PILOT STUDY

A Pilot Study of a Brief Universal CB Intervention as part of Health Classes in Middle School

A Pilot Study of a Brief Universal CB Intervention

as part of Health Classes in Middle School

Himle, J. A., Raknes, S., & Koschmann, E.

Anxiety is considered a mental illness associated with the highest problem load in modern developed countries. However, anxiety prevention programs for adolescents are rare, and only a small proportion of adolescents with anxiety disorders receive evidence-based interventions to reduce anxiety symptoms. Cognitive behavioral therapy (CBT) is an effective treatment for anxiety. However, most young people with mental health problems are not offered evidence-based mental health services. A key barrier to cognitive behavioral (CB) interventions for adolescents, is CB expertise among school professionals, costs associated with interventions, and limited access to CB interventions in arenas where the adolescents spend their time. Large scale public health problems have historically typically been reduced more by prevention initiatives rather than by treatment. This pilot-project will test the hypothesis that a school based CB intervention, developed to be administered within middle school health classes, is feasible in an American Public School. The primary focus of the investigation will be the outcomes related to school professionals. The secondary data will be collected from students that participated in the intervention.

Methods: The present study is an explorative mixed method feasability-study. Slauson Middle School, from the Ann Arbor Community School District will serve as the intervention site for the four session CB intervention. We aim to recruit school professionals, specifically individuals that are teaching middle school health. Once recruited and consented, school professionals will be trained through a hands on, modeling approach within the classroom setting. This project aims to increase school-professionals´ knowledge and utilization of the CB intervention, leading to implementation of evidence-based CB based interventions within the classroom.

The primary data collected in this study will be satisfaction surveys from school professionals. Primary data will assist in observing increased knowledge of the feasibility of integrating a CB preventive intervention as part of health classes in 7th grade. The project also aims to collect data from the students who receive the CB intervention. Secondary data will observe any decreases in anxiety symptoms, increases in self-efficacy, and increases in Health Related Quality of Life following provision of services.

This dissemination program is designed to address barriers to CB interventions by providing training to school professionals, and assisting in building knowledge in CB interventions that can be utilized in the classroom. The project seeks to refine and test a dissemination and implementation model to increase CB interventions within the schools; and to improve the content and quality of mental health services available to students.

Keywords: anxiety, adolescents, school-based, prevention, CBT

Background

Anxiety disorders are among the most prevalent mental health problems in adolescents (Essau, Conradt, & Peterman, 2002; Kessler et al., 2005). They often have a chronic course and may represent a considerable burden to individuals, families and society (Baxter, Vos, Scott, Ferrari, & Whiteford, 2014; Bodden, Dirksen, & Bogels, 2008; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Mykletun et al., 2006). In addition to youth that meet criteria for an anxiety disorders, are individuals who struggle with sub-threshold anxiety problems (Gadermann, Alonso, Vilagut, Zaslavsky, & Kessler, 2012). The knowledge that about one of five pupils in upper secondary school are anxious, and that levels of anxiety are strongly associated with Quality of Life (QoL), makes adolescence anxiety to a large scale challenge for society, as well as hampering for the many adolescents for whom anxiety inhibit and characterize their everyday life. Anxiety in adolescents is associated with decreased level of functioning in many areas; e.g. poor academic performance, social dysfunction, sleep problems, school absenteeism and school drop-out (Mychailyszyn, Mendez, & Kendall, 2010; Peterman et al., 2016; Rao et al., 2007; Van Ameringena, Mancinia, & Farvolden; Verduin & Kendall, 2008). Furthermore, anxiety increases the risk for subsequent depression and substance use in adolescents (Puleo, Conner, Benjamin, & Kendall, 2011; Wittchen, Beesdo, Bittner, & Goodwin, 2003; Wolk, Kendall, & Beidas, 2015). Thus, preventive interventions to reduce adolescent anxiety the adverse effects of anxiety on development, social functioning and school performance are promising.

From treatment to health literacy

At a time when the health system is fragmented, complex and specialized, health literacy on mental health, anxiety included, is important not barely to ask for health services when needed, but also to do what you can yourself, in your daily life, to build mental health. WHO states there is a need for community campaigns, aimed at increasing public awareness, raising mental health literacy, and decreasing the distance between people´s belief about different treatment options and what mental health professionals have to offer (WHO, 2004). Health literacy can be defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (U.S. Department of Health and Human Services, 2010). Low recognition of mental health problems serves as a barrier to treatment (Coles and Coleman, 2010), and lack recognition of severity by lay individuals for anxiety has been documented (Paulus, Wadsworth, & Hayes-Skelton, 2015). Accordingly, if anxiety problems were identified in adolescents and recognized as an important problem the adolescent should get help to reduce, this could possibly reduce adolescent anxiety. Hence, mental health literacy that included information to adolescents, teachers and parents on anxiety and anxiety coping skills may be an appropriate start that will help to set the foundation for prevention of anxiety: With a double goal of the interventions 1) to reduce anxiety level and 2) improve anxiety literacy in adolescents, parents and teachers. Future efforts should focus on improved recognition and education regarding anxiety disorders in the adolescent population, particularly before they become severe. Implementation of universal school-based mental health awareness programs have been found to be promising in reducing stigma associated with mental health disorders and problems, and raising health literacy (Salerno, 2016).

School-based preventive interventions

To reduce the level of anxiety in adolescents, preventive interventions to youth in the school setting, e.g. in health classes, is an alternative to traditional treatment approaches (Mychilyszyn et al., 2011). Adolescents spend much of their time in school and many experience situations in the school environment that may trigger anxiety (e.g. social situations, separation from primary caregivers, being evaluated by teachers and peers). School-based interventions may help to reduce key barriers to access help for adolescents. It have been argued that new interventions have to be adapted to better fit with the school system (Mychilyszyn et al., 2011). This highlights the importance of developing and evaluating a school-based CB interventions for students with anxiety symptoms that reduces the burden on the school system (McLoone & Rapee, 2012). One way of achieving this is by changing to implement preventive, universal interventions within school health classes.

Purpose of the study

This project aims to increase school-professionals´ knowledge and utilization of evidence-based CB interventions with students. The project also aims to report findings that students who receive a CB intervention within the classroom, experience decreases in anxiety symptoms, increases in self-efficacy, and increases in Health Related Quality of Life following provision of services.

This dissemination program is designed to address barriers to CB interventions by providing training to school professionals and assist in building knowledge of CB interventions. The project seeks to refine and test a dissemination and implementation model to increase CB interventions within the schools; and to improve the content and quality of school based interventions for students.

Methods

This is an exploratory, mixed-method pilot study. Research-assistant-administered, paper-and-pencil questionnaires provided the basis for both qualitative and quantitative analyses. UM social workers in the research team will lead the CB intervention in the health classes, while the school professionals (teachers and counsellors) are attending. The school professionals are asked to complete inventories measuring the feasibility of a CB intervention in health classes, after each session. Also, students will be asked to complete inventories measuring the feasibility of the intervention after the intervention, as well as standardized inventories measuring the anxiety symptom level, health related quality of life, and general self-efficacy, before and after the brief intervention (four sessions) is implemented as part of their health classes.

Participants and procedure

Participants will be

1) School professionals attending Health Classes at Slauson Midle School in Ann Arbor, Michigan.

2) Middle school students, between 11 and 14 years old, enrolled in health classes at Slauson Middle School.

Inclusion criteria

  1. School-professionals that have signed informed consent to participate in the study.
  2. Students:
    1. Attend a health class at Slauson Midle School
    2. Assent from the youth and signed informed consent from the parent or gaurdian.

Exclusion criteria

The only exclusion criteria for school personnel will be inability to comply with all aspects of the study outlined in the school professional consent form. There are no exclusion criteria for students from whom we will be collected data.

Student participants may withdraw from participation in the UM survey research part of the study at any time.

Recruitment

School professionals will be recruited following recommendations from the leadership at Slauson Middle School, in the Ann Arbor Public School District. These communications will be via email and in person with Slauson Middle School administration. Once school professionals are recruited, and agree to speak to a UM Study Team Member, they will be asked to sign an informed consent. Upon signing the informed consent, they will be able to participate in the study.

All students in two health classes will be invited to participate as part of their Health classes.

Intervention

Helping Hands – Happy Kids is a manual based CB universal preventive intervention developed for use in middle school health classes. It´s a four sessions intervention, each session will last about fifty minutes and will be implemented by a school professional. The intervention lasts four weeks (one session each week), and is focused on basic CB principles that assist in reducing youth anxiety; e.g. psychoeducation; cognitive restructuring, training exercises, as well as homework assignments. The material used in the intervention is the Helping Hands – Happy Kids (Raknes, 2017), a translation of a Norwegian CB self-help-material (Raknes, 2010). A previous feasibility study in Norway indicated that primary school health workers and teachers found Helping Hands – Happy Kids to be useful, particularly when working with youth experiencing anxiety symptoms (Haugland, Mauseth, & Raknes, 2013).

Assessment

School professionals will complete questionnaires after observing each CB session.

Students will complete questionnaires administered with pen-and-paper, at pre-intervention and post-intervention. Students will be asked to complete self-report questionnaires before the beginning of the first CB session. These questionnaires will be administered and collected by UM Study Team Members. Directly after the completion of the four sessions, (the same) self-report measures will be administered and collected by UM Study Team Members.

Primary outcome measures

Teacher Evaluation of Helping Hands – Happy Kids (developed for this study).

Student Evaluation of Helping Hands – Happy Kids (developed for this study).

Secondary outcome measures completed by students

Spence Children’s Anxiety Scale –child version (SCAS) (Nauta et al., 2004; Spence, 1998) is a questionnaire designed to assess youth anxiety symptoms. The child version contain 38 items (in addition the child version has 6 positive filler items). SCAS consists of six subscales for specific anxiety areas: panic/agoraphobia, social phobia, generalized anxiety, separation anxiety, and specific phobias. Each subscale may be scored separately as well as added together for a score of overall anxiety symptoms. Each item is scored on a 4-point scale from “never” to “always”. SCAS has been found to have good psychometric properties (Arendt, Hougaard, & Thastum, 2014; Nauta et al., 2004; Spence, 1998; Spencea, Barrett, & Turner, 2003). SCAS has been used in many CBT intervention studies, including several Scandinavian treatment studies (Arendt, Thastum, & Hougaard, 2015; Jonsson, Thastum, Arendt, & Juul-Sorensen, 2015; Wergeland et al., 2014).

Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents

Revised Version (KINDL-R) (Ravens-Sieberer & Bullinger, 2000) is a questionnaire for measuring quality of life in children and adolescents. KINDL-R consists of six subscales each with 4 items (physical- and emotional well-being, self-esteem, family, friends and school). All items are scored on a 5-point scale from “never” to “all the time”. The German versions of KINDL-R indicate satisfactory psychometric properties (Ravens-Sieberer & Bullinger, 2000), with the Norwegian translated version being evaluated as promising (Helseth, Lund, & Christophersen, 2006; Jozefiak & Reinfjell, 2012).

General Self-Efficacy Scale (GSE) (Schwarzer & Jerusalem, 1995) is a 10-item questionnaire assessing optimistic self-beliefs to cope with a variety of difficult demands in life. GSE will be completed by the adolescents and scored on a 4-point scale (from “not at all true” to “exactly true”). The scale has shown adequate psychometric properties (Luszczynska, Scholz, & Schwarzer, 2005; Scholz, Gutiérrez-Dona, Sud, & Schwarzer, 2002).

Table 1

Measure Instrument Informant TimePoints for Measurement Administration Type
Teacher Evaluation of Helping Hands-Happy Kids   School Professional All Sessions(1-4) Self Report
Student Evaluation of Helping Hands-Happy Kids SEHH     Self Report
Spencer Children’s Anxiety Scale SCAS Student Pre, Post Self Report
Health related Quality of Life KINDL Student Pre, Post Self Repot

General Self-Efficacy Scale

GSE Student Pre, Post Self Report

Data analytical plan

Data will be collected by pen and paper.

The quantitative data will be analysed using SPSS 22. Changes in secondary outcomes measures will be analysed using ANOVA and further explored by least significant difference post hoc tests. The qualitative data will be analysed using Nvivo. The main themes and sub-themes reflecting feasibility will be derived through a bottom-up analysis of the questionnaires, first by generating initial codes, then searching for themes, and finally reviewing potential themes. Codes, sub-themes, and main themes, including the process of defining and naming the themes, will be discussed by the authors to ensure that themes have singular focus, do not overlap, and address our research questions. Deriving from our experience as psychologists and cognitive behavioural therapists, our terminology and frames for understanding themes stem from a psychological, CBT perspective.

Dissemination

Scientific journals will be used as outlets.

Competing interests

SR developed the Helping Hands – Happy Kids program, but do not receive royalties.

Helping Hands – Happy Kids is a manual based CB universal preventive intervention developed for use in middle school health classes. It´s a four sessions intervention, each session will last about fifty minutes and will be implemented by a school professional. The intervention lasts four weeks (one session each week), and is focused on basic CB principles that assist in reducing youth anxiety; e.g. psychoeducation; cognitive restructuring, training exercises, as well as homework assignments. The material used in the intervention is the Helping Hands – Happy Kids (Raknes, 2017), a translation of a Norwegian CB self-help-material (Raknes, 2010). A previous feasibility study in Norway indicated that primary school health workers and teachers found Helping Hands – Happy Kids to be useful, particularly when working with youth experiencing anxiety symptoms (Haugland, Mauseth, & Raknes, 2013).

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Solfrid Raknes – solfrid.raknes@hotmail.com – +47 416 17 343