understanding anxiety & its effects on school functioning jenny c. yip, psy.d. executive...

Understanding Anxiety & Its Effects on School Functioning

Understanding Anxiety & Its Effects on School Functioning

Jenny C. Yip, Psy.D.Jenny C. Yip, Psy.D.

Executive Director, Licensed PsychologistExecutive Director, Licensed Psychologist

Renewed Freedom Center for Rapid Anxiety ReliefRenewed Freedom Center for Rapid Anxiety Relief

Clinical Assistant Professor of PsychiatryClinical Assistant Professor of Psychiatry

USC, Keck School of MedicineUSC, Keck School of Medicine

www.RenewedFreedomCenter.com

Case Vignette

• 16-year-old adolescent, Jack.

• Keeps to himself.

• Does not initiate social interactions.

• Is a loner and waits for people to approach him.

• Frequently stares out of the window in class.

• Reports that he gets bored easily.

• Teacher reports that Jack is insubordinatein the classroom.

• Jack is constantly behind in his work.

• Parents report Jack prefers independent work.

• Teacher reports Jack has difficulty copying off the board.

• Jack spends an inordinate amount of time on homework.

• Jack often does not have the materials he needs to complete tasks.

• He has a high vocabulary, but cannot perform at the same level on class tests.

• He needs extra time completing assignments and tests.

• He engages in daily rituals.

• He is compassionate and empathic.

• His parents are frustrated that he is not reaching his potential.

• Jack makes astute comments and shows a great deal of general knowledge.

• He exhibits anxiety to any change or new/unfamiliar situations.

• He frequently exhibits emotional meltdowns and irritability.

• Jack often talks about events seen on the news and world problems.

How is Anxiety Related to the Fight-or-Flight Response?

Fight or Flight Trigger

Cute Cuddly Kitty

In the Eye of the Beholder

Anxiety Disorders

• Anxiety is a subjective sense of:– worry– apprehension– fear– distress

• It is important to distinguish between normal levels of anxiety and unhealthy or pathologic levels of anxiety.– Fear vs. Excitement Skydiving

Two Components of Anxiety

• Objective Physical Sensations– Headache– Nausea– Sweating

• Subjective Experience & Emotions– Nervousness– Fear– Worries

• Raises blood pressure and heart rate.

• Cause a multitude of bodily complaints:– Nausea– Vomiting– Stomach pain– Ulcers– Diarrhea– Tingling– Weakness– Shortness of breath

Physiological Effects of Anxiety

Prevalence

• Anxiety disorders overall are the most common mental, emotional, and behavioral problems to occur during childhood and adolescence.

• Often overlooked or misdiagnosed in students for other disorders.

• About 13 of every 100 children and adolescents ages 9 to 17 experience some kind of anxiety disorder.

• 25% of 13-18 year olds will experience an anxiety disorder during their adolescence. (NIMH)

COMMON Anxiety Disorders in STUDENTS

• Panic Disorder = 6%

• Specific Phobia = 15.1%

• Social/Performance Anxiety = 5-10%

• Obsessive-Compulsive Disorder (OCD) = 1-3% (underestimated)

• Generalized Anxiety Disorder (GAD) = 3%

Effects of Anxietyon Students

• Interrupt thinking

• Difficulty with decision-making

• Irritability and low frustration tolerance

• Temper outbursts and anger

• Apprehensive perceptions of the environment

• Interfere with learning and concentration

Panic Disorder

• Recurrent, unexpected panic attacks.

• Persistent concern about having additional attacks and their consequences.

• Changes in behaviors to avoid future attacks.

What are Panic Attacks?

• A panic attack is a period of intense fear, discomfort, and terror.

• Typically has a sudden onset with a fear of impending doom.

• Usually lasts no more than 30 minutes.

• Most people report:

A fear of dying “Going crazy“ “Totally losing touch with reality” Losing control of emotions or behavior

• The experience generally provokes a strong urge to escape or flee the place where the attack began.

Characteristics of Panic Attacks

• Racing, skipping, or pounding heartbeat• Chest pains, pressure, discomfort• Dizziness, lightheadedness, nausea• Shortness in breath, difficulty breathing• Trembling or shaking• Sweaty or clammy hands• Choking sensations or lump in the throat• Stomach problems or sudden diarrhea• Tingling or numbness in parts of the body• Flushes or chills

• Dreamlike sensations or perceptual distortions• Terror--a sense that something unimaginably

horrible is about to occur and one is powerless to prevent it

• Fear of losing control and doing something embarrassing

• Fear of dying

Specific Phobia• Marked and persistent fear that is excessive, cued by the

presence or anticipation of a specific object or situation.

• Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or predisposed Panic Attack.

• Person recognizes that the fear is excessive or unreasonable.

• Phobic situation is avoided or endured with intense anxiety. Animal Type Natural Environment Type (e.g., height, storms, water) Blood-Injection-Injury Type Situational Type (e.g., airplanes, elevators, enclosed places) Other Type (e.g., choking, vomiting, contracting illness, loud

sounds, costumed characters)

Social/Performance Anxiety

• A marked and persistent fear of social or performance situations.

• Feeling as if everyone is watching and judging .

• Excessive fears of making mistakes, appearing foolish, feeling embarrassed and humiliated, or possible scrutiny by others.

• Exposure to the feared social situation almost invariably provokes anxiety that can result in panic attacks.

• Certain people, places, social events, or performance situations are avoided or endured with intense anxiety or distress.

Common Social Phobic Situations

• Public speaking

• Public bathrooms (paruresis)

• Talking to authority figure

• Talking to attractive person

• Meeting new people

• Asking for directions

• Writing or eating in front of others

• Entering crowded room

• Formal affairs

• Reading aloud

• Speaking in class

• Running into friends

What is OCD?

How Does It Fit in the Anxiety Picture?

Vicious OCD Cycle

OBSESSIONS negative thoughts, images, impulses

RELIEF ANXIETYdistress subsides distress, fear,

temporarily shame, disgust

COMPULSIONSrepetitive thoughts, images, actions

Common Common ObsessionsObsessions

Contamination themesContamination themes

“ “My hands are dirty.”My hands are dirty.”

Washing/CleaningWashing/Cleaning

Pathological DoubtingPathological Doubting

“ “Did I lock the door?”Did I lock the door?”

CheckingChecking

Symmetry/ExactnessSymmetry/Exactness

““It doesn’t feel right.”It doesn’t feel right.”

Ordering/ArrangingOrdering/Arranging

Saving/CollectingSaving/Collecting

““I should keep this just in case.”I should keep this just in case.”

Hoarding/CollectingHoarding/Collecting

Sexual themesSexual themes

““I want to say something inappropriate.”I want to say something inappropriate.”

Repeating/TouchingRepeating/Touching

Scrupulosity/Religiosity/Forbidden ThoughtsScrupulosity/Religiosity/Forbidden Thoughts

““It was bad of me It was bad of me to to have these feelings.”have these feelings.”

PrayingPraying

Aggressive themesAggressive themes

“ “I want to hurt my baby.”I want to hurt my baby.”

CountingCounting

Need to tell, ask, confessNeed to tell, ask, confess

“ “I should ask just to be certain.”I should ask just to be certain.”))

Reassurance SeekingReassurance Seeking

Harm to self or othersHarm to self or others

“ “Something bad might happen.”Something bad might happen.”

Making mental lists/Making mental lists/

Retracing past memoriesRetracing past memories

Common Common CompulsionsCompulsions

• OCD is under-recognized and many individuals wait years before being diagnosed.

• OCD is a real illness that affects the brain and tends to run in families. It is NOT a result of something that the child, parent, or others did wrong.

• Pediatric OCD often co-occurs with other disorders, such as tic disorders, ADHD, and anxiety disorders.

• Shame and embarrassment from OCD interferes with a student’s social interactions.

• Intrusive obsessions and repetitive compulsions negatively impact academic functioning.

• OCD can start at any time, even in preschoolers as young as 3yo.

• At least 1 in 100 kids and teens that have OCD, which is more thanthe number of kids with diabetes.

– 4-5 kids with OCD are likely to be enrolled in any average size elementary school.

– In a medium to large high school, there could be more than 20 students struggling with the challenges caused by OCD.

• The empirically-supported ‘cure’ for OCD is cognitive-behavior therapy (CBT) – specifically Prolonged Exposure & Response Prevention (ERP).

• Many professionals, artists, actors, and athletes have OCD. A child’s future success does not have to be limited by OCD!

ImpulseControl

Neurological Neurological DisordersDisorders

Habit Habit DisordersDisorders

Disorders of BodilyDisorders of BodilyPreoccupationPreoccupation

Trichotillomania

Compulsive Skin-Picking

Onychophagia

Pyromania

Kleptomania

Pathological Gambling

Anorexia Nervosa

Hypochondriasis

Binge Eating

Bulimia Nervosa

Body Dysmorphic Disorder

Autism

Tourette’sSyndrome

Sydenham'sChorea

More difficulties in Impulsive Control

More difficulties in Compulsive Control

Generalized Anxiety Disorder

• Rolling thunder vs. Lightening strike

• Excessive, continuous worries

• Restlessness & Can’t relax

• Irritability & Feeling on edge

• Muscle tension & Body aches

• Insomnia

27

Effects of Anxiety on Family Functioning

• Anxiety symptoms typically involve other family members, and cause impaired functioning in the family system.

• In an attempt to reduce the child’s anxiety and fear, family members tend to become servants to the child’s avoidance behaviors and compulsions.

• Family members tend to accommodate in order to avoid conflict and maintain peace.

• However, accommodations only serve to reinforce the fear and the maintenance of the vicious anxiety cycle.

The Vicious Cycle of Family Interactional & Response Pattern Leading to the Maintenance of

Anxiety

Know Your Enemy to Know Your Enemy to Defeat It!Defeat It!

Psychoeducationto Improve Understanding and

Avoid Mislabeling

Vicious Anxiety Avoidance-Reinforcement Cycle

Feared Trigger negative thoughts, situations, sensations

RELIEF ANXIETYdistress subsides distress, fear,

temporarily shame, disgust

Avoidancedistraction, reassurances, escape

Behavior Therapy Guidelines

• You cannot control your thoughts.

• You cannot control your feelings.

• You can control your behaviors.

• As you change your behaviors, your thoughts and feelings will also change.

Mood-Thought-Behavior Triangle

COGNITIVE(Obsessions/Fears)

BEHAVIOR(Compulsions/Avoidances)

AFFECTIVE(Anxiety/Discomfort)

Exposure vs. Escape Response

"Fight or Flight" Response

0

2

4

6

8

10

15 30 45 60 75 90

Time (min)

SU

D (

0-10

0) "FLIGHT" (viciouscompulsive cycle)

"FIGHT" (ERP)

Process of Habituation

"Fight or Flight" Response

0

2

4

6

8

10

20 40 60 80

100

120

140

160

180

200

220

Time (min)

SU

D (

0-10

0) "FLIGHT" (viciouscompulsive cycle)

"FIGHT" (ERP)

Treatment Challenges

• Over-appraisal of catastrophic thoughts.

• Overvaluing feared consequences.

• Misinterpretation of bodily sensations.

• Severe avoidances.

• Although sufferers may admit to fears, few seek mental health treatment due to associated negative stigmas.

Treatments that work• Evidence-based treatments for anxiety disorders are

short-term and very effective.

• Psychoeducation – Reduces misattribution of psycho-physiological symptoms.

• Cognitive-Behavioral Treatment (CBT): Learning to deal with fears by modifying the ways we think and behave.

Cognitive Restructuring – Maintains changes in belief system.

Rational Emotive Behavior Therapy (REBT) – Corrects faulty belief system and over-appraisal of danger.

Acceptance & Commitment Therapy (ACT) – Addresses acceptance of uncertainty and letting go of control.

Mindfulness Training – Increases awareness of physiological sensations to enhance process of habituation to exposures.

Treatments that work (cont)

• Behavior Therapy: Behaving in ways to confront fears and reduce unnecessary fight-or-flight triggers.

Relaxation Training – Reduces physiological symptoms of panic attacks.

Prolonged Exposures – Confronts feared situations to change belief system of danger and ability to endure fight-or-flight discomforts.

Response Prevention – Resists compulsive or safety behaviors and avoidances that only reinforce the anxiety cycle.

• Family Therapy: Reduces conflict, decreases unhealthy accommodations, and focuses on effective solutions.

• Parent Training: Provides support, improves communication skills, and educates methods to decrease anxiety.

ADHD - INATTENTION

• Often does not seem to listen when spoken to directly.

• Does not pay close attention to details or makes careless mistakes.

• Difficulty focusing attention; easily distracted & forgetful.

• Does not follow instructions and fails to finish tasks.

• Often has trouble organizing activities.

• Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time.

• Often loses things needed for tasks and activities.

ADHD - Hyperactivity

• Often fidgets with hands or feet or squirms in seat.• Often gets up from seat when remaining in seat is expected.• Often runs about or climbs when and where it is not

appropriate (adolescents or adults may feel very restless).• Often has trouble playing or enjoying leisure activities quietly.• Is often "on the go" or often acts as if "driven by a motor".• Often talks excessively.

IMPULSIVITY• Often blurts out answers before questions have been finished.• Often has trouble waiting one's turn.• Often interrupts or intrudes on others.

– Butts into conversations or games.

Oppositional Defiant Disorder (ODD)

• Temper tantrums

• Argumentativeness with adults

• Refusal to comply with adult requests or rules

• Deliberate annoyance of other people

• Blaming others for mistakes or misbehavior

• Acting touchy and easily annoyed

• Anger and resentment

• Spiteful or vindictive behavior

• Aggressiveness toward peers

• Difficulty maintaining friendships

• Academic problems

Autism Spectrum Disorder (ASD)

• Also known as Pervasive Developmental Disorders (PDD)

• Deficits in: 1. Social Interaction, 2. Repetitive Behaviors/Circumscribed Interests 3. Communication (Verbal or Nonverbal)

• Trajectory varies.

• Deficits often noticeable by 12-36 months

• Reject people, react strangely to others

• Unusual behaviors form

• Social Symptoms: Poor eye contact Difficulty interpreting social cues Difficulty regulating emotions (not universal)

Giftedness• An early and enduring passion for communication.

• A remarkable capacity for concentration.

• Persistence in pursuing a task

• Emotional intensity

• Perfectionism.

• Anxiety over separation or new situations.

• Learning highs and lows — asynchronous development.

• Issues with over-achievement or underachievement.

• Socialization issues.

• An ability to act older than they really are.

• A belief that they can outsmart their parents.

Pulling It Together

• Case example of Jack:– Anxiety & OCD?– ADHD?– ODD?– ASD?– Giftedness?

Case Example: JackAnxiety/OCD ADHD Giftedness ODD ASD

•Keeps to himself

•Does not initiate• social interactions

•Is a loner, • introverted

•Insubordinate in class

•Has difficulty paying attention

•Keeps to himself

•Stares out window

•Reports getting • bored easily



•Keeps to himself

•Does not initiate social interactions

•Is a loner, introverted


•Reports getting bored easily


•Keeps to himself





•Keeps to himself

•Does not initiate social interactions

•Is a loner, introverted





Jack, continuedAnxiety/OCD ADHD Giftedness ODD ASD

•Behind in work

•Engages in daily rituals

•Throws temper tantrums

•Prefers to work alone

•Difficulty copying off board

•Spends inordinate amount of time on homework

•Behind in work




•Behind in work




•Behind in work



•Behind in work

•Engages in daily rituals



Jack, continuedAnxiety/OCD ADHD Giftedness ODD ASD

•Does not have proper materials to complete tasks

•Needs extra time on tests

•Not reaching potential

•Makes astute comments

•Uncomfortable in new situations

•Talks about world events






•Makes astute comments









•-Not reaching potential

•-Makes astute comments


•-Talks about world events

Collaborating with Schools• Outreach and In-Services

– Increase awareness of behavioral manifestations of various childhood disorders.

– Ensure proper interventions.

• Communication with child and family is key!– Schedule regular check-ins with child.

– Use notebooks and engage in regular, brief conversations with parents to facilitate communication.

• Ask teachers to document behavioral changes in student, both positive and negative.– Consult with parents to determine if changes may be due to

behavioral &/or medical interventions.

Collaborating with Schools• Help teachers establish rapport with student.

– Calm, supportive teacher can improve outcome of treatment.

– If student is in harsh/critical environment, stress levels and anxiety naturally increases -> behavioral manifestations of anxiety will also increase.

– Always speak clearly, calmly, in kindly manner.

• Make sure teachers note each student’s progress based on his or her own behavior and achievements, without comparisons to other classmates.

• Students with anxiety have difficult time making decisions for fear of not making perfect decision.– If student is having difficult time making choices, encourage

him/her to do so within set time frame (e.g., 5 seconds).– Continue to encourage him/her to practice making quick

decisions.

Collaborating with Schools• If student is engaging in behavioral manifestations of anxiety in

the classroom:– Help them to postpone behavior by distracting them if possible.

– Remind student that their urge to engage in behavior is “Anxiety Monster” playing a trick on him/her and not necessarily an actual need.

– Encourage student to step outside or take break to think through situation & reframe as Anxiety Monster’s needs rather than student’s own need.

• If student is engaged in anxiety-types of behavior in the classroom and doesn’t respond to any methods, do not put pressure on him/her to stop.

• Students with anxiety seek reassurances to satisfy their need to know.– Can indicate need for perfection or to get things “just right”.– Learn to identify when student is asking for reassurances.– Respond with ambivalent answers.

Potential Accommodations• Students with severe test anxiety:

– Breaks during testing.– Testing in nondistracting quiet location.– Take tests orally.– Extra time.– Write directly into test booklets rather than transferring answers.

• Students with perfectionism or fears of getting things wrong:– Having directions/instructions available on paper, whiteboard, or

elsewhere lessens anxiety about getting information incorrectly due to distraction, misunderstanding, or perfectionism.

– Ask direct questions rather than open-ended ones, which are less anxiety-provoking to answer.

– Provide time estimates for each assignment, so students who spend an inordinate amount of time on HW can attempt to stay within 10% of the estimated time.

Allow perfectionistic students to make-up work they’ve missed following legitimate absences.

Potential Accommodations• Students with reading compulsions or anxiety:

– Encourage student to read only once through.– Break down reading assignments into shorter

increments/sections.– Reading material tape recorded, books on tape.

• Students with writing compulsions or anxiety:– Tape record lessons.– Photocopy teachers notes or notes from another student.– Provide outline of lesson notes.– Having someone else scribe while student dictates

answers.– Assignments and tests may be typed or submitted on

tape.– No deduction for sloppy hand-writing, misspelled words.

• Classroom/School Environment - Because change and uncertainty can be unsettling, anxious students perform best in a calm, supportive, and structured classroom. – Seat students with anxiety away from rambunctious classmates

to decrease distractions.

– Allow students to sit in an area where necessary breaks can be taken without being easily noticeable.

– Minimize competition between students in the classroom.

– Create ties for socially anxious students by forming small groups of shared activities (e.g., art projects, lunch bunch).

• Limit allowing students to choose groupings themselves with counting-off technique.

• Pair classroom buddies.

– Assign a point person for student to check in with to dispel worries, take deep breaths, and return to class.

Potential Accommodations

Specialized Services

• For severe or persistent anxiety, refer student for psychological evaluation or psychoeducational testing.

• Consult with the appropriate school staff to determine if the student is eligible for:

– IEP for IDEA (Individuals with Disabilities Education Improvement Act) special education services.

– Section 504 Plan (individuals with a handicap).

Anxiety Resources

• Seek assistance from anxiety specialists or national nonprofit resources.

Anxiety & Depression Association of America (ADAA)

www.adaa.org

International OCD Foundation (IOCDF)

www.ocfounation.org

Association for Behavioral & Cognitive Therapies (ABCT)

www.abct.org

National Institute of Mental Health (NIMH)

www.nimh.nih.gov

National Alliance on Mental Illness (NAMI)

www.nami.org

Child Mind Institute

www.childmind.org

Job Corps Job Corps ResourcesResourcesJob Corps Job Corps ResourcesResources

Job Corps Community Health Website

Job Corps Community Health Website (continued)

Mental Health Specialists

• Region 1Dave Kraft, MD, [email protected] Acevedo, [email protected]

• Region 2/LeadValerie Cherry, [email protected]

• Region 3Suzanne Martin, PsyD, [email protected]

• Regions 4 and 6Vicki Boyd, [email protected] Solis, PhDSolis.Lydia

[email protected] • Region 5

Helena MacKenzie, [email protected]

Job Corps Community Disability Website

Regional Disability Coordinators

• Boston Region – Lisa [email protected]

• Philadelphia and Atlanta Regions – Nikki Jackson

[email protected]

• Dallas Region – Laura [email protected]

• Chicago and San Francisco Regions – Kim Jones

[email protected]

understanding anxiety & its effects on school functioning jenny c. yip, psy.d. executive...

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