“Managing Youth and Caregiver Anxious Distress in the Context of COVID-19” was presented by Yesenia Marroquin, Ph.D., and Anne Bijman, LCSW, from CHOPs Department of Psychiatry and Behavioral Sciences and Anxiety Behaviors Clinic.

This was actually, two presentations connected by the impact of COVID-19 on increased behavioral health problems in children, youth, and families. The first half of the 3-hour presentation addressed “Managing Anxious Distress in Youth and Parental Emotion Regulation Strategies in the Context of COVID‐19” with Dr. Marroquin. The second half, presented by Ms. Bijman, addressed “Parent Management Training Core Skills to Support Children and Their Families in Managing COVID-19 Related Distress.” Both speakers had a dynamic and professional presentation style. The workshop was informative and fast paced. The time went by quickly, leaving behind a satisfied audience.

The goals of the first half of the Workshop with Dr. Marroquin included:

• Outline current behavioral health impact of COVID‐19 on youth
• Describe Distress Tolerance and Emotion Regulation strategies that help combat anxious distress
• Review adaptations to exposure-based treatment in the context of COVID‐19

These goals were easily meet during her 90-minute presentation.

Dr. Marroquin began her presentation with an overview of pre-pandemic anxiety disorders in children youth and families. She said that anxiety disorders are among the most common mental health disorders in children and adolescents. “The CDC estimated 20%‐30% lifetime prevalence by age 18 in the United States. Almost 10% reported experiencing suicidal ideation and over 5% reported making previous suicide attempts. Dr. Marroquin stated that recent data from the Centers for Disease Control indicate that emergency department visits related to mental health concerns have increased for youth since the COVID‐19 pandemic started. Rates rose 24% for school‐aged children and 31% for adolescents when compared to the same time period (March‐October) of 2019).”

According to Dr. Marroquin, family impact of Covid-19 included:

• Needing to adapt to a different daily rhythm and losses
• For youth: may lead to increased social withdrawal, hopelessness, anxious rumination
• For youth with social anxiety, there may have been temporary relief during virtual learning. Symptoms exacerbated once there was a shift back to in‐person school
• For caregivers: navigating being a teacher/tutor while working at the same time
• Less available external supports
• Managing their own losses
• Limited ability to act as an “emotional buffer”
• Given increased togetherness, youth mental health symptoms may be detected earlier

In her presentation, Dr. Marroquin talked about treatment of anxiety disorders in youth in general, and specific to the COVID-19 impact on youth. She said that treatment includes:

• Assessment
• Evaluating a young person’s anxious distress and functional impairment 3 months prior to COVID‐19 lockdown and 3 months prior to date of intake
• Inquiring about potential comorbidities
• Informs treatment planning
• Treatment
• Psychoeducation‐ utility of engaging in exposure during COVID‐19 to strengthen bravery muscles
• Troubleshooting engagement in telehealth sessions (e.g., attention challenges; showing   one’s face on a video call)
• Enhancing emotion regulation capacity
• Exposures
• Planning exposures in a way that balances treatment progress with the family’s and CDC guidelines regarding COVID‐19
• Working with caregiver to set up a distraction‐free (as feasible) space
• Adapting typical exposures
• Wearing a “silly” mask while out on an essential errand
• Eating a meal in front of friends via video call
• Present on a topic of patient’s choice via video call
• Cognitive Strategy
• Thought vs Fact • Problem starts when we take a thought and turn it into a fact

Relying on the principles of Cognitive Behavior Therapy (CBT) and Dialectic Behavior Therapy (DBT), Dr. Marroquin presented the requirements for behavior change. These include:

Being present in the moment that is

• Awareness
• Willingness
• Capability

The practice of “Mindfulness” or “Intentionally observing, describing and participating in reality AS IT IS, in a way that is nonjudgmental” is fundamental treatment of anxiety according to Dr. Marroquin. She described 3 states of mind,

1. Emotion Mind

• Thinking and emotions controlled by current emotion
• Facts twisted in a way to align with current emotions
• Thinking/planning in a reasonable way is really challenging
• Vulnerability Factors

2. Reasonable Mind

• Thinking rationally and logically
• Focused on facts
• Ignoring emotions
• Approaching problems with a “cool” head

3. Wise Mind (Linehan, 2015)

• Integration/blend of Reasonable and Emotion Mind
• Finding synthesis between extremes; helps us experience reality as it is
• Emotion Mind + Reasonable Mind + Intuition = Wise Mind
• Not acting on impulse; practicing skills instead to manage distress/strong urges
• Sometimes experienced in a part of the body (e.g., belly; between the eyes); still voice within oneself
• Mindfulness skills are the means through which we can balance emotion mind and reasonable mind to attain wise mind and act effectively

While each state of mind is important and serves a purpose, helping the youth understand the “Wise Mind” goes a long way during treatment of anxiety.

As Dr. Marroquin described, the “Wise Mind” can allow higher levels of tolerance to anxiety and ability to regulate emotions rather than escape or freeze when confronted a trigger. She emphasized that reducing the anxious feelings by escaping or avoiding triggers is not helpful in the long run. Accepting that anxiety is part of life and learning to tolerate the discomfort is essential to treatment.

Dr. Marroquin talked about the therapeutic use of validation to increase tolerance for anxiety.

The Benefits of Validation include:

• Increases effectiveness by:
• Reducing pressure to prove who is right
• Doing what is needed to remain effective outweighs desire to be right
• Emotional reactivity
• Anger and resentment
• Allows our brain to cool off enough to engage in problem‐solving, and improves our relationships

Dr. Marroquin added the importance of Self-Validation which “Helps decrease emotional and physical arousal, decrease Emotion Mind vulnerability, and helps us tune into Wise Mind and Allows us to cool our brains off enough to be able to process information, which in turn helps with problem solving and skillful response to a given situation/emotion.”

During her presentation, Dr. Marroquin discussed emotional regulation. The goals of emotional regulation include:

• Emphasize emotional self-validation
• Increasing emotion awareness in the present moment
• Reducing cognitive rigidity
• Naming and taking efforts to prevent patterns of emotion avoidance and impulsive behaviors driven by emotions

Dr. Marroquin highlighted the importance of using a hierarchy of exposures to help youth learn to tolerate anxiety.

Types of Exposures (Franklin, Freeman, & March, 2019)

• Contrived
• Youth chooses to face a feared situation/stimulus
• Youth is aware of the exposure ahead of time + exposure is practiced during session to disconfirm fear
• Uncontrived (“naturalistic”)
• Youth comes into contact with an OCD trigger on accident/unexpectedly
• Ex: Child with contamination fears sees a peer vomit in the hallway
• Goal: go against compulsion urges
• In‐vivo (“live”) • Thought of as contrived exposures
• Exposures organized via the hierarchy
• Imaginary
• Youth exposed to “worst case scenario” present in obsessions
• Used when youth has a specific feared consequence
• Can be used to “up the ante” during in‐vivo exposures
• As youth is engaging in response prevention, tell them a story about how they are walking through a hallway, lose control, and hurt someone

Conducting Exposures (Franklin, Freeman, & March, 2019)

• Discuss with youth the highest level of distress they are willing to tolerate
• What seems minimal to you may be HUGE to them
• Remind youth that these exposures are “experiments” and they can get through the distress
• Once that has been faced in session, assign therapeutic homework of practicing that   exposure for approximately 20‐30 minutes per day
• Address potential avoidance (e.g., targeting all low‐level exposures first across trigger   “islands”)
• Remind youth that moving to more difficult levels is crucial to regain control over OCD
• Use clinical judgment when moving onto new exposure
• Does not necessarily have to be when distress is reduced by 50%
• Moving on depends on youth’s willingness to tolerate distress
• As exposures progress, ensure that response prevention continues for previously tackled exposure

Dr. Marroquin also talked about the importance of involving the family in the use of exposures, especially due to the limits set by the pandemic.

Finally, during her portion of the workshop, Dr. Marroquin discussed the challenges and Benefits of Treating OCD in the Context of COVID‐19 (Franklin, 2020; Van Kirk, 2020)

Challenges

• “Extreme” exposures are limited
• Ex: eating chips off the floor on the street
• Restrictions around response prevention (e.g., hand washing)
• Restrictions on where exposures can take place
• Limited “in office” exposures
• Difficulty ascertaining whether youth are engaging in safety behaviors (via telehealth)
• Privacy and Attention
• Outlining what is reasonable while being mindful of CDC guidelines

Benefits

• Treating OCD “where it lives”
• Additional caregiver/sibling involvement/observing dynamics as they occur in the home
• Increased therapist creativity
• Bolstering imaginal exposure scripts
• Screen sharing when engaging in exposures using videos
• Caregiver coaching

The second half of this workshop, presented by Anne Bijmann, addressed “Parent Management Training Core Skills to Support Children and Their Families in Managing COVID-19 Related Distress.”

Ms. Bijman’s objectives included:

• Overview of Covid-19’s impact on child/caregiver mental health and its effect on disruptive behavior management in families
• Provide rationale for increasing integration of parent management training (PMT) skills to effectively address externalizing reactions to pandemic distress
• Discuss core components of PMT skills and how to structure sessions to include behavior management skill teaching to parents/caregivers
  • Planning Ahead/Building the PMT Toolbox
  • Strengthening Child-Caregiver Relationships
  • Maintaining Consistency and Routines

Ms. Bijman’s objectives were also met during the workshop.

Beginning with a statistical chart showing the prevalence of child mental health and disruptive behavior disorders in the United States prior to the pandemic, Ms. Bijman made the point that internalizing disorders (anxiety, depression) are often comorbid with externalizing disruptive behavior disorders.

Regarding the impact of COVID-19, Ms. Bijman presented the following information.

Covid-19 and Youth/Caregiver Distress What We Know:

• The pandemic as contributed to a significant increase in child and adult mental health challenges
  • Emergency room visits for child mental health issues between March 2020 to October 2020: 24% increase ages 5-11 years old, 30% increase ages 12-17 years old (Leeb et al., 2020)
  • January 2021: 4 out of 10 adults in the U.S. reported anxiety/depression symptoms, and 400% increase from Jan. 2019 (Panchal et al., 2021)
• There has been a significant increase in severe disruptive/externalizing behaviors in children throughout the pandemic

Study in Japan indicated significant increase in the following disruptive behavior

• symptom categories in school-aged children (grades 1-12) between March 2020 and May 2020: emotional symptoms increased 24.8%, conduct problems increased 22.7%, hyperactivity/inattention increased 36.8%, peer relationship problems increased 36.2%, and lack of prosocial behavior increased 23.5% (Takahashi et al., 2021)
• Two studies have shown that higher parental distress and anxiety and parenting stress during the COVID-19 pandemic were associated with greater child distress, emotional symptoms, hyperactivity, and conduct problems
• Higher parental distress and anxiety and parenting stress during the COVID-19 pandemic were associated with greater child distress, emotional symptoms, hyperactivity, and conduct problems
• Notable relationships between negative and positive child behaviors, level of parent distress, and use of effective parenting practices during periods of “lockdown” related to the pandemic
  • A study from the United States with parents of children aged 0 to 18 years found that parents’ caregiver burden and mental health were related to parental perceptions of children’s stress and that parents’ and children’s distress was significantly linked to a negative parent-child relationship
  • Another study conducted in the United States with parents of children aged 5 to 18 years showed that COVID-19 stressors are related to greater family discord and use of caustic parenting, which, in turn, predict greater child and parent distress (Dubois-Comtois et al., 2021)

Ms. Bijman also outlined how treatment can help:

• Parent/caregiver involvement in individual therapy sessions, including recurrent parent-only sessions to assess for and establish a treatment plan for level of caregiver distress and its impact on family functioning and use of effective behavior management strategies
• Integration of Parent Management Training skills across diagnoses, with particular emphasis on helping families manage children diagnosed with anxiety, depression, and disruptive behavior disorders since the onset of Covid-19
• Including caregivers frequently in their child’s treatment and teaching them behavior management strategies will:
• Strengthen parent-child relationships u Increase positive behaviors in children
• Help establish routines and consistency in parenting practices, as well as helping caregivers develop a “toolbox” of evidence-based behavior management approaches
• Increase use of effective coping/emotion regulation strategies by children and their parents when managing distress
• Provide child mental health clinicians with structured, actionable, and attainable treatment goals that can increase clinical efficacy and relieve symptoms of burnout and stress related to treating child/caregiver distress related to COVID-19

With the above information in mind, Ms. Bijman presented Parent Management Training (PMT) as an effective treatment technique to teach “Core Skills to Support Children and Their Families in Managing Covid-19 Related Distress”.

Parent Management Training: What Is It?

• Skills-based treatment aimed at changing parenting behaviors
• Teaches caregivers positive reinforcement methods to promote an increase in desirable behavior
• Also involves effective ways to manage disruptive behavior, but core focus is on increasing use of positive reinforcement strategies
• Rooted in operant conditioning and applied behavioral analysis principles
• Common types: PCIT, Incredible Years, Positive Parenting Program u Often addresses: ODD, Intermittent Explosive Disorder, Conduct Disorder, ADHD, Unspecified Disruptive Behavior Disorder

According to Ms. Bijman, PMT has three Principles,

Principle 1, Toolbox

Ms. Bijman emphasized that the parents are the experts on their child. The clinician is the expert on the tools for parent management. As she said: “It is the knowledge of the tools and the knowledge of the child that leads to positive home behavior and improved parent-child relationships”.

Positive reinforcement is the core of parent training, although punishment and negative consequences are tools that can be used. Ms. Bijman said that the first step in helping parents build their toolbox is to discuss the behavior goals and assess current behavior management functioning. This discussion with the parent includes:

• What behaviors do they want to target?
• Have parents come up with a list of 5-10 behaviors they would like to see more of from their child. If they are focused on the problem behaviors, have them consider what behavior would be opposite of the undesirable behavior.
• What strategies are they already using for these behaviors? What is working? What isn’t working?
• What factors are getting in the way of child success, parent success, etc.?
• If 2+ caregiver household, discuss co-parenting dynamic.
• How has covid-19 impacted past and current parenting practices?
• Provide psychoeducation about PMT and discuss concept of “Parenting Toolbox”

Principle 2, Establish a Strong Parent-Child Relationship

• Long-term impact: Children who have strong positive relationships with their parents are more likely to develop…
  • More successful and secure future relationships
  • More effective emotional and behavioral regulation
• Short-term impact: Children who have strong positive relationships with their parents are more likely to develop…
• More cooperative behavior in the home setting

Ms. Bijman said that focus of PMT should be on the positive.She said that the stronger the positive foundation of the parent-child relationship, then the more likely the child will comply with consequences. She provided strategies such as attention for good behavior, active ignoring annoying behavior, special play time, and one-on-one time with the child to build the relationship.

Principle 3, Plan Ahead

Ms. Bijman suggested that the therapist rehearse situations that are likely to cause emotions to rise. The parent should practice a response to negative behaviors so the response is not in the moment leading to a regrettable response. She also emphasized that the plan must be consistent. Once established, the parent should be supported to stick to the plan.

Ms. Bijman spend a few minutes talking about the importance of structure and routine during the pandemic. Use of rules, schedules and calendars is important. The family should discuss the rules and consequences for non-compliance. She suggested that the parents meet with the therapist without the child to discuss punishment strategies to avoid such as corporal punishment, yelling and nagging.

At the end of her portion of the workshop, Ms. Bijman presented some key take-aways:

• Children, caregivers, and their families are experiencing an increase in distress due to Covid-19 that is increasing disruptive behaviors in children/teens
• PMT is the main evidenced-based method for addressing problematic internalizing behaviors
• In order to effectively address the levels of distress children/families are presenting with during this time, PMT skills can and should be integrated into individual treatment with children to help caregivers help their children and themselves manage the externalizing results of distress, regardless of clinical origin/pathology
• Therapist and other mental health providers should structure sessions to involve parents/caregivers in treatment as much as possible to engage in these skills and reinforce their use outside of session
• PMT skills will also help lower parental distress as they will gain knowledge and confidence in their ability to implement effective, consistent behavior plans and routines to increase desirable behavior and decrease undesirable behavior in their children
• Clinicians can also benefit from the structure of PMT skills as they provide a clear way to create, implement, and track treatment goals/progress over the course of their work with a family, leading to better treatment outcomes and relieving symptoms of burnout, particularly within the currently stressed-out child mental health system as a result of the pandemic

This was an excellent workshop. Rarely has so much information been presented during a three-hour space of time. While much of the information may have been a review of CBT, DBT, and Parent Training techniques for some participants, the emphasis on added distress during COVID-19 made this workshop unique.

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