What School Based Anxiety Interventions are Effective?

= Making the Grade: School-based Interventions for Pediatric Anxiety Disorders: Primary data presented looking at which school-based anxiety interventions are most effective = Golda S. Ginsburg, Ph.D.

University of Connecticut

This talk was given at MICAMH at FIU in Miami, Florida.

= Intro = • Background: Why Anxiety? Why schools? • What is treatment as usual (TAU) for anxiety dx in schools? • Is CBT better than TAU in schools? • Expanding the network of school providers

Children have valid concerns and worries during childhood. Anxiety is underestimated and under treated in children

Why do they go unnoticed?

 * 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 o Tough parenting causes tensions 
 * Babying- allowing them to avoid situations that cause distress
 * Causes parental conflict
 * Family distress
 * “Gateway illness” more likely to develop other disorders
 * Adult anxiety 
 * Suicidality
 * Other diagnoses

Case Example 1
Primary Diagnosis: Generalized Anxiety

6-year-old boy

Key worries:


 * Making mistakes/perfectionism/changes
 * Hours getting ready looking just right
 * Upset each morning afraid of missing the bus
 * Hours on homework re-does assignments tears up assignment if makes a mistake
 * Seeks reassurance
 * Sought school nurse because of stomach aches
 * Missed school due to anxiety

Case example 2
Separation Anxiety 10 years old girl


 * Must be near mom at all times beg to stay home
 * Leaves bathroom door open
 * Texts mom during day and asks to leave school
 * Stomach aches each morning causing her to be often late to school

How are we doing currently?

 * Less than half of youth received services
 * Likelihood of receiving treatment: 30% anxiety vs 70% ADHD
 * Critical need to enhance access, bring services to school

Why School Interventions?

 * Takes away many barriers to seeking treatment
 * School setting can trigger anxiety
 * Separation, performance, social
 * Better generalization of skills
 * Treatment improves academic functioning

Results
Evidence-based Treatments


 * Cognitive Behavioral Therapy (CBT)
 * Medication-SSRIs

CAMS: Response rates 60%-80%


 * 60% is one treatment alone
 * 80% is when both treatments are used

Primary Aim: Compare the effectiveness of a modular CBT (MCBT) to TAU
Modular CBT takes the elements of CBT but gives more flexibility to the clinician


 * 6 year RCT in MD and CT: MCBT (n = 37) or TAU
 * One day training; optional supervision
 * 12 weeks of tx

Evaluations at pre, post, 1 year follow up

The CBT Modules


 * Psychoeducation 1st session
 * CBT Triangle
 * Exposure 2nd session and throughout
 * Relaxation strategies
 * Cognitive restructuring “changing thoughts”
 * Problem solving
 * Relapse prevention
 * Meditation

Most children had more than one disorder

What is TAU?

 * Primary therapeutic orientation (n=25) CBT 68%
 * Session summary forms (n=475) CBT 67%
 * IE-report (n = 90 sessions) CBT 14%

A lot fell into the category of other for example:


 * Emotional support for feelings
 * Making holiday cards

Conclusions & Limitations

 * School clinicians are thinking about CBT
 * The sample was small may not be generalizable
 * We need more training for school psychologists

Is MCBT Better than TAU in Schools?

 * Anxiety severity
 * Anxiety did go down overtime and remained down
 * Did not differ significantly between groups
 * Global functions
 * Improved over time
 * No significant between group differences

Cams was more effective than stars but why?


 * Lower dose (9 sessions for 20-30)
 * Limited/poor training and supervision
 * 1 day; optional supervision
 * Low MCBT quality
 * Key CBT element of exposure may have been missing
 * Lower clinician adherence of exposure
 * TAU- contaminated
 * Diagnostic report provided
 * Ongoing monitoring conducted
 * Prescribed # of sessions
 * CBT elements were used in TAU

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

Implications and Solutions
More training but there are limits because of funding and cooperation

Expanding School Based Anxiety treatment

Calm Study

 * 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

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 
 * 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