Exposure and Parental Involvement as a Key to Meaningful Progress for Student Anxiety

Megan M. Urbassik, Ph.D.

School Psychologist

Loudoun County Public Schools

Overview

– The session will include a description of a case study dealing with severe anxiety in a female elementary school student. Specifically, the success of using a scientifically informed school- and family-based cognitive-behavioral approach (i.e., the Cool Kids Program®) with a strong exposure component will be described. The criticality of parental involvement as an irreplaceable key to treatment success will be included.

Anxiety 101

Definitions

– Excessive fear about real or imaginary circumstances

– Symptoms can be either physical, behavioral, or cognitive

– Generally, anxiety is normal and adaptive– Huberty (2004)

– Anxiety disorders are the most common disorders among school-age children

– Fortunately, they are also the most treatable set of disorders

Symptoms of Anxiety

– Cognitive/Thoughts

– Difficulty concentrating, worrying, hypervigilance

– Behavioral

– Withdrawal, need for reassurance, habitual behaviors, crying

– Physical

– Heart rate, trembling, shortness of breath

Prevalence Rates

– Lifetime prevalence rate of any anxiety is over 15%

– For children, over 25% for general anxiety and over 8% for severe anxiety

– (Kessler et al., 2009; National Institute of Health, n.d.)

– 70-80% children who receive mental health services receive them in schools given the inadequacy or unavailability of outside mental health services

Thoughts

ActionsFeelings

Treatments

– Well-established treatments for anxiety – Cognitive Behavioral Therapy (CBT)

– Exposure

– Modeling

– Education

– CBT with parents

– CBT plus medication

– (Higa-McMillan et al., 2016; Sadock & Sadock, 2007)

School-Based Treatment

Overview

– Schools are often willing to help, but may not have the resources needed for students to make meaningful progress

– Schools are becoming de facto mental health providers – Providers often do things that are counterproductive to progress – Schools provide support that varies by school, and skillsets vary; however, the

support offered can be productive and help provide meaningful change – There are a variety of strategies, tools, and programs available to trained staff that

can assist in the treatment of students with anxiety in the school setting

– Meaningful growth is RARELY made without joint efforts from the professional and the parents (Dowell & Ogles, 2010)

Cool Kids® Program

– Based on the Coping Kids Program, Coping Koala, and Coping Cat– Research based intervention

– 80% of children who completed the program were diagnosis free or showed marked improvement

– Symptom reduction maintained for up to 6 years

– Better outcomes shown with parental involvement, especially in younger children

– Designed for children age 6 to 12 (a separate program is available for 13-17)

– Can be done in individual or group counseling

– (Lyneham, Abbott, Wignall, & Rapee, 2003)

Session Goals

– Learning about anxiety

– Thinking realistically – Detective Thinking

– Self-rewards and monitoring

– Fight fear by facing fear, fear hierarchy

– Exposure and Worry Surfing

– Skill building

– Maintaining the good and dealing with the bad

Case Study

Anna

Anna

– 7 year old, second grader

– Lives with mom, dad, and two sisters

– Types of fears she exhibited

– Illness, self and others

– Parental, especially dad, separation

– Trying new things (e.g., school work, pool, guitar)

– Special circumstances (e.g., St. Patrick’s Day, ear piercing)

Parent Intake Interview

– Gather pertinent background information

– Lay out treatment plan

– Parents sign agreement

Session Goals

– Learning about anxiety

– Thinking realistically – Detective Thinking

– Self-rewards and monitoring

– Fight fear by facing fear, fear hierarchy

– Exposure and Worry Surfing

– Skill building

– Maintaining the good and dealing with the bad

Session Structure

– High points since last meeting, snack (10 minutes)

– Review homework and talk about low points (10 minutes)

– Lesson (25 minutes)

– Assign homework (5 minutes)

– Parent check in (in person or by phone; 5-20 minutes)

Learning about Anxiety

– What is anxiety?

– Who gets anxious? Why me?

– Three components of anxiety: your body, your thoughts, your actions

– Identifying triggers

– Worry scale

(Lyneham, Abbott, Wignall, & Rapee, 2003)

Detective Thinking

– Pretend you are a detective and look for evidence why bad things will not happen

– Start with self-talk: situation, two thoughts

– Steps– 1) What is the event

– 2) What is the thought behind my feelings

– 3) Look for evidence

– 4) List alternatives

– 5) What is a realistic thought

Fight Fear by Facing Fear(Exposure)– First work on positive self-talk and

rewarding yourself*

– Make a worry list: really hard, sort of hard, a little hard

– Pick a goal

– List all of the steps to get to your goal

– Give each step a worry rating

– Identify a reward for each step

(Lyneham, Abbott, Wignall, & Rapee, 2003)

Worry Surfing

– You will feel anxious! There is no need to fight it – surf it!

– Steps:

– 1) Notice the worry, look for clues that you are getting anxious

– 2) Paddle to the top of your worry wave and choose

– What should you be doing now, and focus on that

– 3) Keep concentrating until your worry fades away

– 4) Then, reward yourself!

– Practice, practice, practice

Parent Check-Ins

– How did homework actually go?

– Give mom assignments and the strategies we were working on

– Letting me know of the events coming up

– Discuss unexpected needs

– Bedtime: http://keltymentalhealth.ca/healthy-living/bedtime-routine

– Positive parent techniques

Where is Anna now?

– Did go to private provider

– I switched schools and the provider that took my place did some of those things that were counterproductive

Questions

Megan.Urbassik@lcps.org

References

– Dowell, K. A. & Ogles, B. M. (2010). The effects of parent participation on child psychotherapy outcome: A meta-analytic review. Journal of Clinical Child & Adolescent Psychology, 39, 151-162. doi: 10.1080/15374410903532585

– Higa-McMillan, C. K., Francis, S. E., Rith-Najarian, L., & Chorpita, B. F. (2016). Evidence base update: 50 years of research on treatment for child and adolescent anxiety. Journal of Clinical Child & Adolescent Psychology, 45, 91-113. doi: 10.1080/15374416.2015.1046177

– Huberty, T. J. (2004). Anxiety and anxiety disorders in children: Information for parents. Helping Children at Home and School II: Handouts for Families and Educators.

– Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., Ustün, T. B., Wang, P. S. (2009). The global burden of mental disorders: An update from the WHO World Mental Health (WMH) surveys. Epidemiological Psychiatric Society, 18, 23–33.

– Lyneham, H. J., Abbott, M. J., Wignall, A., & Rapee, R. M. (2003). The Cool Kids Program – Children’s Workbook. MUARU: Macquarie University, Sydney.

– Lyneham, H. J., Abbott, M. J., Wignall, A., & Rapee, R. M. (2003). The Cool Kids Program – Therapist Manual. MUARU: Macquarie University, Sydney.

– National Institute of Health (n.d.). Any Anxiety Disorder Among Children. Retrieved from https://www.nimh.nih.gov/health/statistics/prevalence/any-anxiety-disorder-among-children.shtml

– Sadock, B. J., & Sadock, V. A. (2007). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th Ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.