Dealing with Anxiety in the Classroom

Alexa Bagnell, MD, FRCPC

July 11, 2012

Objectives Understanding of Anxiety disorders in

children and youth and symptoms to look for

Overview of treatment modalities for anxiety

Strategies to help youth with anxiety in the school environment

6 Month Prevalence Rates of Mental or 6 Month Prevalence Rates of Mental or Addictive Disorders in Children 4-17Addictive Disorders in Children 4-17

Anxiety DisordersAnxiety Disorders 7 %7 % ADHDADHD 5 %5 % Conduct DisorderConduct Disorder 4 % 4 % Mood Disorders Mood Disorders 4 %4 % Substance Use DisordersSubstance Use Disorders 1 %1 % Any Disorder Any Disorder 14 %14 %

Waddell et al, Can J Psychiatry, 2002Waddell et al, Can J Psychiatry, 2002

Whe i have a really big project due a get so worried. I can't sleep at night. Even if i know i will finish it on time i get so freaked out. Is there something wrong with me. Non of my friends feal this way. Can u help me?

What is Normal Anxiety?

Situation or Trigger:

First date Preparing for an exam Performing at a concert

Giving a speech

Moving from home Climbing a tall

ladder

Anxiety:

Apprehension Nervousness Tension Edginess

Nausea Sweating

Trembling

Transient

Does not significantly interfere

Does not prevent a person from achieving their goals

When is it a problem?

Brain RegistersDANGER!

Initiation of Physiologic Cascade

Heart Rate

Tension

Alertness Perception

ANXIETY

Sensory Perception

Taste

Touch

Nose

Ears Eyes

Internal SignalsThoughts Physical

Emotions

No Danger

!?!

!!

When is Anxiety a Disorder? Most children, adolescents and adults use

anxiety to help them make good decisions Anxiety becomes a problem when it makes

the decisions for you, interferes with your life and/or causes distress.

Two forms: misinterpreting threat or extreme response

Epidemiology of Anxiety Disorders

Approximately 1 in 10 children Most prevalent mental health problem in kids High comorbidity with ADHD, Depression,

ODD, substance misuse Functional impairments: school failure and/or

dropout, peer/social difficulties, family dysfunction, restricted career opportunities

What Causes Anxiety?

Genetics/Biological Basis Anxiety runs in families Common for at least one parent to be

anxious Research has shown that what is passed on

from parent to child is not a specific tendency to be shy or worry but a general personality type and/or cognitive style predisposing child to develop anxiety.

What causes anxiety? Parent Reaction

Reactions to child or teen’s anxious behaviour might also play a role in increasing anxiety (e.g., being over-protective, excessive reassurance).

Modeling Children and adolescents copy their parents

coping strategies (e.g., avoiding fearful situations). Stressors/Traumatic Life Events

Bit by a dog, death of a loved one, being bullied, getting sick, academic struggles

Anxiety in the Classroom Irritability/ tiredness Absenteeism Frequent somatic complaints Decline in grades Withdrawal from peer group Use of alcohol/drugs Poor coping with everyday stress Calling home frequently/reassurance seeking Angry outbursts/ suicidal ideation

Anxiety Performance Curve (Yerkes-Dodson Law)

Hebb, D. O. (1955). Psychological Review, 62, 243-254

Anxiety Disorders in Children Separation Anxiety Disorder: separation from

caregivers, concern bad things will happen to them Selective Mutism: Failure to speak in specific social

situation despite speaking in others Generalized Anxiety Disorder: uncontrollable

excessive worry about many areas of life functioning (e.g., school work, family, friends, health)

Social Phobia: fearful of social or performance situations

Anxiety Disorders in Children

Specific Phobia: fear of particular objects or situations Panic Disorder: misinterpret bodily changes and have

a fear of losing control Obsessive Compulsive Disorder: the presence of

intrusive repetitive thoughts (obsessions) or behaviours (compulsions), >1 hour/day

Post traumatic Stress Disorder Experience traumatic event, reexperiencing, avoidance and numbness, increased arousal, >1 month

Treatment of Anxiety Disorders in Children 1st Line: Cognitive Behavioural Therapy-CBT

2nd Line: Medication plus CBT Anxiety disorders including OCD:

SSRI medication has strongest evidence(e.g. sertraline/zoloft, fluoxetine/prozac,

fluvoxamine/luvox, citalopram/celexa)

Three Components of Anxiety

Feeling

ThinkingDoing

THOUGHTS

Thinking Anxious children and teens have unrealistic or

extreme thoughts that centre around harm or threat.

“My mom is late, she’s been in a car accident.” “I can’t do this presentation because my

classmates will think I’m dumb and laugh at me.” “I will get sick in school and throw up, and

everyone will know.” “I will get in trouble if my work is not perfect.”

Thinking Errors Anxious children overestimate how

likely it is that an unpleasant event will happen.

They overestimate how bad the consequences will be if the event does happen.

They underestimate their ability to cope with the anxiety and the unpleasant event

Anxiety and the Brain

Feeling Anxious children and teens become “pumped up” or

aroused. This is the flight-fight response. Immediate or short-term anxiety is named the flight-fight

response. It’s the body’s way of protecting you from danger.

The flight-fight response causes you to sweat, increase heart rate, tense muscles, make you breath faster, feel hot or cold, dry mouth, and feel lightheaded or dizzy.

School Situations: oral presentation, test, separating from parent, substitute teacher, answering question in class

Physiologic arousal

FIGHT/FLIGHT/FRIGHTSignal dangerEnhance alertnessPrepare body for action

Sympathetic Nervous System

Doing- Anxious Behaviours Pace, fidget, cry, cling, shake Avoid

Refusing to go to school or class Refusing to go somewhere alone Complain of headache or stomach ache

to get out of doing something Reassurance seeking.

“Am I going to die?” “Are you sure ________ won’t

happen?” Repetitive behaviours to prevent event

BEHAVIOURS

Core Components of CBT Education about Anxiety Realistic Thinking/Cognitive

Restructuring Skills Training (e.g., relaxation,

problem solving, social skills, assertiveness, stress management)

Exposure **

Cognitive Strategies Realistic Thinking or Detective Thinking

What is the evidence that anxious thought is true or false?

Problem Solving

Identifying problem and generating solutions and potential outcomes

Positive Self Talk

Realistic Thinking

Event Thought/Belief Emotion

Test I will fail worried

Test I don’t care irritable

Test I can pass if I study hopeful

Behavioural Strategies

Coping skills Exposure to anxiety provoking situations and

Response Prevention Encourage and reward all positive steps in

fighting anxiety Modeling and parent education

COPING STRATEGIES Muscle Relaxation Deep Breathing Refocusing – e.g. Five senses Staying on Task Worry Time “Acting as if” (..you are not anxious/worried)

Cognitive Behavioural Therapy 101

Identify what is an anxious behaviour, thought or physical feeling. Label it for them.

“Do you think your stomach ache is really because you are anxious about the test”

“Your heart is racing because of worry.”

Once a behaviour is identified, help the child think of ways to cope on their own:

Take a deep breath. Coping self talk (e.g., “Its just my worry, I am not

going to forget everything. I can do this.”)

Anxiety Behaviour Management 101

Acting as a team- parents and school Remove attention from anxious behaviours

Decrease reassurance seeking, increase positive coping Identify when ignoring the behaviour

“I have already answered that question, go to the next one”

Praise the positive behaviour, as soon as it occurs. “Nice job continuing on with your work” **comments given to individual- not whole class

Avoidance Behaviour- Anxiety Curve

Anxiety Exposure Curve

0

10

20

30

40

50

60

70

80

90

100

Time 0 Time 1 Time 2 Time 3 Time 4

Wo

rry

Sca

le

Exposure

Avoidance

Anxiety

Prevent Avoidance By avoiding feared situations, or seeking reassurance,

children learn they are not able to cope with the situation or their worry

Model being brave and problem solving Encourage them to take little steps toward

accomplishing the feared task Take the bus to school 2 days a week. Oral presentation alone with teacher Go to first class

Safe place to go in school when anxious Reward effort!

Consultation Example Consultation Example 1 10 year old girl not attending school for past 4

weeks. Stomachaches every morning and thinks she is going to be sick.

Mom informs school she is not able to force her to go.

Cognitive Behavioural StrategiesCognitive Behavioural Strategies

a)a) Graded ExposuresGraded Exposures: : n+1 rule n+1 rule (what is step up from current situation?) (what is step up from current situation?)

b) b) DesensitizationDesensitization: visit school after school hours, arrive early : visit school after school hours, arrive early when school is quieterwhen school is quieter

c) c) Flooding:Flooding: force full time return (usually only works for force full time return (usually only works for absences of 2-3 weeks or less)absences of 2-3 weeks or less)

d) d) Remove incentivesRemove incentives for staying home for staying home

Consultation Example 2 15 year old boy in Grade 10. Not completing

assignments or tests, nothing handed in.

Home info: spending 4 hours per night on homework, not completing or not good enough and so won’t hand in.

What to do?

Mental Health Resources for Schools

www.kidsmentalhealth.ca www.cprf.ca “When Something’s Wrong” series www.anxietybc.com www.teenmentalhealth.org www.myhealthmagazine.net www.schoolpsychiatry.org

The Anxiety Workbook for Teens, Author: L. Schab The Relaxation and Stress Reduction Workbook for Kids:

Help for Children to Cope with Stress, Anxiety and Transitions, Author: L Shapiro