Anxiety is challenging to all families Multiple moves pose ...

Anxiety in Young Children: A Coordinated Approach to Diagnosis and Treatment

• Anxiety is challenging to all families

• Multiple moves pose additional challenges for military connected children and families

• MCEC recognizes the challenge

Seminar Session8:15 – 11:30 a.m.

Part 1: Expert Panel – 8:15 – 9:50 a.m.◦ Provide information◦ Share latest thinking on Anxiety◦ Discuss Anxiety in the context of military‐connected children and families

Break: 9:50 – 10:05 a.m.

Part 2: Customize information for families and providers – 10:05‐11:30 a.m.◦ Accurate information communicated simply ◦ Infographic co‐created with participants◦ Plan for sharing to build understanding and capacity

Session Goals

Create a stakeholder‐developed infographic that communicates the most important messages from the Expert Panel (Part 1) to be used by parents and professionals (Infographic first; Dialogue Guide next)

Enable participants to share messages in their current assignment and to take information to future assignments. (Initiative: Leaving Your Footprint: Anxiety)

Encourage participants to connect and interact beyond the session

Presenters

• Michael E. Faran, M.D., Child & Adolescent Psychiatrist

• Eric Flake, M.D., FAAP, Col, USAF MC, Developmental & Behavioral Pediatrician

• Patti Johnson, Ph.D., Pediatric Psychologist

• Kendon Johnson, Ph.D., DoDEA, School Counselor Support

Anxiety in Children Pharmacological Treatment

Michael E. Faran, MD, PhDChild and Family Behavioral Health System

Program Management Office(CAFBHS PMO)

July 2019

UNCLASSIFIED

UNCLASSIFIED

The views expressed are those of the author(s) and do not reflect the official policy of the Department of

the Army, the Department ofDefense or the U.S. Government.

CAFBHS PMO UNCLASSIFIED July 2019

Disclaimer

UNCLASSIFIED

Disclaimer


•Trade Names are used in this module because these drugs are typically only known by their Trade Names due to the numerous formulations of methylphenidate and amphetamines

•Use of Trade Names does not, in any way, endorse these medications, nor promote one medication over another within the same medication class

•Therefore every reasonable attempt was made to include all ADHD medications (by Trade Name) in each medication class discussed in this presentation

UNCLASSIFIED

Anxiety in Children


•Anxiety disorders are one of the most commonpsychiatricdisorders in children and adolescents– Pre‐adolescents: prevalence rate = 8‐10%– Adolescents: prevalence rate = 9‐15%– Military dependents: 1/3 screened positive onmeasuresassessing risk for anxiety

•Anxiety is often undetected or untreated– School offers opportunity for early identification

•Early identification of child anxiety disorders candecrease negative impact upon functioning and persistence into adulthood

UNCLASSIFIED

•Separation Anxiety Disorder•Social Anxiety Disorder (Social Phobia)•Generalized Anxiety Disorder•Specific Phobias•Selective Mutism

•Panic Disorder•Agoraphobia

Hallmark is distress with “normal” activities + avoidance


Anxiety Disorders

UNCLASSIFIED

Severity and Impact of Anxiety Informs Treatment Planning:

– For Mild and some Moderate Anxiety: Cognitive‐Behavioral Therapy (CBT) including exposure is the first line oftreatment

– For Moderate to Severe Anxiety: CBT plus possible inclusion of medication•Consider co‐morbid diagnoses and/or partial response to CBT as indication for use of psychotropic medication

Treatment of Anxiety


UNCLASSIFIED

•Three treatment approaches: Psychoeducation (also a CBT

Component) Psychosocial Treatment – i.e. CBT Pharmacotherapy ‐ SSRIs

recommended :Fluoxetine, Sertraline, and Escitalopram

•Good overall reference on treatment of Anxiety Disorders in Children and Adolescents was published in 20141

Treatment for Anxiety


UNCLASSIFIED

Demonstrated uses of Antidepressants

•Major Depressive Disorder•Persistent Depressive Disorder•Panic Disorder•Generalized Anxiety Disorder•Obsessive Compulsive Disorder•Social Anxiety Disorder•Posttraumatic Stress Disorder•Premenstrual Dysphoric Disorder•Trichotillomania•Anorexia Nervosa•Bulimia Nervosa•Pathological Gambling


UNCLASSIFIED

• Selective Serotonin Reuptake Inhibitors (SSRIs)

• Serotonin partial agonist/reuptake inhibitors (SPARIs) (vilazodone)

• Serotonin modulator (vortioxetine)

• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

• Selective Norepinephrine Reuptake Inhibitors (NRIs)

• Norepinephrine Dopamine Reuptake Inhibitors (NDRIs) (buproprion)

• Alpha‐2 Antagonists (mirtazapine)

• Serotonin antagonist/reuptake inhibitors (SARIs) (trazodone andnefazodone)

• Monoamine Oxidase Inhibitors (MAOIs)

• Tricyclic Antidepressants


Classes of Antidepressants

UNCLASSIFIED

*Parameters of Safety


•FDA Approval in Youth– Requires evidence of short‐term safety

•Sufficient Exposure (10+ Years onMarket)– Minimizes risk of rare adverse events

•Minimal Overdose Harm– Reduces risk of accidental/intentional harm

•No Substantive FDA BoxedWarning– Reduces likelihood of serious adverse event

•No/Minimal Known Long‐Term Risk

*Dr. Mark Riddle, Johns Hopkins Medical School

UNCLASSIFIED

• FDA published “Black Box” Warning for antidepressants in 2004

• FDA 2006 study showed that 4% of patients on SSRI had suicidal ideations/behaviors vs. 2% not on SSRIs = 2% increase

• Other studies have shown risk is not as high

• UpToDate summary states: Taken together, the data suggest that compared with placebo, antidepressant medications in some children and adolescents may result in a small increase in the risk of suicidality

• Risk is higher early on in treatment

• Risk appears to be lower when SSRI started at lowerdose

• After the Black Box warning there were increases in suicide in children and adolescents correlated with decreases in prescriptions of SSRIs in primary care


Antidepressants & “Suicidality”

UNCLASSIFIED

Level 1 MedicationsAnxiety & Major Depressive Disorders


Drug(Mode of Action)

Indication(s) FDA Approval/ Approved Age

Level of Evidence

Generic

• Fluoxetine(SSRI)

ANXMDDOCD

NoYes; ≥ 8Yes; ≥ 7

BAA

Yes

• Sertraline(SSRI)

ANXMDDOCD

No NoYes; ≥ 6

BBA

Yes

• Escitalopram(SSRI)

ANXMDDOCD

NoYes; ≥ 12 No

B AInsuff data

Yes

Dr. Mark A. Riddle, MD Johns Hopkins University

UNCLASSIFIED

•Blocks pre‐synaptic reuptake pump, thereby allowing more serotonin to be in the synaptic space for a longer period of time

•Metabolized in the liver

•Induction of different enzymes

SSRI Pharmacology


UNCLASSIFIED

Workup to includeR/O other Disorder/Disease

•Interview and screening

•Appropriate physical exam

•Labs to rule out other common disorders that give signsand symptoms of depression/anxiety and labs that are recommended before prescribing an SSRI– BHCG (when applicable)– CBC– Chem 7 or equivalent, include glucose– LFTs– TSH– Vit D (higher latitudes or suspected deficiency)– Vit B12/folate (if suspect)


UNCLASSIFIED

Common Adverse Effects of SSRIs

•Headaches

• Insomnia

•Sedation

•Nausea

•Diarrhea

•Sexual dysfunction

•Not common but important Hypomania/Mania –more common in school‐age children than in adolescents


UNCLASSIFIED

• If no response after a 2‐3 weeks, incrementally increase SSRI at intervals of at least a week

• Usual dose increments are: • Fluoxetine 10‐20 mg• Sertraline 25‐50 mg• Escitalopram 5‐10mg

SSRI Dose Optimization


UNCLASSIFIED

What To Do If SSRI Does Not Work?


• Answer theseQuestions

• Is dosemaximized?• Is duration sufficient?• Is poor adherence theproblem?• Is there a co‐morbid disorder and is this the correctdiagnosis?

• Has patient had adequate trial ofCBT?

• For anxiety the **CAMS study demonstrated that CBT increases response rate

**Walkup, JT, et al. 2008. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. NEJM Dec 25;359(26):2753-66.

UNCLASSIFIED

Strategies: Treatment-Resistant Anxiety

Resistant Depression = Consultation or Referral

Strategies the CAFBHS Child Psychiatrist may utilize include:•Add Buspirone – partial 5HT1A•Add Antidepressant with different receptor activity – Several alternative medications

•Add Stimulant if comorbid for ADHD•Add Atypical Antipsychotic, such as aripiprazole or quetiapine•Add Lithium•Add Thyroid hormone•Transcranial magnetic stimulation•ECT (rare in adolescents in US)


UNCLASSIFIED

•Length of SSRI treatment for Anxiety is 6‐12 months

•Even if responds well to medication, may need adjunctive therapy as Anxiety may disrupt developmental tasks

•During maintenance, patient should be re‐assessed monthly

•Discontinuation of therapy should be at low stress time such as summer


Maintenance/Relapse Prevention

UNCLASSIFIED

•When the treatment plan for Anxiety includes medication, SSRIs are the medication of choice

•SSRIs can be effectively provided by the Primary CareManager

•A ‘Start Low, Go Slow’ dosing approach is best for optimal results

•Maintenance is necessary to prevent relapse


Key Take Aways

UNCLASSIFIED

1. Piacentini J, et al. 24 - and 36 - Week Outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS). J Am Acad Child Adol Psych 2014; 53(3):297–310


References

Rank Action Officer / e-mail / phone number Slide 22 of x 08 January 2016

Guidance

Child Anxietyand Special Needs Children

Dr Eric M Flake FAAP Developmental Pediatrics, MAMC

U.S. Trends in Childhood Diagnoses and Treatment

Any 25%Anxiety 7%

U.S. Trends in Childhood Diagnoses and Treatment

● Increasing prevalence● Increasing care utilization● Increasing medication use● Do trends reflect increasing

problems or increasing treatment?● Does historical treatment indicate

risk, health, or both?

Military‐Connected Children and Youth

● Strengths and risks associated with child military experience

● One out of five military children accesses mental health care

● One out of four career military families have a child enrolled in EFMP

What is a “Normal” Childhood?• 15‐20% of children and adolescents suffer a

diagnosable anxiety disorder• Many more children suffer with symptoms that do not

meet diagnostic criteria (Walkup et al, 2008)

• ~20% of grade school children are fearful of heights, are shy in new situations, or are anxious about public speaking and social acceptance (Bell‐Dolan, et al, 1990)

• ~30% of children worry and require considerablereassurance

• ~40% of grade school children have fears of separation from a parent

• ~40% of children have 7 or more fears that aretroublesome

• Girls report more stress than boys

• Most of these worries and stresses recede as children develop

Distinguishing Normal from Pathological

Intensity: Is the degree of distress unrealistic?

Impairment: Does the distress interfere with daily life?

Respond and Recover: Is coping utilized torebalance?

Anxiety and Special Needs: Behavioral and Neurological

• Originates from fear, unease,uncertainty, loss of control, andworry

• Stress ‐ we know what’s causing theworrying

• Anxiety ‐ one is less aware of what is causing the worrying and there is less ability to control it

• The reaction becomes theproblem.

You start to feel anxious about being anxious

The An

xiety Cycle

Anxiety Rates are High in Autism and ADHD• Autism and ADHD areneurodevelopmental disorders that influence development and behavior

• Theory 1 ‐ Anxiety may be caused by the same combination of genes and environmental factors as autism itself.

• Theory 2 ‐ May experience anxiety due to thecommon challenges theyface.

Caring for the Caregiver

• Family Centered Care iscritical

• Parents of special needs children report more anxiety, anger, guilt, frustration, sorrow, social isolation, self‐deprivation, and depression.

5 Things to Remember about Anxiety and Special Needs Children

• New morbidity – new wave of medical concerns formedical, educational and community systems

• Mindset – when does anxiety become a disorder

• Just Breathe – techniques and therapies thatwork

• Medication works – treatment doesn’t have to be long term

• The New Normal – living a life understanding anxiety and itsorigins

Take Away: Anxiety in Children with Special Health Care Needs

• Anxiety is a normal response to stress and can be helpful unless the brain is hijacked and the anxiety is impairing instead of promoting.

• Child anxiety trends are increasingly associated with negative social, educational, and mental health outcomes.

• High rates of co‐morbid anxiety disorders exist in neurodevelopmentalconditions

• (Autism > 80%, ADHD ~40%)

• Caring for the caregiver is a critical component of reducing overall familystress/anxiety

• Researchers, practitioners, and policy makers must learn why society today is less well adapted for promoting the healthy development of children with anxiety and what measures can be taken to reverse these trends.

https://pixabay.com/photos/head‐man‐person‐people‐face‐2379686/

Anxiety in ChildrenPsychosocial Treatments

Patti L. Johnson, Ph.D.Child and Family Behavioral Health System

Program Management Office(CAFBHS PMO)

July 2019

UNCLASSIFIED

UNCLASSIFIED

Anxiety in Children


UNCLASSIFIED

The views expressed are thoseof the author(s) and do not reflect the official policy of the Department of the

Army, the Department of Defenseor the U.S. Government.


Disclaimer

UNCLASSIFIED

•Anxiety disorders are one of the most commonpsychiatricdisorders in children and adolescents– Pre‐adolescents: prevalence rate = 8‐10%– Adolescents: prevalence rate = 9‐15%– Military dependents: 1/3 screened positive onmeasures

assessing risk for anxiety

•Anxiety is often undetected or untreated– School offers opportunity for early identification

•Early identification of child anxiety disorders candecrease negative impact upon functioning and persistence into adulthood


Anxiety in Children

UNCLASSIFIED

•Separation Anxiety Disorder•Social Anxiety Disorder (Social Phobia)•Generalized Anxiety Disorder•Specific Phobias•Selective Mutism

•Panic Disorder•Agoraphobia

Hallmark is distress with “normal” activities + avoidance


Anxiety Disorders

UNCLASSIFIED

Manifestations


UNCLASSIFIED

Manifestations in the Classroom and at School

•School avoidance or refusal•Difficulty separating from parents

•Perfectionism – Hard time finishing work

•Refusal to participate during class and in groups

•Difficulty playing on the playground•Difficulty with transitions

•Sleepy


UNCLASSIFIED

•ADHD• Restless and fidgety• Difficulty focusing

•Disruptive Behavior• Resistive• Act out to avoid anxiety provoking demands/situations

•Physical Problems• Headaches• Stomachaches

•Learning Problems• Difficulty focusing, thinking• Memory problems and poor school performance

•Depression• Crying• Distressed


In the Classroom or At School Anxiety Can Look Like …

UNCLASSIFIED

Assessment ofFunctional Impairment

•How much does the problem interfere in child’s life or impair functioning?

•Is it developmentallyappropriate?

•Does child avoid activities that are important fordevelopment?


UNCLASSIFIED

Severity and Impact of Anxiety Informs Treatment Planning

For Mild to Moderate Anxiety:CBT including Exposure is the first line treatment

For Moderate to Severe Anxiety:CBT plus inclusion of medication is most efficacious treatment

Severity Level and Treatment


UNCLASSIFIED

•Three treatment approaches: Psychoeducation (also a CBT

Component) Psychosocial Treatment – i.e. CBT Pharmacotherapy ‐ SSRIs

recommended :Fluoxetine, Sertraline, and Escitalopram

•Good overall reference on treatment of Anxiety Disorders in Children and Adolescents was published in 20141

Treatment for Anxiety


UNCLASSIFIED

Components ofCognitive Behavioral Therapy

Cognitive Behavioral Therapy for Anxiety

• Psychoeducation/CBT Rationale

• Exposure

• Cognitive Restructuring

• Somatic Management

• Relapse Prevention


UNCLASSIFIED

The CBT Model

BEHAVIOR


COGNITION

EMOTION

UNCLASSIFIED

Cognitive BehavioralTherapy for Anxiety

• Psychoeducation– Teach patient and family about nature of anxietyAnxiety is functional – alerts us to dangerExcessive levels of anxiety are learned – Result from a combination of “sensitive personality”, “cognitive set” to focus on danger and experiencesExcessive levels of anxiety are maintained byavoidance of feared situation or object

– Which provides rationale for treatment approachExposure to feared stimuli – gradual, imaginal, or liveCognitive Restructuring – more realistic appraisalSomatic Management – breathing and relaxation


UNCLASSIFIED

• Exposure – graduated, systematic, and controlled exposure to feared situation(s) to provide experience with using anxiety management skills and corrective emotional experiences to feared situation(s)

Cognitive BehavioralTherapy for Anxiety - Exposure


UNCLASSIFIED

Cognitive BehavioralTherapy for Anxiety - Exposure

School Phobia Example

•Drive into school lot during morning drop off, afternoon pickup•Go into school with parent/support adult for a short time•Go into school office or library with parent/support adult fora couple hours

•Go into the classroom in the morning with parent/support adult for a couple hours

•Stay in classroom half day with parent/support adult present•Stay in classroom full day with parent/support adult present•Stay in classroom half day without parent/support adult•Stay in classroom full day without parent/support adult


UNCLASSIFIED

• Cognitive Restructuring – identifies maladaptive thoughts/beliefs and teaches realistic, adaptive, coping‐focused thinking

• Somatic management – targets autonomic arousal, breaksassociations between physiologic arousal and anxiety– Techniques: Relaxation, Diaphragmatic breathing, Self‐monitoring, mindfulness

• Relapse prevention – focus on consolidating anxietymanagement skills


Cognitive Behavioral Therapy for Anxiety

UNCLASSIFIED How ParentsCan Help Child Succeed

•Encourage at‐home practice• Learn to tolerate child’s distress•Remember that practice/exposure is safe•Coach their child•Be willing to work hard• Stay relaxed•Make the program a high priority•Attend therapy sessions faithfully•Ask provider questions•Don’t attend to or reinforce child’s anxiety symptoms•Model positive coping behaviors vs. anxious copingbehaviors; manage their own anxiety


UNCLASSIFIED

•Encourage at‐school practice•Praise the child’s efforts•Remember that practice is safe•Be nonjudgmental•Remember that parents are likely to be anxious too

•Don’t attend to or reinforce anxiety symptoms

•Model positive coping behaviors vs. anxious coping behaviors

How Teachers/School Personnel Can Help Children Succeed


UNCLASSIFIED

•Anxiety disorders – common, under‐diagnosed, and often untreated

•In the classroom, anxiety can present in many ways and may be mistaken for other types of childhood mental or behavioral health problems

•Cognitive Behavioral Therapy is the psychosocial treatment with the most efficacy, with Exposure being the most important “ingredient” of CBT

•Schools have an important role to support kids with anxiety disorders


Key Take-Aways

UNCLASSIFIED

1. Piacentini J, et al. 24 - and 36 - Week Outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS). J Am Acad Child Adol Psych 2014; 53(3):297–310


References

Rank Action Officer / e-mail / phone number Slide 22 of x 08 January 2016

Questions

ANXIETY IN YOUNG CHILDREN

THE SCHOOL PERSPECTIVEKENDON JOHNSON, PH.D., SCHOOL COUNSELOR SUPPORT

Three Areas ofFocus: Relationships: Trusting relationships and connections with adults who care.

Managing Stress: The goal is not to eliminate stress but to learn to manage stress before it becomes anxiety and build resiliency.

On‐going Support and Partnerships: Communication and collaborative relationships with school, home, and community resources to support ourchildren.


What does anxiety look like in young children at school:

Inattention and restlessness

Attendance concerns and clingy

Disruptive behavior

Trouble answering questions, especially in front of peers

Frequent trips to nurse

Not completing work and/or turning inwork

Avoiding socializing and/or group work


Relationships:

Children must make connections with trusted adults in their schools to include: teachers, administrator, counselors, psychologists, nurses, support personnel, and other adults. (Does every child in the school have a trusted adult they can talk to?)

Check In/Out Daily: Do we have a system where every child is checked in and/or out with daily? Morning greetings, lunch check in, telling students goodbyeas they leave.

Peer Relationships: Do students have social groups and interactionswith their peers?

Social Skills Groups: Is there a group for those students who need support andthe opportunity totalk through their experiences of stress?


Managing Stress:

Stress is a part of life:We do not want to eliminate stress but to teach children to manage their stress. Learning to manage stress helps to build resiliency.

How does the child’s anxiety manifest itself?

Teaching the child coping strategies:

Empathize with the child

Reframe the situation (talk through the situationwith student andbreak down theworry)

Give the student needed time

Give the student clear expectations (Is it clear to the student?)

Practice running through specific difficult situations

Praise for working through the situation


Managing Stress: Some children may need a little more support

RECOMMENDEDACCOMMODATIONS: ExtraTime (TimeAway orTime toTalkThrough or Practice)

Stress Ball

Journaling

Asking student to repeat directions/tasks (breaking multi‐step directions/tasks down)

Preferential Seating

Gentle Reminders

Do Overs (How do we work with children not meeting expectation;notFAILURE)

Relationships are vital: Parents/Families engage with the school to provide on‐going support.


On‐Going School Support: Personnel andServices

Physical Health Concerns (Nurse)

Mental Health/Social Emotional Concerns (Counselor/Psychologist)

Brief Counseling: Individual/Group (School Counselor and School Psychologists)

Social/Emotional and Developmental Groups (School Counselor and School Psychologist)

Student Success Team (SST) Support: Tiered Intervention/SSTPlans

Students with Disabilities (SPED and 504)

Social Emotional/Academic Concerns (Teachers and Other School Specialist, and School SupportPersonnel)

Social Emotional Development from All Adults: All adults MUST cultivate trusted connections with children to ensure positive growth and development.

Working with Community Based Supports (Local Hospital/Clinics that are available, LocalPsychologists/Counselors, Therapist that are available, and MFLC and SBMH, if available)


Take‐Always:

Relationships: Every child must have a trusted adult to connect with daily, while atschool.

Anxiety in School: Can look like many otherbehaviors/disorders.

Managing Stress: How are we supporting/teaching children to manage day‐to‐day stress without working to eliminate stress (building resiliency).

On‐going Support: Meeting the individual child’s needs for on‐going support. (Trusted Connections and Relationshipswith Families and Community Resources).



WellAdjusted Happy Children In School

ANXIETY INYOUNG CHILDREN: SCHOOL PERSPECTIVE

References:

Ehmke, R. (2018), Anxiety in the classroom: what it looks like, and why it’s often mistaken for something else. (http://chlidmind.org/article/classroom-anxiety-in-children). Retrieved from www.childmind.org.

Goldstein, C. (2018),What to do (and not do) when children are anxious: How to respect feelings without empowering fears. (https://childmind.org/article/what-to-do-and-not-do-when-children-are-anxious). Retrieved from www.childmind.org

Hurley, K. (2017), Helping kids with anxiety: Strategies to help anxious children. (https://www.psycom.net/help-kids-with-anxiety). Retrieved from www.psycom.net

Part 2: Defining Messages (10:05 – 11:30 )

10:05 – 10:40 (35 minutes) ◦ Join a table that works on communicating messages from the Panel◦ Review notes to identify key messages. Write your simple messages on Post Its. ◦ Pose important messages to your group◦ As a group, decide which messages are most important◦ Paste them on the large top flip chart◦ Choose a spokesperson to briefly share your discussion and decisions

10:40 – 10:55 (15 minutes)◦ Each table shares three key messages w/ full group

10:55 – 11:20 (25 minutes)◦ Refine key messages within each Infographic sub‐topic (flip charts) w/ full group

11:20 – 11:30 (10 minutes)◦ Dialogue Guide and Leaving Your Footprint Series – Next Steps

This Session: Follow‐through for Impact

Leaving Your Footprint: Anxiety

WITH YOUR INPUT we will develop military family‐friendly Infographics, Dialogue Guide & Resources to be available on the MCEC website for easy retrieval:

◦ Help professionals to share and empower military families

◦ Help military families hold conversation with:◦ Healthcare and Mental Health Professionals◦ Other military families at current and new installations/communities◦ Installation personnel who can act on the information

◦ Over time, build a committed group of individuals who have access to information and will share it freely in their setting.

This Session: Follow‐through for ImpactLeaving Your Footprint: Anxiety

◦ Participate in reviewing the draft infographic ~ TBD, mid‐Octoberish

◦ Develop accurate, military family friendly infographic

◦ Create a link to the infographic and other resources on MCEC website

◦ Help professionals (e.g., healthcare providers, school personnel, etc.) to share and empower military families

◦ Help military families to hold conversation using the infographic with the dialogue guideo with professionals o With other families living on the installation/base or in the civilian communityo with installation/base personnel who can act on the information

◦ Help military families to hold conversation at the next locationo with providerso with other families living on the installation/base or in the civilian communityo with installation/base personnel who can act on the information

◦ Over time, build a committed group of individuals who have access to information and will share it freely in their setting.

Anxiety is challenging to all families Multiple moves pose ...

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