Interview with Michael L. Sulkowski, PhD
Michael Sulkowski, PhD
Dr. Sulkowski is an Assistant Professor in the School Psychology Program at the University of Arizona. He received his doctorate in School Psychology from the University of Florida in 2011. Dr. Sulkowski completed his predoctoral internship in the Louisiana School Psychology Internship Consortium, an APA accredited and APPIC approved internship program based in the Louisiana State University Health Science Center. In the spring of 2012, he completed his postdoctoral fellowship in the Rothman Center for Pediatric Neuropsychiatry at the University of South Florida, a specialty center for pediatric research and evidence-based treatment.
For his research, scholarship, and professional service, Dr. Sulkowski has received awards from the Melissa Institute for Violence Prevention, the American Psychological Association (APA), the National Association of School Psychologists (NASP), the American Academy of School Psychology, the Florida Association of School Psychologists, the College of Education at the University of Florida, the University of Florida Alumni Association, the American Society for the Advancement of Pharmacotherapy (APA Division 55), and the Society for General Psychology (APA Division 1). Dr. Sulkowski also is the Co-Chair for the NASP Early Career Workgroup and he is on the editorial board for the International Journal of School and Educational Psychology, the Journal of School Psychology, and School Psychology Quarterly. Lastly, Dr. Sulkowski is a Nationally Certified School Psychologist (NCSP), he is credentialed as a School Psychologist in Arizona, and he also is licensed as a Psychologist in the same state. He maintains a private practice in Tucson, AZ where he treats individuals using evidence-based forms of psychotherapy.
ATHEALTH: Thank you for taking your time for this interview, Dr. Sulkowski. Many of our readers are interested in the emotional needs of school age children. I know they will benefit from a discussion about anxiety, which is so prevalent in children.
This interview will focus on an article you co-authored with Diana Joyce and Eric Storch in the Journal of Child and Family Studies entitled, Treating Childhood Anxiety in Schools: Service Delivery in a Response to Intervention Paradigm. Please feel free to ad lib and add to the discussion by including newer data that our readers might find interesting, since you wrote that article in 2005. Toward the end of the interview, we would like you to tell us how the DSM-5 and the Affordable Care Act (ACA) might impact the assessment and treatment of anxiety in children.
To begin, tell our readers a little about yourself, your training and how you decided to study childhood anxiety disorders.
DR. SULKOWSKI: Thank you for the warm and kind introduction. I received my doctorate in School Psychology from the University of Florida (UF) in 2011. Prior to this, I had amassed a wealth of clinical experience in many different departments at UF in which I treated children, adolescents and adults with anxiety, obsessive-compulsive, and related disorders. Upon graduation, I began my pre-doctoral internship at the LSU Health Science Center in School Psychology, which is an internship that is accredited by the American Psychological Association. Then, following that, I completed a postdoctoral fellowship at the Rothman Center for Neuropsychiatry, which is a specialty center for treating in anxiety and obsessive-compulsive disorders that is associated with the University of South Florida and Johns Hopkins University. Finally, I came to Tucson in 2012 to accept a tenure-track position in the School Psychology Program at the University of Arizona and most recently, I've opened my own private practice to treat anxiety and obsessive-compulsive disorders.
In these settings, I've been fortunate to learn how to use evidence-based forms of psychotherapy to treat obsessive-compulsive related and anxiety disorders in children, adolescents, and adults. In addition, my background also is in school psychology so I've always been interested in transporting effective treatments from clinical settings to educational environments where many youth can receive help that they otherwise would not be able to receive because of barriers to access.
ATHEALTH: Please set the backdrop with a little historical data. We know anxiety disorders are quite prevalent in school age children. Review for our readers the recent data regarding the prevalence of anxiety disorders in school-age children in the United States.
DR. SULKOWSKI: Research indicates that about 20% of students will experience some sort of mental health problem prior to graduation, and anxiety disorders are among the most prevalent of mental health problems. Therefore, anxiety disorders and problems are relatively common yet still debilitating for many students. I would be so bold as to say that all schools have at least a few students who are impacted by separation anxiety, a specific phobia, social anxiety, obsessive-compulsive concerns, post-traumatic stress, selective mutism, panic attacks, or generalized anxiety.
ATHEALTH: Researchers report that the prevalence rates for children's anxiety disorders "… range from 2-27%..." What causes such a wide range?
DR. SULKOWSKI: This wide range has a lot to do with the methodologies of different epidemiological studies that have been employed to assess anxiety in children. Studies that assess anxiety more generally tend to find higher rates of children with anxiety problems, whereas studies that focus more specifically on assessing children with specific diagnostic criteria in mind tend to find lower estimates. In addition, anxiety symptoms can wax and wane in their severity in such a way that some highly anxious children may or may not meet criteria for having an anxiety disorder on any given day. Lastly, in contrast to children with externalizing problems and disruptive behavior disorders, children with anxiety and other internalizing concerns are less likely to act out and be noticed in school settings, which makes it more challenging to identify these students.
ATHEALTH: Do we know if children are, in general, more prone to anxiety today compared to, say a generation ago?
DR. SULKOWSKI: The data on changes in anxiety over time are not completely unequivocal, especially for children. However, one longitudinal study by Twenge that was conducted a little more than a decade ago found that anxiety among individuals in the U.S. of all ages has been increasing since the 1950s. Specifically, this study found that the average American child in the 1980s reported significantly more anxiety concerns than did child psychiatric patients in the 1950s. This study also controlled for changes in social indices such as divorce and crime rates and the author concluded that the change in anxiety was related to decreases in social connectedness and increases in environmental stressors.
ATHEALTH: Are researchers finding the prevalence rates changing for specific disorders like separation anxiety, generalized anxiety or posttraumatic stress disorder?
DR. SULKOWSKI: I'm unaware of any specific studies that suggest that the prevalence rates are changing for specific disorders such as separation anxiety, generalized anxiety, or posttraumatic stress disorder. Of course, with increases in research and knowledge of these disorders among members of the general public, one can expect increases in recognition of their symptoms and diagnosis. However, it is unclear whether an increase of awareness about specific anxiety disorders accounts for any increases in the diagnosis of these disorders or whether an increase in specific anxiety disorders has occurred. Following WWI, many returning war veterans were described as having "shell shock," which involved having an elevated startle response, flashbacks, and cognitive impairments associated with blunt trauma to their brain. Now of course, many of these individuals would be diagnosed with posttraumatic stress disorder.
ATHEALTH: How has the Information Age impacted our children, are they more or less anxious?
DR. SULKOWSKI: I doubt that the information age has helped reduce anxiety among children. Often, in my own practice, I see children worried about things that they probably wouldn't even know about if it wasn't for the internet and for 24-hour news networks. For example, I recently saw a child who had seen a story on the internet about an American doctor catching Ebola and now the child is losing sleep because of his fears about a possible Ebola outbreak in the U.S. In light of this, I think it is critically important for parents to carefully monitor what their children view on TV and online. The information age has ushered in amazing breakthroughs in allowing anyone to have access to what would have previously been specialized information. However, this information can come with a cost as children now spend an inordinate amount of time interacting with cyber technologies, and it can be hard for them to disconnect. In addition, the information age also has allowed for new forms of peer victimization such as cyberbullying that is associated with the development of anxiety in children.
ATHEALTH: How do anxiety disorders impact the child's education?
DR. SULKOWSKI: A little bit of anxiety can be a good thing for enhancing one's performance on academic tasks and learning. However, the problem is that anxious children often are too stressed to perform their best on graded tests and assignments. Unfortunately, instead of being able to devote the majority of their attention to solving problems or coming up with answers to questions, they may be wrestling with anxious thoughts such as "these questions are too hard," "I'm going to fail this test," and "my parents will think I'm dumb if I don't do well on this test."
Research indicates that even anxiety associated with a stereotype threat (i.e., "this test had shown gender performance differences in the past") can impair performance on an academic task for individuals who have been biased against. Therefore, it is important for educators to be aware of and actively combat biases that exist against certain groups of students, and this is especially true for helping anxious students, who may be even more sensitive to negative biases and stereotype threats. Ultimately, to help anxious students to perform their best in school, the focus should be more on the learning process than on specific outcomes like grades. In other words, it is better to reward students for their effort than for the grades they receive.
ATHEALTH: When a child's anxiety is not treated or, possibly, undertreated, they are more likely to suffer from anxiety, depression and substance use and/or abuse as adults. How big of a problem is this? What percentage of children receive adequate treatment for their anxiety?
DR. SULKOWSKI: Unfortunately, despite being a prevalent problem, only a small percentage of youth receive any treatment for anxiety. Moreover, when they do receive treatment, usually it is not an empirically supported or evidence-based form of treatment such as cognitive behavioral therapy (CBT). Although anxiety symptoms wax and wane in severity, the general trend is that untreated anxiety symptoms and disorders get worse and more impairing over time and lead to other problems such as maladaptive coping with substance abuse or depression as a person's world gets smaller and smaller because of the impairment that anxiety has on their daily functioning.
Therefore, early treatment is important for preventing negative long-term outcomes. In addition, CBT has been found to be just as effective in treating childhood anxiety as it is for treating adults with anxiety. With that said, it does not make any sense to delay getting treatment for anxious children, especially because early treatment might prevent the development of comorbid or co-occurring problems that can result down the road.
ATHEALTH: Dr. Elizabeth Farmer reports that more children enter mental health treatment through the education sector than by way of specialty mental health services or general medicine. Tell us how the school became one of the best places to meet the child's mental health needs.
DR. SULKOWSKI: Over the past couple of decades there has been a push to provide school-based mental health services. This makes a lot of sense. The great majority of children attend school at some point in their academic career, schools are located in all communities across the country, children often feel connected and comfortable at school compared to other places, and providing mental health services at school has been shown to reduce disparities in the provision of these services in other settings. Therefore, traditional barriers to receiving mental health services such as having to travel to a clinic, having health insurance, being able to attend therapy in the evenings, and so on, are reduced by providing mental health services in school settings.
Increased training opportunities now exist for school-based mental health professionals that were not readily available a couple of decades ago. For example, school psychologists now regularly have coursework in counseling or therapy and seek supervised training in this regard during their practicum and internship experiences. At the University of Arizona we're proud to have a school mental health research group, and many of our students who go on to work in schools specialize in learning how to conduct evidence-based forms of psychotherapy.
ATHEALTH: Are parents, generally, supportive of school-based services? How often do parents object and for what reason(s)?
DR. SULKOWSKI: Yes. Most parents support having their children receive school-based mental health services. However, a few parents or caregivers occasionally refuse having their child seen by a school-based mental health professional. In these cases, it is important to work with the parents to develop trust and disabuse any notions that the child will be stigmatized or that the parents are being judged because their child is anxious. In my experience, parents who refuse supportive services for their child at school often have had negative experiences at school either themselves when they were growing up or when their older children were going through school. Essentially, in these cases, it is important for parents to feel heard, and mental health professionals should be open about addressing any concerns they have. In addition, a lot of confusion exists in the lay public about the types of services that school-based mental health professionals provide. Therefore, these professionals should be clear that they are not a psychiatrist and that they will not prescribe any form of psychiatric medication to the child.
ATHEALTH: Looking at policies affecting school-based mental health care, briefly describe the importance of the Individuals with Disabilities Education Act (IDEA) and the Individuals with Disabilities Education Improvement Act of 2004 (IDEIA).
DR. SULKOWSKI: The Individuals with Disabilities Education Improvement Act of 2004 (IDEIA) re-authorized most of the provisions in the Individuals with Disabilities Education Act (IDEA). Essentially, these laws govern how public education agencies such as schools provide early intervention, special education, and related services to children with disabilities. The laws aim to ensure that all children—regardless of their disability—have access to a free and appropriate education that will prepare them for success in school and beyond.
IDEIA includes 14 specific categories of disability. However, a few categories pertain most directly to students with anxiety disorders, and these include Emotional Disturbance (ED) and other Health Impaired (OHI). If students are evaluated by a multidisciplinary team of professionals at school and found to meet classification criteria for a IDEIA-recognized disability that is negatively impacting their educational performance, they are provided with an Individualized Education Plan (IEP) that specifies the type of services they must receive to help them succeed in school. For students with an anxiety disorder, they might meet criteria for ED if their anxiety is so severe that it is impairing their ability to learn and build or maintain satisfactory interpersonal relationships with peers and educators. These students can then be provided with counseling or therapy as part of their IEP.
It should be noted; however, that students do not need to be classified as having an IDEIA-related disability or an IEP to receive school mental health services. Schools have the liberty of providing therapeutic services to any students who may benefit from them under different service delivery models such as response to intervention and multi-tiered systems of support. I'll write in greater depth about these service-delivery models in a bit.
ATHEALTH: How does the Federal Registry impact whether or not a child receives school-based services?
DR. SULKOWSKI: The Office of Special Education and Rehabilitative Services of the Department of Education of the United States issued the Federal Register, which basically spells out the specific rules and regulations that must be followed for evaluating students with specific disabilities that are recognized by IDEIA. State Education Agencies (SEAs) are responsible for interpreting and carrying out the rules and regulations that are specified in the Federal Register. Because states have some leeway in how they interpret the provisions of the Federal Registrar, variability exists cross states in some of the names and specific criteria included in the disability classification categories. For example, ED is called Emotional Handicapped (EH) or Serious Emotionally Disturbed (SED) in some states. Furthermore, some states report that a student should not be classified as having ED if they are socially maladjusted, even though they do not specify what social maladjustment is or how it is different from ED. To date, no adequate distinction has been made between these two terms so students should not be denied services because they are suspected to be socially maladjusted as opposed to ED. The practice of denying students with ED access to therapy or other supportive services because they are perceived to be socially maladjusted must stop.
ATHEALTH: Describe the multi-method assessment approach and how it works for children with anxiety.
DR. SULKOWSKI: This assessment approach involves assessing multiple traits (e.g., anxiety, depression), using multiple assessments (e.g., behavior rating scales, classroom observations), and collecting data from multiple respondents across settings (e.g., parents, teachers). Essentially, the purpose of this approach is to triangulate data and smooth out any biases or anomalies that might exist from only collecting data from one source.
For children with anxiety, it is important to assess them with validated omnibus behavior rating scales such as the Behavior Assessment Scale for Children, Second Edition (BASC-2) and then follow up this assessment with a more targeted anxiety measure such as the Revised Children's Manifest Anxiety Scale, Second Edition (RCMAS-2). The BASC-2 includes self-, parent-, and teacher-report formats and the RCMAS-2 is a self-report measure of childhood anxiety. Collectively, data on these scales will allow a clinician to compare a child's anxiety levels to a representative sample of youth to determine if the child displays clinically elevated anxiety.
In addition to behavior rating scales, clinicians also should observe the student with a suspected anxiety disorder in a range of settings at school during structured (e.g., in class) and unstructured settings (e.g., at lunch, on the playground). To qualify a student with a disability under IDEIA, many states require a school-based professional to conduct systematic behavior observations to confirm the presence of problems or rule-out other explanations about why a student may be struggling. Lastly, it is important for a clinician to interview the student him or herself as well as others who know the student well such as caregivers at home and teachers who interact regularly with the student.
ATHEALTH: It seems that current laws/policies encourage the treatment of anxiety in schools. In general, how would you grade U.S. schools in meeting the needs of children identified with anxiety disorders?
DR. SULKOWSKI: Progress has been made in meeting the needs of students with anxiety in educational settings, but there still is marked room for improvement. Unfortunately, students who receive treatment for anxiety still are in the minority and substantial barriers to treatment still exist in many school districts such as not having enough highly-trained mental health providers and prioritizing testing and academics over fully supporting the whole student.
Some states have been more progressive in their efforts to help students with anxiety disorders or other disabilities. For example, Colorado removed the socially maladjusted clause in their interpretation of the IDEIA ED definition. Additionally, Illinois has implemented social-emotional learning (SEL) state-wide in its public schools. According to Collaborative for Academic, Social, and Emotional Learning, SEL is an evidence-based and effective program that aims to teach children the skills they need to understand and manage emotions, set and achieve prosocial goals, feel and show empathy for others, establish and maintain positive relationships, and make responsible decisions. Clearly, all students can benefit from improvements in these skills, including anxious students.
ATHEALTH: What is Response to Intervention (RtI)?
DR. SULKOWSKI: Response to intervention (RtI) is a multi-tiered school-based service delivery framework that is being applied in many states to address youth with various academic, behavioral, and medical needs. The term multi-tiered systems of support (MTSS) also is used in many states and school districts to describe multi-tiered service delivery efforts to help students. In fact, use of the term MTSS seems to be gaining in popularity, especially as it relates to addressing students emotional and behavioral needs.
Anyway, these contemporary service-delivery models involve universally screening students for academic, behavioral, and emotional problems while providing them with services that likely benefit all students such as SEL or positive behavior intervention supports (PBIS). Then, students who are identified as displaying significant problems are provided with more intensive support services such as group counseling for a student with anxiety problems. Lastly, depending on the student's response to the previous intervention(s), a school-based team might assess the student more aggressively, if they think that an IDEIA-recognized disability is inhibiting the student's success or provide the student with even more intense services such as individualized therapy.
ATHEALTH: Describe the three (3) tiers associated with RtI (see Figure 1).
DR. SULKOWSKI: As service delivery models, RtI and MTSS involve providing a range of services to different populations of students. All students receive Tier I or universal services which could be exposure to SEL or PBIS. Tier II services are a little more selective and generally are provided to about 5-10% of the student population. There is not a hard or fast rule about what services should be provided as Tier II services, especially for anxious youth. However, many schools consider group counseling or check in/check-out to be two Tier II options. Then finally, Tier III services usually are provided to only about 1-5% of students in the school population who display the most intense needs and have not responded adequately to Tier I or Tier II services. It is important to note that Tier III services are not synonymous with special education services, and students do not have to have a recognized disability to receive these services. Moreover, regardless of what level of service-delivery a student is classified at or his or her educational placement (e.g., general education, special education), it is important that the student still has access to Tier I services such as SEL.
ATHEALTH: What RtI primary prevention protocols yield the best results, safe-schools or bullying?
DR. SULKOWSKI: Relatively recent research on school-based bullying prevention programs indicate that the programs result in a modest reduction in bullying at school. Thus, there is no magic solution for eliminating bullying at school. However, the goal of eliminating bullying is in itself a little misguided. Instead of eliminating bullying, we ought to be promoting the safety and security of school climates and fostering the emotional wellbeing for all students. I'm a strong believer that if all students felt safe, supported, and connected to their school community, school bullying would be far less of a problem, and students would be much more resilient to the negative effects of being bullied.
ATHEALTH: Generally, children with anxiety are not seen as "troublesome" in school. How much does that hinder their receiving the care they need?
DR. SULKOWSKI: Teachers report that anxious students often are model students in that they rarely disrupt class and often dutifully complete their assignments without complaining. Thus, anxious children may suffer in silence for a long time before being identified and provided with help. It is my hope that along with increases in awareness in the general public about mental health issues that impact students, increases in paying attention to the signs of childhood anxiety will also result.
ATHEALTH: It is important to initiate treatment as soon as possible after a child displays anxiety symptoms. Does the U.S. Preventive Services Task Force (USPSTF) recommend routine screening for school age children?
DR. SULKOWSKI: The U.S. Preventive Services Task Force (USPSTF) currently does not recommend screening for anxiety in children or adolescents. In fact, I don't think they even address this issue on their webpage. The USPSTF recommends screening for adolescent depression yet not for children because they report that the current evidence is insufficient to assess the balance of benefits and harms of screening for depression in children. In addition, the USPSTF also concludes that evidence is insufficient to screen for suicidal behavior in children and adolescents. Therefore, in light of these positions, I do not anticipate the USPSTF recommending screening for anxiety in youth in the foreseeable future. However, this does not mean that screening for anxiety is not a worthwhile endeavor.
ATHEALTH: Do you recommend specific instruments to screen children for anxiety in the pediatrician's office?
DR. SULKOWSKI: The Brief Problem Checklist is a quick and dirty 15-item checklist that can be used by pediatricians to screen for both internalizing and externalizing psychopathology. However, the measure does not allow for the assessment of any specific anxiety disorders. Therefore, pediatricians might want to use other freely available instruments for this task such as the Pediatric Anxiety Rating Scale (PARS). The PARS also comes with instructions on how to administer and score the measure. Furthermore, pediatricians also can use freely available child- and parent-report measures of internalizing psychopathology and anxiety symptoms such as the Self-Report for Childhood Anxiety Related Disorders (SCARED) scale, the Revised Children's Anxiety and Depression Scale (RCADS), and the Brief Problem Checklist.
Click on a link below to access downloadable and printable versions of the aforementioned assessments.
Revised Children's Anxiety and Depression Scale (RCADS-25) – Short Version
ATHEALTH: In your opinion, what are the best anxiety screening instruments for a) overall school population, b) at-risk children or c) the individual child?
DR. SULKOWSKI: The Behavioral and Emotional Screening System (BASC-2 BESS), probably, is the best established screener for emotional and behavioral problems in school settings. This instrument contains about 30 items, takes about five minutes to complete, and it can be used for school-wide assessment and progress monitoring. The BASC-2 BESS, also, has been incorporated into Review360, which is a powerful data aggregation and analysis software program that allows for tracking behavioral RtI data.
As discussed above, the BASC-2 is a well-validated instrument that can assess for anxiety problems in students. Similarly, the Achenbach Child Behavior Checklist (CBCL) is another valid instrument for assessing internalizing disorder symptomalogy in children. In contrast to the BASC-2, the CBCL is a little more calibrated toward assessing students with more severe forms of psychopathology and is more commonly administered in psychiatric/mental health settings as opposed to in schools where the BASC-2 is more commonly used.
Overall, I'm a proponent of using the multi-method assessment for assessing anxiety in individual children, especially if important service-delivery or treatment decisions are going to be made in response to assessment data. Screening is great for population-based assessment. However, it is too laden with Type I errors or false positives to be used to make programming or treatment-related decisions for particular individuals.
ATHEALTH: Are there web-based or computerized programs that you recommend? If so, for which age groups?
DR. SULKOWSKI: Yes. A few such programs exist. I would recommend Camp Cope-A-Lot (CCAL), which is an evidence-based computer program for treating childhood anxiety. CCAL provides youth (ages 7–13 years) with six computer-assisted CBT therapy sessions that can be followed with therapist-directed exposure therapy sessions. In schools, a counselor or therapist could start a student on CCAL as part of a Tier II intervention plan and then conduct the exposure sessions after the child masters the preliminary modules of the program that largely focus on cognitive restructuring, perspective taking, and fostering the development of other adaptive skills. Through using this program, school-based mental health professionals could help many more anxious students.
ATHEALTH: How well is the average school performing when it comes to screening their students for anxiety?
DR. SULKOWSKI: Despite the development of promising tools such as the BASC-2 BESS and other instruments, screening practices for childhood anxiety are largely non-existent in most schools. Schools often use naturally occurring school data such as office discipline referrals (ODR), in-school suspensions (ISS), and incidents of out-of-school (OSS) suspensions to identify students with externalizing behavior problems. However, equivalent naturally occurring school data do not exist to help identify students with internalizing problems as these students generally are not disruptive to the school environment. As a pretty progressive approach toward trying to identify students with anxiety problems, schools could track somatic complains, trips to the nurse, excused absences, and days missing from school to try and identify anxious students because many—but not all—of anxious students display these issues.
ATHEALTH: Cognitive behavioral therapy (CBT) seems to be the treatment of choice for children's anxiety. Would you help our readers understand why CBT is preferred?
DR. SULKOWSKI: Cognitive-behavioral therapy (CBT) is the first-line treatment for childhood anxiety disorders because of the extensive body of research supporting its efficacy as well as the low risks associated with treatment. CBT is a change-oriented form of psychotherapy that has achieved "'well established'' status as an effective treatment (the highest possible rating) by the American Psychological Association's Task Force on Promotion and Dissemination of Psychological Procedures.
CBT can be implemented in the schools by school-based mental health professionals such as school psychologists, counselors, and social workers, and research on the application of CBT in schools is favorable. In general, research on the implementation of CBT in schools to treat childhood anxiety suggests that most students respond to treatment and experience at least a moderate reduction in their anxiety symptoms.
ATHEALTH: CBT, generally, includes several treatment components, including psychoeducation, exposure therapy, and cognitive restructuring, etc. Explain how the child's developmental age must be considered for each of CBT's components.
DR. SULKOWSKI: Cognitive or thinking interventions, such as cognitive restructuring, require at least a modicum of metacognition skill or the ability to understand how one's own thinking works. These skills take time to develop in children, and therefore, the benefits of cognitive restructuring likely will be lost on young children who have not developed them yet. Other CBT components such as exposure therapy, which is very behavioral in nature, have been found to be effective with individuals up and down the developmental spectrum. Thus, CBT for young children should be more behavioral and less cognitive in its application.
Here is a helpful case example that illustrates the previous point. I once worked with a four-year-old girl and her mother to increase the girl's willingness to wear clothes. The girl met all of her developmental milestones on time and was in the normal range for cognitive functioning. However, she had developed an extreme aversion to wearing clothes of any kind and she would cry profusely when required to do so. In addition, she started engaging in avoidant behaviors associated with wearing clothes, such as hiding her clothes in various places around the house (e.g., her brother's closet, under the bed in a guest room). When treatment began, the girl had not worn any article of clothing for about two weeks, and her parents wrapped her in a blanket if they had to take her out in public.
Treatment for the child basically involved shaping, differential reinforcement for wearing clothes, choice making, and exposure therapy (all very behavioral approaches). Essentially, the girl was reinforced with a tangible reinforcer (i.e., M&Ms) while playing a reinforcing game with the therapist and her mother (i.e., "hot and cold" with M&Ms). While the girl was working toward displaying greater successive approximations of clothes wearing behavior (e.g., having one sock on, having both socks on, wearing pants, wearing a dress, wearing pants and a shirt, etc.), the reinforcing game continued, and the girl was able to earn reinforcers. However, as soon as she removed an article of clothing, the therapist and the girl's mother disengaged and stopped interacting with the girl until she put the article of clothing back on or chose a different article to wear.
Eventually the game generalized to any form of child-directed play, and the girl was able to play whatever game she wanted in the therapist's office or watch developmentally-appropriate YouTube videos as long as she was displaying the right criterion of clothes wearing behavior. Lastly, the girl was encouraged to wear clothes that she said "hurt her" (mostly included heavier dresses, coats, gloves, and hats) for longer periods of time to receive reinforcrers. Therefore, she exposed herself to perceived (not actual) discomfort associated with wearing these clothes for greater durations of time until she habituated to them and her mind shifted to other concerns. Thus, as illustrated in the aforementioned case example, using a behavioral approach to address the child's problematic behaviors allowed for change in her behavior that then resulted in changes in her thinking patterns. In my opinion, because of her age-related metacognition limitations, the treatment would not have been successful if we had tried to target her thoughts directly.
ATHEALTH: Are there new treatment(s) on the horizon?
DR. SULKOWSKI: With regard to childhood anxiety, "new treatments" often are existing treatments with new packaging. Anything that is heralded as a "cure" for childhood anxiety should be met with a dose of healthy skepticism because expecting for any form of psychopathology to disappear overnight is unrealistic.
At this point, I think that the focus should be more on refining and improving existing effective treatments for childhood anxiety such as CBT over trying to innovate new psychotherapies. A significant discrepancy already exists between the number of youth who can benefit from CBT and those who receive the treatment. To address this discrepancy, innovative research is needed on reducing barriers to treatment access, transporting treatments across settings, and using stepped-care treatment strategies to triage and better calibrate treatment for individuals. Additionally, more research is need to asses which components of CBT are effective and for what individuals. Currently, most people who seek treatment get the full CBT protocol; however, we do not know what parts of the protocol are most potent and which parts are less so and can be trimmed down or even eliminated.
ATHEALTH: What level of training would you recommend as a minimum for Tier 2, school-based group services or Tier 3 services?
DR. SULKOWSKI: It is important for school-based mental health professionals to have had coursework, supervised practice, and continuing education in providing mental health services to students in need of Tier II services such as group counseling. Many resources exist to provide knowledge of this training. In fact, with my colleague, Dr. Diana Joyce-Beaulieu from the University of Florida, we soon will be releasing a book entitled: "Cognitive Behavioral Therapy in K-12 Schools: A Practitioners' Workbook" * through Springer publishers. This book contains information on the fundamentals of applying CBT in school settings, and it includes case examples on which practitioners can model their own practice. However, as a caveat, novice or inexperienced practitioners should seek supervision from more experienced colleagues when they start doing intervention work with anxious students. Books are great for learning, but they are not a substitute for supervised training.
* Preface to Cognitive Behavioral Therapy in K-12 Schools: A Practitioners' Workbook is published at the end of this interview.
ATHEALTH: Would you recommend group services to children with social anxiety? What are the benefits of treating these children in groups?
DR. SULKOWSKI: Research indicates that group-based treatments for social anxiety disorder are an especially powerful treatment option. The mere task of sitting in a group and sharing one's thoughts and feelings can be an exposure task for students with high social anxiety. Furthermore, groups allow for students to give and receive social support from their peers to accomplish their own treatment-related goals. I think we all do a little better with some help from our friends.
One easily manageable challenge of conducting group-based treatment in schools relates to the ethical prerogative to protect students' privacy. Therefore, as soon as is feasible, the therapist should have a discussion with the students in the group about the importance of protecting the confidentiality of what other members share in the group.
ATHEALTH: In your experience, how well do children adhere to rules of confidentiality?
DR. SULKOWSKI: In my experience, most children respect the confidentiality of the information that their peers discuss in group sessions. When discussing the concept of confidentiality, I am always careful to provide children with developmentally appropriate examples, such as not sharing embarrassing secrets of their best friends. Then, I work through specific scenarios the children encounter, such as how to respond to a classmate who is interested in where they are going when they go to group sessions, who attends the sessions, and what they discuss. In response to these questions, it also can be a good idea to role play and definitely ask questions to ensure that children understand the notion of confidentiality.
ATHEALTH: Describe the Coping Cat program?
DR. SULKOWSKI: The Coping Cat program was developed by Philip Kendall and his colleagues at Temple University. It is a CBT program that is designed to specifically treat childhood anxiety using a multi-component and manualized format. The Coping Cat uses the following acronym to help children understand anxiety and how it impacts their life: FEAR, which stands for "Feeling frightened; Expecting bad things to happen; Attitudes and Actions that can help; and Results and Rewards. The Coping Cat program employs the following therapeutic components: modeling, relaxation, in vivo exposure tasks, contingency management, problem solving, and self-evaluation.
As a time-limited CBT protocol, the Coping Cat program follows a 16-session format, and it includes a therapist manual and client workbook. The therapist manual helps structure and pace treatment, and the workbook contains developmentally appropriate worksheets and activities that guide the treatment process. Many studies over the last 10 to 15 years have been conducted on the Coping Cat, and the program has been found to be an effective treatment for childhood anxiety.
ATHEALTH: How many CBT sessions are normally recommended for treating a school-age child with anxiety? Which session(s) focus on psychoeducation and which focus more on behavioral exposures?
DR. SULKOWSKI: The number of CBT sessions that are needed to establish a robust therapeutic benefit varies on a case-by-case basis. I've seen some children benefit significantly from only a handful of sessions, whereas other children needed as many as 20 sessions to achieve similar results. Often complications such as the presence of comorbid depression, high anxiety sensitivity, poor insight, low parental support, and poorly treated or regulated medical problems can interfere with treatment gains and may need to be addressed prior to or during treatment.
The main thing for a clinician to consider is whether the child is still making regular progress in treatment. Even if the progress is slow, it still is important to help the child on his or her trajectory toward living a life that is not dominated by anxiety.
The proportion of sessions that should be allocated to different CBT components (e.g., psychoeducation, cognitive restructuring, behavioral exposures) remains a point of contention in the field. Current manualized treatments such as the Coping Cat recommend doing cognitive therapy exercises following the provision of psychoeducation. However, I often do the opposite, especially when treating OCD, Specific Phobia, Social Anxiety Disorder, and Separation Anxiety Disorder. My rationale for this is that I think that behavioral exposures carry the largest proportion of the treatment effect associated with CBT and that people benefit from having the process explained to them. Thus, when it comes to CBT, I think experience should come before explanation for most clients.
ATHEALTH: What treatment outcomes instruments are commonly used to track treatment progress?
DR. SULKOWSKI: At the simplest and most basic level, therapists can track students' Subjective Units of Distress (SUDs) in and across sessions to assess how quickly and markedly a student habituates to exposure tasks.
The Clinical Global Impression Scale (CGIS) is also commonly used as a quick measure of treatment-related improvement. The CGIS is a relatively old measure that has been used in many studies, and it can be used to assess anxiety symptom severity as well as treatment response in individual youth. It is also freely available.
ATHEALTH: Do you recommend using Scott Miller's Session Rating Scale (SRS) and/or Outcome Rating Scale (ORS) to measure progress of children being treated for anxiety?
DR. SULKOWSKI: I personally have not used the Session Rating Scale (SRS) and/or Outcome Rating Scale (ORS) so I cannot comment on them from personal experience. I think that good therapists track client functioning and the quality of the therapeutic alliance over the course of psychotherapy so any measures that can help improve this process might have utility. However, the SRS and ORS are proprietary instruments, which will inevitably limit their appeal and clinical utility, especially in settings such as schools where money for purchasing such instruments is often limited.
ATHEALTH: What should the private practice, office-based mental health professional, who works with children, know about the concept, Response to Intervention (RtI)?
DR. SULKOWSKI: This is a good question. I think the fundamental thing that they should know is that RtI has changed the psychoeducational assessment game. Many states now require RtI data and behavioral observation data to be included in psychoeducational reports that can be used to qualify students for services. Because they do not work in schools or have the ability to implement RtI-related interventions, for classification/qualification decisions, evaluation reports generated by clinical or private practice professionals may need to be augmented by data collected by school-based professionals.
ATHEALTH: Who is responsible for funding school-based services? In your opinion, is the funding adequate?
DR. SULKOWSKI: Many schools bundle together and submit funding packages for reimbursement to Medicaid. However, this is often a highly time-consuming and complicated process that may necessitate a full-time position that many small or underfunded school systems cannot afford. Therefore, even if federal funding is available to increase the provision of school-based mental health services, the current dissemination process is highly inefficient, and it is in need of further reform.
ATHEALTH: Are there model(s) of school-based programs that you would like our readers to know about?
DR. SULKOWSKI: Yes. The first program that comes to mind is the School Mental Health Project that currently is underway in rural portions of North Carolina in collaboration with faculty and psychology students from Appalachian State University. Despite the formidable barriers to mental health in the region, students participating in the program display outcomes that are comparable in efficacy to results obtained at major medical centers and university-affiliated research hospitals. My colleague, Dr. Kurt Michael, directs the Watauga High School Mental Health Partnership in Boone, NC; please click the link for more information.
ATHEALTH: Many of our readers face Health Insurance Portability and Accountability Act (HIPAA) compliance issues, daily. Tell us about the major confidentiality and privacy issues mental health professionals face when providing school-based services. How should clinicians protect themselves?
DR. SULKOWSKI: HIPAA only pertains to the electronic transmission and storage of medical records. In addition, as an older act, the Family Educational Rights and Privacy Act generally trumps HIPAA in school settings when these laws contradict. Among other things, FERPA protects the inappropriate disclosure of students' educational records.
Essentially, the impact that HIPAA has on the practice of school mental health professionals depends on the degree to which health service providers are present in school settings and the way that these individuals store and transmit student health information. In many schools, only a handful of personnel, such as school nurses and school psychologists, are designated as health service providers and subjected to HIPAA.
It is critically important to note that although ethical prerogatives exist to protect the confidentiality of students receiving mental health services at schools, there are not well-established legal precedents to protect the confidentiality of these students. Some experts even go so far as to say that because students are minors and school environments are public in nature, there is no confidentiality at school, and students should be notified as such before entering into a therapeutic relationship.
ATHEALTH: Would you recommend that community mental health professionals become involved in their local school(s) to support students with anxiety disorders?
DR. SULKOWSKI: Absolutely. With the consent of legal guardians and the assent of students, community mental health professionals can become key allies in helping anxious students. They can help inform school-based professionals about treatment plans, helpful resources, and even attend IEP or student study team meetings. In general, interdisciplinary and cross-discipline collaboration between school and community-based professionals can be very positive.
ATHEALTH: Does the Affordable Care Act (ACA) impact school-based mental health treatment?
DR. SULKOWSKI: I think that the Affordable Care Act (ACA) has the potential to make a big impact on the delivery of school-based mental health care services. Right now, various professions are working hard to be recognized as health service providers under ACA, which will enable them to enhance their role in being compensated for providing mental health services. Often, it takes a little while for different disciplines to adjust to new laws that govern school-based service delivery, and I think we're in a transition phase with ACA right now. It will be interesting to see how things play out with APA and the provision of school-based mental health care over the next couple of years.
ATHEALTH: Since the passage of the ACA, are you more or less optimistic that school-based treatment of childhood anxiety will become widespread?
DR. SULKOWSKI: I'm optimistic that the passage of ACA will open up increased opportunities for increasing the provision of school-based treatment for childhood anxiety. I think that it will be a while for the benefits of ACA to be sufficiently felt by millions of students, though, especially anxious students who can be a challenge to identify and may not actively seek treatment. Therefore, it is important for school-based mental health professionals to remain proactive and steadfast in their efforts to assist anxious students at school and not wait for improvements in practice that might result down the road from ACA.
ATHEALTH: Before we end the interview, would you tell us how you see the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), might impact the diagnosis and treatment of childhood anxiety disorders?
DR. SULKOWSKI: There have been some notable changes in diagnostic categories associated with childhood anxiety in DSM-5. OCD has been moved to a new diagnostic category that includes obsessive-compulsive and related disorders such as trichotillomania (compulsive hair pulling), excoriation (skin picking) disorder, and body dysmorphic disorder, and PTSD has been moved to a category that includes trauma- and stressor-related disorders. Although these disorders are no longer listed under the anxiety disorder subheading in DSM-5, crippling or impairing anxiety still is a central feature of these disorders and must be treated in therapeutic plans.
Separation Anxiety Disorder and Selective Mutism also have been moved from a DSM-IV-TR section that is entitled "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" into the Anxiety Disorders section in DSM-5, which, I think, is a positive change because of the notable phenomenological similarities between these and other anxiety disorders. At one time, Selective Mutism was called "elective mutism," which implied the mistaken belief that the majority of children with this disorder did not speak because they were being oppositional/defiant as opposed to being highly anxious.
Other DSM-5 related modifications to diagnostic criteria are available on the DSM-5 workgroup webpage.
Regarding the impact that the aforementioned modifications will have on treatment for childhood anxiety, I would not expect to see many major changes. Shifting these disorders around in where they are classified does not change their core nature or the effective interventions that have been developed over the past few decades to address their symptoms.
ATHEALTH: Anything else you would like to add before we finish?
DR. SULKOWSKI: Although there is considerable room for improvement in efforts to help anxious students at school, thousands of school-based mental health professionals already are making great strides in this regard and these ought to be recognized. Every day students from across the U.S. and beyond benefit from the dedicated efforts of these professionals, and I'm excited that each year graduate training programs are turning out more graduates that have dynamic skills for helping the anxious students they will serve.
Thank you for the opportunity to respond to these excellent and thoughtful questions!
If readers have additional questions, please contact me at:
Mailing Address: 1430 E. 2nd Street, P.O. Box 210069, Tucson, AZ 85721
* Cognitive Behavioral Therapy in K-12 Schools: Practitioners' Workbook – Preface
In the Cognitive Behavioral Therapy in K-12 Schools: Practitioners' Workbook, we have attempted to provide practitioners with an easily accessible and practical guide for implementing basic Cognitive Behavioral Therapy (CBT) counseling strategies in K-12 school settings. Because of the unmet mental health needs displayed by millions of students in these settings as well as because of advancements in the training and provision of school mental health services during the past couple of decades, school-based mental health professionals such as counselors, school psychologists, social workers and others are increasingly being asked to provide evidence-based counseling and intervention services such as CBT.
Therefore, to address this need, the current text provides an overview of conducting effective CBT interventions in school settings, understanding and counseling students with internalizing problems through using CBT, and understanding and counseling students with externalizing problems with CBT. In addition, reproducible worksheets and practical resources for practitioners who work with students in elementary and secondary school grades are provided. Two chapters also provide counseling case samples and reports for students affected by different disorders and problems that practitioners can use to scaffold their own efforts to provide CBT in contemporary school settings that often require progress monitoring and measureable outcomes. Thus, the content covered in this text is nested within contemporary school-based service-delivery models such as response-to-intervention (RtI) and multi-tiered systems of support (MTSS) that are becoming more commonly adopted and implemented in K-12 schools.
As written, this book differs from many extant CBT guides and workbooks in that it is designed for the busy practitioner who primarily works in K-12 school settings and must balance a range of different roles and responsibilities. Thus, this book is not a comprehensive or research-heavy handbook; rather, it aims to serve as a workbook that can be used to help practitioners get better acclimated with CBT and then integrate this therapeutic approach into their own regular practice. From decades of study, a wealth of research is available that supports the efficacy of CBT for treating various disorders and forms of psychopathology in youth and this research has been applied and referenced in the construction of this text. Because of its format and content included therein, it is our hope that this book will be both engaging and useful for practitioners who work with students in K-12 school settings. We have found the strategies discussed in this text to have great utility in our own practice and we trust that you will as well.