Testing Anxiety Toolkit
This toolkit offers a collection of materials, primarily for practitioners, with some handouts for parents and teachers to help students manage anxiety related to testing.
2. Anxiety And Anxiety Disorders In Children: Information For Parents Thomas J. Huberty, PhD, NCSP Indiana University
6. Test and Performance Anxiety Thomas J. Huberty, PhD, NCSP Indiana University
11. Research-Based Practice Assessing and Treating Childhood Anxiety in School Settings Savannah Wright & Michael L. Sulkowski
17. Cognitive Behavioral Strategies For Working With Anxious Youth In Schools (PowerPoint Slides) Elana R. Bernstein, PhD Morgan J. Aldridge, MS Jessica May, MS
28. Anxiety: Tips For Teens Patricia A. Lowe, PhD, Susan M. Unruh, EdS, & Stacy M. Greenwood University of Kansas
32. High Stakes Testing & Children’s Well-Being: A Guide for Parents NYASP
35. High Stakes Testing & Children’s Well-Being: A Guide for Teachers NYASP
38. Reducing Test Anxiety to Increase Academic Performance (PowerPoint Slides) Peter Faustino PhD and Tom Kulaga M.S.
104. Utilizing Video Self-Modeling and Reattribution Training to Alleviate Test Anxiety (PowerPoint Slides) Shahrokh-Reza Shahroozi, B.S.
ANXIETY AND ANXIETY DISORDERS IN CHILDREN: INFORMATION FOR PARENTS
By Thomas J. Huberty, PhD, NCSP Indiana University
Anxiety is a common experience to all of us on an almost daily basis. Often, we use terms like jittery, high strung, and uptight to describe anxious feelings. Feeling anxious is normal and can range from very low levels to such high levels that social, personal, and academic performance is affected. At moderate levels, anxiety can be helpful because it raises our alertness to danger or signals that we need to take some action. Anxiety can arise from real or imagined circumstances. For example, a student may become anxious about taking a test (real) or be overly concerned that he or she will say the wrong thing and be ridiculed (imagined). Because anxiety results from thinking about real or imagined events, almost any situation can set the stage for it to occur.
Defining Anxiety There are many definitions of anxiety, but a useful one is apprehension or excessive fear about real or imagined circumstances. The central characteristic of anxiety is worry, which is excessive concern about situations with uncertain outcomes. Excessive worry is unproductive, because it may interfere with the ability to take action to solve a problem. Symptoms of anxiety may be reflected in thinking, behavior, or physical reactions.
Anxiety and Development Anxiety is a normal developmental pattern that is exhibited differently as children grow older. All of us experience anxiety at some time and cope with it well, for the most part. Some people are anxious about specific things, such as speaking in public, but are able do well in other activities, such as social interactions. Other people may have such high levels of anxiety that their overall ability to function is impaired. In these situations, counseling or other services may be needed. Infancy and preschool. Typically, anxiety is first shown at about 7–9 months, when infants demonstrate stranger anxiety and become upset in the presence of unfamiliar people. Prior to that time, most babies do not show undue distress about being around strangers. When stranger anxiety emerges, it signals the beginning of a period of cognitive development when children begin to discriminate among people. A second developmental milestone occurs at about 12–18 months, when toddlers demonstrate separation anxiety. They become upset when parents leave for a short time, such as going out to dinner. The child may cry, plead for them not to leave, and try to prevent their departure. Although distressing, this normal behavior is a cue that the child is able to distinguish parents from other adults and is aware of the possibility they may not return. Ordinarily, this separation anxiety is resolved by age 2, and the child shows increasing ability to separate from parents. Both of these developmental periods are important and are indicators that cognitive development is progressing as expected. School age. At preschool and early childhood levels, children tend to be limited in their ability to anticipate future events, but by middle childhood and adolescence these reasoning skills are usually well developed. There tends to be a gradual change from global, undifferentiated, and externalized fears to more abstract and internalized worry. Up to about age 8 children tend to become anxious about specific, identifiable events, such as animals, the dark, imaginary figures (monsters under their beds), and of larger children and adults. Young children may be afraid of people that older children find entertaining, such as clowns and Santa Claus. After about age 8, anxiety-producing events become more abstract and less specific, such as concern about grades, peer reactions, coping with a new school, and having friends. Adolescents also may worry more about sexual, religious, and moral issues, as well how they compare to others and if they fit in with their peers. Sometimes, these concerns can raise anxiety to high levels.
Helping Children at Home and School II: Handouts for Families and Educators S5–1 Anxiety Disorders present to a significant degree, can indicate anxiety that When anxiety becomes excessive beyond what is needs attention. As a parent, you may be the first person expected for the circumstances and the child’s to suspect that your child has significant anxiety. developmental level, problems in social, personal, and academic functioning may occur, resulting in an anxiety Relationship to Other Problems disorder. The signs of anxiety disorders are similar in Although less is known about how anxiety is related children and adults, although children may show more to other problems as compared to adults, there are some signs of irritability and inattention. The frequency of well-established patterns. anxiety disorders ranges from about 2 to 15% of Depression. Anxiety and depression occur together children and occurs somewhat more often in females. about 50–60% of the time. When they do occur together, There are many types of anxiety disorders, but the most anxiety most often precedes depression, rather than the common ones are listed below. opposite. When both anxiety and depression are present, Separation anxiety disorder. This pattern is there is a higher likelihood of suicidal thoughts, although characterized by excessive clinging to adult caretakers suicidal attempts are far less frequent. and reluctance to separate from them. Although this Attention Deficit Hyperactivity Disorder. At times, pattern is typical in 12–18-month-old toddlers, it is not anxiety may appear similar to behaviors seen with expected of school-age children. This disorder may Attention Deficit Hyperactivity Disorder (ADHD). For indicate some difficulties in parent-child relationships example, inattention and concentration difficulties are or a genuine problem, such as being bullied at school. In often seen in children with ADHD and with children who those cases, the child may be described as having have anxiety. Therefore, the child may have anxiety school refusal, sometimes called school phobia. rather than ADHD. Failing to identify anxiety accurately Occasionally, the child can talk about the reasons for may explain why some children do not respond as feeling anxious, depending on age and language skills. expected to medications prescribed for ADHD. The age Generalized anxiety disorder. This pattern is of the child when the behaviors were first observed can characterized by excessive worry and anxiety across a be a useful index for determining if anxiety or ADHD is variety of situations that does not seem to be the result present. The signs of ADHD usually are apparent by age of identified causes. 4 or 5, whereas anxiety may not be seen at a high level Post-Traumatic Stress Disorder. This pattern often until school entry, when children may respond to is discussed in the popular media and historically has demands with worry and needs for perfectionism. A been associated with soldiers who have experienced thorough psychological and educational evaluation by combat. It is also seen in people who have experienced qualified professionals will help to determine if the traumatic personal events, such as loss of a loved one, problem is ADHD or anxiety. If evaluation or physical or sexual assault, or a disaster. Symptoms may consultation is needed, developmental information include anxiety, flashbacks of the events, and reports of about the problem will be useful to the professional. seeming to relive the experience. School performance. Children with anxiety may Social phobia disorder. This pattern is seen in have difficulties with school work, especially tasks children who have excessive fear and anxiety about requiring sustained concentration and organization. being in social situations, such as in groups and crowds. They may seem forgetful, inattentive, and have difficulty Obsessive-compulsive disorder. Characteristics organizing their work. They may be too much of a include repetitive thoughts that are difficult to control perfectionist and not be satisfied with their work if it (obsessions) or the uncontrollable need to repeat does not meet high personal standards. specific acts, such as hand washing or placing objects in Substance use. What appears to be anxiety may be the same arrangement (compulsions). manifestations of substance use, which may begin as early as the pre-teen years. Children who are abusing Characteristics of Anxiety drugs or alcohol may show sleep problems, inattention, Although the signs of anxiety vary in type and withdrawal, and reduced school performance. Although intensity across people and situations, there are some substance abuse is less likely with younger children, the symptoms that tend to be rather consistent across possibility increases with age. anxiety disorders and are shown in cognitive, behavioral, and physical responses. Not all symptoms are exhibited Interventions in all children or to the same degree. All people show Anxiety is a common experience for children, and, some of these signs at times, and it may not mean that most often, professional intervention is not needed. If anxiety is present and causing problems. Most of us are anxiety is so severe that your child cannot do expected able to deal with day-to-day anxiety quite well, and tasks, however, then intervention may be indicated. significant problems are not common. The chart at the end of the handout demonstrates behaviors that, if
S5–2 Anxiety and Anxiety Disorders in Children: Information for Parents Does My Child Need Professional Help? anxiety will be removed; rather, the goal should be Answering the following questions may be helpful in to get the anxiety to a level that is manageable. deciding if your child needs professional help: • Teach your child simple strategies to help with anxiety, such as organizing materials and time, • Is the anxiety typical for a child this age? developing small scripts of what to do and say, • Is the anxiety shown in specific situations or is it either externally or internally, when anxiety more pervasive? increases, and learning how to relax under stressful • Is the problem long term or is it recent? conditions. Practicing things such as making • What events may be contributing to the problems? speeches until a comfort level is achieved can be a • How are personal, social, and academic useful anxiety-reducing activity. development affected? • Listen to and talk with your child on a regular basis and avoid being critical. Being critical may increase If the anxiety is atypical for the child’s age, is long pressure to be perfect, which may be contributing to standing, does not seem to be improving, and is causing the problem in the first place. Do not treat emotions, significant problems, then it is advisable to talk with a questions, and statements about feeling anxious as professional, such as the school psychologist or silly or unimportant. They may not seem important to counselor, who might recommend a referral to a you but are real to your child. Take all discussion community mental health professional. Individual seriously, and avoid giving too much advice and counseling, or even group or family counseling, may be instead be there to help and offer assistance as used to help the child deal with school, family, or personal requested. You may find that reasoning about the issues that are related to the anxiety. In some cases, a problem does not work. At times, children may physician may recommend medication. Although realize that their anxiety does not make sense, but medication for childhood disorders is not well researched are unable to do anything about it without help. and side effects must be monitored, this treatment may • Do not assume that your child is being difficult or be helpful when combined with counseling approaches. that the problem will go away. Seek help if the problem persists and continues to interfere with How Can I Help My Child? daily activities. Although professional intervention may be necessary, the following list may be helpful to parents in Conclusion working with the child at home: Untreated anxiety can lead to depression and other problems that can persist into adulthood. However, • Be consistent in how you handle problems and anxiety problems can be treated effectively, especially if administer discipline. detected early. Although it is neither realistic nor • Remember that anxiety is not willful misbehavior, advisable to try to completely eliminate all anxiety, the but reflects an inability to control it. Therefore, be overall goal of intervention should be to return your patient and be prepared to listen. Being overly child to a typical level of functioning. critical, disparaging, impatient, or cynical likely will only make the problem worse. Resources • Maintain realistic, attainable goals and expectations Bourne, E. J. (1995). The anxiety and phobia workbook nd for your child. Do not communicate that perfection (2 ed.). Oakland, CA: New Harbinger. ISBN: 1- is expected or acceptable. Often, anxious children 56224-003-2. try to please adults, and will try to be perfect if they Dacey, J. S., & Fiore, B. (2001). Your anxious child: How believe it is expected of them. parents and teachers can relieve anxiety in children. • Maintain a consistent, but flexible, routine for San Francisco: Jossey-Bass. ISBN: 0-78796-040-3. homework, chores, and activities. Manassis, K. (1996). Keys to parenting your anxious • Accept mistakes as a normal part of growing up, child. New York: Barrons. ISBN: 0-81209-605-3. and that no one is expected to do everything equally well. Praise and reinforce effort, even if Website success is less than expected. There is nothing Anxiety Disorders Association of America—www.aada.org wrong with reinforcing and recognizing success, as National Mental Health Association—www.nmha.org long as it does not create unrealistic expectations Thomas J. Huberty, PhD, NCSP, is Professor and Director and result in unreasonable standards. of the School Psychology Program at Indiana University, • If your child is worried about an upcoming event, Bloomington, IN. such as giving a speech in class, practice it often so
that confidence increases and discomfort © 2004 National Association of School Psychologists, 4340 East West Highway, decreases. It is not realistic to expect that all Suite 402, Bethesda, MD 20814—(301) 657-0270.
Helping Children at Home and School II: Handouts for Families and Educators S5–3 Types of Anxiety Disorders
Cognitive Behavioral Physical
• Concentration difficulties • Shyness • Trembling or shaking • Overreaction and • Withdrawal • Increased heart rate catastrophizing relatively • Frequently asking questions • Excessive perspiration minor events • Frequent need for • Shortness of breath • Memory problems reassurance • Dizziness • Worry • Needs for sameness • Chest pain or discomfort • Irritability Avoidant • Flushing of the skin • Perfectionism • Rapid speech • Nausea, vomiting, diarrhea • Thinking rigidity • Excessive talking • Muscle tension • Hyper vigilant • Restlessness, fidgety • Sleep problems • Fear of losing control • Habit behaviors, such as • Fear of failure hair pulling or twirling • Difficulties with problem • Impulsiveness solving and academic performance
S5–4 Anxiety and Anxiety Disorders in Children: Information for Parents student services student services student services
amantha’s story: Fourteen-year-old Samantha went to the school nurse Test and on a weekly basis, complaining of stomach aches and being nervous and Sworried about school. The nurse referred her to the school psychologist, Performance who talked with her about the visits to the nurse’s office. Samantha reported that when taking tests or having to speak in public, she became anxious and was Anxiety not able to do well, although she thought that she knew the material. When describing her anxiety, she said, “My mind goes blank,” “I get shaky,” and “I get sweaty and red.” Anxiety is a normal Upon further discussion, the school psychologist found that Samantha also human emotion that felt anxious often when not at school and that her mother had high expectations can be detrimental in for her schoolwork. The school psychologist talked to her mother, who indicated that she had high expectations of Samantha, but she also described her daughter a school setting, but as being anxious, fearful, and a “worrier” since she was a small child. good communication and support can help Anxiety in Adolescents tends to generalize to many evaluative minimize its negative Cases like Samantha’s are more situations, contributing to more per- impact. common in school settings than vasive underachievement. Additional most school professionals realize. In consequences of chronic test anxiety the majority of cases, test and per- can include lowered self-esteem, By Thomas J. Huberty formance anxiety is not recognized reduced effort, and loss of motiva- easily in schools, in large part because tion for school tasks. Other forms of adolescents rarely refer themselves for anxiety that can be seen in the school Thomas J. Huberty ([email protected]) emotional concerns. Not wanting to include generalized anxiety, fears, pho- is a professor and the director of the School risk teasing or public attention, anx- bias, social anxiety, and extreme social Psychology Program at Indiana University. ious adolescents suffer in silence and withdrawal. underperform on school-related tasks.
Student Services is produced in collaboration with Anxiety is one of the most basic Characteristics of Anxiety the National Association of School Psychologists human emotions and occurs in every The central characteristic of anxiety (NASP). Articles and related handouts can be person at some time, most often is worry, which has been defined by downloaded from www.nasponline.org/resources/ principals. when someone is apprehensive about Vasey, Crnic, and Carter (1994) as uncertain outcomes of an event or set “an anticipatory cognitive process of circumstances. Anxiety can serve involving repetitive thoughts related an adaptive function, however, and to possible threatening outcomes and is also a marker for typical develop- their potential consequences” (p. 530). ment. In the school setting, anxiety is Although everyone worries occasion- experienced often by students when ally, excessive and frequent worry can being evaluated, such as when taking impair social, personal, and academic a test or giving a public performance. functioning. It can contribute to feel- Most adolescents cope with these ings of loss of control and perhaps situations well, but there is a subset of depression, especially in girls. up to 30% of students who experience When people become highly severe anxiety, a condition most often anxious, they tend to view more situ- termed “test anxiety.” ations as potentially threatening than When test anxiety is severe, it can do most of their peers. They have an have significant negative effects on irrational fear that a catastrophe will a student’s ability to perform at an occur and feel that they are unable optimal level. Over time, test anxiety to control outcomes. Often, there is
12 z Principal Leadership z September 2009 a rational basis for the anxiety, but will worsen an adolescent’s anxiety, it is greatly disproportionate to the further impairing performance, self- circumstances. esteem, and motivation. Anxiety is manifested in three ways: cognitively, behaviorally, and Ty p e s o f An x i e t y physiologically. Often the symptoms There are two forms of anxiety that are apparent in all three areas, such as are pertinent to understanding the worry, increased activity, and flushing formation and maintenance of anxiety. of the skin. (See figure 1.) Many of “Trait anxiety” refers to anxiety that is the behaviors exhibited by anxious chronic and pervasive across situations children and youth reflect attempts and is not triggered by specific events. to control the anxiety and minimize Trait anxiety is the basis for a variety its effects. The majority of adolescents of anxiety disorders, including general- who are anxious are not disruptive ized anxiety and social phobia. “State and are more likely to withdraw and anxiety” refers to anxiety that occurs avoid anxiety-producing situations. In in specific situations and usually has extreme cases, they may be seen by a clear trigger. Not all people who teachers as unmotivated, lazy, or less have high state anxiety have high trait capable than their peers. On the other anxiety, but those who have high trait extreme, some students with perfor- anxiety are more likely to experience mance anxiety may act out, con- state anxiety (Spielberger, 1973). Although everyone sciously or unconsciously, as a way of While taking tests, state anxiety worries occasionally, avoiding the risk of being embarrassed may occur, although the student may or failing. School personnel should be also have tendencies toward trait excessive and frequent aware of students whose disruptive or anxiety. Therefore, if a student shows worry can impair negative behavior aligns with upcom- high state anxiety, it is possible that ing performance-based assignments. he or she has high trait anxiety. It is social, personal, and important to identify adolescents with academic functioning. Ca u s e s o f An x i e t y high trait anxiety, because it can be The specific conditions and mecha- a sign of significant emotional prob- It can contribute to nisms that cause anxiety are not well lems and may be a precursor for the feelings of loss of control understood, but there is evidence that development of depression, especially youth who are test-anxious tend to in adolescent girls. In cases of severe and perhaps depression, have high levels of general anxiety anxiety, referral to a school psycholo- especially in girls. that are exacerbated during evalua- gist for more extensive evaluation is tions. There is considerable research recommended. In Samantha’s case, the evidence that some children have school psychologist concluded that biological predispositions to high she had high levels of trait anxiety, levels of general anxiety, making which worsened her test/state anxiety. them more susceptible to the effects High parental expectations likely also of being evaluated (Huberty, 2008). contributed to both her trait and state Repeated difficulties with test-taking anxiety. or other performances tend to lower self-confidence, which in turn can cre- High-Stakes Testing ate conditions for more frequent and Over the last several years, graduation intense experiences of anxiety. Also, has come to depend on passing stan- excessive pressure or coercion likely dardized tests. As a consequence, more
September 2009 z Principal Leadership z 13 student services student services student services
students are likely to have anxiety abilities, may find those examinations at risk for developing it. Some sugges- when taking such tests and their abil- especially challenging, increasing their tions include: ity to do their best will be impaired. anxiety. Therefore, schools should n Communicating that test anxi- Consequently, some students may consider screening all students who ety is a real psychological issue fail sections of these exams despite fail those examinations. and does not reflect laziness, knowing the material. Although there lack of motivation, or lack of is little research to suggest that high- School-Based Interventions capability by the student stakes testing causes anxiety disorders If test anxiety is not complicated by n Communicating to staff in adolescents, it is likely that students other problems, such as anxiety dis- members and parents that test with high trait or test anxiety are orders or depression, it is treatable in anxiety should be a priority for more vulnerable to underperform- the school setting by properly trained schools to address ing. A key indicator that test anxiety mental health specialists (e.g., school n Providing inservice training may occur in students is when they psychologists) and teachers with the about how to recognize and do not do well, despite indications to help of principals and parents. Each treat anxiety and to consider it the contrary (e.g., current achieve- of the following groups has a role to to be a genuine and pervasive ment). School personnel should be play in identifying and supporting problem alert to this possibility and follow up students. n Leading efforts to identify spe- with students who unexpectedly fail cialists in the school to identify parts of an examination to check for Principal s performance- and test-anxious the possibility of trait or state anxiety. Principals can be instrumental in students and provide support Moreover, students who struggle in working with staff members to help to them (Huberty, in press). school, particularly those with dis- students who have test anxiety or are Sc h o o l Me n t a l He a l t h Pr a c t i t i o n e r s Primary Characteristics of Anxiety Mental health specialists, such as school psychologists, social workers, Cognitive Behavioral Physiological and counselors, can work singly and Concentration problems Motor restlessness Tics collaboratively to develop and imple- ment interventions for students and Memory problems Fidgets Recurrent, localized pain to consult with teachers about how to Attention problems Task avoidance Rapid heart rate identify and work with students in the classroom. There are several interven- Oversensitivity Rapid speech Flushing of the skin tions that can be used in the school Difficulty solving Erratic behavior Perspiration setting to help students prevent and problems control test and performance anxiety. Irritability Headaches These strategies include: Worry Withdrawal Muscle tension n Providing relaxation training Cognitive dysfunctions n Using test-anxiety hierarchies Perfectionism Sleeping problems —Distortions for assessments and public —Deficiencies Lack of participation Nausea performances using variations of systematic desensitization Attributional style Failure to complete tasks Vomiting n Using pretask rehearsal problems Seeking easy tasks Enuresis n Using practice tests n Reviewing task content before
Source: Huberty, T. J. (in press). Performance and test anxiety. In L. Paige & A. Canter (Eds.), examinations Helping children at home and at school III. Bethesda, MD: National Association of School n Modifying tasks, such as break- Psychologists. ing them into smaller units
14 z Principal Leadership z September 2009 What Parents Can Do n Be consistent in how you handle problems and administer discipline. n Be patient and be prepared to n Developing mnemonic devices Although anxiety and depression listen. to help recall often are considered and treated as n Using cognitive-behavioral separate and distinct problems, they n Avoid being overly critical, techniques to reduce charac- frequently occur together with an disparaging, impatient, or cynical. teristics often associated with overlap of symptoms. Often adoles- n Maintain realistic, attainable goals test anxiety, such as “cognitive cents meet the clinical criteria for and expectations for your child. scripts” for students to use both disorders simultaneously. The n Do not communicate that when taking tests or perform- overlap has been reported to be perfection is expected or is the ing, self-monitoring techniques, as high as 50% in clinical samples. only acceptable outcome. positive self-talk, and self- Further, if both disorders are present n Maintain a consistent but flexible relaxation simultaneously, anxiety most likely routine for homework, chores, n Relaxing grading standards or preceded depression. Consequently, activities, and so forth. procedures if it is possible to the school psychologist must be pre- n Accept mistakes as a normal part do so without lowering perfor- pared to identify the presence of and of growing up and let your child mance criteria provide intervention and prevention know that no one is expected to n Recognizing effort as well as for both problems (Huberty, 2008). do everything equally well. performance n Avoiding criticism, sarcasm, or Pa r e n t s n Praise and reinforce effort, punishment for performance Parents can be highly instrumental in even if the outcome is less than problems working with their test-anxious ado- expected. Practice and rehearse n Using alternative forms of lescents. In some cases, parents may upcoming events, such as a assessment benefit from consulting with school speech or other performance. n Modifying time constraints and personnel to help determine whether n Teach your child simple strategies instructions high expectations are contributing to to help with his or her anxiety, n Emphasizing success, rather the problem. If that is the case, the such as organizing materials and than failure (Huberty, in press). school psychologist or other mental time, developing small “scripts” of Mental health specialists can also health professional can help parents what to do and say when anxiety provide inservice training to school develop realistic expectations of their increases, and learning how to personnel and parents. This training children. Parents can also help their relax under stressful conditions. can include information about: students better prepare for examina- n Do not treat feelings, questions, n The characteristics of anxiety tions and performances by working and statements about feeling n The types of cognitive prob- with them at home. anxious as silly or unimportant. lems experienced by perfor- n Often, reasoning is not effective mance-anxious students Te a c h e r s in reducing anxiety, so do not n The task conditions that can In addition to providing inservice criticize your child for being affect the experience and training to school personnel and direct unable to respond to rational expression of anxiety services to students, school psycholo- approaches. n The nature, types, and causes gists and other mental health profes- of anxiety sionals can consult with teachers to n Seek outside help if the problem n The tendency of test-anxious help them identify and work with persists and continues to interfere adolescents to have high trait test-anxious students. Consultation with daily activities.
anxiety and the need for some can include: Source: Huberty, T. J. (in press). students to receive such inter- n Providing education and infor- Performance and test anxiety. In L. Paige ventions as social skills training mation to the teacher about & A. Canter (Eds.), Helping children n A description of interventions test anxiety at home and at school III. Bethesda, that can be used (Huberty, in n Interviewing students, teachers, MD: National Association of School press). and parents Psychologists.
September 2009 z Principal Leadership z 15 student services student services student services
n Assessing individual stu- are key to identifying students who Samantha learned how to relax, plan dents to determine cognitive, have text anxiety. for examinations, rehearse public behavioral, and physiological Effective intervention begins with performances, and develop test-taking symptoms school administrators, who can cre- strategies. The psychologist worked n Training teachers, students, ate an awareness of the problem and with the teachers of the classes in and parents in how to use commit to providing resources and which Samantha was most anxious to rehearsal, relaxation, and other leadership for mental health special- help them become aware of her anxi- techniques at home and at ists and teachers so that they can help ety. The teachers helped Samantha school students. Mental health specialists and develop test-taking strategies, such as n Helping teachers plan, imple- teachers can be strong advocates who organizational skills, practice exercises, ment, and evaluate interven- help anxious students improve school and study guides. tions (Huberty, in press). performance and reduce the risk of Finally, the psychologist talked the development of other problems, with Samantha’s mother to help her Leadership Commitment particularly depression. Properly ad- better understand Samantha’s anxiety, Test and performance anxiety are dressed, test and performance anxiety how her expectations contributed to common problems for adolescents can be significantly reduced in the her daughter’s problems, and how to in the school setting and can impair school setting. help prepare Samantha at home to achievement in as many as one-third take tests and give oral presentations. of students. Because adolescents may Returning to Samantha Samantha’s anxiety was reduced and not be aware of the problems, do The school psychologist worked with she performed better, with a signifi- not know what to do, or do not refer Samantha directly, consulted with her cant reduction in visits to the nurse’s themselves for help, school personnel teachers, and talked with her mother. office. Although there was little effect on her trait anxiety, her state anxiety was reduced to help her improve her school performance. PL
References n Huberty, T. J. (2008). Best practices in school-based interventions for anxiety and depression. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology: Vol. 5 (pp. 1473–1486). Bethesda, MD: National Association of School Psychologists. n Huberty, T. J. (in press). Performance and test anxiety. In L. Paige & A. Canter (Eds.), Helping children at home and at school III. Bethesda, MD: National Associa- tion of School Psychologists. n Spielberger, C. A. (1973). State-Trait Anxiety Inventory for Children [Manual]. Palo Alto, CA: Consulting Psychologists Press. n Vasey, M. W., Crnic, K. A., & Carter, W. G. (1994). Worry in childhood: A develop- mental perspective. Cognitive Therapy and Research, 18, 529–549.
16 z Principal Leadership z September 2009 Assessing and Treating Childhood Anxiety Page 1 of 6
Research-Based Practice Assessing and Treating Childhood Anxiety in School Settings
By Savannah Wright & Michael L. Sulkowski
Between 2% to 27% of children and adolescents suffer with an anxiety disorder and many more struggle with distressing yet subclinical levels of anxiety (Costello, Egger, & Arnold, 2005; Mychailyszyn, Mendez, & Kendall, 2010). However, only about 6% of youth receive treatment for their anxiety symptoms or related sequelae (Esser, Schmidt, & Woerner, 1990). This service provision deficit is concerning because of the large body of research indicating that anxious youth are at risk for school absenteeism, academic underachievement, low social acceptance, and impaired psychosocial functioning (Kearney & Albano, 2004; McDonald, 2001; Mychailyszyn et al., 2010; Spencer, DuPont, & DuPont, 2003). Furthermore, if they do not receive effective treatment, anxious youth are at risk for developing mental health problems (e.g., depression, substance abuse, anxiety) and impaired occupational functioning (Donovan & Spence, 2000; Kendall, Safford, Flannery- Schroeder, & Webb, 2004; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005; Woodward & Fergusson, 2001).
Fortunately, effective interventions such as cognitive–behavioral therapy (CBT) exist for treating childhood anxiety, and school psychologists can have an important role in implementing these interventions (Sulkowski, Joyce, & Storch, 2012). As professionals who often know the most about psychology in school settings and education in clinical settings and because of the importance of addressing both academic and mental health needs in anxious youth, school psychologists are uniquely positioned to assist anxious students. In addition, due to their specific training (e.g., psychoeducational assessment, progress monitoring, direct intervention, consultation, data-based decision making) and the roles that they assume in school systems, school psychologists possess a dynamic skill set that can be utilized to identify anxious students, ensure that these youth receive evidence-based interventions services, and monitor how students respond to interventions once they are implemented (Wnek, Klein, & Bracken, 2008). In recognition of this skill set and because of the importance of treating childhood anxiety, this article will highlight how school psychologists can support anxious students through using a multitiered framework that can be flexibly applied to fit different types of school settings.
Why Treat Anxiety in School Settings
Obtaining access to mental health services may be a challenge for families that reside in communities with few service providers. Additionally, significant transportation, monetary, and logistical barriers may prevent youth from receiving services. Schools, however, exist in almost all communities and are the most common entry point for accessing mental health services in the United States (Farmer, Burns, Phillips, Angold, & Costello, 2003). Furthermore, research suggests that providing mental health services in schools can reduce disparities in service utilization among high need subpopulations (e.g., Racial/ethnic minority youth; Cummings, Ponce, & Mays, 2010). Therefore, given the large discrepancy between anxious children who need and receive services, treating childhood anxiety in school settings has the potential to address the needs of many youth who would otherwise be disenfranchised from receiving intervention.
Despite being an ancillary aim of many school psychologists and other school-based mental health professionals, efforts to address childhood anxiety in school settings display considerable promise and applicability to common practice. As the most comprehensive evaluation to date, a meta-analysis by Neil and Christensen (2009) suggest that school-based cognitive–behavioral interventions are moderately effective for treating childhood anxiety, with effect sizes ranging from .11 to 1.37 (Mdn = .57). This study also illustrates the utility of using a multitiered service delivery model to address childhood anxiety as 59% of the interventions were universally delivered, 11% were selective or geared toward specific at-risk groups of students, and 30% involved implementing individual interventions or treatment plans. Collectively, these results highlight the potential to address childhood anxiety across different service-delivery tiers, particularly at the universal or school-wide level.
Assessing and Treating Anxiety in School Settings
Time and resource limitations commonly encountered by school psychologists enhance the importance of identifying and remediating student problems with great efficiency. In this regard, a multitiered systems of support (MTSS) such as the multiple- gating approach for identifying social–emotional problems and the responseto- intervention (RTI) service delivery framework can help with determining which students should receive specific interventions as well as the dosage of these interventions. To help with identifying anxious youth and with intervention delivery efforts, a version of a multiple gating approach is discussed below as well as how collected data can inform intervention service delivery. However, a comprehensive review of these procedures is beyond the scope of this article, so readers may wish to review Sulkowski et al. (2012) for a more complete discussion.
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Assessing Anxiety in Students
Symptoms of internalizing disorders such as anxiety and depression often are inconspicuous, which can make identifying these symptoms a challenge (Whitcomb & Merrell, 2013). Anxious individuals do, however, display observable characteristics that knowledgeable observers can identify. Some of these observable characteristics include frequently asking for reassurance, being clingy, displaying avoidant behavior, performing checking behavior, hyperventilating when not active, complaining of somatic issues, and engaging in repetitive rituals. In excess, these characteristics might be obvious and suggestive of an anxiety disorder; however, none of them are sufficient by themselves to identify a child who may have anxiety problems. Therefore, as a more objective and thorough approach for assessing childhood anxiety, school psychologists can administer systematic behavior screeners to help identify youth who may have elevated anxiety symptoms.
Currently, two commonly used and commercially available behavior screeners exist. The Behavioral Assessment Scale for Children, Second Edition, Behavioral and Emotional Screening System (BASC- 2, BESS; Kamphaus & Reynolds, 2007) screens for general internalizing and externalizing symptoms. This measure has been incorporated into the AIMSweb data screening, monitoring, and management system. Similarly, the Brief Problem Monitor (Achenbach, McConaughty, Ivanova, & Rescorla, 2011) also allows users to screen for internalizing problems. The Brief Problem Monitor is a new screener and progress monitoring measure that is part of the Achenbach System of Empirically Based Assessment (ASEBA). Although both of these screeners assess internalizing symptoms, neither measure independently assesses anxiety. Assessing anxiety symptoms on behavior screeners requires assessors to inspect students' responses to individual screening items.
Following universal screening for anxiety problems, a multitrait, multisetting, and multi-informant assessment approach can be used to assess for anxiety problems and related concerns in at-risk youth (Whitcomb & Merrell, 2013). In addition to conducting clinical interviews with multiple informants and observations across settings, this process generally involves administering omnibus behavior rating scales that include items that purport to assess anxiety such as the BASC-2, Child Behavior Checklist (CBCL), Clinical Assessment of Behavior (CAB; Bracken & Keith, 2004), and the Conners' Comprehensive Behavior Rating Scale (CCBRS; Conners, 2009), as well as narrow- construct anxiety measures such as the Revised Children's Anxiety Scale, Second Edition (RCMAS-2; Reynolds & Richmond, 2008), State-Trait Anxiety Scale for Children (STAI-C; Spielberger, 1973), the Beck Anxiety Inventory for Youth (BAI-Y; Beck, Beck, & Jolly, 2001), and the Spence Children's Anxiety Scale (Spence, 1997). When analyzing data obtained through this assessment process, consistency in ratings across informants, settings, and identified traits allows the assessor to have greater confidence in the assessment results. For example, if a child was found to be at-risk on the BESS, in the clinically significant range on the BASC-2 for Anxiety Problems, and for any of the anxiety constructs represented on the RCMAS-2 across informants, it is likely that the child is suffering from clinically significant anxiety. Table 1 lists the number of items, types of rating formats, internal consistency estimates, and the constructs that are measured by each of the previously listed behavior rating scales.
Table 1. Omnibus and Narrow Measures of Childhood Anxiety CONSTRUCTS ASSESSED NUMBER OF ITEMS RELIABILITY (α) Teacher Parent Self Teacher Parent Self OMNIBUS BASC-2 Anxiety Problems 17 17 13 .88 .84 .82 Anxiety Problems, Internalizing Scales CBCL 112 112 112 .89 .80 .82 (Anxious/Depressed) CAB Internalizing Behaviors Scale 70 70 — .99 .97 — Generalized Anxiety Disorder; Separation CCBRS Anxiety Disorder; Social Phobia; Obsessive- 204 203 179 .84 .82 .85 Compulsive Disorder NARROW Physiological Anxiety; Worry; Social .79 RCMAS-2 — — 49 — — Anxiety; Defensiveness –.92 .80 STAI-C State Anxiety, Trait Anxiety — — 20 — — –.90 .86 BYI-II Anxiety — — 20 — — –.96 Generalized Anxiety, Panic/Agoraphobia, Social Phobia, Separation Anxiety, .69 Spence — 38 44 — .80–.91 Obsessive Compulsive Disorder, Physical –.93 Injury Fears
Note: BASC -2 = Behavior Assessment System for Children, Second Edition; CBCL = Child Behavior Checklist; CA B = Clinical Assessment of Behavior; CC BRS = Conners' Comprehensive Behavior Rating Scale; RCMAS -2 = Revised Children's Anxiety Scale, Second Edition; STA I-C = State-Trait Anxiety Inventory for Children; BYI-II = Beck Youth Inventories, Second Edition; Spence = Spence Children's Anxiety Scale
Lastly, to confirm a clinical diagnosis, a school psychologist may wish to conduct the Anxiety Diagnostic Interview Schedule (ADIS; Silverman & Albano, 2004) with a child and a caregiver because of its adherence
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to Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association, 2000) criteria for assessing all childhood anxiety disorders and many psychiatric disorders that occur in children (e.g., major depression disorder, attention deficit hyperactivity disorder). Although a psychiatric diagnosis is not needed for a student to receive services under RTI, under the Individuals with Disabilities Education Improvement Act (IDEIA), or Section 504 of the Rehabilitation Act, schools that bill for Medicaid may need to include diagnostic information in order to be reimbursed for services. In addition, provisions in the Patient Protection and Affordable Care Act will impact the availability of health insurance and the ability of schools to bill for mental health services. Therefore, the role of school psychologists in diagnosing psychopathology and classifying students to receive interventions may increase.
Treating Anxiety in School Settings
Universal service delivery. Even though the majority of students do not have anxiety problems, all students may benefit from universal programs that can reduce stress and anxiety in schools as well as help foster supportive learning environments. Currently, no anxiety- specific school-based universal prevention or intervention programs exist; however, programs that aim to reduce bullying, school violence, and support healthy and safe school communities also may reduce anxiety because of the relationship between school climate and anxiety in members of school communities (Sulkowski, Wingfield, Jones, & Coulter, 2011). Additionally, as a promising approach to facilitating well-being and reducing anxiety that can be universally implemented, mindfulness-based programs may help students cope better with distress. In a preliminary investigation, Mendelson et al. (2010) found that students (N = 97) from high stress and economically disadvantaged school communities benefited from 12-weeks of a school-wide mindfulness- based intervention program. Active participants in this study displayed lower levels of stress, worrying, and peer relationship problems posttreatment compared to a control group. Thus, although this finding warrants replication before it can be generalized broadly, mindfulness-based programs may be effective universal interventions. Although awaiting future research, a variety of programs, media resources, and practitioner- oriented workbooks have been developed and some of these resources may have applications for school- based practice (Biegel, 2009; Kabat-Zinn, 2012).
Targeted service delivery. Many students do not respond to universal interventions and need more intensive and targeted intervention services. To identify these students, school psychologists can employ behavioral screeners and rating scales to find youth who display elevated internalizing and anxiety scores. Collectively, and consistent with an RTI or a graduated approach to service provision, these students may benefit from targeted interventions that can be delivered to groups of youth who display similar concerns.
Several studies support the efficacy of group-based CBT interventions for treating childhood anxiety (e.g., Barrett, 1998; Flannery-Schroeder & Kendall, 2000; Masia-Warner, Fisher, Shrout, Rathor, & Klein, 2007; Mendlowitz et al., 1999; Silverman et al., 1999). These interventions may be particularly effective because group members can identify with each other, provide and receive social support, and help to facilitate therapeutic engagement and treatment adherence (Masia-Warner et al., 2005). In addition, the mere act of participating in an anxiety treatment group can be therapeutic for youth with social anxiety because interacting with other group members is a form of behavioral exposure, which is an effective component of CBT (Masia-Warner et al., 2007).
Computer delivered CBT programs also may be effective for treating anxious children or students who are at-risk for experiencing anxiety problems. Although research is needed to establish the program's efficacy in school settings, the Camp Cope-A-Lot (CCAL; Khanna & Kendall, 2008) computerized CBT program has been specifically designed to address childhood anxiety. Camp Cope-A-Lot is designed for use with children and young adolescents (ages 7–13 years). It includes six computer-assisted anxiety-reductive therapy sessions that can be followed with six therapist-directed exposure therapy sessions. Results from a randomized controlled clinical trial support the efficacy, feasibility, and likeability of CCAL (Khanna & Kendall, 2010). Specifically, 81% of youth who received 12 sessions of CCAL displayed greater reductions in anxiety posttreatment compared to youth in a control condition.
Intensive service delivery. Anxious students who do not respond effectively to universal (e.g., mindfulness- based intervention) or targeted interventions (e.g., group therapy) likely will need intensive intervention services. These services might involve individualized CBT or CBT combined with pharmacotherapy. These youth can be identified either directly through a MTSS assessment process or through analyzing their response to previously attempted interventions. In general, these youth would be expected to already display functional impairments in their academic, social, and family functioning because of their anxiety problems. For example, they may be reluctant to go to school, be socially withdrawn, or even refuse outright to attend school.
All mental health professionals must be adequately trained to deliver intensive CBT. This training should be obtained through supervised graduate training experiences or through attending CBT workshops and obtaining supervision from experienced colleagues (Mychailyszyn et al., 2011). In school systems that lack experienced CBT therapists, skilled CBT practitioners in the community can be located via databases maintained by the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the Anxiety and Depression Association of America (ADAA). In collaboration with a community-based therapist, school-based mental health professionals can work together to optimize treatment and ensure that treatment gains generalize to the school environment (Sulkowski et al., 2011).
Evidence-based treatment protocols such as the Coping Cat (Kendall & Hedtke, 2006) can help with structuring and delivering CBT to treat childhood anxiety. The Coping Cat program has a 16-session format that aims to teach youth to identify, regulate, and cope with anxiety-provoking thoughts, feelings, and
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sensations. As a multicomponent treatment program, the Coping Cat involves modeling being calm, relaxation/ self-calming strategies, in vivo exposure tasks, and learning problem solving strategies.
Several studies support the efficacy of the Coping Cat for treating childhood anxiety in a variety of clinical and educational settings (for review, see Kendall and Suveg, 2006). In addition, Beidas and Kendall (2010) report that the treatment program can be flexibly adapted for school settings and applied by school-based mental health professionals. However, this process might involve modifying therapy sessions to accommodate a school's schedule and sessions may need to be scheduled around other important events that occur at school (e.g., exams, field trips). Furthermore, preliminary research suggests that even a brief course of treatment using the Coping Cat (approximately 8 sessions) can be effective for reducing moderate forms of childhood anxiety, which highlights the program's utility and versatility (Crawley et al., 2013).
Conclusion
Many youth suffer with anxiety; however, few receive the treatment they need. Treatment for childhood anxiety often occurs in clinical settings yet school-based interventions for anxiety display considerable promise (Neil & Christensen, 2009). Treating anxiety in school settings can help overcome some extant treatment barriers, and providing services in schools allows for the needs of anxious youth to be addressed across a continuum of services. A multitiered framework was presented in this article that can be flexibly applied to fit different types of school settings and address students' needs across universal, targeted, and intensive levels of service delivery.
Promising universal efforts to assist anxious youth include conducting universal screeners to identify youth with internalizing problems and implementing universal prevention programs that improve school climate and connectedness. At the targeted service delivery level, school psychologists can conduct more comprehensive assessments to identify students who currently display (or are at risk for) anxiety problems, and then help to facilitate the delivery of interventions to address these problems. Lastly, students who display serious anxiety problems can be provided with effective interventions such as CBT, which is an evidence-based intervention that can be effectively translated to school settings (Neil & Christensen, 2009; Sulkowski et al., 2012).
To conclude, school psychologists display unique skills that can help them be key stakeholders in efforts to address childhood anxiety. In addition, resources exist that can help school psychologists obtain advanced training in the delivery of evidence-based interventions for childhood anxiety such as CBT. For example, informational and didactic presentations often are featured at national conferences that are sponsored by the National Association of School Psychologists, IOCDF, and ADAA. However, even if not directly involved in service delivery, school psychologists also can be key stakeholders in efforts to address childhood anxiety through collaborating with other professionals. In this regard, the IOCDF and ADAA provide extensive lists of CBT specialists that school psychologists can refer to or contact to facilitate professional case collaboration. As professionals who often know the most about psychology in school settings and education when communicating with clinical professionals, school psychologists are uniquely positioned to support the needs of anxious youth.
References
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Savannah Wright is a doctoral student in the school psychology program at the University of Arizona. Her research interests include behavioral disorders and childhood anxiety. Michael L. Sulkowski, PhD, is an assistant professor in school psychology program at the University of Arizona.
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http://www.nasponline.org/publications/cq/41/8/anxiety.aspx 10/17/2013 NASP Convention School-Based CBT for Anxiety
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Presentation Overview
COGNITIVE BEHAVIORAL 1. Anxiety: Overview, prevalence & long-term impact 2. School-based services for anxiety STRATEGIES FOR WORKING WITH 3. Case examples ANXIOUS YOUTH IN SCHOOLS 4. CBT: Overview, theoretical underpinnings, & important concepts 5. CBT: The nuts & bolts a) Affective National Association of School Psychologists b) Cognitive Seattle, WA c) Behavioral February 12th 2013 6. A typical CBT session presented through a case example
7. School-based implementation of CBT: Challenges & pitfalls Elana R. Bernstein, PhD 8. School-based implementation of CBT: Application at multiple tiers Morgan J. Aldridge, MS 9. Questions Jessica May, MS
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Prevalence Costs & Consequences
• Anxiety disorders have the highest prevalence rates of • $42.3 billion spent nationally on the treatment of anxiety. mental health problems occurring in children and • Children who suffer from anxiety are more likely to adolescents. experience: • Estimated overall lifetime prevalence rates of 8-27% • School drop-out • Rates are estimated to be higher when children with subclinical • Lower quality of life symptoms (not meeting criteria for a diagnosis) are considered • Psychopathology in adulthood • Children with internalizing disorders are often overlooked • Unsuccessful peer and family relationships • Median age of onset is 11 years old. • Comorbid diagnoses • Anxiety is among the earliest developing psychopathologies. • Substance use • Anxiety disorders are chronic and persist into adulthood. • Low self-esteem • Social rejection • Academic failure
Costello, Egger & Angold (2005); Fox, et al. (2012); Kendall, Aschendrand, & Hudson (2003); Greenberg et al. (1999); Kendall et al. (2003); Kendall (2012); Menutti, Christner, & Freeman (2012) Mennuti, Christner, & Freeman (2012) Ramirez et. al (2006); U.S. Department of Health and Human Services (2001)
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Anxiety In The Schools The Importance of Early Intervention
• Despite high prevalence • When schools provide mental • “The longer students suffer with unidentified anxiety problems, rates, anxiety is often health services to students, the more adverse the effects of anxiety can have on children’s overlooked in schools results include: development…which are difficult to reverse” (Ramirez et al., • Difficulties in recognizing • Lower costs 2006, p.273). internalizing symptoms • Less mental health stigmatization • Children encounter anxiety • More accessibility to mental • Research shows that 75% of children who receive mental triggers in school health services health services do so in school. • Academic pressure, social • Lower school drop out rate interactions, test anxiety, • NCLB (2001) emphasizes the perfectionism, school refusal, • frequent trips to nurse, etc. use of evidence-based When mental health services are provided in schools, common interventions in schools. barriers that prevent youth from receiving care are removed • School-based treatment has “ecological validity” – the • Schools provide an ideal and (Mychailyszyn, et al., 2011). benefits can be realized in the “least restrictive environment” environment that is clinically & to provide mental health services. • Services are most effectively provided within a multi-tiered practically meaningful. system of support (MTSS).
Tomb & Hunter (2004); Ramirez et al. (2006) Allen (2011); Doll (2008); Herzig-Anderson et al. (2012); Merikangas et al. (2011); Mychailyszyn et al. (2011)
Bernstein, Aldridge, & May (2013) 1 NASP Convention School-Based CBT for Anxiety
7 8 ASSESSMENT PREVENTION/INTERVENTION Anxiety: Important Concepts and Indicated Assessment Few Indicated Prevention ~5% Definitions Some • Anxiety: disproportionate • DSM-IV Symptoms: Selected Assessment ~15% Selected Prevention fear response to a • Difficulty falling asleep/staying asleep perceived threat. • Irritability/outbursts of anger • Overwhelming sense of • Difficulty concentrating fear that can be • Hypervigilance characterized by physical • Exaggerated startle response Universal Assessment Universal Prevention symptoms (e.g., sweating, • Motor restlessness tension, increased pulse). • Anxiety disorders most commonly seen in schools: • The Core of Anxiety: • Specific phobias • Negative affectivity • School refusal • Separation Anxiety The only way to • Perception of Control move through the • Social Phobia tiers is with DATA! ALL • Specific Life Examples • Selective Mutism ~80% of Students • Anxious Thinking • Generalized Anxiety Disorder
Multi-Tiered System of Support (MTSS) Source: www.pbis.org Chorpita (2007); DSM-IV-TR (2000); Dozois & Dobson (2004)
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Case Examples
• Vivi, Preschooler
• Allison, 3rd grader See Handout #1
• Bryan, 11th grader WHAT CAN WE DO TO HELP THESE STUDENTS?
Cognitive-Behavioral Therapy (CBT): An Overview
11 12 CBT: Overview CBT: Empirical Support
• Multifaceted; can be applied to multiple problem areas in • A growing body of evidence over 20 years supports the school-based practice. efficacy and effectiveness of CBT with children and adolescents.
• Cognitive behavioral therapy (CBT) has been noted to be an efficacious • The therapist’s role in CBT is to improve the cognitive treatment for childhood anxiety according to guidelines set forth by the APA Task Force on Psychological Interventions: information processing of clients in social contexts and 1) It has been shown to be more effective than all of the following attend to the client’s emotional state(s) by using scenarios: no treatment, a placebo, or an alternate treatment structured behavioral practice. 2) Multiple trials have been conducted 3) The trials were conducted by different investigative teams
• The strategies in CBT are designed to produce changes • Note: Studies are mainly limited to clinical (not school) settings or in thinking, feeling, and behavior have utilized outside providers who implement the treatment in a school setting.
Kendall, Aschenbrand, & Hudson (2003); Mennuti & Christner (2012)
Bernstein, Aldridge, & May (2013) 2 NASP Convention School-Based CBT for Anxiety
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CBT in the Schools: Empirical Support CBT: Theoretical Underpinnings
• Recently we are seeing more research on the school-based Cognitions (Thoughts) implementation of CBT for a range of mental health diagnoses. These facets are • School services are often reactive and considered examined as they pertain to the child’s successful if the problem goes away. social/ interpersonal • We need to teach coping skills/strategies to prevent contexts & situations. problems, such as anxiety, from re-emerging down the road. There is often a trigger • CBT is a framework for teaching these skills. or threatening situation that sets the child down • Can be used in a reactive and preventive manner. an anxious path. • Can address problems both in school and those outside of school that impact school functioning. Physiological Behaviors/ Feelings/Emotions Actions The relationship among Allen (2011) these variables is multi- directional, not linear.
15 16 CBT: Theoretical Underpinnings Cognitions (Thoughts): “I am definitely going to fail this test!” • “Cognitive problem solving strategies are not transmitted magically from parents to children…they Social/ interpersonal contexts & situations: are acquired through experience, observation, and
-Suburban School District interaction with others” (Kendall, 2012, pg. 4). -Supportive home life -Overachieving friends • We can increase the use of these strategies through Trigger/Threat: intentional intervention/instruction. -Test in class • Information processing affects how individuals make sense of the world. Physiological Behaviors: • We can intervene by correcting (challenging) faulty Feelings/Emotions: • Crying information processing (distorted thinking). • Upset/anxious • Avoidance • Headache Allison • Goes to • Stomach ache Nurse’s office
17 18 The “C” in CBT: What do we mean by What do we mean by ‘cognitive’? ‘cognitive’? – attributions – are the resulting • Cognitive structures cognitions that emerge from the interaction of information, • Memory (accumulation of experiences), aka ‘cognitive cognitive structures, content, and processes. schemas’ • These vary considerably across individuals. • Cognitive content • Related back to temperament • Can shape how individuals perceive and respond to environmental • Stored information (the contents of the structure) events (either real or imagined!) • Cognitive processes • Psychopathology (such as anxiety) may be due to problems in any or all of these. • How we perceive/interpret experiences Kendall’s dog @#$t example • In CBT, we attend to all of these (through the child’s self- talk, processing style, & attributional preferences). • Challenging the child’s current way of thinking • Building a more beneficial cognitive structure/template Kendall (2012)
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Cognitive Distortions vs. Deficiencies The “B” in CBT: Changing Behavior
• Cognitive processing deficiencies = an absence of • Specifically, we are changing anxious (avoidance) thinking (when it would be helpful), i.e., minimal behavior. forethought/problem-solving skills. • And what about emotions? • ADHD, aggression (often externalizing) • Anxious youth demonstrate a lack of understanding of how to hide and change their emotions. • Cognitive distortions = dysfunctional thinking processes. • They struggle to modify their emotional states. • They lack coping skills for a range of emotions. • Depression, anxiety, eating disorders (often internalizing) • They experience more intense emotions.
• CBT can improve an anxious child’s knowledge of and ability to • CBT does not aim to remove existing cognitive structures, regulate emotional states. but rather help clients develop new templates for making • Helpful when anxiety and depression are comorbid. sense of future experiences.
Southam-Gerow & Kendall (2000); Suveg, Sood, Comer, & Kendall (2009); Suveg & Zeman (2004)
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CBT: Primary Components Features of CBT
AFFECTIVE COGNITIVE • Time-limited - Psychoeducation - Coping Modeling (verbalizing) - Developing a fear hierarchy - Cognitive Restructuring (changing • Present-oriented self-talk; identifying and disputing • Solution-focused dysfunctional ideas) • Can be implemented at multiple tiers • School-wide prevention, groups, classroom-based and individual BEHAVIORAL OTHER interventions - Role-play activities (teaching - Therapeutic Relationship problem-solving techniques) - Practice - Exposure & Homework - Contingency Management - Reinforcement of positive behavior and skill mastery (Self-reward)
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Affective (Feelings)
• Anxious youth demonstrate a heightened sensitivity to negative or threatening events, things, and information. • Anxious youth have more difficulty regulating their emotions. CBT: • Somatic (physical) complaints are common with anxious children (e.g., stomachaches, headaches, etc.). AFFECTIVE COMPONENTS • We treat this through psycho- (affective) education. • Has positive effects in behavioral, emotional, and social functioning Psychoeducation & Developing a Fear Hierarchy in children and adolescents • Is a frequent element in most evidence-based anxiety interventions
Kendall (2012)
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Psychoeducation: Teaching about Anxiety Developing a Fear Hierarchy
• Also known as social and emotional learning (SEL) • “A list of all related, fear-producing situations or objects, • Explain what anxiety is ordered from least to most anxiety producing” (Merrell, 2008, • Teach youth about the connection between physical, cognitive, & behavioral components of anxiety. pg. 175). • Use the “false alarm” metaphor • Used to uncover the specific fear-provoking stimuli/ • Normalize the fear/anxiety circumstances for the child • Teach recognition of somatic responses • “Where do you feel anxiety?” • Help the child rank fears from least to most anxiety • Teach feelings identification producing • Feelings faces • Feelings charades See Handout #2 • Feelings collage • Feelings bingo • “How do you know when…?” • Use role plays, videotapes, magazine pictures, bibliotherapy, etc.
Merrell (2000)
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Fear Hierarchy Example
My Fear = School 0 = playing in the yard with friends at home 1 = going to bed on a school night 2 = going to school w/ mom (no students present) Let’s look at fear 3 = spending time with my teacher in the classroom when hierarchy examples for no students are there Vivi, Allison, & Bryan. CBT: 4 = getting ready for school in the morning See Handout #1 5 = riding the bus to school COGNITIVE COMPONENTS 6 = walking to the classroom • Modifications for Vivi • Shorten from 10 to 5 Modeling, Building a Cognitive Template, & Cognitive 7 = staying in class ½ day (allowed to call home) • Utilize pictures, index Restructuring 8 = staying in class whole day (allowed to call home) cards, social stories, etc. 9 = staying in class ½ day (not allowed to call home) 10 = staying in class whole day (not allowed to call home)
29 30 Examples of Cognitive Distortions In Cognitive (Thoughts) The School Setting • Cognitive Processes: the procedures by which the cognitive system operates • Dichotomous Thinking • Personalization • How we perceive/interpret experiences • Overgeneralization • Should/Must Statements • Mind Reading • Comparing • Our cognitive interpretation of the world shapes how we • Emotional Reasoning • Selective Abstraction view situations, events, and interactions • Disqualifying The • Labeling
Positive • Cognitive distortions: dysfunctional thinking processes • Catastrophizing
See Handout #3
Kendall (2012) Menutti & Christner (2012)
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CBT: Building a Cognitive Coping Template Teaching Children To Problem-Solve
• Help children identify and modify negative self-talk • Problem-Solving: it’s what we do best! • But, remember: school psychologists should not solve students’ • Recognize and challenge the student’s misinterpretations problems for them, but instead teach them how to problem-solve. • Example: “If you fail this one test, does that definitely mean that you won’t get • Help children develop confidence in their ability to overcome problems into college?” and use their experiences to problem-solve in the future • Help students recognize that other perceptions of the same situation exist • Model brainstorming skills by pointing out plausible and • Assist students in building new perceptions that encompass appropriate impossible situations coping strategies • Teach students the five-step problem-solving process: • The goal: when anxiety provoking events occur, the student will (1) What is the problem? view the stressful event through the new coping template and be (2) What are all the things I could do about it? (3) What will probably happen if I do those things? reminded to use appropriate coping strategies (4) Which solution do I think will work best? • The goal is not to overload the anxious student with positive self- (5) After I have tried it, how did I do? talk, but to reduce the negative self-talk • “The power of non-negative thinking” (Kendall, 1984). Vivi’s refusal to get out of her mom’s car when she arrives to school.
Kendall (2012) Kendall (2012)
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Coping Modeling The Steps of Cognitive Restructuring
• Based on social learning theory (Bandura, 1986) • Identify negative self-talk • “Everyone is going to laugh at me when the teacher calls on me • Observational or vicarious learning. and I answer her question wrong.” • May occur through a live model or a video model. • Examine the list of common errors in thinking together. • Use detective thinking to examine the evidence • Coping Modeling (verbalizing): • Past Experience: • Having a problem similar to the client, demonstrating strategies to • “Has anyone laughed when you have been called upon in the past? overcome the problem, and then demonstrating successful • Alternative possibilities: performance • “If so, could they have been laughing at something else?” • Rather than saying, “Watch me – I’ll show you how to do it,” model the same fears and strategies to overcome the situation. • General Knowledge: • Verbalizing Coping Model: a coping model who talks out loud • “How often do you get answers wrong? How about the other students? through the steps and gives specifics (think aloud). What does the teacher do when other students get the answer wrong?” • Example: School psychologist pretends as if he or she was the one who • Different Perspective: was nervous and the student walks the school psychologist through the • How do others feel about answering the teacher’s questions? fear plan.
35 36 Thought Bubbles Activity: What are they thinking? The Steps of Cognitive Restructuring
• Identify a positive replacement thought • “I usually do pretty well in school.” • “If I don’t know the answer, I’ll just say so.” • Use realistic thinking in some situations • Ask: “What if someone laughs?” • “I’ll just ignore it.” : Techniques/Strategies • Group Activity – “Changing Maladaptive Thoughts to Coping Thoughts” See Handout #4
• Thought bubbles activity (see the following slide) • Use magazines and have students fill in ones for anxious thoughts. • Using a thought record
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Where Emotion/ Negative Evidence that Evidence that Alternative/ Where Emotion Negative Evidence that Evidence that Alternative/ were Feeling Automatic supports the does not support Coping were Feeling Automatic supports the does not support Coping you? Thought thought the thought Thought you? Thought thought the thought Thought
Chemistry Worried, “Girls were I was stuttering They may have I don’t really Class stomach laughing in and stumbling been laughing at know why hurt the back of on my words each other or the they were the room, while I was teacher. laughing they must have been presenting. and I am laughing at confident in me” my project. What was What error the What error Modifications for younger in thinking situation? in thinking children like Vivi: did I make? did I • Use only 3 columns: Getting up make? (feelings, negative thought, ______to present positive thought) my project Selective • Use pictures Abstraction
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Role Play
• We need to practice doing things, we can’t just talk about it! • Practicing can be different for different kids • Role play is an opportunity to practice in private before you perform in public. • Give the child an opportunity to be active in the session. CBT: • We role play cognitive, behavioral, and problem-solving strategies with the child. • Role plays should be situations relevant to the child (derived BEHAVIORAL COMPONENTS from his/her fear hierarchy) Role-play, Exposure, Contingency Management, Self- • Is the child resistant to role play? reward, & Relaxation Training • Be silly, act out something first and then let the child join in.
: Bryan’s anxiety about calling a friend on the phone.
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Exposure Exposure: Evidence Base
• “Placing the child in a fear-evoking experience, either • Exposure strategies are a critical component in CBT. imaginally or in vivo to help him/her acclimate to the distressing • Consistently shown to be an indispensable component of anxiety situation and to provide opportunities to practice coping skills interventions (Chorpita, 2007). within simulated or real-life situations” (Kendall, 2012, p. 160). • Graduated exposure vs. flooding & response prevention • “Hundreds of clinical trials and dozens of meta-analytic reviews have helped establish (exposure) as the most empirically • An important distinction! supported psychological intervention for the anxiety disorders” • Remember the fear hierarchy? Here is where we will apply it. (Deacon, 2012, p.10).
• The exposure plan is crafted with the child’s input. • Chorpita, Daleiden, & Weisz (2005) found that of the studies • Explain the purpose (treatment rationale) to the child. evaluated, successful treatment of anxiety disorders and specific • Consider developmental level as an important factor here. phobia always included exposure. • Remember there is an art to exposure- you have to keep tasks • The National Institute for Clinical Excellence (2011) recommends challenging, but not so challenging that they are impossible to exposure-based CBT as a first line in anxiety treatment. accomplish!
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Challenges with Exposure What should you do during exposure?
• Before • Failure to reach within-trial habituation • Remind the child of the purpose of exposure (a decrease in reported fear during a practice session) • Reinforce the idea that exposure is a learning experience • Solution: Extend the exposure session (preferred method) or start • It is meant to test whether their anxiety is “real” or a “false alarm” with an easier stimulus next session • During • Be quiet, observe, and take notes of the child’s behavioral response – • Failure to reach between-trial habituation do they demonstrate avoidance? Outward anxiety? • Only speak if a corrective prompt is needed- avoid reinforcing or (a decrease in reported fear between practice sessions) distracting the student • Solution: Schedule more exposure sessions to reduce time • After between sessions; Include practice sessions at home • Praise the student, using specific statements when possible • “I really like how you stuck with it and whispered to your friend.” • Encourage the student to share their success with a parent • Use this time to review and ask questions about the experience
Chorpita (2007) Chorpita (2007)
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Relaxation Training Relaxation Training
• Teaches youth how to develop awareness and control over • Techniques/Strategies their somatic reactions to anxiety. • Progressive Muscle Relaxation (Jacobson technique) • Research has shown that relaxation training is most effective • The Benson Technique (cue-controlled) when combined with exposure (particularly in vivo) interventions. • Guided Imagery • Elevator Breathing • Dosage is important! • Mindful Meditation • Research shows that you need more than four relaxation sessions to show an effect • Robot/Ragdoll • Typically implemented as part of systematic desensitization; has demonstrated positive effects on its own. • What about teens who are reluctant to participate? • A study done 3.5 years post-treatment asked kids what they • Work with their interests (golf example). remembered: • Provide reinforcement for relaxation. 1. Therapist name 2. You made me do things I didn’t want to do • “Wait ‘em out.” 3. Take a deep breath when I get nervous • Most of their life they’ve had people talk for them. • Let them sit. Kendall (2012); Merrell (2008); Morris & Kratochwill (1998); Ollendick & King (1998)
47 48 Exposure + Relaxation = “I can do this...take Systematic Desensitization deep To teach Allison relaxation strategies it is breaths!” helpful to have a script or recording, for • Gradual exposure to • Modifications for Fear example, “Allison, I want you to… feared stimuli Hierarchy 1) Find a comfortable position in a quiet setting. younger children such 2) Close your eyes. as Vivi: 3) Pay attention to your breathing. Take a deep • Shorter script breath in and let it out slowly. • Less muscle groups 4) Imagine your worries leaving with your breath. • Use developmentally • Challenging 5) Tense and tighten your muscles, one by one appropriate metaphors maladaptive starting with your feet and moving up to your such as the robot/ragdoll. thoughts Cognitive Systematic head/neck. Then release them and notice how • Thought stopping Strategies Desensitization you feel. • First pretend with an • Utilize coping inanimate object like a thoughts/positive 6) Allow your entire body to relax and keep self-statements taking deep breaths in and slow breaths out. teddy bear. • Demonstrate it first for her. 7) Imagine a comforting place, perhaps your favorite place. • Bryan would likely be able 8) Continue these steps for several minutes and to do the full progressive • Relaxation Behavioral sit peacefully a bit longer.” muscle series. Strategies Strategies • Reinforcement/ Reward
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49 50 The Importance of the Therapeutic Contingency Management Relationship in CBT • Based on operant conditioning; focuses on the consequences of behavior • The therapeutic relationship is essential in CBT. • Focuses less on anxiety reduction and more on facilitating • Establishing trust with and demonstrating warmth and approach responses through appropriate reward/ reinforcement positive regard for the client must precede any strategy • For anxiety, we typically use: implementation. • Shaping, Fading • In CBT the therapist acts more as a “coach” • Positive Reinforcement • The therapist does not have all the answers. • Emphasis on self-reward for effort and (partial) success • Perfection is not expected! • The therapist collaborates with the client in problem-solving. • Graduated practice leads to a developing confidence (social-cognitive theory; • In sessions = practice; Real life = the game self-concept). • Extinction • Effective at reducing multiple anxiety-related behaviors
(i.e., selective mutism, social phobic behaviors, etc.) McGivern, Ray-Subramanian, & Bernstein (in press)
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What about Parents? What Does CBT Look Like in Practice?
• An important part of CBT. • Case conceptualization (as opposed to diagnosis)
• Helps the practitioner make decisions regarding the sequence and • Parents are consultants, not co-clients. selection of particular treatment components.
• In essence, a modular approach (e.g., Chorpita, 2007) • It is helpful to collaborate with parents on the intervention plan and maintain their cooperation and support. • Base the treatment on the child’s age, developmental level, and presenting problem(s). 1. Examine family dynamics that maintain anxiety. Parents often model anxious behavior themselves, or deal • Consider verbal/cognitive abilities. with anxiety in a maladaptive way. • If the child is particularly sensitive to physical symptoms, you may begin Parent-child interactions contribute to anxiety. with deep breathing or progressive muscle relaxation. 2. Solicit their help in developing the fear hierarchy. • If the child first identifies catastrophic thinking patterns, you may start 3. Have the child teach their parent(s) the skills (i.e., relaxation, with labeling cognitive distortions. positive self-talk, etc.) to help generalize the intervention effects. Vivi 4. Teach parents basic behavioral parenting strategies such as positive/negative reinforcement, planned ignoring, modeling, etc.) • We would emphasize behavioral versus cognitive components based on her developmental level.
53 54 A Typical CBT Session CBT: Challenges in School-Based Session Components: Practical Application: 1. Set the agenda 1. “Here is what we are going to do today…” (write it out) Implementation “…the school context is complex and (Check in on the relationship) (utilize empathy; engage in “parlor talk”) dynamic, making delivery of services • Time, time, time… a challenge” (Allen, 2011). 2. Review status and events since 2. “Last week we talked about the physical sensations • Resources last session you feel when you are anxious…” • But wait! You don’t need a packaged program, you need a collection 3. Solicit feedback re: last session 3. “Did you think more about what you learned?” of evidence-based strategies. • Schools are unpredictable 4. Review “homework” 3. “Did you notice these sensations during the week and - Examples write it down in your journal?” • Scheduling constraints • Familial factors 5. Focus on main agenda item (e.g., 5. “Today we are going to talk about how our thinking cognitive restructuring) impacts how we feel and what we do…” • Parents maintaining anxiety • Soliciting parent involvement 6. Develop new homework for 6. “I want you to take some time this week to use the • Child factors between-session thought record…” • Comorbidity, symptom severity, developmental delays, language/ 7. Progress Monitoring, Praise, & 7. “How anxious do you feel today on the fear processing difficulties, etc. Self-Reward thermometer (from 1 to 10)? What have you accomplished on your fear ladder?” “Great job!” (self Davis, Whiting & May (2012) reward)
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55 56 CBT: Challenges in School-Based Maintaining Treatment Integrity & Implementation, cont. Acceptability • Common concerns reported by practitioners when treating kids • Measure it! with anxiety in the school: • Even if you are the intervention agent, use a formal • Youth with severe anxiety (e.g., vomiting due to anxiety) • Make outside referrals when appropriate measure of treatment integrity • Not having enough time to reduce the child’s anxiety before returning • Solicit input from the child, parents, and teachers on them to the classroom. • Save 5-8 minutes at the end of a session to engage in a pleasant activity. treatment acceptability • Ensure that their self-reported ratings of anxiety following exposure are • Ongoing measures of acceptability allow you to make adjustments reduced by ~50%. to the treatment • Schedule longer sessions for exposure or even after school. • Higher acceptability yields higher compliance with treatment • Logistics of conducting exposure tasks in school. • We need to step back and look at exposure differently.
: How could we craft an in vivo exposure task for Bryan’s anxiety? Let’s look at his fear hierarchy on Handout #1.
Mychailyszyn, et al. (2011)
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Outcome Evaluation CBT Applications at Multiple Tiers
• Is it working? How can we measure outcomes? • Evaluate what level of intervention is needed within a multi-tiered system of support (MTSS). • Set measurable goals & monitor progress • Goal Attainment Scaling (GAS) • Tier 1: Preventative intervention implemented class or • Transfer the fear hierarchy into a GAS school-wide • Use pre-post measures (e.g., MASC-2) • Tier 2: Small group intervention targeting sub-clinical levels of anxiety • Review extant data • School attendance, office referrals, etc. • Tier 3: Targeted intervention for students experiencing high-risk and clinical levels of anxiety
59 60 ASSESSMENT PREVENTION/INTERVENTION
Indicated Assessment: Few Indicated Prevention: - Rating scales - Individual counseling with Manualized Interventions - Behavioral observations ~5% anxious youth utilizing a - Interviews CBT framework. Some • Highly structured ~15% Selected Assessment: Selected Prevention: - Small groups for youth • Allows for more methodological control - Teacher/Parent referral/ at risk focused on nomination cognitive-behavioral • More easily able to assess treatment integrity - Screening tools skill acquisition • Flexibility is a concern Universal Assessment: Universal Prevention: • Evidence-based manualized interventions: - Outcome evaluation for - School- or class- programs selected • Coping Cat (Kendall & Hedtke, 2006) wide programs to teach relaxation/stress • Camp-Cope-A-Lot (CCAL; Kendall & Khanna, 2008) reduction • Computer-based CBT modeled after Coping Cat • FRIENDS for Children Program (Barrett, et al., 2000) The only way to move through the • Cognitive-Behavioral Intervention for Trauma in Schools (CBITS; system is with ALL Jaycox, 2003) DATA! ~80% of Students Kendall & Southam-Gerow (1995); Weisz, Wiess, & Donenberg (2011) Multi-tiered System of Support (MTSS) for Anxiety Source: www.pbis.org
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Modularized Interventions
• Case conceptualization approach • Problem-solving framework • More flexibility and individualization • Maintains a level of structure • Evidence-based modularized intervention: • Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders (Chorpita, 2007) QUESTIONS
Murphy & Christner (2012)
Bernstein, Aldridge, & May (2013) 11 ANXIETY: TIPS FOR TEENS
By Patricia A. Lowe, PhD, Susan M. Unruh, EdS, & Stacy M. Greenwood University of Kansas
… Robin has trouble concentrating in her chemistry class because she’s getting so little sleep at night. She lies awake for hours worrying, and, when she does get to sleep, she’s jerked awake by nightmares. … Liz is starting to skip school and her grades are suffering. She had a blow up with her friends and now she’s afraid of being rejected socially whenever she’s at school. … Kendrick saw an exchange of gunfire between rival gangs in his neighborhood and now, whenever he hears a loud noise, his palms get sweaty and he has a hard time catching his breath. Except for school, where he feels safe, he avoids going out of his house.
Anxiety is one of the most common problems facing teenagers in schools today. Worry and anxiety are normal reactions to concerns about what might happen in the future. Most teenagers worry at times about school performance, classmates and friends, family, appearance, health, and personal harm. A certain amount of anxiety is healthy, especially when it results in productive action, such as when we worry about getting a bad grade on a test and, consequently, we study extra hard. We all know what it means to have butterflies in our stomach and to feel restless and tense from time to time. For some of us, though, anxieties and worries begin to control our lives. We may turn to drugs and alcohol in an attempt to reduce our anxieties or we may avoid participating in regular activities. These actions limit our enjoyment of life. Approximately 1 out of 11 teenagers is diagnosed with anxiety severe enough to be considered a disorder, with girls being more likely to develop an anxiety disorder than boys. Common anxiety symptoms that can affect people at any age tend to increase during the adolescent years.
Anxiety Affects Us in Different Ways Our feelings. The emotions commonly associated with anxiety are discomfort, fear, and dread. We may feel irritable and angry with others or we may feel that everyone is judging us and we can never quite measure up to others’ expectations. Our body’s response. Sweating, nausea, shaking, headaches, muscle tension, fatigue, and generally being on edge are among the body’s physiological responses to anxiety. Some of us may also experience dizziness, shortness of breath, and an accelerated heartbeat. Our behaviors. Some of us who are anxious often engage in behaviors of avoidance and withdrawal, such as missing school and avoiding social gatherings. Our thoughts. Some of us have difficulty concentrating when we are worried and anxious. Thoughts may be negative and unrealistic, and consequently events may be misinterpreted. For example, Mike may be worried about his acne. When he walks by a group of girls in the hallway and they are laughing, he is certain that they are laughing at him. In reality, they were not talking about him and did not even notice that his face broke out, but he starts to avoid talking to girls and keeps his head down whenever his skin breaks out.
Causes of Anxiety There are many different causes of anxiety. Anxiety appears to develop from an interaction among different factors rather than from any single cause. In general, we are more likely to experience anxiety if one or both parents exhibit anxiety symptoms. That is, anxiety tends to run in families.
Helping Children at Home and School II: Handouts for Families and Educators S10–5 Behavioral inhibition, a temperament style, has also The attack usually lasts 10–15 minutes. There is been linked to anxiety in children and teens. Infants with intense fear and a shortness of breath, shakiness, this type of temperament are described as shy, timid, dizziness, sweating, heart palpitations, and chest and wary, and seem to be at a greater risk for pain. These people live in fear that they are going to developing an anxiety disorder when they are older. have another panic attack and will avoid situations We can learn to be anxious as a result of our that may bring on another attack, such as avoiding experiences or conditioning. This is especially true for school and social situations they associate with those who have excessive fears (phobias) for certain ob- panic attacks. jects or situations. For example, a frightening experience • Phobia: People who experience a specific phobia such as being chased by a dog can become associated have an intense, persistent, and maladaptive fear of with any dog, resulting in an unreasonable fear of all dogs. a specific object such as an animal or insect or of a Certain styles of thinking also contribute to devel- situation such as standing on a tall ladder or being oping anxiety. Those of us who experience excessive in an enclosed space. They avoid the feared object worries and anxieties tend to develop a pattern of or situation leading to interference with their daily negative and unrealistic thinking. We can misinterpret routines. harmless situations as threatening and focus our • Post-traumatic stress disorder: People with a post- attention on what we perceive as threatening. traumatic stress disorder experience severe anxiety Other environmental factors that may cause anxiety symptoms in response to a traumatic event. The include exposure to a stressful environment or a trau- traumatic event may involve a natural disaster such matic event, observing others’ anxious behavior, having as a tornado, a violent act such as a school shooting overly protective and controlling parents, and learning or abuse, or a frightening act such as a car accident to avoid certain situations to relieve anxiety symptoms. in which they were either a witness or a victim. The traumatic event may be re-experienced over and Types of Anxiety Disorders over again in nightmares, flashbacks, thoughts, or What follows are the most common types of anxiety memories. These people avoid anything associated disorders experienced by teens: with the trauma. They startle easily, have difficulty concentrating and doing their school work, • Generalized anxiety disorder: People with a general- experience sleep disturbances and irritability, and ized anxiety disorder experience excessive, unrealistic, have problems getting along with their friends. and persistent worry about everyday life events and • Separation anxiety disorder: People with a activities such as their school performance. They separation anxiety disorder experience excessive find it difficult to control their worrying. They may worry or anxiety when separated from their parents worry about their school work all the time and spend or primary caregivers. The excessive worry or fear is hours doing and redoing their work because it is not in response to routine separations such as their perfect. Their worry causes a tremendous amount of leaving home and going to school for the day. They distress. They may experience physical symptoms may have physical complaints, such as stomach- including headaches, stomachaches, fatigue, and aches and headaches, refuse to attend school, do muscle tension. Other symptoms may be restless not like to sleep alone or away from home, and and irritable behaviors, difficulty concentrating, and experience unrealistic worry that harm will come to problems sleeping. themselves or their parents. • Obsessive-compulsive disorder: People with an obses- • Social phobia or social anxiety: People with a social sive-compulsive disorder have repetitive thoughts phobia or social anxiety show intense fear in (obsessions) or behaviors (compulsions) that seem situations in which they may experience criticism, impossible to control. They realize that their obses- embarrassment, or humiliation in public. They may sions and compulsions are excessive and meaning- also experience anxiety in social situations when less, but the repetitive thoughts and behaviors are there is no identifiable stressor to others. Common difficult to stop and cause distress. Common social phobias include intense fear associated with obsessions include fear of contamination and public speaking and avoidance of strangers. They thoughts of harm to themselves or family and friends. avoid feared situations, and their avoidance beha- Common compulsions include washing and cleaning viors restrict their daily lives. Isolation and possibly rituals, and checking and rechecking behaviors. depression may follow as a result of their behaviors. • Panic disorder: People who experience a panic disorder have recurrent, unexpected panic attacks.
S10–6 Anxiety: Tips for Teens What You Can Do • Be optimistic: Try to be optimistic. View a problem The following suggestions may be helpful to combat or a situation as a challenge that can be overcome anxiety and worry: instead of an obstacle to be avoided or a situation that causes distress. Use positive self-talk to meet a • Social support network: Develop a social support problem or a situation directly. This will put you in a network. It is important to have someone to talk to, better position to resolve your problem or situation a friend, a parent, an uncle or aunt, when you are with less distress. feeling anxious or worried, and just talking it out can sometimes help reduce whatever anxiety or Who You Can Contact for Help worry you may be experiencing. Sometimes you may need help in dealing with your • Exercise: Exercise on a regular basis. A 20- to 30- anxieties and worries, especially if anxiety increases in minute workout three to five times a week can be severity and interferes with your everyday life. Do not be energizing, and can make you more alert and can calm embarrassed about seeking help. Almost everybody you. However, before beginning any exercise program, needs help at one point in their lives. And those who it is important to be sure you are in good health. Ask have not sought help probably should have done so. So, your family doctor if this is a good idea for you. here are a few people you can contact to help you • Eat a healthy diet: Eating a healthy diet is important. through this difficult time. A balanced diet low in sugar and caffeine and junk foods is highly recommended. Eating well can • Parent or primary caregiver: They care. They are increase your mental and physical energy and may there with you and know about you. Talk to them. lessen your anxiety. Tell them your worries and anxieties. Maybe they • Sleep: Quality and quantity of sleep are important. can help. Fatigue wears on our emotions. Sleep requirements • School psychologist, school social worker, guidance vary, though. If you get enough sleep and if you counselor, or school nurse: Sometimes it is good to have a regular sleep schedule (a specific time to go speak to people who are not related to you and who to bed at night and a specific time to get up in the are trained to help you. They can provide you with morning) you will feel more refreshed and are in a information about anxiety and can possibly treat or better frame of mind to tackle worries and concerns. make a referral to another mental health profession- • Learn to relax: Different activities are relaxing to al who specializes in the treatment of teens with different people. If you are feeling anxious or anxiety problems. worried you can go for a long walk to relax or you • Family physician: Visit your doctor. Your doctor can can listen to soft music, read a book, draw or paint, rule out other possible medical causes for the do yoga or martial arts such as tai chi or tae-kwon- symptoms you are experiencing and can help do, take a nice warm bath, listen to relaxation tapes, determine if you have an anxiety disorder and can practice deep breathing and muscle relaxation then help refer you to someone who specializes in exercises, or do anything that you find relaxing. teens with anxiety problems. • Prepare ahead of time: If you feel anxiety before or during a test, for instance, it is a good idea to What Help Is Available develop good study habits, time management skills, Anxiety problems are serious but treatable. Possible and organizational skills. Being well prepared may treatments include individual or family therapy, parent give you a sense of confidence and reduce anxiety. training, and medication. These treatments may be used If you are concerned about public speaking or if you alone or in combination. have to talk in front of others during a public forum, Two approaches to therapy include changing the practice parts of the speech beforehand and prepare way we think and behave, and changing specific well. This may be easier said than done, but give it a behaviors by replacing ineffective behaviors with more try. Being prepared does help. desirable behaviors. • Set realistic goals: It may not be a good idea to set Therapists can help you sort out your thoughts, goals that are too unrealistic because if you do not feelings, and problems and may come up with solutions reach them then you may feel that you have failed to resolve your problems. A relationship of trust and yourself and have failed those who count on you. Be rapport first has to be established with the therapist. more realistic. You know what you can accomplish You have to speak honestly with the therapist, and the and what you cannot. Be patient. Feel good about therapist has to discuss with you and your family limits what you have accomplished and can accomplish. on confidentiality, or information that will and will not
Helping Children at Home and School II: Handouts for Families and Educators S10–7 be shared with others. You have to set ground rules with your therapist about what can and what cannot be discussed with your parents, for instance, or with anybody else. Parents should also learn to use techniques that may The National Association of School help you lessen your worries and anxieties. A therapist Psychologists (NASP) offers a wide can work with several members of your family or the variety of free or low cost online resources to parents, teachers, and others entire family to address issues that relate to your anxiety. working with children and youth through And, finally, sometimes medication prescribed by the NASP website www.nasponline.org your physician can be used in addition to therapy. If and the NASP Center for Children & Families website medication is prescribed, be sure to take it exactly as www.naspcenter.org. Or use the direct links below to instructed and let your parents or school nurse know if access information that can help you improve outcomes for the children and youth in your care. you are experiencing any side effects—feeling sick, being more anxious or extra sleepy or having trouble About School Psychology—Downloadable brochures, sleeping. You are the best judge. Medication does not FAQs, and facts about training, practice, and career work for everyone and sometimes it takes a while to find choices for the profession. www.nasponline.org/about_nasp/spsych.html the right medication or the right dose. Crisis Resources—Handouts, fact sheets, and links Resources regarding crisis prevention/intervention, coping with Davis, M., Robins-Eshelman, E., & McKay, M. (1995). The trauma, suicide prevention, and school safety. relaxation and stress reduction workbook. Oakland, www.nasponline.org/crisisresources
CA: New Harbinger. ISBN: 1572242140. Culturally Competent Practice—Materials and resources Greenberger, D., & Padesky, C. A. (1995). Mind over promoting culturally competent assessment and mood. New York: Guilford. ISBN: 0898621283. intervention, minority recruitment, and issues related to Hipp, E. (1995). Fighting invisible tigers: A stress cultural diversity and tolerance. www.nasponline.org/culturalcompetence management guide for teens. Minneapolis, MN: Free Spirit. ISBN: 0915793806. En Español—Parent handouts and materials translated Powell, M. (2003). Stress relief: The ultimate teen guide into Spanish. www.naspcenter.org/espanol/ (It happened to me, 3). Lanham, MD: Scarecrow. ISBN: 0810844338. IDEA Information—Information, resources, and advocacy tools regarding IDEA policy and practical implementation. Seaward, B. L., & Bartlett, L. K. (2002). Hot stones and www.nasponline.org/advocacy/IDEAinformation.html funny bones: Teens helping teens cope with stress and anger. New York: Health Communications. Information for Educators—Handouts, articles, and ISBN: 0757300367. other resources on a variety of topics. www.naspcenter.org/teachers/teachers.html
Patricia A. Lowe, PhD, is on the faculty of the School Information for Parents—Handouts and other resources Psychology program at the University of Kansas. Susan a variety of topics. M. Unruh, EdS, is a doctoral student in School Psychology www.naspcenter.org/parents/parents.html at the University of Kansas. Stacy M. Greenwood is an Links to State Associations—Easy access to state EdS student in School Psychology at the University association websites. of Kansas. www.nasponline.org/information/links_state_orgs.html
© 2004 National Association of School Psychologists, 4340 East West Highway, NASP Books & Publications Store—Review tables of Suite 402, Bethesda, MD 20814—(301) 657-0270. contents and chapters of NASP bestsellers. www.nasponline.org/bestsellers Order online. www.nasponline.org/store
Position Papers—Official NASP policy positions on key issues. www.nasponline.org/information/position_paper.html
Success in School/Skills for Life—Parent handouts that can be posted on your school’s website. www.naspcenter.org/resourcekit
S10–8 Anxiety: Tips for Teens New York Association of School Psychologists August 2013
High Stakes Testing & Children’s Well-Being: A Guide for Parents
As the pressures and demands of “high stakes” testing and assessment increase, so too do the worries of parents. Aside from concerns regarding a child’s academic progress and performance on these measures, more and more parents are worried about the emotional toll and overall impact these experiences have on their children’s well-being. With this in mind, the New York Association of School Psychologists has created the following list of suggestions to help parents.
Handling Stress Before, During, & After the Assessment:
Before: Make sure your child gets plenty of sleep, not only the night before, but several days leading up to the assessment Provide a high quality breakfast (and lunch if your child brings lunch from home- some tests are given in the afternoon) Try to keep a normal routine at home, but consider temporarily scaling back on after-school activities if your child’s evenings tend to be heavily scheduled Allow plenty of time for physical activity, free play and opportunities to unwind Be positive with your child and point out all of the things your child does well Remind the child that he or she is well prepared for the test and will likely do well Be patient and be prepared to listen to your child’s concerns. Answer all questions honestly, but with short answers Monitor your own anxiety; kids quickly pick up on the anxieties of the important adults in their lives Maintain realistic, attainable goals and expectations for your child. Do not communicate that perfection is expected or is the only acceptable outcome. Accept mistakes as a normal part of growing up and let your child know that no one is expected to do everything equally well Teach a few specific relaxation and stress management strategies, not just to minimize anxiety around the tests, but as a general life skill. Strategies could include: o Deep controlled breathing New York Association of School Psychologists August 2013
o Mindfulness exercises o Listening to relaxing music o Asking what things might help them relax - this sends the message that there are concrete things they can do to manage stress and anxiety, which are normal parts of the human experience Share a time when you felt anxious and how you coped with the feeling Often, reasoning is not effective in reducing anxiety, so do not criticize your child for being unable to respond to rational approaches. Seek help from the school if the problem persists and continues to interfere with daily activities. Start with the classroom teacher, but you may also consult with the school psychologist, counselor, or social worker.
If your son or daughter becomes anxious during testing, you can give them strategies to use ahead of time, such as: Deep breathing, breathing in through the nose and out through the mouth in a smooth motion. “Calming statements,” such as simply saying “relax” quietly to self. Shifting negative thoughts to more positive coping thoughts, such as “I will do the best that I can” or “I prepared well for this test.” Focusing on the problems that are easier first, and then go back to more difficult problems.
After: Ask one or two general questions about the test, such as “how did it go?” Do not ask questions such as “How many do you think you got wrong?” or “Do you think you did better than the other kids?” Ask what your son or daughter learned in school? Ask what he or she did that was fun? Help your child keep the testing in perspective. You can say things like, “Sure, the test are important and you need to do the best that you can, but remember tests aren’t the only things that matter, and they aren’t the things that are the most important”
Understanding and Learning from Challenging Experiences:
Research on motivation (Dweck, 2006) has found that how a person responds to academic challenges, not grades or intellectual ability, is one of the best predictors of later success in life. A child can view a failure or a challenging experience as a reflection of either their lack of ability, or as a reflection of the strategies and effort that were used during this experience. Those with the latter view tend to perceive these challenges as something to “master” or have a “mastery orientation.” They tend to face the next challenge with greater determination, a more positive outlook, and ultimately experience greater learning and success. They will seek out more challenges in learning and in life and tend to be willing to stretch themselves beyond where they are comfortable. Because of this approach, in the end, they achieve more. Parents should understand this and explain it to their children. Ultimately, we may find that it is how the New York Association of School Psychologists August 2013 child understands his or her success or difficulty that is the best predictor of his or her future success.
There are certain vulnerable groups of children, who are more easily emotionally impacted by high stakes testing. These may include students with learning difficulties or English Language Learners, who tend to have a negative perception of tests in general. However, even students at the opposite end of the education spectrum, to whom good grades, high achievement, and academic accomplishment have come relatively easy, are vulnerable to test anxiety. While at first, this may seem counter-intuitive, upon closer analysis, it quickly becomes clear that their anxiety is a result of their own perception of the test determining their academic status or their “demand” to perform well on all tests. For all of these children, it is important to remind them:
Ability and knowledge can be demonstrated in many ways, not just through standardized testing – providing examples of the many ways they have been successful and have demonstrated their talents Their worth is greater than the sum of their achievement. They are loved for who they are, and not for what they achieve The value in some activities is not in the outcome, but in initiating a task and knowing that your gave it your all
Things to Watch For:
If your child seems to have a preoccupation with the tests (e.g., talks about them constantly, comes to you with “what if” scenarios, etc.) or has an extreme reaction (e.g., unable to sleep, becoming sick, refusing to go to school the day of the test, etc.) and your attempts to reassure him or her have not alleviated the anxiety, it may be helpful to speak with other caring adults in your child’s life. You may wish to speak with your child’s teacher, school psychologist, or principal. School employed mental health personnel should be able to provide information regarding your child’s presentation in school and give you additional strategies and support to help your child.
In this new era of reliance on data and ever increasing levels of accountability, standardized testing will not go away. Furthermore, when used correctly, as part of (rather than the sum of) a child’s educational experience they can provide useful information to educators. With this in mind, it is incumbent upon parents and educators to minimize the unintended negative effects on the overall well-being of the child.
Additional Resources:
NYASP Resources for Families - http://www.nyasp.org/forfamilies/ Scholastic.com - search for “high stakes testing” in the “parent” section for ideas, resources, and printable material, www.scholastics.com
New York Association of School Psychologists August 2013
High Stakes Testing & Children’s Well-Being: A Guide for Teachers
As the pressures and demands of “high stakes” testing and assessment increase, so too do the worries of teachers. Aside from concerns regarding a child’s academic progress and performance on these measures, and how scores are tied to teacher evaluation, teachers are also worried about the emotional toll and overall impact these experiences have on their students’ well-being. With this in mind, the New York Association of School Psychologists has created the following list of suggestions to help teachers.
Handling Stress Before, During, & After the Assessment:
Recommend that the students get enough sleep the night before and have breakfast the morning of the test. This could be their only “homework assignment.” Consider having a “bagel breakfast” the morning of the test to lighten the mood in class, but also to ensure that the children have had some nutrition. Local bagel shops/bakeries will often donate items for these events. Keep to the normal routine as much as possible, but build in plenty of physical movement, self-directed time, or socialization o Give students a chance to unwind after taking the test Tell the students what to expect the day of the test, even if they have taken it before. You can say things like, “When you come in tomorrow, your desks will be in rows and not in our usual groups.” Or “Mr. Smith will be here tomorrow to help us with the test.” Have extra supplies available if the students are supposed to bring their own materials. Testing days are not the time for lessons in personal responsibility or materials management Help your students keep the testing in perspective. You can say things like: “Sure, the test are important and you need to do the best that you can, but remember tests aren’t the only things that matter and they aren’t the things that are the most important” Select class read alouds that tell stories about testing for younger students (e.g., The Big Test by Julie Danneburg or Testing Miss Malarkey by Judy Fincher and Kevin O’Malley). For older students hold brief class meetings, that give students a chance to speak about their feelings if they wish. By New York Association of School Psychologists August 2013
simply acknowledging that the stress is out there, helps to reduce the pressures that some students feel. Point out previous student successes Remind the students that they are well prepared for the test and are likely to do well on the test Acknowledge that the test may contain questions that are meant to be challenging; if they are struggling with an item, it is probably because it is a hard question, not because there is something that is wrong with them Never add pressure to the students by telling them that “your job depends on their scores” Monitor your own anxiety; kids quickly pick up on the anxieties of the important adults in their lives Throughout the year, teach specific relaxation and stress management strategies, not just to minimize anxiety around the tests, but as a general life skill. Strategies could include: o Deep, slow, controlled breathing o Mindfulness exercises o Progressive muscle relaxation or simple Yoga poses o Listening to relaxing music o Share a time when you were anxious and how you managed those feelings o Empower your class by asking what things might help them relax - this sends the message that there are concrete things they can do to manage stress and anxiety, which are normal parts of the human experience Utilize the services of the school employed mental health professionals (school psychologists, counselors, social workers) to consult with you on classroom-based strategies or actually come into your class to talk about test anxiety and stress management
Understanding and Learning from Challenging Experiences:
Research on motivation (Dweck, 2006) has found that how a person responds to academic challenges, not grades or intellectual ability, is one of the best predictors of later success. A child can view a failure or a challenging experience as a reflection of either their lack of ability, or as a reflection of the strategies and effort that were used during this experience. Those with the latter view tend to perceive these challenges as something to “master” or have a “mastery orientation.” They tend to face the next challenge with greater determination, a more positive outlook, and ultimately experience greater learning and success. They will seek out more challenges in learning and in life and tend to be willing to stretch themselves beyond where they are comfortable. Because of this approach, in the end, they achieve more. Teachers should understand this and explain it to their students. Ultimately, we may find that it is how the student understands his or her success or difficulty that is the best predictor of his or her future success. New York Association of School Psychologists August 2013
Students who are mastery-oriented think about learning, not about proving how smart they are. When they experience a setback, they focus on effort and strategies instead of worrying that they are incompetent. This leads directly to what teachers can do to help students become more mastery-oriented: Teachers should focus on students' efforts and not on their abilities. When students succeed, teachers should praise their efforts or their strategies, not their intelligence. Contrary to popular opinion, praising intelligence backfires by making students overly concerned with how smart they are and overly vulnerable to failure. When students fail, teachers should also give feedback about effort or strategies -- what the student did wrong and what he or she could do now. This has been shown to be a key ingredient in creating mastery-oriented students. In other words, teachers should help students value effort.
In a related vein, teachers should teach students to relish a challenge. Rather than praising students for doing well on easy tasks, they should convey the joy of confronting a challenge and of struggling to find strategies that work. Finally, teachers can help students focus on and value learning. Too many students are hung up on grades and on proving their worth through grades. Grades are important, but learning is more important.
There are certain vulnerable groups of children, who are more easily emotionally impacted by high stakes testing. These may include students with learning difficulties or English Language Learners, who tend to have a negative perception of tests in general. However, even students at the opposite end of the education spectrum, to whom good grades, high achievement, and academic accomplishment have come relatively easy, are vulnerable to test anxiety. While at first, this may seem counter-intuitive, upon closer analysis, it quickly becomes clear that their anxiety is a result of their own perception of the test determining their academic status or their “demand” to perform well on all tests. For all of these children, it is important to remind them:
Ability and knowledge is demonstrated in many ways, not just through standardized testing – providing example of the many ways they have been successful and have demonstrated their talents Their worth is greater than the sum of their achievement. They are loved for who they are, and not for what they achieve The value in some activities is not in the outcome, but in initiating the task and knowing that your gave it your all
In this new era of reliance on data and ever increasing levels of accountability, standardized testing will not go away. Furthermore, when used correctly, as part of (rather than the sum of) a child’s educational experience they can provide useful information to educators. With this in mind, it is incumbent upon parents and educators to minimize the unintended negative effects on the overall well-being of the child.
Additional Resources: Reducing Test Anxiety To Increase Academic Performance
Peter Faustino & Tom Kulaga When an elementary school teacher heard we were doing a presentation on test anxiety, she ran to her classroom and returned with a book.
We’d like to start off with her suggested reading.
This book is great…
Really, we didn’t make it up. It’s a real book.
Note the attention to test security pictured here. … and here.
Also note the expressions on the children’s faces.
Do they seem a bit anxious? In the classroom we see the usually nice Miss Malarkey acting a little weird while talking to her class about … THE TEST This boy, who is playing a video game, explains (to a parent) that “Miss Malarkey said THE TEST wasn’t that important.”
A student reminds the teacher, “Miss Malarkey, you shouldn’t bite your nails.”
This student reports playing Multiplication Mambo and Funny Phonics at recess. He quotes his teacher, “You never know what’s going to be on THE TEST.” We’re not sure exactly what’s going on here. Maybe Miss Malarkey is supposed to be teaching to THE TEST. TEST DAY approaches and things get weirder and weirder. Principal Wiggins is yelling about pencils. “I want the good No. 2 pencils. Not the kind with the crumbly erasers…” The cafeteria lady, Mrs. Slopdown, took away the potato chips and served only fish. In art class, students make posters about THE TEST and are shown how to color in little circles. In gym, Mr. Fittanuff explains to students that they have to prepare their minds and bodies for THE TEST. “When mom read me my bedtime story, I had to complete a ditto and give the main idea before I could go to sleep.” Dr. Scoreswell answers questions at the PTA meeting.
“How will the test scores affect real estate prices?” TEST DAY
More teachers than kids were waiting for the nurse. Principal Wiggins waves the flag to start THE TEST. Something happens to his hair. Morgan got a stomachache and when Miss Malarkey said to erase all your pencil marks, Janet erased her whole test. After THE TEST everybody got prizes and extra recess. The teachers were happy. WHAT IS ANXIETY?
• Anxiety is a very complex human reaction that has both physical and mental elements to it. The physical elements include things such as sweaty palms, accelerated heartbeat, and a queasy stomach. • The mental elements include self-doubts and constant worry about things. To control your test anxiety you will need to deal with both of these elements. WHAT IS ANXIETY?
• One way to define anxiety is to say that it is a fear-like arousal, when the situation really isn't that threatening. • Granted, a test can be threatening to your grade point average, but it is not a physical threat and doesn't warrant a full- blown physical reaction. WHAT IS TEST ANXIETY & HOW DID I GET IT?
• Have you ever had any of the following types of reactions?
• "I felt I was ready for the test, but when it started my mind just went blank."
• "Before the test started I felt sick. I just wanted to get out of there." WHAT IS TEST ANXIETY & HOW DID I GET IT?
• "I kept thinking to myself what would happen if I did poorly on this test, I just knew it would be awful because I was going to fail again."
• "I thought I did just fine, but when the grade came back it was a 'D', I don't know what happened."
• "I am always feeling under pressure, my life is just too hectic." WHY DO I FEEL THIS WAY?
• Sympathetic. (The part that gets us "pumped up")
• Our heart starts to beat rapidly, and blood pressure increases. • The blood goes to our muscles and less to the thinking part of our brain (which is why we go blank when nervous). WHY DO I FEEL THIS WAY?
• Digestion is slowed down. • Breathing rate increases. • Blood sugar is released to give us energy (also depleting energy reserves). • The rate of perspiration increases (you sweat!). • Adrenalin is released in the body giving an overall excited effect. WHY DO I FEEL THIS WAY?
• Parasympathetic. (the part that calms you down)
• Breathing is slowed down. • Digestive processes increase. • Heart rate slows down and blood pressure decreases. • Perspiration returns to normal. IS A LITTLE ANXIETY GOOD?
There is a myth that all anxiety is bad, but a little bit of sympathetic arousal might be good for times when you have to take a test because it will get you "up" for the test and make you more alert. IS A LITTLE ANXIETY GOOD? However, too much of this type of reaction will make it hard to concentrate. One explanation is that all the body's energy is being focused into the large muscle groups and the brain-stem (which controls the automatic functions of your body), and not enough is being brought to the cerebral cortex which is responsible for thinking. This explains why you go "blank" when you are real nervous, then everything comes back to you when you relax later. What are the effects? WHAT IS ANXIETY?
• Attitudes and beliefs help determine how we react. One way we look at these attitudes and beliefs is through what is called, self-talk. Self- talk is literally what we say to ourselves. The following are examples of self-statements that students may be making:
• "Boy that assignment sounds like fun, I will learn something new." WHAT IS ANXIETY?
• "Give me a break, he knows we won't have time to do all that."
• "That is my worst area, what will I do? I'm sure I can't get that done."
• "Well, I guess that is what I expected."
The Five Causes Of Test Anxiety
• Unfamiliarity. • Preparation. • General Lifestyle. • Conditioned Anxiety. • Irrational Thinking. Twelve Myths Of Test Anxiety
• Students are born with test anxiety. • Test anxiety is a mental illness. • Test anxiety cannot be reduced. • Any level of test anxiety is bad. • All students who are not prepared have test anxiety. • Students with test anxiety cannot learn math. • Doing nothing about test anxiety will make it go away. Twelve Myths Of Test Anxiety • Students who are well prepared will not have test anxiety. • Very intelligent students and students taking high level courses, such as calculus, do not have test anxiety. • Attending class and doing all my homework should reduce all of my test anxiety. • Being told to relax during a test will make you relaxed. • Reducing test anxiety will guarantee better grades. How To Reduce Test Anxiety
RELAXATION TECHNIQUES
THE TENSING AND THE DEEP DIFFERENTIAL PALMING RELAXATION BREATHING METHOD METHOD How To Reduce Test Anxiety The Tensing And Differential Relaxation Method
1. Put your feet flat on the floor. 2. With your hands, grab underneath the chair. 3. Push down with your feet and pull up on your chair at the same time for about five seconds. How To Reduce Test Anxiety The Tensing And Differential Relaxation Method
4. Relax for five to ten seconds. 5. Repeat the procedure two or three times. 6. Relax all your muscles except for the ones that are actually used to take the test. How To Reduce Test Anxiety The Palming Method 1. Close and cover your eyes using the center of the palms of your hands.
2. Prevent your hands from touching your eyes by resting the lower parts of your palms on your cheekbones and placing your fingers on your forehead. Your eyeballs must not be touched, rubbed or handled in any way.
How To Reduce Test Anxiety The Palming Method
3. Think of some real or imaginary relaxing scene. Mentally visualize this scene. Picture the scene as if you were actually there, looking through your own eyes.
4. Visualize this relaxing scene for one to two minutes. How To Reduce Test Anxiety Deep Breathing
1. Sit straight up in your chair in a good posture position. 2. Slowly inhale through your nose. 3. As you inhale, first fill the lower section of your lungs and work your way up to the upper part of your lungs. How To Reduce Test Anxiety Deep Breathing
4. Hold your breath for a few seconds. 5. Exhale slowly through your mouth. 6. Wait a few seconds and repeat the cycle. Long- Term Relaxation Techniques
Learning long-term relaxation techniques can be helpful in conquering test anxiety permanently.
After sufficient practice of such techniques you can induce your own relaxation.
Long- Term Relaxation Techniques
• The best long-term relaxation technique is cue- controlled relaxation response. This form of relaxation involves the repetition of cue words, such as: “I am relaxed,” “I can get through this,” or “Tests don’t scare me.”
• It is essential to avoid use of negative cue words or self-talk and to concentrate on more positive phrases. Discussion
What relaxation technique do you use?
What works at different ages/grades? RATIONAL THINKING
Albert Ellis discovered that many of his patients said things to themselves that contributed to their problems.
It was their irrational beliefs (beliefs not based on the facts or reality) that were contributing to strong emotional reactions and negative behaviors. RATIONAL THINKING
By helping his patients think in a more rational (based on the facts) manner, many of their problems were eliminated or reduced.
From this experience he built a very simple explanation of this mental and emotional sequence, and called it his A-B-C method: RATIONAL THINKING
• A - Activating Event. Something that triggers the whole sequence. It could be something inside our minds or bodies, or it could be in our environment.
• B - Belief. These are the thoughts we have regarding the activating event.
• C - Consequences. This is what happens as a result of A and B. RATIONAL THINKING
An example of a sequence of thinking follows:
• A - Activating Event. While taking a difficult test a student begins to feel physically tense.
• B - Belief. When I feel this way I always get into trouble, and I can't stop it.
• C - Consequences. The student gets a full blown anxiety attack and goes completely blank. CHANGING IRRATIONAL BELIEFS • Negative self-talk (cognitive anxiety) is defined as the negative statements you tell yourself before and during tests.
• These statements cause students to lose confidence and give up on tests.
• Positive self-talk can build confidence and decrease test anxiety.
CHANGING IRRATIONAL BELIEFS Changing negative into positive self-talk: Neg: “No matter what I do, I will not pass this test.” to Pos: “I studied all of the material, I will do great on this test.”
Neg: “I am no good at math, so why should I try?” to Pos: “I’ve worked hard and I will try my best on this test.” Thought-Stopping Techniques
• Some students have difficulty stopping their negative self-talk.
• In order to prevent these negative thoughts from causing anxiety students should practice silent shout. Thought-Stopping Techniques
• Silent shout is a thought-stopping technique.
• Silently shouting to yourself “Stop!” or “Stop thinking about that,” interrupts the worry response before it can cause high anxiety. Thought-Stopping Techniques
• After you eliminate the negative thoughts immediately replace them with positive self-talk or relaxation.
• This will enable the student to think more clearly and concentrate more on the test. The Test Monster
The Test Monster is a fun activity that help younger children get rid of test anxiety.
Children may be given an outline print of a monster and instructed to draw facial features as well as thoughts associated with test anxiety. The Test Monster
Once the details of the monster are completed, students can crumple up the drawing and secure it in a box, symbolizing the elimination of anxiety. Discussion
What cognitive restructuring technique do you use?
What works at different ages/grades? MANAGING THE TEST SITUATION
There are no magic tricks to reducing the anxiety in the middle of a test, because what works for one person may not work for another person.
Below are some things that you might try. MANAGING THE TEST SITUATION
1. Plan to Use the Entire Time. 2. Stop, Pause, and Relax. 3. Start Skipping Around. 4. Ask for a Change of Location. 5. Do Something. Discussion
What study technique do you use?
What works at different ages/grades? Coping Strategies - A Review
• The coping strategies approach assumes that you cannot totally eliminate all the anxiety in a testing situation, you have to accept it as a normal part of life.
• By anticipating the anxiety and planning what you are going to do, you will keep it at a manageable level. Coping Strategies - A Review
Physical Relaxation Positive Self-Talk Managing the Test Situation Coping Strategies - A Review
It is not easy to change how you think overnight, it has taken you quite a few years to establish the patterns that you have and habits are hard to break.
But by attacking and challenging a few of the negative thoughts that you have, you begin the process of change.
Thank You New York Association of School Psychologists August 2013
NYASP Resources for Educators - http://www.nyasp.org/foreducators/ NYASP Resources for Families - http://www.nyasp.org/forfamilies/ NYSED Engage – Information on Common Core Curriculum and Standardized Testing, http://www.engageny.org/ Scholastic.com - search for “high stakes testing” in the “teacher” section for ideas, resources, and printable material, www.scholastics.com
Utilizing Video Self-Modeling and Reattribution Training to Alleviate Test Anxiety
CALIFORNIA STATE UNIVERSITY, LONG BEACH
SHAHROKH-REZA SHAHROOZI, B.S.
NASP Convention February 24th, 2011 Acknowledgments
Thesis Committee: ¡ Brandon Gamble, Ph.D. ¡ Bita Ghafoori, Ph.D. ¡ Simon Kim, Ph.D.
CSULB ¡ Kristin Powers, Ph.D. ¡ Kristi Hagans, Ph.D. ¡ James Morrison, Ph.D. ¡ Judy McBride, Ph.D.
Non-Public School Staff ¡ Sabrina Schuck, Ph.D. ¡ Joe Newkirk ¡ Sue Schecter-Keir
The 4th through 6th grade students who participated. Abstract
The present study examined the effectiveness of video self- modeling of appropriate test-taking strategies and reattribution training on elementary students at a non-public school. In a mixed-methods and non-experimental design, pre and post-treatment quantitative and qualitative data was collected through a series of interviews, anxiety rating scales, and two videoed testing sessions.
It was hypothesized that the participants would report feeling more positively about their test-taking experience as a result of the treatment. Post-treatment results suggest that students who identified themselves as test-anxious felt more at ease and confident in a testing situation, whereas students who did not identify tests as anxiety-inducing reported little to no benefit. Introduction
Researchers such as Spielberger (1962) and Hembree (1988) have detailed the effects of test anxiety on students and how exam performance can be significantly impaired as a result.
Current modifications that instructors may provide include providing “second chances” post- test, familiarizing students with test format and grading scheme, and lowering the impact of any one test (McKeachie & Svinicki, 2005).
What is Test Anxiety?
Test anxiety is an affliction that in excess impairs our capacity to think, plan, and perform on tests.
The current emphasis placed on high-stakes testing à increased pressure on students to perform
This pressure may lead to maladaptive behaviors in any child, especially those with disabilities. Test Anxiety Theory
In the early days, theorists defined test anxiety in motivational terms, believing that it was an expression of one’s general anxiety in evaluative situations (Spence & Spence 1966).
There came a shift to a cognitive approach to the problem. Test anxious students were thought to be splitting their time between task relevant and task- irrelevant thoughts (Wine, 1971). Test Anxiety Theory Pt. 2
The 80s brought about the test taking and study skills paradigm ¡ Students with poor study skills have difficulty encoding classroom material à fail repeatedly on tests à onset of test anxiety (Benjamin et.al 1981)
Self-regulation, self-worth, and transactional process models dominated the 90s (Carver, Scheier, Covington, Spielberger & Vagg) ¡ Self regulation: self-defeating thoughtsà task irrelevant behavior ¡ Self worth: doing poorly is a reflection of my incompetency ¡ Transactional: situational anxiety (testing is threatening) Test Anxiety Model
Engel (1977) & Schwartz (1982) Statement of the Problem
Presently, there is limited research on evidence- based interventions to treat test anxiety, and none of the currently available studies target self-awareness skills. ¡ Self awareness on two levels: 1. Externally with regard to physical symptoms/behaviors 2. Internally with regard to attributions
There are many studies documenting the effects of attribution on academic achievement, but very few discuss their effects on test anxiety. Purpose of the Study
Research Questions: ¡ How do students perceive test anxiety having an effect on their test performance? ¡ What are students’ existing methods of coping with test anxiety? ¡ How do students perceive attribution training and video modeling of test taking skills as having an effect on their levels of test anxiety? ¡ Is a combined treatment of video self-modeling and reattribution training effective in reducing test anxiety? Purpose Pt. 2
Research Hypotheses: ¡ Students equate their perceptions of self-worth with test performance, which creates pressure and anxiety
¡ Many existing coping strategies of test anxious students only serve to exacerbate their symptoms.
¡ Students will gain an insight into their internalizing and externalizing behaviors as a result of VSM and reattribution training.
¡ It was hypothesized that the treatment condition would result in improved test performance and the perception of a decrease in test anxiety exhibited by subjects. Recent Studies
• In the summer of 2007, Laura E. Johnson proposed a 9-week intensive course of progressive muscle relaxation and systematic desensitization for students identified as being test-anxious.
• She found that this intervention resulted in better test scores among research participants.
• She further proposed that PMR and SD be used as a preventative measure, as opposed to a reactive one. Rationale for Video Self-Modeling
Many appropriate test-taking behaviors are implicit. ¡ These are just a few of the test behaviors expected of our students: q Positive thinking/ Self-belief q Regulating breathing q Working efficiently q Focusing on one’s own progress q Self-advocacy q Clarification q Physical Needs
● Do all kids come with this built-in blueprint? Benefits of VSM
Time and cost effective Effects tend to generalize Skills are maintained Videos/clips portable to enhance maintenance Documented social validity Successfully combined with other interventions Targets self-awareness and emotional regulation
Bellini, 2010 Materials Needed for Video Modeling/Editing
Flip Recorder (or smartphone)
Computer
Television Definitions
Self-Observation: Viewing oneself performing at present levels – good, bad, ugly – e.g. athletes watching game film.
Self-Modeling: Allowing people to view themselves performing a skill or task that is slightly beyond their present ability. = All positive.
Two Forms of Self-Modeling
1. Positive Self-Review: Going over and reinforcing already known skills to improve performance/fluency
2. Feedforward: Video of skills not yet learned. Introducing a new skill or behavior.
Dowrick, 1977 Video Self-Modeling Procedures
Video Modeling Procedures ¡ Picking a target behavior (Before Video) ¡ Picking a target setting ¡ Pre-teaching/Frontloading ¡ Adult models the skill ¡ Child models the skill w/assistance ¡ Video Editing ¡ Priming child with video prior to activity Why Video Modeling?
Albert Bandura’s modeling research:
Most effective peers are those closest to attributes and abilities of observer - including ability (Bandura).
Self-Efficacy = If you think you can, you are more likely to succeed ! Necessary Requisites for Successful Modeling (Bandura)
1. Attention 2. Memory 3. Imitation/Behavioral Production
Bandura Attention
Without attention there will be no learning
Often times the break down in perspective is from inattention
Bellini, 2007 Memory
Remembering what you have done
Can be facilitated through scheduled viewings of the video to promote retention of the skill
Bellini, 2007 Imitation and Behavioral Production
The priorities of video modeling are behavioral imitation and production.
The Zone of Proximal Development (ZPD) is what the child can do autonomously (Vygotsky, 1978).
Important to pick behaviors that are within the child’s skill level. ¡ Increases the child’s feelings of self-efficacy ¡ Increases the likelihood for the behavior to be reproduced
Vygotsky, 1978 An Example of the ZPD at Work
Vince Carter Me
Attribution (Weiner, 1986)
In general, people can attribute success or failure to one of four things: 1) Luck 2) Ability 3) Effort 4) Difficulty
Internal vs. External Locus of Control (Rotter, 1954)
Weiner, 1986 Two Types of Student Theorists (Dweck, 1999)
Fixed IQ theorists: Untapped Potential Theorists:
These students believe These students believe that their ability is that ability and success fixed, probably at birth, are due to learning, and there is very little if and learning requires anything they can do to time and effort. In the improve it. case of difficulty one must try harder, try another approach, or seek help etc. What type of student performs best?
In 1978, Cassandra Whyte found a correlation between high locus of control and academic success in students enrolled in higher education courses.
This suggests the need for parents and educators alike to foster this belief in their students as early as possible.
Whyte, 1978 Setting
The study was originally intended to be conducted in a public school with students identified as having demonstrated test or performance anxious behavior. ¡ Approval was denied by the school board due to academic time to be missed during treatment sessions.
The study took place in a non-public school specializing in the treatment of ADHD and related behavioral and learning disorders. ¡ Treatment was a more seamless process, as it served to support the therapy and reinforcement systems that were already in place. Participants (Males)
Student #1 ¡ 12 year old male in the 6th grade ¡ Dx: ADHD and Generalized Anxiety ¡ History of limited academic production , poor writing skills, low self- esteem, and performance anxiety Student #2 ¡ 10 year old male in the 4th grade ¡ Dx: ADHD and sleep disorder ¡ Challenges with low self-esteem and motivation Student #3 ¡ 10 year old male in the 4th grade ¡ Dx: ADHD combined/ODD ¡ History of distractibility, low work-productivity, dependence on assistance Participants (Female)
Student #4 ¡ 12 year old female in the 6th grade ¡ Dx: ADHD and Anxiety Disorder ¡ Difficulties with sustaining attention, completing work, and regulating mood ( social anxiety) Student #5 ¡ 11 year old female in the 5th grade ¡ Dx: Asperger’s syndrome ¡ History of non-compliance, low-work productivity, and social anxiety. Procedures
1. Teacher consultation 1. Identifying target students 2. Matching exam type (math, writing, reading comp, etc.) to the student 2. Video Recorded Initial Exam (30 minutes) 3. Individual Counseling Session (30-45 minutes) 1. Interviews 2. Reattribution training 3. Review of video 4. Teaching of replacement behaviors 4. Video Priming ~10 minutes before Final Exam 5. Video Recorded Final Exam (30 minutes) 6. Final Counseling Session (30-45 minutes) Multidimensional Anxiety Scale for Children (MASC)
Self-report instrument that assesses the major dimensions of anxiety in young people aged 8 to 19 years.
Analyses show high validity and reliability (1996 and 1997) ¡ Test-Retest Reliability Coefficient (0.93) ÷ 3 weeks and 3 months
Pre and post-treatment measures taken over the course of 3 weeks
John S. March, M.D. Interview Questions
15 open-ended questions ranging from: ¡ Test Anxiety ÷ Helpful/Harmful? ÷ Why? ¡ Feelings before, during, and after a test ¡ Current strategies being used? ¡ What could you have done differently? ¡ What could teachers do to help? ¡ What do tests measure? ¡ Describe any sources of pressure. ¡ How video self-modeling impacted their 2nd exam, if at all? ¡ Perceptions of the treatment (pre and post) Reattribution Training: Shifting Schemas
Existing Schema Reformed Schema
I’m just bad at math, I have the ability, but I writing, etc. and that need help accessing it. will never change. The effort I put into my I have no control over work is what I’ll get out how I do, even if I try. of it Tests are trials that are If I do poorly on a test, ’ intended to measure I m a bad student. My what we know and what parents and teachers we need to work on (no will think I’m stupid. more and no less). Maladaptiveà Functional Test-Taking Strategies (VSM)
Maladaptive Strategies Functional Strategies
Poor body language Positive body language ¡ Slumped shoulders ¡ Sitting up straight ¡ Staring up at the ceiling ¡ Eyes on your paper Verbal and physical Positive self-talk expressions of Controlled breathing frustration Moving at your own Comparing progress on pace test to others Student # 1 (12 year old male, 6th grade) Notable Comments
Effects of Test Anxiety: ¡ Positive ÷ It can help you concentrate. ÷ It makes you want to get it done. ¡ Negative ÷ It can cause you to get fed up with it, and you can't concentrate at all. Gets you upset. What do tests measure? ¡ They measure your IQ…what you’re capable of. Pressures? ¡ When I first hear that I'm going to take a test I feel pressure. The second I hear that I jump into mental panic mode. ¡ I think about how the teacher will think about me depending on how good or bad I do. Student #1 Notable Comments Pt. 2
Things teachers can do? ¡ I would like them to kind of walk me through it (frontloading) ¡ I want them to motivate me somehow ÷ Give me some kind of goal to shoot for Thoughts about Reattribution: ¡ My feelings definitely changed about tests for sure, because I never really thought about it like that. Thoughts about VSM: ¡ I thought it definitely helped. I knew what to expect. Like I learned not to get frustrated when someone else finishes before me. Overall thoughts: ¡ I think it helped, and in the classroom I had to do another test later in the day, and I referred back to this and I think it helped.
Student #5 (11 year old female, 5th grade) Notable Comments
Effects of Test Anxiety: ¡ Positive ÷ It gets you going ¡ Negative ÷ You start getting all worried and it's like oh my gosh, time is running out, oh no. Thoughts about Reattribution: ¡ I just thought that “that’s cool.” It don’t think it changed anything, but it was something I hadn’t thought of before. Thoughts about VSM: ¡ It felt kind of good to see me being good at taking tests, but I was pretty good before. Overall thoughts: ¡ It made me think about some new things, but nothing really changed, although it definitely didn’t hurt! Results Pt.1 (Rating Scale Data)
Student # MASC Overall MASC Overall Performance Performance (Pre) (Post) Scale (Pre) Scale (Post) 1 T=52 T=49 Raw=5 Raw=3 2 T=33 T=32 Raw=2 Raw=0 3 T=45 T=45 Raw=2 Raw=0 4 T=37 T=48 Raw=4 Raw=6 5 T=27 T=26 Raw=0 Raw=0
• Paired samples t-test (MASC Overall) • t = 0.4804 df = 4 P=0.650 • standard error of difference = 2.498 • Difference was not statistically significant
• Paired samples t-test (Performance Scale) • t = 1.0000 df = 4 P=0.3739 • standard error of difference = 0.800 • Difference was not statistically significant
Results Pt.2 (Interview Questions)
The research yielded several salient patterns: ¡ Students place lots of value on exam performance. ÷ Parental, teacher, and self-satisfaction ÷ Some feel it is a measure of their intellectual standing in the class ¡ They also seemed aware of their behaviors, but saw them in a different light when shown the video. ÷ They consciously tried to change their behavior in the 2nd examination. ¡ They regarded test anxiety as negatively impacting their test performance. ÷ Most students agreed that a little bit of anxiety helped spur them into action, but after a certain point it would be to their detriment. Limitations/Areas for Future Development
Non-experimental design Very small sample size (3 males, 2 females) Only anecdotal teacher feedback, though generally positive Non-typical school setting ¡ Highly reinforcing behavioral program ¡ Small class sizes (~ 15 students in a class) ¡ Non-typical population (students without disabilities?) MASC is not very sensitive to change in the specific area of test anxiety ¡ More targeted scales are being developed (TAICA, WTAS) Retention of learned skills? Vital to look at the impact of test anxiety on ethnic minorities and English Language Learners. ¡ Stereotype threat? Implications
Parents and school staff alike need to be very mindful of the impact of test anxiety on their students. ¡ Important to push our students (facilitating anxiety), but they should not be made to feel that test performance is a measure of their self-worth (debilitating). The current push with high stakes testing (e.g.: CST, GATE, CAHSEE) is inevitably going to rouse tensions in certain students. ¡ Highlights the importance of a preventative curriculum to address student concerns
Proposed Test Anxiety Treatment Model Under RTI
Intensive: • Video Self-Modeling of Test Taking Skills • Individual Counseling • Reattribution Training • Continued progress monitoring
Targeted: • Students identified as being test anxious Tier 3 • Group Counseling/Talk Therapy Tier • Progress monitoring to note positive 2 or negative change Tier 1 Universal: • Universal Screening (TAI, WTAS, TAICA) • Preventative curriculum addressing test-taking skills • Environmental modifications The Role of the School Psychologist
Triad of School Mental Health
Academic Behavioral Performance Output
Social/Emotional Health
Are we responsible for all 3 elements?
Shahroozi, 2011 Advocacy Groups and More Information…
www.gotanxiety.org. A website directed towards college students and the unique anxieties they experience, developed by the Anxiety Disorders Association of America. www.adaa.org. The official website of the Anxiety Disorders Association America (ADAA), the leading non-profit organization whose mission is to promote the prevention, treatment and cure of anxiety disorders and to improve the lives of all people who suffer from them. http://kidshealth.org/teen/school_jobs/school/test_anxiety.html. A website dedicated to improving the health and spirit of children and teens, developed by the Nemours Foundation. www.dartmouth.edu/~acskills/success/stress.html. A website for the Academic Skills Center at Dartmouth College that focuses on test anxiety. My contact info: ¡ Reza Shahroozi ¡ [email protected] Questions IF YOU SEE OTHER THAN TWO DOLPHINS IT’S TIME FOR A BREAK