Previous Award Number: R305A140657
Previous Awardee: Johns Hopkins University

Purpose: The goal of this project was to develop an intervention for school nurses to help students with anxiety. Anxiety disorders are among the most common psychiatric conditions affecting youth, with overall prevalence rates ranging from 10 to 20 percent. 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. Schools are, therefore, an ideal location for nurses to deliver interventions for reducing childhood anxiety.

Project Activities: The researchers developed and refined the CALM (Child Anxiety Learning Modules) intervention using an iterative development process that included 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, the researchers randomly assigned school nurses (one per school) to deliver the CALM intervention (treatment) or relaxation training (CALM-R, an active control) to determine the promise of the intervention for reducing children's anxiety symptoms and improving their cognitive functioning and school performance.

Key Outcomes:

• The project team developed CALM (Drake, K.L., et al., 2015), an intervention for school nurses based on cognitive behavioral therapy to help students with anxiety.
• In an open trial (Muggeo, M.A., et al., 2017) and in a pilot of promise (Gingburg, G.S., 2019), the researchers found that task shifting responsibility for delivering brief mental health interventions to school nurses is feasible.
• Both school nurse interventions (CALM and CALM-R) resulted in clinically meaningful reductions in student anxiety and related disability (Gingburg, G.S., 2019) at post intervention and at a 3-month follow-up.

Structured Abstract

Setting: The research took place in elementary schools in Maryland and Connecticut.

Sample: The final sample for this study included 39 school nurses (12 in the open trials and 27 in the pilot study) and 68 children (14 in the open trials and 54 in the pilot study) with elevated anxiety symptoms. Children were 7 through 12 years old and enrolled in grades 1 through 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 is 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 (e.g., behavioral exposure), L = Listen to scary thoughts and change them into coping thoughts, and M = Manage problems using problem solving strategies. An intervention manual describes the content of each session and provides examples to illustrate how nurses can convey the content to children effectively.

Research Design and Methods: The researchers developed CALM using an iterative process in which versions of the intervention and its implementation procedures were tried out sequentially and refined in response to feedback from expert consultants, school nurses, children, parents, and school personnel until it was found usable in the school environment. The proposed format of the intervention was 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 allowed the 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 informed modifications for the second open trial. Feedback from the second open trial was used to make modifications to CALM in preparation for a cluster-randomized design pilot study in which researchers randomized school nurses (one per school) to intervention or an active control group. Nurses recruited potentially eligible children and independent evaluators screened them to determine eligibility. Those eligible children received 8 weeks of treatment (CALM or relaxation training) depending on their school nurse's random assignment. Children in both conditions were 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 study, children in schools where nurses were assigned to the control group received relaxation training.

Key Measures: Nurses' knowledge of cognitive behavioral therapy strategies was assessed using the Clinician Knowledge of CBT Test. Anxiety symptoms were 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 were 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 completed the Treatment Satisfaction Questionnaire. School records provided 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) was used to explore the relationship between anxiety and working memory, which has been hypothesized to account for academic impairment among anxious youth. The researchers used the Woodcock-Johnson Tests of Achievement (WJ-III) 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) were used during the development phase. For the pilot study, the impact of the intervention on children's academic performance and anxiety was 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 were included in the models as covariates.

Related Projects: Enhancing the Capacity of School Nurses to Reduce Excessive Anxiety in Children: An Efficacy Trial of the CALM Intervention (R305A200195)

PRODUCTS AND PUBLICATIONS

ERIC Citations: Find available citations in ERIC for this award here or here.

Select publications:

Caron, E. B., Drake, K. L., Stewart, C. E., Muggeo, M. A., & Ginsburg, G. S. (2020). Intervention Adherence and Self-Efficacy as Predictors of Child Outcomes in School Nurse-Delivered Interventions for Anxiety. The Journal of School Nursing , 1059840520925522.

Drake, K. L., Stewart, C. E., Muggeo, M. A., & Ginsburg, G. S. (2015). Enhancing the capacity of school nurses to reduce excessive anxiety in children: Development of the calm intervention. Journal of Child and Adolescent Psychiatric Nursing, 28 (3), 121–130.

Ginsburg, G. S., Drake, K. L., Muggeo, M. A., Stewart, C. E., Pikulski, P. J., Zheng, D., & Harel, O. (2019). A pilot RCT of a school nurse delivered intervention to reduce student anxiety. Journal of Clinical Child & Adolescent Psychology , 1–10.

Muggeo, M. A., Stewart, C. E., Drake, K. L., & Ginsburg, G. S. (2017). A school nurse-delivered intervention for anxious children: An open trial. School Mental Health , 1–15.