Supporting Students with Anxiety in School

Anxiety and Anxiety Disorders in Children and Adolescents

Anxiety is a healthy human emotion that helps children and adolescents prepare for challenges like taking a test or manage dangerous situations like riding a bike on a busy street. Healthy anxiety is usually expectable and proportionate to the challenge. Typically, the better prepared the person is the less (healthy) anxiety they will experience. 

For example:

• A student studied hard for the test and is prepared;
• An adolescent is highly skilled at bike riding, wears a helmet and protective clothing, and rides only in the bike lane.

In contrast, the less prepared a child or adolescent is, the more (healthy) anxiety they might experience. 

That said, some children and adolescents live in situations where they are exposed to persistent and severe stressors. They can have severe and persistent anxiety – an expectable and appropriate reaction to challenging life circumstances. 

Healthy Anxiety in the Classroom

A teacher may notice that some students:

• Come to school less prepared and thus, have more anxiety about the schoolwork;
• Have problems with learning and have more anxiety about their area of challenge;
• Have problems paying attention or sitting still and have anxiety about not understanding and doing the work in the classroom;
• Live in challenging environments and have anxiety about their safety and the wellbeing of their family, and home/neighborhood environment.

All of the above situations would be ‘normal,’ expectable anxious reactions to challenging circumstances. 

In the examples above, students

• With good coping skills, and family and teacher support will do better;
• Without good coping skills or family or teacher support will do less well.

What Differentiates Healthy Anxiety from Symptoms of an Anxiety Disorder

There are 4 main types of anxiety disorders:

• Separation Anxiety Disorder;
• Social Anxiety Disorder;
• Selective Mutism;
• Generalized Anxiety Disorder;
• Additional types of anxiety include panic disorder, agoraphobia, specific phobia substance/medication induced anxiety.

The 4 main types of anxiety disorders begin in elementary school (6-12 years of age) or even before, however, they are not always identified or treated until adolescence. Sadly, many students never get assessed or treated.

The triggers for these anxiety disorders are normal developmental activities that most children routinely master or even enjoy. The school environment by its nature exposes students to developmentally appropriate challenges and thus schools are environments where students will commonly demonstrate symptoms of an anxiety disorder.

Triggers for Separation Anxiety Disorder are developmentally appropriate separations from parents or caregivers, and include:

• Going to school;
• Going to other kids’ houses for play dates;
• Doing sleep overs or going away to camp;
• Falling asleep alone at night;
• Being in a different room in the house from the caregiver.

When faced with developmentally appropriated separations they may express physical symptoms, “melt downs,” or tantrums.

Triggers for Social Anxiety Disorder are developmentally appropriate social and interactional challenges. It may be expressed in the following ways:

• Being extremely self-conscious, worry about ‘goofing up,’ being laughed at or humiliated in social situations; observers sometimes consider them to be shy;
• Will not raise their hand to ask questions;
• When called on, will not make eye contact (when culturally appropriate to do so) and will speak softly or use single word answers;
• Will not join a group of children to play;
• Does not like to attend parties or social events;
• Will not volunteer to read aloud or go to the board when others are watching.

Speaking in developmentally appropriate situations (Selective Mutism) is described as

• An early onset and more severe form of social anxiety;
• Normal speaking ability in the home environment but will not speak at school or other situations outside the home.

Triggers for Generalized Anxiety Disorder are developmentally appropriate levels of uncertainty and performance challenges. These children and adolescents struggle with not knowing everything that might happen at school, at home or in the world; and are excessively driven to perfection.  These children and adolescents worry excessively about the past, current events, and the future. 

For example:

• 6 year olds worrying about going to college.
• 8 year olds worrying about whether the teacher will be sick or at school today, if there might be a test that they don’t know about or whether they forgot to do something for school.
• Asks a lot of “what if…” questions and doesn’t respond to appropriate reassurance.
• Often lives with dread that something will go wrong even in routine activities.
• Often perfectionistic (maybe even a teacher favorite), but rigid and can’t tolerate change or ambiguity at school. 
  
  • Studies hard – sometimes too much.
  • Can “freeze up” or experience their mind “going blank” and do poorly when under pressure.
  • Complains of muscle tension.
  • May know the answer but isn’t “sure,” may over think and then make a wrong choice.
  • Get diagnosed with inattention but their inattention is due to preoccupation with worry about performance and uncertainty, but not ADHD.

What Can Schools do to Help Children and Adolescents with Anxiety?

There is a difference between healthy anxiety and anxiety disorders. Developing a classroom/school environment that helps students build their capacity to manage healthy school anxiety related to routine academic and social challenges can also

• Promote the development of coping and adaptation skills;
• Work to match challenges to students’ capacity to help students grow;
• Provide needed support for those who have greater support needs;
• Promote family and supportive teacher relationships;
• Encourage positive peer relations.

It is important to understand that some students with anxiety disorders have a unique set of challenges that can be identified at school, particularly in elementary school.

• Students who struggle to transition to and maintain engagement in the school environment due to separation anxiety disorder;
• Students who struggle to socialize and engage fully in educational activities due to social anxiety disorder;
• Students who worry excessively about the everyday uncertainties at school, home, and the world and unduly drive themselves to perform perfectly and experience undo distress from routine learning challenges due to generalized anxiety disorder.

School Refusal: Young children with separation anxiety disorder can refuse to go to school, have a pattern of frequent absences often on Mondays or after vacations or long weekends or have frequent physical symptoms of anxiety – headaches or stomach aches leading to frequent visits to the nurse or leaving school for home. Adolescents with social anxiety disorder can also stop going to school as the pressure for socialization in middle and upper school can feel overwhelming. School personnel can work in partnership with the student, family and pediatrician to problem solve how best to help students return to or stay in school.

Students with anxiety disorder can become symptom-free with evidence base treatment and school personnel can provide important information to the family and the pediatrician about anxiety disorder symptoms in the school environment.

Pediatrician’s Role

Pediatricians can support schools in understanding the difference between those with healthy anxiety and symptoms of anxiety disorders. Pediatricians recognize that anxiety disorder symptoms fit patterns that they can recognize and may work to coordinate with the school to confirm that the anxiety disorder symptoms are also present in the classroom. Pediatricians can support students in a variety of ways, including:

• Help families help their children and adolescents develop a strong set of coping and adaptation skills so that they can master the healthy anxiety associated with routine academic and social challenges at school.
• Utilize anxiety rating scales (e.g., Hamilton Anxiety Rating Scale, Screen for Child Anxiety Related Disorders (SCARED) or GAD-7) that capture the symptoms of the anxiety disorders, and may ask the parent/family and the teacher to complete anxiety rating scales to capture the full range of anxiety disorder symptoms.
• Share modifications that can be made to decrease anxiety, including: decreasing use of social media and screens in general, limiting caffeinated beverages, ensuring the student is getting enough sleep and increasing exercise.
• Support treatment for anxiety disorders. Many adolescents and children experience full remission of anxiety disorder symptoms with evidence-based treatments.