SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 3

Day 3

Keynotes

Reactivity to Community Violence Exposure: Rethinking Desensitization in Youth of Color in Urban Communities

Presenter: Noni K. Gaylord-Harden, Ph.D., Associate Professor, Clinical Psychology, Loyola University Chicago

Notes:

The curvilinear relationship between ECV and depression but the linear effect for anxiety Desensitization - a reduction in emotional or physical reactivity to stimuli Hyper-vigilance and hyper-arousal appear to be protective against future ECV and victimization Different observed effect in sample with older boys Possible grief/loss response Unique sample due to identity stress Adaptive calibration model (conditional adaptation) - in contexts of high stress/adversity, young people exhibit behaviors that allow them to adapt to that setting that may not translate outside of that setting Instead of viewing those symptoms as pathological, they may be conditional Dangerous/unpredictable environments shape stress response system towards vigilant and unemotional patterns Demonstrates the need for a public health approach as opposed to a criminal justice/delinquency perspective Next steps: What are the age and gender effects on curvilinear association? What are the long-term effects of hyper-arousal Trauma-informed interventions - what post? grief/loss interventions, ADHD & Disruptive Behavior Disorders, substance use Q&A Q: Conditional adaptation may be protective - maybe the only way of intervening is to make the environment safer A: Yeah (laughing) Q: I see some of these things daily in school - they can’t adapt to the school that may be adaptive outside. We need to teach the skill of adapting, but how do you go about that? A: Emphasis on the fact that there aren’t always skill deficits Q: When you found the mediation between high hyper-vigilance/high aggression related to low long term violence, what do you find in peer relations? A: Question of peer endorsement - adolescents are sensitive to the evaluation of others. If their peers approve of their behaviors, they are more likely to engage in them. Q: The studies deal with high-threat perceived environments - have you looked into their perception of violence? Some kids feel like they live in a world of violence and behave as such. A: Social media and what’s available at any moment can have an exposure effect. Desmond Patton at Columbia - “internet banging” looking at how violence plays out on the internet. Kids can be exposed to violence through what they see online and on the news. Q: Referring to the study of 18 to 25-year-olds, is there a correlation between hyper-vigilance in young men who live in conditional adaptation environments and those who work in those communities (i.e., what about the difference between seeing it as pathological or adaptive)? A: The pathological perspective comes from researchers and outsiders and is not how the people in those communities actually see it.

A Storm of Innovations: Bringing the Best of the Free Mental Health Tools to the People Who Would Benefit

Presenter: Eric Youngstrom, Ph.D., Professor of Psychology and Neuroscience and Psychiatry, The University of North Carolina at Chapel Hill

Powerpoint: A Storm of Innovations: Using the Web to Work Together and Bring the Best Psychology Information to the People Who Would Benefit

Notes:

Updates since last time: Assessment center and wiki Keep everything free, problem- no marketing budget, people don't use tools because it is not advertised. Use Wikipedia because anyone can edit, free, lots of people use it Translations Remixes: Crisis response Vignettes What is HGAPS? Started as a club at UNC, incorporated as a 501c3 Sister chapters at UCLA, App Vision: bring best info about psych science to the people who would benefit (parents, clinicians, etc) for free EBA Pages on Wiki QR code leads to EBA on wikiveristy Can use Wikiversity “to teach a class” and share info with people If printed as a book- wiki info is 300 pages of material, all for free Link can be shared with anyone Goal: make easier for clinicians to use info Wiki Impact 173 new articles, edited 600 pages, 11000 edits, 150 mil views How do we pay for this? Started with grants from SCCAP for pizza Assessment Center Free measures that are easier to to find, connected to wiki If electronic, we could score for you and give a summary of results Most audacious idea: giving away everything! QR code goes directly to assessment center- everyone sees what we have Over 65 assessments on the assessment center Each contains an intro, instructions, disclaimer, demographics, questionnaire, calculated scores, resources for general public, and tools for clinicians Assessment batteries Made in Qualtrics, for use for clinicians or parents Several issues are assessed by the three batteries Hard part of the assessment center: how to do it responsibly? Have been live with a pilot version for more than a year now (rebuilt the DBSA) and it has been used 30000 times (only 9 assessments) Current one is even more Translations All assessments are in English 25 measures in at least 2 languages (usually Spanish) A few measures in 25 languages Today we plan on translating a lot of them in Spanish Will be doing this with Open Science Framework (OSF) If you know of a Spanish translation, can email it to us Will add this to OSF (a free library) Remixes Crisis response Grew out of parkland Lead with resources to manage stress Goals were to create EBA and repackage it in a way that was accessible to the public so that it could be disseminated to those who would benefit Visuals look more accessible and attractive to public Able to use resources and remake them for different situations (shootings in Pittsburgh and Orlando) Have more than 30 infographics Can use social media to disseminate resources Can do targeting advertising for different audiences Some infographics have been translated to Spanish (UNCC) Can also be used in response to natural disasters (I.E. hurricanes) a lot of this came from Miami After Hurricane, went to the Friday Center (red cross shelter) and gave qr codes to infographics Outcomes of dissemination- posters Vignettes Not limited to clients Hannah Baker from 13RW- show what a counselor could have done differently, what Hannah could have done differently Talked with Dr. Helen Hsu who was a consultant for the show and said it was fine to do Trying to take hard information and make it useful for people Questions SAMSA: similar to assessment center, we use some links to their toolkit SAMSA is big, hard to make connections Difficult to find new things in SAMSA (such a large library) Perhaps adding more interactive pieces? Videos have been made (a couple, but may not be appropriate) By the end of 2020 should have some Have you thought about making an app? Did have an attempt with a kick-starter grant Problems: login security is so high it's inaccessible Business partner doesn't want it to be free Suggestions: How many have shared the link with professionals they know? Ask everyone to do it

Making the Grade: School-based Interventions for Pediatric Anxiety Disorders

Presenter: Golda Ginsburg, Ph.D., Professor of Psychiatry, University of Connecticut (UConn Health)

Notes:

Introduction Studies Stars study Calm study TAPES study Do evidence-based practices work in settings such as schools with younger than college aged populations? Cartoon: parents talking about how carefree childhood is, child is outside racked with worry about global warming, exams, etc. Anxiety in students is underidentified and undertreated Perhaps people think its transient Parents and teachers begin to accommodate the child’s anxiety (basically let it go) Background: Why Anxiety? Anxiety disorders are most common pediatric disorders: 10-20% prevalence rate, 2 in 20 students affected (clinical criteria) but also likely 2 that don't technically meet clinical criteria Know that students have anxiety, but still don't get adequate help Causes significant impairment in many facets of life: social, academic, familial (parents don't know how to handle it- ignore it, accommodate it, etc), personal stress (somatic symptoms such as nausea, sleep problem) Anxiety has a chronic course: 6-10 years after treatment, ½ still meet diagnostic criteria for anxiety disorder Anxiety is a gateway illness: having anxiety as a child leads to greater chance of developing depression, substance use disorder, etc as an adult Most common in youth: GAD, social phobia, specific phobia, specialized anxiety disorder Why schools? What is treatment as usual (TAU) for anxiety diagnosis in schools? Is CBT better than TAU in schools? Expanding the network of school providers Children have valid concerns and worries during childhood. * Anxiety is underestimated and under treated in children Why do they go unnoticed? Not apparent and disruptive Anxiety in the classroom is avoided Try to adapt to the child and not put them in situations that cause discomfort Care providers believe they will grow out of it or it is not serious Why is anxiety in children important to study? Measurement of anxiety is getting better Anxiety disorder is the most common psychiatric disorder- and is on the rise! 10-20% lifetime prevalence rates 2 in 20 students affected 2 more will not meet criteria but will likely meet some of the items Problems caused by Childhood anxiety Social interactions Fewer friends Little to No extracurricular activities o Less likely to attend events like field trips Academic Preform lower Attendance is lower Familial Tough parenting causes tensions Babying- allowing them to avoid situations that cause distress Causes parental conflict Family distress “Gateway illness” more likely to develop other disorders Adult anxiety Suicidality Other diagnoses Case Example 1 Primary Diagnosis: Generalized Anxiety Disorder (GAD) 6-year-old boy Key worries: Making mistakes/perfectionism/changes Hours getting ready looking just right Upset each morning afraid of missing the bus Upset by changes in plans Hours on homework re-does assignments tears up assignment if makes a mistake Seeks constant reassurance Sought school nurse because of stomach aches Missed school due to anxiety Case Example 2 Separation Anxiety 10-year-old girl Must be near mom at all times so begs to stay home Could not be alone in a room in the house Sleeps with mom Leaves bathroom door open Texts mom during day and asks to leave school Stomach aches each morning causing her to be often late to school How are we doing currently? Less than half of youth received services High impairment, less than half receive services they need. Likelihood of receiving treatment: 30% anxiety vs 70% ADHD Critical need to enhance access, bring services to school Why School Interventions? Takes away many barriers to seeking treatment (fees and transport) School setting can trigger anxiety, clinical advantage - student can get corrective feedback immediately unlike outpatient care Separation, performance, and social Better generalization of skills Treatment improves academic functioning Results Evidence-based Treatments Cognitive Behavioral Therapy (CBT) Medication-SSRIs CAMS: Response rates 60%-80% 60% is one treatment alone (independent) 80% is when both treatments are used (together) STARS Study Are school clinicians using CBT? Primary Aim: Compare the effectiveness of Modular CBT (more flexible for each child)(MCBT) to TAU Modular CBT takes the elements of CBT but gives more flexibility to the clinician Modules: start with psychoeducation (what is anxiety and how does CBT work) Exposure Relaxation Cognitive 6 year randomized control trial (RCT) in MD and CT: MCBT (n = 37) or TAU Clinicians were not trained in CBT so they had one day of training with optional supervision 12 weeks of treatment but the average was 9 Evaluations at pre, post, 1 year follow up 216 students (6-18 year olds) The CBT Modules Psychoeducation 1st session CBT Triangle Exposure 2nd session and throughout Relaxation strategies Cognitive restructuring “changing thoughts” Problem solving Relapse prevention Meditation Most children had more than one disorder What is (Treatment as Usual (TAU)? Clinicians reported their primary therapeutic orientation and then after each session evaluated therapeautic strategies(n=25) Before clinicians were trained, clinicians reported 68% used CBT Session by session summary forms data (n=475) clinicians reported: 67% used CBT IE-report (n = 90 sessions) showed that only 14% were actually using CBT when evaluated TAU involved more relationship building like playing games together A lot fell into the category of other for example: Emotional support for feelings Making holiday cards Conclusions & Limitations Majority of clinicians report using CBT or CBT elements Evaluations reveal low CBT use School clinicians are thinking about CBT The sample was small may not be generalizable We need more training for school psychologists Highlight need for better training Is MCBT Better than TAU in Schools? Outcomes assessed by trained evaluators at post and 1 year follow up to assess anxiety severity, global functioning, and clinical improvement Using CGI-S Anxiety did go down over time and stay low over time, however no between group differences (CBT = TAU) Same with global functioning Clinically meaningful improvement no group differences Were expected to get 60% improvement (like CAMS) but only got 30%, showing school based CBT isn't as effective and isn't more effective than TAU Why lower MCBT response rate? Had a lower dose (only about 9 sessions) Poor training and supervision (only 1 day of training) Low MCBT quality CBT content missing (exposure) Did clinicians adhere to MCBT? Adherence is around 70-80%, bit quality is not great Clinicians reported they adhered to exposure, bit many actually did not when evaluated Could TAU be contaminated? A diagnostic report was provided Ongoing monitoring conducted Prescribed number of sessions Could have made TAU better than normal Cams was more effective than stars but why? Lower dose (9 sessions for 20-30) Limited/poor training and supervision 1 day; optional supervision Low MCBT quality Key CBT element of exposure may have been missing Lower clinician adherence of exposure TAU- contaminated Diagnostic report provided Ongoing monitoring conducted Prescribed # of sessions CBT elements were used in TAU Cochrane report (2013) data are “limited and inconclusive if CBT is more effective over TAU” Implications and Solutions More training but there are limits because of funding and cooperation Must enhance training of school clinicians or outsource mental health professionals Explore alternative treatments? What in a session is best to help kids improve Expanding School-Based Anxiety Treatment Expanding school based providers Calm Study Why and Who School nurses could help Familiarity with kids because of somatic problems Less stigma and beloved by students Overview 3-year study Intervention 1: CBT 6 Calm modules based on CBT Intervention 2: Only using relaxation exercises Relaxation, meditations, and other strategies Results Anxiety went down Somatic symptoms were reduced Behavioral avoidance decreased Automatic thoughts significant reductions** TAPES High need for anxiety treatment, but shortage of school clinicians Can task shift- use people not trained in mental health necessarily but teach them to work with kids with anxiety First was calm study (use school nurses) Kids with anxiety are frequent flyers in the nurse’s office, but the nurses were not trained to handle pediatric anxiety disorders Less stigma associated with going to see school nurse and also have better relationship with them CALM Developed two nurse intervention CALM uses CBT 6 modules CALM-R uses relaxation training only N = 30 (nurses) and 54 (kids) Nurses make a big difference, anxiety went from clinical to subclinical range Somatic symptoms also decreased Behavioral avoidance also decreased Anxious thoughts decreased Case study 1 boy had decreased symptoms (went 2 months without going to nurse) Case study 2 girl was able to try a sleepover, be alone in a  room conclusion Progression in the right direction TAPES Uses teachers Can easily identify students with anxiety Published in TRIALS Meet with student and parent together Uses school home model (teachers and parents use same language) 5 30-minute teacher led meetings Teachers have increase in knowledge of CBT, decrease in accommodation of anxiety Students have reductions in anxiety as reported by parents and teachers Anxiety severity Anxiety did go down overtime and remained down Did not differ significantly between groups Global functions Improved over time No significant between group differences Follow up of Case 1 and Case 2 Many of the issues were resolved or reduced TAPES Study Who and why Teachers, can easily identify problems Overview Intervention development Open trails Randomized Control Trial (RCT) Why a school and home model Better communication between teachers and parents is associated with better outcomes Trial run Reduction of anxiety From parent, child, and teacher report

Workshops

The Need for Contextually-Relevant and Culturally-Specific Trauma-Informed Interventions for Youth Exposed to Community Violence

Presenters: Noni K. Gaylord-Harden, Ph.D., Associate Professor, Clinical Psychology, Loyola University Chicago

Finding, Using, Sharing, and Improving the Best Free Mental Resources

Presenter: Eric Youngstrom, Ph.D., Professor of Psychology and Neuroscience and Psychiatry, The University of North Carolina at Chapel Hill

Powerpoint: Testing, Tuning, and Translating the Best of the Free Tools for Assessment, Treatment, and Education about Mental Health

Modular CBT for Pediatric Anxiety Disorders: Calling All School Personnel

Presenter: Golda Ginsburg, Ph.D., Professor of Psychiatry, University of Connecticut (UConn Health)

Supporting Social, Emotional, and Behavioral Competencies in the Elementary School Setting

Presenter: Erika Coles, Ph.D. Clinical Director, Center for Children and Families; Director of Clinical Training, Clinical Science Program in Child and Adolescent Psychology, Florida International University

Other 2020 Days

• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 1
• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 2