make it useful for people
 * Questions
 * SAMSA: similar to assessment center, we use some links to their toolkit
 * SAMSA is big, hard to make connections
 * Difficult to find new things in SAMSA (such a large library)
 * Perhaps adding more interactive pieces?
 * Videos have been made (a couple, but may not be appropriate)
 * By the end of 2020 should have some
 * Have you thought about making an app?
 * Did have an attempt with a kick-starter grant
 * Problems: login security is so high it's inaccessible
 * Business partner doesn't want it to be free
 * Suggestions: How many have shared the link with professionals they know?
 * Ask everyone to do it

Making the Grade: School-based Interventions for Pediatric Anxiety Disorders
Presenter: Golda Ginsburg, Ph.D., Professor of Psychiatry, University of Connecticut (UConn Health)

Introduction

 * 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?

 * 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?

 * 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

 * 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

Case Example 1
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

Case Example 2
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?

 * 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?

 * 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

Results
Evidence-based Treatments CAMS: Response rates 60%-80%
 * Cognitive Behavioral Therapy (CBT)
 * Medication-SSRIs
 * 60% is one treatment alone (independent)
 * 80% is when both treatments are used (together)

STARS Study
Primary Aim: Compare the effectiveness of Modular CBT (more flexible for each child)(MCBT) to TAU The CBT Modules
 * Are school clinicians using CBT?
 * 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)
 * 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
 * 68% used CBT
 * Session by session summary forms data (n=475) clinicians reported:
 * 67% used CBT
 * 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

 * 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?

 * 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? Cochrane report (2013) data are “limited and inconclusive if CBT is more effective over TAU”
 * 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

Implications and Solutions
More training but there are limits because of funding and cooperation Expanding School-Based Anxiety Treatment Calm Study TAPES
 * 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 providers
 * 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**
 * 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
 * CALM uses CBT
 * 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
Many of the issues were resolved or reduced

TAPES Study

 * 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

The Need for Contextually-Relevant and Culturally-Specific Trauma-Informed Interventions for Youth Exposed to Community Violence
Presenters: Noni K. Gaylord-Harden, Ph.D., Associate Professor, Clinical Psychology, Loyola University Chicago

Finding, Using, Sharing, and Improving the Best Free Mental Resources
Presenter: Eric Youngstrom, Ph.D., Professor of Psychology and Neuroscience and Psychiatry, The University of North Carolina at Chapel Hill

Powerpoint: Testing, Tuning, and Translating the Best of the Free Tools for Assessment, Treatment, and Education about Mental Health

Modular CBT for Pediatric Anxiety Disorders: Calling All School Personnel
Presenter: Golda Ginsburg, Ph.D., Professor of Psychiatry, University of Connecticut (UConn Health)

Supporting Social, Emotional, and Behavioral Competencies in the Elementary School Setting
Presenter: Erika Coles, Ph.D. Clinical Director, Center for Children and Families; Director of Clinical Training, Clinical Science Program in Child and Adolescent Psychology, Florida International University

Other 2020 Days

 * SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 1
 * SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 2