Helping Highly Anxious Students

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Helping Highly Anxious Students

• Dr. Greg Schoepp
• Chartered Psychologist
• gschoepp_at_cha.ab.ca
• [phone]
• Capital Health Authority
• University of Alberta Hospital
• Stollery Childrens Hospital

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What is Anxiety?

• A complex pattern of behavioral, cognitive, and
  physical reactions to a real or imagined threat.
• Physical responses heart rate, sweating, muscle
  tension, skin temperature, stomach upset.
• Cognitive/affective responses thoughts of being
  scared, danger, self critical thoughts, hyper
  sensitivity to physical symptoms
• Behavior responses avoidance, trembling voice,
  crying, anger outburst, loss of emotional control

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Relationship Between Thoughts and Feelings

• Emotions are a direct result of your thoughts and
  beliefs about an event.
• Event Thought/belief Emotional
• Reaction
• attending might be useful motivation
• anxiety session interest

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Characteristics of Anxious Students

• get upset at changes in routines or at mistakes
• is a loner or prefers small group of safe
  people
• limited social skills, refuse to participate in
  social activities
• difficulty separating from caregiver at start of
  day
• associated health issues - asthma, severe
  allergies
• poor concentration, irritability, restlessness,
  distractibility

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Characteristics of Anxious Students

• Learning problems and anxiety
• increased anxiety about being different
• black white thinking style, hard to
  differentiate exaggerated vs realistic worries
• more rigid, inflexible approach
• combination of issues -i.e. tourettes, ADHD,
  lower cognitive functioning

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Viewing the World as Dangerous

• thinking biases - more threatening
  interpretations of ambiguous situations
• overestimate likelihood unpleasant event
  occurring or overestimating probability
• overestimate how negative consequences will be if
  event happens, catastrophizing outcomes
• preference for poor coping responses
• enhanced memory for threatening information

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Types of Anxiety

• Separation Anxiety
• Generalized Anxiety
• Specific phobia
• Specific Phobia
• Obsessive-Compulsive Disorder

• Panic Attack
• Panic Disorder
• Acute Post Traumatic Stress
• Adjustment Disorder
• School Refusal (not in DSM-IV)

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Ineffective Teacher Responses

• excessively reassure the student, for example,
  repeatedly telling the student that "every thing
  will be all right
• being too directive. Tell the student exactly how
  to handle the situation
• remove the student from the feared the situation
  or allow the child to avoid the situation

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Ineffective Teacher Responses

• empathize with student's anxiety by discussing in
  detail what makes them anxious and afraid.
  Modeling anxious behavior
• become impatient with the student, frustration,
  anger

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Effective Teacher Responses

• reward brave, non anxious behavior
• ignore anxious, clingy behavior you don't want,
  especially when child seeks reassurance from you
  that "everything will be all right"
• help student to find their own solutions. Coach
  student to problem solve. Increase coping
  thoughts, challenge negative self talk. Expect
  good things to happen

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Effective Teacher Responses

• model brave, non anxious behavior
• prevent avoidance
• provide opportunities for developing
  independence, i.e. run message to office for you
• allow student to experience natural consequences
  of their fear
• encourage help-seeking (i.e. school counsellor)
  and destigmatise the issue

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Effective Teacher Responses

• encourage gradual exposure to fear. With
  students help, establish set of challenges to
  help overcome fears
• when possible and appropriate, develop exposure
  with parents who provide incentives for success
  (reward effort)
• refer student for specialist help when anxiety
  over whelming

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Anxiety ThermometerFor Young children
Small Worry MediumWorry Big worry
1 2 3
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Relaxation Strategies

• address the physical reaction when feeling
  worried, nervous or afraid
• awareness of body clues, i.e. feeling ill before
  math test
• relaxation
• robot/ragdoll exercise
• progressive muscle relaxation
• deep breathing
• visualization

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Four Steps to Challenging Anxious Thoughts

• 1. Identify thought behind emotion - have student
  state what they worry might happen
• Ill make a mistake and people will laugh at
  me
• 2. Look for evidence - use questions with student
• Past experience
• Alternative possibilities
• General Knowledge
• Take Different Perspective (adolescents)

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Four Steps to Challenging Anxious Thoughts

• 3. Evaluate Thought on Basis of Evidence
• How likely is it that the bad thing Im
  expecting will actually happen?
• Use percentages or descriptors, not likely
• 4. Examine Consequences of Feared Event
• For adolescents-challenging consequences
• What is the worst that could happen here?
• Formulate coping strategies

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Addressing Anxious Thoughts

• Realistic Thinking or Detective Thinking (Rapee,
  2000) Thought Challengers (Barrett, 2000)
• (event) What is happening?
• (thought) What am I thinking?
• Worry rating? 1-10

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• (evidence) What are the facts? What do I know
  about the situation?
• What happened before when I was worried?
• What else could happen?
• What is likely to happen?
• How likely is it that the bad thing Im
  expecting will actually happen?
• (coping) What is my helpful (realistic thought)?
• What will I do to cope with this situation?

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Evidence Questions for Older Students

• Have I ever been in a situation like this before,
  and was it really that bad?
• How many times has this terrible thing actually
  happened before?
• What will most likely happen in this situation?
• What is the worst thing that can really happen?
• Am I 100 sure that this will happen?
• What else might that person be thinking about me?
• So what if the situation does not go perfectly?
• Am I the only person who has ever had to deal
  with this situation?

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Simplifying Realistic ThinkingJanice, age 11

• (Evidence)
• Check things out
• What do I see?
• What do I hear?
• What do I smell?
• What do I feel?

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Simplifying Realistic ThinkingJanice, age 11
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Fear and Worry List

• These things are really hard to do Worry
  Scale (0-10)
• __________________________________________________
  ________________________________
• __________________________________________________
  ________________________________
• These things are hard to do
• __________________________________________________
  ________________________________
• __________________________________________________
  ________________________________
• These things make me a little worried
• __________________________________________________
  ________________________________
• __________________________________________________
  ________________________________

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Fear and Worry List ExampleAmber, age 12, grade 7

• Skating competitions 10
• Away from family, mom 9
• Giving speech 8
• Getting interviewed 10
• Going somewhere on
• my own 10
• _____________________________________________
• Making friends 7
• Lunch at school 5
• Late for school 7

• Shopping w/o parents 7
• Talking to strangers 7
• _______________________________________________
• Falling asleep 4
• Being with people I dont
• know 4
• Giving my opinion 3
• Being dark by self 2

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Step by Step Plan (Exposure Hierarchy)

• My Goal Not to be bothered by making mistakes
  at school
• STEP 10 Dont have correct textbook for a
  lesson
• STEP 9 Deliberately give wrong answer to a
  question in class
• STEP 8 Forget to return library books on
  library day
• STEP 7 Answer question in class without being
  100 sure
• STEP 6 Hand in assignment with two spelling
  errors
• STEP 5 Draw doodle in margin of page to turn
  in
• STEP 4 Make deliberate mistake in math
  exercise
• STEP 3 Dont bring permission slip back to
  school on first due date
• STEP 2 Cross out homework mistake and hand in
  without rewriting
• STEP 1 Listen to music for half hour before
  doing homework after school

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Making Exposure Effective

• fears are faced gradually, slightly difficult to
  most difficult
• student experiences progression in difficulty and
  anxiety
• student must remain in situation long enough to
  confirm negative belief is not true
• practice and repetition keys to success. Student
  learns situation is not threatening

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Its Hard Work, Rewards Help

• help students evaluate their performance in terms
  of partial success
• for older children - Think like a winner
• The situation was..
• Positive aspects of the situation were
• Things I could improve on next time...

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Its Hard Work, Rewards Help

• for younger children- performance barometer for
  self-evaluation
• How well did I cope?
• Super Well, Well, Okay, A little, Didnt try
  very hard, Didnt try at all
• negotiate reward/incentive for each step before
  starting plan, parents are important here
• rewards for large steps or milestones important

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Social Skills Competence

• body language skills - eye contact, posture,
  facial expression
• voice quality skills - tone, volume, clarity
• conversational skills - greetings
  introductions, initiating and maintaining
  conversations
• instruction, rehearsal feedback, practice
• modelling most effective (video, modelling by
  teacher or peer)

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Social Skills Rehearsal (Rapee et al.., 2000)

• Conversation game - 30 second paired conversation
  with prompted cues, job interview (adolescents)
• hobby talk, tale time ( 3 min. reading or
  speech), in the movies (act out scripts)
• conversation brainstorm, movie scriptwriter
  (adolescents), scenario game

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Social Skills Practice

• set tasks where student can practice skills in
  real-life situations
• graded exposure tasks to increase skills and
  confidence
• use school activities and assignments as practice
  situations - i.e. class presentation, paired
  reading

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Assertiveness Training (Rapee et al., 2000)

• helping students differentiate assertive, wimpy
  (passive), and grouchy (aggressive) behavior
• develop skills in non-verbal and verbal assertive
  behavior
• rehearse with role plays and real-life situations
• practice in front of mirror, with family members,
  groups of students

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Assertiveness Training (Rapee et al., 2000)

• Assertiveness Checklist
• strong EYE contact
• good POSTURE
• clear VOICE
• SAY WHAT YOU WANT politely (content)
• APPEAR confident
• BEHAVE appropriately

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Assertiveness Training (Rapee et al., 2000)

• Outsmarting Bullies
• TALK to others
• get an AUDIENCE
• do something DIFFERENT
• develop CLEVER COME-BACKS
• Tease Youre so stupid
• Come-back Youre observant, ever thought of
  being a news reporter?

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Importance of School Environment

• anxiety problem not necessarily within child or
  home-based
• responses of teachers, administrators, other
  staff can be crucial
• deal with differences in how staff conceptualize
  childs problem - important in JH and SH grades
• effective teachers DO make a positive difference
  for anxious students

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When and How to Refer Families For Help

• when child is overwhelmed, unable to cope
• community counselling agencies
• family physician or pediatrician referral
• psychologists
• child psychiatrists
• medication
• self-help books