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Page 1: Fit for LA Mental Health Protocols · The UCLA Fit for Los Angeles Program is funded by the UniHealth Foundation Teasing Protocol (8-18 yo) ... -oppositional -child abuse/neglect

Fit for LAMental Health

Protocols

Contents:1. Teasing Protocol- (8-18 yo)2. Bullying Protocol- (5-18 yo)3. Anxiety Protocol- Children (8-12 yo)4. Anxiety Protocol- Teens (13-18 yo)5. Depression Protocol- Children (8-12 yo)6. Depression Protocol- Teens (13-18 yo)

Developed by the UCLA Fit for LA Program:Tiffany McClure, BS

Danyale McCurdy-McKinnon, PhDAmanda Feinstein, PhD

Cambria Garell, MDAlma Guerrero, MD, MPH

Miranda Westfall, MPH, RDNancy Quintanilla, BS

Wendy Slusser, MD, MS

The UCLA Fit for Los Angeles Program is funded by the UniHealth Foundation

Page 2: Fit for LA Mental Health Protocols · The UCLA Fit for Los Angeles Program is funded by the UniHealth Foundation Teasing Protocol (8-18 yo) ... -oppositional -child abuse/neglect

Teasing Protocol(8-18 yo)

Assess

Normalize

• Validate difficulty of being teased, while normalizing the experience• “It is usually really hard to cope with being teased…”• “Unfortunately, we also know that teasing is pretty common amongst patients …”• “Most people experience teasing at some point during this period of their lives…”

Explain why people tease

• They want to get a reaction out of you• They are trying to “push your buttons”• They are putting on a show for others

Effective response to teasing

• The teaser / bully is….

Non-aggressive peer Physical bully An authority figure

Tease the tease• Act like comment

doesn’t bother you• Comebacks

• Whatever• Anyway• Big deal• So what• Yeah, and?

Do not tease the tease• Lay low• Stay with the crowd• Avoidance• Do not befriend the

bully

Do not tease the tease• Risk of appearing

disrespectful

• Discuss teasing with patient without specifics / exact nature of teasing hx due to sensitive nature of topic

• Reflect to feelings “It sounds like you feel…” • Simple restatements “It sounds like you’ve been experiencing...”

Role play as practice

Developed by the UCLA Fit for LA Program with funding from the UniHealth Foundation

Page 3: Fit for LA Mental Health Protocols · The UCLA Fit for Los Angeles Program is funded by the UniHealth Foundation Teasing Protocol (8-18 yo) ... -oppositional -child abuse/neglect

Bullying ProtocolDefinition: unwanted aggressive behaviors (verbal, physical, or social) that:

1. Involves real or perceived power imbalance & 2. Is repeated or has potential to be repeated

Bully Perpetrator Bully Victim Bully Bystander

Annual Screening (starting at age 5)

High Risk-Screen More Frequently -ADHD -family conflict/violence-oppositional -child abuse/neglectdefiant disorder -parental mental health

-conduct disorder -disruptive disorder

Signs/Symptoms-Screen Immediately -worsening school -criminal activity

performance -suicidal behaviors-drug use -disruptive behaviors

Annual Screening (starting at age 5)

High Risk-Screen More Frequently -overweight/obese -autism-children with special -food allergy

health care needs -LGBTSigns/Symptoms-Screen Immediately

-psychosomatic -refusal to go to school complaints -worsening school performance-bruises -sleep difficulty-torn clothes -alcohol/drug use-enuresis -cuts/scratches

Annual Anticipatory Guidance (starting at age 5)

-“Make everyone feel welcome and included.” -Tattling vs. Telling:

Tattling: when you tell an adult to get a student into trouble. Telling: when you tell an adult because another student’s actions were unsafe or hurt another person.

-“When you see bullying, never encourage the bully or join in the bullying.”

Clinician Steps -Teach child how to help (Ex: “Cool it! This

isn’t going to solve anything.”)-Tell child not to cheer on or even quietly

watch a conflict-Encourage child to tell a trusted adult aboutthe bully. It’s not “tattling”; it’s an act ofcourage and promotes safety

-Help child support children who tend to bevictims (ex: include the child in activities;play with child during lunch/recess)

Screening Suggestions -“How are things going at school?” -“Do you ever pick on other kids?” -Ask parents if his/her child has had disciplinary

issues at school-Ask parent if concerns about his/her child

getting into trouble at school-Ask parent if concerns about his/her childrepeatedly acting mean towards friends

Screening Suggestions -“How are things going -“Do you ever feel lonely at school?” at school or left out of -“Do you have friends?” activities?” -“Is anyone mean to you -“Who do you spend lunch or picking on you?” or recess with?” -“Do kids ever call you -“Do you ever feel afraid mean names, or tease you?” to go to school?”

Clinician Steps -Acknowledge parent’s feelings-Screen for family conflict/stressors-Screen child for high-risk health behaviors-Screen child for mental health conditions(ADHD, ODD, CD) and referral if necessary forchild and family therapy

-Referral for parental mental health should alsobe considered

Clinician Steps -Acknowledge child’s distress-Reinforce that bullying is not the child’s fault-Never tell the child to ignore the bully-Follow the “Teasing Protocol”-Teach child to speak calmly and walk away. Never fightback.-Remind child to stay with friends as much as possible-Use school as mediator, do not contact other child’sparents-Screen child for mental health conditions (depression,anxiety, suicidal ideation, alcohol /drug use), referral ifnecessary

Screening Suggestions

-“Have you seen other kids be mean to or tease a classmate?”

-“Do you know kids who are left out of games or activities?”

Developed by the UCLA Fit for LA Program with funding from the UniHealth Foundation

Page 4: Fit for LA Mental Health Protocols · The UCLA Fit for Los Angeles Program is funded by the UniHealth Foundation Teasing Protocol (8-18 yo) ... -oppositional -child abuse/neglect

Anxiety Protocol - Children(8-12 yo)

Normalize

Identify feelings and coping actions• Provide examples of feelings such as anxious, nervous, scared, etc and ask child to identify

actions as helpful or unhelpful• “When people feel anxious they tend to want to do something to make themselves

feel better. Sometimes those actions can be helpful at making us feel better, and other times they are not so helpful.”

• If child cannot think of coping actions, give examples – avoidance, eating, etc.

Connect thoughts, feelings, actions

Relaxation strategies

• Help child make connections between “what I think, what I feel and what I do”• Emphasize practicing being aware of feelings and actions is a successful coping strategy

• Normalize anxiety as a normal reaction, many children feel anxious or worried• “Sometimes we might have a certain feeling or emotion, but we don’t how to

explain or let other people know what’s going on inside our heads. Have you ever had that experience? It can happen to adults as well as children. “

• If child endorses…• Rapid breathing ---> Belly breathing• Muscle tension / agitated movements ---> Muscle relaxation

• Lead child in relaxation exercise and have her reflect after exercise• “How do you feel? What do you notice in your body? Your mind? Does your body

feel any different than before we did this exercise?

Can be conducted over 3 separate sessions

Cognitive restructuring

• Distinguish between helpful and unhelpful thoughts• “Unhelpful thoughts twist up reality and trick us into focusing on things that are

untrue or unhelpful. Let’s imagine we’re detectives and our thoughts are possible suspects, and let’s collect evidence to figure out which thoughts are the unhelpful ones we need to get rid of.”

• Review examples of negative chain of thinking• “I’m not good at soccer - I can’t keep up - Other kids are faster than me ->

Avoidance of soccer team and playing soccer with friends -> Increase worry about playing sports or exercise in general”

• Emphasize helpful thoughts with child and reinforce child’s ability to generate helpful, adaptive thoughts

Developed by the UCLA Fit for LA Program with funding from the UniHealth Foundation

Page 5: Fit for LA Mental Health Protocols · The UCLA Fit for Los Angeles Program is funded by the UniHealth Foundation Teasing Protocol (8-18 yo) ... -oppositional -child abuse/neglect

Anxiety Protocol - Teens(13-18 yo)

Normalize

Identify feelings and coping actions• Help teen identify feelings that occur when anxious and helpful versus unhelpful responses.

• “In order to start to address anxiety, we must become more familiar with when it is impacting us, and how we respond to it.”

• “I want to encourage you to start paying closer attention to HELPFUL and UNHELPFUL behaviors and actions. When you notice yourself taking an action step that is unhelpful, see if you can do something instead, that would be more helpful”

Relaxation training

• Normalize anxiety as a normal reaction, many teens feel anxious or worried• “There are a number of different ways that we can experience anxiety. Some of the

most common are in our bodies, in our thoughts, and in our behaviors/actions. Let’s talk about each of these”

• Provide psycho-education about common ways people experience anxiety (somatic, behaviors / actions and thoughts)

• Encourage teen to identify anything that helps anxiety or worries. Offer examples (talking to someone, going outside, facing the fear anyway)

• Practice additional techniques depending on endorsed somatic symptoms • Deep breathing• Mindfulness• Guided imagery

• “The reason we would like you to practice this is so that you have one more way to deal with nervous feelings. I’d like you to practice when you don’t necessarily feel nervous, just so you can build up your skill at this practice. Then, you will be able to use it whenever you want to help you feel more calm and peaceful.”

Can be conducted over 3 separate sessions

Cognitive restructuring• Distinguish between helpful and unhelpful thoughts

• “When we feel anxious or worried, it is more likely that we are having an unhelpful thought. These unhelpful thoughts can then have an impact on our feelings and behaviors. It is important to become aware of these thoughts and then figure out which thoughts are the unhelpful ones we need to get rid of or change”

• Review examples of negative chain of thinking• “I’m not good at soccer - I can’t keep up - Other kids are faster than me ->

Avoidance of soccer team and playing soccer with friends -> Increase worry about playing sports or exercise in general”

• Have teen generate helpful thought and link new thought to a chain of events• Emphasize activity engagement rather than avoidance behavior

Developed by the UCLA Fit for LA Program with funding from the UniHealth Foundation

Page 6: Fit for LA Mental Health Protocols · The UCLA Fit for Los Angeles Program is funded by the UniHealth Foundation Teasing Protocol (8-18 yo) ... -oppositional -child abuse/neglect

Depression Protocol - Children(8-12 yo)

Educate and normalize

Identify feelings and coping actions

• Help child make the connection between events and emotions• “What we want to start doing is getting in the habit of labeling our feelings and

then being a detective and trying to figure out what might have led to that feeling.”• Help child identify appropriate coping actions (talk to parent, art, exercise, game) and

emphasize relationship between exercise and mood, sleep, energy• “If we are able to identify our emotions and get better at understanding why we

feel that way, we can do something different, instead of [ ] to cope with feelings.”

Connect mood and emotions

Thoughts – feelings - actions

• Mood rating – help child connect activities and her associated moods• “Do you notice certain things that often put you into a (better / bad) mood?

• “Sometimes we may be having a certain feeling or emotion, but not know how to explain or let other people know what’s going on inside our heads. Have you ever had that experience? It can happen to adults as well as children. “

• Have child come up with recent example and work through how one area of the cycle influences the others

• “So now we can see, that our thoughts can affect our behaviors and they can also affect our mood. It’s like a cycle! All of them can affect the other ones.”

Can be conducted over 3 separate sessions

Adaptive thoughts

• Have child come up with examples of unhelpful thoughts she has said to herself and help her generate adaptive / helpful thoughts to replace the unhelpful ones

• Have child generate statement(s) she can say to herself about the situation and a statement that acts as a form of praise for using a helpful statement

• “I was able to do a good job taking control of that thought.” “That was a good thing to say to myself, now I think I can prevent myself from eating that snack that I was about to reach for.”

Behaviors / Actions

Thoughts

Feelings

Developed by the UCLA Fit for LA Program with funding from the UniHealth Foundation

Page 7: Fit for LA Mental Health Protocols · The UCLA Fit for Los Angeles Program is funded by the UniHealth Foundation Teasing Protocol (8-18 yo) ... -oppositional -child abuse/neglect

Depression Protocol - Teens(13-18 yo)

Psychoeducation

Connect mood and emotions

Thoughts – feelings - actions

• Mood rating – help teen connect activities and her associated moods• “Do you notice certain things that often put you into a (better / bad) mood?

• Discuss connection between mood and exercise • Goal setting for physical activity

• “Have you ever noticed that your mood and feelings can be connected to thoughts you’ve had or actions that you’ve taken? “

• Discuss helpful versus unhelpful thoughts• “We all can have both, but sometimes we start to have more of the unhelpful

thoughts. When we have a lot of those, it can start to affect our emotions and our actions. “

• Help teen identify actions that he takes when he has unhelpful thoughts and hard emotions

• “Events in our lives can bring up thoughts, emotions, and then lead us to take other actions. Sometimes we don’t realize why we are behaving certain ways, and it can be the upsetting thoughts and emotions that are driving our behaviors. Our eating habits and exercise behaviors are really good examples of things that can be affected by our emotions and thoughts."

• Have teen come up with recent example and work through how one area of the cycle influences the others

• “So now we can see, that our thoughts can affect our behaviors and they can also affect our mood. It’s like a cycle! All of them can affect the other ones.”

Can be conducted over 3 separate sessions

Adaptive thoughts

• Discuss examples with teen of unhelpful thoughts she has said to herself and help her generate adaptive / helpful thoughts to replace the unhelpful ones

• Have teen generate statement(s) she can say to herself about the situation and a statement that acts as a form of praise for using a helpful statement

• “I was able to do a good job taking control of that thought.” “That was a good thing to say to myself, now I think I can prevent myself from eating that snack that I was about to reach for.”

Behaviors / Actions

Thoughts

Feelings

Developed by the UCLA Fit for LA Program with funding from the UniHealth Foundation