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Intervention Plan Running head: INTERVENTION PLAN

Intervention Plan for Separation Anxiety Jenn Christy Seton, Shauna Thompson, and Alicia Woloschuk University of Calgary

Intervention Plan

DSM Diagnosis and Functional Analysis A clinical interview was completed with responses scored on the Diagnostic Interview for Children and Adolescents-IV (DICA-IV). Observation was done in-home and in school, and an interview was conducted with Jenn Sampson, her mother Stacey Sampson, and her teacher Mrs. Carter. Jenn visited her pediatrician for a medical assessment to ensure she had no physical illnesses. The following information is provided based on the results of the interviews and observations. Jenn shows developmentally inappropriate and excessive anxiety concerning separation from her mother. She tantrums and has long crying periods when left with a babysitter, she becomes extremely upset and inconsolable at school to the point where her mother removes her, and she refuses to stay overnight with her aunt unless her mother is also present. Jenns mother has reported that Jenn is starting to refuse going to her aunts house to play with her cousin, and she refuses to go out and play with other friends. As reported by her mother, Jenn cries and complains of a stomach ache each morning that she has to go to school, and she currently misses 1-2 days of school per week. After visiting the pediatrician no physical cause was found for the physical complaints that come mainly on mornings before she goes to school. These complaints and disturbances have been happening with increasing frequency and intensity over the past six months, and are causing significant distress and impairment with Jenns functioning in social and academic domains. Based on this information, Jenn meets the criteria set out in the DSM-IV-TR (Diagnostic and Statistical Manual, Fourth Edition, Text Revision) for Separation Anxiety Disorder (SAD) (309.21).

Intervention Plan Separation Anxiety SAD is found in approximately 10% of all children, making it the most commonly occurring anxiety disorder during childhood. Although displaying fears of separation are important and relatively normal for children up until the preschool years, some children

continue to display such anxiety long after the age when it is typical and expected (Mash & Wolfe, 2005). As Shaffer, Wood and Willoughby (2002) explain, separation anxiety normally appears at 6 to 8 months of age... peaks at 14 to 18 months, and gradually becomes less frequent and less intense throughout infancy and the preschool period (p. 410). Accordingly, children with SAD can be characterized as displaying ageinappropriate, excessive and disabling anxiety [in regards to] being apart from their parents or away from their home (Mash & Wolfe, 2005, p. 186). Specifically, young children with SAD tend to be clingy to their parents and may fuss, scream or cry to avoid separation. In addition, children may report feeling physical symptoms such as headaches and stomachaches and may become increasingly withdrawn, depressed and display flat affect. Often, symptoms related to SAD progress from being mild to more severe and increase the likelihood of the child developing comorbid or future disorders (Mash & Wolfe, 2005). Additionally, the academic performance of children with SAD may begin to suffer due to frequent school absences and preoccupation with distress and separation concerns, ultimately increasing the likelihood of them having to repeat the school year (Albano, Chorpita & Barlow, 2003). Consequently, it is of the utmost importance to address separation anxiety as when left untreated, it can become a debilitating condition with several possible long-term consequences, including educational underachievement,

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substance abuse, psychiatric problems, and low social support (Doobay, 2008, p. 261). As a result, this paper will address the concerns displayed by Jenn and recommend an empirically-based intervention plan to treat her separation anxiety and school refusal behaviour. Treatment of Separation Anxiety Disorder As Mash and Wolfe (2005) suggest, it is imperative that treatment for separation anxiety targets all identifying problems and symptoms including, ones distorted information processing, lack of control, physiological reactions, and excessive escape and avoidance behaviours. As such, taking a collaborative approach will help ensure a comprehensive and consistent means to treatment, ultimately helping to address Jenns wide range of problems (Sattler & Hoge, 2006). For instance, a review of literature points to the particular importance of including parents in the therapeutic process and suggests that such involvement unquestionably facilitates treatment success (Suveg, 2006). As Suveg et al (2006) explain, parents can perhaps be thought of as invaluable members of the treatment team whether their role is that of providing information regarding the nature of the childs functioning or assisting the therapist in the design and implementation of exposure tasks (Suveg, 2006, p. 297). Similarly, teachers can assist by ensuring that intervention strategies are implemented across different contexts, strengthening the consistency of treatment procedures (Mash & Wolfe, 2005). Therefore, it is recommended that Jenns SAD be treated using a series of on-going interventions implemented by her therapist, family, and school personnel who will work together to make appropriate accommodations useful in reducing the sources of Jenns anxiety (Massachusetts General Hospital, 2010).

Intervention Plan In regards to treatment, several methods have shown to contribute to reducing symptoms of SAD, however, the use of cognitive-behavioural therapy (CBT) has been studied more extensively than any other approach and holds a more reliable evidence-base (Doobay, 2008). As Masi, Mucci & Millepiedi (2001) explain, while pharmacological treatments for instance, can be relatively successful in hindering SAD-related symptoms, results from clinical trials remain controversial and inconsistent. CBT however, has not only repeatedly proven to be effective in reducing and diminishing symptoms, but it has also shown to help increase ones coping skills as well as provide long-term effects and preventative outcomes (Doobay, 2008).

Furthermore, while medications may be able to treat a particular symptom, they are unable to provide a multidimensional means of intervention and do not take into account individual and contextual differences (Masi et al., 2001). In contrast, the CBT approach tends to be multifaceted and uses a variety of cognitive and behavioral techniques. It also incorporates the childs social context by including the parents and school and is therefore is able to shape therapy to the childs direct and individual needs (Gosch, FlannerySchroeder, Mauro, & Compton, 2006, p. 248). Accordingly, a vast variety of controlled studies have shown the efficacy of [CBT] in children with anxiety disorders... [and] support this approach as the best proven treatment (Masi et al., 2001, p. 97). The following section will therefore, conceptualize CBT and provide an empirical argument for implementing this approach with Jenn. Cognitive-Behavioural Therapy (CBT) Cognitive-behavioural approaches to treatment assume that faulty thought patterns in addition to faulty learning and environmental experiences are to blame for psychological

Intervention Plan disturbances, such as anxiety. In other words, according to CBT, the ways in which

children think about their environment largely determines how they will react to it (Mash & Wolfe, 2005). A major goal of treatment therefore, is to identify maladaptive or negative cognitions and replace these thoughts with more adaptive ones. As Weissman, Antinoro and Chu (2009) explain, cognitive distortions are considered to play a key role in the etiology, expression, and maintenance of anxiety, as they lead to misinterpretations of environmental threats and the childs own coping abilities (p. 184). Consequently, additional goals include teaching the child to use both, cognitive and behavioural coping strategies as well as to regulate their own behaviour. As a result, the child will ultimately be able to think more positively and use more effective coping strategies and social skills to react to feared stimuli (Mash & Wolfe, 2006; Masi, Mucci, & Millepiedi, 2001). In keeping with the goals of CBT, several techniques may be used, most of which are based on principles of classical conditioning, vicarious learning, or operant conditioning (Doobay, 2008). Specific techniques aim to expose the child to the feared stimuli (such as counter-conditioning, extinction, and modeling). According to Doobay (2008), this exposure is an imperative component to the treatment of anxiety disorders. In classical conditioning, two stimuli are paired which produce incompatible responses. For instance, a child may be forced to attend school and repeatedly shown that their parent will be present to pick them up at the end of each day. Eventually, the child should begin to realize that they will return to their parent despite temporary separation. Furthermore, the use of modeling demonstrates to the child how to use coping behaviours in the absence of parents and, operant conditioning incorporates positive reinforcement to encourage

Intervention Plan children to display desired behaviour while ignoring behaviour which is unacceptable (Doobay, 2008; Gosch et al., 2006). Additionally, subsequent techniques such as cognitive restructuring are commonly used to help change a childs irrational or unrealistic beliefs about separation. Within this process, the therapist strives to challenge the childs cognitions and help them form more positive and more rational self-statements (Cristea, Benga, & Opre, 2008). Taken together, the amount of empirical support for the use of CBT to treat childhood separation anxiety is overwhelming. Repeatedly, results from clinical trials

indicate the importance of exposure experiences as well as modifying the childs cognitive processes. That is, changing the childrens expectancies regarding the dangerousness of stimuli, their own self-efficacy, and their experience of anxiety are key treatment targets... [as is] skill building to increase a childs... adaptive responses and... their sense of mastery and control (p. 253). Consequently, the proposed intervention plan for Jenn is largely built from the theoretical concepts of CBT, implementing techniques which are cognitively and behaviourally based. However, it also takes into account the importance of comprehensiveness and consistency, achieved through collaboration and working as a team. Rationale Within the past six months to a year, Jenn has developed anxious type behaviours when she becomes separated from her mother, Stacey. These behaviours have escalated to a point where they are now interfering with Jenns daily functioning and are impacting her social-emotional and academic well-being.

Intervention Plan More specifically, Jenn has exhibited school refusal behaviours and commonly needs her mother to pick her up early from school, resulting in Jenn missing a significant amount of learning. When at school, it is reported that she is unable to remain focused. She has also started to make somatic complaints and engages in tantrums and excessive

crying when she is separated from her mother. It is reported that Jenn expresses the need to be close to her mother at all times. In addition to these anxious behaviours, Jenn also appears to be quiet and socially withdrawn. Where she once was a very social and active child, she is no longer interested in swimming or play dates with friends and chooses to play in her room alone. Jenn has reported feeling that nobody likes her and that her friends no longer want to play with her. Jenns mother, Stacey, reports that Jenn will sleep until she drags her out of bed whereas before she would be up early wanting to play. Jenns teachers report that Jenn will cry when called upon to answer questions in class and is often heard expressing negative, selfdefeating, thoughts about herself such as, Im stupid in math and Im ugly. Given these emergent behavioral concerns, it is essential that an intervention plan address the underlying separation anxiety-based contributors in order to assist Jenn in returning to a normal way of functioning. Intervention Description As previously discussed, there is a significant amount of empirical evidence supporting the use of CBT to treat SAD in children. Consequently, this specific intervention plan centers around CBT-based strategies. It also aims to appreciate the importance of collaboration and consistency across the various environments in which Jenn functions. Thus, in order to achieve a holistic approach, Jenns intervention plan requires

Intervention Plan the involvement of Jenn, her mother Stacey, and her older brother Mike, as well as her teacher Mrs. Carter, school counselor, and psychologist.

The proposed intervention will occur over a period of six weeks with follow-up and maintenance support provided as necessary following intervention completion. Within the six week process, Jenn will be supported with a graduated return to attending school fulltime. Jenn and her family will additionally be supported in addressing Jenns anxiety, and its related symptoms, within the home, school and community environments. The following section provides a brief outline of the proposed intervention plan. A more detailed schedule and description of this intervention is provided in the Appendix. Week One The first week of the intervention will focus on a graduated return to half-time school for Jenn. During the first two days of the week (Monday and Tuesday), it is planned that Jenn only attend her single favorite class each day. For the next two days (Wednesday and Thursday), Jenn is expected to attend two of her favorite classes as well as lunch or recess. The hope is that initially attending her favorite classes, during this graduated return, will ease some of Jenns anxiety associated with being separated from her mother and ultimately, create a positive experience to initiate a return to full-time school. By the end of the first week, it is anticipated that Jenn will be able to remain at school for a full half-day, either the morning or afternoon, including lunchtime. Additionally, Jenn and her mother, Stacey, will attend three counseling sessions with a psychologist during this first week. It is expected that Stacey may need to sit in on the initial sessions until Jenn is comfortable enough to have her wait outside. The first session will focus on rapport building and psycho-education regarding Jenns anxiety and

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related behaviours in order to normalize the experience and provide a basic understanding of the motivation for such behaviours. The subsequent two sessions in week one focus on teaching Jenn relaxation skills that she can apply in situations where she feels anxious. Relaxation techniques include deep breathing, physical relaxation, counting to 10, and visualizing a soothing place. By teaching Jenn how to relax she will be empowered to develop mastery over her anxious symptoms and ultimately, experience an improved sense of control over her body. The psychologist may consider tape recording some of these instructional sessions so that Jenn is able to listen to these at home throughout subsequent weeks. Additionally, the psychologist will support Jenn in preparing for her graduate return to full-time school by engaging her in other CBT-based activities such as role playing, social skills training, and cognitive restructuring of her negative thoughts. Following each counseling session, the psychologist will meet with Stacey alone, to provide further information and education on how she can support Jenn in applying her new skills and strategies within the home. Stacey will also receive instruction regarding specific contingency management strategies such as rewarding Jenns positive behaviours and ignoring negative or anxiety-based ones. It will be important for Stacey to have a clear understanding of Jenns separation anxiety, as it will be easier for Stacey to sympathize with Jenn if she understands how she feels. In addition, it is critical that Stacey meet with the psychologist after Jenns sessions in order to learn the suggested therapeutic activities (e.g. muscle relaxation and deep breathing) and can therefore, assist Jenn with homework by encouraging and helping her use the tools at home between therapy sessions. Also, early in this first week, it is important that the psychologist meet with school staff who work with Jenn on a daily basis, such as her teacher and school counselor. This

Intervention Plan meeting will serve to provide information regarding psycho-education specific to Jenns anxiety, discuss Jenns graduated school return, and share how they can make this a positive experience for Jenn. School staff will also be informed of contingency

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management strategies and how to support Jenn in applying her newly learned CBT skills. Week Two With respect to school attendance, the second week of intervention will focus on Jenns graduated return to full-time school with a continuation of gradually adding classes. It is expected that Jenn be attending full school days by the end of this second week. In order to maintain consistency with the intervention process, should Jenn become anxious and want to leave school, she will be supported by her mother and school staff to utilize her relaxation skills and she will not be picked up early by her mother. It is important that her teacher and school counselor be aware of, and available to provide positive reinforcement, intervene in negative interactions, and provide regular check-ins with Jenn so that she feels supported in this process. Also within the second week, Jenn will attend two counseling sessions with her psychologist. During these sessions, Jenn will discuss her return to school and review the positives as well as discuss her concerns. In continuing with CBT, Jenn will learn and develop additional problem solving strategies, coping skills, and will be supported in further identifying her negative thought patterns and engage in cognitive restructuring. In the second session this week, Jenns fears and anxieties around situations aside from school, such as staying with a babysitter or her aunt, will be explored. Following each session, the psychologist will again meet with Stacey to review contingency management, and encourage her to talk with Jenn regularly about her fears and concerns so that she is

Intervention Plan able to support the generalization of Jenns new problem solving and cognitive restructuring strategies. This week, the psychologist will attend the school and observe Jenn in her

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classroom to ensure effective implementation of support strategies by her teachers, as well as to observe how Jenn is responding to this support. Following this, the psychologist will also check-in with school staff to hear how Jenn is progressing in the school environment, answer any questions which they may have, and provide any necessary feedback to teachers based on the classroom observation. During this conversation, the psychologist will further explore the contingency management and supportive strategies used with Jenn. At this time, it may be appropriate for school staff to gradually reduce the level of special attention and consideration Jenn has been receiving. Weeks Three and Four It is expected that Jenn be attending school full-time and not missing days or being picked-up early by her mother. The hope is that she will have developed relaxation, coping, and problem solving skills, in addition to the ability to restructure her negative thoughts, sufficient to support her in managing her anxiety for a full school day. In week four, the psychologist should once again visit the school and complete a classroom observation to ensure the integrity of the intervention strategies within the classroom. Jenn will continue to attend two counseling sessions each week with the psychologist. During these sessions, the aim will be to explore situations outside of school that elicit high levels of anxiety for Jenn such as at home or within her community. Jenn will further be supported by the psychologist, as well as her mother, to implement the anxiety reduction strategies she has previously learned in these situations. The idea of

Intervention Plan having Jenns brother, Mike, involved to model appropriate reactions and behaviours in

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these settings should be explored. Once again, the psychologist will continue to meet with Stacey at the end of each session to gain an understanding of how Jenn is progressing at home and to further guide Stacy in supporting Jenn with applying her newly learned strategies. Week Five and Six Jenn will continue to receive guidance and support from her teachers and counselor at school. A final classroom observation session will be completed by the psychologist to further assess effective implementation and provide corrective feedback to teachers, if necessary. Additionally, Jenn will attend one counseling session with her psychologist during each of these weeks. These two sessions will mainly focus on relapse prevention. Jenn will receive guidance in generalizing her new CBT-skills to all situations. Intervention Integrity and Assessing Effectiveness In order to ensure the integrity of this intervention program, Jenns mother, teachers and school counselors will be given ample opportunities throughout this six week period to connect with the psychologist and ask questions or seek feedback. In addition to this, it is important that the psychologist attend and observe Jenn in the classroom environment on at least three occasions. This observation will allow the psychologist to assess the teachers implementation of the intervention strategies and ensure effective and correct use. The psychologist will be able to provide feedback to the teachers based upon these observations. Parent, teacher and self reports will also be collected on a weekly basis to evaluate the frequency and consistency of use for classroom and in-home based strategies.

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A clear and measurable method of assessing the effectiveness of the intervention is essential to ensure Jenn is receiving the full benefit of the proposed recommendations. This also allows for opportunities to adjust certain strategies if needed, in order to improve the overall effectiveness of the intervention process. Throughout this six week period, the psychologist and school counselor will continuously follow-up with Jenn, her mother, and her teacher. These three individuals can report their observations and feelings around: (a) any changes in Jenns anxious behaviours; (b) what they have noticed to be effective in reducing her anxiety; and (c) which practices have not produced positive outcomes. Jenn will also be asked to provide feedback regarding her feelings about the effectiveness of the strategies implemented for her. In addition to this, it is recommended that the DICA-IV be re-administered to Jenn following completion of the intervention to measure changes in her levels of anxiety. These results will provide clear, data-based information regarding the interventions success and overall effectiveness. Suggested Classroom Based Strategies Involving Jenns classroom teacher, Mrs. Carter in the intervention process is important. Doing so will not only help maintain consistency across contexts, but it will also facilitate a smoother transition and integration back into school (Lauchlan, 2003). That is, open, collaborative communication between a childs family, school, and treatment professionals optimizes the care and quality of life for the child with separation anxiety disorder (Massachusetts General Hospital, 2010). Accordingly, a number of classroombased recommendations are made for Jenn. In order to constantly encourage Jenn to behave appropriately, it is recommended that a reward system and reinforcement schedule be implemented within the classroom. As

Intervention Plan a vast amount of research has found positive reinforcement to be a successful means for shaping desirable behaviour in school children, it will be beneficial for Jenns teacher to

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begin using a token economy (Mash & Wolfe, 2005). As Lefton, Boyes and Ogden (2000) explain, token economies are used to modify behaviour in social settings... [and] aim to strengthen behaviours that are compatible with social norms (p. 580). To implement this strategy, Jenns teacher should provide her with tokens throughout the school day each time she achieves a particular goal or displays a desirable behaviour. For example, for every class which Jenn attends during the day, she may receive a token and, if Jenn is able to stay at school for the entire day and attend all of her classes, she would receive 5 additional tokens. When Jenn collects a pre-determined number of tokens, she can trade them in for a desirable reward of her choice (Lefton et al., 2000). Suitable rewards may include candy, games, or special activities with her mom, such as going to the movies on the weekend. Accordingly, it is particularly important for Jenns teacher to be thorough with reinforcing positive behaviours and subsequently, ignoring negative ones. As Doobay (2008) points out, responding to negative behaviours such as crying or staying home from school is a way of inadvertently reinforcing undesired, anxious behaviours by providing positive attention and removing the child from the feared stimulus. As such, this recommendation requires considerable consistency which is why it is beneficial for Jenns parents and teachers to work collaboratively in reducing her undesirable behaviour. An additional recommendation is for Jenns teacher to implement a buddy system within the classroom whereby select students model appropriate behaviour while Jenn engages in these behaviours simultaneously. That is, Jenns teacher should select one or

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two appropriate buddies who can provide peer support and assist Jenns reintegration into the classroom (Lauchlan, 2003). As Schunk (1987) explains, observing models perform threatening or prohibited activities without experiencing negative consequences lead observers to perform the behaviors themselves (p. 150). Consequently, this recommendation will not only help to encourage appropriate social skills, but it will also provide Jenn with individuals who she can begin to trust and feel comfortable with. It is suggested that Jenn be seated next to these individuals throughout the school day and be paired with them for group projects. By doing so, it is hoped that Jenn will be able to establish warm and trusting friendships without being overwhelmed by the number of students in her classroom. Accordingly, she is less likely to stand out and feel awkward if she is interacting with other students, ultimately minimizing the opportunity for other students to call her weird. Eventually, it is assumed that through the use of modeling, Jenn will establish appropriate coping and social skills, ultimately feeling at ease in the presence of her modeling peers. As research finds, observing other students successes, failures, rewards, and punishments creates outcome expectations in observers that they are likely to experiences similar outcomes for performing the same behaviors [therefore,] are more likely to perform behaviors when they believe they will be successful or rewarded than when they expect to be punished (Schunk 1987, p. 151). It should be noted that if Jenn is reluctant to interact with the selected peers, the positive reinforcement strategies outlined in the previous recommendation will help to encourage her cooperation. In addition, Jenn will benefit from a variety of classroom modifications intended to help her feel special and at ease. For instance, Jenns teacher should allow her to assist with

Intervention Plan simple classroom activities such as helping to erase the chalkboard or leading the line of

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students down the hallway during classroom transitions. Such tasks will give Jenn a sense of importance and help her understand that she plays a valuable role within the classroom. As Lauchlan (2003) explains, special classroom responsibilities given to the pupil on return to school can be rewarding and encouraging for the young person (p. 138). Subsequently, Jenns teacher may allow her to sit near the door or opt to avoid calling on her in class in an attempt to reduce anxiety and increase her overall level of comfort (Scott & Cully, 1995). If however, Jenn becomes willing to answer questions, such behaviour should be reinforced using the previously described strategies. Suggested In-Home Strategies As Stacey has now been dealing with Jenns anxious behaviours for the past six months, it will be important for her to have a good routine of self-care. Since Stacey has mentioned feeling trapped and as though she cannot have any alone time, it is critical that Stacey develop a plan to take care of herself so that she can feel balanced and calm while helping Jenn work though this difficult period. Though it may be quite difficult, it is important that Stacey keep calm when Jenn is upset about separation, and provide reassurance about their upcoming reunion. This will help Jenn see that her mom does not express any fear or worry about their time apart and will ultimately act as a model to Jenn for how she should act during periods of separation. It will be important for Stacey to develop a strategy (or strategies) that she relies on if she becomes overwhelmed with Jenns behaviours throughout the intervention. This could include having a friend or family member available at short notice for support, using

Intervention Plan outside resources, or taking individual time in different parts of the house until feeling ready to proceed. It will be important for Stacey to take the time to talk with Jenn and listen to her feelings. The isolation that Jenn is currently experiencing due to her withdrawal from friends, school and enjoyable activities like visiting with her cousin increases Jenns risk

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for low self-esteem and depression. Feeling heard and listened to by her mother may have a powerful and reassuring effect on Jenns anxious feelings. It is also important that Stacey talk with Jenn about her anxiety, as it will help her understand more about anxiety, such as what it is, how to recognize it, and how to change or influence her anxious thoughts and feelings. Simple conversations about her feelings along with supportive redirection about misconceptions or errors in thinking will help Jenn to rebuild her self-confidence and self-esteem. Since anxious children tend to see the world as more threatening and dangerous than it really is, it is important that Stacey support Jenn in identifying and changing her negative self-talk (e.g. I dont want to play with my friends because they dont like me). While these strategies will be worked on in individual therapy sessions, it will be crucial for Stacey to carry the techniques into the home environment so Jenn learns to apply them across different situations, and not solely in the therapists office. A daily routine or schedule will help Jenn have some predictability in her daily experiences, and may help lessen some of Jenns anxious feelings about what might happen during the day. Stacey should endeavour to be caring, firm, and consistent with Jenn throughout the intervention process. Limits that Stacey sets must be complied with firmly and followed consistently. For example, if there is an agreement that Jenn may phone

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Stacey once per hour to check-in while she is separated from her mother (e.g. at her aunts house or with a baby-sitter), it is important that the agreement be followed. Consistency is critical to ensuring that Jenn is able to effectively manage her anxious thoughts and feelings. Inconsistency teaches children that if they are persistent in trying to get what they want, they will eventually succeed. Finally, Stacey will be able to play an active role in supporting Jenns participation in healthy activities (e.g. going to school, playing with her cousin, visiting with friends). Providing encouragement for Jenn to engage with friends again (e.g. planning a fun/enjoyable outing with 1 or 2 supportive friends) can help to build Jenns confidence and self-esteem in the areas of school and friendship. As well, it will be important for Stacey to help Jenn monitor and celebrate the progress she is making as they move through the intervention process together. Even if improvements are very small, every good effort should be praised, again helping to re-establish a healthy self-esteem and self-concept, as well as a healthier relationship between mother and daughter. Suggested Community Resources In order to receive ongoing community based supports, it is recommended that Stacey access Family Supports for Children with Disabilities (FSCD), Families Learning Together, Single Parent Support Program, and the Families Matter Society. FSCD is a government funded program available to provide financial support and compensation to families with children who have been diagnosed with any disability. Given Jenns diagnosis of SAD, this program would be able to provide financial coverage for therapeutic programs, parking for appointments, and respite services. Families are able to refer themselves to this program by calling the intake line at 403-297-6022. Parents are

Intervention Plan required to provide a letter of diagnosis in order to qualify for this benefit. Following the completion of the phone intake, a representative from the FSCD program will visit the familys home to match the available services to meet the familys needs. It is also recommended that Stacey, Jenn, and Mike access the Families Learning

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Together program. This program provides group workshops to parents and children free of charge in the Calgary area. These workshops are designed to encourage parents and their children to relate to, and understand, each others needs and respective roles within the family system. With the provision of strategies, understanding, and support, this program is designed to strengthen the family unit. Given the stressed relationships within Jenns family system, this program can assist Stacey and both children in developing strategies to address stress and strengthen their family system. This program can be accessed by the family by contacting The Childrens Link Society at 403-230-9158 or e-mailing child@nucleus.com. The experience of raising a young child with SAD as a single parent can be extremely stressful and overwhelming. In order to access supports through the community to support through this process, it is recommended that Stacey explore the Single Parent Wellness Group through the Single Parent Support Program in Calgary. This program is available on a self-referral basis and Stacey can register by calling 403-275-6668 ext: 222 or going to the website at http://www.weconnectyou.ca/programs/sp_wellness_groups.htm. Additionally, the Families Matter Society offers free educational workshops for parents. Specifically, two of the programs currently being offered could support Stacey in learning additional strategies and tips to support and facilitate improvement in Jenns self esteem: (1) Parenting Tip Time: Fostering Self-Esteem in Children; and (2) Family Life

Intervention Plan Education: Healthy Self-Esteem in Children. Given the current situation for Jenn, it is

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evident that her self-esteem is low and that this is impacting her social interactions and peer relationships in a negative way. Stacey could gain information specific to supporting her daughter to improve her self-esteem. All of the Families Matter programs are available through self-referrals and Stacey can register by calling 403-205-5178. Information on additional programs and services is available on the website at https://www.familiesmatter.ca. Should the family require community supports or services in addition to the ones recommended above, additional resource and service information is available by calling 211 in the Calgary area. Finally, it is also recommended that Stacey visit the website: childrenslink.ca to explore what other resources and relevant activities are available to families in Calgary. Suggested Follow-Up In order to ensure that this intervention has long lasting effectiveness in decreasing Jenns anxiety to a manageable level, it is important that there be a follow-up plan. In this specific intervention, a follow-up counseling session will be planned for one month after completion of the intervention. At this time, Jenn and her mother will meet with the psychologist individually to share their thoughts, observations, and feelings specific to Jenns overall wellbeing. Jenn will be asked to share details about her anxiety and the situations which continue to elicit such reactions. She will also be asked to identify the techniques which she finds to be most effective in helping her manage her anxiety as well as the strategies she finds least effective. The psychologist will then be able to supplement these ineffective strategies with new ideas for Jenn to try.

Intervention Plan Stacey will also be asked to share her perceptions of how Jenn has improved and

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which strategies have been effective or ineffective. It is important that the psychologist reemphasize the importance of consistency with Stacey to ensure that she remains vigilant about supporting Jenn in managing her anxiety. During this time frame, the psychologist should be connecting with the school either in person or over the phone to gain their insights and observations about Jenns functioning. It is important that Jenn continue to attend school full-time and that Stacey is not picking her up early for anxiety-related reasons. Rather, it is essential that the school continue to support Jenn in utilizing her CBT strategies to reduce anxiety in the moment. Further to this, the psychologist could gain information from the school with respect to Jenns peer relationships and social presentation to ensure that Jenn is making stable improvements. In ending the intervention, it is important that Jenn, Stacey and the school understand that the psychologist remains available for follow-up sessions when and if needed, should Jenn start to revert back to her old behavioural patterns. Recommended Universal Intervention Program In order to create a positive learning environment that may help to prevent all of the social-emotional behavioural difficulties that Jenn is experiencing, particularly the school-refusal behaviour, it is recommended that the school implement a Positive Behaviour Approach as detailed in the report published by the Government of Alberta (2008). In synthesizing relevant recent research articles and studies, the report provides a detailed plan for a school-wide intervention to create safe, healthy, positive learning environments for all students. Behaviour issues in schools can interfere with learning,

Intervention Plan classroom instruction, and the maintenance of a positive school atmosphere. An integrated system of a school wide approach, a targeted classroom management approach, and an intensive individualized approach targets all students, from those who need only basic guidelines to those who need very specific and individualized attention and planning. This type of structure facilitates academic success and the healthy social development of students in a safe, supportive learning environment. A school-wide approach to positive behaviour supports effectively promotes a safe, orderly and predictable environment for learning and teaching. Within the school community, this approach creates a positive school culture that students, parents and staff perceive as safe and caring. This type of approach also helps clearly identify the students who demonstrate high-risk behaviour, and need intensive, individualized interventions and support on an ongoing basis. In this way, social-emotional problems such as those experienced by Jenn may be caught earlier, and possibly prevented. There are a number of components outlined in the report that are key for the successful implementation of a universal school-wide behaviour support system. The elements are interrelated and overlapping, and their individual degrees of importance are reported to vary depending on the needs, strengths and priorities of each school community. It is critical that all teachers and related adults in the school are consistent in the integration of the components, as consistency and predictability are necessary for the systems success. The components of the support system follow below. Components that take place largely within the larger school environment include evaluating the state of student-teacher relationships, the school environment, and current behavioural expectations. The first component of the system is foundational

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Intervention Plan for all schools, and that is the fostering of positive relationships. The school must promote positive relationships that value each individuals contribution to the school community, therein promoting a sense of belonging for all staff and students. Next, it may be necessary to modify the school environment to ensure daily routines and a physical environment that supports positive behaviours and reduces problem behaviours. It is important that the school provides deliberate, active adult supervision, positive social contact and reinforcement with students, teaching of social skills in-themoment, and immediate consequences for negative behaviour. The school must implement school-wide behavioural expectations, where school rules and expectations are clear, and staff members consistently reinforce those expectations in all areas of the school throughout the school day. It is important for students to be provided with ample opportunity to get positive reinforcement so they are encouraged to behave in positive ways. Effective feedback must be given consistently by all school staff throughout the school day and across school settings. For students whose negative behaviour adversely affects the school community there must be fair and predictable consequences for their actions. Components that take place largely within the classrooms include the use of differential instruction based on student needs and abilities, social skills instruction, and positive reinforcement. It is recognized that all children do not learn the same way, so the use of a differential instruction approach ensures that the school is able to respond to student diversity and create opportunities for all students to learn in a way that responds to their current abilities, strengths, learning preferences, interests and needs. Teachers and the administration must work together to develop, implement and monitor

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Intervention Plan clear school and classroom behavioural expectations in response to the needs of students, staff and the school community. While the development of the expectations is a larger-scope occurrence, the monitoring and facilitation occur largely within classrooms, and must be done consistently by all staff with all students. Finally, students with strong social skills can interpret social situations and respond appropriately. Though many students come to school with a grasp of basic social skills, the majority of students would benefit from the teaching of social skills such as listening, having a conversation, making friends, dealing with feelings, accepting consequences, resolving arguments, and dealing with bullying. Social skills can be taught through role modeling by teachers or by direct instruction. By learning social skills, students are more likely to develop enhanced self-confidence, greater selfcontrol, greater respect for the rights of others, and a greater sense of responsibility for their own actions. Finally, the components of the system that rely on a schools administration include having collaborative leadership that is committed to creating and maintaining a positive school culture for all students and staff. It is important that the system undergo a constant process of evaluation and data-driven decision making where through an ongoing process of analysis there is a good understanding of areas that need improvement and the strengths and needs of the school community require constant reassessment. Regular data-collection and analysis should inform any changes made to the system. Lastly, it is recommended that at all steps along the way of implementing the plan that there be an action plan for school change developed with teachers and support staff. Within the action plan, all staff members should remain informed and

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Intervention Plan educated about the positive behaviour system, as well as any changes to be implemented throughout the process. Conclusion Taking the proposed CBT approach to treating Jenns separation anxiety into account, it is anticipated that under the coordination of Jenns therapist, and in collaboration with her family, school personnel, and community resources, that Jenn will be able to increase her competence in managing and coping with separation.

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References Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (2nd ed.) (pp. 279-329). New York: Guilford Press. Alberta (2008). Supporting positive behaviour in Alberta schools: An intensive individualized
approach. Retrieved April 7, 2010, from http://education.alberta.ca/

admin/special/resources.aspx American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author. Cristea, I., Benga, O., & Opre, A. (2008). The implementation of a rational-emotive educational intervention for anxiety in a 3rd grade classroom: An analysis of relevant procedural and developmental constraints. Journal of Cognitive and Behavioral Psychotherapies, 8(1), 31-51.

Intervention Plan Doobay, A. F. (2008). School refusal behaviour associated with separation anxiety

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disorder: A cognitive-behavioral approach to treatment. Psychology in the Schools, 45(4), 261-272. Gosch, E. A., Flannery-Schroeder, E., Mauro, C. F., & Compton, S. N. (2006). Principles of cognitive-behavioral therapy for anxiety disorders in children. Journal of Cognitive Psychotherapy: An International Quarterly, 20(3), 247-262. Lauchlan, F. (2003). Responding to chronic non-attendance: a review of intervention approaches. Educational Psychology in Practice, 19(2), 133-146. Lefton, L. A., Boyes, M. C., & Ogden, N. A. (2000). Psychology (CAN ed.). Scarborough, ON: Pearson Education. Mash, E. J., & Wolfe, D. A. (2005). Abnormal child psychology (3rd ed.). Belmont, CA: Thomson. Masi, G., Mucci, M., & Millepiedi, S. (2001). Separation anxiety disorder in children and adolescents. Therapy in Practice, 15(2), 93-104. Massachusetts General Hospital. (2010). Separation anxiety disorder. Retrieved April 4, 2010, from http://www2.massgeneral.org/schoolpsychiatry.separationanxiety_print.asp Sattler, J. M., & Hoge, R. D. (2006). Assessment of children: Behavioral, social, and clinical foundations (5th ed.). La Mesa, CA: Jerome M. Sattler Publisher Inc. Schunk, D. H. (1987). Peer models and childrens behavioral change. Review of Educational Research, 57(2), 149-174. Scott, J., & Cully, M. (1995). Helping the separation anxious school refuser. Elementary School Guidance and Counselling, 29(4), 289-298. Shaffer, D. R., Wood, E., & Willoughby, T. (2002). Developmental psychology:

Intervention Plan Childhood and adolescence (1st CAN ed.). Scarborough, ON: Thomson Suveg, C., Roblek, T. L., Robin, J., Krain, A., Aschenbrand, S., & Ginsburg, G. S.

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(2006). Parental involvement when conducting cognitive-behavioural therapy for children with anxiety disorders. Journal of Cognitive Psychology: An International Quarterly, 20(3), 287-299. Weissman, A. S., Antinoro, D., & Chu, B. C. (2009). Cognitive-behavioral therapy for anxious youth in school settings: Advances and challenges. In M. J. Mayer, R. Van Acker, J. E. Lochman & F. M. Gresham (Eds.), Cognitive-behavioral interventions for emotional and behavioural disorders: School-based practice (pp. 173-232). New York: Guilford Press.

Intervention Plan Appendix Detailed Intervention Schedule for Jenn Sampson Week One School. Graduated return to school - Jenn to attend one period each day (to be her

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favorite class) for two days (day one and two) then increase to two favorite classes working up to a half-day and lunch by end of week (day three, four, and five). For example: Monday - favorite class Tuesday - favorite class Wednesday - 2 favorite classes Thursday - 2 favorite classes plus lunch Friday - half-day plus lunch Counselling. Three 50 minute sessions for Jenn, each followed by 20 minute sessions for Stacey with the psychologist. Session one. (Jenn and Mom for full session, 1:1 with Mom after session) - Rapport building. - Psycho-education regarding anxiety for Mom and Jenn. - Teach relaxation skill #1 (deep breathing suggested as most effective for young kids). - 1:1 with Mom for 20 minutes: Additional psycho-education as needed and encouragement to practice relaxation skill #1 with Jenn between sessions. Session 2. (Jenn with Mom in half-session, 1:1 with Mom after session) - Rapport building (mom leaves half-way through session to waiting room). - Teach relaxation skill #2 (progressive muscle relaxation, visualization) and provide a tape-recording so Jenn can do this independently at home. - Discuss attending school and explore how graded exposure program is working for her. - Prepare for full day at school.

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- Talk about fears regarding being separated from mom and attending school. - Role play possible scenarios and responses. - Social skills training including possible use of video modeling. - Re-education (cognitive restructuring) for negative thoughts. - 1:1 with Mom for 20 minutes: Plan for attending school, moms contingency management skills (i.e. education for rewarding Jenn's positive behaviours and ignoring negative ones re: anxiety and school refusal). Session 3. (Jenn and Mom separately) - Video-modeling a students morning routine and arrival at/participation in school day. - Role-play some scenarios from the video. - Practice use relaxation and coping techniques and discuss how and when they might be needed and used when getting ready for school/entering school environment again. - 1:1 with Mom for 20 minutes: Develop a stress-free morning routine with Jenn. - Review contingency management skills and how to support Jenns positive behaviours/ignore negative ones. Psychologist consultation with school (day two).The psychologist will meet with Jenns teachers and school counsellor to discuss the graduated exposure plan for Jenns return to school. - Psycho-education regarding Jenns reasons for being out of school and about gradual return plan. - Emphasize that it is essential for her return to be positive. - Teach contingency management to reinforce positive behaviours but disallow former maladaptive coping strategies (e.g. calling mom, going home early). - Identify two classmates to be positive social support for Jenns return to school.

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- Discuss possibility of special status for Jenn in classroom (e.g. classroom helper, etc.). - Designate counsellor to meet with Jenn each day to see how she does at school. Additionally, tag counsellor as a support-person Jenn can seek out if she needs help using coping/relaxation skills. - Ensure teachers and counsellor will be aware of and intervene in any negative interactions upon Jenns return to school. Week Two School. Jenn to will continually add classes throughout the week. Plan is that she be attending school fulltime by the end of this week. Counselling. Two 50 minute sessions for Jenn, each followed by 20 minute sessions for Stacey with the psychologist. Session 4. (Jenn and Mom separately) after school - Discuss return to school (+s/-s). - Implement problem solving, social skills training, coping skills training, modeling via video and role playing. - Identify negative thoughts/assumptions and provide cognitive restructuring. - 1:1 with Mom for 20 minutes: Discuss return and how Mom felt. - Reinforce contingency management skills with Mom. - Encourage Mom to talk with Jenn about concerns/fears and help her with problem solving and cognitive restructuring at home in order to help Jenn generalize skills to life outside of school and counselors office. Session 5. (Jenn and mom separately) after school - Discuss return to school (+s/-s). - Implement problem solving, social skills training, coping skills training, modeling via video and role playing. - Identify negative thoughts/assumptions and provide cognitive restructuring.

Intervention Plan - Discuss other anxious situations with Jenn (babysitter, visiting cousins house) and how to use relaxation skills in those situations. - Teach and role play relaxation skills for these situations.

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- 1:1 with Mom for 20 minutes: Discuss return to school plan and how mom felt. - Reinforce contingency management skills to continue the decrease of Jenns separation anxiety and to continue talking with Jenn about concerns/fears (support as needed). - Begin to discuss relapse prevention. - Encourage reintroduction of aunts house as with school (short visits followed by increasingly long visits; encourage mom to educate Aunt on contingency management skills to help Jenn). Psychologist classroom observation and consultation with school. Psychologist will observe Jenn in the classroom environment to assess intervention integrity and effectiveness. Following this observation, the psychologist will meet once again with school staff. - Meet with Jenns teachers and school counsellor to discuss how Jenns return to school went. - Discuss Jenns ongoing concerns. - Answer questions from teachers/counsellor. - Encourage continued use of contingency management skills in the classroom/school setting. - Support gradual reduction of special attention given to Jenn. Week Three and Four School. Jenn will be attending school full-time. Counselling. Two 50 minute sessions for Jenn, each followed by 20 minute sessions for Stacey with the psychologist. Sessions 6, 7, 8, 9. (Jenn and mom separately) after school

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- Discuss separation concerns that arise outside of school at home an in the community (eg. going to her aunts house, staying with a babysitter). - Implement anxiety reduction strategies as needed. - Explore brother as model for these activities. Psychologist classroom observation and consultation with school. Psychologist will once again observe Jenn in the classroom environment to assess intervention integrity and effectiveness and will provide feedback to teachers. Week Five and Six School. Jenn will be attending school full-time. Counselling. One 50 minute sessions for Jenn, each followed by 20 minute sessions for Stacey with the psychologist. Sessions 10 and 11. (Jenn and mom separately) after school - Support learned coping strategies and relaxation skills. - Teach new skills and strategies if additional ones are required. - Support relapse prevention and generalizability of CBT strategies. Psychologist classroom observation and consultation with school. Psychologist will once again observe Jenn in the classroom environment to assess intervention integrity and effectiveness and will provide feedback to teachers. Follow-Up Counselling. One 50 minute sessions for Jenn, each followed by 20 minute sessions for Stacey with the psychologist. Session 12. (Jenn and mom separately) after school Explore effectiveness of intervention and new strategies. Reinforce continued use of these strategies for Jenn and Mom. Supplement any strategies that are not effective with new suggestions.

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