Dealing with Anxiety in the ClassroomPresentation Transcript
Dealing with Anxiety in the ClassroomAlexa Bagnell, MD, FRCPCJuly 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 Addictive Disorders in Children 4-17 Anxiety Disorders 7% ADHD 5% Conduct Disorder 4% Mood Disorders 4% Substance Use Disorders 1% Any Disorder 14 % Waddell et al, Can J Psychiatry, 2002
Whe i have a really big projectdue a get so worried. I cantsleep at night. Even if i know iwill finish it on time i get sofreaked out. Is there somethingwrong with me. Non of myfriends feal this way. Can uhelp me?
What is Normal Anxiety? Situation or Trigger: Transient Anxiety:First date Apprehension Does not Preparing foran exam Nervousness significantly Performing Tension interfere Edginessat a concert Nausea Giving a Does not Sweating speech Trembling prevent a Moving from person fromhome achieving their Climbing a tall goals ladder
When is it a problem? ! !? ! Brain Registers ! No DANGER!Danger ANXIETY Ears Eyes Initiation Nose Sensory Taste of Physiologic Perception Cascade Touch ↑ Heart Rate Internal ↑ Alertness Thoughts Signals Physical ↑ Perception ↑ Tension Emotions
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 inChildren 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 Thinking Doing
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
Sympathetic Nervous SystemPhysiologic arousalFIGHT/FLIGHT/FRIGHT Signal danger Enhance alertness Prepare body for action
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
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 ThinkingWhat is the evidence that anxious thought is true or false? Problem SolvingIdentifying problem and generating solutions and potential outcomes Positive Self Talk
Realistic ThinkingEvent Thought/Belief EmotionTest I will fail worriedTest I don’t care irritableTest 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 100 90 80 70Worry Scale 60 Exposure 50 Avoidance 40 Anxiety 30 20 10 0 Time 0 Time 1 Time 2 Time 3 Time 4
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 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 Strategies a) Graded Exposures: n+1 rule (what is step up from current situation?) b) Desensitization: visit school after school hours, arrive early when school is quieter c) Flooding: force full time return (usually only works for absences of 2-3 weeks or less) d) Remove incentives 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