Evidence-Based Assessment & Management of Symptons of ......(Psychological) contagion • Exposure to a distressing event or behavior via a peer group, social media, or mass media

© Katherine Dahlsgaard, PhD

Evidence-Based Assessment& Management of Symptomsof Anxiety & Depression in Youth After ConcussionKatherine Dahlsgaard, Ph.D., ABPPDirector, Food Allergy Bravery ClinicDivision of Allergy and Immunology / Department of Child & Adolescent Psychiatry & Behavioral Sciences Children’s Hospital of Philadelphia

Founder and DirectorBrave is Better LLC


HELIX Conference9 November 2020


Conflicts of Interest / DisclosuresThe content represents the presenter’s personal opinions and does not necessarily represent the position of the presenter’s employer or previous training sites.

Contributer to:The Philadelphia Inquirer

Private Practice:Brave is Better LLC

Honoraria and Speaking Fees:Workshops and CME events



Learning ObjectivesAfter this workshop, participants will be able to:

1. Identify brief and valid screeners and assessment tools for symptoms of anxiety, depression, and PTSD following mild TBI / concussion

2. Discuss presented data on pre-existing anxiety and depression as risk factors for increased and prolonged symptoms of concussion

3. Discuss evidence-based recommendations for co-management of potential symptoms of anxiety and depression following mild TBI and concussion

Brave is Better LLC © Katherine Dahlsgaard, PhD


Anxiety & Depressive SymptomsConsiderations with regard to concussion



(Psychological) contagion• Exposure to a distressing event or behavior via a peer group, social media, or mass

media can increase the odds of that phenomenon or behavior in others (Gould, 1990; Gould et al., 2003).

– Koro epidemic of 1967; The Girls of Le Roy, NY; Suicide clusters

• Adolescents and young adults are thought to be particularly vulnerable

• Theory: the more sensational and relentless the media coverage, the worse the contagion effect (Etzersdorfer et al., 2004; Motto, 1970; Hagihara et al., 2007)

• Has led to changes in terms of how suicides are covered in the media (example: see AFSP Media Guidelines)


Anxiety Sensitivity


•The tendency to pay attention to physical sensations of anxiety and interpret them in a catastrophic way (Reiss & McNally, 1985)

•Those low on anxiety sensitivity certainly don’t enjoy the physical sensations of anxiety, but interpret them in a decatastrophizing way – “Hmmm. Interesting. Annoying. This will pass. No big deal.”

•Anxiety sensitivity is a trait; that is, people are born with a propensity for more or less of it and it tends to be stable over time (Reiss et al., 1986).

•Stable but malleable.


Anxiety Sensitivity


•Those high on anxiety sensitivity are more at risk for developing all sorts of anxiety disorders, most notably Panic Disorder, but also phobias, PTSD, social anxiety disorder, etc (McNally, 2002; Schmidt et al., 1997, 1999).

•Anxiety Sensitivity also predicts increased symptoms of concussion and longer recovery time post concussion…


Anxiety: diathesis for increased symptoms of concussion?

Post-injury: • “Anxiety sensitivity” concurrently associated with increased symptoms of

concussion among adults (Wood et al., 2011)

• Pediatric patients with premorbid anxiety diagnosis and/or treatment predicted increased postconcussive symptoms (Kirkwood et al., 2014)

• Anxiety post-injury concurrently and prospectively associated with more severe self-reported symptoms of concussion (King, 1996)


Anxiety: diathesis for longer-than-expected recovery?

Corwin et al. (2014)• Pediatric patients with premorbid anxiety took 2.3x longer become

symptom free (168 days vs. 76 days)

• ALL these patients took > 4 weeks to recover, required school accommodations, and reported declining grades

• Patients with pre-existing anxiety or depression tend to have prolonged course, delayed resolution of symptoms


Rumination (Michl et al., 2013)


•“Rumination involves repetitive and passive focus on the causes and consequences of one’s symptoms of distress without engagement in active coping or problem-solving to alleviate dysphoric mood.”

•Prospective studies show tendency to ruminate a risk factor for:•Depressive and anxiety symptoms•Risk for onset of major depression and chronicity of depression

•Experimental induction of rumination over distraction prolongs both anxious and depressed mood states

•Tendency to ruminate is a trait, but…


Rumination, part 2 (Michl et al., 2013)


• Stressful experiences increase engagement in rumination

• Stress = “social and environmental circumstances that require psycholoical and physiological adaptation over time by an organism.”

•Negative events create discrepancies between•Goals and desired states vs. one’s current state

•One might ruminate about how to reduce that discrepancy•Worse when the stressor is uncontrollable or chronic

• Stress might also increase rumination by undermining self-regulation skills• Indeed, anxiety and sadness also result in reduced executive functioning


A possible mechanism

CONCUSSION

“I feel nauseous.”

Increased symptoms (anxiety,

concussion, both??)

Heightened symptom sensitivity



CONCUSSION

“I feel irritable and sad today.”

Increased symptoms (depressed

mood, concussion,

both??)




CONCUSSION

“I really need to stay home so this doesn’t get

worse.”

Increased opportunity

for rumination



Prospective baseline symptomsChild Athletes (9-12 years)

Boys Girls

Sleepier 30% 23%

More tired 25% 16%

Nervousness/Worry 17% 26%

Headaches 10% 10%

Hunt et al., (2016)


Prospective baseline symptomsYouth Athletes (13-17 years)

Boys Girls

Fatigue 50% 66%

Nervousness 20% 32%

Headaches 24% 28%

Drowsiness 30% 22%

Difficulty Concentrating 24% 23%

Hunt et al., (2016)

© Katherine Dahlsgaard, PhDBrave is Better LLC © Katherine Dahlsgaard, PhD

Recent Reviews Specific to Child & Adolescents (Emery et al., 2016)

• Few rigorous studies have examined psychological, behavioral, and psychiatric outcomes following mTBI in youth

• There is increased likelihood of problems in the short term (see also Keightleyet al., 2014)

• Most research is retrospective recall, not prospective• Small number of studies; mostly self-report• Most compares mTBI to non-injured controls• “Little evidence to suggest that emotional/behavioral problems persist

beyond the acute & sub-acute period following a mTBI.”• Increased prevalence more likely if

• mTBI associated with hospitalization; occurs < 6 years old; multiple previous mTBIs; pre-existing psychiatric illness


Recent Reviews Specific to Child & Adolescents (Durish et al., 2018)

• Reviewed 14 studies on TBI and depressive symptoms in youth• Relative dearth of high quality research on this topic• Depressive symptoms (not disorder) are more common after TBI when

comparing to healthy and orthopedically injured populations• Predictors of depressive symptoms include

• Lesions in the brain;• presence of pain; • older age at injury; • low SES

• “Depression likely a secondary outcome of pediatric TBI than a direct result of the injury itself.”


Studies on mTBI and PTSD in youth

• Hajek et al., 2010• Parent-rated PTSD symptoms• Ratings taken at 1-2 weeks; 3 months, and 12 months post mTBI• No difference found between mTBI and orthopedically injured control group• Conclusion: Injury in general (not specifically mTBI) related to PTSD symptoms

• O’Connor et al., 2012• Self-reported PTSD symptoms• Youth with mTBI reported significantly more symptoms than orthopedically injured youth


Anxiety, Depression, & PTSDSome General Considerations


Normal AnxietyAll youth experience worries & anxiety… These represent emerging abilities and are usually adaptive.

These fluctuate in response to stress – that is, increase during a stressor and abate when stressor is conquered or simply passes.

“Distress, in and of itself, represents an inadequate criterion for distinguishing among normal and pathological anxiety states in children” (Beesdo et al., 2009, p. 484).


What maintains problematic anxiety?



In general…

1. Safe & healthy

2. Developmentally appropriate challenges

3. Temporary & bearable

Avoidance Anxiety


In general…

1. Removes us from sources of positive emotion

2. May alter sleep & lead to sleep disturbances

Withdrawal Depression


Problematic Anxiety = Problematic Coping Skills

The emotion of anxiety – including the INTENSITY!!!! of the emotion – is not what determines “problematicness.”

Rather, the defining feature of PROBLEMATIC anxiety is over-reliance on avoidance and escape behavior that is pervasive, persistent, and moderately-to-severely impairing.

That is, habitual avoidance and escape of things or situations that are either: a) safe and healthy, though possibly stressful challenges b) unlikely to happen c) temporary & bearable if they do happen


Evidence-Based Psychosocial Treatment for Child/Adolescent Anxiety Disorders

Cognitive-Behavioral Therapy (CBT) designated as the scientifically “well-established” and “first-line” treatment (AACAP, 2020; Higa-McMillan et al., 2016; Wang et al., 2017)

Exposure is deemed the primary active ingredient within CBT for all kinds of anxiety (American Psychiatric Association, 2009; Deacon & Abramowitz, 2004; National Institute for Child Excellence, 2011)


Evidence-Based Treatments for Depression in Children

Well-Established

Probably Efficacious

Possibly Efficacious •Overall CBT•Group CBT•Technology Assisted CBT•Behavior Therapy

Experimental •Individual CBT•Psychodynamic Therapy•Family-based Intervention

Questionable Efficacy

Source:Weersing. et al. (2017). “Evidence base update for psychosocial treatments for child and adolescent depression.”Journal of Clinical Child & Adolescent Psychology, 46 (1), 11-43.


Evidence-Based Treatments for Depression in Adolescents

Well-Established •Overall CBT•Individual CBT •Group CBT•Overall IPT•Individual IPT

Probably Efficacious •Group IPT

Possibly Efficacious •Group Mind Body Skills•Individual Integrated Therapy for Complex Trauma

Experimental •Individual Client-Centered Play Therapy•Individual Mind-Body Skills•Individual Psychoanalysis

Questionable Efficacy •Group Creative-Expressive + CBT

Source:Weersing. et al. (2017). “Evidence base update for psychosocial treatments for child and adolescent depression.”Journal of Clinical Child & Adolescent Psychology, 46 (1), 11-43.


From Dorsey et al., 2017 Evidence-Base Update• About 2/3 of American youth exposed to a traumatic event before age 18• Prevalence of PTSD for females = 7%; for males = 3-4% during

childhood/adolescence• Per Great Smoky Mountains Study, trauma exposed youth show…

– Behavioral problems (19.2%)– Depressive symptoms (12.1%)– Anxiety symptoms (9.8%)– “Significant impairment” = 21.9% (but increases to nearly half with 2 or more

exposures)

Prevalence and Course of PTSD in Youth


Evidence-Based Treatments for PTSD in Youth

Well-Established •Individual CBT (aka TF-CBT; Prolonged Exposure)•Individual CBT w/ Parental Involvement•Group CBT

Probably Efficacious •Group CBT w Parental Involvement•EMDR

Possibly Efficacious •Group Mind Body Skills•Individual Integrated Therapy for Complex Trauma

Experimental •Individual Client-Centered Play Therapy•Individual Mind-Body Skills•Individual Psychoanalysis

Questionable Efficacy •Group Creative-Expressive + CBT

Source:Dorsey, S. et al. (2017). “Evidence base update for psychosocial treatments for children and adolescents exposed to traumatic events.”Journal of Clinical Child & Adolescent Psychology, 46 (3), 303-330.


DSM-5 Criteria for PTSDBasic Criteria

A. Qualifying StressorB. Persistent re-experiencing /Intrusion

SymptomsC. AvoidanceD. Negative alterations in cognition or moodE. Changes in arousal & reactivityF. Persistence of above symptoms for more

than one monthG. Significant distress or functional

impairmentH. Not due to substance use, medication,

illness

Some changes from DSM-IV1. Deleted: Criterion requiring that the individual’s

response to the event must include intense fear, helplessness or horror (wasn’t great at predicting the onset of PTSD)

2. New : Preschool Subtype - for children younger than 6

3. New: Dissociative Subtype1. Primary presentation is dissociation2. Feeling detached from mind/body3. Experiences seem unreal, dreamlike, or

distorted


PTSD & ASD Criterion A: Traumatic Event

The individual must (1 or more):1. directly experience the traumatic event;2. witness the traumatic event in person; 3. learn that the traumatic event occurred to a close family member or close

friend - with the actual or threatened death being either violent or accidental

4. experience first-hand repeated or extreme exposure to aversive details of the traumatic event - not through media, pictures, television or movies


DSM-5 Criteria for Acute Stress Disorder

Criteria are exact same as for PTSD, with exception of durationA. Qualifying StressorB. Persistent re-experiencing /Intrusion SymptomsC. AvoidanceD. Negative alterations in cognition/moodE. Changes in arousal & reactivityF. Duration of symptoms is 3 days to 1 month after trauma exposure

Note: Symptoms typically begin immediately after the trauma, but must last for 3 days

Note: Acute Stress Reaction (ASR) is a transient reaction that can be evident immediately after the traumatic event & typically resolves within 2–3 days


AssessmentOf Concussion and Psychiatric Symptoms


Concussion Symptoms: Brief & Validated Symptom Measures for Youth1. Post Concussion Symptom Scale (PCSS) (Lovell & Collins, 1998)

• 22-item; self-report measure • ages 11 and older• Appears to be in the public domain

2. Post-Concussion Symptom Inventory (PCSI) (Gioia et al., 2009)• 13-26 items; self- and parent/teacher-report• ages 5-18

3. Health and Behavior Inventory (HBI) (Ayr et al., 2009)• 20-item; self- and parent-report• Ages 8- 15 years


Post Concussion Symptom Scale (PCSS)(Note: appears to be in public domain)


Assessment of Emotional Disorders

1. The most valid and reliable means of assessing and diagnosing emotional disorders is via Structured Clinical Interview

• Examples: K-SADS, ADIS, SCID; PSSI

2. However, there a many validated questionnaires available in public domain

• Can be used to screen; inform referrals• Provide baseline scores• Measure symptoms over time• Are not in themselves diagnostic tools


Anxiety: Brief & Validated Symptom Measures – Free (Available via website or emailing the author)

1. Screen for Child Anxiety Related Disorders (SCARED) (Birmaher et al., 1999)

• 41-item self- and parent-report measure; Ages 8 – 18 years• Provides Total Score and domain scores (e.g., Panic/Somatic; Generalized Anxiety; Separation

Anxiety; Social Anxiety; School Avoidance)• http://www.wpic.pitt.edu/research

2. Generalized Anxiety Disorder 7-Item Scale (GAD-7) (Spitzer et al., 2006)• Specific to Generalized Anxiety Disorder/Worry• Self-report only; 13 years and older• http://www.phqscreeners.com/

3. Penn State Worry Questionnaire for Children (PSWQ-C) (Chorpita et al., 1997)• Self-report only; 7 – 17 years• http://www.childfirst.ucla.edu/Resources.html


Depression: Brief & Validated Symptom Measures – Free (Available via website or emailing the author)

1. Center for Epidemiologic Studies Depression Scale for Children (CES-DC) (Faulstichet al., 1986)

• 20-item self-report; Ages 6 – 17 years• http://www.brightfutures.org

2. Depression Self Rating Scale for Children (DSRSC) (Birleson, 1978)• 18-item self-report only; Ages 8-14 years• http://www.scalesandmeasures.net

3. PHQ-9 Modified for Adolescents (PHQ-A) (Johnson et al., 2002)• 9-item self-report only; 11 – 17 years• http://www.phqscreeners.com/


Trauma: Brief & Validated Symptom Measures – Free (Available via website or emailing the author)

1. Child PTSD Symptom Scale (CPSS) (Foa et al., 2001)

• 24-item self-report; ages 8 – 18 years• http://www.aacap.org

2. Pediatric Emotional Distress Scale (PEDS) (Saylor et al., 1999)• 21-item PARENT-report only; Ages 2-10 years• Email: [email protected]



Post Concussion Mental Health SymptomsStrategies for School Staff and Caregivers


Strategy #1Prevention


Knowledge is power!• Harnessing scientific data to encourage positive expectations, normalize

experiences, & counter (understandable) catastrophic thinking

• Remind kids AND parents that short-term recovery is by far the norm…• Return to normal functioning within the first 3 weeks for most children and

adolescents (Collins et al., 2006)• In a prospective study of HS football players (Collins et al., 2012)

• 42-47% deemed “functionally recovered” at 1 week• 84-94% deemed functionally recovered by 4 weeks

• Gradual reintroduction of activities according to an informed plan with accommodation and management, rather than anxious avoidance.


Normalize anxiety, sadness & desire for escape

Normalize anxiety/sadness/anger as part of the process – concussion is a stressor!

Normalize that symptoms may come up during recovery and cause painful emotions AND VICE VERSA

• “It’s OK in the recovery process to have mild symptoms. We just don’t want you to have horrible symptoms.” (Dr. Christina Master, Philadelphia Inquirer, January 11, 2018)

You don’t have to wait until the symptoms are gone! “Rehab at school” model!


Example of Return to Learn PlanFrom Master et al., 2012, Pediatric Annals


Further Detail on Return to Learn PlanFrom Master et al., 2012, Pediatric Annals“At this point, it is important for the patient’s family to know that children should undertake cognitive activity for only the portion of the time that it took to produce mild symptoms (ie, subsymptom threshold for cognitive activity). For example, if reading for a half an hour produced head pressure or a mild headache, the child should read for only 20 minutes on the next attempt, and then take a cognitive break, before symptoms are exacerbated. This can be repeated several times in a day as tolerated. The following day, patients can attempt an increase in the duration of cognitive activity, but only up to the point at which they become symptomatic. They should stop the activity when mild symptoms develop and before severe symptoms develop, in order to take a cognitive break. When patients feel better after that break, they can resume cognitive activity once more, either by participating in the same or another activity. The process of subsymptom threshold cognitive activity is then repeated (p. 4).”


Strategy #2Adult Response to Prolonged Symptoms



Adults Can Model a Calm, Optimistic Outlook


Research shows that caregiver response influences children’s responseExamples:

•Parental anxiety highly predictive of child anxiety•High correlation of parental stress and parental report of their child’s stress following a traumatic event (Hiller et al, 2016)

Counter Strategies•Recognition that kids take their cues from adults•Recognition that kids do not have the cognitive capacity nor life experience to understand these events as adults do•“Little pitchers”•Think “coach,” not “helicopter”


Normalize and Empathize Big Emotions and Scary Thoughts

We forget just how helpful having someone in a position of authority acknowledge and name our emotions

Examples:“I can see why you are feeing anxious.”“I can tell that you are frustrated.”“If that happened to me, I would be feeling a bit hopeless, too.”

Empathic statements should come first, and may not need to be followed up with any problem-solving

Simply naming and then giving a moment is enough!


Strategy #3Flexible Thinking & Anti-Perfectionism

© Katherine Dahlsgaard, PhDBrave is Better LLC

Common Thinking Traps During Stress/Recovery #1


1. All-or-Nothing Thinking• Examples:

• “Am I a failure / wimp / fragile / broken?”• “Am I ever going to recover?”• “I can’t do it.”

• Antidote• Compassionately identify all-or-nothing thinking• Challenge “Yes/No” Questions with “Why?” “How” or “By What Means?” Questions• Open-ended questions promote problem-solving and flexible, hopeful thinking

• Counter-Strategies:• “What did you do well enough today?”• “What are you doing to keep yourself safe enough?”• “Which part are you going to try first?”


A Note on The Concept of “Safe Enough”

Rationale:•It is normal to worry as symptoms begin to abate if an activity is “safe.”•The reality is that almost no activity prior to a concussion was completely safe

Examples:•Driving / Riding in a car•Having a pool / swimming in the ocean

The reality is that we tolerate uncertainty and engage in risk assessment all the time.

Keep focus on what kids / families / school is doing to keep them “safe enough.”• A good metaphor: “What do you do to keep yourself ‘safe enough’ when you’ve broken an arm?”



2. Catastrophic Thinking•Examples:

•OVER-prediction of negative outcomes•OVER-prediction of catastrophic consequences•UNDER-prediction of one’s ability to cope

•Antidote•Acknowledge that this is normal and even helpful during a stressor – helps us ORIENT and PLAN•Compassionately acknowledge that such thinking is unhelpful when it leads to

•Rumination and/or Chronic avoidance

•Counter-Strategies:•Distraction in these cases may be very helpful•Maintaining a routine; sleeping, eating, exercise, social connection•Designated “worry time” or “Covid-19 time”



3. Pessimistic Thinking•Examples:

• “There is nothing to hope for.”• “My life is ruined.”•Pessimism is PAINFUL (cf. Scheier & Carver, 1992)

•Antidote•Much research shows us that optimistic people tend to consider undesirable outcomes as external, temporary, and specific (cf. Peterson & Steen, 2009):

•Counter-Strategies:•“Let’s think short-term for now.”•“This is likely due to external circumstances.”•“We can choose they way we think about this – why not choose hopeful?”•GROWTH MINDSET


Strategy #4Anti-Rumination Techniques


A. Be careful about excessive reassurance Reassurance-seekers, as opposed to information seekers…

Ask the same question over and over Are not satisfied with the answer Are seeking a specific answer Are using your reassurance as a maladaptive way of escape from temporary distress

Avoid… Answering the same question over and over.

Instead…. Answer the question once. After that, you can say, compassionately,

Some version of: “That sounds like Worry asking; what do we say to worry?” OR “I don’t know.”


E. “Save it for Worry Time.”Containment is an excellent strategy for excessive, ruminative worry

Worry is a form of avoidance So, how much time do you want the child to waste on worry a day?

Avoid… Allowing the child unlimited time to talk about worries. Especially in the morning.

Especially at bedtime. Especially at school.

Instead…. Pick a guaranteed 5-minute time the child can voice worries (i.e. before dinner;

during recess). Set a timer. Otherwise: “Save it for worry time!” Remind the child to get busy doing something else in the meantime. Pssst…. bedtime ritual should be “3 Thankfuls” or “3 Good Things,” etc.


B. Encourage (small) actions over (excessive) avoidance“A little goes a long way.”

Completing small tasks & activities are hope interventions They are also mini-exposures (treat anxiety symptoms) They are also behavioral activation (treats depressive symptoms)

Avoid… Inadvertent collusion with avoidance / withdrawal

Instead…. Re-direct child to something small they can do now Help them to monitor mood/anxiety level before and after Praise effort; not outcome


Strategy #5Encourage good sleep hygiene


A poll conducted by the National Sleep Foundation revealed:

• Majority of parents thought their adolescents were getting enough sleep, but…

• 59% of middle school students weren’t• 87% of high school students weren’t• Average high school student sleeps ~7 hours• Half of all adolescents reported being “too tired” during the day• 25% fell asleep in school at least once a week• 14% arrived late/missed school at least once a week

• 20% of 11-17 year olds report less than 6 hours per night (Roberts, Roberts, & Xing, 2011)


What Are The Issues Limiting Sleep in Adolescents?

Many Variables• Homework• Activities• Social Media• Poor Sleep Hygiene (inconsistent bed times, staying in room/bed while awake, using

electronics/social media right before bed)

Entering adolescence = Normal Physiologic Change in Circadian Rhythms• Circadian rhythms help to regulate sleep and wake schedules• Because of this shift in circadian rhythms, most students cannot fall asleep

earlier than ~10:30pm

What Causes Students to Wake Up Earlier than their physiology?•School Start Times


The Cost to Adolescent Health and Well-Being (AAP, 2014; Carskadon & Dement, 2010)

Insufficient sleep in youth linked to…• Anxiety• Irritability / behavior problems• Depression / Suicide Ideation• Compromised school achievement• Missed school• Poor health / illness

Drowsy Driving (and crashes)• 20% of car crashes are sleep-related• Over 50% of those happen to 25 & younger• 17-19 hours without sleep = drunk (Williamson & Feyer, 2000)

Poor concentration / memory retention• “It takes a sleepy student 5 hours to do 3 hours of homework.” Judith Owens, M.D.


Encourage / Educate on Sleep Hygiene• Set a bedtime

• Children 10-11 years significantly more likely to report parent-imposed bedtimes than 12-13 year olds

• Only 5% of HS students had a set-by-parents school-night bedtime

• Limit caffeine (none 10 hours before bedtime)

• Good sleep hygiene (see AASM Guidelines, 2016)• Half hour of calm prior to bedtime – no screens for 30 minutes• Calming, consistent bedtime routine• Bed is for sleep• Get up & out of bed in AM


Encourage / Educate on Sleep Hygiene II

More good sleep practices• Curfew on screen-time (that means everybody)• No screens in the bedroom• No driving when sleep-deprived• No driving between 12 – 6 am• Do everything possible to sleep later on weekdays• Try to curtail sleeping-in on weekends. • Sleep is a “non-negotiable priority”• Sleep is something to look forward to!


Questions?…or just email me via contact page at:www.katherinedahlsgaard.com


Recommended Online Resources - General


ABCT.org – Association for Behavioral and Cognitive Therapies

Effectivechildtherapy.org – APA website with up-to-date information on the evidence-base for psychotherapies for most childhood disorders

Selectivemutism.org - Selective Mutism Association’s website

ADAA.org – Anxiety and Depression Association of America

IOCDF.org – International OCD Foundation

BFRB.org – The TLC Foundation for Body-Focused Repetitive Behavior Disorders (e.g., hair-pulling, skin-picking, lip-biting)

NJCTS.org - NJ Center for Tourette Syndrome & Associated Disorders

Tourette.org – Tourette Association of America


Recommended Resources – Sleep & ScreensOn sleep:

•National Sleep Foundation: Excellent, nonprofit organization for evidence-based information on all things sleep, sleep hygiene, and addressing sleep difficulties: Sleepfoundation.org

On screen-time/ electronics and sleep:•American Association of Pediatrics: “Media and Children Communication Toolkit” at aap.org•Also from AAP: Create a personalized family media use plan: www.HealthyChildren.org/MediaUsePlan

With regard to school start times:•A good nonprofit grassroots organization may be found at www.startschoollater.net


Recommended Online Resources for Child/Adolescent Trauma & Treatment

Child Abuse Research Education & Service (CARES) Institute at Rowan Universityhttp://www.caresinstitute.org/Links to:•Training & Education opportunities•Referral sources

The National Child Traumatic Stress Network http://nctsnet.org/Links to:•Great PDFs for school personnel•Great informational PDFs for youth & families




Official website for Trauma-Focused CBT http://tfcbt.musc.edu/

Links to: web-based training course, resources for professionals, A PDF treatment manual!Long list of books recommended for parents & youth



Center for the Treatment & Study of Anxiety (CTSA), UPennhttp://www.med.upenn.edu/ctsa/index.html

Links to: Announcements for Prolonged Exposure workshops & trainingsCertified PE supervisorsresources for professionals Updates on research


Recommended Books for Child/Adolescent Trauma & Treatment


Documents

Evidence-Based Assessment & Management of Symptons of ......(Psychological) contagion • Exposure to a distressing event or behavior via a peer group, social media, or mass media