Addressing Anxiety in the Schools: A Multi-Tier Service Delivery Model

1. Addressing Anxiety in the Schools: A Multi-Tier Service Delivery Model Lychelle Leatham Gretchen Peacock Donna Gilbertson Emilie Larsen

2. GOALS Background Multi-Tiered System Assessment Multi-Tiered System Supports and Case Examples Applications in ethnically diverse populations

3. Who is anxious? • Teacher hands out an assignment: • Student 1: works quietly until complete • Student 2: looks it over, completes a few, then raises hand for help • Student 3: looks but is quickly distracted, watches others, fidgets • Student 4: immediately asks for help • Student 5: starts a few, quits • Student 6: quits and when prompted get frustrated saying “It’s too hard for me” • Student 7: even with help begins to get upset and may cry

4. Facts about Anxiety Disorders • Among the most common psychiatric disorders that affect youth • Prevalence 10% - 37% - often unidentified and misdiagnosed • Mean age of onset: 7-15 years old • Comorbidity common • Additional anxiety disorder: 30-80% • Mood disorder: 12-60% • With other disorders (ADHD, autism, LD ): 25% -60%

5. AWARENESS3 Symptoms

6. When is anxiety a problem? • Excessive • Persistent • Developmentally inappropriate • Poor problem solving • Leading towards depression • Avoids and weakens relationships • Clingy • Non-assertive • Victim • Emotional can’t do • Avoids work • Avoids school • Makes mistakes • Results in too much accommodation by others

7. Underserved Source: Bradshaw, Buckley, & Ialongo, 2008

8. Earlier support Age of First Symptoms and Initial Diagnosis Source: O’Connell, Boat, & Warner, 2009

9. Multi Tiered Model Assessment Support

10. Gated Assessment Gate 1: Teacher nomination Universal Behavioral Screener Fall (after 2 months) and mid year Universal Screening Team Review Parent consent / participant assent for additional assessment Gate 2: Teacher, Parent, Student Questionnaires / record review Tier Process Team Review Gate 3: Observations, Interviews for severe needs Team Review Parent notification of results and consent for selected supports Progress monitoring when placed in Tier

11. Screening Measure Characteristics • Sensitivity • Ability to identify those who have problems • = True positives / true positives + false negatives • Specificity • Ability to identify those who don’t have problems • = True negatives / true negatives + false positives • Practical • Linked to effective interventions

12. Tier I Assessment • Universally administered behavioral screeners • Behavioral and Emotional Screening System (BESS) • Preschool through grade 12 • Forms for parents, teachers, students (grades 3-12) • 25 to 30 items covering broad emotional / behavioral problems • Get t-scores / percentiles • Social Skills Improvement System (SSIS) • AIMSweb Behavior Assessment and Data Management • Includes items from BESS and SSIS • Universal Measures focus on a variety of social / emotional behaviors

13. Tier I AssessmentTeacher Nominations • Worries more than others • Just can’t seem to relax, difficulty concentrating, tired, or clingy

14. Other ideas for Tier I Assessment Parent nomination ODRs Attendance problems CBMs (anxiety may impact academic performance)

15. What About Informed Consent? Protection of Pupil Rights Amendment (PPRA) Must obtain parental consent before requiring participation in survey, analysis, evaluation that reveals certain information: (1) political affiliations; (2) mental and psychological problems potentially embarrassing to the student or his family; (3) sex behavior and attitudes; (4) illegal, anti-social, self-incriminating and demeaning behavior; (5) critical appraisals of other individuals with whom respondents have close family relationships; (6) legally recognized privileged or analogous relationships, such as those of lawyers, physicians, and ministers; or (7) income (other than that required by law to determine eligibility for participation in a program or for receiving financial assistance under such program),

16. Tier 2 or 3 Measures (examples) • Broadband scales • Child Behavior Checklist / Teacher’s Report Form • Behavioral Assessment System for Children • Specific Anxiety Measures • Multidimensional Anxiety Scale for Children • State-Trait Anxiety Scales • Revised Children’s Manifest Anxiety Scale • Functional Assessment

17. Assessment Resources • List of free mental health assessment measures (updated 12/2012): • http://csmh.umaryland.edu/Resources/ClinicianTools/Summmary%20of%20Free%20Assessment%20Measures%2012.12.12.pdf • List of screening measures for social / emotional problems • www.pbisnetwork.org/wp-content/uploads/2010/09/Screening-Tools-Table.doc

18. Considerations in Assessment • Protect student and family privacy • Educate teachers about confidentiality and labeling • Procedures for records (what happens to screening information?) • Provide clear and student and family friendly information about the benefits of screening and intervention and consent forms • Screening must lead to intervention for those identified as high risk • Qualified and trained staff interpret and intervene

19. Multi Tiered Model Assessment Support Functional assessments More in-depth and focused measures for identification Progress Monitoring Teachernomination Parent nomination Universal screening measures CBM, Attendance, ODRs

20. Child functional needs Can do Self regulation or perception Can’t do • Not learned at all • Expressing emotions • Conflict resolution • Social skills • Problem solving • Coping skills • Stress self care • Few opportunities to use • Others do not respond due to history Avoiding thoughts, discomfort, failure Anger, frustrated, cry Misinterprets cues Distorted thinking

21. Team functional needs Positive Outcomes Intervention Targets • Academics • Independent work • Emotional regulation • Positive peer interactions • Attendance / participation Anxiety/ worry Avoidance behaviors Social skills Academic support Coping skills Emotional regulation

22. Empirical Support Universal Social Emotional Learning • 11-percentile point gains in academics • improved school climate, interpersonal relationships • reduced externalizing and internalizing problems Group or Individual • 60% - 65% students responded to CBT treatment • < 30% receive treatment • Catalono et al, 2002; Durlak et al. 2011; Greenberg et al., 2003; Kendall et al., 2012; Neil and Christensen 2009

23. What Is Cognitive Behavior Therapy? Change thinking and behaving by: • Recognizing anxious physical reactions, feelings, and thoughts with anxiety related stimuli • Understanding how thoughts contribute to anxiety • Modifying distorted thoughts to decrease symptoms • Using a coping plan for dealing with anxiety with positive self statements and problem solving • Using skills to change anxious avoidance behaviors

24. Symptoms and Skills Psycho-education

25. Working things out • Class schedule • Service providers • Consult to Support Skill Use • Prompt • Assistance with peer interactions • Rewards for efforts and successes • Accurate self monitoring/ regulation • Plan for transitions, new routines, safe place when stressed • Mentor system or Check-in and out • Confidentiality

26. Team planning Enter criteria Moderate / High Risk on screening CBM at risk Poor Attendance Grades < 3.0 Discipline record % disruption/ work completion Intensity School psychologist • 10 sessions / 30 min • CICO Teacher • Academic support plan Recess Supervisor  • Social support plan Exit Criteria • 80% on task • 80% correct work for 2 weeks • Improved grades • Low at-risk on screening Supports CBT Skill Practice Check in & out Academic plan Social plan Self-monitoring

27. Case Example Assessment Step 1: Teacher FBA interview (there is a student FBA too) Step 2: Observation of Recess context Step 3: Descriptive FBA observation Step 4: CBM assessment Treatment Step 5: Treatment group program Step 6: Class Intervention Training steps Step 7: Monitor and follow-up support Step 8: Generalization or fading planning as needed

28. Reason for referral Child is exhibiting anxious behaviors that are competing with their ability to effectively complete school work Background • Current grade level: 3rd • Ethnicity: Chinese • ELL services: Yes • Special Education Classification: LD –language arts services

29. Interviews Teacher For problem behavior: Teacher Reported low skills: positive statements about self, problem solving skills, emotional regulation, coping skills Student reported anxious times:

30. CBM Conclusion: The student is performing below expected level in math and writing due to a combined can’t do/won’t do deficit

31. Results of CLASS observation

32. Results of RECESS observation Conclusions: Student is engaging in positive interactions with several peers or is engaging in parallel play.

33. CBT Program FRIENDS program modified Stop when feel anxious Keep CALM Ican try my best thinking Look for a plan and support to solve the problem Let’s just try the plan! Self reward my victory

34. Hypothesis & Target Behaviors: The type of problem is a won’t/ can’t do individual academic problem. When frustration, negative talk, giving up occurs, teacher gives helpright after the behavior, so that the student seems to get to escape from completing work by himself.

35. Chart for Academic Support Plan Not at all 0% Not at all 0% Not at all 0% Not at all 0% Some 50% Some 50% Some 50% Some 50% Totally 100% Totally 100% Totally 100% Totally 100%

36. Academic Support Treatment Scripted Instructions This procedure is designed to support a student to use coping strategies with difficult work to increase independent efforts, task persistence with help, and feeling proud for efforts. Materials Needed: behavior recording chart

37. Student and Integrity Data Before Treatment Treatment

38. Multi Tiered Model Assessment Support Functional assessments FBA Behavior Intervention Planning Community support More in-depth and focused measures for identification Progress Monitoring Skills/CBT Groups Academic class support plan Social support plan Check in and out Self-monitoring Social/Academic Instructional Groups Teacher nomination Parent nomination Universal screening measures CBM, Attendance, ODRs Violence Prevention Social Emotional Learning PBS: Positive reinforcement with effective classroom management

39. Multicultural Adaptations Instructional Language Modifications to Support Understanding of the Material

40. Multicultural Adaptations

41. Multicultural Adaptations

42. MC Adaptations

43. What are you already doing?