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