SCHOOL-BASED PREVENTATIVE & EARLY INTERVENTION STRATEGIES FOR CHILDHOOD ANXIETY

1. SCHOOL-BASED PREVENTATIVE & EARLY INTERVENTION STRATEGIES FOR CHILDHOOD ANXIETY Presenters: Narelle Anger, Principal Speech Pathologist Shylaja Gooley Senior Psychologist Child and Youth Mental Health Service

2. PART ONE: MENTAL HEALTH (mh) PROMOTION, PREVENTION & EARLY INTERVENTION IN SCHOOLS

3. SCHOOL INVOLVEMENT & MENTAL HEALTH INTERVENTION • Education – Key Strategic Sector in mh • School entry - major life transition associated with pivotal developmental learning tasks • Coincides with emergence of emotional and behavioural problems of childhood • School onset as precipitant • School setting - place of early identification • Majority of children receive mh treatment from school-based and not specialist services

4. Mental health and well being Academic and learning goals

5. SPECTRUM OF INTERVENTIONS FOR MENTAL HEALTH PROBLEMS • Placing treatment of MH problems and MH disorder in the context of school-based mental health:- • PROMOTION • PREVENTION • EARLY INTERVENTION

6. FIG. 1:- SPECTRUM OF MH INTERVENTION

7. WHAT IS MENTAL HEALTH? • Mental Health DISORDER • Diagnosable illness • Different types and degrees of severity • Marked interference with functioning • Mental Health PROBLEM • Spectrum of cognitive, emotional and behavioural problems • Less severe and shorter duration • Mild-moderate interference in functioning

8. MENTAL HEALTH • Not simply the absence of mental illness – as described by WHO (1999), mental health refers to a person’s: • State of well-being • Realising their abilities and aspirations • Productivity and aspirations • Capacity to cope with normal stressors

9. WHAT IS REQUIRED TO ACHIEVE MENTAL HEALTH? • A coordinated interplay of individual and systemic efforts to facilitate RESILIENCE by: • Reducing risk factors • Enhancing protective factors • Effective responses must be based on research of known risk and protective factors at the individual and systemic level

10. DEFINITION – RISK AND PROTECTIVE FACTORS • A risk factor increases the likelihood that a particular individual/group will develop a problem • A protective factor reduces the likelihood of problems developing by:- • Reduces exposure to risk • Reduces effect of risk  confers resilience in face of adversity

11. Risk Factors

12. Protective Factors

13. MENTAL HEALTH PROMOTION, PREVENTION AND EARLY INTERVENTION • MH PROMOTION • Actions to maximise mh & well being • Interventions enhancing a sense of belonging & connectedness within school • MH PREVENTION • Actions that reduce the influence of risk and build resilience – before onset of a MH disorder • 3 pathways:-

14. Universal prevention:- Targets the whole group who have not been identified on the basis of risk • Selective prevention:- Targeted to individuals/small groups who have been identified as “at-risk” though not displaying symptoms • Indicated prevention:- Targeted at individuals who are showing early signs of problems

15. HEALTH PROMOTING SCHOOL’S FRAMEWORK – WHO (1994)

16. THE ROLE OF SCHOOLS IN MH PROMOTION AND PREVENTION OF CHILDHOOD ANXIETY DISORDERS • Promoting resilience in normally occurring anxiety • Recognising vulnerability and offering preventative approaches • Moving from prevention to early intervention and specialist treatment • Collaboration – school-family-other services

17. PART TWO: A LITTLE MORE ON ANXIETY

19. DECIDING WHAT’S NORMAL ? • Adaptive & in fact necessary for normal development • Provides opportunity to: • acquire skills to cope with aversive situations • discriminate safety and danger • Learn when it’s appropriate to be afraid & avoid

20. DECIDING WHAT’S NORMAL ? • Degree of distress and impairment in functioning • Limited response to intervention • ALSO:- • Type of behaviour • Frequency • Duration • Severity • Interference with functioning

21. Prevalence • Child self-report in general population 17-21% • Clinically significant anxiety problems 8% require treatment

22. National Mental Health Report (2005) Externalising & Internalising Disorders

23. DEVELOPMENTAL STAGES & ANXIETY • Content of fears vary across time/ developmental stages and gender (girls more than boys) • Generally: moving from fears about the concrete/external to abstract/internal

24. COMMONLY ENDORSED ANXIETY SYMPTOMS • Fear of harm to attachment figure • Fear of calamitous event to self • Fear of crowds • Fear of heights • Fear of dark • Fear of public speaking • Fear of blushing 17/90 symptoms endorsed • Fear of dressing in front of others by at least 10% of a • Fear of insects nonclinic sample • Excessive worry • Excessive worry about past behaviour • Overconcern about competence • Excessive need for reassurance • Somatic complaints • Self conscious • Shrinks from contact from others • Social withdrawal

25. PART THREE: PSYCHOLGOCIAL MANAGEMENT OF ANXIETY

26. CHILDHOOD ANXIETY –RESPONSE TO FEARS • COMPONENTS:- • COGNITIVE – worries, over-concern, self-consciousness • BEHAVIOURAL – staying away, need for reassurance • AFFECTIVE – dysphoric feeling, afraid, irritable • PHYSIOLOGICAL – restlessness, fatigue, lack of concentration

27. COPING RESPONSE • Overestimation of threat and consequences of exposure to perceived and underestimation of coping resources • Underestimation of coping resources • Avoidance - Withdrawal

28. PART FOUR: COMMUNICATION AND ANXIETY

29. Anxiety Disorders in Children with Communication Disorders: Correlates & Outcome” Cantwell and Baker 1987 600 children (Under 16 yrs) in community Speech Language Services • 25% had speech only disorders, • 66% had speech and language, • 9% language only. • 52% presented with comprehension only problems, • 72% with expression and • 35% with processing problems.

30. Anxiety Disorders in Children with Communication Disorders: Correlates and Outcome”Cantwell and Baker 1987 • Well group – 331 children • Behaviour Disordered group – 211 children • Anxiety and emotional disorder group – 83 children • Emotional/anxiety disordered group 60 met DSM11 diagnostic criteria for anxiety disorder • 29 avoidant disorder • 19 separation anxiety • 12 overanxious disorder • 1 simple phobia • 23 adjustment disorders

31. “Withdrawn and Sociable Behaviour of Children with Language Impairment” Fujiki et al 1999 Classroom teachers rated withdrawn & sociable behaviours • 41 LI children aged 5-8: 10-13 years & 41 TDP • LI group - significantly ↑ levels of reticent behaviour than TDP group; • LI boys - significantly ↑ levels of solitary active withdrawal than girls with LI or TDP; • LI group - significantly below TDP on measures of impulse control, likeability and pro-social behaviour

32. An Investigation of the Language Skills of Students with Emotional Disturbance Served in Public Schools: Nelson et al 2005 • 166 students (136 boys + 30 girls; K-12) • Special Education services for Emotional Disturbance; • Relatively high performing school district • 68% met CELF111 criteria for a language deficit • Language deficits were stable over time • Students with internalising disorders were less likely to experience form and content related language deficits than externalising students

33. Evaluation of Emotional & Behavioural problems in language impaired children using the Child Behaviour Checklist; Noterdaeme et al 1999 83 LI children, mean age 8.2 years – referred for diagnosis to a unit for developmental & behavioural disorders. 41% - Expressive LI; 59% - Receptive LI • 66 of the children had a psychiatric diagnosis; • Attention problems – 39 • Withdrawn – 32

34. Behaviour in Children with Language Development Disorders: Willinger et al 2003 • 94 LI children aged b/w 4 – 6 years and 94 TDP • CBCL • 34% LI -in the clinical range compared to 6% TDP • Conclusions • Increasing emotional behavioural difficulties with age for LI children • Neuro developmental immaturity may be the one factor underlying both LI and behavioural problems.

35. Language & Social Cognition in Children with Specific Language Impairment; Marion Farmer 2000 4 Groups aged 10 to 11 years • Group 1 – SLI children being educated in special schools for children with SLI • Group 2 – SLI children educated in 2 language units attached to 2 mainstream schools • Group 3 – chronologically matched TDP • Group 4 - Language age matched TD children

36. Language & Social Cognition in Children with Specific Language Impairment; Marion Farmer 2000 • Pro-social behaviours – no significant differences found b/w groups • Behavioural Difficulties – For SLI groups - neither language dev nor chronological age was linked to behaviour • Significant negative correlations b/w behaviour and scores on socio-cognitive tasks

37. Social Anxiety in late Adolescence: The importance of early childhood language impairment. Voci et al Anxiety Disorders 20 (2006) 915-930 • Prospective longitudinal community study • 142 children • Compared TD controls to individuals with a history of early language impairment at 5 years • Language disordered group at age 19 years showed 2.7 times more social phobia than normal controls

38. Social Cognition and Language in Children with Specific Language Impairment SLIMarton et al 2005 Social Cognition • Emotion Perception • Social Problem Solving • Self Cognition Developmental & Neuro pathological data supported a strong relationship between language development and social cognition.

39. Social Cognition and Language in Children with Specific Language Impairment SLIMarton et al 2005 Children with SLI experience difficulty in: • Initiating and maintaining peer relationships • Self esteem • Difficulties initiating social interactions • Negotiating with others • Resolving conflicts

40. Social Cognition and Language in Children with Specific Language Impairment SLIMarton et al 2005 • SLI (19) + normal controls (19) – 7 to 10 yrs • All SLI group received Speech Pathology services and were 1.5 SD below age average on the CELF-R • Normal Performance IQ • English as their primary language

41. Hypothetical scenarios Test of self esteem Test of self esteem Parent and teacher questionnaires Social relations Linguistic skills Conversational skills Nonverbal communication Adaptive behaviour Social Cognition and Language in Children with Specific Language Impairment SLIMarton et al 2005

42. Social Cognition and Language in Children with Specific Language Impairment SLIMarton et al 2005 • Hypothetical scenarios • SLI group performed significantly lower in areas of: • Syntactic measures • Social pragmatics skills. • Exhibited significantly lower social pragmatic skills than linguistic skills

43. Social Cognition and Language in Children with Specific Language Impairment SLIMarton et al 2005 SLI - use more non verbal coping strategies than TDC possibly reflecting poor conflict resolution. • Evidence of physical aggression • Passive/withdrawn reactions Production of inappropriate questions and comments – poor understanding of others perspective, poor social analysis. Use of simple verbal clichés.

44. Social Anxiety in late Adolescence: The importance of early childhood language impairment.Voci et al Anxiety Disorders 20 (2006) 915-930 • Lifetime prevalence of social phobia among language impaired group was 22.7% as compared to 11.3% in normal controls. • Severity of language impairment is not related to prevalence of social phobias • No significant gender differences. • Mean age of onset was 11.6 years

45. School Refusal and Communication Impairment Naylor et al. 1994 27 adolescents with persistent school refusal - significantly higher incidence of language and learning disorders compared to controls.

46. Primary Diagnosis by Language ScoresAngela Clarke: Barrett (50 cases)

47. Comparison of young children with S&L Delays/Dis V TDP - child focus CBCLQ. Health Hanen ITTT study 2004

48. Anxiety Disorders andCommunication Impairment No specific language studies for • Obsessive Compulsive Disorder, • Tourettes or • Separation anxiety

49. Social Cognition in children with SLI Conflicting research findings 1. SLI children do not have impairment of social cognitions 2. SLI children do have impairment of social cognition

50. Why the association b/w Language Disorders and Behavioural Problems? • Disorders in language development may lead to behavioural problems • Serious emotional problems flow from the child’s inability to express himself or comprehend others appropriately • Puts the child at risk emotionally and educationally • Interacts and compounds with behavioural problems over time