An open trial was conducted to evaluate the effectiveness of a brief, school nurse-delivered cognitive behavioral therapy (CALM) intervention for reducing anxiety in children. Nine school nurses delivered the six-session CALM intervention to 11 anxious children ages 5-11. Measures from children, parents, teachers, and evaluators showed statistically significant reductions in parent- and child-reported anxiety and somatic symptoms, as well as improvements in clinical severity ratings and functioning after the intervention. The majority of nurses, parents, and children perceived the intervention as helpful. However, the open trial design without a comparison group limits conclusions about the intervention's efficacy.

1. Enhancing the Capacity of School Nurses to Reduce Anxiety in Children:
An Open Trial of the CALM Intervention
Michela A. Muggeo, Psy.D¹ , Catherine E. Stewart¹, Taryn Wilson¹, Aliya Webermann¹, Juan C. Gonzales¹,
Kelly L. Drake, Ph.D², and Golda S. Ginsburg, Ph.D¹
¹University of Connecticut Health Center ²Anxiety Treatment Center of Maryland. Ellicott City, MD
• Nurse participants: 9 volunteer elementary school nurses in MD and CT,
100% Caucasian females, ages 34-60 (M =age 52.44 SD = 8.3; M years of
school nursing experience = 13, SD = 15.42).
• Child participants: 11 children (6 Males; 90.9 % Caucasian) ages 5-11 (M
age = 8.09, SD = 1.81) with elevated symptoms of anxiety.
Introduction
Conclusions & Discussion
Method
Procedures
Measures
Results
•Pediatric anxiety disorders are common; yet less than half of anxious children
receive treatment, highlighting the need for more providers.
•Because anxious youth often visit the school nurse due to physical complaints,
nurses are ideally suited to identify & provide early interventions.
•This study presents results of an open trial of a newly developed school nurse-
delivered intervention for anxious youth.
Pre-Intervention
Evaluation
Six nurse-delivered
intervention sessions
Post-Intervention
Evaluation
• Based on multiple informants, reductions in anxiety, concentration problems,
and physical symptoms, and improvement in global functioning were
observed after children completed a brief nurse-delivered intervention.
• The intervention was perceived as very/somewhat helpful by the majority of
nurses and parents, but only from half of the children.
• A brief, school nurse-delivered intervention (CALM) holds promise for
enhancing access to behavioral health services for anxious youth.
• Due to the open trial design, evaluators were not blind and there was no
comparison condition. An RCT is needed to test efficacy.
• Screen for Child Anxiety-Related Emotional Disorders (SCARED; Birmaher
et al., 1999) – 41 item self-and parent-report of anxiety symptoms
• Children’s Somatization Inventory (CSI-24; Walker et al., 2009) – self- and
parent-report of the child’s somatic symptoms
• Clinical Global Impression Severity (CGI-S; Guy, 1976) - Evaluator global
rating of anxiety severity
• Children’s Global Assessment Scale (CGAS; Shaffer et al., 1983) -
Evaluator rating of the child’s global functioning and impairment
• Teacher Observation of Classroom Adaption Checklist (TOCA-C; Koth,
Bradshaw, & Leaf, 2009) – 21 item teacher report of student behavior
• Training Satisfaction: One item “Overall, how satisfied are you with the
CALM training day?” 1 = not at all - 7 = very much.
• Intervention Helpfulness: One item: “How much do you think being in the
CALM program helped this child (your child/you) better cope with fear,
anxiety and worries?” 0 = Unhelpful, 4 = very helpful
0
5
10
15
20
25
30
35
40
45
Child SCARED Parent SCARED Child CSI-24 Parent CSI-24
Pre Post
26.7
16.7
24.8
15.27
38.3
30 30.9
26.9
45
50
55
60
65
Pre Post
CGAS
0
1
2
3
4
5
Pre Post
CGI-S
•Children attended on average 5.45 CALM sessions (range 4-8)
• Nurses completed a one-day training on the CALM intervention. Nurses
endorsed high levels of training satisfaction (M = 7, SD = .00).
• The CALM intervention consists of six 15-30 minute modules over 8 weeks
• Modules are based on the core components of cognitive behavior therapy
Figure 2. Mean scores on SCARED and CSI-24 at pre and post intervention
Figure 1. Study Design
Figure 3. Mean scores on CGI-S and CGAS at pre and post intervention
Figure 4. Mean scores on TOCA subscales at pre and post intervention
0
0.5
1
1.5
2
2.5
3
3.5
4
Concentration Problems Disruptive Behaviors Prosocial Behaviors
Pre Post
2.8
.6
3.19
.6
3.45
3.61
Figure 5. Perceived helpfulness of the CALM intervention
70.0%
10.0%
20.0%
Nurse
50.0%
30.0%
10.0%
10.0%
Child
(N = 5)
81.9%
9.1%
9.1%
Parent
(n = 1)
(N = 1)
(N = 9)
Very Helpful/Somewhat helpful
A little helpful
Unsure
Unhelpful
(N = 2)
(N = 1)
(N = 7) (N = 3)
(N = 1)
(N = 1)
Paired t-tests on pre-post intervention measures showed statistically significant
reductions on the SCARED (Parent: t(10) = 4.13, p = .01; Child t(9) = 3.42 p
= .01); CSI-24 (Parent: t(10) = 2.48, p = .03; Child t(9) = 2.33 p = .05)
Paired t-tests showed significant reductions in symptoms, CGI-S (t (10) =
5.24, p < .01) and improvements in functioning, CGAS (t (10) = 3.45, p = .01);
Paired t-tests showed significant reductions on TOCA concentration problems
(t(10) = 2.33, p = .042); No changes on disruptive behaviors (t(10) = .201, p =
.844) or prosocial behaviors (t(10) = .860, p = .410).
Intervention helpfulness was high overall and across reporters.
Intervention
Modules
Psychoeducation
C = Calm down by learning relaxation strategies
A = Actions that will reduce anxiety
L = Listen to scary thoughts and change them into coping thoughts
M = manage problem using problem-solving strategies
Relapse Prevention
Optional: Parent psychoeducation module
This research was funded by the US Department of Education’s Institute of Education Sciences
grant # R305A140694 to the last two authors.