When Anxiety Affects Learning:

How to Help Children with

School-Related Anxiety

March 27, 2017

Jonathan Dalton, Ph.D.

Center for Anxiety and Behavioral Change

Why this is so important

Median age of onset 11 – earliest of all

forms of psychopathology

8 % of children between ages 13 and 18

currently have an anxiety disorder

31.9% will have an anxiety disorder

between the ages of 13 and 18

8.3% will have “severe” anxiety disorder

Only 18 % of these teens receive treatment

Children and Adolescents

Adolescents Girls

38% of girls will have at least one anxiety

disorder between the ages of 13 and 18,

(compared with 26.1% for boys)

Compared with 4.2% of girls will have

ADHD, 10.2% with have a substance abuse

disorder, 3.8% will have an eating disorder

Comorbidity of Anxiety and

Learning Differences

For children with a Specific Learning

Disability, 28.8% meet criteria for an

Anxiety Disorder

For children with a Nonspecific Learning

Disability, 16.4% meet criteria for an

Anxiety Disorder

For children with ADHD, 38.7% have

comorbid anxiety disorder

Adults

28.8 percent lifetime prevalence

Most common category of mental health

disorders

18 % of adults currently have an anxiety

disorder (40 million)

$42 billion in annual health costs

Adaptive Anxiety vs. Disordered

Anxiety

Adaptive Anxiety

Keeps us safe

A response to real danger

Prevents the repeating of

mistakes

Disordered Anxiety

Results in functional

impairment

Equivalent to a “false

alarm”

Leads to unnecessary

avoidance

“If it made sense, it wouldn’t be a

disorder”

3797 ways to have a panic attack (4 of 12

symptoms are required)

A student may show behavior incongruent

with an anxiety disorder in various

situations

Safety behaviors

“Anxiety is the Baskin Robbins

of mental disorders”

Panic Disorder

Separation Anxiety Disorder

Generalized Anxiety Disorder

Post Traumatic Stress Disorder

Social Phobia

Specific Phobia

Selective Mutism

Obsessive Compulsive Disorder *

“Having an anxiety disorder is like being stuck in that

moment when you realize you’ve leaned too far back in your

chair, but have not yet fallen.” – teenage patient

Definition of School Refusal

School refusal is defined as:

Refusal to attend or difficulty remaining in

school for an entire day

Epidemiological Data

Lifetime Prevalence rate 5 to 28%

Higher rates in urban school districts

3-month prevalence rate is 2%

Equally common in boys and girls

Does not seem to be related to SES(e.g., Kearney & Albano, 2004)

Age-Related Distribution

Two peaks in age of onset

5 to 6 years of age

10 to 11 years of age

Acute onset more likely for younger children, insidious onset for older

Common Antecedents

Death or illness in parent or caregiver

Change of class or school

Traumatic events at school (including

bullying)

Prolonged absence from illness

Associated Disorders

Separation Anxiety Disorder (38% of cases)

Social Phobia

Adjustment Disorders

Specific Phobias (e.g., fire alarms, bees, dogs,

etc.)

Perfectionism

Depression

Sleep Disorders

Consequences of School Refusal

Duration of school-refusal correlated with short and long term psychopathology in the individual including:

- lowered academic achievement

- occupational difficulties

- family/marital discord

- poor social relationshipsKearney (2001)

Long-Term Sequelae in Children

with School Refusal

Did not complete high school……….45%

Adult psychiatric outpatient care……43%

Still living with parents at

20-year follow-up……………………14%

Married at 20-year follow-up………..41%

No children at 20-year follow-up……59%

- Flakierska-Praquin et al. (1997)

Allergic Reaction to a Casserole

Exploring Obstacles and Creative

Accommodations“If I had a magic wand, what would it take for you to be back

in school tomorrow?”

No tests, quizzes,

homework, or being

called on for set period

of time

Dropping a class

Liberal use of flash

passes

Eating lunch in

alternative setting

Ability to use nurse’s

office restroom

Pleasurable activity

upon arrival (e.g.,

caring for class

hamster)

Creation of “cover

story”

Signs and Symptoms

Signs and Symptoms

-cont-

Expert chameleons

Can appear oppositional and out of

character

Perfectionism “Needing A’s”

Fatigue from “two full-time jobs”

Irritability

Increased Absenteeism

“Imagine trying to learn calculus

right now”

Treatment Works!

“Ultimately we know deeply that on the other side

of every fear is freedom” – Marilyn Ferguson

Treatment success rates for anxiety disorders

with CBT (exposure therapy) range from 60%

to 90%

Tragically low utilization rates

(18% compared with 79% for ADHD)

Three Pillars of Anxiety

Uncertainty

Lack of control

Perception of danger

Anxiety Acquisition

Classical Conditioning

Modeling

Information Transfer

Anxiety Maintenance

Avoidance is the “lifeblood” of any anxiety

disorder

Avoidance is a very strongly reinforced

behavior

We are hardwired to avoid perceived threats

Anxiety Reduction

Education

Cognitive Reframing

Behavior Change

“We don’t treat anxiety; We treat

avoidance”

Decreasing Avoidance“Urges do not dictate actions.”

Metacognitive awareness of urge to avoid

or escape

Rehearsal of self-instruction

Building distress tolerance

“Stop swatting the butterflies.”

Basic Template for the Treatment

of Anxiety Disorders in

Adolescents

Assessment

Psychoeducation

Cognitive Reappraisal Strategies

Exposure

Parent Training

Relapse Prevention

Psychoeducation“Here is the owner’s manual for you nervous

system”

“Good package deal”

Acquisition, maintenance, and extinction of

fear response

Importance of decreasing avoidance

Concept of exposure

Outlasting fear

Cognitive Reappraisal of

Anxious Arousal“Don’t believe everything you think!”

Body is doing the right thing at the wrong

time

Perspective of “curious observer”

“In this moment…”

Fire alarm at the top of the

Empire State Building

Cognitive Strategies“Why don’t the palm trees care when the wind

blows?”

Coping cards

Problem-solving skills training

Cognitive flexibility exercises

Coping Cards“Just because I’m scared…”

I am stronger than my

fear

Scary thoughts can

never hurt me

I know I can do this

because…

Just because I’m

scared doesn’t mean I

can’t do it

It’s ok to be scared

Just do it anyway

Anxiety is temporary

and harmless

Fear Reduction

Through Behavior Change“Courage is what you do, not what you feel”

Exposure to the feared situation in the

absence of the feared consequence produces

fear reduction

Exposure can be conducted in a variety of

manners, but exposure always remains the

“active ingredient” (e.g., acetaminophen

comes in tablets, caplets, gelcaps, etc.)

The way to respond to anxiety is just as

counterintuitive as diving into the wave that’s

about to hit you.”

Three Critical Variables for

Habituation to Occur

(Successful Exposure)

Frequency

Intensity

Duration

Graduated Exposure

Akin to entering a cold pool slowly

Preferred technique for most pediatric anxiety disorders

Critical that the child assists in the creation of the fear hierarchy (“ladder” for younger children)

The child earns more points, tokens, etc. for more difficult exposures

Habituation“We turn fear into boredom”

Continuous exposure to a constant stimulus

reduces the subjective experience of that

stimulus (e.g., cold water at the beach, baby

crying on airplane, white noise machine in

your office, etc.)

Fear follows this same process of

habituation

bigfoot

Flexibility is Strength

Self-Oriented Perfectionism

Very different from appropriately high

standards

Risk factor for eating disorders, depression,

suicide

Self-worth derived from achievement and

productivity

Tend to function well in low stress

environment

“The perfect igloo can kill you.”

Teaching “Optimalism”

Optimal – “Best or most effective”

Failure as feedback

Adaptable and flexible

Accepts natural variation

Balance as goal

Success is not linear

“Model what you want the sudent

to feel.”

“Be the counterweight.”

Accommodating vs. Enabling

Specifics

No universal rule – changes over time

Calm consistency

“To what end”

Alternative strategy vs “get out of jail free”

Expectation of effort

Psychoeducation

for Parents

“Fear and Avoidance are Teammates”

Parent-training is paramount!

Begin with education regarding the negative

reinforcement of anxious behavior

“Protection Trap”

“Water the seeds, not the weeds.”

Nuts and Bolts“Your attention is your child’s paycheck, so be

exceptionally careful what you pay him/her for”

Functional analysis

Positive reinforcement

Negative reinforcement

Coercive behavior cycle

Extinction

Extinction Burst

Habituation

scene from Ray

Relapse Prevention

Problem-solving skills training

Increase perceived social support

Emphasis on continued self- directed

exposure

Relaxation training

Reframe potential recurrence of symptoms

as opportunity for future learning

Increase self-efficacy to deal with future

fears

Jonathan Dalton, Ph.D.

Center for Anxiety and

Behavioral Change

drjdalton@gmail.com

301-610-7850