dealing with anxiety in the classroom
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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
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