When Anxiety Affects Learning: How to Help Children with School-Related Anxiety

Transcription

1 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

2 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 % will have severe anxiety disorder Only 18 % of these teens receive treatment

3 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

4 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

5 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

6 Adaptive Anxiety vs. Disordered Anxiety Adaptive Anxiety Keeps us safe Disordered Anxiety Results in functional impairment A response to real danger Equivalent to a false alarm Prevents the repeating of mistakes Leads to unnecessary avoidance

7 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

8 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 *

9 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

10 Definition of School Refusal School refusal is defined as: Refusal to attend or difficulty remaining in school for an entire day

11 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)

12 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

13 Common Antecedents Death or illness in parent or caregiver Change of class or school Traumatic events at school (including bullying) Prolonged absence from illness

14 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

15 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)

16 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)

17 Allergic Reaction to a Casserole

18 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

19 Signs and Symptoms

20 Signs and Symptoms Expert chameleons -cont- Can appear oppositional and out of character Perfectionism Needing A s Fatigue from two full-time jobs Irritability Increased Absenteeism

21 Imagine trying to learn calculus right now

22 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)

23 Three Pillars of Anxiety Uncertainty Lack of control Perception of danger

24 Anxiety Acquisition Classical Conditioning Modeling Information Transfer

25 Anxiety Maintenance Avoidance is the lifeblood of any anxiety disorder Avoidance is a very strongly reinforced behavior We are hardwired to avoid perceived threats

26 Anxiety Reduction Education Cognitive Reframing Behavior Change

27 We don t treat anxiety; We treat avoidance

28 Decreasing Avoidance Urges do not dictate actions. Metacognitive awareness of urge to avoid or escape Rehearsal of self-instruction Building distress tolerance

29 Stop swatting the butterflies.

30 Basic Template for the Treatment of Anxiety Disorders in Adolescents Assessment Psychoeducation Cognitive Reappraisal Strategies Exposure Parent Training Relapse Prevention

31 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

32 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

33 Fire alarm at the top of the Empire State Building

34 Cognitive Strategies Why don t the palm trees care when the wind blows? Coping cards Problem-solving skills training Cognitive flexibility exercises

35 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

36 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.)

37 The way to respond to anxiety is just as counterintuitive as diving into the wave that s about to hit you.

38 Three Critical Variables for Habituation to Occur (Successful Exposure) Frequency Intensity Duration

39 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

40 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

41 bigfoot

42 Flexibility is Strength

43 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

44 The perfect igloo can kill you.

45 Teaching Optimalism Optimal Best or most effective Failure as feedback Adaptable and flexible Accepts natural variation Balance as goal Success is not linear

46 Model what you want the sudent to feel.

47 Be the counterweight.

48 Accommodating vs. Enabling

49 Specifics No universal rule changes over time Calm consistency To what end Alternative strategy vs get out of jail free Expectation of effort

50 Psychoeducation for Parents Fear and Avoidance are Teammates Parent-training is paramount! Begin with education regarding the negative reinforcement of anxious behavior Protection Trap

51 Water the seeds, not the weeds.

52 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

53 scene from Ray

54 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

55 Jonathan Dalton, Ph.D. Center for Anxiety and Behavioral Change