Mental Health Education and Training Initiative 2005 Learning Session II

1. Mental Health Education and Training Initiative 2005 Learning Session II National Assembly on School-Based Health Care

2. IcebreakerWhat is your skill? • Listening • Asking for Help • Apologizing • Deep Breathing • Muscle Relaxation • Positive Self-talk • Cognitive restructuring • Resisting Peer Pressure • Scheduling Pleasurable Activities • Problem Solving Skills

3. Overview of Day: Learning Session II Agenda • What are Core Skills? • Core Skills – Review and Role Play • Anxiety • Depression • Disruptive Behavior Disorders • Substance Abuse • Mental Health Documentation and Treatment Planning for MH Providers • Storyboards • Group Interventions: • Review and Select Manualized Interventions • Work plan Development

4. National Assembly on School-Based Health Care Washington, DC www.nasbhc.org info@nasbhc.org 202-638-8872 or 1-888-286-8727 - toll free

5. Center for School Mental Health Analysis & Action Director: Mark Weist, Ph.D. Director of Research and Analyses: Sharon Stephan, Ph.D. • email: csmha@psych.umaryland.edu • web: http://csmha.umaryland.edu • phone: 410-706-0980 (888-706-0980)

6. Mental Health Education and Training (MHET) Initiative • Funded by the HRSA Maternal and Child Health Bureau and the Bureau of Primary Health Care • Developed by the National Assembly on School-Based Health Care in collaboration with the Center for School Mental Health Assistance (CSMHA) at the University of Maryland • In partnership with Columbia University TeenScreen Program • 2004-2005 • 7 SBHCs from Colorado, Louisiana, New Jersey, North Carolina • 2005-2006 • 13 SBHCs from Michigan and West Virginia

7. MHET Mission • Increase knowledge and implementation of mental health • screening, • diagnosis, • referral, • coding, and • empirically-supported short-term interventions among SBHC primary care and mental health providers.

8. Learning Session Two Pre-assessment – Core Skills

9. MHET Objectives: Learning Session II • OBJECTIVE 7: To increase SBHC primary care and mental health professionals’ knowledge about skills related to youth mental health, and to anxiety, depression, substance abuse, and disruptive behavior disorders, more specifically, and to increase interventions aimed to train youth in these skills.

10. A Four-Pronged Approach to Evidence-Based Practice in School Mental Health • Decrease stress/risk factors • Increase protective factors • Train in core skills • Implement manualized interventions

11. Training in Core Skills

12. What are “core skills”? • Based in cognitive behavioral theory • Buffer against the development of mental health problems • Assist in coping with mental health problems

13. What is Cognitive Behavior Therapy (CBT)? • Relatively short-term, focused psychotherapy • Focus: • How you are thinking (your cognitions) • How you are behaving and communicating • Emphasis on present rather than past • Learn coping skills

14. Skills training for Anxiety • Deep Breathing • Progressive Muscle Relaxation • Mental Imagery/Visualization • Systematic Desensitization • General Stress Busters • Cognitive Restructuring

15. Deep Breathing • Breathe from the stomach rather than from the lungs • Can be used in class without anyone noticing • Can be used during stressful moments such as taking an exam or while trying to relax at home

16. Progressive Muscle Relaxation • Alternating between states of muscle tension and relaxation helps differentiate between the two states and helps habituate a process of relaxing muscles that are tensed • Many good tapes/c.d.’s available on relaxation • Especially suited for middle and high school students

17. Mental Imagery/Visualization • Can enhance other relaxation techniques or be used on its own • Provides relief from troubling thoughts, emotions, or feelings • Evokes a pleasing, calming mental image (e.g., the beach, park, forest, playing with a favorite pet)

18. Systematic Desensitization • Anxiety reducing strategy involving exposure of the phobic child to the feared object or situation. • The child learns to tolerate the feared object by means of a series of steps beginning with the least anxiety producing aspect of the process and ending with the most difficult step. • Construction of the Anxiety Hierarchy

19. General Stress Busters • Go for a walk • Take a nap • Play with a pet • Take a bath • Listen to music • Talk to a friend • Exercise • Write in a journal • Write a letter that you never send • Do something creative – an art project, poem, write a rap • Watch television • Talk on the phone • Read

20. Cognitive Restructuring • Change cognitive distortions (irrational negative thoughts and beliefs someone has about different situations) and to increase positive self talk • Steps: • Recognize and get rid of negative self talk • Counter the negative thoughts with realistic positive self talk • Believe the positive self talk!

21. Case Example and Role Play:Anxiety

22. MH Provider Role PlayAnxiety: Systematic Desensitization • Marcus has come for a follow-up appointment at the SBHC. He reported several anxiety symptoms during his comprehensive risk assessment, and screened positively for panic attacks during the Diagnostic Predictive Scales. Marcus indicates that the panic attacks are triggered by a fear of being called on in class. He experiences symptoms of panic (heart palpitations, nervousness, sweating, etc) on the way to school, while sitting in class, and even just thinking about being in class. • Begin the process of Systematic Desensitization with Marcus. • Teach Relaxation techniques (Deep Breathing, Muscle Relaxation, Imagery) • Create a Fear Hierarchy • Practice imaginal exposure to feared situations using the fear hierarchy.

23. Primary Care Provider Role PlayAnxiety: Relaxation Techniques • Marcus has come for an initial appointment at the SBHC. He appears short of breath, and reports that he is having heart palpitations. He is sweating, and reports nervousness. Upon interview, Marcus indicates that his symptoms were triggered by a fear of being called on in class. He has had similar symptoms before, and believes they are panic attacks. He is unsure of how to relax when he has these symptoms, but is concerned that he is “going crazy,” and worries that his friends will tease him if they find out. • Review relaxation techniques with Marcus, including Deep Breathing, Progressive Muscle Relaxation, and Mental Imagery/Visualization. • First, explain to Marcus how relaxation is important in reducing symptoms of Anxiety. • Next, introduce each relaxation technique, and PRACTICE with Marcus. • Encourage Marcus to practice each technique several times, and schedule a follow-up appointment to review progress.

24. Skills training for Depression • Cognitive Restructuring • Thought Stopping • Activity Scheduling • Social Skills Training • Problem Solving • Relaxation Training

25. Cognitive Restructuring • Change cognitive distortions (irrational negative thoughts and beliefs someone has about different situations) and to increase positive self talk • Steps: • Recognize and get rid of negative self talk • Counter the negative thoughts with realistic positive self talk • Believe the positive self talk!

26. Thought Stopping • Replaces “racing thoughts” or disturbing thoughts with neutral thought. • Neutral thought – e.g., something positive and affirming; relaxing location • Thoughts can be “stopped” by practicing an abrupt interruption of thought – e.g., shouting “stop!”; snapping rubberband on wrist • Return to thinking only about the neutral situation.

27. Activity Scheduling • Scheduling enjoyable and goal-directed activities into the child’s day • Assists withdrawn students reengage in pleasurable activities • Provides the child with the opportunity to feel more effective as he or she completes tasks such as school projects • Child needs to be educated about the relationship between involvement in an activity and improvement in mood.

28. Problem Solving • Assist students in generating solutions to problems • Only focus on one problem at a time. • Steps: • Define the problem. • Brainstorm all possible solutions. • Focus your energy and attention to be able to complete your task • Identify outcomes related to the various solutions, including who will be affected by the outcomes. • Make a decision and carry out. • Have a contingency plan in case the solution does not work out as planned. • Evaluate the outcome.

29. Relaxation Training • Deep Breathing • Progressive Muscle Relaxation • General Stress Busters

30. Case Example and Role Play:Depression

31. MH Provider Role PlayDepression: Cognitive Restructuring • Tonya has come for an initial appointment to the SBHC. During the risk assessment, Tonya reports a number of depressive symptoms, but no suicidal ideation. Tonya seems to display a lot of negative thinking and cognitive distortions. For example, she believes that “nobody” likes her and that s/he will “never” be successful in school. Her math teacher often compliments her work, but Tonya dismisses the teacher’s comments as him “just trying to be nice.” Tonya has good grades in all classes except for one, yet she only acknowledges her below average Chemistry grade. • Practice the process of Cognitive Restructuring with Tonya. • Describe the relationship between ways of thinking and depressive symptoms • Help Tonya to identify her cognitive distortions • Identify ways of countering cognitive distortions • Have Tonya practice countering these distortions

32. Primary Care Provider Role PlayDepression: Activity Scheduling, Thought Stopping • Tonya has come for an initial appointment to the SBHC. During the risk assessment, Tonya reports a number of depressive symptoms, but no suicidal ideation. Tonya reports not engaging in any activities that she used to. For example, she used to spend time with friends after school, and used to enjoy reading. She hasn’t done either recently, and just seems bored most of the time. She also reports having difficulty concentrating in class because she is constantly thinking about her problems. • Practice the processes of Activity Scheduling and Thought Stopping with Tonya. • Discuss with Tonya activities she used to enjoy. • Identify specific enjoyable activities for Tonya to do this week. • Identify times and places for each activity, and discuss potential obstacles. • Explain the process of Thought Stopping to Tonya, and discuss how Tonya could use this strategy when she has intrusive thoughts.

33. Introduction to the Manuals

34. FRIENDS • Skillstreaming • Defiant Children/Teens • Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

35. FRIENDS (Paula Bartlett) • Group-administered cognitive-behavioral treatment for depression and anxiety symptoms for children ages 7-11 (FRIENDS for Children) or adolescents age 12-16 (FRIENDS for Youth). • 10 sessions between 45-60 minutes in length, administered on a weekly basis, with two follow-up booster sessions and four optional parent sessions. • Groups should be comprised of 12 or fewer youth.

36. FRIENDS addresses the three major components of chronic anxiety symptoms: • mind (i.e., cognition), • body (i.e. physiological responses), • and behavior (i.e., learning new coping skills). • Two manuals are necessary to implement the approach: the group leader’s manual, a children’s workbook. • Manuals are $65.00 each

37. Skillstreaming (Arnold Goldstein) • Designed to enhance youths’ social skills, can be used as a universal classroom or a selected smallgroup intervention. • Separate curricula exist for K-6 (Skillstreaming for Elementary School Children) and 7-12 grades (Skillstreaming for Adolescents). • Instructors can run through the entire protocol or select different component skills to meet the needs of specific youth. • Cue cards are used to prompt students to use Skillstreaming strategies. • To implement Skillstreaming, a therapists’ manual ($19.95), student workbook ($12.95), student materials ($16.95), and student skill cards ($25.00) are needed.

38. Defiant Children and Defiant Teens (Barkley, Robin, Edwards) • 18-step program designed both to teach parents the skills they need to manage difficult child/adolescent behavior and to improve family relationships overall. • Delineate clear procedures for assessing defiance in children/teens and working with parents, alone or in groups, to reverse problem behavior • Clinicians are shown how to help all family members learn to negotiate, communicate, and problem-solve more effectively, while facilitating adolescents' individuation and autonomy (for Defiant Teens) • Clinician Manuals $36.00 each; Contain reproducible handouts for parents and adolescents

39. Cognitive Behavioral Intervention for Trauma in Schools (CBITS; Lisa Jaycox) • 10-session school-based, cognitive behavioral intervention for trauma exposed adolescents • Optional 1-3 individual sessions • It incorporates cognitive behavioral therapy (CBT) skills in a group format to address symptoms of PTSD, depression, and anxiety related to trauma exposure • Informational components for teachers and parents • Clinician manuals $34.95; Contains reproducible handouts

40. Disruptive Behavior Disorder Family Involvement Classroom Management

41. The research on interventions for disruptive behavior disorders • Other than stimulant medication for ADHD, no individual or group interventions have been proven effective • Some evidence that group interventions make problems worse (peer contagion) • All empirically-supported interventions for disruptive disorders involve the youth’s key socialization agents: parents and teachers • Engaging parents in process is crucial

42. MH interventions with little or NO evidence of effectiveness for DBD: • Special elimination diets • Vitamins or other health food remedies • Psychotherapy or psychoanalysis • Biofeedback • Play therapy • Chiropractic treatment • Sensory integration training • Social skills training • Self-control training

43. Engaging Parents in Family Interventions • Make services user-friendly to parents • Validate parent frustration and the fact that child is difficult • Never blame parents for child’s problems • Appeal to parent’s desire for things to be better • Address misperceptions about learning parenting skills • Help parents with other things they need – be helpful person in multiple ways

44. What are Behavior Management and Parent Training? • Why children misbehave – correcting misperceptions • Identifying and removing barriers to effective child management • Paying attention to and reinforcing child’s good behavior (improving emotional relationship) • Issuing effective commands (compliance training) • Use of time-out • Reinforcement and response cost system (tokens or points) for appropriate/inappropriate behaviors • Extension to school and public settings - behavior report card

45. Rewards and Response Cost Systems • Desired and inappropriate behaviors clearly specified • Tokens for younger children; points for older • Implement rewards first, then introduce loss of points • Points exchanged for small (daily), medium (weekly), and larger (monthly) rewards; should be primarily non-tangibles • Pair with social reinforcers • Fade system as behavior improves (4-6 months)

46. Improving family management of older youth (13+) • Parental engagement is still crucial, and engaging parents of adolescent sometimes involves different issues • Interventions must take into account child’s developmental needs • Improve emotional climate of family – increase cohesion, reduce conflict • Youth needs to be involved in family decision making and rule-setting – parents need to learn how to go “one-down” to go “one up”

47. Parent regression technique • To address parental detachment from a teenager resulting from problematic behavior (and resistance to changing parenting behavior) • What was it like when ____ was first born? What did you hope/wish for ____? • What went wrong? (non-blaming) What can be done now? • Emphasize that its not too late and address parents’ fear of failing again

48. Improving family management of older youth cont’d • Age-appropriate rewards and punishments are still necessary, but point system no longer effective • Improve parent monitoring and consistency in delivering consequences • Break deviant peer group ties • Strongly promote appropriate peer group ties • Parents pulling together to set common rules, curfews, etc.

49. Classroom-based interventions • Many engagement issues are the same – what can YOU do for the teacher? • Identify important classroom behaviors to target from the teachers’ perspective • Modify intervention protocols to teacher’s needs • Emphasize prevention • Start small – build on small gains

50. Social Skills • Students who display disruptive behaviors often have a difficult time with social interactions (e.g., reacting hostilely) • AND often become a source of ridicule by other students • Social skills can be enhanced by: • role modeling • role playing • providing positive feedback and support for appropriate behaviors • Assist students in identifying perceptions and interpretations that others have of them as well as others’ intents.