Teacher Anxiety Program for Elementary Students
Condition: Anxiety
MeSH terms: Anxiety Disorders
Study type: Interventional

Summary: 
      The purpose of the study is to compare two teacher trainings developed to assist elementary
      students who struggle with excessive anxiety. The goal of both teacher trainings is to
      improve teachers' knowledge and skills for identifying and assisting students with excessive
      anxiety. The first training program is called TAPES (Teacher Anxiety Program for Elementary
      Students) and involves a 6 hour teacher training. Teachers in this training program will
      implement anxiety reduction skills in the classroom and complete 5 brief (approximately 30
      minute) meetings with the student and his or her parent(s)/guardian(s). The second training
      program, Teacher Anxiety Training (TAT), involves a 3 hour teacher training. Teachers in the
      TAT condition learn to implement anxiety reduction skills in the classroom, but do not
      conduct individual meetings with parents and students. The investigators do not know if TAT
      and TAPES work equally well, or if one is better than the other. Both will be administered by
      teachers to see if they help youth with excessive anxiety feel less worried.
    

Detailed description: 
      Summary, Benefit to Stakeholders, and Aims: Teachers lack the knowledge and skills to support
      the learning of students with excessive anxiety who have, or at risk of developing, an
      identified disability. Excessive student anxiety is a common problem that severely impairs
      short and long term academic functioning and increases teacher burden. Conversely, reducing
      student anxiety has been associated with improvement in educational functioning. Because
      anxiety manifests daily in the classroom, teachers are in an ideal position to identify and
      help students manage their anxiety. One universal intervention for anxiety reduction exists,
      but its feasibility and efficacy are not established. The aims of this project are to address
      this gap in teacher training. Specifically, the aims of this proposal include: Aim 1) to
      develop the Teacher Anxiety Program for Elementary Students (TAPES) and assess its usability,
      acceptability and feasibility; Aim 2) to determine whether teachers can implement TAPES with
      high fidelity and quality; Aim 3) to examine the impact of TAPES, compared to a standard
      professional development condition, on teacher a) knowledge and b) use of anxiety reduction
      strategies with students with excessive anxiety (Primary Outcomes); and Aim 4) to examine the
      impact of TAPES on student outcomes. Exploratory aims will examine the mediators, predictors,
      and moderators of TAPES impact on teachers' knowledge and skill. If effective, TAPES has the
      potential to directly benefit: 1) teachers--by providing training in an important and
      relevant, but neglected area that will enhance their professional development and
      effectiveness in the classroom; and 2) children--by reducing their anxiety and improving
      their educational, social, and behavioral functioning.

      Description of TAPES: The proposed teacher training is appropriate for elementary teachers to
      enhance their capacity to support students with excessive anxiety. The training includes one
      full day of instruction, materials to use with individual students and their parents (in 5
      meetings), and guidelines for classroom-wide strategies to reduce anxiety. The section below
      describes 1) the content of the teacher training and supportive empirical evidence, 2) how
      this training differs from current teacher practices for anxious students, 3) a proposed
      theory of teacher and child behavior change and 4) evidence supporting the feasibility of
      implementing TAPES in an authentic school environment. This teacher training is not intended
      to replace or change the role of existing mental health providers or other members of
      schools' interdisciplinary teams. Given that teachers are members of an interdisciplinary
      team, the study team will obtain input from school personnel to ensure that the
      teacher-training fits within the goals/mission of the interdisciplinary team.

      Description of TAPES content: Overview: The primary goal of TAPES is to enhance teachers'
      capacity to identify and reduce anxiety in their students. Toward this end, the proposed
      content of TAPES consists of three core components: 1) training in evidenced-based anxiety
      reduction strategies that teachers will implement to identify and assist specific anxious
      students and classroom-wide strategies helpful to all students, 2) evidenced-based material
      for teachers to review with parents regarding how to reduce student anxiety at home, thus
      improving school-home communication and shared goals and 3) training in how to conduct
      conjoint teacher-parent-student meetings to improve the quality of the teacher-parent-student
      relationship. Each component is described below.

      Training and Evidence Related to Child Anxiety Reduction Skills: Teachers will learn skills
      based on cognitive behavioral strategies (CBT) including relaxation training (to reduce
      physiological arousal), behavioral strategies (e.g., "exposure" or facing anxiety provoking
      situations which lowers anxiety via new learning), addressing maladaptive thoughts that
      maintain anxiety, and problem solving skills. To implement these new skills with specific
      children teachers will be trained to use a school-home journal that includes a type of daily
      report card that tracks behavioral exposures and use a reward system for increasing brave
      behavior /adaptive coping skills.). These "common elements" of CBT are powerful agents of
      change and have been implemented by CBT experts and non-experts. As such, these skills are
      established and empirically-supported; however, they have not been evaluated when delivered
      by teachers.

      Teachers will also receive training in effective classroom-based accommodations that may be
      needed (e.g. untimed testing) or may need to be gradually faded if they are maintaining
      anxiety through negative reinforcement (e.g. allowing child to avoid participating in class
      due to anxiety). Another component of the teacher training includes skills that teachers
      deliver to their classroom (i.e., such as leading the entire class in a relaxation exercise
      prior to an exam; teacher using a coping model or teacher reducing their accommodation of
      avoidant/anxious behavior for all students). Finally, teachers will be trained in how to
      modify their own behaviors that have been shown to increase student anxiety (e.g., hostility,
      over-control). These modifications are also designed to improve the quality of the
      teacher-student relationship. Research on the role of teacher behavior in the development
      and/or maintenance of child anxiety suggests that teachers who exhibit highly controlling
      behaviors, such as issuing frequent directives, tend to increase child anxiety and negatively
      affect children's ability to learn. Conversely, positive teacher-child relationships have
      been found to protect youth from developing internalizing behavior problems over time.
      Consequently, TAPES aims to modify these teacher behaviors.

      Training and Evidence Related to Conjoint Parent-Teacher-Student Meetings. Training teachers
      in conducting conjoint meetings will enhance teachers' ability to formalize mechanisms for
      sharing information about anxiety reduction and will enhance communication and relationship
      quality between parent, teacher, and student. Training in these conjoint meeting will also
      allow the teacher to clarify roles and responsibilities with respect to helping the child,
      and devise a collaborative plan with similar language and tools to facilitate generalization
      of skills between school and home. Implementation of this component will involve
      approximately 5 conjoint-30 minute meetings over an 8 week period. During these meetings,
      parents, students, and teachers will create and modify anxiety hierarchies, mutually decide
      on practice tasks, and develop a contingency management plan. Target behaviors are
      individualized based on the needs of the child (e.g., raising a hand to answer a question in
      class for a child with social anxiety; separating from parents for a child with separation
      anxiety). These meetings can be supplemented by phone and email contacts between teacher and
      parents/students as needed.

      TAPES Training Format and Implementation: Students' primary teacher will participate in a
      one-day training (approximately 6 hours). One of the most important strategies for ensuring
      that TAPES is implemented with high fidelity is appropriate training and ongoing
      consultation. Training strategies will be based on published guidelines and will include
      active/experiential learning strategies, opportunities for observation (via video clips),
      live modeling and role plays, and coached practice. Ongoing performance feedback and
      consultation has been found to enhance learning and is related to higher fidelity. Thus,
      teachers will be offered 30-minutes of weekly consultation by the PIs for each active TAPES
      students. Consultation will include case review, skill rehearsal, problem-solving obstacles,
      and feedback regarding performance based on audiotaped sessions. Meetings will be held in
      person, over the phone, or via Skype at times convenient for teachers. After each teacher
      identifies their first child, the PIs will attend one conjoint meeting in order to provide
      performance feedback (all conjoint meetings are audiotaped for fidelity). The PIs will also
      provide in classroom coaching for 30-minutes for each student enrolled. Training materials
      will be available on the internet or thumb drive for reference.

      Research Plan Overview: Design and Methods. This three-year development project consists of 3
      stages. Stage one (months 1-6) involves establishing a Development Team (DT) that will review
      the initial draft of TAPES and provide feedback to ensure that TAPES is acceptable to
      teachers and feasible for the school setting. Stage two (months 7-20) involves two successive
      open trials of the TAPES protocol with 15 teachers and 20 children. This stage will allow for
      "trial runs" of the training to assess feasibility, acceptability and utility of the
      training. Data and qualitative feedback gleaned during the first open trial will inform
      modifications for the second open trial. The investigators will present and discuss data with
      the DT after each open trial. Study staff will also ask 5 teachers from open trial 1 to test
      out the revisions for open trial 2. Based on knowledge gained in this stage, appropriate
      modifications will be made for stage three. Stage three (months 21-34) involves a pilot
      Randomized Controlled Trial (RCT) using a randomized controlled design comparing TAPES to the
      Teacher Anxiety Training (TAT). TAT (developed by the PIs for use in other studies and
      described below) will be used to represent "typical" teacher professional development
      training. The RCT will be conducted in three phases. Phase 1 consists of recruiting,
      randomizing, and training teachers in either TAPES or TAT. Also during this phase (but after
      the training), teachers will recruit anxious children and study staff will screen and
      evaluate them to determine eligibility. In Phase 2 teachers will implement TAPES or TAT.
      Phase 3 involves a post-intervention (after 8 weeks) and a three-month follow-up assessment
      of the primary (teacher behavior) and secondary (child) outcomes. Trained independent
      evaluators (IEs) will assess primary outcomes (teacher behavior). The culmination of these
      iterative stages will be a final version of the training that will be ready for evaluation in
      a larger efficacy trial.

      Detailed Description of Each Stage Stage 1: Establish DT and refine initial version of the
      TAPES Protocol. The DT will strive to ensure that the teacher training will be acceptable,
      feasible, and usable in the school setting. The DT will consist of the PIs, two national
      experts in teacher training, two experts in school-home collaborative interventions, and two
      experts in training school-based personnel in CBT techniques for anxious youth. A CT school
      psychologist and two CT elementary teachers will complete the DT. DT members will provide
      detailed feedback about the TAPES strategies, study methods/measures, perceived barriers to
      successful implementation and adoption by teachers, and solutions to potential barriers.
      Information from this meeting will be used to revise the protocol in preparation for the
      first open trial as well as successive phases of the study.

      Stage 2: Open Trials. During Stage 2, teachers and IEs will be trained, and the study team
      will conduct two sequential open trials. Study staff will engage in screening activities of
      students and IEs will complete baseline evaluations on referred students. The purpose of the
      open trials is to evaluate the feasibility of the training, modify methods as needed, allow
      teachers to implement the skills learned in the training and receive real time coaching and
      consultation with anxious children. Data on TAPES usability, acceptability, fidelity,
      satisfaction, and teacher and child outcomes will also be collected. After each open trial,
      feedback (via exit interviews and standardized measures) from teachers, students, and parents
      will be integrated by the research team and presented to the DT for another revision of the
      protocol. Teachers will be asked to participate in an exit interview after they implement
      TAPES with an anxious child.

      Stage 3: Pilot RCT. In stage 3, the study team will conduct a pilot RCT with 40 teachers and
      a maximum of 60 anxious youth. The RCT will be conducted in 3 phases.

      Phase 1 - Recruitment, Randomization, Training, Student Screening, and Baseline Evaluations:
      In Phase 1, teachers will be randomly selected from the pool of interested participants and
      randomized to TAPES or TAT. Once randomized, teachers will complete their assigned training.
      Teachers will then identify potentially eligible students from their classes and provide
      information about the study to their parents. Interested parents will contact study staff and
      complete a brief phone screen. Students who appear eligible based on the phone screen (e.g.,
      have elevated anxiety; are in elementary school) will be invited to complete informed consent
      and a full baseline evaluation with an IE. Families who meet criteria on the baseline
      evaluation will be considered eligible (see Inclusion/Exclusion criteria).

      Phase 2 - TAPES/TAT Implementation: Teachers will implement TAPES or TAT depending on their
      random assignment over 8 weeks from child enrollment.

      Phase 3 - Post- and Follow-up Evaluations: At the end of the 8 weeks, teachers and children
      in both groups will complete a post evaluation. Teachers, students, and parents will complete
      a TAPES satisfaction measure and provide feedback to enhance the protocol. Teachers will
      complete an exit interview. Students who need mental health services will be referred to the
      school counselor or community provider for treatment. A 3 month follow-up evaluation to
      assess sustained use of TAPES/TAT skills will be conducted.
    

Intervention name(s): Teacher Anxiety Program for Elementary Students; Teacher Anxiety Training
Intervention type(s): Behavioral; Behavioral
Intervention description(s): TAPES consists of three core components: 1) training in evidenced-based anxiety reduction strategies that teachers will implement to identify and assist specific anxious students and classroom-wide strategies helpful to all students, 2) evidenced-based material for teachers to review with parents regarding how to reduce student anxiety at home, thus improving school-home communication and shared goals and 3) training in how to conduct 5 brief (30 minute) teacher-parent-student meetings to teach and practice the TAPES anxiety-reduction strategies.; The TAT is a 3-hour professional development training for teachers. Training focuses on recognizing the signs and symptoms related to child anxiety and utilizing classroom-wide strategies to help reduce anxiety in the classroom.
Other intervention name(s): TAPES; TAT
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This study uses a parallel Randomized Controlled Trial Design. Following teacher enrollment, randomization occurs at the teacher level with a 1:1 (20 TAPES condition: 20 TAT condition) ratio. Teachers in each condition complete the training and intervention concurrently.
Masking: Single (Outcomes Assessor)
Primary purpose: Other
Keywords: Excessive Anxiety; Teacher Training; Elementary School; School-based; Effectiveness Research; Randomized Controlled Trial