SCHOOL BASED, EARLY INTERVENTION FOR ANXIOUS YOUTH An example of primary care psychology in Norway

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1 SCHOOL BASED, EARLY INTERVENTION FOR ANXIOUS YOUTH An example of primary care psychology in Norway SYMPOSIUM FOR THE EUROPEAN CONGRESS OF PSYCHOLOGY, MILAN, July 8 th, 2015

2 Project group Bente S.M. Haugland (PI) PhD, senior researcher, Uni Research Health Asle Hoffart, PhD, senior researcher Modum Bad, professor II, UiO Åshild Tellefsen Håland, PhD, senior researcher Sørlandet Sykehus ABUP Jon F. Bjaastad, Doctor of Psychology (clin), senior researcher, Uni Research Health, Helse Stavanger Gro Janne Wergeland, M.D, PhD, Helse Bergen, Uni Research Health. Valborg Baste Statistician, senior researcher, Uni Research Health. Solfrid Raknes, PhD candidate, Uni Research Health / UiB Anja Høie Rogde Community psychology, Fjell Municipality, Uni Research Health Hilde Øverby Leading health nurse, Modum Municipality

3 Bente Storm Mowatt Haugland PhD., clinical psychology Regional Centre for Child and Youth Mental Health and Child Welfare, Uni Research Health, Bergen, Norway

4 AIMING TO DEVELOP AND IMPLEMENT A PRIMARY HEALTH CARE INTERVENTION FOR ANXIOUS YOUTH The intervention should be evidence based low-threshold school-based group format health nurses as group leaders Examine the effects of the interventions (anxiety symptoms, depressive symptoms and quality of life) Examine whether a low-intensity intervention has equal effect as a more extensive program

5 International co-operators Professor Ron A. Rapee, PhD. Centre for Emotional Health, Macquarie University, Sydney, Australia. Associated professor Joseph A. Himle, PhD, Department of Psychiatry and School of Social Work, University of Michigan, USA. Professor Pim Cuijpers, PhD., Department of Clinical Psychology, University of Amsterdam, Netherland. Professor Birgit Watzke, PhD, Department of Psychology, Clinical Psychology and Psychotherapy Research, University of Zurich, Switzerland.

6 FUNDING The Research Council of Norway (NFR) Regional Research Funding (RFFVEST) The Norwegian Directorate of Health Funding from the three cooperating research centers (Uni Research Health, Sørlandet Sykehus and Modum Bad) and from the 9 participating municipalities

7 Anxiety in youth Among the most prevalent mental health problems in youth % life time prevalence in adolescents (Costello et al, 2003; Essau et al., 2000; Kessler et al., 2005) Without effective treatment many will not remit with time (Kessler et al. 2009) adults with anxiety disorders often report that problems started during childhood A gateway disorder - risk for other mental health problems e.g. depression and/or substance abuse (Fröjd et al, 2011; Kendall et al., 2004;Puleo et al, 2011) Anxiety - the larges group of those granted disability benefits due to psychiatric disorders (Mykletun 2013) Colourbox

8 Anxiety negatively influences. family processes social functioning school performances leisure activities sleep self-esteem quality of life (e.g. Essau et al. 2000; Gregory et al., 2002, Alfano, et al. 2007) Colourbox

9 Challenges for anxious youth in school Separation anxiety Difficulties being away from home and from primary caretaker e.g. staying at school all day, participating in birthday-parties and school trips/events Generalized anxiety Continuous worrying e.g. about schoolwork, making mistakes, changes at school, the future, possible accidents, illnesses Social anxiety Difficulties with social challenges e.g. asking or answering questions, oral presentations, reading loud, sport achievements, taking the school bus, meeting new children and/or adults

10 How to offer help to anxious youth within the primary health service? Cognitive behavioral therapy (CBT) an effective treatment and prevention intervention for youth anxiety (James et al., 2013) Challenges: 1. Most anxious youth do not get help and are not in contact with mental health services (Essau et al., 2000; Heiervang et al., 2007) 2. Lack of trained CBT therapists - and limited resources in specialized mental health services to treat all young people with anxiety problems Solutions: Implement early intervention with anxious youth to prevent and arrest the development of anxiety disorders Make the interventions school-based - to improve the access to health services for anxious youth

11 Health workers relevant for participation in our project School health nurses (approx. 3200) - mental and physical health promotion, prevention and early intervention for all school children (6-20 years) Community psychologists (approx. 220) - prevention and early intervention of psychosocial problems in the municipality Challenges: Health nurses and community psychologists: - use much of their time consulting with individual clients - may have limited knowledge/skills in evidence based interventions

12 Feedback from a pilot study (N=80 youth) School nurses were enthusiastic about doing manualized CBT for anxious youth - and eager to learn the skills Groups for anxious youth can be delivered in the school-setting School nurses wanted to continue to use the CBT manual as a regular part of their work but found it difficult to run programs of long duration (i.e. 10 sessions)

13 LOW-INTENSITY CBT(Bennet-Levy et al., 2012) Strategies to increase access to evidence-based therapies make it more available to many more people ( democratize CBT) Moving from face-to-face high intensity interventions by specialist mental health professionals - to for example use of self-help material, involving groups, shorter sessions, internet-based interventions Focus on early interventions and preventive programs - mainly developed for patients with mild to moderate disorders May involve practitioners who may not have high-intensity CBT /therapy qualifications

14 LOW-INTENSITY CBT A low-intensive CBT program might be easier to implement in school health services - but will it be as effective as an extended program? Colourbox

15 INTERVENTIONS «Coping with anxiety» VAAG ( DARE ) Five sessions + two short phone calls/sms Self help material Parents participate in one joint session (Raknes et al., 2014, UNI Research) CHILLED Ten sessions Workbook for the adolescents Two separate parent sessions A parent work-book (Rapee et al, 2006, Macquairy University) FOR BOTH INTERVENTIONS o o o o CBT principles for anxiety Group format (6-8 youth) Two group leaders Video-taping of sessions

16 Informing teachers, parents and youth at included schools about adolescent mental health and the availability of the skill-building prevention programs of this study Recruiting anxious youth (school survey, school nurses, primary health workers, teachers, self-recruitment) T1 Assessed for eligibility Pre-assessment and potential predictors of outcome RANDOMISATION Not included Not meeting inclusion criteria Excluded Exclusion criteria Low-intensity CBT (5 sessions,10 weeks) VÅG Wait-list control (10 weeks) Standard CBT program (10+2 sessions,10 weeks) CHILLED T2 Assessment 4 weeks after onset of intervention T3 Post-intervention assessment. Assessing participants 10 weeks after onset of intervention. Wait-list control subjects randomized to either CHILLED or VÅG T4 One-year follow up assessing for symptoms of anxiety/depression, mental health symptoms and quality of life

17 PROJECT ORGANIZATION WEST NORWAY Three municipalities 9 middle schools/junior high school (12-16 years) 11 school health nurses 3 community psychologists SOUTH NORWAY Three municipalities 5 middle schools (junior high schools) 4 health nurses + one community psychologist + 7 therapists from local CAMS EAST NORWAY Three municipalities 4 middle schools (junior high school) 6 school health nurses

18 IMPLEMENTATION STRATEGIES 1. Group leaders receive: training in the two CBT manuals (4 days + 2 days + 2 days) regular supervision by experiences CBT therapists (clinical psychologists or psychiatrist) 2. Participation in project voluntary for the school nurses Colorbox 3. Approved by school- and health leaders in the municipalities + the ethic committee

19 Key principles in the CBT interventions Identifying thoughts and feeling. Challenging unrealistic or non-helpful thoughts related to anxiety-provoking situations Linking thoughts, emotions, body reactions and situation Systematical exposure to anxiety-provoking situations (facing fear and testing cognitions) Reducing avoidance. Help care-givers support the youth when facing his/her fears. Colourbox

20 Effectiveness study - real life research Broad inclusion criteria: Self-reported level of anxiety symptoms and interference in everyday life of youth/family (Heightened score the anxiety inventories SCAS c/p and CALIS c/p) The adolescent and at least one parent understand and read Norwegian Signed consent from the adolescent and at least one parent Few exclusion criteria: A behavior inconsistent with participation in group sessions judged by the school nurse in collaboration with teacher (e.g. major attention problems, serious rule-breaking or behavioral problems)

21 HOW ARE WE DOING? After nine months of inclusion - 19 groups have been randomized, including 127 youths from 16 schools (of a total of 18) Aiming to recruit 400 youth during the next months Assessed 137 Not-included 7 5% Excluded 3 2.2% Included ,7% Drop-outs %

22 Characteristics of the included adolescents so far. Sample N=127 M (SD) % Female 82.7% Age 14.2 (.79) Live with both mother & father 55.9% Born in Norway 90.6% Family economy average 75.6% Contact with health services (weekly or monthly) *School health service 23.2% *Psychiatric outpatient clinic 12.9% *GP 2.4% *Child welfare services 2.4% *Others 9.6% Fears and woories upset me quite a lot or very much 66.2% Anxiety symptoms (SCAS) 45.8 (17.4) Depressive symptoms (SMFQ) 12.4 (7.5)

23 Conclusions A need to focus on early interventions to prevent development of chronic anxiety and/or the onset of comorbid disorders in adolescents Few anxious youth seek treatment school based, indicated prevention groups seems to be a possible way to offer help and to increase access to evidence based interventions for anxious youths It remains to be seen if these interventions have effect and if a low intensity intervention is sufficient to help (some?) of the anxious youths Colourbox

24 Thank you for the attention! Colourbox