SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2018/Day 1

Day 1

Keynotes

Brief, Intensive Treatments for Childhood Anxiety and Phobic Disorders: The Future That Is Now

Presenter: Thomas H. Ollendick, Ph.D., University Distinguished Professor, Department of Psychology, Virginia Tech,

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/86v7g/?action=download%26mode=render

Learning Outcomes:

Acquire up-to-date information about the child and adolescent phobic and anxiety disorders

Anxiety disorders are extremely common- 28.8% of kids will have one before they’re 18 Specific phobias are the most common at 12.5% Anxiety disorders are more common as children reach adolescence (as well as other disorders) Depression drug use and ODD also increase overtime with anxiety with age. Risk Factors for etiology and Maintenance of Anxiety Disorders Genetic factors, temperament, attachment, learning, biases, peers, neuroanatomical Example- Temperament: Behavioral inhibition is the basic disposition towards the unfamiliar that can change over time. Children are born with a predisposition of how they will interact with people. 10-15% of children have shy, introverted temperament. Example- Parental Influences: Overprotection- Like mothers who make children do things that stand out from peers Example- Direct conditioning- A child was attacked by a dog. The direct effect developed from something happening to someone like events such as being on the scene of a mass shooting. Indirect- Some people can develop a fear or phobia of shooting even if they were not at the shooting but just seeing it on the news. Someone can vicariously experience an event which can lead to anxiety. Example- A surge of kids with phobias of flying in airplanes developed from 9/11. Conceptual frame- Developmental psychology Equifinality- Any outcome can result from multiple and diverse pathways. Anticipate that some children will be depressed, anxious or struggle with eating problems after a traumatic event. For instance, a mass shooting can have many different outcomes, it affects each student/person differently. You may come across non-textbook cases. One example is a 12-year-old girl who developed ODD, which is rare, from her dad never coming home after he got shot but the brother didn’t develop it. Multifinality- Any cause or pathway can result in multiple or diverse outcomes. After a school shooting some kids might be depressed, anxious, develop an eating disorder

Learn about evidence-based brief psychosocial interventions for these disorders and how to evaluate them

CBT Treatments for Phobic and Anxiety disorders: Summary Reviews There is very little play therapy studies. Only about 50-60% are diagnosis free after treatment Long-term outcomes of CBT at follow up- no remission rate of 50-60%. So, if ⅔ of the patients get better and half of them remained better over time then 30% of people got better and stayed better. On the other hand, 1/10 of people of nonevidence-based treatment stay mentally well. Where to from here? Alice’s Adventures in Wonderland: Alice said, “Would you tell me, please, which way I ought to go from here?” Cheshire Cat responded, “That depends a good deal on where you want to get to.” Yogi Berra: "If you don't know where you are going, you will end up somewhere else." Relatively New directions- The Future that is Now Self-help treatments/bibliotherapy, enhanced family approaches, computer-assisted, virtual reality, attention bias modification training, Brief low and brief high-intensity treatments etc. Brief CBT Interventions Brief low-intensity interventions (CBT lite) (Bibliotherapy, self-help books, self-delivered internet program, 30-minute clinician advice, brief interventions from a pediatrician and primary care physicians) Estimated currently serving about 10% of kids who need help Brief high-intensity interventions (CBT strong)- modification of CBT by reducing the number of sessions or time period over which treatment is done- rather than once per week for an hour-long session where only 40 or 45 minutes of the time with patient is spent in contact with reversing the behavior while the rest is waste of time and nonhelpful talking. Why CBT-Strong? The most effective ingredient of any psychotherapy is exposure to the problem, like experiencing anxiety, or talking about it, unless anxiety is brought out through CBT session then it is not working. You must address misattributions, faulty thinking, and how to deal with the problem through exposure. A person's body can’t be anxious for long periods of time, but if someone is anxious for prolonged periods of time. They will learn that what they fear won’t happen by setting up behavioral tests, exposures to maximum effect close in proximity to each session because once a week is not enough. Most important thing- exposure to problem area so talking about anxiety or depression If the patient doesn't experience anxiety in the treatment it isn’t helpful Address misattributions that are happening and have exposure Have to show the client that what they fear won’t happen Therapy sessions need to be close together and have different situations for the client to become accustomed to Brief intensive treatments meta-analysis [1] (Ost and Ollendick) Ost and Ollendick examined brief interventions lasting 1 week compared to standard 8-10-16-24 weeks or so, findings followed 4-7 years. Compared standard 16-week treatments to either one session or 5 sessions in one week- remission rates not statistically different. So brief interventions doing as well as standard interventions with reduced time. So we can reach more people and cut costs down for people. Brief intervention treatment was not as effective as standard treatment for social phobia. Possibly because social anxiety often times is preceded by behavioral inhibition. Thus, the child learned over time to be quiet, look around and scan for threats or scowls when around others. One-session treatment of specific phobias in youth compared to Carl Rogers non-directive psychotherapy. One-session Treatment (OST)- one 3 hour session with all methods combined for the clinical trial: psychoeducation about anxiety, in vivo exposure, cognitive reinforcement done by masters level therapists. 6-hour session in practice: tell the insurance company that you can pay us now or later 6 hours versus 18 hours in the long run. Therefore, OST saves time and money. Exposure In-Vivo/Cognitive challenges- The therapist demonstrates how to interact with the object of fear. Anxiety cannot remain for long periods so by having them stay for a while. They tested cortisol and galvanic cell bodily conduction in the clinical treatment trials like climbing ladders as an in-vivo exposure challenge if they were afraid of heights. Therapy is important because severe phobias that are not treated do not get better on their own. A 7-year-old girl was so afraid of worms that she could not go out and play, go on vacation and then became school avoidant. Clinical severity is on an 8-point-scale of severity. 4 is the cut off for diagnosis on clinical severity rating. The severity of the phobia was measured pre-treatment, post-treatment and at 6 months follow-up. A score of 3 is still subclinical and somewhat healthy avoidance of what they used to have a phobia of. The Waitlist group had little change, the OST was better than the education support treatment (EST) and had good follow-up results.

Contemplate moderators and mediators of change for these brief, intensive interventions

Moms with high anxiety or control benefit more from one session treatment (OST). Moderation by Mom SCL-90 Phobic Anxiety: OST is needed if they have extreme phobic anxiety but if standard anxiety then OST or EST is same and if the mom is high in control then they benefit better from OST. Augmented OST- 3 hours- During the first hour the parent is behind a one-way mirror observing their child in therapy while one therapist explains it to them, then during the second hour the parent is given more information about the therapy, lastly for the third hour the parent goes in the room to try it out in order to transfer control from the therapist to the parent. It was hypothesized that the child plus the parent with OST would do better but the child alone does about the same, it sometimes helps and sometimes doesn't. This might occur as a result of parents exhibiting safety behaviors like "shielding" the child through comfort which prevents the child from getting the necessary exposure. The only significant moderator was ADHD comorbidity- Kids with ADHD did less well but this was expected because it requires a lot of focus to get through a treatment that long. If a child has ADHD and a phobia, then they are less likely to get better in a 1 3-hour session of treatment because they are not attentive the whole time but distracted so then they are not receiving full exposure. Many people travel to get treatment from Dr. Ollendick’s clinic. About 60 sessions, will travel for treatment. Until people get trained for OST then patients will travel for it. Example- Kid went to Disney world and had been helped get over the fear of mascots and characters Future to come- Need to supplement/augment short or regular treatments with other approaches like self-help, virtual reality, internet, drug supplemented interventions, "In theory, theory and practice are the same. In practice, they are not" - Albert Einstein How long will we continue to do treatments that have little evidence for effectiveness? It is unethical to give treatment that is not working.

State of the science on early interventions for children with ASD

Presenter: Connie L. Kasari, Ph.D., Professor, Human Development and Psychiatry, University of California, Los Angeles

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/2uwmc/?action=download%26mode=render

Learning Outcomes:

Identify two core areas of impairment for children with ASD

1 in 68 kids have autism Gap between research and practice LAUSD: district, 2nd largest school - mostly Hispanic White kids take most of the services even though only 30% of population with autism 3 issues to consider Research and practice gap Most kids have never been in a research study Most interventions haven’t been tested Need naturalistic developmental behavioral interventions JASPER- Joint Interventions vary on how much direct instruction is involved and targets of intervention She’s arguing that there isn’t evidence for 40 hour treatments being effective What is evidence based model for early interventions: 2 ways: comprehensive: long hours many sessions, Target model: more like basic CBT where you focus on specific issues DDT: 30 hours vs 10 hours, 2 years 50 IQ and treatment increase in 28 kids in study. Early start denver model- similar results 24 kids was replicated in 2005 and no significant results Denver wasn’t significant when reproduced with larger amount of kids Rare for follow up studies: non significant, What do findings mean: consider outcome measures and active ingredients. We don’t know active ingredients of comprehensive, IQ is only thing really tested, IQ is important but not a core deficient of autism, most end up in normal IQ, IQ gets more significant around 7, 50-60-70 range it is unstable in preschool age. BCBA (Board Certified Behavior Analyst) therapist gets more insurance funding in cali than a clinical psychologist from insurance companies Who administers? Didn’t focus on content but dose and teaching methods Focusing on social communication, restricted, repetitive behavior

Identify at least two research tested methods for improving core impairments

Focusing on social communication, restricted, repetitive behavior No joy in playing, very rigid, see playing as a task and being done and not reinforcing for him to play object focused not joining engaged either Communicative gestures in typical 17 month old: engaged, looking where you point, smiling, making sounds, turning head, joy. ASD 17 month, quiet, no joy, not into clinician Focus on core impairments because being able to speak in full sentences predicts social skills, play skills associated as cognitive abilities, JASPER (Joint attention, symbolic play, engagement, and ), not an easy intervention to learn and teach, 164 kids: JASPER or in school treatment DTT teaching symbolic play, 6 months, play assessment in beginning before each study DTT: 5 year old shared looking, 5 words used, functional play in baseline assessment, in later test it is repetitive tasks, that are learned symbolic play, the ideas come from the therapist but in real play it comes from the child’s ideas and imagination. JASPER: 5 year old, did a show to the camera so a bit joint attentions but not much communication just like other case, in follow up assessment: wait time, modeling shaping of behaviors, more developmental, more talking, more spontaneous child initiations JASPER: He pointed to others which is a sharing point of someone coming into the room not a requesting point, 9 randomized control trials all same findings, if you give them content, everyday for 6 weeks joint attention or play, or just ABA programs, in 90s they were not focusing on joint or play, play and joint were much better with language skills, 40 hours a week in ABA so it is the content not the dose, kids with lowest amount of language did better if in joint attention so moderator effect Parent Mediated Interventions: Comparative efficacy: JASPER better Imitation skill focused gives you better joint attention Parental synchrony reduced the symptomatology of ASD In JASPER mirror pacing is better than prompting the child for a response

Identify two ways to individualize their clinical practice in order to better meet their client needs

Modules can be added into JASPER to make it more individualized Need a sequence of treatment not just one Focusing on subgroups like minimally verbal often excluded, school aged kids, 5-6 year olds not speaking, some kids Adapt the treatment based on kids response: Adaptive intervention designs systematize clinical practice Some people want density and some want spacing out with practice on their own in between SMART takes adaptive model and tests it in a study: goal is to help clinicians systemize their practicing so they can replicate what works Same intervention and half got augmentative speech generating device JASPER is slow and steady course 5 ½ year old 0 words in the beginning, device present that he doesn’t use, after he squeaks and uses magine with 300 devices, he can talks now Day 2: No joy 3 year old player with ipad, now had toys that don’t insert places and he used the device and more engaged Not only about implementation but child outcome What does JASPER look like later so checked at 10 year olds and IQ is in normal range, add peer intervention component because the JASPER by itself doesn’t really help. Only some needed social intervention if they just had JASPER. Assess the need for intervention because only some need JASPER.

Racism and African American Youth Mental Health

Presenter: Enrique W. Neblett, Jr., Ph.D., Associate Professor, Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill

Learning Outcomes:

Name at least three forms of racism-related stress that confer risk on the mental health of African American children, adolescents and young adults

Kalief was wrongly convicted for an act he did not do, he committed suicide Just prior an article was published about the high risk of black youth for suicide Racism and poor mental health and suspension connected Black children are unproportionately impoverished (1 in 3) but they are resilient and have similar or lower rates of mental illnesses relative to their white counterparts Clark Doll experiment- showed African American children dolls (black and white) and told them to pick the doll associated with good or bad characteristics (they picked white dolls for good characteristics and black dolls for bad characteristics)- might not just be that they all have low self esteem APA started task force on resilience and strength on black youth Racism and mental health Racism is a stressor that can lead to truncated economic mobility and reduced access to resources Discrimination induces physiological and psychological problems Some black youth internalize negative views which affects their mental health Biopsychosocial model of racism : Psychological stress feeds nervous system making them dulled reaction to later assault Racial discrimination is major factor that should be taken into account when studying minority population Racism is cultural and institutional Definitions from James Jones’ 1972 work: POWER: consists of 2 elements which are prejudice (negative cognitions) and discrimination (differential treatment) Tripartite model of racism - individual, institutional, and cultural (in symbols and language of a culture, maybe subtle cues in TV or movies) Racism and well-being for young people- link between discrimination and lower well-being including mental health outcomes Studied how racism is viewed by youth- they said it wasn’t explicit like their parents, more nonverbal and microaggressions like a teacher slowing down speech when talking to them Not a lot of institutional work done on racism Shift from old fashioned racism to modern racism with micro aggression, more subtle, less name calling more of a blurred line Are people withdrawing from social interaction, increased vigilance may lead to more anxiety A lot of speculations

Define racial identity and explain how it acts as a protective or vulnerability factor for African American youth

Ethnic/racial identity- how important is race/ethnicity to the individual, 2004 study with late teens and asked about racial experiences, racial identity buffers effects of racism and mental health, medium level of racial centrality had higher levels of mental health issues. Being black is important to who i am had the highest level of negative affect/mood like anger and disgust. Racial centrality is supposed to be a protective factor… subtle instances of racism caused more emotions to uprise who are high centrality, not consistent with the idea that high centrality have the most heightened psychological stress and struggles even though stronger connection to identity is supposed to mitigate effects of racism. How they talk to kids about race: Barrier and pride and equality not about race talks to kids. Positive are combo of barrier and pride talks, negative are saying bad things about being black and trying to make them act white, and parents who don’t talk about race. Positive talked to kids had lower levels of perceived stress of discrimination and it protects kids when talking about race. Racial socialization: How do black parents talk to their child about race and coping with racism, how to have conversations about racism Africentric worldview might mitigate more stress- psychological can influence physiological Asked kids how much they care about material possessions- low value had more spiritual values and less physiological change to discrimination but opposite for those who value it highly Racial discrimination is a risk factor for negative affect and negative mental health outcomes African-central values like spirituality reduce the physiological repercussions of discrimination

Identify at least two cultural adaptations of behavioral interventions that may alleviate the mental health suffering of African American youth who experience racism-related stress

CBT Approaches for racism-related stress Promote positive ethnoracial identity (ERI) Assess stage of ID development Support client in exploring ERI Encourage involvement in cultural activities Black youth who report higher ERI report more heightened vigilance in regards to racist events Cultural sensitivity and CBT- therapist has to understand clients’ identities, invite conversations about marginalized status (do you think your anxiety is related to the race of the people?), improve psychoeducation using things that have actually happened to them, adapting cognitive restructuring (don’t invalidate client’s claim of experiencing racism but challenge their negative cognitions), modify exposure using knowledge of culture But not very developmentally appropriate, so how do we apply to younger kids? Racism recovery/safety plans- plans like the plans made for suicidal patients- how to stay grounded when experiencing racism, what are the triggers Recommendations and future directions Elucidate mechanisms and pathways- needs more longitudinal work Investigate impact of institutional and cultural racism Adopt developmental/life course perspective Integrated biopsychosocial models Include racial-ethnic risk and protective factor measures in clinical work, but attention to instrumentation Acknowledge and investigate the intersection of cultural identities In conclusion Racism is bad- risk to mental functioning of racial/ethnic minority youth Protective factors Take into account race

Body Dissatisfaction: Why should we care and what can we do about it?

Presenter: Carolyn Black Becker, Ph.D., Professor, Department of Psychology, Trinity University

Learning Outcomes:

Explain why body dissatisfaction is an important construct to understanding and treating adolescent mental health

Why should we care? Body dissatisfaction is common in boys and girls in western cultures Is it a problem in boys? Yes, but more so in girls- less research with boys Increase in BMI associated with worse body-image (weight-stigma) Consequences of body dissatisfaction in adolescents- immediate distress, depression, suicide, unsafe sex, weight gain (counter intuitive), low self-esteem, overweight girls who hate their body gain more over time than girls who love their body. Just like you treat/care a car, pets, possessions better if you like/love it. If you have a car, shoes, etc. you like you treat it much better Body dissatisfaction can emerge in childhood- 5 (or even as young as 2) Associated with problematic weight loss strategies and eating disorders 55% of girls in 14 country survey reported not engaging in activities when they were worried about their appearance BD is a problem for girls and boys Exists before puberty but increases after Has a wide range of negative outcomes

List mental health problems for which body dissatisfaction serves as a risk factor
Disorders Eating disorders Suicide Depression Low self-esteem

Describe 3 interventions found to reduce body dissatisfaction

What can we do to address body dissatisfaction? Considering 4 studies that influenced at least one BD factor as far as a follow-up with a decent sample size Lots of current interventions (especially in schools) don’t work Student bodies interventions Stanford and WashU eating disorder prevention focusing mostly on college students One study showed less objective (anyone says it’s a lot of food) and subjective (eat like 3 cookies and feel out of control) binges Meta-analysis- a wide range of moderate effects on body image Happy being me Made in Australia- effects found months after on several body image factors Expanded to England Susan.paxton@latrobe.edu.au ? Media smart Also from Australia Studies use boys and girls Fight back against media images they’re being shown Body project- originally eating disorders but also gets at body image Over 40 RCT (the majority of studies with college-aged women) Cognitive dissonance- if beliefs and actions in opposition, people usually change beliefs Becker and Stice 2017 in JCCP covers most of the development in one paper Intervention- works well in different groups because based on individual’s ideal appearance- costs to pursue? Times they felt pressured to pursue? * Behavioral challenge (exposure to wearing shorts outside if you usually don’t), mirror homework (stand naked and write only positive things) Reduction of onset of eating disorders Research only so good need it to work in the real world Public health impact= effect size x reach Body project implementation success- being implemented by clinicians and lay providers (even college undergraduates can run the program) Inexpensive- all stuff available for free online Train people to train trainers so self-sufficient Free being me- girl scouts and Dove- body project in different garb 2018- 19 languages, 139 countries Still need good empirical data Limitations- Insufficient research for younger children Almost nothing for boys Nothing for gender non-conforming children and adolescents

Workshops

Promoting Body Acceptance in a World that Fosters Body Hatred: Lessons from the Body Project

Presenter: Carolyn Black Becker, Ph.D., Professor, Department of Psychology, Trinity University

Learning Outcomes:

1. Explain how cognitive dissonance can be used to reduce body dissatisfaction
2. Implement several core components of the Body Project
3. Describe other strategies used to reduce body dissatisfaction

Obsessive Compulsive Disorder in Children and Adolescents

Presenter: Tara S. Peris, Ph.D., Associate Professor of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/fnkhp/?action=download%26mode=render

Learning Objectives:

Gain familiarity with the phenomenology of child and adolescent OCD

It is not a requirement for kids to have insight in contrast to adult OCD diagnosis criteria. DSM 5 gave OCD and Related Disorders its own section because underlying biological factors for Anxiety and OCD are different and treatment with SSRI outcome is a different response. Body-Focused Repetitive Behavior (BFRB) like hair pulling disorder and skin picking disorder is much more common than expected. We used to think OCD was rare in kids but we now know it is just as frequent in kids than adults. One difference is that in children OCD comes first and depression follows when comorbidity takes place. Cognitive Behavioral Therapy (CBT) is the front line intervention for mild to moderate OCD cases. Assessment Dream List: Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS) assesses symptom severity using semi‐structured interview and 10-item checklist that assesses for the presence of OCD symptoms over the last week, distress, and control. CYBOCS scores in the 14-15 range to mid 20s scores is a mild-moderate OCD score, but more acute and extreme scores are in 20-30s. CYBOCS can show tangible signs of improvement, not just 3-4 scores lowered.. COIS-R: Assesses functional impairment related to OCD. COIS-R assesses the specific impact of OCD symptoms on youth functioning. Parents and teachers see interference of daily living and assess. Family Accommodation Scale for Obsessive-Compulsive Disorder (FAS) is a semi-structured interview but can be done as a self report that assesses family accommodation of symptoms and what the outset looks like in the family. The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) is a semistructured clinical interview designed to assess comorbidity conditions like anxiety, mood, and externalizing symptoms for ages 6 to 16 years old. The clinician-administered interview has a child and parent version and allows for differential diagnosis of anxiety and anxiety-related disorders. Behavior Assessment: Other ways to collect information on the severity or specific problems of the child's OCD is through additional parameters. Conduct small experiments to assess the scope of functioning and impairment. Ask them what would happen if they touched a "contaminated object", not washing, refraining from compulsions etc. Show them what would happen if they do not receive reassurance when anxious. Participate in the experiments of exposure like eating M&M's off of a toilet seat, sitting in a trashcan for a certain amount of time. Comorbidity in Childhood OCD: Please reference page 4 of Dr. Peris' Workshop Handout to see the UCLA Child OCD Program breakdown of children with comorbidity with OCD. CBT is less effective with comorbidity cases except for those with OCD and ADHD.

Identify two evidence-based treatments for pediatric OCD

Historical Perspective: Mary Cover Jones was the first person to experiment with exposure to reverse irrational fears. In 1924 she began her work after being inspired by Dr. John B. Watson's "Little Albert Experiment" and began her experiments of reversing "Little Peter's" fear of rabbits and anything that reminded him of white rabbits. Her work also provided support for the behavior paradigm and served as the foundation for systematic desensitization and modeling. Cognitive Behavioral Approach to OCD & How We Think OCD Works Research is focused on how children with OCD have automatic thoughts filled with cognitive distortions about danger and risk appraisal that cause threat bias and worries. These thoughts may lead to physiological reactions such as somatic (physical) symptoms/feelings of discomfort. Causing Behavioral rituals as an act of avoidance or reassurance. As the clinician you want kids to know that they can simplify their OCD into 3 channels of anxiety that can get them stuck, Cognitive, Physiological (Feelings) and Behavioral Rituals. Through the Cognitive Behavioral Approach, the child can tailor them to make them feel better since approach gives the child creative ability. CBT for OCD It’s only a false alarm manual Think about your thinking and how true it is All CBT needs homework assignment, exposures, things to practice at home, CBT needs to be skill focused for kids to practice at home so they can manage symptoms at home. Myths about CBT Symptom substitution is a myth, if you work on one symptom the others will not get worse. CBT is a stepwise approach and will get to all symptoms in time. Myths all have morsels of truth if CBT is not done well. Myth: doesn’t allow room for relationships like friendship and family relations. Patient Expectations Matter for Outcome If the outlook of the patients' views on CBT are positive treatment expectations like it will work then there will be more homework compliance early. This is the key to adherence. Psychoeducation Ethological conceptualization and Universal and adaptive response Anxiety is a "False Alarm". The first step is to explain OCD and how it works and how CBT works. Our emotions are there for a reason and it is important to tune into but some get too anxious when it is not needed so it is a "False Alarm". Identify false alarms and do not react unless you need to. Explaining Anxiety as a "False Alarm" with Fire Alarm Analogy: The fire alarm is scary sounding to get your attention and make you leave the school building in case there’s a fire. But sometimes the alarm goes off when there’s no fire (a false alarm). It still sounds scary, even though there’s no real danger. Anxiety is like a false fire alarm. It makes you scared even when there’s no real danger. In treatment, you will learn how to ignore your anxiety false alarm so it doesn’t bother you anymore. When is anxiety a "Disorder"? Point out how it can get in the way of functionality in their life. Go over the 3 channels of anxiety Then present an overview of treatment to correct the "False Alarm" reactions. Ethological Perspective ANXIETY HAS BEEN CONSERVED AS AN EVOLUTIONARY TRAIT ACROSS SPECIES BECAUSE IT SERVES A PROTECTIVE FUNCTION Anxiety serves as an adaptive advantage Example: Two cavemen see a sleeping cyber tooth. Their anxiety tells them to do not disturb the animal and run. Conserve usefulness of anxiety. OCD Psychoeducation The Goal: Reduce stigma, blame, and anxiety. Point out that they aren’t alone that others struggle with it by sharing the prevalence of OCD (0.5-2%). Talk about the Neurobiological Framework: The brain is malleable. OCD is just like other medical conditions like Asthma. Use this analogy to normalize it and take away blame. Lastly go other the Ethological Perspective: Anxiety as a "False Alarm". Anxiety/OCD Compulsive Cycle Thought pops in your head and makes you stressed so you try to relieve it with rituals which relieve's the feelings but it doesn't get rid of thought but strengthens and reconditions the ritual as a reaction to the feeling of disgust over thought or actions. This gets you stuck going in a circle so how do you stop it? Disrupt process by resisting the urge of compulsions because you can’t control thought process. CBT for Childhood Anxiety Coping Cat shows CBT: How you think about things really shapes the way you think or feel about things. A cat looking at a sleeping dog as a cute puppy versus viewing it as a mean snarling bulldog. CBT for OCD CBT for OCD is different than CBT for Anxiety Anxiety: If we change thoughts and feelings first, then the behavior is easier to change. In children, typically start with most concrete aspects of anxiety which are emotions and somatic symptoms then move to cognitions. OCD: Change behavior first, then thoughts will follow. Cognitive Biases in OCD We all experience intrusive thoughts. Similar content to obsessions from patient samples. Reactions to thoughts are more important than content. Thought-Action Fusion: Thinking is the same as doing it. People have the same thought content as normal population but people with OCD can’t filter out these thoughts and get stuck. It is extremely distressing, the sense of "but what if?!". If the thought is that scary and outcome is so distressing then this makes some people perform compulsions. 3rd session: exposure, test out obsessions and start lower on the hierarchy, Most important part of exposure is how you talk and learn from it and probe after exposure, how do you make sense of that, we should know how OCD works and a base of experience they need to make sense of. Track symptoms, anxiety during exposure. Exposure is all about distress tolerance, to build resilience and tolerance. You don’t have to habituate the child, disregard 50% rule, violate assumptions instead and make new memories, build up resilience like strength training, see if feelings pass, mindfulness is used to tolerate unhealthy thoughts OCD symptom hierarchy should get creative with it, get each of symptoms on indexes and arrange them in order of doing We will never make you do something you don't want to do so collaborate, the anxiety won't be too much to bear but tell them it needs to be a little to bear so the challenge needs to be the right amount of weight so it isn't too easy nor too hard. All about scaffolding. Setting up the exposure: walk your talk, don't make them do anything you won't due, come at things creatively, manageable small steps to keep it real, experiment on what they can do, room for stepwise building, track them but don’t be distracting, probe how they think or feel about this process, be Socratic, it only works if they believe it themselves, what do you make of this, is there something else that OCD is telling you right now? Was it accurate? Graph anxiety during exposure so it can give them encouragement and feeling of control Writing crooked: write with left hand if perfectionist Make it a game so it is less stigmatizing and more like who cares because it is all just an experiment Mindfulness interventions: adjunct or mono, it doesn't have a ton of support on its own. Not the same as relaxation training, observing present moment without judgment and with awareness, do it in a few minutes, MARC at UCLA, audio files you can access for free. Homework: what type of OCD thoughts, how are you going to cope, do you need a reminder, ask if they are going to do it alone or with someone, how long, if you are worried he isn't doing homework then tell me don't police it. Reward program: even for most enthusiastic kids will wane. 3 points: point for coming, point for trying your best, point for doing homework, talk about what points are worth, it is all about efforts not the outcome, the goal is to try.

Learn strategies for effectively engaging families in OCD treatment

Families should be involved: Not everyone responds to treatment so sicker skills, the number of diagnoses, motivation, FAMILY FACTORS Start with family first: no evidence that it adds to treatment outcome but it still is important. 80-85% of kids report being overwhelmed with their OCD Open anger in the family and anxious kids have anxious parents, POTS trial: Family accommodation: pulling parents into symptoms so make parents do homework, if unchecked it can maintain or keep OCD cycle going Cohesion: warmth and support not enmeshed PFIT 6 session fam therapy module, designed to be used as an adjunct to individual child CBT. Going after the family factor to promote cohesion. Go beyond psychoeducation Be willing to watch your kid get anxious, don’t teach your kid bad stuff, be a better powerful model, tolerate distress, Build positivity and gratitude and list strengths to build it up to keep cool and solve problems more effectively Does PFIT Improve Outcomes? Next steps: independent replication, longer follow up window, smart trial/stepped care methodology to develop evidence-based strategies for tailoring treatment, making adjustments, Novel pharmacological approaches Accurate diagnosis of OCD in Youth: stigma, lack of awareness of the range of behaviors, fewer people know that thoughts of worrying about being immoral, sexual, do they under-report due to embarrassment or because they don’t see the problem. Sexual obsessions Identify two evidence-based treatments for pediatric OCD

One Session Treatment of Specific Phobias: Prevention and Intervention

Presenter: Thomas H. Ollendick, Ph.D., University Distinguished Professor, Department of Psychology, Virginia Tech

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/g4qf5/?action=download%26mode=render

Learning Outcomes:

Acquire knowledge about recent developments in the etiology and diagnosis of specific phobias in youth

Applies to many anxiety disorders including OCD, PTSD, and acute stress disorder even though those aren’t “anxiety disorders” in DSM V, which Dr. Ollendick is opposed to Don’t do this (exposure) with suicidal individuals because harder to control anxiety Specific phobia- 12.5% of kids have phobia within last year Characteristics of specific phobia in adults Mean age of onset 9.7 years and mean duration 20.1 years Highly comorbidity with other anxiety/mood disorders Higher risk in females and lower income Only 8% of adults with phobias receive treatment “Gateway disorder”- signal that your psychological self is having trouble adjusting to your environment So, treatment at early age helps prevention broadly Diagnostic criteria for specific phobia (DSM) Dr. Ollendick says we need to throw out the DSM and its diagnoses because the behaviors are what’s important Excessive fear that provokes immediate anxiety, sometimes a panic attack. Endure object with much anxiety. DSM 4 said at least 6 months but 5 threw that out Types- animal (most common), blood injection injury, natural environment, situational (airplanes, elevators), other(vomiting, loud sounds, costumes or characters) But, even though there’s commonality there are many differences Etiology and maintenance- Lots of pathways- hyper-vigilance, traumatic event Want to understand best you can how the phobia developed- experience, parent afraid Behavioral inhibition- shy temperament - 30% go on to develop specific phobia Even just eye contact can produce oxytocin to strengthen bond- a dog interprets gaze avoidal as threatening This treatment isn’t effective if kids have comorbidity ADHD with their anxiety problems Might be direct like a little girl attacked by a dog Possible effects of overprotection- the little engine who couldn’t because his parents did everything for him

Obtain knowledge and experience with administering and scoring evidence-based measures of specific phobias in youth

Many online free methods of assessment ADIS common interview anxiety disorder interview schedule Strengths and Difficulties Questionnaire (SDQ) good and free and short, CBCL good, school anxiety scale (Lyneham), fear survey schedule, STAXI State-trait anxiety inventory, spence children’s anxiety scale, CASI Behavioral observations also helpful for anxiety- many physical symptoms Behavioral approach test (BAT) might be asked to climb a ladder etc. whatever their fear is and then record their behaviors and physiological responses like heart rate Parent will accommodate like if a child has an elevator phobia the parent will walk up all the stairs and this makes the phobia problem worse Daily monitoring forms for behaviors associated with phobias

Become aware of evidence-based treatments for specific phobias including the One Session Treatment and observe demonstration of this treatment in action

Many procedures for treatment- focus on integrated brief intervention- one session treatment Primarily in-vivo exposure and modeling with a max of 3 hours, done by masters level clinicians Brief cognitive behavioral analysis- focus on child’s catastrophic beliefs because that belief maintains the avoidance behavior (avoidance in negative reinforcement) What will happen if you can’t get away from the snake? It will crawl up my leg, under my clothes, and bite me. Then what? I’d die. 100% likely I’d die. How convinced are you now that you’re with me thinking about it rationally? 30% Pre-treatment instructions- Tell them that it’s teamwork Therapist will never do anything in the therapy room without the child’s permission High level of anxiety is not a goal, the goal is to get better Exposure in vivo- child remains until anxiety fades at least 50% Example- social anxiety might be taking a test or giving a speech to a camera Starts with therapist pretending he can’t see object so patient describes it Education component- teach them how to interact with the object like a dog No relaxation or meditation or breathing training because those are safety behaviors because we want them to feel anxiety Transfer activity from therapist to patient If unsuccessful, move to the next stage eventually to medication Question- phobias might generalize, for instance from dogs to subways. In this case, treat the original phobia first

Social Communication Intervention for Children with ASD

Presenter: Connie L. Kasari, Ph.D., Professor, Human Development and Psychiatry, University of California, Los Angeles

Powerpoint: https://mfr.osf.io/render?url=https://osf.io/6ay57/?action=download%26mode=render

Learning Outcomes:

1. Differentiate between preverbal and minimally verbal children with ASD
2. Identify at least two research tested methods for improving spoken language for children with ASD
3. Identify two ways to individualize their clinical practice in order to better meet their client needs

Resilient Sexualities: Sexual Health and Well-Being Despite Childhood Trauma and Adversity

Presenter: Nicole M. Fava, Ph.D., Assistant Professor, School of Social Work, Florida International University

Learning Outcomes:

1. Understand increased risk for negative sex-related outcomes among youth experiencing trauma and adversity
2. Evaluate biases
3. Describe impact of gender and sex messages for youth
4. Articulate positive and accepting messages to give youth
5. Engage in trauma-informed discussions
6. Utilize developmentally appropriate conversations

Other 2018 Resources

• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2018/Day 2
• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2018/Day 3