Chronic Pain Syndromes: Understanding & Managing Impact on School Barbara Rzepski, Ph.D. Institute...
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Chronic Pain Syndromes: Understanding & Managing Impact on School Barbara Rzepski, Ph.D. Institute of Living Connecticut Children’s Medical Center May 20, 2010
Chronic Pain Syndromes: Understanding & Managing Impact on School Barbara Rzepski, Ph.D. Institute of Living Connecticut Children’s Medical Center May
Chronic Pain Syndromes: Understanding & Managing Impact on
School Barbara Rzepski, Ph.D. Institute of Living Connecticut
Childrens Medical Center May 20, 2010 Barbara Rzepski, Ph.D.
Institute of Living Connecticut Childrens Medical Center May 20,
2010
Slide 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
Slide 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
Slide 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
Slide 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
Slide 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
Slide 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
Slide 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)
Slide 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
Slide 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
Slide 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
Schools 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
Slide 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
Slide 15
Somatic Complaints Stay out of the nurses office Empathy but
expect function Over-solicitiousness AVOID morbidity: get parents
on board, specify limits to attending to physical complaints Stay
out of the nurses office Empathy but expect function
Over-solicitiousness AVOID morbidity: get parents on board, specify
limits to attending to physical complaints
Slide 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
Slide 17
Bullying Its 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
Its 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
Slide 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 Dont
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 Dont
forget the internet Not a substitute for assertiveness The new
harassment environment
Slide 19
Practical Guidance Parental guidance Separation issues, turn
the cell phone off Encourage exposure Confront stable behavioral
inhibition: some problems kids dont 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 dont grow out of it Adult support/availability
Realistic expectations, personal attention
Slide 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
Slide 21
Wellness Plan Build in time for coping(not based on cant take
it any longer) Coping/distraction strategies Build in time for
coping(not based on cant take it any longer) Coping/distraction
strategies