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I Don’t Feel Good! When Anxiety Negatively Impacts a Child’s Education Dorothy Stubbe, MD Program Director Associate Professor Yale Child Study Center

CT-AAP Critical Issues in School Health March 31, 2016

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•  Disclosures

–  None

–  I am on faculty of Yale Child Study Center and Medical Director of ACCESS-Mental Health Yale Hub

Participants will:

• Understand the types of anxiety and anxiety becomes an anxiety disorder;

• Be able to describe the process of assessment, collaboration and educational planning for children and youth presenting with anxiety disorders and school avoidance;

• Engage in a problem-solving discussion regarding children with anxiety disorders and their families when anxiety interferes with education

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Everyone feels anxiety some of the time……

Some situations provoke anxiety in most people:

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ANXIETY IS A DISORDER WHEN A CHILD:

•  IS ANXIOUS TOO MUCH OF THE TIME; •  IS SO ANXIOUS THAT IT INTERFERES

WITH AGE- APPROPRIATE FUNCTIONING IN FAMILY, SOCIAL, SCHOOL, OR OTHER AREAS OF LIFE;

•  IS ANXIOUS ABOUT THINGS THAT DO NOT REPRESENT REAL THREATS.

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Wendy Silverman, Ph.D. and Eli Lebowitz, Ph.D. Yale Child Study Center Program for Anxiety Disorders

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SIGNS OF ANXIETY– THINGS TO LOOK FOR: •  THOUGHTS:

– Worry, Bad Thoughts, Bad Dreams, Expecting the Worst, Asking Parents for Reassurance Excessively.

•  PHYSIOLOGY: – Racing Heart, Shallow Breathing,

Trembling, Dizziness, Vomiting, Freezing, Clinging, Stomachache/Headache, Sleep Problems, Crying, DFA

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SIGNS OF ANXIETY– THINGS TO LOOK FOR: •  BEHAVIOR:

– Child Avoids Things That Other Children Do: Staying Home Alone, Sleeping Alone, Speaking with Other People, Animals (e.g., Dogs, Cats, Snakes, Bugs), Social Activities, School

•  EMOTION:

– Fear, Anger, Irritability, Mood Swings or Blunted Emotions, Lack of Interest in Social or Other Activities.

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Types of Anxiety Disorders

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Panic Disorder Sudden surges in anxiety– usually with intense physical arousal (palpitations, sweating, can’t catch their breath), and intense psychological distress (fear of dying or going crazy). The child fears having another panic attack.

Agoraphobia Fear of certain situations (Ex: buses, malls, cars, crowds) because of the fear of having panic symptoms and not being able to escape

Generalized Anxiety Disorder Excessive worry which is difficult to control and leads to physical fatigue and/or cognitive impairment.

Obsessive-Compulsive Disorder Newly re-categorized in DSM-5 as impulse control disorder. Preoccupation with having things “just right,” irrational fears of something bad happening, and often ritualized behavior to prevent that.

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Types of Anxiety Disorders

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Separation Anxiety Disorder Excessive fear/distress when anticipating or experiencing separation from home or caregivers.

Social Anxiety Fear in situations in which the child is exposed to the scrutiny of others. (Ex: speaking in public, being in new social situations)

Selective Mutism Failure to speak in specific social situations (Ex: in school or with adults other than parents). The child is able to speak in other situations

Specific Phobias Marked fear about particular objects or situations

Epidemiology:

•  Between 10-20% of children suffer from a diagnosable anxiety disorder at some time;

•  Tends to run in families; •  Child temperament is important; •  Symptoms vary by developmental level of

child; •  May develop in context of environmental

adversity/trauma(e.g. being teased or bullied)

•  Is exacerbated by accommodation (parents and others attempting to help the child avoid the situations that make them anxious).

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Assessment

•  Use screening tools: – BASC parent, teacher, student reports – NICHQ Vanderbilt Assessment Scale-

PARENT • Questions 41- 47

– Screen for Child Anxiety Related Disorders (SCARED)

– Generalized Anxiety Disorder (GAD-7) Scale

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Assessment

•  Rule out physical causes (e.g. GI disorder, medication side-effects, caffeine drinks, migraines or other headaches, hyperthyroidism, etc.)

•  Get data from multiple sources (child, home, PCP, school)

•  Developmental history •  Family history of anxiety or depression? •  Trauma or stressors?

•  Substance abuse?

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Diagnostic considerations

•  Medical Disorder – For physical symptoms (stomachache,

headache, etc), do medical work-up, consider tox screen, but concomitantly consider anxiety and begin screening;

•  Trauma or Family Tensions

– New onset of anxiety, fears, sleep problems, enuresis

– Bullying, cyber-drama, embarrassment or humiliation

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School Avoidance

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Functions of School Refusal Behavior (SRB):

Escape from Negative Emotion

Escape from Social Evaluation

Attention Seeking

Tangible Reinforcements

SRB

School refusal cycle

Missed days

Child learns that staying home is

‘possible’

Secondary gains Child misses class material

Child worries about peer questions

Get student back to school quickly

Remove temptations of staying home

Formulate plan with school, family, child, MH providers, PCP

Practical advice: e.g. invite friend to accompany student

Avoid giving medical excuses

Stay matter-of-fact and supportive

Set a specific expectation

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School Avoidance

•  A psychiatric “urgency” •  Assess and intervene quickly to decrease

the risk of chronic school refusals

•  This is one of the few times that short-term use of benzodiazepines may be useful for children and adolescents

•  Collaboration with school personnel, parents, child, and OP treaters to assist in adding support, systematic desensitization (child goes to school building and meets with SW, then add from there)

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Treatment

•  School intervention: Assess functions of anxiety in school setting; add support: Section 504, IEP, stress-reduction, address bullying;

•  Psychoeducation and family support– try to help family not to accommodate (e.g. avoid giving school attendance excuses for a child with school avoidance) and get child into treatment;

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Treatment

•  Collaboration with PCPs: Let them know the issue, call if a medical excuse is provided; let them know about ACCESS-Mental Health (free telephone consultation and referrals to care)

•  Psychotherapy– usually CBT, relaxation

•  Specialized evaluation/treatment with research design are offered at no cost to eligible youth: anxiety.yale.edu

203-785-2540

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Medication Treatment

•  SSRI: start low and go slow (e.g. escitalopram, fluoxetine or sertraline)

•  Benzodiazepines very short-term for acute school avoidance or panic symptoms, while other methods are tried (when child wakes up—usually lorazapam)

•  Alpha agonists (guanfacine and clonidine) for autonomic hyperarousal or sleep issues

•  Buspirone

•  Antipsychotics for agitation

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Treatment

•  Slow re-integration into school (often starting at the end of the day with tutoring, and integrating one class at a time, with increases at least weekly)

•  Keep to agreed upon time-table, even if child says they want to do more (unless a meeting is held to re-work the plan). Failed re-integration often occurs if it is not gradual

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Treatment

•  Small classroom (e.g. resource room) is often helpful for re-integration and to help the child catch up with work;

•  Modified homework/ catch-up work expectations;

•  Quiet spot to regroup with a time; expectation (e.g. 10 minutes to calm);

•  Counseling – often helps to meet trusted school personnel when student comes in;

•  Taper to at least weekly school counseling

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Treatment

•  Family with Service Needs (FWSN) or DCF services may be required;

•  IICAPS or other in-home services; •  Avoid in-home tutoring– library tutoring if

required;

•  Assess for special education eligibility (emotional disturbance or other);

•  If in-school and home supports are not adequate, a therapeutic school may be required.

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Case Discussions •  Jessica is a 16-year- old, 11th grade regular education

Hispanic female who lives with her mother and three younger siblings (6, 4, 2)

•  She has Section 504 accommodations for anxiety: can get a pass to leave classroom; testing in a quiet location; weekly SW support

•  Jessica is experiencing an increase in anxiety symptoms and panic attacks (particularly in the mornings), leading to her being late or missing school altogether. She is also experiencing intermittent suicidal ideation, without a plan. She has a history of performance and school anxiety, and some depressive symptoms.

•  She is at risk for being held back due to number of tardies and absences.

What to do?

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BASC

•  Teacher report: Clinically significant or at-risk for:

– Adaptability – Anxiety – Somatization

– Withdrawal – Study Skills

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BASC

•  Parent report: Clinically significant or at-risk for:

– Leadership – Depression – Adaptability

– Anxiety – Conduct at-risk

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Other testing

•  Average cognitive scores, with processing speed and working memory in low average range

•  No learning disorder

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Other information

•  Mother was teen parent •  Pregnancy and early development were

generally normal

•  Witnessed domestic violence as a child. •  Father moved back to El Salvador and she

has no contact (7 years) •  Has had another step-father (reportedly

was verbally abusive to Jessica and her mother). Divorced 2 years ago (sibs visit)

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Family history

•  Biological father with alcohol abuse, mood disorder

•  Mother with anxiety and depression •  Other family members with ADHD, anxiety,

depression, PTSD

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Summary

•  Biological – Strengths:

• Cognitively intact

• No learning issues • Generally healthy

– Areas of concern

• Biological predisposition to anxiety, depression, substances

• Tested with processing speed and working memory in low average range

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Summary

•  Psychological – Areas of strength

• Has reasonable insight into her problems

• Is motivated to come to school and become a beautician when she graduates

– Areas of concern • Poor coping skills to deal with stress • Functionally-disabling anxiety

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Summary

•  Social – Areas of strength

• Has several good friends

• Is able to engage with treaters – Areas of concern

• Very anxious in new social situations

• Has panic symptoms around performance in public

• Overly sensitive or misperceives social situations as negative

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Interventions

•  Determine special education eligibility (ED) •  Modify school plan to more effectively assist

Jessica with getting to school (i.e. parent providing increased privileges for getting to school, additional school counseling to teach/reinforce relaxation skills, support group at school, no electronics if does not go to school; call to home or home visit if she does not come to school)

•  Additional transition planning to assist Jessica is thinking about/planning for life after high-school

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Treatment

•  Begin outpatient therapy and medication management;

•  Outpatient therapist: collaborate with school, family, youth, PCP to re-establishing regular routine, consistent school attendance, and build coping skills to deal with stress and anxiety

•  Medication recs: (Lexapro 5.0 mg q am, titrate up to 10.0 mg). Watch for activation, suicidal thoughts, GI problems, sleep issues;

•  Melatonin 3.0 mg q pm to assist with sleep cycle problems;

Open Discussion

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