1. Chronic Pain Syndromes: Understanding & Managing Impact on School Barbara Rzepski, Ph.D. Institute of Living Connecticut Children’s Medical Center May 20, 2010 Barbara Rzepski, Ph.D. Institute of Living Connecticut Children’s Medical Center May 20, 2010

2. Introduction Behavioral Inhibition Anxiety Impact on School Functioning School Avoidance Nurses as First Responders Practical Guidance Behavioral Inhibition Anxiety Impact on School Functioning School Avoidance Nurses as First Responders Practical Guidance

3. Behavioral Inhibition Temperamental style Vulnerability to anxiety disorders: early manifestation of familial predisposition Stress Reactivity: physiologic response to perceived threats, increased response to uncertainty, heightened sensitivity to gut visceral sensations, excessive muscle tenderness, lowered pressure pain threshold Comorbidity of parental anxiety is risk for childhood onset anxiety Temperamental style Vulnerability to anxiety disorders: early manifestation of familial predisposition Stress Reactivity: physiologic response to perceived threats, increased response to uncertainty, heightened sensitivity to gut visceral sensations, excessive muscle tenderness, lowered pressure pain threshold Comorbidity of parental anxiety is risk for childhood onset anxiety

4. Stability of behavioral inhibition: strong predictor of anxiety disorders Inhibition & psychopathology not equivalent Up to 70% inhibited children without anxiety disorders Stability of behavioral inhibition: strong predictor of anxiety disorders Inhibition & psychopathology not equivalent Up to 70% inhibited children without anxiety disorders

5. Benefits of Inhibition Tend to avoid high risk behaviors Less experimentation: sex, drugs, and rock & roll “Type A” vs conscientious student Increased focus & organization Tend to avoid high risk behaviors Less experimentation: sex, drugs, and rock & roll “Type A” vs conscientious student Increased focus & organization

6. Normal vs.. Pathological Anxiety Anxieties & fears are normal in childhood Usually related to age and/or developmental status Most fears dissipate with age Fears that are long-lasting or interfere with functioning may require intervention Anxieties & fears are normal in childhood Usually related to age and/or developmental status Most fears dissipate with age Fears that are long-lasting or interfere with functioning may require intervention

7. Prevalence Significant mental health disorders in 14 - 20% of children & adolescents Minority seen by mental health specialists Majority of children with mental health disturbance seen in Primary Care 50% pediatric office visits involve behavior, psychological, education issues Anxiety disorders most prevalent; least treated Significant mental health disorders in 14 - 20% of children & adolescents Minority seen by mental health specialists Majority of children with mental health disturbance seen in Primary Care 50% pediatric office visits involve behavior, psychological, education issues Anxiety disorders most prevalent; least treated

8. Anxiety Prevalence Parent & Child Informants: 7% & 23% in primary care setting had sub threshold anxiety 7% & 11% met criteria for anxiety dx(based on symptom, duration, severity) Parent & Child Informants: 7% & 23% in primary care setting had sub threshold anxiety 7% & 11% met criteria for anxiety dx(based on symptom, duration, severity)

9. Transient vs. Persistent Anxiety Reassurance is never enough Symptoms increase over time Symptoms generalize to more situations Child increasingly avoidant Interferes with normative experiences Fears are unreasonable or extreme Significant developmental regression Reassurance is never enough Symptoms increase over time Symptoms generalize to more situations Child increasingly avoidant Interferes with normative experiences Fears are unreasonable or extreme Significant developmental regression

10. Sub-Clinical/Prodromal Anxiety Common Declines with age Girls more than boys Early onset & chronic course Common Declines with age Girls more than boys Early onset & chronic course

11. Impact on School Functioning Academic Functioning/Attendance Often tardy Excessive visits to school nurse Frequent/prolonged absences Academic Functioning/Attendance Often tardy Excessive visits to school nurse Frequent/prolonged absences

12. Classroom Behaviors Attention/concentration Underachievement Behaviors: participation, oral reports, overly dependent Evaluative Tasks: Homework(checking, erasing, excessive) Tests(continuous checking, non-completion) Attention/concentration Underachievement Behaviors: participation, oral reports, overly dependent Evaluative Tasks: Homework(checking, erasing, excessive) Tests(continuous checking, non-completion)

13. School’s Role Understanding vs.. accountability Prevention of morbidity: collaborative relationship, making transition successful Communication Titrate workload Understanding vs.. accountability Prevention of morbidity: collaborative relationship, making transition successful Communication Titrate workload

14. School Avoidance Identify primary issue sustaining school refusal Functional approach Collaboration(everybody “on the same page”) Not the same as truancy Identify primary issue sustaining school refusal Functional approach Collaboration(everybody “on the same page”) Not the same as truancy

15. Somatic Complaints Stay out of the nurse’s office Empathy but expect function Over-solicitiousness AVOID morbidity: get parents on board, specify limits to attending to physical complaints Stay out of the nurse’s office Empathy but expect function Over-solicitiousness AVOID morbidity: get parents on board, specify limits to attending to physical complaints

16. Nurses as First Responders Accommodations for students with chronic pain(Logan,et al. 2010) Teachers rated 6 different options for accommodations for students with pain: go home, rest at desk, send to nurse, reduce workload, alter deadlines, make students be nice to student with pain 83% rated “send to nurse”, more likely response than any other option Accommodations for students with chronic pain(Logan,et al. 2010) Teachers rated 6 different options for accommodations for students with pain: go home, rest at desk, send to nurse, reduce workload, alter deadlines, make students be nice to student with pain 83% rated “send to nurse”, more likely response than any other option

17. Bullying It’s a new world; behavior outside of school can impact behavior in school 58% of school children reported staying home at least 1 day to avoid bullying High level of suspicion Anxious/inhibited children may need specific help in assertiveness It’s a new world; behavior outside of school can impact behavior in school 58% of school children reported staying home at least 1 day to avoid bullying High level of suspicion Anxious/inhibited children may need specific help in assertiveness

18. Practical Guidance Anticipate and plan: holidays, illness, developmental challenges Rule-out comorbid learning problems Teach social skills and conflict resolution “vicious cycle”: social skills deficits increase negative social outcomes and avoidance Don’t forget the internet Not a substitute for assertiveness The “new” harassment environment Anticipate and plan: holidays, illness, developmental challenges Rule-out comorbid learning problems Teach social skills and conflict resolution “vicious cycle”: social skills deficits increase negative social outcomes and avoidance Don’t forget the internet Not a substitute for assertiveness The “new” harassment environment

19. Practical Guidance Parental guidance Separation issues, turn the cell phone off Encourage exposure Confront stable behavioral inhibition: some problems kids don’t “grow out of it” Adult support/availability Realistic expectations, personal attention Parental guidance Separation issues, turn the cell phone off Encourage exposure Confront stable behavioral inhibition: some problems kids don’t “grow out of it” Adult support/availability Realistic expectations, personal attention

20. 504 Plan: Beyond the Elevator Key “Go to School full-time”: what schedule, for whom? Individualize re-entry plan Clarify current/past expectations Tutoring: pros/cons Decisions re: attendance based on goals, not symptoms NO TRICKS Co-ordination(everybody on same page); flexibility “Go to School full-time”: what schedule, for whom? Individualize re-entry plan Clarify current/past expectations Tutoring: pros/cons Decisions re: attendance based on goals, not symptoms NO TRICKS Co-ordination(everybody on same page); flexibility

21. Wellness Plan Build in time for coping(not based on “can’t take it any longer”) Coping/distraction strategies Build in time for coping(not based on “can’t take it any longer”) Coping/distraction strategies