The document discusses anxiety disorders in children and youth, providing statistics on prevalence rates and describing common symptoms. It outlines treatment approaches for anxiety including cognitive behavioral therapy and medication. The document also provides strategies for helping anxious youth in the school environment such as promoting realistic thinking, teaching coping skills, and using exposure activities.

1. Dealing with Anxiety in
the Classroom
Alexa Bagnell, MD, FRCPC
July 11, 2012

2. 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

3. 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

4. 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?

5. What is Normal Anxiety?
Situation or
Trigger: Transient
Anxiety:
First date
Apprehension
Does not
Preparing for
an exam Nervousness significantly
Performing
Tension interfere
Edginess
at a concert Nausea
Giving a
Does not
Sweating
speech Trembling prevent a
Moving from person from
home achieving their
Climbing a tall goals
ladder

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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

13. Anxiety Performance Curve
(Yerkes-Dodson Law)
Hebb, D. O. (1955). Psychological Review, 62, 243-254

15. 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

16. 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

17. 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)

19. Three Components of Anxiety
Feeling
Thinking
Doing

20. THOUGHTS

21. 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.”

22. 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

23. Anxiety and the Brain

24. 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

25. Sympathetic Nervous System
Physiologic arousal
FIGHT/FLIGHT/FRIGHT
Signal danger
Enhance alertness
Prepare body for action

26. 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

27. BEHAVIOURS

28. Core Components of CBT
 Education about Anxiety
 Realistic Thinking/Cognitive
Restructuring
 Skills Training (e.g., relaxation,
problem solving, social skills,
assertiveness, stress management)
 Exposure **

29. 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

30. 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

31. 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

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

33. 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.”)

34. 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

35. Avoidance Behaviour- Anxiety
Curve
Anxiety Exposure Curve
100
90
80
70
Worry Scale
60 Exposure
50 Avoidance
40 Anxiety
30
20
10
0
Time 0 Time 1 Time 2 Time 3 Time 4

36. 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!

37. 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.

38. 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

39. 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?

40. 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