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