When Anxiety Affects Learning: How to Help Children with School-Related Anxiety March 27, 2017 Jonathan Dalton, Ph.D. Center for Anxiety and Behavioral Change Why this is so important Children and Adolescents . Median age of onset 11 – earliest of all forms of psychopathology . 8 % of children between ages 13 and 18 currently have an anxiety disorder . 31.9% will have an anxiety disorder between the ages of 13 and 18 . 8.3% will have “severe” anxiety disorder . Only 18 % of these teens receive treatment Adolescents Girls . 38% of girls will have at least one anxiety disorder between the ages of 13 and 18, (compared with 26.1% for boys) . Compared with 4.2% of girls will have ADHD, 10.2% with have a substance abuse disorder, 3.8% will have an eating disorder Comorbidity of Anxiety and Learning Differences . For children with a Specific Learning Disability, 28.8% meet criteria for an Anxiety Disorder . For children with a Nonspecific Learning Disability, 16.4% meet criteria for an Anxiety Disorder . For children with ADHD, 38.7% have comorbid anxiety disorder Adults . 28.8 percent lifetime prevalence . Most common category of mental health disorders . 18 % of adults currently have an anxiety disorder (40 million) . $42 billion in annual health costs Adaptive Anxiety vs. Disordered Anxiety Adaptive Anxiety Disordered Anxiety . Keeps us safe . Results in functional impairment . A response to real danger . Equivalent to a “false alarm” . Prevents the repeating of . Leads to unnecessary mistakes avoidance “If it made sense, it wouldn’t be a disorder” . 3797 ways to have a panic attack (4 of 12 symptoms are required) . A student may show behavior incongruent with an anxiety disorder in various situations . Safety behaviors “Anxiety is the Baskin Robbins of mental disorders” . Panic Disorder . Separation Anxiety Disorder . Generalized Anxiety Disorder . Post Traumatic Stress Disorder . Social Phobia . Specific Phobia . Selective Mutism . Obsessive Compulsive Disorder * “Having an anxiety disorder is like being stuck in that moment when you realize you’ve leaned too far back in your chair, but have not yet fallen.” – teenage patient Definition of School Refusal School refusal is defined as: Refusal to attend or difficulty remaining in school for an entire day Epidemiological Data . Lifetime Prevalence rate 5 to 28% . Higher rates in urban school districts . 3-month prevalence rate is 2% . Equally common in boys and girls . Does not seem to be related to SES (e.g., Kearney & Albano, 2004) Age-Related Distribution . Two peaks in age of onset 5 to 6 years of age 10 to 11 years of age . Acute onset more likely for younger children, insidious onset for older Common Antecedents . Death or illness in parent or caregiver . Change of class or school . Traumatic events at school (including bullying) . Prolonged absence from illness Associated Disorders . Separation Anxiety Disorder (38% of cases) . Social Phobia . Adjustment Disorders . Specific Phobias (e.g., fire alarms, bees, dogs, etc.) . Perfectionism . Depression . Sleep Disorders Consequences of School Refusal . Duration of school-refusal correlated with short and long term psychopathology in the individual including: - lowered academic achievement - occupational difficulties - family/marital discord - poor social relationships Kearney (2001) Long-Term Sequelae in Children with School Refusal . Did not complete high school……….45% . Adult psychiatric outpatient care……43% . Still living with parents at 20-year follow-up……………………14% . Married at 20-year follow-up………..41% . No children at 20-year follow-up……59% - Flakierska-Praquin et al. (1997) Allergic Reaction to a Casserole Exploring Obstacles and Creative Accommodations “If I had a magic wand, what would it take for you to be back in school tomorrow?” . No tests, quizzes, . Ability to use nurse’s homework, or being office restroom called on for set period . Pleasurable activity of time upon arrival (e.g., . Dropping a class caring for class . Liberal use of flash hamster) passes . Creation of “cover ” . Eating lunch in story alternative setting Signs and Symptoms Signs and Symptoms -cont- . Expert chameleons . Can appear oppositional and out of character . Perfectionism “Needing A’s” . Fatigue from “two full-time jobs” . Irritability . Increased Absenteeism “Imagine trying to learn calculus right now” Treatment Works! “Ultimately we know deeply that on the other side of every fear is freedom” – Marilyn Ferguson .Treatment success rates for anxiety disorders with CBT (exposure therapy) range from 60% to 90% .Tragically low utilization rates (18% compared with 79% for ADHD) Three Pillars of Anxiety . Uncertainty . Lack of control . Perception of danger Anxiety Acquisition . Classical Conditioning . Modeling . Information Transfer Anxiety Maintenance . Avoidance is the “lifeblood” of any anxiety disorder . Avoidance is a very strongly reinforced behavior . We are hardwired to avoid perceived threats Anxiety Reduction . Education . Cognitive Reframing . Behavior Change “We don’t treat anxiety; We treat avoidance” Decreasing Avoidance “Urges do not dictate actions.” . Metacognitive awareness of urge to avoid or escape . Rehearsal of self-instruction . Building distress tolerance “Stop swatting the butterflies.” Basic Template for the Treatment of Anxiety Disorders in Adolescents . Assessment . Psychoeducation . Cognitive Reappraisal Strategies . Exposure . Parent Training . Relapse Prevention Psychoeducation “Here is the owner’s manual for you nervous system” . “Good package deal” . Acquisition, maintenance, and extinction of fear response . Importance of decreasing avoidance . Concept of exposure . Outlasting fear Cognitive Reappraisal of Anxious Arousal “Don’t believe everything you think!” . Body is doing the right thing at the wrong time . Perspective of “curious observer” . “In this moment…” Fire alarm at the top of the Empire State Building Cognitive Strategies “Why don’t the palm trees care when the wind blows?” . Coping cards . Problem-solving skills training . Cognitive flexibility exercises Coping Cards “Just because I’m scared…” . I am stronger than my . Just because I’m fear scared doesn’t mean I . Scary thoughts can can’t do it never hurt me . It’s ok to be scared . I know I can do this . Just do it anyway because… . Anxiety is temporary and harmless Fear Reduction Through Behavior Change “Courage is what you do, not what you feel” . Exposure to the feared situation in the absence of the feared consequence produces fear reduction . Exposure can be conducted in a variety of manners, but exposure always remains the “active ingredient” (e.g., acetaminophen comes in tablets, caplets, gelcaps, etc.) The way to respond to anxiety is just as counterintuitive as diving into the wave that’s about to hit you.” Three Critical Variables for Habituation to Occur (Successful Exposure) . Frequency . Intensity . Duration Graduated Exposure . Akin to entering a cold pool slowly . Preferred technique for most pediatric anxiety disorders . Critical that the child assists in the creation of the fear hierarchy (“ladder” for younger children) . The child earns more points, tokens, etc. for more difficult exposures Habituation “We turn fear into boredom” . Continuous exposure to a constant stimulus reduces the subjective experience of that stimulus (e.g., cold water at the beach, baby crying on airplane, white noise machine in your office, etc.) . Fear follows this same process of habituation bigfoot Flexibility is Strength Self-Oriented Perfectionism . Very different from appropriately high standards . Risk factor for eating disorders, depression, suicide . Self-worth derived from achievement and productivity . Tend to function well in low stress environment “The perfect igloo can kill you.” Teaching “Optimalism” . Optimal – “Best or most effective” . Failure as feedback . Adaptable and flexible . Accepts natural variation . Balance as goal . Success is not linear “Model what you want the sudent to feel.” “Be the counterweight.” Accommodating vs. Enabling Specifics . No universal rule – changes over time . Calm consistency . “To what end” . Alternative strategy vs “get out of jail free” . Expectation of effort Psychoeducation for Parents “Fear and Avoidance are Teammates” . Parent-training is paramount! . Begin with education regarding the negative reinforcement of anxious behavior . “Protection Trap” “Water the seeds, not the weeds.” Nuts and Bolts “Your attention is your child’s paycheck, so be exceptionally careful what you pay him/her for” . Functional analysis . Positive reinforcement . Negative reinforcement . Coercive behavior cycle . Extinction . Extinction Burst . Habituation scene from Ray Relapse Prevention . Problem-solving skills training . Increase perceived social support . Emphasis on continued self- directed exposure . Relaxation training . Reframe potential recurrence of symptoms as opportunity for future learning . Increase self-efficacy to deal with future fears Jonathan Dalton, Ph.D. Center for Anxiety and Behavioral Change [email protected] 301-610-7850.