Running head: INTERVENTION PLAN

Intervention Plan for Carey Tocher Angela Chiasson, Caitlin Foran, Meagan Keashly, Sharon Kroeker and Karen Zwicker University of Calgary

INTERVENTION PLAN Intervention Plan for Carey Tocher Background Information (Meagan)

Carey is a seven-year-old girl who lives in Vancouver, British Columbia. She lives with with her mother, Stacey Tocher, who often works evenings and weekends. Carey has no siblings and has had no contact with her father since birth. She is not currently on any medications. Carey attends grade two at Crestwood Elementary. According to Ms. Tocher and Careys teachers (Ms. Jones and Ms. Bradshaw), Carey is a creative, polite girl who cares about others. However, they are concerned about her behavior. She has been absent from school one to two days per week over the past two months. Her teachers report that when Carey comes to school she is often tired and tearful, and will sometimes become so upset that Ms. Tocher has to pick her up. They have observed that Carey completes very little work, is unable to remain focused, and will remain silent and cry when called upon to answer questions. They are concerned Carey is not learning many of the important concepts being taught and is falling more behind each day. In the past six months Carey has increasingly made disparaging remarks about herself, prefers to play by herself more and more, and will not engage in games. Careys teachers note that Careys friends play with her less and less, and that the girls in her class have noticed her change in behaviour. Ms. Tocher reports that a year ago Carey appeared to be a happy girl who enjoyed playing with friends and going to her aunts house. However, in the past six months, Carey has increasingly become withdrawn and quiet. She refuses to stay at her aunts house unless Ms. Tocher is there and will often engage in tantrums or long crying episodes when left with a babysitter. Ms. Tocher reports that every morning Carey cries and says she has a stomach ache. She has noticed that Carey prefers to play by herself and often states that nobody likes her. Ms. Tocher also reports that she now has a difficult time getting Carey out of bed in the morning.

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Ms. Tocher stated she is becoming resentful toward Carey because she never has any time alone and feels trapped. Due to these concerns, an intervention plan will be developed for Carey, with Carey, Ms. Tocher, Ms. Jones, Ms. Bradshaw and Mrs. Watson (resource teacher) as participants. Goals (All) Carey is demonstrating symptoms of separation anxiety disorder and possible depressed mood. Her symptoms include avoidance, somatic complaints, withdrawal, lethargy, low selfesteem, lack of emotional regulation and academic decline. Carey is experiencing significant distress and impairment in home, school, and social settings. An interview to determine if any potential stressful events have occurred within the past year and a medical assessment to rule out physiological reasons for stomach aches and tiredness are necessary. Based on the available information regarding Careys symptoms, two goals have been developed to address Careys needs. By June 2012, Carey will use strategies learned from the FRIENDS for Children (FRIENDS) program to help cope with anxiety-provoking situations 50% of the time across settings. Careys target behaviours/emotions/skills will include (a) increasing engagement in play, school, and social activities; (b) becoming aware of her feelings (emotional and physiological states) and thoughts; (c) increasing concentration on the task at hand; (d) developing/acquiring skills for coping, emotional regulation, and problem solving (to provide alternatives to and reduce dependence on avoidance as a solution); (e) acquiring and demonstrating peer socialization and play skills; and (f) improving academic performance due to increased engagement in academic tasks. Furthermore, by June 2012, Carey will attend school 90% of the time. Careys target behaviours/emotions/skills will encompass (a) developing a warm, supportive, and trusting relationship with mom; (b) being away from mom for increasingly longer increments of time; (c) having regular bed time and morning routines; and (d) improving academic performance due to increased school attendance.

INTERVENTION PLAN Evidence-Based Intervention for Carey Overview of Selected Intervention (Karen)

Anxiety disorders are among the most common psychiatric disorders in childhood with pediatric prevalence rates range from 10-22% and a lifetime persistence of almost 29% (Mash & Barkley, 2003). Anxiety is also the most comorbid disorder with depression (rates ranging from 4-69%), with anxiety most often preceding depressive symptoms or disorder (Angold, Costello, & Erkanli, 1999). As previously mentioned, due to Carey's presenting symptoms, (e.g., avoidance and school refusal) it is believed she may currently be experiencing separation anxiety disorder with secondary symptoms of depression. According to Weissman, Antinoro, and Chu (2009), school refusal is one of the most common reasons for referral associated with clinical levels of anxiety in children. Furthermore, separation anxiety disorder is most commonly associated with refusal behaviours (Weissman et al., 2009). Without early prevention and treatment methods, childhood anxiety can be associated with many negative long-term complications such as major depression, suicide attempts, alcohol abuse, and nicotine dependence (Mash & Barkley, 2003). These complications are further exacerbated when comorbidity is present (Mash & Barkley, 2003). Currently, best practice denotes that cognitive behavioural therapy (CBT) is the most effective and preferred method of treatment for anxiety and depression (Beck & Dozois, 2011; Huberty, 2009). In brief, the theoretical underpinning of CBT suggests the information processing system is crucial for human adaptation and survival. This system is linked to affective, motivational, and behavioural systems, all which interact and influence ones thoughts and behaviours. Pathology arises when an individual has maladaptive thoughts that operate in coordination with maladaptive affect, motivation, behaviour, and physiological responses. These maladaptive thoughts, or cognitive distortions, are considered to play a key role in the etiology,

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expression, and maintenance of anxiety due to their resulting misinterpretations of environmental threats and the individuals ability to deal and manage those threats (Weissman et al., 2009). CBT is therefore targeted at helping individuals identify and shift their maladaptive and dysfunctional cognitions, affect, and behaviours (Beck & Dozois, 2011). Through application of coping strategies that utilize behavioural principles and techniques, individuals are able to shift their belief systems and faulty cognitions into those that are adaptive and healthy, in turn restoring ones ability to function appropriately and adequately within their environments (Beck & Dozois, 2011). The basic underlying treatment components of CBT include: psychoeducation, relaxation training, modelling, role playing, cognitive restructuring, exposure, positive reinforcement and performance feedback, and parent training (Schoenfield & Morris, 2009). This approach to therapy has been shown to be effective for as many as 70% of clinically referred children (Miller, Short, Garland, & Clark, 2010). More recently, efforts to move CBT from the clinical setting into the school setting have been increasing with the aim of promoting prevention and early intervention (Barrett & Turner, 2001). This translation across settings is of importance due to the need for cost-effective and efficient delivery of mental health programming to children both at risk for and those with anxiety disorders (Miller et al., 2010). This translation across settings is also of practical significance and importance as school is the childs natural environment and as such this setting is often the first to detect problems of this nature within the child (Barrett & Turner, 2001). Therefore, treatment within the school should provide optimal opportunity for meaningful change for Carey. In addition, this setting allows the opportunity for peer support, and a sense of acceptance and belonging. Recognizing this need for translation, Barrett and Turner (2001) have formulated a school-based universal CBT preventative and intervention programming for

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children aged 7-11 who are experiencing symptoms of anxiety, including separation anxiety, called FRIENDS. In accordance with best practices, the standards set out by the Task Force on EvidenceBased Interventions in School Psychology, and the specific intervention needs for Carey, FRIENDS is an appropriate program selection (Huberty, 2009). In addition, FRIENDS is an evidence-based, manualized program that incorporates all aspects of CBT, has shown successful implementation within the school setting, and effectively addresses symptoms of anxiety, such as those displayed by Carey (Schoenfield & Morris, 2009). Since the programs inception, there has been a continual growth in the strong evidence base supporting the effectiveness of all aspects in the FRIENDS programming in reducing and even eliminating anxiety and symptoms of depression (Schoenfield & Morris, 2009). In fact, FRIENDS is the only childhood anxiety prevention and treatment program acknowledged by the World Health Organization as it has over eight years of empirical support from rigorous randomized controlled trials, and success across settings, countries, and languages (Briesch et al., 2010). The evidence surrounding the FRIENDS program also supports the success of implementation in a school setting by trained individuals regardless of background (e.g., teachers, school nurses, or trained clinicians) (Schoenfield & Morris, 2009). Overall findings suggest, up to 80% of children showing signs of an anxiety disorder no longer display that disorder after completing the program (Barrett & May, 2005, p. 7). Furthermore, long-term results have been found six years following initial treatment (Barrett, Farrell, Ollendick, & Dadds, 2006). The FRIENDS programming will teach Carey how to cope with and manage her anxiety, emphasizing techniques such as relaxation, cognitive restructuring, assisted exposure, and family and peer support (Bartlett & Turner, 2001). The intervention program will encourage Carey to

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think of her body as her friend, to be a friend to herself, to make friends with others, and to talk with friends when she is in an anxiety-provoking situation. Theoretically based upon the peer-learning model and experiential learning, FRIENDS target cognitive, physiological, and learning processes, all of which play a role in the development and maintenance of anxiety (Schoenfield & Morris, 2009). Within the cognitive domain, the programming will teach Carey how to examine her thoughts about herself, others, and situations that provoke feelings of anxiety. The physiological domain will entail teaching and encouragement of deep breathing and muscle relaxation techniques to enable Carey to cope with the associated physical reactions to worry and anxiety. Lastly, to promote learning, the program will teach Carey coping and anxiety management skills (Schoenfield & Morris, 2009). More information about these processes will be presented in the Classroom Strategies section. In effort to ensure that Carey and other children remember the strategies within FRIENDS, the strategies are taught as part of an acronym which stands for the following: F = Feelings; R = Remember to relax, Have quiet time; I = I can do it! I can try my best!; E = Explore solutions and Coping Step Plans; N = Now reward yourself!, Youve done your best!; D = Dont forget to practice; S = Smile!, Stay calm for life! (Briesch et al., 2010). Through the aforementioned cognitive, physiological, and learning processes, each of these strategies is applied. The specific application of these processes and strategies will be further described throughout this intervention plan. Approach to Implementation (Karen) In order to effectively and efficiently address Careys needs, the FRIENDS programming will be conducted by a trained certified school resource teacher (Mrs. Watson) who will provide the program through small group sessions with other identified anxious youth Careys age. Carey will complete the first eight sessions of the FRIENDS program in a small group, with the

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possibility of completing the remaining sessions within her class, who will be completing the program simultaneously during health class. Additionally, Carey will receive two booster sessions scheduled at one and three months, or as deemed appropriate. Research has provided support for the effectiveness of FRIENDS implemented across settings (e.g., clinic and school), by a variety of trained individuals (e.g., teacher, counselor, psychologist), and through different formats (e.g., school-wide, classroom-wide, small group sessions) (Briesch et al., 2010). Mrs. Watson will implement the lessons as laid out within the FRIENDS programming manual. The application of FRIENDS within a small group setting may be beneficial to Carey as it can provide a means to encourage mutual support, encouragement, and acceptance. Peer groups may also enable opportunity for social role-play and increase peer contact (Weissman et al., 2009). The FRIENDS programming also incorporates a parent-training component, as involvement maximizes therapeutic effectiveness and generalizes the treatment gains to the home environment (Weissman et al., 2009). Furthermore, Ms. Tocher, will encourage Careys compliance with and practice of the skills she acquires throughout the programming (Schoenfield & Morris, 2009). These psychoeducational parent-sessions will provide Ms. Tocher with an opportunity to learn about the programme Carey is completing, and to discuss parenting and reinforcement strategies (Barrett & Turner, 2001). This training and opportunity for discussion may help Ms. Tocher deal with her noted feelings of resentment, entrapment, and loss of patience (Schoenfield & Morris, 2009). As research shows parental behaviour has a significant influence on the development and maintenance of anxiety and depression, implementing parent education and management programs is an important component of intervention for many children (Huberty, 2009). The specific details regarding the application of the FRIENDS programming will be further discussed at length throughout this intervention plan. Treatment Integrity and Effectiveness (Caitlin)

INTERVENTION PLAN As mentioned above, research demonstrates the various benefits regarding the

implementation of the FRIENDS program as a cognitive behavioral strategy to manage anxiety in children. Despite the positive benefits of this program, without assessment and evaluation of implementation, it is difficult to determine the specific outcomes of such programs. Elliot and Roach (2008) state that evaluation of treatment integrity is one of the most important services in determining efficacy of an intervention. Furthermore, research demonstrates that when integrity is achieved and maintained, intervention efforts are more likely to provide positive, improved outcomes for students (Elliot & Roach, 2008). Elliot and Roach (2008) define integrity as the degree to which an intervention is implemented as planned (p.196). Treatment integrity is a multifaceted concept, including consideration of both the process and content of program implementation (Elliot & Roach, 2008). In order to facilitate and evaluate intervention integrity, it is important to gather and analyze data regarding implementation efforts. Integrity is specifically evaluated by a comparison of how an intervention is implemented and how it is actually being implemented (Elliot & Roach, 2008). In regards to treatment integrity for the FRIENDS program in Careys school, it will be crucial that Mrs. Watson, who will be implementing the program, receive appropriate training throughout the implementation (Barrett, Moore & Sonderegger, 2001). Arora, Funk and Stark (2011) emphasize the importance of maintaining fidelity of implementation by ensuring clinical competence (p.278) of those administering evidence based interventions. Clinical competence is achieved and maintained by ongoing supervision and support throughout implementation. In this case, support for Mrs. Watson will be coordinated through the training facilitators of the program. These facilitators will also be available to have weekly phone discussions with the Mrs. Watson to ensure any and all questions or concerns around her implementation are addressed appropriately. In addition to facilitation of the

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FRIENDS program, Mrs. Watson will ensure ongoing intervention effectiveness and integrity over the 8 weeks of implementation through a variety of methods. As mentioned previously, Careys target goals are to demonstrate adaptive coping skills and increase school attendance. To obtain an overall sense of effectiveness of the FRIENDS program for Carey, a variety of assessments methods will be utilized. More specifically, a combination of direct and indirect observation, self-reflection, informal interviews, and environmental assessment will be used. Although many of Careys aforementioned behaviors occur in a variety of settings (school, home, Aunts home), school is the most feasible and available setting for observation, and therefore, the majority of it will take place throughout Careys school day. School observations are a desired form of assessment in this intervention as they allow for a functional evaluation of behaviors as well as a comprehensive description and evaluation of specific behaviors. As peer interaction is an area of growth for Carey, her school setting will allow for contained observation of her ongoing bidirectional interactions with peers and teachers. It will also enable Mrs. Watson to observe any gains made in her attention and focus in the classroom, as well as mastery in any academic tasks. School observations are crucial in the assessment of intervention appropriateness as observational data has greater external and ecological validity than rating scales, and it provides details around the functions of specific displayed behaviors (Kurtz & Nock, 2005). In order to ensure appropriate progress monitoring of intervention effectiveness, school observations will occur weekly throughout the entire eight weeks of implementation. The multiple observations will familiarize the presence of Mrs. Watson within the classroom and therefore reduce reactivity from Carey or the other children (Kurtz & Nock, 2005).

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In addition to the initial interview with Ms. Tocher and Carey, several unstructured interviews will be held with Carey, Ms. Tocher and Careys teachers throughout the eight week implementation process. Corbin and Morse (2003) describe unstructured interviews to be a chance for interviewees to share their stories and become comfortable with the researcher. The purpose of interviews in this situation will be to determine effectiveness of the FRIENDS program for Carey based on Ms. Tochers, Careys, and her teachers opinions. The collaboration of information will be helpful in determining whether progress is achieved. Interviewing will occur on a regular basis, once per week, to ensure appropriate evaluation, and to also build the therapeutic relationship between Mrs. Watson and Carey. Regular unstructured interviewing with Carey will give her a sense of control within these situations and will hopefully enable her to become comfortable with Mrs. Watson, creating a sense of trust and openness within their relationship (Corbin & Morse, 2003). More specifically, interviews with Carey will involve self-reflection of her feelings and thoughts as she progresses through the FRIENDS program. As this is one of her identified goals, it will be important to continually reassess her own opinions on her ability to manage anxiety-provoking situations. Additionally, these interviews will allow time for Ms. Watson to analyze and evaluate Careys current coping skills ability, as well as her self-regulation and problem solving abilities. It is hoped that by the end of the FRIENDS intervention that Carey will demonstrate an increase in skills in all mentioned areas. Interviewing with Ms. Tocher will involve discussion around Careys home behaviour. Conversation around their perceived relationship as well as morning and bed time routines will be helpful in determining transference of coping strategies across various environments. This will also be a time for Ms. Tocher and Mrs. Watson to reflect on Ms. Tochers experience in the parent portion of the intervention (Schoenfield & Morris, 2009).

INTERVENTION PLAN The ongoing interviews with Ms. Jones and Ms. Bradshaw will allow for detailed

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information of Careys progress within the classroom. Careys teachers will be able to provide evidence of the use of anxiety coping strategies and hopefully less withdrawal when Carey appears anxious. They will also provide direct feedback regarding Careys peer interactions and any improvement made in her focus and attention in the classroom. Finally, they will be able to offer evidence of any academic gains made, as well as information regarding Careys attendance at school throughout implementation. Overall, the interviews with Ms. Tocher and Careys teachers will allow for ongoing feedback for the resource teacher. Any changes in behavior can be noted and tracked along the eight week implementation process. This type of progress monitoring will be key in implementation of the FRIENDS program as Elliot & Roach (2008) demonstrate the importance of progress monitoring in documenting the effectiveness and integrity of an intervention. Lastly, checklists can be used to track the number of Careys phone calls to her mother, the number of days she has somatic complaints, and the amount of absenteeism throughout the 8weeks. Event recording would be the most useful and beneficial form of recording for these specific variables. This information will provide measurable evidence as to the impact the FRIENDS program has on these variables. Upon completion of the 8-week FRIENDS program, Mrs. Watson will re-evaluate Careys initial goals, based on feedback provided from Carey, her teachers and her mother. Depending on her level of progress after 8 weeks, and her potential need for extended intensive instruction, a decision will be made to implement the final two sessions, either in her small group with Mrs. Watson, or within the classroom as a whole. Regardless of the decision made, Carey will receive two booster sessions at one month and three months after completing the program.

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Overall, the continual re-evaluation and ongoing assessment of the FRIENDS program will provide appropriate measurement of the implementation effectiveness, as well as the treatment integrity of the program. Intervention integrity is a critical component of professional practice and is best practice for those committed to facilitating improves student outcomes (Elliot & Roach, 2008). In addition to the above mentioned intervention analysis, further follow up will be completed after one month of implementation. Classroom Strategies (Meagan) The FRIENDS program consists of 10 sessions conducted weekly, with each session lasting between 60 and 90 minutes (Barrett, 2004). As mentioned previously, Carey will complete the first eight sessions in a small group lead by Mrs. Watson, who has received training as a FRIENDS group leader. The purpose and content for the first eight sessions of the FRIENDS program is outlined in Table 1.
Table 1 Outline of FRIENDS Sessions Session Purpose Session 1 Introduce group members and provide program overview Session 2 Discuss thoughts and feelings and their impact on behavior Content Establish guidelines for group Work on understanding anxious feelings Identify coping strategies Identify feelings and recognize body language and facial expressions Learn to control thoughts and behaviors by finding alternative ways to think and feel Create lists of people, places, and things that evoke comfort and anxiety Recognize physiological signs of worry Identify situations that provoke anxiety Introduce techniques for muscle relaxation and deep breathing Introduce self-talk Discuss the impact of thoughts on coping Transform negative thoughts to positive ones Consider alternate ways to react to fear provoking situations

Session 3

Introduce F (Feelings) and R (Remember to Relax and Feel Good) Introduce I (I can do it! I can try my best!)

Session 4

Session 5 Session 6

Introduce E (Explore Solutions and Coping Step Plans) Reintroduce E and other

Discuss how attention to details can impact thoughts and feelings Introduce Coping Step Plans Discuss the importance of social support, forming a social support team,

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problem-solving strategies Session 7 Introduce N (Now reward yourself! Youve done your best!) and identifying role models Introduce the 6 stage Problem-Solving Plan Learn strategies for positive reinforcement

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Reintroduce N; Introduce Use the FRIENDS plan to help cope with challenging situations D (Dont forget to practice) and S (Smile! Stay calm) Note. Adapted from Cognitive-Behavioral Interventions for Emotional and Behavioral Disorders (p. 208-209), by Gretchen Schoenfield & Richard J. Morris, 2009, New York, NY: The Guilford Press. Session 8

The sessions of the FRIENDS program address cognitive, physiological and learning processes. The first area of the physiological component, awareness of body clues, will teach Carey what happens to her body when she feels nervous or worried (Barrett, 2004). This is important because children with anxiety may have difficulty connecting the physical symptoms of anxiety and the events that provoke the anxiety (Barrett, 2004). In the second area, relaxation/deep breathing, Carey will learn how to engage in deep breathing and progressive muscle relaxation, which is important because children with anxiety are often tense and not skilled at engaging in relaxation (Barrett, 2004; Barrett, Dadds, & Rapee, 1996). The cognitive component has two areas. The first, positive self-talk, is based on the principle that thoughts influence feelings and behavior. Mrs. Watson will teach Carey how to cope with difficult situations by changing her negative, unhelpful thoughts to thoughts that are more positive and helpful (Barrett, 2004). This is important because children with anxiety often engage in negative self-talk (Barrett et al., 1996). The second area, self-reward, will help Carey make more realistic and positive evaluations of herself by teaching her to reward herself for partial success (Barrett, 2004). Self-reward is important because children with anxiety often expect high levels of perfection from themselves (Barrett et al., 1996). The last component, learning, encompasses three areas. Problem-solving involves teaching Carey a six-stage problem solving process: identify a problem, how to resolve it,

INTERVENTION PLAN potential outcomes, choose the best solution, put the solution into action, and evaluate the

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outcome (Schoenfield & Morris, 2009, p. 208). Problem-solving is important because children with anxiety often regard their worries as overwhelming and view themselves as not able to cope with challenging situations (Barrett, 2004). Exposure refers to gradually exposing individuals to experiences that evoke fear. Carey will engage in a Coping Step Plan, where she will break down feared or worrisome situations into small, manageable steps (Barrett, 2004). This technique is important for children with anxiety because they often avoid difficult or worrying situations (Barrett, 2004). The last area, reward systems, will encourage Carey to reward herself when she approaches difficult or worrying situations. For example she will be taught to reward herself when she attempts a step of her Coping Step Plan (Barrett, 2004). During the group sessions, Mrs. Watson will encourage Carey to learn from her own experiences and those of her group members. Each group member will be given a private workbook that can be used to record personal thoughts and feelings. With her group, Carey will engage in discussion, brainstorm ideas, build on past experiences and learn from new experiences. Carey will be given opportunities to learn through observing others and will practice newly learned skills within a safe and supportive environment (Barrett, 2004). Throughout, Mrs. Watson will normalize similarities and differences, reflect main ideas and focus on student empowerment (Barrett, 2004). It will be important that Careys classroom teachers reinforce the skills taught in the FRIENDS sessions when Carey is in the classroom. Carey would also benefit from frequent check-ins and the use of cues to remind her to employ the skills she has learned. Providing her with increased opportunities for social interaction at school would also be beneficial as it allows for additional practice of skills learned from the FRIENDS sessions (e.g., her teachers could run a games club during two recesses per week). Additionally, based on her progress in the program, it

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may be beneficial for Carey and her teachers to co-create a behavioral contract where Carey will receive positive reinforcements for school attendance. In-home Strategies (Angela) Research supports that overly anxious children can negatively impact family functioning (Eugster, 2012). Fortunately, anxious children like Carey, can benefit greatly from parental support. To create a warm, safe, and supportive environment for Carey, Ms. Tocher will establish consistent daily routines and structure, help Carey identify her feelings, provide opportunities for Carey to communicate about her feelings, respect Careys fears, model and encourage brave behaviour, teach relaxation skills, encourage feeling good activities, teach problem solving strategies, and challenge unhelpful thoughts. The FRIENDS program will aide Ms. Tocher in supporting Carey in all of these domains, for, as previously mentioned, parent involvement in the FRIENDS program maximizes therapeutic effectiveness and generalizes the treatment gains to the home environment (Weissman et al., 2009). The FRIENDS program offers a parent-training component with four sessions intended to provide in-depth information and to discuss strategies for parenting and use of reinforcement procedures (Schoenfield & Morris, 2009). Ms. Tocher can complete the FRIENDS For Life Parent Program online (http://www.friendsparentprogram.com), or via a face-to-face workshop through the Families Organized for Recognition and Care Equality (F.O.R.C.E.) Society for Kids Mental Health (www.forcesociety.com). Once Ms. Tocher has learned how to reinforce FRIENDS skills at home, she will be ready to administer the following home activities. Session 1 home activities include setting personal goals and identifying happy, comforting thoughts (Schoenfield & Morris, 2009). The introduction to the FRIENDS program aides Ms. Tocher in identifying Careys style of responding to anxiety: fight, flight or freeze.

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Once Ms. Tocher is familiar with Careys response to stressful situations, she can help her change her body reactions when needed. Session 2 home activities encompass practicing deep breathing and muscle relaxation (Schoenfield & Morris, 2009). This session introduces F (feelings) and R (remember to relax and feel good). Ms. Tocher will support Carey in completing the feelings worksheet to describe her thoughts as well as physical and emotional feelings. Furthermore, Carey will practice muscle relaxation with the help of her mother through a relaxation script or through special activities they like to do together, such as baking. This is important, because, as previously mentioned, children with anxiety have difficulty knowing how to relax (Barrett, 2004). Deep breathing and relaxation exercises change physiological symptoms, such as an increased heart rate, to a more comfortable, decreased heart rate. Session 3 home activities consist of identifying negative thoughts in a workbook scenario and practicing to replace these thoughts with positive self-talk and monitoring and recording thoughts during the upcoming week (Schoenfield & Morris, 2009). By introducing I (I can do it! I can try my best!), Carey will be able to distinguish between red (negative) and green (positive) thoughts. In this stage of the plan, Ms. Tocher will help Carey focus on the positive aspects of differing situations and help to remind her of her strengths. This is critical, because those who suffer from anxiety often have pessimistic thinking patterns (Eugster, 2012). Session 4 home activities include thinking of an anxiety-provoking situation and creating Coping Step Plans, and identifying helpful thoughts that will assist in moving through each of the steps (Schoenfield & Morris, 2009). In this stage, Carey will create a Coping Step Plan for when she is in a situation away from her mother, such as sleep over with her aunt. This plan is gradual and can take as many steps as necessary, for example, step one would include going to her aunts house for a hour, step two, going for dinner, step three, watching a movie, and so on until Carey

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reaches the final step, which is the sleep over. This process is beneficial, because children struggling with anxiety have constant worry about what might happen (Eugster, 2012). Session 5 home activities encompass solving a problem using the 6-Block Problem Solving Plan with family or friends, discussing role models with family members, practicing the first step in the Coping Step Plans, and practicing relaxation and positive self-talk (Schoenfield and Morris, 2009). Reintroducing E (Explore Solutions and Coping Step Plans) enables Carey to go through the problem solving process by 1) defining the problem, 2) brainstorming all possible solutions, 3) selecting pros and cons for each solution, 4) selecting the best solution, 5) following through, and 6) evaluating. This step by step plan is important because those with anxiety are known to procrastinate, have poor memory and may show withdrawal from certain activities (Eugster, 2012). Session 6 home activities consist of identifying positive aspects of difficult situations and moving through additional steps in the Coping Step Plans (Schoenfield & Morris, 2009). While, session 7 home activities include practicing Coping Step Plans rewarding for effort and evaluating plan implementation (Schoenfield & Morris, 2009). Finally, session eight, which is the booster session, includes reviewing steps in forming support teams, generalizing skills to new situations, and practicing (Schoenfield & Morris, 2009). The use of intrinsic rewards guide Ms. Tocher in helping Carey learn that she has inner strengths to draw on during times of stress. Furthermore, extrinsic rewards can also be used to encourage mother-daughter activities, such as a family picnic or visit to the pet store. The final sessions are designed on the premise that Carey needs to practice in order to improve her abilities. It is important for Ms. Tocher to remember to be patient, practice together, get creative, repeat skills, model good practice, track practice, and put aside time. Community Resources (Angela)

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As Wiessman et al. (2009) reveal, access to appropriate services remains a major obstacle for children and adolescents with anxiety disorders (p. 194). Highly anxious children can be demanding and can become very emotional, which can be taxing on the family environment, as evident in the family relationship between Carey and Ms. Tocher. Family involvement throughout treatment of separation anxiety will greatly enhance treatment effects, thus community supports are essential for success (Camacho & Hunter, 2008). Ms. Tocher may be experiencing feelings of being alone, frustration, and lack of proper knowledge concerning anxiety, thus community resources that promote a sense of belonging and knowledge may be helpful. The following section gives an overview of community and online resources that may be beneficial. The FRIENDS for Life Parent Program was developed for parents by parents and is a great resource for parents to follow the FRIENDS program step-by-step, from home, with their child. Furthermore, this site also offers an online community to meet with other parents to discuss and share thoughts on building resiliency and helping with anxiety issues in children and youth. Secondly, the F.O.R.C.E Society for Kids Mental Health is a provincial organization that provides families with an opportunity to speak with other families going with similar issues. This organization provides information and tools on how to assist children with mental health difficulties such as anxiety. Additionally, Anxiety BC (www.anxietybc.com) provides a rich resource of self-help information and programs, as well as resources for parents and caregivers. Their mission is to increase awareness, promote education and improve access to programs that work. Moreover, parent books such as, Keys to Parenting Your Anxious Child by Katharina Manassis
(1996), The Anxiety Cure for Kids: A Guide for Parents by E.D. Spencer (2003), The Worried Child: Recognizing Anxiety in Children and Helping them Heal by Paul Foxman (2004), and Helping Your

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Anxious Child: A Step-By-Step Guide for Parents by Ronald Rapee (2000) may be beneficial in aiding Ms. Tocher to support Carey, as well as herself.

If the 8-week intervention does not result in significant improvement in Careys symptoms of anxiety, she may benefit from attending counselling with a qualified Psychologist who practices CBT, as Careys negative thought patterns and emotions are significantly impacting her daily living. Registered psychologists in Vancouver can be located by using this website: http://www.psychologists.bc.ca. Furthermore, family or parent counselling may be helpful in providing support and education for Ms. Tocher, while helping her to develop realistic expectations for Carey. The following resource may be helpful in finding a counselling service: http://www.counsellingbc.com. Follow-up Plans (Sharon) After the 8-week intervention plan is completed and progress has been assessed, it will be important to monitor and follow-up to maintain gains and prevent relapse to maladaptive coping strategies. The follow-up provides an opportunity to assess the continuance of skills learned in treatment, progress toward desired changes, and the provision of positive reinforcement, redirection, and booster information to encourage and support continuing progress (Camacho & Hunter, 2008). Follow-up will be done with Carey, Ms. Tocher, Mrs. Watson, Ms. Jones and Ms. Bradshaw one month after ending the intervention. In addition to personal follow-up, two small group booster sessions, at one month and three months respectively, are included in the postintervention phase to support the maintenance of more adaptive coping skills (Schoenfield & Morris, 2009). Follow-up with Carey will include an informal discussion-based assessment of her use of new skills to reduce overall anxiety and how those skills are working for her. Specifically, the use of relaxation strategies, social skills, and effects of cognitive restructuring will be reviewed in

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regards with how they are being applied in anxiety-provoking situations like going to school and being away from mom (Laughlan, 2003). A feeling thermometer can be used for self-assessment, providing a visual means to rate performance towards objectives while encouraging awareness and self-reward (Comacho & Hunter, 2008). If there is low response to this intervention attempt, Carey will be referred for psycho-educational assessment by the school board psychologist. Environmental follow-up occurs through discussion with Ms. Tocher and Careys teachers to ensure that environmental changes have remained consistent and have not reverted to supporting or reinforcing maladaptive behaviors. Discussions concerning what and how behaviors are being reinforced provide an opportunity to reinforce the concept of contingency management to promote desired behaviors (Doobay, 2008). The frequency of behaviors, such as school attendance rates, psycho-somatic complaints, and requests to call home from school, can be checked to provide measurable evidence of progress or maintenance of desired behaviors. School-based booster sessions will occur within the small group, through an applied review of salient material from the FRIENDS curriculum and one booster session will occur at home with Ms. Tocher. Recommended School-Wide Interventions (Sharon) Universal intervention programs are intended for all students as preventative measures for a large range of possible problems. They are implemented through curriculum and school climate development. Universal implementation of FRIENDS, a focus on community-building, and positive behavioral supports (PBS) are recommended for the school to prevent anxietyrelated problems and subsequent negative outcomes from occurring. Universal mental health interventions can be integrated into regular health curricula to reach all students. School-wide implementation of specific programs promotes reinforcement of concepts and consistency of social-emotional language and strategies among teachers and

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students. Anxiety can be addressed through preventative psycho-education that targets adaptive coping strategies, problem-solving, and social skills (Tomb & Hunter, 2004). It is recommended that the FRIENDS program is extended from the current Grade 2 implementation up to Grade 6, and downwards to Kindergarten and Grade 1 with the Fun FRIENDS program. These programs address anxiety through the development of relaxation techniques, cognitive restructuring, attentional training, and peer support (Schoenfield & Morris, 2009). The development of a positive, welcoming school climate can also be considered a universal preventative strategy for anxiety and attendance problems (Kearney, 2008). A positive school environment is built around supportive relationships, open communication, and consistency. Teaching staff can effectively model and teach community values and caring for each other and students, resulting in increased social skills and sense of security (Alberta Education, 2008). Developing a relationship with at least one adult in school has been reported to positively affect the students feelings about school (Alberta Education, 2008). Besides relationships, school-based extra-curricular activities can also provide a sense of belonging and school community. Supervised early morning and after-school activities, such as a breakfast program, gym activities, open library or computer lab, and informal tutoring are recommended. Additionally, open-door policies, regular newsletters with good-news stories, and friendly phone calls can support home-school communication and reduce anxiety regarding school coming from the home environment (Alberta Education, 2008). PBS is recommended as an empirically based, universal preventative technique used primarily for disruptive behaviors, but also useful for developing a positive school climate. In developing a school-wide PBS program, a few positive behavioral values are selected and used as a framework for talking about and teaching school-wide behavioral expectations (Alberta Education, 2008). Training and reinforcement of behavioral values across all classes by all

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school staff provides a standard of acceptable behavior and a sense of security for students. Positive reinforcement, such as a school-wide token economy and public recognition, for desired behaviors is recommended to promote school climate change. It is important that all students have access to positive reinforcement, which requires consistency among staff members. Undesired behaviors must also result in predictable consequences that are not reinforcing but are instructional, such as corrective feedback and self-analysis, response-cost strategies, and making restitution (Alberta Education, 2008). Recommended Resources for Practitioners (Sharon and Meagan) Table 2 provides a sample of educational and professional resources that may be useful when working with an anxious child.
Table 2

Anxiety Resources for Educators and Psychologists

Category Professional resources Authors Paula Barrett John S. Dacey Bruce Chopita Gretchen Peacock & Brent Collett Andrew Eisen Kenneth Merrell Andrew Eisen & Charles Schaeffer Alberta Education Phillip Kendall Paul Foxman Childrens books Nancy Pando & Kathy Voerg Kari Buron Title FRIENDS for Life: Group Leaders Manual for Children & FRIENDS for Life: Workbook for Children (4th ed.) Your Anxious Child: How Parents and Teachers Can Relieve Anxiety in Children Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders Collaborative Home-School Interventions: Evidence-Based Solutions for Emotional, Behavioral, and Academic Problems Treating Childhood Behavioral and Emotional Problems: A Step-by-Step, Evidence-Based Approach Helping Students Overcome Depression and Anxiety Separation Anxiety in Children and Adolescents: An Individualized Approach to Assessment and Treatment Supporting Positive Behavior in Alberta Schools Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual (2nd ed.) The Worried Child: Recognizing Anxiety in Children and Helping them Heal I Dont Want to Go to School: Helping Children Cope with Separation Anxiety When My Worries Get Too Big: A Relaxation Book for Children Who Live with Anxiety

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Lawrence Shapiro & Robin Sprague Dawn Huebner Electronic resources Education Queensland BC Ministry of Children and Families National Institute of Health Anxiety Disorders Association of America

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The Relaxation and Stress Reduction Workbook for Kids: Help for Children to Cope with Stress, Anxiety and Transitions What to Do When You Worry Too Much: A Kids Guide of Overcoming Anxiety Document: Education adjustments-Anxiety (http://www.learningplace.com.au/deliver/content.asp?pid=34810) Video: Understanding Anxiety from the Child and Parent Perspective (http://www.mcf.gov.bc.ca/mental_health/images/clinical-anxiety.wmv) Video: Bridging Science, Treatment and Public Education of Anxiety Disorders (http://videocast.nih.gov/summary.asp?Live=9780) Website: Understanding anxiety (http://www.adaa.org/understanding-anxiety)

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Alberta Education. (2008). Supporting Positive Behavior in Alberta Schools: A school-wide approach. Edmonton, Alberta: Author. Angold, A., Costello, E.J., & Erkanli, A. (1999). Comorbidity. Journal of Child Psychology and Psychiatry, 40(1), 57-87. Arora, P., Funk, C.L. & Stark, K.D. (2011). Training School Psychologists to Conduct Evidence-Based Treatments for Depression. Psychology in the Schools, 48, 272-282. Barrett, P. (2004). Friends for Life: Group leaders manual for children. Browen Hills, Queensland, Australia: Australian Academic Press. Barrett, P.M., Dadds, M.R., & Rapee, R.M. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64(2), 333342. Barrett, P.M., Farrell, L.J., Ollendick, T.H., & Dadds, M. (2006). Long-term outcomes of an Australian universal prevention trial of anxiety and depression symptoms in children and youth: an evaluation of the friends program. Journal of Child and Adolescent Psychology, 35(3), 403-411. Barrett, P.M., & May (2005). Introduction to FRIENDS: Anxiety Prevention and Treatment for children aged 711 and youth aged 1216. Queensland, Australia: Australian Academic Press. Barrett, P.M., & Turner, C. (2001). Prevention of anxiety symptoms in primary school children: Preliminary results from a universal school-based trial. British Journal of Clinical Psychology, 40, 399-410. Beck, A.T., & Dozois, D.J.A. (2011). Cognitive Therapy: Current Status and Future Directions. Annual Review of Medicine, 62, 397-409. doi: 10.1146/annurev-med-052209-100032.

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Briesch, A.M., Hagermoser Sanetti, L.M., & Briesch, J.M. (2010). Reducing the prevalence of anxiety in children and adolescents: An evaluation of the evidence base for the FRIENDS for Life program. School Mental Health, 2, 155-165. doi: 10.1007/s12310-010-9042-5 Camacho, M., & Hunter, L. (2008). Effective interventions for students with separation anxiety disorder (pp. 51-73). In C. Franklin, M.B. Harris, & A. Allen-Meares (Eds.) The School Practitioners Concise Companion to Mental Health. New York, NY: Oxford University Press. Corbin, J. & Morse, J. (2003). The Unstructured, Interactive Interview: Issues of Reciprocity and Risk when Dealing with Sensitive Topcis. Qualitative Inquiry, 9, 335-354. Doobay, A.E. (2008). School refusal behavior associated with separation anxiety disorder: A cognitive-behavioral approach to treatment. Psychology in the Schools, 45(4), 261-272. doi: 10.1002/pits.20299 Elliot, S.N. & Roach, A.T. (2008). Best practices in facilitation and Evaluating Intervention Integrity (pp.195-207). In A. Thomas and J. Grimes (Eds.) Best Practices in School Psychology V. Bethesda, MD: National Association of School Psychologists. Eugster, K. (2012). Anxiety in children: how parents can help. Retrieved from http://www.kathyeugster.com/articles/article004.htm Huberty, T.J. (2009). Best practices in school-based interventions for anxiety and depression (pp.1473-1486). In A. Thomas and J. Grimes (Eds.) Best Practices in School Psychology V. Bethesda, MD: National Association of School Psychologists. Kearney, C.A. (2008). An interdisciplinary model of school absenteeism in youth to inform professional practice and public policy. Educational Psychology Review, 20(3), 257-282. doi: 10.1007/s10648-008-9078-3

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Kurtz, S.M.S. & Lock, M.K. (2005). Direct Behavioral Observation in School Settings:Bringing Science to Practice. Cognitive and Behavioral Practice, 12, 359-370. Lauchlan, F. (2003). Responding to chronic non-attendance: A review of intervention approaches. Educational Psychology in Practice, 19(2), 133-146. doi: 10.1080/0266736032000069938 Miller, L.D., Short, C., Garland, J.E., & Clark, S. (2010). The ABCs of CBT (Cognitive Behavior Therapy): Evidence-Based Approaches to Child Anxiety in Public School Settings. Journal of Counseling & Development, 88, 432-439. Mash, E.J., & Barkley, R.A., (2003). Child psychopathology (2nd Ed.). NY: The Guilford Press. Schoenfield, G., & Morris, R.J. (2009). Cognitive-behavioural treatment for childhood anxiety disorders: Exemplary programs (pp.204-232). In M.J. Mayer (Ed.) Cognitive-behavioural interventions for emotional and behavioural disorders: school-based practice. New York, NY: The Guilford Press. Shortt, A., Barrett, P.M., & Fox, T. (2001). Evaluating the FRIENDS program: A cognitive behavioural group treatment of childhood anxiety disorders: An evaluation of the FRIENDS program. Journal of Clinical Child Psychology, 30(4), 523533. Tomb, M., & Hunter, L. (2004). Prevention of anxiety in children and adolescents in a school setting: The role of school-based practitioners. Children and Schools, 26(2), 87-101. Weissman, A.S., Antinoro, D., & Chu, R.J. (2009). Cognitive-behavioural therapy for anxious youth in school settings: Advantages and challenges (pp.173-203). In M.J. Mayer (Ed.) Cognitive-behavioural interventions for emotional and behavioural disorders: schoolbased practice. New York, NY: The Guilford Press.