Testing Anxiety Toolkit

Transcription

1 Testing Anxiety Toolkit This toolkit offers a collection of materials, primarily for practitioners, with some handouts for parents and teachers to help students manage anxiety related to testing. 2. Anxiety And Anxiety Disorders In Children: Information For Parents Thomas J. Huberty, PhD, NCSP Indiana University 6. Test and Performance Anxiety Thomas J. Huberty, PhD, NCSP Indiana University 11. Research- Based Practice Assessing and Treating Childhood Anxiety in School Settings Savannah Wright & Michael L. Sulkowski 17. Cognitive Behavioral Strategies For Working With Anxious Youth In Schools (PowerPoint Slides) Elana R. Bernstein, PhD Morgan J. Aldridge, MS Jessica May, MS 28. Anxiety: Tips For Teens Patricia A. Lowe, PhD, Susan M. Unruh, EdS, & Stacy M. Greenwood University of Kansas 32. High Stakes Testing & Children s Well- Being: A Guide for Parents NYASP 35. High Stakes Testing & Children s Well- Being: A Guide for Teachers NYASP 38. Reducing Test Anxiety to Increase Academic Performance (PowerPoint Slides) Peter Faustino PhD and Tom Kulaga M.S Utilizing Video Self- Modeling and Reattribution Training to Alleviate Test Anxiety (PowerPoint Slides) Shahrokh- Reza Shahroozi, B.S.

2 ANXIETY AND ANXIETY DISORDERS IN CHILDREN: INFORMATION FOR PARENTS By Thomas J. Huberty, PhD, NCSP Indiana University Anxiety is a common experience to all of us on an almost daily basis. Often, we use terms like jittery, high strung, and uptight to describe anxious feelings. Feeling anxious is normal and can range from very low levels to such high levels that social, personal, and academic performance is affected. At moderate levels, anxiety can be helpful because it raises our alertness to danger or signals that we need to take some action. Anxiety can arise from real or imagined circumstances. For example, a student may become anxious about taking a test (real) or be overly concerned that he or she will say the wrong thing and be ridiculed (imagined). Because anxiety results from thinking about real or imagined events, almost any situation can set the stage for it to occur. Defining Anxiety There are many definitions of anxiety, but a useful one is apprehension or excessive fear about real or imagined circumstances. The central characteristic of anxiety is worry, which is excessive concern about situations with uncertain outcomes. Excessive worry is unproductive, because it may interfere with the ability to take action to solve a problem. Symptoms of anxiety may be reflected in thinking, behavior, or physical reactions. Anxiety and Development Anxiety is a normal developmental pattern that is exhibited differently as children grow older. All of us experience anxiety at some time and cope with it well, for the most part. Some people are anxious about specific things, such as speaking in public, but are able do well in other activities, such as social interactions. Other people may have such high levels of anxiety that their overall ability to function is impaired. In these situations, counseling or other services may be needed. Infancy and preschool. Typically, anxiety is first shown at about 7 9 months, when infants demonstrate stranger anxiety and become upset in the presence of unfamiliar people. Prior to that time, most babies do not show undue distress about being around strangers. When stranger anxiety emerges, it signals the beginning of a period of cognitive development when children begin to discriminate among people. A second developmental milestone occurs at about months, when toddlers demonstrate separation anxiety. They become upset when parents leave for a short time, such as going out to dinner. The child may cry, plead for them not to leave, and try to prevent their departure. Although distressing, this normal behavior is a cue that the child is able to distinguish parents from other adults and is aware of the possibility they may not return. Ordinarily, this separation anxiety is resolved by age 2, and the child shows increasing ability to separate from parents. Both of these developmental periods are important and are indicators that cognitive development is progressing as expected. School age. At preschool and early childhood levels, children tend to be limited in their ability to anticipate future events, but by middle childhood and adolescence these reasoning skills are usually well developed. There tends to be a gradual change from global, undifferentiated, and externalized fears to more abstract and internalized worry. Up to about age 8 children tend to become anxious about specific, identifiable events, such as animals, the dark, imaginary figures (monsters under their beds), and of larger children and adults. Young children may be afraid of people that older children find entertaining, such as clowns and Santa Claus. After about age 8, anxiety-producing events become more abstract and less specific, such as concern about grades, peer reactions, coping with a new school, and having friends. Adolescents also may worry more about sexual, religious, and moral issues, as well how they compare to others and if they fit in with their peers. Sometimes, these concerns can raise anxiety to high levels. Helping Children at Home and School II: Handouts for Families and Educators S5 1

3 Anxiety Disorders When anxiety becomes excessive beyond what is expected for the circumstances and the child s developmental level, problems in social, personal, and academic functioning may occur, resulting in an anxiety disorder. The signs of anxiety disorders are similar in children and adults, although children may show more signs of irritability and inattention. The frequency of anxiety disorders ranges from about 2 to 15% of children and occurs somewhat more often in females. There are many types of anxiety disorders, but the most common ones are listed below. Separation anxiety disorder. This pattern is characterized by excessive clinging to adult caretakers and reluctance to separate from them. Although this pattern is typical in month-old toddlers, it is not expected of school-age children. This disorder may indicate some difficulties in parent-child relationships or a genuine problem, such as being bullied at school. In those cases, the child may be described as having school refusal, sometimes called school phobia. Occasionally, the child can talk about the reasons for feeling anxious, depending on age and language skills. Generalized anxiety disorder. This pattern is characterized by excessive worry and anxiety across a variety of situations that does not seem to be the result of identified causes. Post-Traumatic Stress Disorder. This pattern often is discussed in the popular media and historically has been associated with soldiers who have experienced combat. It is also seen in people who have experienced traumatic personal events, such as loss of a loved one, physical or sexual assault, or a disaster. Symptoms may include anxiety, flashbacks of the events, and reports of seeming to relive the experience. Social phobia disorder. This pattern is seen in children who have excessive fear and anxiety about being in social situations, such as in groups and crowds. Obsessive-compulsive disorder. Characteristics include repetitive thoughts that are difficult to control (obsessions) or the uncontrollable need to repeat specific acts, such as hand washing or placing objects in the same arrangement (compulsions). Characteristics of Anxiety Although the signs of anxiety vary in type and intensity across people and situations, there are some symptoms that tend to be rather consistent across anxiety disorders and are shown in cognitive, behavioral, and physical responses. Not all symptoms are exhibited in all children or to the same degree. All people show some of these signs at times, and it may not mean that anxiety is present and causing problems. Most of us are able to deal with day-to-day anxiety quite well, and significant problems are not common. The chart at the end of the handout demonstrates behaviors that, if present to a significant degree, can indicate anxiety that needs attention. As a parent, you may be the first person to suspect that your child has significant anxiety. Relationship to Other Problems Although less is known about how anxiety is related to other problems as compared to adults, there are some well-established patterns. Depression. Anxiety and depression occur together about 50 60% of the time. When they do occur together, anxiety most often precedes depression, rather than the opposite. When both anxiety and depression are present, there is a higher likelihood of suicidal thoughts, although suicidal attempts are far less frequent. Attention Deficit Hyperactivity Disorder. At times, anxiety may appear similar to behaviors seen with Attention Deficit Hyperactivity Disorder (ADHD). For example, inattention and concentration difficulties are often seen in children with ADHD and with children who have anxiety. Therefore, the child may have anxiety rather than ADHD. Failing to identify anxiety accurately may explain why some children do not respond as expected to medications prescribed for ADHD. The age of the child when the behaviors were first observed can be a useful index for determining if anxiety or ADHD is present. The signs of ADHD usually are apparent by age 4 or 5, whereas anxiety may not be seen at a high level until school entry, when children may respond to demands with worry and needs for perfectionism. A thorough psychological and educational evaluation by qualified professionals will help to determine if the problem is ADHD or anxiety. If evaluation or consultation is needed, developmental information about the problem will be useful to the professional. School performance. Children with anxiety may have difficulties with school work, especially tasks requiring sustained concentration and organization. They may seem forgetful, inattentive, and have difficulty organizing their work. They may be too much of a perfectionist and not be satisfied with their work if it does not meet high personal standards. Substance use. What appears to be anxiety may be manifestations of substance use, which may begin as early as the pre-teen years. Children who are abusing drugs or alcohol may show sleep problems, inattention, withdrawal, and reduced school performance. Although substance abuse is less likely with younger children, the possibility increases with age. Interventions Anxiety is a common experience for children, and, most often, professional intervention is not needed. If anxiety is so severe that your child cannot do expected tasks, however, then intervention may be indicated. S5 2 Anxiety and Anxiety Disorders in Children: Information for Parents

4 Does My Child Need Professional Help? Answering the following questions may be helpful in deciding if your child needs professional help: Is the anxiety typical for a child this age? Is the anxiety shown in specific situations or is it more pervasive? Is the problem long term or is it recent? What events may be contributing to the problems? How are personal, social, and academic development affected? If the anxiety is atypical for the child s age, is long standing, does not seem to be improving, and is causing significant problems, then it is advisable to talk with a professional, such as the school psychologist or counselor, who might recommend a referral to a community mental health professional. Individual counseling, or even group or family counseling, may be used to help the child deal with school, family, or personal issues that are related to the anxiety. In some cases, a physician may recommend medication. Although medication for childhood disorders is not well researched and side effects must be monitored, this treatment may be helpful when combined with counseling approaches. How Can I Help My Child? Although professional intervention may be necessary, the following list may be helpful to parents in working with the child at home: Be consistent in how you handle problems and administer discipline. Remember that anxiety is not willful misbehavior, but reflects an inability to control it. Therefore, be patient and be prepared to listen. Being overly critical, disparaging, impatient, or cynical likely will only make the problem worse. Maintain realistic, attainable goals and expectations for your child. Do not communicate that perfection is expected or acceptable. Often, anxious children try to please adults, and will try to be perfect if they believe it is expected of them. Maintain a consistent, but flexible, routine for homework, chores, and activities. Accept mistakes as a normal part of growing up, and that no one is expected to do everything equally well. Praise and reinforce effort, even if success is less than expected. There is nothing wrong with reinforcing and recognizing success, as long as it does not create unrealistic expectations and result in unreasonable standards. If your child is worried about an upcoming event, such as giving a speech in class, practice it often so that confidence increases and discomfort decreases. It is not realistic to expect that all anxiety will be removed; rather, the goal should be to get the anxiety to a level that is manageable. Teach your child simple strategies to help with anxiety, such as organizing materials and time, developing small scripts of what to do and say, either externally or internally, when anxiety increases, and learning how to relax under stressful conditions. Practicing things such as making speeches until a comfort level is achieved can be a useful anxiety-reducing activity. Listen to and talk with your child on a regular basis and avoid being critical. Being critical may increase pressure to be perfect, which may be contributing to the problem in the first place. Do not treat emotions, questions, and statements about feeling anxious as silly or unimportant. They may not seem important to you but are real to your child. Take all discussion seriously, and avoid giving too much advice and instead be there to help and offer assistance as requested. You may find that reasoning about the problem does not work. At times, children may realize that their anxiety does not make sense, but are unable to do anything about it without help. Do not assume that your child is being difficult or that the problem will go away. Seek help if the problem persists and continues to interfere with daily activities. Conclusion Untreated anxiety can lead to depression and other problems that can persist into adulthood. However, anxiety problems can be treated effectively, especially if detected early. Although it is neither realistic nor advisable to try to completely eliminate all anxiety, the overall goal of intervention should be to return your child to a typical level of functioning. Resources Bourne, E. J. (1995). The anxiety and phobia workbook (2 nd ed.). Oakland, CA: New Harbinger. ISBN: Dacey, J. S., & Fiore, B. (2001). Your anxious child: How parents and teachers can relieve anxiety in children. San Francisco: Jossey-Bass. ISBN: Manassis, K. (1996). Keys to parenting your anxious child. New York: Barrons. ISBN: Website Anxiety Disorders Association of America National Mental Health Association Thomas J. Huberty, PhD, NCSP, is Professor and Director of the School Psychology Program at Indiana University, Bloomington, IN National Association of School Psychologists, 4340 East West Highway, Suite 402, Bethesda, MD (301) Helping Children at Home and School II: Handouts for Families and Educators S5 3

5 Types of Anxiety Disorders Cognitive Behavioral Physical Concentration difficulties Shyness Trembling or shaking Overreaction and Withdrawal Increased heart rate catastrophizing relatively Frequently asking questions Excessive perspiration minor events Frequent need for Shortness of breath Memory problems reassurance Dizziness Worry Needs for sameness Chest pain or discomfort Irritability Avoidant Flushing of the skin Perfectionism Rapid speech Nausea, vomiting, diarrhea Thinking rigidity Excessive talking Muscle tension Hyper vigilant Restlessness, fidgety Sleep problems Fear of losing control Habit behaviors, such as Fear of failure hair pulling or twirling Difficulties with problem Impulsiveness solving and academic performance S5 4 Anxiety and Anxiety Disorders in Children: Information for Parents

6 student services student services student services Test and Performance Anxiety Anxiety is a normal human emotion that can be detrimental in a school setting, but good communication and support can help minimize its negative impact. By Thomas J. Huberty Thomas J. Huberty (huberty@indiana.edu) is a professor and the director of the School Psychology Program at Indiana University. Student Services is produced in collaboration with the National Association of School Psychologists (NASP). Articles and related handouts can be downloaded from principals. Samantha s story: Fourteen-year-old Samantha went to the school nurse on a weekly basis, complaining of stomach aches and being nervous and worried about school. The nurse referred her to the school psychologist, who talked with her about the visits to the nurse s office. Samantha reported that when taking tests or having to speak in public, she became anxious and was not able to do well, although she thought that she knew the material. When describing her anxiety, she said, My mind goes blank, I get shaky, and I get sweaty and red. Upon further discussion, the school psychologist found that Samantha also felt anxious often when not at school and that her mother had high expectations for her schoolwork. The school psychologist talked to her mother, who indicated that she had high expectations of Samantha, but she also described her daughter as being anxious, fearful, and a worrier since she was a small child. Anxiety in Adolescents Cases like Samantha s are more common in school settings than most school professionals realize. In the majority of cases, test and performance anxiety is not recognized easily in schools, in large part because adolescents rarely refer themselves for emotional concerns. Not wanting to risk teasing or public attention, anxious adolescents suffer in silence and underperform on school-related tasks. Anxiety is one of the most basic human emotions and occurs in every person at some time, most often when someone is apprehensive about uncertain outcomes of an event or set of circumstances. Anxiety can serve an adaptive function, however, and is also a marker for typical development. In the school setting, anxiety is experienced often by students when being evaluated, such as when taking a test or giving a public performance. Most adolescents cope with these situations well, but there is a subset of up to 30% of students who experience severe anxiety, a condition most often termed test anxiety. When test anxiety is severe, it can have significant negative effects on a student s ability to perform at an optimal level. Over time, test anxiety tends to generalize to many evaluative situations, contributing to more pervasive underachievement. Additional consequences of chronic test anxiety can include lowered self-esteem, reduced effort, and loss of motivation for school tasks. Other forms of anxiety that can be seen in the school include generalized anxiety, fears, phobias, social anxiety, and extreme social withdrawal. Characteristics of Anxiety The central characteristic of anxiety is worry, which has been defined by Vasey, Crnic, and Carter (1994) as an anticipatory cognitive process involving repetitive thoughts related to possible threatening outcomes and their potential consequences (p. 530). Although everyone worries occasionally, excessive and frequent worry can impair social, personal, and academic functioning. It can contribute to feelings of loss of control and perhaps depression, especially in girls. When people become highly anxious, they tend to view more situations as potentially threatening than do most of their peers. They have an irrational fear that a catastrophe will occur and feel that they are unable to control outcomes. Often, there is 12 z Principal Leadership z September 2009

7 a rational basis for the anxiety, but it is greatly disproportionate to the circumstances. Anxiety is manifested in three ways: cognitively, behaviorally, and physiologically. Often the symptoms are apparent in all three areas, such as worry, increased activity, and flushing of the skin. (See figure 1.) Many of the behaviors exhibited by anxious children and youth reflect attempts to control the anxiety and minimize its effects. The majority of adolescents who are anxious are not disruptive and are more likely to withdraw and avoid anxiety-producing situations. In extreme cases, they may be seen by teachers as unmotivated, lazy, or less capable than their peers. On the other extreme, some students with performance anxiety may act out, consciously or unconsciously, as a way of avoiding the risk of being embarrassed or failing. School personnel should be aware of students whose disruptive or negative behavior aligns with upcoming performance-based assignments. Causes of Anxiety The specific conditions and mechanisms that cause anxiety are not well understood, but there is evidence that youth who are test-anxious tend to have high levels of general anxiety that are exacerbated during evaluations. There is considerable research evidence that some children have biological predispositions to high levels of general anxiety, making them more susceptible to the effects of being evaluated (Huberty, 2008). Repeated difficulties with test-taking or other performances tend to lower self-confidence, which in turn can create conditions for more frequent and intense experiences of anxiety. Also, excessive pressure or coercion likely will worsen an adolescent s anxiety, further impairing performance, selfesteem, and motivation. Types of Anxiety There are two forms of anxiety that are pertinent to understanding the formation and maintenance of anxiety. Trait anxiety refers to anxiety that is chronic and pervasive across situations and is not triggered by specific events. Trait anxiety is the basis for a variety of anxiety disorders, including generalized anxiety and social phobia. State anxiety refers to anxiety that occurs in specific situations and usually has a clear trigger. Not all people who have high state anxiety have high trait anxiety, but those who have high trait anxiety are more likely to experience state anxiety (Spielberger, 1973). While taking tests, state anxiety may occur, although the student may also have tendencies toward trait anxiety. Therefore, if a student shows high state anxiety, it is possible that he or she has high trait anxiety. It is important to identify adolescents with high trait anxiety, because it can be a sign of significant emotional problems and may be a precursor for the development of depression, especially in adolescent girls. In cases of severe anxiety, referral to a school psychologist for more extensive evaluation is recommended. In Samantha s case, the school psychologist concluded that she had high levels of trait anxiety, which worsened her test/state anxiety. High parental expectations likely also contributed to both her trait and state anxiety. High-Stakes Testing Over the last several years, graduation has come to depend on passing standardized tests. As a consequence, more Although everyone worries occasionally, excessive and frequent worry can impair social, personal, and academic functioning. It can contribute to feelings of loss of control and perhaps depression, especially in girls. September 2009 z Principal Leadership z 13

8 student services student services student services Primary Characteristics of Anxiety students are likely to have anxiety when taking such tests and their ability to do their best will be impaired. Consequently, some students may fail sections of these exams despite knowing the material. Although there is little research to suggest that highstakes testing causes anxiety disorders in adolescents, it is likely that students with high trait or test anxiety are more vulnerable to underperforming. A key indicator that test anxiety may occur in students is when they do not do well, despite indications to the contrary (e.g., current achievement). School personnel should be alert to this possibility and follow up with students who unexpectedly fail parts of an examination to check for the possibility of trait or state anxiety. Moreover, students who struggle in school, particularly those with disabilities, may find those examinations especially challenging, increasing their anxiety. Therefore, schools should consider screening all students who fail those examinations. School-Based Interventions If test anxiety is not complicated by other problems, such as anxiety disorders or depression, it is treatable in the school setting by properly trained mental health specialists (e.g., school psychologists) and teachers with the help of principals and parents. Each of the following groups has a role to play in identifying and supporting students. Principals Principals can be instrumental in working with staff members to help students who have test anxiety or are Cognitive Behavioral Physiological Concentration problems Motor restlessness Tics Memory problems Attention problems Oversensitivity Difficulty solving problems Worry Cognitive dysfunctions Distortions Deficiencies Attributional style problems Fidgets Task avoidance Rapid speech Erratic behavior Irritability Withdrawal Perfectionism Lack of participation Failure to complete tasks Seeking easy tasks Recurrent, localized pain Rapid heart rate Flushing of the skin Perspiration Headaches Muscle tension Sleeping problems Nausea Vomiting Enuresis Source: Huberty, T. J. (in press). Performance and test anxiety. In L. Paige & A. Canter (Eds.), Helping children at home and at school III. Bethesda, MD: National Association of School Psychologists. at risk for developing it. Some suggestions include: n Communicating that test anxiety is a real psychological issue and does not reflect laziness, lack of motivation, or lack of capability by the student n Communicating to staff members and parents that test anxiety should be a priority for schools to address n Providing inservice training about how to recognize and treat anxiety and to consider it to be a genuine and pervasive problem n Leading efforts to identify specialists in the school to identify performance- and test-anxious students and provide support to them (Huberty, in press). Sc h o o l Men ta l He a lt h Pr ac t i t i o n e r s Mental health specialists, such as school psychologists, social workers, and counselors, can work singly and collaboratively to develop and implement interventions for students and to consult with teachers about how to identify and work with students in the classroom. There are several interventions that can be used in the school setting to help students prevent and control test and performance anxiety. These strategies include: n Providing relaxation training n Using test-anxiety hierarchies for assessments and public performances using variations of systematic desensitization n Using pretask rehearsal n Using practice tests n Reviewing task content before examinations n Modifying tasks, such as breaking them into smaller units 14 z Principal Leadership z September 2009

9 n Developing mnemonic devices to help recall n Using cognitive-behavioral techniques to reduce characteristics often associated with test anxiety, such as cognitive scripts for students to use when taking tests or performing, self-monitoring techniques, positive self-talk, and selfrelaxation n Relaxing grading standards or procedures if it is possible to do so without lowering performance criteria n Recognizing effort as well as performance n Avoiding criticism, sarcasm, or punishment for performance problems n Using alternative forms of assessment n Modifying time constraints and instructions n Emphasizing success, rather than failure (Huberty, in press). Mental health specialists can also provide inservice training to school personnel and parents. This training can include information about: n The characteristics of anxiety n The types of cognitive problems experienced by performance-anxious students n The task conditions that can affect the experience and expression of anxiety n The nature, types, and causes of anxiety n The tendency of test-anxious adolescents to have high trait anxiety and the need for some students to receive such interventions as social skills training n A description of interventions that can be used (Huberty, in press). Although anxiety and depression often are considered and treated as separate and distinct problems, they frequently occur together with an overlap of symptoms. Often adolescents meet the clinical criteria for both disorders simultaneously. The overlap has been reported to be as high as 50% in clinical samples. Further, if both disorders are present simultaneously, anxiety most likely preceded depression. Consequently, the school psychologist must be prepared to identify the presence of and provide intervention and prevention for both problems (Huberty, 2008). Pa r e n t s Parents can be highly instrumental in working with their test-anxious adolescents. In some cases, parents may benefit from consulting with school personnel to help determine whether high expectations are contributing to the problem. If that is the case, the school psychologist or other mental health professional can help parents develop realistic expectations of their children. Parents can also help their students better prepare for examinations and performances by working with them at home. Te a c h e r s In addition to providing inservice training to school personnel and direct services to students, school psychologists and other mental health professionals can consult with teachers to help them identify and work with test-anxious students. Consultation can include: n Providing education and information to the teacher about test anxiety n Interviewing students, teachers, and parents What Parents Can Do n Be consistent in how you handle problems and administer discipline. n Be patient and be prepared to listen. n Avoid being overly critical, disparaging, impatient, or cynical. n Maintain realistic, attainable goals and expectations for your child. n Do not communicate that perfection is expected or is the only acceptable outcome. n Maintain a consistent but flexible routine for homework, chores, activities, and so forth. n Accept mistakes as a normal part of growing up and let your child know that no one is expected to do everything equally well. n Praise and reinforce effort, even if the outcome is less than expected. Practice and rehearse upcoming events, such as a speech or other performance. n Teach your child simple strategies to help with his or her anxiety, such as organizing materials and time, developing small scripts of what to do and say when anxiety increases, and learning how to relax under stressful conditions. n Do not treat feelings, questions, and statements about feeling anxious as silly or unimportant. n Often, reasoning is not effective in reducing anxiety, so do not criticize your child for being unable to respond to rational approaches. n Seek outside help if the problem persists and continues to interfere with daily activities. Source: Huberty, T. J. (in press). Performance and test anxiety. In L. Paige & A. Canter (Eds.), Helping children at home and at school III. Bethesda, MD: National Association of School Psychologists. September 2009 z Principal Leadership z 15

10 student services student services student services n Assessing individual students to determine cognitive, behavioral, and physiological symptoms n Training teachers, students, and parents in how to use rehearsal, relaxation, and other techniques at home and at school n Helping teachers plan, implement, and evaluate interventions (Huberty, in press). Leadership Commitment Test and performance anxiety are common problems for adolescents in the school setting and can impair achievement in as many as one-third of students. Because adolescents may not be aware of the problems, do not know what to do, or do not refer themselves for help, school personnel are key to identifying students who have text anxiety. Effective intervention begins with school administrators, who can create an awareness of the problem and commit to providing resources and leadership for mental health specialists and teachers so that they can help students. Mental health specialists and teachers can be strong advocates who help anxious students improve school performance and reduce the risk of the development of other problems, particularly depression. Properly addressed, test and performance anxiety can be significantly reduced in the school setting. Returning to Samantha The school psychologist worked with Samantha directly, consulted with her teachers, and talked with her mother. Samantha learned how to relax, plan for examinations, rehearse public performances, and develop test-taking strategies. The psychologist worked with the teachers of the classes in which Samantha was most anxious to help them become aware of her anxiety. The teachers helped Samantha develop test-taking strategies, such as organizational skills, practice exercises, and study guides. Finally, the psychologist talked with Samantha s mother to help her better understand Samantha s anxiety, how her expectations contributed to her daughter s problems, and how to help prepare Samantha at home to take tests and give oral presentations. Samantha s anxiety was reduced and she performed better, with a significant reduction in visits to the nurse s office. Although there was little effect on her trait anxiety, her state anxiety was reduced to help her improve her school performance. PL References n Huberty, T. J. (2008). Best practices in school-based interventions for anxiety and depression. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology: Vol. 5 (pp ). Bethesda, MD: National Association of School Psychologists. n Huberty, T. J. (in press). Performance and test anxiety. In L. Paige & A. Canter (Eds.), Helping children at home and at school III. Bethesda, MD: National Association of School Psychologists. n Spielberger, C. A. (1973). State-Trait Anxiety Inventory for Children [Manual]. Palo Alto, CA: Consulting Psychologists Press. n Vasey, M. W., Crnic, K. A., & Carter, W. G. (1994). Worry in childhood: A developmental perspective. Cognitive Therapy and Research, 18, z Principal Leadership z September 2009

11 Assessing and Treating Childhood Anxiety Page 1 of 6 10/17/2013 Research-Based Practice Assessing and Treating Childhood Anxiety in School Settings By Savannah Wright & Michael L. Sulkowski Between 2% to 27% of children and adolescents suffer with an anxiety disorder and many more struggle with distressing yet subclinical levels of anxiety (Costello, Egger, & Arnold, 2005; Mychailyszyn, Mendez, & Kendall, 2010). However, only about 6% of youth receive treatment for their anxiety symptoms or related sequelae (Esser, Schmidt, & Woerner, 1990). This service provision deficit is concerning because of the large body of research indicating that anxious youth are at risk for school absenteeism, academic underachievement, low social acceptance, and impaired psychosocial functioning (Kearney & Albano, 2004; McDonald, 2001; Mychailyszyn et al., 2010; Spencer, DuPont, & DuPont, 2003). Furthermore, if they do not receive effective treatment, anxious youth are at risk for developing mental health problems (e.g., depression, substance abuse, anxiety) and impaired occupational functioning (Donovan & Spence, 2000; Kendall, Safford, Flannery- Schroeder, & Webb, 2004; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005; Woodward & Fergusson, 2001). Fortunately, effective interventions such as cognitive behavioral therapy (CBT) exist for treating childhood anxiety, and school psychologists can have an important role in implementing these interventions (Sulkowski, Joyce, & Storch, 2012). As professionals who often know the most about psychology in school settings and education in clinical settings and because of the importance of addressing both academic and mental health needs in anxious youth, school psychologists are uniquely positioned to assist anxious students. In addition, due to their specific training (e.g., psychoeducational assessment, progress monitoring, direct intervention, consultation, data-based decision making) and the roles that they assume in school systems, school psychologists possess a dynamic skill set that can be utilized to identify anxious students, ensure that these youth receive evidence-based interventions services, and monitor how students respond to interventions once they are implemented (Wnek, Klein, & Bracken, 2008). In recognition of this skill set and because of the importance of treating childhood anxiety, this article will highlight how school psychologists can support anxious students through using a multitiered framework that can be flexibly applied to fit different types of school settings. Why Treat Anxiety in School Settings Obtaining access to mental health services may be a challenge for families that reside in communities with few service providers. Additionally, significant transportation, monetary, and logistical barriers may prevent youth from receiving services. Schools, however, exist in almost all communities and are the most common entry point for accessing mental health services in the United States (Farmer, Burns, Phillips, Angold, & Costello, 2003). Furthermore, research suggests that providing mental health services in schools can reduce disparities in service utilization among high need subpopulations (e.g., Racial/ethnic minority youth; Cummings, Ponce, & Mays, 2010). Therefore, given the large discrepancy between anxious children who need and receive services, treating childhood anxiety in school settings has the potential to address the needs of many youth who would otherwise be disenfranchised from receiving intervention. Despite being an ancillary aim of many school psychologists and other school-based mental health professionals, efforts to address childhood anxiety in school settings display considerable promise and applicability to common practice. As the most comprehensive evaluation to date, a meta-analysis by Neil and Christensen (2009) suggest that school-based cognitive behavioral interventions are moderately effective for treating childhood anxiety, with effect sizes ranging from.11 to 1.37 (Mdn =.57). This study also illustrates the utility of using a multitiered service delivery model to address childhood anxiety as 59% of the interventions were universally delivered, 11% were selective or geared toward specific at-risk groups of students, and 30% involved implementing individual interventions or treatment plans. Collectively, these results highlight the potential to address childhood anxiety across different service-delivery tiers, particularly at the universal or school-wide level. Assessing and Treating Anxiety in School Settings Time and resource limitations commonly encountered by school psychologists enhance the importance of identifying and remediating student problems with great efficiency. In this regard, a multitiered systems of support (MTSS) such as the multiple- gating approach for identifying social emotional problems and the responseto- intervention (RTI) service delivery framework can help with determining which students should receive specific interventions as well as the dosage of these interventions. To help with identifying anxious youth and with intervention delivery efforts, a version of a multiple gating approach is discussed below as well as how collected data can inform intervention service delivery. However, a comprehensive review of these procedures is beyond the scope of this article, so readers may wish to review Sulkowski et al. (2012) for a more complete discussion.

12 Assessing and Treating Childhood Anxiety Page 2 of 6 10/17/2013 Assessing Anxiety in Students Symptoms of internalizing disorders such as anxiety and depression often are inconspicuous, which can make identifying these symptoms a challenge (Whitcomb & Merrell, 2013). Anxious individuals do, however, display observable characteristics that knowledgeable observers can identify. Some of these observable characteristics include frequently asking for reassurance, being clingy, displaying avoidant behavior, performing checking behavior, hyperventilating when not active, complaining of somatic issues, and engaging in repetitive rituals. In excess, these characteristics might be obvious and suggestive of an anxiety disorder; however, none of them are sufficient by themselves to identify a child who may have anxiety problems. Therefore, as a more objective and thorough approach for assessing childhood anxiety, school psychologists can administer systematic behavior screeners to help identify youth who may have elevated anxiety symptoms. Currently, two commonly used and commercially available behavior screeners exist. The Behavioral Assessment Scale for Children, Second Edition, Behavioral and Emotional Screening System (BASC- 2, BESS; Kamphaus & Reynolds, 2007) screens for general internalizing and externalizing symptoms. This measure has been incorporated into the AIMSweb data screening, monitoring, and management system. Similarly, the Brief Problem Monitor (Achenbach, McConaughty, Ivanova, & Rescorla, 2011) also allows users to screen for internalizing problems. The Brief Problem Monitor is a new screener and progress monitoring measure that is part of the Achenbach System of Empirically Based Assessment (ASEBA). Although both of these screeners assess internalizing symptoms, neither measure independently assesses anxiety. Assessing anxiety symptoms on behavior screeners requires assessors to inspect students' responses to individual screening items. Following universal screening for anxiety problems, a multitrait, multisetting, and multi-informant assessment approach can be used to assess for anxiety problems and related concerns in at-risk youth (Whitcomb & Merrell, 2013). In addition to conducting clinical interviews with multiple informants and observations across settings, this process generally involves administering omnibus behavior rating scales that include items that purport to assess anxiety such as the BASC-2, Child Behavior Checklist (CBCL), Clinical Assessment of Behavior (CAB; Bracken & Keith, 2004), and the Conners' Comprehensive Behavior Rating Scale (CCBRS; Conners, 2009), as well as narrow- construct anxiety measures such as the Revised Children's Anxiety Scale, Second Edition (RCMAS-2; Reynolds & Richmond, 2008), State-Trait Anxiety Scale for Children (STAI-C; Spielberger, 1973), the Beck Anxiety Inventory for Youth (BAI-Y; Beck, Beck, & Jolly, 2001), and the Spence Children's Anxiety Scale (Spence, 1997). When analyzing data obtained through this assessment process, consistency in ratings across informants, settings, and identified traits allows the assessor to have greater confidence in the assessment results. For example, if a child was found to be at-risk on the BESS, in the clinically significant range on the BASC-2 for Anxiety Problems, and for any of the anxiety constructs represented on the RCMAS-2 across informants, it is likely that the child is suffering from clinically significant anxiety. Table 1 lists the number of items, types of rating formats, internal consistency estimates, and the constructs that are measured by each of the previously listed behavior rating scales. OMNIBUS Table 1. Omnibus and Narrow Measures of Childhood Anxiety CONSTRUCTS ASSESSED NUMBER OF ITEMS RELIABILITY (α) Teacher Parent Self Teacher Parent Self BASC-2 Anxiety Problems CBCL Anxiety Problems, Internalizing Scales (Anxious/Depressed) CAB Internalizing Behaviors Scale CCBRS NARROW RCMAS-2 Generalized Anxiety Disorder; Separation Anxiety Disorder; Social Phobia; Obsessive- Compulsive Disorder Physiological Anxiety; Worry; Social Anxiety; Defensiveness STAI-C State Anxiety, Trait Anxiety 20 BYI-II Anxiety 20 Spence Generalized Anxiety, Panic/Agoraphobia, Social Phobia, Separation Anxiety, Obsessive Compulsive Disorder, Physical Injury Fears Note: BASC -2 = Behavior Assessment System for Children, Second Edition; CBCL = Child Behavior Checklist; CA B = Clinical Assessment of Behavior; CC BRS = Conners' Comprehensive Behavior Rating Scale; RCMAS -2 = Revised Children's Anxiety Scale, Second Edition; STA I-C = State-Trait Anxiety Inventory for Children; BYI-II = Beck Youth Inventories, Second Edition; Spence = Spence Children's Anxiety Scale Lastly, to confirm a clinical diagnosis, a school psychologist may wish to conduct the Anxiety Diagnostic Interview Schedule (ADIS; Silverman & Albano, 2004) with a child and a caregiver because of its adherence

13 Assessing and Treating Childhood Anxiety Page 3 of 6 10/17/2013 to Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association, 2000) criteria for assessing all childhood anxiety disorders and many psychiatric disorders that occur in children (e.g., major depression disorder, attention deficit hyperactivity disorder). Although a psychiatric diagnosis is not needed for a student to receive services under RTI, under the Individuals with Disabilities Education Improvement Act (IDEIA), or Section 504 of the Rehabilitation Act, schools that bill for Medicaid may need to include diagnostic information in order to be reimbursed for services. In addition, provisions in the Patient Protection and Affordable Care Act will impact the availability of health insurance and the ability of schools to bill for mental health services. Therefore, the role of school psychologists in diagnosing psychopathology and classifying students to receive interventions may increase. Treating Anxiety in School Settings Universal service delivery. Even though the majority of students do not have anxiety problems, all students may benefit from universal programs that can reduce stress and anxiety in schools as well as help foster supportive learning environments. Currently, no anxiety- specific school-based universal prevention or intervention programs exist; however, programs that aim to reduce bullying, school violence, and support healthy and safe school communities also may reduce anxiety because of the relationship between school climate and anxiety in members of school communities (Sulkowski, Wingfield, Jones, & Coulter, 2011). Additionally, as a promising approach to facilitating well-being and reducing anxiety that can be universally implemented, mindfulness-based programs may help students cope better with distress. In a preliminary investigation, Mendelson et al. (2010) found that students (N = 97) from high stress and economically disadvantaged school communities benefited from 12-weeks of a school-wide mindfulness- based intervention program. Active participants in this study displayed lower levels of stress, worrying, and peer relationship problems posttreatment compared to a control group. Thus, although this finding warrants replication before it can be generalized broadly, mindfulness-based programs may be effective universal interventions. Although awaiting future research, a variety of programs, media resources, and practitioneroriented workbooks have been developed and some of these resources may have applications for schoolbased practice (Biegel, 2009; Kabat-Zinn, 2012). Targeted service delivery. Many students do not respond to universal interventions and need more intensive and targeted intervention services. To identify these students, school psychologists can employ behavioral screeners and rating scales to find youth who display elevated internalizing and anxiety scores. Collectively, and consistent with an RTI or a graduated approach to service provision, these students may benefit from targeted interventions that can be delivered to groups of youth who display similar concerns. Several studies support the efficacy of group-based CBT interventions for treating childhood anxiety (e.g., Barrett, 1998; Flannery-Schroeder & Kendall, 2000; Masia-Warner, Fisher, Shrout, Rathor, & Klein, 2007; Mendlowitz et al., 1999; Silverman et al., 1999). These interventions may be particularly effective because group members can identify with each other, provide and receive social support, and help to facilitate therapeutic engagement and treatment adherence (Masia-Warner et al., 2005). In addition, the mere act of participating in an anxiety treatment group can be therapeutic for youth with social anxiety because interacting with other group members is a form of behavioral exposure, which is an effective component of CBT (Masia-Warner et al., 2007). Computer delivered CBT programs also may be effective for treating anxious children or students who are at-risk for experiencing anxiety problems. Although research is needed to establish the program's efficacy in school settings, the Camp Cope-A-Lot (CCAL; Khanna & Kendall, 2008) computerized CBT program has been specifically designed to address childhood anxiety. Camp Cope-A-Lot is designed for use with children and young adolescents (ages 7 13 years). It includes six computer-assisted anxiety-reductive therapy sessions that can be followed with six therapist-directed exposure therapy sessions. Results from a randomized controlled clinical trial support the efficacy, feasibility, and likeability of CCAL (Khanna & Kendall, 2010). Specifically, 81% of youth who received 12 sessions of CCAL displayed greater reductions in anxiety posttreatment compared to youth in a control condition. Intensive service delivery. Anxious students who do not respond effectively to universal (e.g., mindfulnessbased intervention) or targeted interventions (e.g., group therapy) likely will need intensive intervention services. These services might involve individualized CBT or CBT combined with pharmacotherapy. These youth can be identified either directly through a MTSS assessment process or through analyzing their response to previously attempted interventions. In general, these youth would be expected to already display functional impairments in their academic, social, and family functioning because of their anxiety problems. For example, they may be reluctant to go to school, be socially withdrawn, or even refuse outright to attend school. All mental health professionals must be adequately trained to deliver intensive CBT. This training should be obtained through supervised graduate training experiences or through attending CBT workshops and obtaining supervision from experienced colleagues (Mychailyszyn et al., 2011). In school systems that lack experienced CBT therapists, skilled CBT practitioners in the community can be located via databases maintained by the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the Anxiety and Depression Association of America (ADAA). In collaboration with a community-based therapist, school-based mental health professionals can work together to optimize treatment and ensure that treatment gains generalize to the school environment (Sulkowski et al., 2011). Evidence-based treatment protocols such as the Coping Cat (Kendall & Hedtke, 2006) can help with structuring and delivering CBT to treat childhood anxiety. The Coping Cat program has a 16-session format that aims to teach youth to identify, regulate, and cope with anxiety-provoking thoughts, feelings, and

14 Assessing and Treating Childhood Anxiety Page 4 of 6 10/17/2013 sensations. As a multicomponent treatment program, the Coping Cat involves modeling being calm, relaxation/ self-calming strategies, in vivo exposure tasks, and learning problem solving strategies. Several studies support the efficacy of the Coping Cat for treating childhood anxiety in a variety of clinical and educational settings (for review, see Kendall and Suveg, 2006). In addition, Beidas and Kendall (2010) report that the treatment program can be flexibly adapted for school settings and applied by school-based mental health professionals. However, this process might involve modifying therapy sessions to accommodate a school's schedule and sessions may need to be scheduled around other important events that occur at school (e.g., exams, field trips). Furthermore, preliminary research suggests that even a brief course of treatment using the Coping Cat (approximately 8 sessions) can be effective for reducing moderate forms of childhood anxiety, which highlights the program's utility and versatility (Crawley et al., 2013). Conclusion Many youth suffer with anxiety; however, few receive the treatment they need. Treatment for childhood anxiety often occurs in clinical settings yet school-based interventions for anxiety display considerable promise (Neil & Christensen, 2009). Treating anxiety in school settings can help overcome some extant treatment barriers, and providing services in schools allows for the needs of anxious youth to be addressed across a continuum of services. A multitiered framework was presented in this article that can be flexibly applied to fit different types of school settings and address students' needs across universal, targeted, and intensive levels of service delivery. Promising universal efforts to assist anxious youth include conducting universal screeners to identify youth with internalizing problems and implementing universal prevention programs that improve school climate and connectedness. At the targeted service delivery level, school psychologists can conduct more comprehensive assessments to identify students who currently display (or are at risk for) anxiety problems, and then help to facilitate the delivery of interventions to address these problems. Lastly, students who display serious anxiety problems can be provided with effective interventions such as CBT, which is an evidence-based intervention that can be effectively translated to school settings (Neil & Christensen, 2009; Sulkowski et al., 2012). To conclude, school psychologists display unique skills that can help them be key stakeholders in efforts to address childhood anxiety. In addition, resources exist that can help school psychologists obtain advanced training in the delivery of evidence-based interventions for childhood anxiety such as CBT. For example, informational and didactic presentations often are featured at national conferences that are sponsored by the National Association of School Psychologists, IOCDF, and ADAA. However, even if not directly involved in service delivery, school psychologists also can be key stakeholders in efforts to address childhood anxiety through collaborating with other professionals. In this regard, the IOCDF and ADAA provide extensive lists of CBT specialists that school psychologists can refer to or contact to facilitate professional case collaboration. As professionals who often know the most about psychology in school settings and education when communicating with clinical professionals, school psychologists are uniquely positioned to support the needs of anxious youth. References Achenbach, T. M., McConaughty, S. H., Ivanova, M. Y., & Rescorla, L. A. (2011). Manual for the ASEBA Brief Problem Monitor. Burlington, VT: ASEBA. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Barrett, P. M. (1998). Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. Journal of Clinical Child and Adolescent Psychology, 27, doi: / s jccp2704_10 Beck, J. S., Beck, A. T., & Jolly, J. B. (2001). BECK Youth Inventories of Emotional & Social Impairment: Depression Inventory for Youth, Anxiety Inventory for Youth, Anger Inventory for Youth, Disruptive Behavior Inventory for Youth, Self-concept Inventory for Youth: Manual. San Antonio, TX: The Psychological Corporation. Beidas, R., & Kendall, P. C. (2010). Training therapists in evidence-based practice: A critical review of studies from a systems contextual perspective. Clinical Psychology: Science and Practice, 17, doi: /j x Biegel, G. M. (2009). The stress reduction workbook for teens: Mindfulness skills to help you deal with stress. Oakland, CA: Instant Help Books. Bracken, B. A., Keith, L. K., & Psychological As- sessment Resources, Inc. (2004). CAB, Clinical Assessment of Behavior: Professional manual. Lutz, FL: Psychological Assessment Resources. Conners, C. K. (2009). Conners: Manual. North Tonawanda, NY: Multi-Health Systems. Costello, E. J., Egger, H., & Angold, A. (2005). 10-year research update review: The epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. Journal of the American Academy of Child and Adolescent Psychiatry, 44, doi: /01.chi c0

15 Assessing and Treating Childhood Anxiety Page 5 of 6 10/17/2013 Crawley, S. A., Kendall, P. C., Benjamin, C. L., Brodman, D. M., Wei, C., Beidas, R. S., Mauro, C. (2013). Brief cognitive-behavioral therapy for anxious youth: Feasibility and initial outcomes. Cognitive and Behavioral Practice, 20, , doi: /j.cbpra Cummings, J. R., Ponce, N. A., & Mays, V. M. (2010). Comparing racial/ethnic differences in mental health service use among high-need subpopulations across clinical and school-based settings. Journal of Adolescent Health, 46, doi: /j. jadohealth Donovan, C. L., & Spence, S. H. (2000). Prevention of childhood anxiety disorders. Clinical Psychology Review, 20, doi: / S (99) Esser, G., Schmidt, M. H., & Woerner, W. (1990). Epidemiology and course of psychiatric disorders in schoolage children results of a longitudinal study. Journal of Child Psychology and Psychiatry, 31, doi: /j tb01565.x Farmer, E. M. Z., Burns, B. J., Phillips, S. D., Angold, A., & Costello, E. J. (2003). Pathways into and through mental health services for children and adolescents. Psychiatric Services, 54, doi: /appi.ps Flannery-Schroeder, E. C., & Kendall, P. C. (2000). Group and individual cognitive-behavioral treatments for youth with anxiety disorders: A randomized clinical trial. Cognitive Therapy and Research, 24, doi: /a: Kabat-Zinn, J. (2012). Mindfulness for beginners: Reclaiming the present moment and your life. Boulder, CO: Sounds True. Kamphaus, R. W., & Reynolds, C. R. (2007). Behavioral & Emotional Screening System. Bloomington, MN: Pearson. Kearney, C. A., & Albano, A. M. (2004). The functional profiles of school refusal behavior: Diagnostic aspects. Behavior Modification, 28, doi: / Kendall, P. C., & Hedtke, K. A. (2006). Cognitive- behavioral therapy for anxious children: Therapist manual. Ardmore, PA: Workbook Publishing. Kendall, P. C., Safford, S., Flannery-Schroeder, E., & Webb, A. (2004). Child anxiety treatment: Outcomes in adolescence and impact on substance use and depression at 7.4-year followup. Journal of Consulting and Clinical Psychology, 72, doi: Kendall, P. C., & Suveg, C. (2006). Treating anxiety disorders in youth. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitivebehavioral procedures (3rd ed.). New York, NY: Guilford Press. Khanna, M. S., & Kendall, P. C. (2008). Computer- assisted CBT for child anxiety: The coping cat CD-ROM. Cognitive and Behavioral Practice, 15, doi: /j. cbpra Khanna, M. S., & Kendall, P. C. (2010). Computer- assisted cognitive behavioral therapy for child anxiety: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 78, doi: /a McDonald, A. S. (2001). The prevalence and effects of test anxiety in school children. Educational Psychology, 21, doi: / Masia-Warner, C., Fisher, P. H., Shrout, P. E., Rathor, S., & Klein, R. G. (2007). Treating adolescents with social anxiety disorder in school: An attention control trial. Journal of Child Psychology and Psychiatry, 48, doi: /j x Masia-Warner, C., Klein, R., Dent, H., Fisher, P., Alvir, J., Albano, A. M., & Guardino, M. (2005). Schoolbased intervention for adolescents with social anxiety disorder: Results of a controlled study. Journal of Abnormal Child Psychology, 33, doi: / s z Mendelson, T., Greenberg, M. T., Dariotis, J. K., Gould, L. F., Rhoades, B. L., & Leaf, P. J. (2010). Feasibility and preliminary outcomes of a school-based mindfulness intervention for urban youth. Journal of Abnormal Child Psychology, 38, doi: / s x Mendlowitz, S., Manassis, K., Bradley, S., Scapillato, D., Miezitis, S., & Shaw, B. (1999). Cognitivebehavioral group treatments in childhood anxiety disorders: The role of parental involvement. Journal of the American Academy of Child and Adolescent Psychiatry, 38, doi: / Mychailyszyn, M. P., Beidas, R. S., Benjamin, C. L., Edmunds, J. M., Podell, J. L., Kendall, P. C. (2011). Assessing and treating child anxiety in schools. Psychology in the Schools, 48, doi: /pits Mychailyszyn, M. P., Mendez, J. L., & Kendall, P. C. (2010). School functioning in youth with and without anxiety disorders: Comparisons by diagnosis and comorbidity. School Psychology Review, 39, doi: / pits.20548

16 Assessing and Treating Childhood Anxiety Page 6 of 6 10/17/2013 Neil, A. L., & Christensen, H. (2009). Efficacy and effectiveness of school-based prevention and early intervention programs for anxiety. Clinical Psychology Review, 29, Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney, L. (2005). Prevention and early intervention of anxiety disorders in inhibited preschool children. Journal of Consulting and Clinical Psychology, 73, Reynolds, C. R., & Richmond, B. O. (2008). Revised Children's Manifest Anxiety Scale, second edition (RCMAS-2): Manual. Los Angeles, CA: Western Psychological Services. Spence, S. H. (1997). Structure of anxiety symptoms among children: A confirmatory factoranalytic study. Journal of Abnormal Psychology, 106, Spencer, E. D. P., DuPont, R. L., & DuPont, C. M. (2003). The anxiety cure for kids: A guide for parents. Hoboken, NJ: Wiley. Silverman W. K., & Albano, A. M. (2004). Anxiety Disorders Interview Schedule, fourth edition. New York, NY: Graywind Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Lumpkin, P. W., & Carmichael, D. H. (1999). Treating anxiety disorders in children with group cognitive-behavioral therapy: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, doi: / x Spielberger, C. D. (1973). State Trait Anxiety Inventory for Children: STAIC; professional manual. Redwood City, CA: Mind Garden. Sulkowski, M. L., Wingfield, R. J., Jones, D., & Coulter, W. A. (2011). Response to intervention and interdisciplinary collaboration: Joining hands to support children's healthy development. Journal of Applied School Psychology, 27, doi: / Sulkowski, M. L., Joyce, D. K., & Storch, E. A. (2012). Treating childhood anxiety in schools: Service delivery in a response to intervention paradigm. Journal of Child and Family Studies, 21, doi: /s Whitcomb, S. A., & Merrell, K. W. (2013). Behavioral, social, and emotional assessment of children and adolescents, fourth edition. New York, NY: Routledge. Wnek, A., Klein, G., & Bracken, B. (2008). Professional development issues for school psychologists. School Psychology International, 29, doi: / Woodward, L. J., & Fergusson, D. M. (2001). Life course outcomes of young people with anxiety disorders in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 40, doi: / Savannah Wright is a doctoral student in the school psychology program at the University of Arizona. Her research interests include behavioral disorders and childhood anxiety. Michael L. Sulkowski, PhD, is an assistant professor in school psychology program at the University of Arizona. National Association of School Psychologists, 4340 East West Highway, Suite 402, Bethesda, MD Phone: (301) Toll Free: (866) 331-NASP Fax: (301) Site Map RSS Feeds Copyright FAQs Contact Us Privacy Policy

17 NASP Convention School-Based CBT for Anxiety 1 2 Presentation Overview COGNITIVE BEHAVIORAL STRATEGIES FOR WORKING WITH ANXIOUS YOUTH IN SCHOOLS National Association of School Psychologists Seattle, WA February 12 th 2013 Elana R. Bernstein, PhD Morgan J. Aldridge, MS Jessica May, MS 1. Anxiety: Overview, prevalence & long-term impact 2. School-based services for anxiety 3. Case examples 4. CBT: Overview, theoretical underpinnings, & important concepts 5. CBT: The nuts & bolts a) Affective b) Cognitive c) Behavioral 6. A typical CBT session presented through a case example 7. School-based implementation of CBT: Challenges & pitfalls 8. School-based implementation of CBT: Application at multiple tiers 9. Questions 3 4 Prevalence Anxiety disorders have the highest prevalence rates of mental health problems occurring in children and adolescents. Estimated overall lifetime prevalence rates of 8-27% Rates are estimated to be higher when children with subclinical symptoms (not meeting criteria for a diagnosis) are considered Children with internalizing disorders are often overlooked Median age of onset is 11 years old. Anxiety is among the earliest developing psychopathologies. Anxiety disorders are chronic and persist into adulthood. Costello, Egger & Angold (2005); Fox, et al. (2012); Kendall, Aschendrand, & Hudson (2003); Mennuti, Christner, & Freeman (2012) Costs & Consequences $42.3 billion spent nationally on the treatment of anxiety. Children who suffer from anxiety are more likely to experience: School drop-out Lower quality of life Psychopathology in adulthood Unsuccessful peer and family relationships Comorbid diagnoses Substance use Low self-esteem Social rejection Academic failure Greenberg et al. (1999); Kendall et al. (2003); Kendall (2012); Menutti, Christner, & Freeman (2012) Ramirez et. al (2006); U.S. Department of Health and Human Services (2001) 5 6 Anxiety In The Schools Despite high prevalence rates, anxiety is often overlooked in schools Difficulties in recognizing internalizing symptoms Children encounter anxiety triggers in school Academic pressure, social interactions, test anxiety, perfectionism, school refusal, frequent trips to nurse, etc. School-based treatment has ecological validity the benefits can be realized in the environment that is clinically & practically meaningful. When schools provide mental health services to students, results include: Lower costs Less mental health stigmatization More accessibility to mental health services Lower school drop out rate NCLB (2001) emphasizes the use of evidence-based interventions in schools. Schools provide an ideal and least restrictive environment to provide mental health services. Allen (2011); Doll (2008); Herzig-Anderson et al. (2012); Merikangas et al. (2011); Mychailyszyn et al. (2011) The Importance of Early Intervention The longer students suffer with unidentified anxiety problems, the more adverse the effects of anxiety can have on children s development which are difficult to reverse (Ramirez et al., 2006, p.273). Research shows that 75% of children who receive mental health services do so in school. When mental health services are provided in schools, common barriers that prevent youth from receiving care are removed (Mychailyszyn, et al., 2011). Services are most effectively provided within a multi-tiered system of support (MTSS). Tomb & Hunter (2004); Ramirez et al. (2006) Bernstein, Aldridge, & May (2013) 1

18 NASP Convention School-Based CBT for Anxiety ASSESSMENT Indicated Assessment Selected Assessment Universal Assessment The only way to move through the tiers is with DATA! 7 PREVENTION/INTERVENTION Few Indicated Prevention ~5% Some ~15% Selected Prevention Universal Prevention ALL ~80% of Students Anxiety: Important Concepts and Definitions Anxiety: disproportionate fear response to a perceived threat. Overwhelming sense of fear that can be characterized by physical symptoms (e.g., sweating, tension, increased pulse). The Core of Anxiety: Negative affectivity Perception of Control Specific Life Examples Anxious Thinking DSM-IV Symptoms: Difficulty falling asleep/staying asleep Irritability/outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response Motor restlessness Anxiety disorders most commonly seen in schools: Specific phobias School refusal Separation Anxiety Social Phobia Selective Mutism Generalized Anxiety Disorder 8 Multi-Tiered System of Support (MTSS) Source: Chorpita (2007); DSM-IV-TR (2000); Dozois & Dobson (2004) 9 10 Case Examples Vivi, Preschooler Allison, 3 rd grader Bryan, 11 th grader See Handout #1 WHAT CAN WE DO TO HELP THESE STUDENTS? Cognitive-Behavioral Therapy (CBT): An Overview CBT: Overview Multifaceted; can be applied to multiple problem areas in school-based practice. The therapist s role in CBT is to improve the cognitive information processing of clients in social contexts and attend to the client s emotional state(s) by using structured behavioral practice. The strategies in CBT are designed to produce changes in thinking, feeling, and behavior CBT: Empirical Support A growing body of evidence over 20 years supports the efficacy and effectiveness of CBT with children and adolescents. Cognitive behavioral therapy (CBT) has been noted to be an efficacious treatment for childhood anxiety according to guidelines set forth by the APA Task Force on Psychological Interventions: 1) It has been shown to be more effective than all of the following scenarios: no treatment, a placebo, or an alternate treatment 2) Multiple trials have been conducted 3) The trials were conducted by different investigative teams Note: Studies are mainly limited to clinical (not school) settings or have utilized outside providers who implement the treatment in a school setting. Kendall, Aschenbrand, & Hudson (2003); Mennuti & Christner (2012) Bernstein, Aldridge, & May (2013) 2

19 NASP Convention School-Based CBT for Anxiety CBT in the Schools: Empirical Support Recently we are seeing more research on the school-based implementation of CBT for a range of mental health diagnoses. School services are often reactive and considered successful if the problem goes away. We need to teach coping skills/strategies to prevent problems, such as anxiety, from re-emerging down the road. CBT is a framework for teaching these skills. Can be used in a reactive and preventive manner. Can address problems both in school and those outside of school that impact school functioning. Allen (2011) CBT: Theoretical Underpinnings These facets are examined as they pertain to the child s social/ interpersonal contexts & situations. Physiological Feelings/Emotions Cognitions (Thoughts) The relationship among these variables is multidirectional, not linear. There is often a trigger or threatening situation that sets the child down an anxious path. Behaviors/ Actions Social/ interpersonal contexts & situations: -Suburban School District -Supportive home life -Overachieving friends Physiological Feelings/Emotions: Upset/anxious Headache Stomach ache Cognitions (Thoughts): I am definitely going to fail this test! Allison 15 Trigger/Threat: -Test in class Behaviors: Crying Avoidance Goes to Nurse s office CBT: Theoretical Underpinnings Cognitive problem solving strategies are not transmitted magically from parents to children they are acquired through experience, observation, and interaction with others (Kendall, 2012, pg. 4). We can increase the use of these strategies through intentional intervention/instruction. Information processing affects how individuals make sense of the world. We can intervene by correcting (challenging) faulty information processing (distorted thinking). 16 The C in CBT: What do we mean by cognitive? Cognitive structures Memory (accumulation of experiences), aka cognitive schemas Cognitive content Stored information (the contents of the structure) Cognitive processes How we perceive/interpret experiences 17 Kendall s example Kendall (2012) What do we mean by cognitive? attributions are the resulting cognitions that emerge from the interaction of information, cognitive structures, content, and processes. These vary considerably across individuals. Related back to temperament Can shape how individuals perceive and respond to environmental events (either real or imagined!) Psychopathology (such as anxiety) may be due to problems in any or all of these. In CBT, we attend to all of these (through the child s selftalk, processing style, & attributional preferences). Challenging the child s current way of thinking Building a more beneficial cognitive structure/template 18 Bernstein, Aldridge, & May (2013) 3

20 NASP Convention School-Based CBT for Anxiety Cognitive Distortions vs. Deficiencies Cognitive processing deficiencies = an absence of thinking (when it would be helpful), i.e., minimal forethought/problem-solving skills. ADHD, aggression (often externalizing) Cognitive distortions = dysfunctional thinking processes. Depression, anxiety, eating disorders (often internalizing) CBT does not aim to remove existing cognitive structures, but rather help clients develop new templates for making sense of future experiences. The B in CBT: Changing Behavior Specifically, we are changing anxious (avoidance) behavior. And what about emotions? Anxious youth demonstrate a lack of understanding of how to hide and change their emotions. They struggle to modify their emotional states. They lack coping skills for a range of emotions. They experience more intense emotions. CBT can improve an anxious child s knowledge of and ability to regulate emotional states. Helpful when anxiety and depression are comorbid. Southam-Gerow & Kendall (2000); Suveg, Sood, Comer, & Kendall (2009); Suveg & Zeman (2004) CBT: Primary Components Features of CBT AFFECTIVE - Psychoeducation - Developing a fear hierarchy BEHAVIORAL - Role-play activities (teaching problem-solving techniques) - Practice - Exposure & Homework - Contingency Management - Reinforcement of positive behavior and skill mastery (Self-reward) COGNITIVE - Coping Modeling (verbalizing) - Cognitive Restructuring (changing self-talk; identifying and disputing dysfunctional ideas) OTHER - Therapeutic Relationship Time-limited Present-oriented Solution-focused Can be implemented at multiple tiers School-wide prevention, groups, classroom-based and individual interventions Affective (Feelings) CBT: AFFECTIVE COMPONENTS Psychoeducation & Developing a Fear Hierarchy Anxious youth demonstrate a heightened sensitivity to negative or threatening events, things, and information. Anxious youth have more difficulty regulating their emotions. Somatic (physical) complaints are common with anxious children (e.g., stomachaches, headaches, etc.). We treat this through psycho- (affective) education. Has positive effects in behavioral, emotional, and social functioning in children and adolescents Is a frequent element in most evidence-based anxiety interventions Kendall (2012) Bernstein, Aldridge, & May (2013) 4

21 NASP Convention School-Based CBT for Anxiety Psychoeducation: Teaching about Anxiety Also known as social and emotional learning (SEL) Explain what anxiety is Teach youth about the connection between physical, cognitive, & behavioral components of anxiety. Use the false alarm metaphor Normalize the fear/anxiety Teach recognition of somatic responses Where do you feel anxiety? Teach feelings identification Feelings faces Feelings charades See Handout #2 Feelings collage Feelings bingo How do you know when? Use role plays, videotapes, magazine pictures, bibliotherapy, etc. Developing a Fear Hierarchy A list of all related, fear-producing situations or objects, ordered from least to most anxiety producing (Merrell, 2008, pg. 175). Used to uncover the specific fear-provoking stimuli/ circumstances for the child Help the child rank fears from least to most anxiety producing Merrell (2000) Fear Hierarchy Example My Fear = School 0 = playing in the yard with friends at home 1 = going to bed on a school night 2 = going to school w/ mom (no students present) 3 = spending time with my teacher in the classroom when no students are there 4 = getting ready for school in the morning 5 = riding the bus to school 6 = walking to the classroom 7 = staying in class ½ day (allowed to call home) 8 = staying in class whole day (allowed to call home) 9 = staying in class ½ day (not allowed to call home) 10 = staying in class whole day (not allowed to call home) Let s look at fear hierarchy examples for Vivi, Allison, & Bryan. See Handout #1 Modifications for Vivi Shorten from 10 to 5 Utilize pictures, index cards, social stories, etc. CBT: COGNITIVE COMPONENTS Modeling, Building a Cognitive Template, & Cognitive Restructuring Cognitive (Thoughts) Cognitive Processes: the procedures by which the cognitive system operates How we perceive/interpret experiences Our cognitive interpretation of the world shapes how we view situations, events, and interactions Cognitive distortions: dysfunctional thinking processes 29 Examples of Cognitive Distortions In The School Setting Dichotomous Thinking Overgeneralization Mind Reading Emotional Reasoning Disqualifying The Positive Catastrophizing Personalization 30 Should/Must Statements Comparing Selective Abstraction Labeling See Handout #3 Kendall (2012) Menutti & Christner (2012) Bernstein, Aldridge, & May (2013) 5

22 NASP Convention School-Based CBT for Anxiety CBT: Building a Cognitive Coping Template Help children identify and modify negative self-talk Recognize and challenge the student s misinterpretations Example: If you fail this one test, does that definitely mean that you won t get into college? Help students recognize that other perceptions of the same situation exist Assist students in building new perceptions that encompass appropriate coping strategies The goal: when anxiety provoking events occur, the student will view the stressful event through the new coping template and be reminded to use appropriate coping strategies The goal is not to overload the anxious student with positive selftalk, but to reduce the negative self-talk The power of non-negative thinking (Kendall, 1984). Kendall (2012) Teaching Children To Problem-Solve Problem-Solving: it s what we do best! But, remember: school psychologists should not solve students problems for them, but instead teach them how to problem-solve. Help children develop confidence in their ability to overcome problems and use their experiences to problem-solve in the future Model brainstorming skills by pointing out plausible and impossible situations Teach students the five-step problem-solving process: (1) What is the problem? (2) What are all the things I could do about it? (3) What will probably happen if I do those things? (4) Which solution do I think will work best? (5) After I have tried it, how did I do? Vivi s refusal to get out of her mom s car when she arrives to school. Kendall (2012) Coping Modeling Based on social learning theory (Bandura, 1986) Observational or vicarious learning. May occur through a live model or a video model. Coping Modeling (verbalizing): Having a problem similar to the client, demonstrating strategies to overcome the problem, and then demonstrating successful performance Rather than saying, Watch me I ll show you how to do it, model the same fears and strategies to overcome the situation. Verbalizing Coping Model: a coping model who talks out loud through the steps and gives specifics (think aloud). Example: School psychologist pretends as if he or she was the one who was nervous and the student walks the school psychologist through the fear plan. 33 The Steps of Cognitive Restructuring Identify negative self-talk Everyone is going to laugh at me when the teacher calls on me and I answer her question wrong. Examine the list of common errors in thinking together. Use detective thinking to examine the evidence Past Experience: Has anyone laughed when you have been called upon in the past? Alternative possibilities: If so, could they have been laughing at something else? General Knowledge: How often do you get answers wrong? How about the other students? What does the teacher do when other students get the answer wrong? Different Perspective: How do others feel about answering the teacher s questions? 34 The Steps of Cognitive Restructuring 35 Thought Bubbles Activity: What are they thinking? 36 Identify a positive replacement thought I usually do pretty well in school. If I don t know the answer, I ll just say so. Use realistic thinking in some situations Ask: What if someone laughs? I ll just ignore it. : Techniques/Strategies Group Activity Changing Maladaptive Thoughts to Coping Thoughts See Handout #4 Thought bubbles activity (see the following slide) Use magazines and have students fill in ones for anxious thoughts. Using a thought record Bernstein, Aldridge, & May (2013) 6

23 NASP Convention School-Based CBT for Anxiety Using a Thought Record Where were you? Emotion/ Feeling Negative Automatic Thought Evidence that supports the thought Evidence that does not support the thought Alternative/ Coping Thought Where were you? Emotion Feeling Negative Automatic Thought Evidence that supports the thought Evidence that does not support the thought Alternative/ Coping Thought What error in thinking did I make? Chemistry Class What was the situation? Getting up to present my project Worried, stomach hurt Girls were laughing in the back of the room, they must have been laughing at me What error in thinking did I make? Selective Abstraction I was stuttering and stumbling on my words while I was presenting. They may have been laughing at each other or the teacher. Modifications for younger children like Vivi: Use only 3 columns: (feelings, negative thought, positive thought) Use pictures I don t really know why they were laughing and I am confident in my project Role Play CBT: BEHAVIORAL COMPONENTS Role-play, Exposure, Contingency Management, Selfreward, & Relaxation Training We need to practice doing things, we can t just talk about it! Practicing can be different for different kids Role play is an opportunity to practice in private before you perform in public. Give the child an opportunity to be active in the session. We role play cognitive, behavioral, and problem-solving strategies with the child. Role plays should be situations relevant to the child (derived from his/her fear hierarchy) Is the child resistant to role play? Be silly, act out something first and then let the child join in. friend on the phone. : Bryan s anxiety about calling a Exposure Placing the child in a fear-evoking experience, either imaginally or in vivo to help him/her acclimate to the distressing situation and to provide opportunities to practice coping skills within simulated or real-life situations (Kendall, 2012, p. 160). Graduated exposure vs. flooding & response prevention An important distinction! Remember the fear hierarchy? Here is where we will apply it. The exposure plan is crafted with the child s input. Explain the purpose (treatment rationale) to the child. Consider developmental level as an important factor here. Remember there is an art to exposure- you have to keep tasks challenging, but not so challenging that they are impossible to accomplish! 41 Exposure: Evidence Base Exposure strategies are a critical component in CBT. Consistently shown to be an indispensable component of anxiety interventions (Chorpita, 2007). Hundreds of clinical trials and dozens of meta-analytic reviews have helped establish (exposure) as the most empirically supported psychological intervention for the anxiety disorders (Deacon, 2012, p.10). Chorpita, Daleiden, & Weisz (2005) found that of the studies evaluated, successful treatment of anxiety disorders and specific phobia always included exposure. The National Institute for Clinical Excellence (2011) recommends exposure-based CBT as a first line in anxiety treatment. 42 Bernstein, Aldridge, & May (2013) 7

24 NASP Convention School-Based CBT for Anxiety Challenges with Exposure Failure to reach within-trial habituation (a decrease in reported fear during a practice session) Solution: Extend the exposure session (preferred method) or start with an easier stimulus next session Failure to reach between-trial habituation (a decrease in reported fear between practice sessions) Solution: Schedule more exposure sessions to reduce time between sessions; Include practice sessions at home What should you do during exposure? Before Remind the child of the purpose of exposure Reinforce the idea that exposure is a learning experience It is meant to test whether their anxiety is real or a false alarm During Be quiet, observe, and take notes of the child s behavioral response do they demonstrate avoidance? Outward anxiety? Only speak if a corrective prompt is needed- avoid reinforcing or distracting the student After Praise the student, using specific statements when possible I really like how you stuck with it and whispered to your friend. Encourage the student to share their success with a parent Use this time to review and ask questions about the experience Chorpita (2007) Chorpita (2007) Relaxation Training Teaches youth how to develop awareness and control over their somatic reactions to anxiety. Research has shown that relaxation training is most effective when combined with exposure (particularly in vivo) interventions. Dosage is important! Research shows that you need more than four relaxation sessions to show an effect Typically implemented as part of systematic desensitization; has demonstrated positive effects on its own. A study done 3.5 years post-treatment asked kids what they remembered: 1. Therapist name 2. You made me do things I didn t want to do 3. Take a deep breath when I get nervous Kendall (2012); Merrell (2008); Morris & Kratochwill (1998); Ollendick & King (1998) Relaxation Training Techniques/Strategies Progressive Muscle Relaxation (Jacobson technique) The Benson Technique (cue-controlled) Guided Imagery Elevator Breathing Mindful Meditation Robot/Ragdoll What about teens who are reluctant to participate? Work with their interests (golf example). Provide reinforcement for relaxation. Wait em out. Most of their life they ve had people talk for them. Let them sit To teach Allison relaxation strategies it is helpful to have a script or recording, for example, Allison, I want you to 1) Find a comfortable position in a quiet setting. 2) Close your eyes. 3) Pay attention to your breathing. Take a deep breath in and let it out slowly. 4) Imagine your worries leaving with your breath. 5) Tense and tighten your muscles, one by one starting with your feet and moving up to your head/neck. Then release them and notice how you feel. 6) Allow your entire body to relax and keep taking deep breaths in and slow breaths out. 7) Imagine a comforting place, perhaps your favorite place. 8) Continue these steps for several minutes and sit peacefully a bit longer. Modifications for younger children such as Vivi: Shorter script Less muscle groups Use developmentally appropriate metaphors such as the robot/ragdoll. First pretend with an inanimate object like a teddy bear. Demonstrate it first for her. Bryan would likely be able to do the full progressive muscle series. Exposure + Relaxation = Systematic Desensitization Gradual exposure to feared stimuli Challenging maladaptive thoughts Thought stopping Utilize coping thoughts/positive self-statements Relaxation Strategies Reinforcement/ Reward Fear Hierarchy Cognitive Strategies Behavioral Strategies Systematic Desensitization I can do this...take deep breaths! Bernstein, Aldridge, & May (2013) 8

25 NASP Convention School-Based CBT for Anxiety Contingency Management Based on operant conditioning; focuses on the consequences of behavior Focuses less on anxiety reduction and more on facilitating approach responses through appropriate reward/ reinforcement For anxiety, we typically use: Shaping, Fading Positive Reinforcement Emphasis on self-reward for effort and (partial) success Perfection is not expected! Graduated practice leads to a developing confidence (social-cognitive theory; self-concept). Extinction Effective at reducing multiple anxiety-related behaviors (i.e., selective mutism, social phobic behaviors, etc.) 49 The Importance of the Therapeutic Relationship in CBT The therapeutic relationship is essential in CBT. Establishing trust with and demonstrating warmth and positive regard for the client must precede any strategy implementation. In CBT the therapist acts more as a coach The therapist does not have all the answers. The therapist collaborates with the client in problem-solving. In sessions = practice; Real life = the game McGivern, Ray-Subramanian, & Bernstein (in press) 50 What about Parents? An important part of CBT. Parents are consultants, not co-clients. It is helpful to collaborate with parents on the intervention plan and maintain their cooperation and support. 1. Examine family dynamics that maintain anxiety. Parents often model anxious behavior themselves, or deal with anxiety in a maladaptive way. Parent-child interactions contribute to anxiety. 2. Solicit their help in developing the fear hierarchy. 3. Have the child teach their parent(s) the skills (i.e., relaxation, positive self-talk, etc.) to help generalize the intervention effects. 4. Teach parents basic behavioral parenting strategies such as positive/negative reinforcement, planned ignoring, modeling, etc.) 51 What Does CBT Look Like in Practice? Case conceptualization (as opposed to diagnosis) Helps the practitioner make decisions regarding the sequence and selection of particular treatment components. In essence, a modular approach (e.g., Chorpita, 2007) Base the treatment on the child s age, developmental level, and presenting problem(s). Consider verbal/cognitive abilities. If the child is particularly sensitive to physical symptoms, you may begin with deep breathing or progressive muscle relaxation. If the child first identifies catastrophic thinking patterns, you may start with labeling cognitive distortions. Vivi We would emphasize behavioral versus cognitive components based on her developmental level. 52 Session Components: 1. Set the agenda (Check in on the relationship) 2. Review status and events since last session A Typical CBT Session Practical Application: 1. Here is what we are going to do today (write it out) (utilize empathy; engage in parlor talk ) 2. Last week we talked about the physical sensations you feel when you are anxious 3. Solicit feedback re: last session 3. Did you think more about what you learned? 4. Review homework - Examples 5. Focus on main agenda item (e.g., cognitive restructuring) 6. Develop new homework for between-session 7. Progress Monitoring, Praise, & Self-Reward 3. Did you notice these sensations during the week and write it down in your journal? 5. Today we are going to talk about how our thinking impacts how we feel and what we do 6. I want you to take some time this week to use the thought record 7. How anxious do you feel today on the fear thermometer (from 1 to 10)? What have you accomplished on your fear ladder? Great job! (self reward) 53 CBT: Challenges in School-Based Implementation Time, time, time Resources But wait! You don t need a packaged program, you need a collection of evidence-based strategies. Schools are unpredictable Scheduling constraints Familial factors Parents maintaining anxiety Soliciting parent involvement Child factors Comorbidity, symptom severity, developmental delays, language/ processing difficulties, etc. 54 the school context is complex and dynamic, making delivery of services a challenge (Allen, 2011). Davis, Whiting & May (2012) Bernstein, Aldridge, & May (2013) 9

26 NASP Convention School-Based CBT for Anxiety CBT: Challenges in School-Based Implementation, cont. Common concerns reported by practitioners when treating kids with anxiety in the school: Youth with severe anxiety (e.g., vomiting due to anxiety) Make outside referrals when appropriate Not having enough time to reduce the child s anxiety before returning them to the classroom. Save 5-8 minutes at the end of a session to engage in a pleasant activity. Ensure that their self-reported ratings of anxiety following exposure are reduced by ~50%. Schedule longer sessions for exposure or even after school. Logistics of conducting exposure tasks in school. We need to step back and look at exposure differently. : How could we craft an in vivo exposure task for Bryan s anxiety? Let s look at his fear hierarchy on Handout #1. 55 Maintaining Treatment Integrity & Acceptability Measure it! Even if you are the intervention agent, use a formal measure of treatment integrity Solicit input from the child, parents, and teachers on treatment acceptability Ongoing measures of acceptability allow you to make adjustments to the treatment Higher acceptability yields higher compliance with treatment 56 Mychailyszyn, et al. (2011) Outcome Evaluation Is it working? How can we measure outcomes? Set measurable goals & monitor progress Goal Attainment Scaling (GAS) Transfer the fear hierarchy into a GAS Use pre-post measures (e.g., MASC-2) Review extant data School attendance, office referrals, etc. CBT Applications at Multiple Tiers Evaluate what level of intervention is needed within a multi-tiered system of support (MTSS). Tier 1: Preventative intervention implemented class or school-wide Tier 2: Small group intervention targeting sub-clinical levels of anxiety Tier 3: Targeted intervention for students experiencing high-risk and clinical levels of anxiety ASSESSMENT Indicated Assessment: - Rating scales - Behavioral observations - Interviews Selected Assessment: - Teacher/Parent referral/ nomination - Screening tools Universal Assessment: - Outcome evaluation for programs selected The only way to move through the system is with DATA! Few ~5% Some ~15% ALL ~80% of Students 59 PREVENTION/INTERVENTION Multi-tiered System of Support (MTSS) for Anxiety Indicated Prevention: - Individual counseling with anxious youth utilizing a CBT framework. Selected Prevention: - Small groups for youth at risk focused on cognitive-behavioral skill acquisition Universal Prevention: - School- or classwide programs to teach relaxation/stress reduction Source: Manualized Interventions Highly structured Allows for more methodological control More easily able to assess treatment integrity Flexibility is a concern Evidence-based manualized interventions: Coping Cat (Kendall & Hedtke, 2006) Camp-Cope-A-Lot (CCAL; Kendall & Khanna, 2008) Computer-based CBT modeled after Coping Cat FRIENDS for Children Program (Barrett, et al., 2000) Cognitive-Behavioral Intervention for Trauma in Schools (CBITS; Jaycox, 2003) 60 Kendall & Southam-Gerow (1995); Weisz, Wiess, & Donenberg (2011) Bernstein, Aldridge, & May (2013) 10

27 NASP Convention School-Based CBT for Anxiety Modularized Interventions Case conceptualization approach Problem-solving framework More flexibility and individualization Maintains a level of structure Evidence-based modularized intervention: Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders (Chorpita, 2007) QUESTIONS Murphy & Christner (2012) Bernstein, Aldridge, & May (2013) 11