Late Childhood and Adolescent Anxiety Disorders

1. Late Childhood and Adolescent Anxiety Disorders

2. Table of Contents • Thought experiment………………………….........................3-8 • Overview • General definition…………………………………………….9-11 • Social Anxiety Disorder………………….........................12 • Generalized Anxiety Disorder……………………............13 • Anxiety disorders within the IDEA framework……………....14-17 • Prevalence…………………………………………………………..18 • Rate of identification and support………………….......…….19 • Explaining the gap between prevalence and support……..20-21 • Effect on health, learning, and social life…………………….22-23 • Article reviews • Article 1………………………………………………………..24-25 • Article 2………………………………………………………..26-27 • Article 3………………………………………………………..28-30 • Recommendations overview…………………………………….31 • Identification: • Characteristics……………………………………….....32-33 • Somatic complaints…………………………………….34 • Self report questionnaires…………………………....35 • School based treatment programs and advocacy….....36-41 • Non research based classroom interventions………….42-50 • Pros and cons of inclusion……………………………………….51 • Application to my classroom…………………………………...52-53 • References………………………………………………………….54-55

3. A quick thought experiment… • Take a moment to think… • Think of something in the past that made you really nervous or worried. • Think of something that gave you butterflies in your stomach, or made your palms sweat, or made your legs feel shaky… • Maybe it was a job interview or an important speech you had to give…maybe something else…

4. Thought Experiment Continued… • Now, try to remember the feeling you had just before doing it.

5. Thought Experiment Continued… • Whatever it was you just imagined, when you were actually in that situation your breathing and heart rate probably increased. Your mind probably focused intently on whatever it was you were about to do; most likely, your mind was entirely consumed by it…you were probably able to think of nothing else. • Those feelings are normal. In fact, anxiety in stressful situations is advantageous because it makes us more focused and more alert; it readies us for the abnormally challenging situation we are about to face ("Generalized anxiety disorder," 2010).

6. Thought Experiment Continued… • But, imagine what it would be like if that worried, anxious feeling you’ve been imagining lasted an entire day…. • Imagine it continuing throughout the night. • Imagine, save a possible moment of respite here and there, feeling this way for an entire week, month, or year.

7. Thought Experiment Continued… • Now imagine feeling like this as you walk into school each day. • How might it effect your relationships with friends and teachers? • How difficult would it be to focus on The Odyssey, or multiplying fractions, or the reasons Napoleon failed in his invasion of Russia? • Would you be able to make and keep friends, pay attention in class, complete your homework, do well on a test?

8. Thought Experiment Continued… • All of these activities would probably be quite difficult for you because… • “Anxiety produces a state of physiological arousal that narrows the focus of attention onto the perceived threat, with such arousal impairing the ability to concentrate on other nonthreatening stimuli” (Mychailyszyn, Méndez, & Kendall, 2010). • This is great if you are minutes away from giving a big speech or doing battle with a large tiger…not so great if you are attempting to pay attention in a series of classes or interact with a variety of different people… if you are trying to function in normal, everyday life.

9. Overview: Definition • Broadly,anxiety disorders are characterized by an irrational fear of a situation or stimulus, or a pattern of worry with no defined content, that is in excess of what would be considered reasonable and age appropriate (McLoone, Hudson, & Rapee, 2006). • Of course, the above is simply a blanket description covering many specific types of abnormal fear and anxiety, each with its own specific definition. • There are a wide variety of specific anxiety disorders including…

10. Overview: Definition • Obsessive Compulsive Disorder • Panic Disorder • Posttraumatic stress disorder • Separation anxiety disorder • Social anxiety disorder (SAD) • Generalized anxiety disorder (GAD) • It is also very important to note that in clinical populations, children presenting with a single anxiety disorder are the exception; 70-80% of children receive multiple anxiety disorder diagnoses (McLoone, Hudson, & Rapee, 2006).

11. Overview • Separation anxiety, Social anxiety, and Generalized anxiety are three of the most common types of anxiety disorders found in school age children. • While social anxiety and generalized anxiety are commonly found in late childhood and adolescence, separation anxiety occurs more commonly in younger children and tends to decrease with age (McLoone, Hudson, & Rapee, 2006). • Because this presentation is primarily concerned with late childhood and adolescence, the next several slides highlight Social Anxiety Disorder (SAD) and Generalized Anxiety Disorder (GAD).

12. Social Anxiety Disorder (SAD) • Social anxiety disorder is described by the American Psychiatric Association as: • A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. • The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.   • Exposure to the feared situation almost invariably provokes anxiety.  • The person recognizes that this fear is unreasonable or excessive. • The feared situations are avoided or else are endured with intense anxiety and distress. • The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. • In individuals under age 18, the duration is at least 6 months. (Richards, 2010) • It is important to note that there are two overlapping but distinct components to social anxiety: performance anxiety and interpersonal anxiety (Klein, 2009). • Students with social anxiety are usually not disruptive: • They go out of their way to avoid drawing attention to themselves. • As a result, their anxiety is often dismissed as shyness that does not warrant intervention (Herbert, Crittenden, & Dalrymple, 2004). • For youth with SAD, school is often the most anxiety producing environment imaginable because it is a setting that is almost entirely characterized by social experiences and performance tasks (Mychailyszyn, Méndez, & Kendall, 2010).

13. Generalized Anxiety Disorder (GAD) • Generalized anxiety disorder is a condition characterized by "free floating" anxiety or apprehension not linked to a specific cause or situation. Children with GAD will worry excessively, about numerous events, for a long period of time. Anxiety will often occur in recurring episodes, lasting days, weeks, or even months at a time. For official diagnosis of GAD, a child must have more days with anxiety than not over a period of at least six months (McLoone, Hudson, & Rapee, 2006; "Generalized anxiety disorder," 2010). • GAD has a vary high comorbidity rate with other anxiety disorders; 90% or more of those diagnosed with GAD also have another type of anxiety disorder (Klein, 2009). • School is a particularly difficult place for students with GAD because they are often troubled by concerns about academic performance and its implications for the future (McLoone, Hudson, & Rapee, 2006).

14. Anxiety disorders within the IDEA framework • There are 13 categories of disability recognized under IDEA (Autism, hearing impairment, Traumatic Brain injury, Specific Learning Disability, etc.) • One of the 13 disability categories is “emotionally disturbed” (more commonly referred to as emotional behavioral disorder or EBD). • IDEA defines emotionally disturbed as: …a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child's educational performance: (a) An inability to learn that cannot be explained by intellectual, sensory, or health factors. (b) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers. (c) Inappropriate types of behavior or feelings under normal circumstances. (d) A general pervasive mood of unhappiness or depression. (e) A tendency to develop physical symptoms or fears associated with personal or school problems” (Schoenfeld, & Janney, 2008).

15. Anxiety disorders within the IDEA framework • There are two broad dimensions of disordered behavior (Hallahan, Kauffman, & Pullen, 2009). • Internalizing behaviors • Externalizing behaviors • Anxiety, depression, and other mental or emotional conflicts are types of internalizing EBD. • The chart on the next page provides a visual representation of the where anxiety disorders are placed within the IDEA framework.

16. Anxiety disorders within the IDEA framework

17. Anxiety disorders within the IDEA framework • Anxiety disorders fall well within the definition of emotional disturbance that is provided by IDEA. • When anxiety disorders occur in combination with diminished academic achievement, schools have a clear responsibility to intervene (Schoenfeld, & Janney, 2008). • Unfortunately, despite this responsibility, students with anxiety disorders are rarely identified or provided with the additional support and services they need. • The next section, subtitled “Prevalence and Detection”, provides an overview of the rate at which anxiety disorders occur in school age children, the rate at which they are detected, and reasons for the extreme gap between prevalence and detection.

18. Prevalence • Anxiety disorders are one of the most prevalent psychiatric disorders effecting children and adolescents (Hughes, Lourea-Waddel, & Kendall, 2008). • Studies have estimated the prevalence of anxiety disorders in school age children at between 6.5% and 21%, with more than half of all studies finding that more than 10% of school age children have an anxiety disorder (Schoenfeld, & Janney, 2008). • In 2001, The National Institutes of Health reported that 13% of children and adolescents experience anxiety disorders (Schoenfeld, & Janney, 2008). • While the precise number of students specifically receiving special education services (or treatment of any kind) for anxiety is not known, consider the following…

19. Rate of identification and support • Less than 1% of school children are identified as emotionally disturbed for special education purposes, and of that 1%, the majority have externalizing disorders (remember, anxiety is an internalizing disorder) (Hallahan, Kauffman, & Pullen, 2009). • So…less than ½ of 1% of students are identified as EBD internalizing, a subcategory which also includes depression and other mental or emotional conflicts. • Even if a student with internalizing EBD is referred for special education services, she is less likely to actually receive them than an externalizing peer. • So…while at least 10% of students have an anxiety disorder, only a very small fraction of 1% receive special education support for anxiety. • Why the large gap between prevalence and detection? Two major reasons…

20. Explaining the gap between Prevalence and Support 1) An extreme LACK OF RESEARCH • Anxiety disorders appear only rarely in either descriptive or intervention based research (Schoenfeld, & Janney, 2008). • The lack of descriptive research into anxiety disorders makes identification particularly difficult – to date, there are no workable observation based measures of anxiety available to educators. This means that Functional Behavioral Assessments, which are crucial in identifying and supporting other disabilities, have not been developed for anxiety disorders (Schoenfeld, & Janney, 2008). Instead, schools must rely on parent, child, and teacher reports. In other words, we know the criteria for anxiety disorder, but we have no standard way of confirming its presence in children (Klein, 2009). • Only 11 studies have focused on anxiety interventions, all of which were restricted to assessing the effectiveness of small-group and school-wide treatment programs utilizing variations of cognitive behavioral therapy. Not even one study has focused on interventions that can be used by the teacher in a general education classroom (Schoenfeld, & Janney, 2008). • Not even one study has specifically addressed anxiety interventions in special education settings (Schoenfeld, & Janney, 2008).

21. Explaining the gap between Prevalence and Support 2) TEACHERS more often focus on other forms of EBD • Teachers usually focus on referring students with EBD who’s behavior effects the classroom. The focus is rarely on the way behavior effects the individual child (Schoenfeld, & Janney, 2008). • Students with anxiety disorders rarely disrupt the classroom. In fact, they often go out of their way to comply with classroom expectations so as not to draw anxiety producing attention to themselves. • Teachers are simply much less informed about anxiety disorders than other types of EBD (Herbert, Crittenden, & Dalrymple, 2004).

22. Effects of anxiety disorders on health, learning, and social life Health: • One of the most important things to note is that anxiety disorders are frequently comorbid with depression, substance abuse, and suicide (Herbert, Crittenden, & Dalrymple, 2004). • 10%-15% of adolescents with an anxiety disorder also have a comorbid depressive disorder and 20%-25% of adolescents with a depressive disorder also have a comorbid anxiety disorder (Hale, Raaijmakers, Muris, Hoof, & Meeus, 2009). • Anxiety disorders are associated with suicide rates equal to those associated with depression (Schoenfeld, & Janney, 2008). Social: • Anxiety is related to poor self esteem, impaired social and personal development, and difficulty developing peer relationships (McLoone, Hudson, & Rapee, 2006; Schoenfeld, & Janney, 2008). • Children with anxiety disorders are rated by peers as less popular and less likable compared to those who are non-anxious (Mychailyszyn, Méndez, & Kendall, 2010). Learning: • Child anxiety is associated with poorer academic performance and higher dropout rates. One study found that fifth graders in the top third of self reported anxiety symptoms were 10 times more likely to be in the bottom third of achievement (Hughes, Lourea-Waddel, & Kendall, 2008). • Anxiety disorder is associated with lower standardized test scores (Mychailyszyn, Méndez, & Kendall, 2010). • Children with anxiety disorders are less likely to pursue higher education (Hughes, Lourea-Waddel, & Kendall, 2008).

23. Effects of anxiety disorders on health, learning, and social life Long Lasting Effects: • The majority of childhood anxiety disorders do not remit over time without treatment (Hughes, Lourea-Waddel, & Kendall, 2008). • Left untreated, child anxiety follows students into adulthood where the relationship between anxiety and suicide increases (Goldston, Daniel, Erkanli, Reboussin, Mayfield, Frazier, & Treadway, 2009). • Childhood anxiety leads to a greater likelihood of financial dependency and employment difficulties in adulthood (Schoenfeld, & Janney, 2008). • Arguably, individuals with anxiety disorders have access to the most help and support while they are in school. Failure to identify their disorders and provide support means they will enter adulthood with their disorders in tact but without the resources and skills they need to deal with them. This is particularly concerning because early adulthood is also a time when individuals face a variety of new stressors (financial, employment, legal, relationships).

24. Article review #1School Functioning in Youth With and Without Anxiety Disorders: Comparisons by Diagnosis and Comorbidity Purpose and methods used: • The purpose of this research study was to compare the school functioning of youths diagnosed with separation anxiety, social anxiety, and generalized anxiety to those with no diagnosis. • The study also examined the effect that comorbidity with other anxiety disorders and with non-anxiety disorders has on school performance. • 227 youths, age 7-14 were included in the study. 40 had been previously diagnosed with separation anxiety disorder, 58 with social anxiety disorder, 76 with generalized anxiety disorder, and 53 with no previous diagnosis. • Anxiety disorders and comorbid conditions were assessed in clinician-child interviews using The Anxiety Disorders Interview Schedule for Children. • School functioning was based on parent and teacher reports of student performance. Parents rated their children’s behavior and social competencies using the Child Behavioral Checklist. Teachers rated the child’s classroom functioning using the Teacher Report Form. Mychailyszyn, M.P., Méndez, J.L., & Kendall, P.C. (2010). School functioning in youth with and without anxiety disorders: comparisons by diagnosis and comorbidity. School Psychology Review, 39(1), 106-121.

25. Article review #1School Functioning in Youth With and Without Anxiety Disorders: Comparisons by Diagnosis and Comorbidity Findings: • Overall, students with no diagnosis were rated as working significantly harder, learning significantly better, doing significantly better academically, and being significantly happier than children diagnosed with anxiety disorders. • Youth with behavioral (e,g., ADHD, oppositional defiant disorder), mood (e.g,, depression, dysthymia), and other anxiety disorders in addition to their principal anxiety disorder were most often found to display the greatest impairment in school functioning. Conclusions: • Schools should begin to accept greater responsibility for meeting the needs of anxious youth. • Anxious students experience real and meaningful deficits in school functioning, and these needs may differ based on the type of anxiety and presence of comorbidity with other disorders. • Treatment programs should pay attention to comorbidity and begin to focus on meeting the unique needs of different types of anxious youth. Mychailyszyn, M.P., Méndez, J.L., & Kendall, P.C. (2010). School functioning in youth with and without anxiety disorders: comparisons by diagnosis and comorbidity. School Psychology Review, 39(1), 106-121.

26. Article Review #2Somatic Complaints in Children with Anxiety Disorders and their Unique Prediction of Poorer Academic Performance Purpose and methods used: • The purpose of this research study was to determine which factors associated with high levels of anxiety cause poorer academic performance. Specifically, the study examined whether somatic complaints (complaints of pain or discomfort with no medical explanation) in children with anxiety disorders independently predict poorer academic performance. • 108 children, age 8-14, were included in the study. 69 children were diagnosed with an anxiety disorder, 39 children were non-anxious and served as a control group. • Anxiety disorders were diagnosed in clinical interviews using the Anxiety Disorders Interview Schedule for Children. • Students reported somatic complaints by completing a self report survey (The Multidimensional Anxiety Scale for Children). Parents also reported their children’s somatic complaints using the Child Behavior Checklist. • Teachers reported on students’ academic performance across several academic subjects using the Teacher Report Form. Hughes, A.A., Lourea-Waddel, B., & Kendall, P.C. (2008). Somatic complaints in children with anxiety disorders and their unique prediction of poorer academic performance. Child Psychology and Human Development, 39, 211-220.

27. Article Review #2Somatic Complaints in Children with Anxiety Disorders and their Unique Prediction of Poorer Academic Performance Findings: • Overall, children with anxiety disorders performed worse academically than their non-anxious peers. • Overall, children with anxiety disorders had more somatic complaints than the non-anxious control group. • Within the anxiety disorder group, the frequency of somatic complaints independently predicted lower academic performance, whereas the presence of an anxiety disorder on its own, or the presence of internal anxiety symptoms on their own, did not independently predict lower performance. Conclusions: • School-based cognitive behavioral therapy (CBT) has proved effective in treating youth anxiety disorders. This success may be due, in large part, to the portion of the programs that focus on helping students identify and reduce somatic complaints. • These findings may be significant as professionals continue to develop treatment programs for anxiety disorders; they suggest that programs which focus on reducing somatic complaints may be most effective in increasing academic performance. Hughes, A.A., Lourea-Waddel, B., & Kendall, P.C. (2008). Somatic complaints in children with anxiety disorders and their unique prediction of poorer academic performance. Child Psychology and Human Development, 39, 211-220.

28. Article Review #3Identification and Treatment of Anxiety in Students with Emotional or Behavioral Disorders: A Review of the Literature Purpose and methods used: • The purpose of this research study was to review and summarize the available literature on (1) the prevalence of anxiety disorders in students with EBD, (2) the academic effects of anxiety disorders and (3) the school interventions designed to prevent and treat them. • Each of the three reviews was conducted through an extensive electronic search of peer reviewed publications, examination of the reference section of all qualified studies for additional relevant material, and letters sent to leading childhood anxiety researchers requesting any additional published or unpublished studies. Schoenfeld, N.A., & Janney, D.M. (2008). Identification and treatment of anxiety in students with emotional or behavioral disorders: a review of the literature. Education and Treatment of Children, 34(4), 583-610

29. Article Review #3Identification and Treatment of Anxiety in Students with Emotional or Behavioral Disorders: A Review of the Literature Findings: • 8 studies examined the effect of anxiety on academic performance. Of these, one took place within an EBD program while the rest examined the effects of anxiety disorders on students in the general population. • All but one study found that anxiety had a negative effect on academic performance. • 4 studies examined the prevalence of anxiety in students with EBD. • Based on a very limited set of data, the studies showed that students with anxiety are found in the EBD population at approximately the same rate as they are found in the general population. • Schools continue to identify anxiety disorders primarily by means of structured interviews, rating scales, and questionnaires (observational methods such as functional behavioral assessments are not yet available for use in identifying anxiety disorders). • 11 studies examined school based interventions. Notably, this study was initially intended to survey anxiety interventions in EBD settings. After finding zero studies focused on EDB settings, the study was expanded to include all educational environments. • All 11 intervention programs utilized variations of cognitive behavioral therapy in their intervention component. • All but two studies found school based anxiety intervention to be effective in reducing anxiety symptoms. Schoenfeld, N.A., & Janney, D.M. (2008). Identification and treatment of anxiety in students with emotional or behavioral disorders: a review of the literature. Education and Treatment of Children, 34(4), 583-610

30. Article Review #3Identification and Treatment of Anxiety in Students with Emotional or Behavioral Disorders: A Review of the Literature Conclusions: • To date, there has been a surprising lack of research focused on students with anxiety disorders. • Further studies are needed, particularly those that focus on: • Developing data based, observational methods for identifying anxiety disorders in student populations. • Identifying research based anxiety interventions for EBD settings. Schoenfeld, N.A., & Janney, D.M. (2008). Identification and treatment of anxiety in students with emotional or behavioral disorders: a review of the literature. Education and Treatment of Children, 34(4), 583-610

31. Recommendations: The teacher’s role • As was mentioned in the previous article, no studies have attempted to identify specific teaching strategies or classroom environments that best serve the needs of students with anxiety disorders (Schoenfeld, & Janney, 2008). • However, based on the research that has been conducted, teachers can play two crucial roles insupporting students with anxiety disorders: • Identification and referral • Despite the typical age of onset for anxiety disorders being in early adolescence, they are rarely recognized and treated until adulthood. Because of the early age of onset, school professionals are arguably in the best position to detect symptoms and provide appropriate referrals for further assessment and intervention. • Early referral can make a huge difference in a child’s life; treatment programs and antidepressants (specifically SSRI’s) are very effective interventions for childhood anxiety disorders. (Research based treatment programs will be discussed at length later in this presentation). • Advocating for small group and/or school wide prevention and treatment programs • While very effective, these treatment programs are seldom available in schools. Advocating for their availability may be one of the most important ways that teachers can help studentswith anxiety disorders.

32. Identification: Characteristics of students with anxiety disorders • Students may report consistent difficulty sleeping (Queensland Government: Child and youth mental health service, 2005). • You may notice other physical symptoms like sweating, clamminess, and an inability to sit still or relax (Queensland Government: Child and youth mental health service, 2005; McLoone, Hudson, & Rapee, 2006). • The student may be fatigued and may have difficulty participating in activities (anxiety disorders are often exhausting; emotional energy expended on obsessive worry can be just as draining as physical exertion) (Dutton, 2010). • Because of persistent worries about the quality of their work, anxious students, particularly those with GAD, frequently seek out reassurance from their parents, teachers, and peers (McLoone, Hudson, & Rapee, 2006). • Students may have strong, tense reactions to common life events or respond to perceived stressful situations with anger or aggression (Waldon, 2010).

33. Identification: Characteristics of students with anxiety disorders continued… • Students may seem to have a sudden inability to think or act (too much anxiety can paralyze an individual’s ability to function. When this happens the student may appear frozen, “checked out”, or very distant (Dutton, 2010). • Crying or near crying, but in a way that attempts not to draw attention (Waldon, 2010). • Students with performance anxiety may become perfectionists who spend hours re-doing tasks (Queensland Government: Child and youth mental health service, 2005). • Complaints of test anxiety are an excellent indicator of anxiety disorder. In one study, 60% of students with test anxiety were found to have an anxiety disorder (Mychailyszyn, Méndez, & Kendall, 2010). • School refusal – a pattern in which a child experiences severe anxiety related to attending school. This leads to repeated absenteeism (Queensland Government: Child and youth mental health service, 2005).

34. Identification: Somatic Complaints • Somatic Complaints (complaints that do not appear to be caused by an underlying medical issue) are extremely common in anxious students and may provide one of the clearest ways of identifying students who are at risk for or have an anxiety disorder (Hughes, Lourea-Waddel, & Kendall, 2008). • Somatic complaints areways for children with anxiety disorders to express their emotional distress and avoid anxiety producing situations. • Somatic complaints commonly associated with anxiety disorders include: • Stomachaches, nausea, vomiting • Headaches • Dizziness • Muscular tension • Sweating • Heart racing • Feeling jittery • Tiredness • While many students may complain of these symptoms from time to time, students with anxiety disorders exhibit more somatic complaints than their peers, and their complaints more often result in avoidance of classroom activities, visits to the school nurse, and visits to their doctor (Hughes, Lourea-Waddel, & Kendall, 2008).

35. Identification: Self Report Questionnaires • Beyond simply being on the lookout for the characteristics most commonly associated with anxiety disorders, teachers can also utilize self report questionnaires which ask students to rate their own level of anxiety based on a series of simple questions. • Self-report questionnaires are relatively low in cost and are easy to administer to large groups of students simultaneously. Virtually no training is needed for the administration or assessment of the questionnaires. • Examples of self report questionnairesthat could be used in the classroom include: • The Spence Children's Anxiety Scale (SCAS). The SCAS can be downloaded at www.scaswebsite.com. This website also includes an overview, a parent version of the assessment, diagnostic instructions, and supporting scholarly articles. • The Multidimensional Anxiety Scale for Children (MASC). The MASC can be purchased for $88 at www.pearsonassessments.com; this include the manual and 25 quick-score forms. • Self-reports are vary useful in identifying those children who report accurately, but the tendency for someanxious children is to "fake good“. To overcome this and to obtain further information, consider questionnaires that include a parent version(McLoone, Hudson, & Rapee, 2006).

36. OK, you’ve noticed a student with high anxiety and you’ve referred them for additional assessment and support…now what? • To date, there have not been any research studies on anxiety interventions in special education EBD settings. • And, there have not been any research studies focused on identifying teacher based interventions that can be used in the general education classroom(Schoenfeld, & Janney, 2008). • But, as was mentioned earlier, 11 studies have focused on the effectiveness of small group and school wide prevention and treatment programs. In almost every case, these programs have been extremely effective in reducing student anxiety; when available, they represent an excellent intervention option. • A general overview of these programs is provided below, followed by summaries of three of the most effective programs.

37. Recommendations: Small group and school-wide interventions “The results…are unequivocal: school based intervention for anxiety disorders is effective. Students with anxiety disorders who participate in cognitive-behavioral intervention at school emerge with fewer anxious symptoms than non-participants…”(Schoenfeld, & Janney, 2008, p. 597). The next three slides briefly review three of the most successful school based anxiety programs. While they differ in a variety of ways, they all share two key components: • Cognitive restructuring teaches children to identify their anxious thoughts and understand how their thoughts affect their feelings. People with anxiety disorders tend to overestimate the likelihood that a negative event will occur, as well as the magnitude of its consequences. So, cognitive restructuring teaches students to challenge their anxious thoughts by searching for more realistic evidence. • Graded exposure takes into account the fact that individuals with anxiety disorders tend to avoid situations they fear; rather than enabling that avoidance, it seeks to break fear inducing events down into a series of gradually increasing steps. This allows the child to be exposed to the fear gradually. By encountering and mastering the least threatening steps first, the child gains confidence and is supported as he gradually over comes his fears (McLoone, Hudson, & Rapee, 2006).

38. Recommendations: Small group and school-wide interventions Cool Kids • The Cool Kids program is an anxiety treatment program, administered to small groups of children age 7 to 17 who are selected as at risk of developing, or currently indicating symptoms of anxiety. • Screening is necessary to determine which children will benefit most from involvement in the program. Once selected, a trained school counselor leads the small group of approximately six students through each of the ten hourly sessions, held weekly. • Cool Kids also includes two follow up sessions and parent-therapist meetings. • By the end of treatment, children should be able to manage their anxiety better, face previously feared situations with little to no avoidance, and do this independently of their parents or the therapist. • Based on child, teacher, and parent reports, The Cool Kids program has shown significant reductions in anxiety and related problems compared to children receiving no treatment (McLoone, Hudson, & Rapee, 2006).

39. Recommendations: Small group and school-wide interventions The FRIENDS Program • Available in primary and secondary school versions, The FRIENDS Program is a universal prevention program that is part of the curriculum delivered to all students in the classroom. It is designed to prevent the development of anxiety and depression in children and adolescents. It is administered by a trained teacher in 10, one-hour weekly sessions. Three sessions are also offered to parents aimed at helping them support their children. • School-based trials indicate that students in The FRIENDS intervention group, when compared to a control group, report less anxiety symptoms post-treatment. 75.3% of children who experienced clinical levels of anxiety symptoms before treatment reported a drop in anxiety symptoms to sub-clinical levels after completing the program(McLoone, Hudson, & Rapee, 2006).

40. Recommendations: Small group and school-wide interventions Skills for Social and Academic Success • Specifically designed to treat social phobia, students are selected based on three self-report measures of social anxiety as well as teacher nominations. • The program, which consists of 12, 45-minute sessions, is led by a clinical psychologist trained in the delivery of the SASS program. • It also includes two short individual sessions for each student and is followed by two group booster sessions. • Parents, teachers and friends are included in the therapeutic process. • The program also includes peer assistants (classmates who agree to befriend a child participating in the social phobia program and accept social invitations where the child can practice their new skills). • After completing the program, 67% of anxious studentsno longer met criteria for a diagnosis of social phobia (McLoone, Hudson, & Rapee, 2006).

41. Advocacy • Despite the extremely high levels of success reported by these intervention programs, school based intervention for anxiety disorders is “almost unheard of in either general or special education” (Schoenfeld, & Janney, 2008). • Although training teachers and counselors to implement these programs is costly and time consuming, as of now they represent the only research based interventions available to students suffering from anxiety disorders. • As teachers, one way we can help support students with anxiety disorders is by advocating for the adoption of these programs in our schools.

42. Beyond detection, referral, and advocacy: Non research based classroom interventions • For youth with anxiety disorders, school is an extremely stressful place; students with anxiety disorders cite school related stressors including tests, homework, peers, teachers, and parent-school relations as some of the most disruptive aspects of their lives (Mychailyszyn, Méndez, & Kendall, 2010). • With this in mind, and because there are no research based anxiety interventions currently available to classroom teachers, teachers may want to consider non-research basedstrategies for supporting students with anxiety disorders. • The following recommendations are gathered from interviews with my former students who have anxiety disorders, my own personal experience as a student with an anxiety disorder, and the following three websites: • http://www.learningplace.com.au/deliver/content.asp?pid=34810 • http://www.dollandassociates.com/sft184/helpingstudentswithanxietydisorders.pdf • http://www.associatedcontent.com/article/288225/teaching_students_with_anxiety_disorders.html?cat=70

43. Beyond detection, referral, and advocacy: Non research based classroom recommendations Classroom Environment • Despite the very high prevalence of anxiety disorders throughout society, those who have them often feel like they are alone with their painful feelings; an anxious student often feels like they are the only one who feels the way they do, they are embarrassed about it, and they do not know how to make things better. • One of the most important things we can do as teachers is to make stress and anxiety a part of the classroom conversation. Make a conscious effort to create a classroom environment where students are aware of anxiety and comfortable talking about it. • Most obviously, discuss anxiety with your class. Let your students know how prevalent it is (normalize it). Let them know that many children, teens, and adults feel anxious, and encourage your students to discuss any anxious feelings with their parents, friends, school counselor, or with you. • Consistently remind your students that you are always available if they want to chat about anything AND make sure they know, specifically, when and where they can find you to discuss something in private (your daily office hours, during lunch, before/after school on specific days, etc.) Remember, students with anxiety disorders will often feel vary anxious about discussing their anxiety with others. Specific knowledge about when you are available to talk may allow them to set up a known appointment in their mind rather than worrying all day about when they might be able to approach you.

44. Beyond detection, referral, and advocacy: Non research based classroom recommendations Classroom Environment continued… • Model stress management in front of your students: calmly recognize your own stressful situations out loud, take a deep breath, and voice a positive coping thought. • Consider teaching stress management strategies to the entire class. Since everyone experiences stress at various times throughout their lives, everyone will benefit. This will also help students with anxiety recognize that you are aware of their difficulties, and it will help create an open environment for discussing anxiety. • Use self report questionnaires to identify anxious students. These can be given to all students in your class as part of your beginning of the year “get to know everyone” activities. It may also be a good idea to use them periodically throughout the year, perhaps as a warmup exercise. (A list of high quality self report questionnaires was provided in slide 35)

45. Non research based classroom recommendations Classroom interventions for specific students: • Work closely with school counselors and parents to understand how anxiety manifests with the individual student. What does it look like at home, during lunch, after school, etc.? It may also be helpful to get permission to speak with any mental health professionals who are involved with the child. • For those with anxiety disorders, the unexpected and unknown can cause a great deal of stress. In order to reduce these, consider: • Providing very explicit guidelines for assignments – be specific about (1) what is expected and (2) how it will be assessed. For those with performance anxiety, a lack of clarity in these areas may result in obsessive, pervasive worry. • Provide clear, consistent feedback to the student. Provide positive feedback for small achievements. This type of heightened communication can go a long way toward lowering the stress of students with performance anxiety. • When possible, discuss changes in classroom or daily routine in advance. Let them know what changes will be made and what the results will look like. Doing so will reduce the likelihood that the student will fixate on and worry about the results of changes when they are announced. • Make a special effort to discuss changes in seating assignment with the student well in advance of making any changes. Often, students with anxiety disorders are walking a fine line between functioning and debilitating stress. They may not be able to cope with the unexpected additional social stress that comes with sitting next to new classmates.

46. Non research based classroom recommendations Classroom interventions for specific studentscontinued… • Class syllabus – Pay particular attention to the way students react to the syllabus you hand out at the beginning of the term. For most students, the class syllabus is very insignificant – they will simply ignore it, stuff it in their backpack, or leave it on the floor of your classroom; this is probably not true for students with an anxiety disorder. While it may seem like the syllabus is a great way to remove the unexpected and unknown from your class, the opposite is usually true. Viewed from the perspective of a student with an anxiety disorder, most syllabi simply surround them with unknowns; anxious students often view them as long lists of vague expectations linked to performance expectations; suddenly, there is a swarm of new things to worry about, but none of them are clear enough to deal with. The fact that many items on the syllabus will not be required for weeks or months may not keep the student from worrying about them. You may want to find time to individually discuss the syllabus with your anxious student. • Preferential seating - Discuss this with your anxious student. For some, sitting near the back of the room or off to the side may feel better, particularly for those with social anxiety disorder. Others may feel more supported sitting as close to you as possible. Some students may feel calmest, safest, and most supported sitting next to their close friends (this may be a great option as long as it is not disruptive). • Exit Plan – Together with your anxious student, create a plan that allows them to leave the classroom if they begin to feel overly anxious. You should agree on a pre-arranged safe place where they will be supervised by an adult. Not only will this give them a place to calm down when needed, the knowledge that a plan is in place will likely reduce the student’s need for it. The exit plan helps reduce stress in two ways: first, the student no longer feels trapped once he enters your classroom. Second, anxiety caused by not knowing what to do if he begins to lose control will be removed – having a plan in place before it is needed makes the student feel safer and more in control of the situation.

47. Non research based classroom recommendations Classroom interventions for specific studentscontinued… • Tests • Test anxiety is linked to lower levels of performance on exams and quizzes, but not for regular in-class work, essays, reports, etc (Mychailyszyn, Méndez, & Kendall, 2010). If tests cause elevated stress for your student, consider other forms of assessment that are less focused on one single high-stakes product. Assessing the student’s work over a longer period of time, perhaps by collecting journals or portfolios, is less likely to cause elevated levels of stress. • If tests are necessary, consider altering the format: • Can you provide extra time for the student? • Would the student perform better with an oral examination? • Rather than requiring students to answer every question, consider allowing them to choose which ones they wish to answer (for example, require them to answer any 8 out of 10 questions); this strategy is likely to greatly reduce stress for students who’s anxiety manifests in perfectionist tendencies because it will allow them to earn a perfect score without feeling the need to master every single detail. • Obviously, pop quizzes are likely to cause increased stress; they introduce an unknown and they are a single, high-stakes evaluation of performance.

48. Non research based classroom recommendations Classroom interventions for specific studentscontinued… • Many if not most students with social anxiety disorder will experience heightened levels of stress with oral presentations. The following modifications may be helpful: • Rather than presenting live in front of the class, encourage the student to record her presentation and present via video. • Allow the student to present in front of a smaller audience: teacher only, small group of friends, family, etc. • Allow the student to alter the format of the presentation: instead of standing up in front of class, the presentation could be given from the student’s seat. Or, rather than a lecture format, the student may be more comfortable leading a discussion or debate focused on his topic.

49. Non research based classroom recommendations Classroom interventions for specific studentscontinued… • Often, students with anxiety disorders, particularly GAD, have difficulty identifying what it is that is causing their stress; they feel surrounded or buried by pressures and responsibilities that they cannot quite put their finger on (students who feel like this often find it difficult to identify a starting point). Providing extra organization and time management support may help your student clarify their responsibilities, see them more realistically, and begin addressing them one at a time. • Organization strategies that include to-do lists, scheduling of tasks on a calendar, and breaking large tasks down into manageable chunks may be particularly helpful. • It may also be useful to include strategies the student should use if he gets stuck on a particular to-do item (skip it and move to the next one, ask a parent for help, call a classmate, call the teacher, etc.). • Discuss these strategies with parents so they can support their children at home.

50. Non research based classroom recommendations Classroom interventions for specific studentscontinued… • Students with anxiety disorders, particularly those with social anxiety disorder, may experience heightened levels of stress during unstructured break time (this time represents an “unknown” and it often comes with the expectation that they will interact with peers). Students may actually worry about or dread these unstructured times well before they actually take place. Working with your student to create a plan for structuring their break times may help reduce stress.