Enhancing the Capacity of School Nurses to Reduce Excessive Anxiety in Children
Co-Principal Investigator: Kelly Drake (Johns Hopkins University)
Purpose: Anxiety disorders are among the most common psychiatric conditions affecting youth, with overall prevalence rates ranging from 10 to 20 percent. Excessive symptoms of anxiety that are impairing but do not meet diagnostic thresholds are also common and occur in approximately 42 percent of children. Excessive anxiety has a broad range of negative effects on academic functioning including poor academic performance, increased grade retention, excessive absenteeism and school refusal, and school dropout. School nurses are often faced with a perplexing subgroup of students who over-utilize school health services and comprise the majority of school health office visits due to frequent, vague physical complaints. There is growing evidence that youth who frequently visit the school nurse are exhibiting early signs of anxiety disorders. These children have high rates of school absences and, when they are in school, miss more classroom instruction and activities due to frequent visits to the school nurse which may be a means of avoiding situations in school that provoke stress and anxiety. Schools are therefore an ideal location for nurses to deliver interventions for reducing childhood anxiety. Unfortunately, the vast majority of anxious children never receive treatment for anxiety and even fewer are identified early to receive prevention or early intervention. The goal of this project is to enhance the capacity of elementary school nurses to help children with excessive anxiety by developing a nurse-administered intervention (CALM; Child Anxiety Learning Modules) designed to reduce anxiety symptoms and improve academic functioning and to assess its feasibility, fidelity, and utility in a school setting.
Project Activities: Researchers will develop and refine the CALM intervention using an iterative development process that includes expert review and two successive open trials with school nurses and elementary school students screened for anxiety symptoms. In the final year of the project, a pilot study that randomly assigns school nurses (one per school) to deliver the CALM intervention (treatment) or relaxation training ( active control) will be used to determine the promise of the intervention for reducing children’s anxiety symptoms and improving their cognitive functioning and school performance.
Products: The products of this project include the CALM intervention, a program to help children who experience excessive anxiety that is delivered by school nurses. The project will also provide evidence of the usability, feasibility and fidelity of implementation of the program as well as promise for improving student outcomes (anxiety, cognitive functioning, and school achievement). Researchers will also produce peer-reviewed publications.
Setting: The research will take place in elementary schools in Maryland and Connecticut.
Sample: Participants for this study include up to 30 school nurses (5 in each open trial and 20 in the RCT) and 80 children (10 in each open trial and 60 in the RCT) with elevated anxiety symptoms (7-12 years old enrolled in grades 1-5). The student body within the participating school districts is diverse in terms of gender, socioeconomic status, and racial/ethnic background.
Intervention: CALM is based on empirically supported cognitive behavioral therapy (CBT) strategies. It will be designed to be a brief, manualized intervention that can be delivered over 5 to 8 sessions by school nurses during short (20 to 30 minute) visits with the individual anxious child. The first session is intended to teach children about anxiety—what it is, how it shows up and what makes it worse or better. The remaining sessions focus on CBT strategies that address the core symptoms of anxiety (somatic, behavioral, and cognitive) and are intended to be administered sequentially (C-A-L-M): C = Calm down by learning relaxation strategies, A = Actions that will reduce anxiety (i.e., behavioral exposure), L = Listen to scary thoughts and change them into coping thoughts and M = Manage problems using problem solving strategies. An intervention manual will describe the content of each session and provide examples to illustrate how nurses can convey the content to children effectively.
Research Design and Methods: Researchers will develop CALM using an iterative process in which versions of the intervention and its implementation procedures will be conducted sequentially and refined in response to feedback from expert consultants, school nurses, children, parents, and school personnel until it is usable in the school environment. The proposed format of the intervention will be evaluated and modified as needed to ensure a balance between feasibility and potency with respect to the length of the intervention (feasibility) and nurses’ capacity (fidelity/competence). Two successive open trials will allow researchers to identify obstacles to implementation, feasibility of the assessments, and acceptability and utility of the training and intervention manual and the supervision process. Feedback gleaned during the first open trial will inform modifications for the second open trial. Feedback from the second open trial will be used to make appropriate modifications to CALM in preparation for a cluster-randomized design pilot study with school nurses (one per school) randomized to intervention or active control groups. Nurses will recruit potentially eligible children and study staff will screen and evaluate them to determine eligibility. Eligible children will receive 8 weeks of treatment (CALM or relaxation training) depending on their school nurse’s random assignment. Children in both conditions will be monitored on a monthly basis via brief phone calls to their parents and assessed at post-intervention and three months following the completion of treatment by a member of the research team blind to the child’s study condition.
Control Condition: During the pilot RCT, children in schools where nurses have been assigned to the control group will receive relaxation training.
Key Measures: Nurses’ knowledge of cognitive behavioral therapy strategies will be assessed using the Clinician Knowledge of CBT Test. Anxiety symptoms will be assessed using the Screen for Child Anxiety-Related Emotional Disorders, Child and Parent Versions (SCARED), the Anxiety Disorders Interview Schedule for DSM-IV, Parent and Child Versions and the Clinical Global Impression – Severity (CGI-S) and Improvement (CGI-I) Scales. Academic and classroom functioning will be assessed using the Teacher Observation of Classroom Adaptation-Revised Checklist (TOCA-R), the Behavior Assessment System for Children (BASC-2), and the Child Anxiety Impact Scale (CAIS). Children will complete the Treatment Satisfaction Questionnaire. School records will provide information about academic grades, attendance, referrals to the nurse, referrals for special education evaluations, grade retentions, and referrals for disciplinary actions (e.g., suspensions, detentions). In addition, the Digit Span Backward from the Wechsler Intelligence Scale for Children—4th Edition (WISC-IV) will be used to explore the relationship between anxiety and working memory, which has been hypothesized to account for academic impairment among anxious youth, and the Woodcock-Johnson Tests of Achievement (WJ-III) will be used to measure cognitive factors (e.g., efficiency, speed) that are believed to be affected by anxiety.
Data Analytic Strategy: Descriptive analyses (e.g., comparison of mean scores) will be used during the development phase. For the pilot RCT, the impact of the intervention on children’s academic performance and anxiety will be analyzed using intent-to-treat two-level mixed effect models of the post-pre change score. Nurses’ years of experience, the proportion of students in the nurse’s school that are eligible for free or reduced lunch, and children’s’ baseline outcome measures will be included in the models as covariates.