Helping Highly Anxious Students

1. Helping Highly Anxious Students Dr. Greg Schoepp Chartered Psychologist gschoepp@cha.ab.ca (780) 407-7075 Capital Health Authority University of Alberta Hospital Stollery Children’s Hospital

2. What is Anxiety? • A complex pattern of behavioral, cognitive, and physical reactions to a real or imagined threat. • Physical responses: heart rate, sweating, muscle tension, skin temperature, stomach upset. • Cognitive/affective responses: thoughts of being scared, danger, self critical thoughts, hyper sensitivity to physical symptoms • Behavior responses: avoidance, trembling voice, crying, anger outburst, loss of emotional control Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

3. Relationship Between Thoughts and Feelings Emotions are a direct result of your thoughts and beliefs about an event. EventThought/beliefEmotional Reaction attending might be useful motivation anxiety session interest Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

4. Characteristics of Anxious Students • get upset at changes in routines or at mistakes • is a loner or prefers small group of “safe people” • limited social skills, refuse to participate in social activities • difficulty separating from caregiver at start of day • associated health issues - asthma, severe allergies • poor concentration, irritability, restlessness, distractibility Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

5. Characteristics of Anxious Students Learning problems and anxiety • increased anxiety about being “different” • black & white thinking style, hard to differentiate exaggerated vs realistic worries • more rigid, inflexible approach • combination of issues -i.e. tourettes, ADHD, lower cognitive functioning Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

6. Viewing the World as Dangerous • thinking biases - more threatening interpretations of ambiguous situations • overestimate likelihood unpleasant event occurring or overestimating probability • overestimate how negative consequences will be if event happens, catastrophizing outcomes • preference for poor coping responses • enhanced memory for threatening information Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

7. Separation Anxiety Generalized Anxiety Specific phobia Specific Phobia Obsessive-Compulsive Disorder Panic Attack Panic Disorder Acute & Post Traumatic Stress Adjustment Disorder School Refusal (not in DSM-IV) Types of Anxiety Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

8. Ineffective Teacher Responses • excessively reassure the student, for example, repeatedly telling the student that "every thing will be all right” • being too directive. Tell the student exactly how to handle the situation • remove the student from the feared the situation or allow the child to avoid the situation Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

9. Ineffective Teacher Responses • empathize with student's anxiety by discussing in detail what makes them anxious and afraid. Modeling anxious behavior • become impatient with the student, frustration, anger Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

10. Effective Teacher Responses • reward brave, non anxious behavior • ignore anxious, clingy behavior you don't want, especially when child seeks reassurance from you that "everything will be all right" • help student to find their own solutions. Coach student to problem solve. Increase “coping” thoughts, challenge negative self talk. Expect good things to happen Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

11. Effective Teacher Responses • model brave, non anxious behavior • prevent avoidance • provide opportunities for developing independence, i.e. run message to office for you • allow student to experience natural consequences of their fear • encourage help-seeking (i.e. school counsellor) and destigmatise the issue Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

12. Effective Teacher Responses • encourage gradual exposure to fear. With student’s help, establish set of challenges to help overcome fears • when possible and appropriate, develop exposure with parents who provide incentives for success (reward effort) • refer student for specialist help when anxiety over whelming Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

13. Anxiety ThermometerFor Young children Small Worry MediumWorry Big worry 1 2 3 Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

14. Relaxation Strategies • address the physical reaction when feeling worried, nervous or afraid • awareness of body clues, i.e. feeling ill before math test • relaxation • robot/ragdoll exercise • progressive muscle relaxation • deep breathing • visualization Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

15. Four Steps to Challenging Anxious Thoughts 1. Identify thought behind emotion - have student state what they worry might happen “I’ll make a mistake and people will laugh at me” 2. Look for evidence - use questions with student Past experience Alternative possibilities General Knowledge Take Different Perspective (adolescents) Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

16. Four Steps to Challenging Anxious Thoughts 3. Evaluate Thought on Basis of Evidence “How likely is it that the bad thing I’m expecting will actually happen?” Use percentages or descriptors, “not likely” 4. Examine Consequences of Feared Event For adolescents-challenging consequences “What is the worst that could happen here?” Formulate coping strategies Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

17. Addressing Anxious Thoughts Realistic Thinking or Detective Thinking (Rapee, 2000); Thought Challengers (Barrett, 2000) (event) What is happening? (thought) What am I thinking? Worry rating? 1-10 Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

18. (evidence) What are the facts? What do I know about the situation? What happened before when I was worried? What else could happen? What is likely to happen? How likely is it that the bad thing I’m expecting will actually happen?” (coping) What is my helpful (realistic thought)? What will I do to cope with this situation? Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

19. Evidence Questions for Older Students Have I ever been in a situation like this before, and was it really that bad? How many times has this terrible thing actually happened before? What will most likely happen in this situation? What is the worst thing that can really happen? Am I 100% sure that this will happen? What else might that person be thinking about me? So what if the situation does not go perfectly? Am I the only person who has ever had to deal with this situation? Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

20. Simplifying Realistic ThinkingJanice, age 11 (Evidence) Check things out What do I see? What do I hear? What do I smell? What do I feel? Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

21. Simplifying Realistic ThinkingJanice, age 11 Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

22. Fear and Worry List These things are really hard to do Worry Scale (0-10) __________________________________________________________________________________ __________________________________________________________________________________ These things are hard to do __________________________________________________________________________________ __________________________________________________________________________________ These things make me a little worried __________________________________________________________________________________ __________________________________________________________________________________ Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

23. Skating competitions 10 Away from family, mom 9 Giving speech 8 Getting interviewed 10 Going somewhere on my own 10 _____________________________________________ Making friends 7 Lunch at school 5 Late for school 7 Shopping w/o parents 7 Talking to strangers 7 _______________________________________________ Falling asleep 4 Being with people I don’t know 4 Giving my opinion 3 Being dark by self 2 Fear and Worry List ExampleAmber, age 12, grade 7 Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

24. Step by Step Plan (Exposure Hierarchy) My Goal: Not to be bothered by making mistakes at school STEP 10: Don’t have correct textbook for a lesson STEP 9: Deliberately give wrong answer to a question in class STEP 8: Forget to return library books on library day STEP 7: Answer question in class without being 100% sure STEP 6: Hand in assignment with two spelling errors STEP 5: Draw doodle in margin of page to turn in STEP 4: Make deliberate mistake in math exercise STEP 3: Don’t bring permission slip back to school on first due date STEP 2: Cross out homework mistake and hand in without rewriting STEP 1: Listen to music for half hour before doing homework after school Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

25. Making Exposure Effective • fears are faced gradually, slightly difficult to most difficult • student experiences progression in difficulty and anxiety • student must remain in situation long enough to confirm negative belief is not true • practice and repetition keys to success. Student learns situation is not threatening Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

26. It’s Hard Work, Rewards Help • help students evaluate their performance in terms of partial success • for older children - “Think like a winner” The situation was….. Positive aspects of the situation were…… Things I could improve on next time…... Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

27. It’s Hard Work, Rewards Help • for younger children- performance barometer for self-evaluation How well did I cope? Super Well, Well, Okay, A little, Didn’t try very hard, Didn’t try at all • negotiate reward/incentive for each step before starting plan, parents are important here • rewards for large steps or milestones important Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

28. Social Skills Competence • body language skills - eye contact, posture, facial expression • voice quality skills - tone, volume, clarity • conversational skills - greetings & introductions, initiating and maintaining conversations • instruction, rehearsal & feedback, practice • modelling most effective (video, modelling by teacher or peer) Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

29. Social Skills Rehearsal (Rapee et al.., 2000) • Conversation game - 30 second paired conversation with prompted cues, job interview (adolescents) • hobby talk, tale time ( 3 min. reading or speech), in the movies (act out scripts) • conversation brainstorm, movie scriptwriter (adolescents), scenario game Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

30. Social Skills Practice • set tasks where student can practice skills in real-life situations • graded exposure tasks to increase skills and confidence • use school activities and assignments as practice situations - i.e. class presentation, paired reading Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

31. Assertiveness Training(Rapee et al., 2000) • helping students differentiate assertive, wimpy (passive), and grouchy (aggressive) behavior • develop skills in non-verbal and verbal assertive behavior • rehearse with role plays and real-life situations • practice in front of mirror, with family members, groups of students Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

32. Assertiveness Training(Rapee et al., 2000) Assertiveness Checklist • strong EYE contact • good POSTURE • clear VOICE • SAY WHAT YOU WANT politely (content) • APPEAR confident • BEHAVE appropriately Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

33. Assertiveness Training(Rapee et al., 2000) Outsmarting Bullies • TALK to others • get an AUDIENCE • do something DIFFERENT • develop CLEVER COME-BACKS Tease: You’re so stupid Come-back: You’re observant, ever thought of being a news reporter? Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

34. Importance of School Environment • anxiety problem not necessarily within child or home-based • responses of teachers, administrators, other staff can be crucial • deal with differences in how staff conceptualize child’s problem - important in JH and SH grades • effective teachers DO make a positive difference for anxious students Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital

35. When and How to Refer Families For Help • when child is overwhelmed, unable to cope • community counselling agencies • family physician or pediatrician referral • psychologists • child psychiatrists • medication • self-help books Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital