## Contents

* 1 Making the Grade: School-based Interventions for Pediatric Anxiety Disorders: Primary data presented looking at which school-based anxiety interventions are most effective
* 2 Intro
* 2.1 Why do they go unnoticed?
* 2.2 Why is anxiety in children important to study?
* 2.3 Problems caused by Childhood anxiety
* 2.3.1 Case Example 1
* 2.3.2 Case example 2
* 2.4 How are we doing currently?
* 2.5 Why School Interventions?
* 2.6 Results
* 2.6.1 STARS
* 2.6.1.1 Primary Aim: Compare the effectiveness of a modular CBT (MCBT) to TAU
* 2.6.1.2 What is TAU?
* 2.7 Conclusions & Limitations
* 2.7.1 Is MCBT Better than TAU in Schools?
* 2.8 Implications and Solutions
* 2.8.1 Calm Study
* 2.8.1.1 Follow up of Case 1 and Case 2
* 2.8.2 TAPES Study

# Making the Grade: School-based Interventions for Pediatric Anxiety Disorders: Primary data presented looking at which school-based anxiety interventions are most effective[edit | edit source]

Golda S. Ginsburg, Ph.D.

University of Connecticut

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

# Intro[edit | edit source]

• 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?[edit | edit source]

* 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?[edit | edit source]

* 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[edit | edit source]

* 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[edit | edit source]

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[edit | edit source]

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?[edit | edit source]

* 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?[edit | edit source]

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

## Results[edit | edit source]

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

### STARS[edit | edit source]

##### Primary Aim: Compare the effectiveness of a modular CBT (MCBT) to TAU[edit | edit source]

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?[edit | edit source]

* 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[edit | edit source]

* 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?[edit | edit source]

* 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[edit | edit source]

More training but there are limits because of funding and cooperation

Expanding School Based Anxiety treatment

### Calm Study[edit | edit source]

* 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[edit | edit source]

Many of the issues were resolved or reduced

### TAPES Study[edit | edit source]

* 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