Dealing with Anxiety in the Classroom


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  • * 07/16/96 * ## Physical Symptoms: Insomnia Palpitations Increased heart rate Suffocation Dizziness Shaking or tremors Shortness of breath Stomach upset Restlessness Diarrhea Change in appetite Flushing Blushing Sweating Faintness Chest pain Thinking/Cognitive Symptoms: Worry/Apprehension Difficulty making decisions Poor concentration Repeatedly thinking the same distressing thoughts: ie., Obsessions & Ruminations Catastrophic thinking Increased or Decreased awareness of one’s surroundings Confusion Behavioral Symptoms: Aggression Avoidance Agitation Restlessness Substance use: Alcohol Benzodiazepines Sleep Medicines Social Withdrawal Repeated behaviors (Compulsions)
  • * 07/16/96 * ## Dysfunction of the danger signaling mechanism can lead to triggering of the ‘physiologic cascade’ in the absence of real danger: This is called ‘Anxiety’
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  • Dealing with Anxiety in the Classroom

    1. 1. Dealing with Anxiety in the ClassroomAlexa Bagnell, MD, FRCPCJuly 11, 2012
    2. 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. 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. 4. 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?
    5. 5. 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
    6. 6. 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
    7. 7. 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
    8. 8. 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
    9. 9. 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.
    10. 10. 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
    11. 11. 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
    12. 12. Anxiety Performance Curve (Yerkes-Dodson Law) Hebb, D. O. (1955). Psychological Review, 62, 243-254
    13. 13. 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
    14. 14. 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
    15. 15. 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)
    16. 16. Three Components of Anxiety Feeling Thinking Doing
    17. 17. THOUGHTS
    18. 18. 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.”
    19. 19. 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
    20. 20. Anxiety and the Brain
    21. 21. 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
    22. 22. Sympathetic Nervous SystemPhysiologic arousalFIGHT/FLIGHT/FRIGHT Signal danger Enhance alertness Prepare body for action
    23. 23. 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
    24. 24. BEHAVIOURS
    25. 25. Core Components of CBT Education about Anxiety Realistic Thinking/Cognitive Restructuring Skills Training (e.g., relaxation, problem solving, social skills, assertiveness, stress management) Exposure **
    26. 26. 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
    27. 27. Realistic ThinkingEvent Thought/Belief EmotionTest I will fail worriedTest I don’t care irritableTest I can pass if I study hopeful
    28. 28. 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
    29. 29. COPING STRATEGIES Muscle Relaxation Deep Breathing Refocusing – e.g. Five senses Staying on Task Worry Time “Acting as if” ( are not anxious/worried)
    30. 30. 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.”)
    31. 31. 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
    32. 32. 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
    33. 33. 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!
    34. 34. 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.
    35. 35. 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
    36. 36. 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?
    37. 37. Mental Health Resources for Schools “When Something’s Wrong” series 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