December 2001/January 2002

December 2001/January 2002 | Volume 59 | Number 4
Understanding the Law Pages 82-83

These are anxious times. The intensity of recent events and the sense of uncertainty make everyone feel uneasy. As anxious feelings become commonplace, the potential for the appearance of serious anxiety disorders increases. Differentiating between normal responses to intensely uncomfortable situations and potentially pathological states of anxiety becomes particularly important, especially for educators.

What is anxiety? Although psychologists debate the definition of this emotional state, most agree that anxiety is a transient, disagreeable feeling associated with a sense of impending danger or doom. Anxiety is different from fear, a more charged emotion associated with the identification of a clear threat. Typically, anxiety motivates people to act in ways that avoid or neutralize a less-precisely identified peril.

Anxiety is not necessarily maladaptive. The capacity to sense and avoid potential dangers is a potent tool, allowing an individual to escape the more traumatic effects of direct confrontation. As with many emotional states, however, anxiety exists along a continuum. Anxiety that disrupts functioning will in many instances be counterproductive and extremely maladaptive. In children and adolescents, pathological anxiety can disrupt academic performance and derail social and cognitive development. Early detection of anxiety disorders is therefore crucial.

Four common anxiety disorders experienced by school-aged children are Generalized Anxiety Disorder, Separation Anxiety Disorder, Social Phobia, and Panic Disorder. The Diagnostic and Statistical Manual of Mental Disorders, the reference book for mental health professionals, lists formal criteria for these disorders and for other anxiety-related states, including post traumatic disorders (see "The Shrink in the Classroom," October 2001) and the more complicated anxiety states related to Obsessive Compulsive Disorder.¹ With the exception of Separation Anxiety Disorder, mental health professionals first defined the characteristics of all these disorders in adults and then later extrapolated the characteristics to children. Because of this history, the exact criteria for anxiety disorders as they relate to children and adolescents are sometimes controversial. As with all psychosocial symptoms, however, any anxiety state that noticeably disrupts development deserves prompt attention, regardless of whether or not it meets criteria for a formal disorder.

Generalized Anxiety Disorder

Intense, chronic worries that are often difficult to control define Generalized Anxiety Disorder. Although the intensity of an afflicted child's generalized anxiety may wax and wane, the hallmark of the disorder is its chronic and persistent nature. Children may also complain of stomachaches and headaches, and parents and teachers often note that young people with this condition have great difficultly relaxing. Recent studies suggest that this disorder affects 3 percent of children and 4 percent of adolescents.

Separation Anxiety Disorder

Persistent and severe anxiety when separating from primary caregivers characterizes Separation Anxiety Disorder. Children with this disorder will express fears for their parents' or caregivers' well-being and may resist going to school or to other activities that require them to leave their parents' or caregivers' side. Children with this disorder also frequently express physical complaints but will only experience their stomachaches or headaches in the context of separation. Wishing to sleep in a parent's bed is also characteristic of this condition. At a very young age, separation anxiety is a normal aspect of development. Infants and toddlers often display intense distress when parents are leaving for work or leaving them at day care. When this behavior persists or resurfaces during later years, however, it is obviously disruptive to almost every aspect of the child's development. Most studies suggest that this order occurs in roughly 4 percent of children and adolescents.

Social Phobia

This disorder involves intense anxiety when interacting in public settings. Individuals with Social Phobia will be dramatically affected by criticism and will fear public humiliation. Important school-related tasks—speaking in public, trying out for sports or dramatic performances, or even forming close friendships—may be impaired, and children with this disorder are generally quite lonely as they negotiate their world in shadows, avoiding public scrutiny. Social Phobia is different from normal shyness. Most temperamentally shy children will still involve themselves in social situations, and parents and educators need to take care not to pathologize normal aspects of a child's personality.

Panic Disorder

Panic Disorder involves discrete events known as panic attacks. In these instances, individuals experience immense emotional discomfort and fear and have accompanying physical symptoms, all consistent with a fight-or-flight response. Panic attacks can involve heart palpitations, shortness of breath, profuse sweating, choking, dizziness, or a feeling of being outside of one's body or losing control of one's actions. Episodes of panic sometimes have clear precursors—fear of bridges or tunnels, apprehension on opening night of a play, or anticipation of speaking in public—but panic attacks also can seem to occur out of nowhere. Some studies suggest that roughly 5 percent of juveniles admit to experiencing at least one panic attack.

Treatment

Separating disorders into discrete entities is helpful for identifying different expressions of pathological anxiety and for avoiding inappropriate treatment. Often the apparently "spaced-out" student is actually terrified, and reprimands to pay more attention can lead to diminished self-esteem and failure. An incorrect diagnosis of Attention Deficit Disorder can lead to improper medical treatment and can make anxiety worse. Also, sometimes symptoms overlap. Children with Social Phobia may experience panic attacks, for example, or separation anxiety may occur in the context of more generalized anxiety. All these difficulties carry the potential to be enormously disruptive. A student whose anxiety is paralyzing and incapacitating deserves prompt attention, both in and out of the classroom.

Outside the Classroom

Many students with overwhelming anxiety will require services outside the classroom. In these instances, teachers should consult with designated school officials to arrange a more formal evaluation and potential treatment. Treatment for these syndromes usually involves some combination of psychotherapy or counseling and medications, including selective serotonin reuptake inhibitors or such agents as buspirone and tricyclic antidepressants. Also, behavioral therapies can offer young people important tools in dealing with their fears. These treatments involve slowly exposing a child to situations likely to provoke distress while at the same time helping him or her master the situation and stay relaxed and in control. This technique is especially helpful with panic attacks and Social Phobia.

For separation fears involving refusal to attend school, the parents or educators need first to ask such questions as what the student gains by staying at home and what risks he or she takes by attending school. Removing incentives to stay at home while helping the student to slowly reintegrate with the school environment can be helpful. If intense anxiety prevents school attendance, forcing the student to suddenly participate in all parts of the school day will often intensify the student's hopelessness and increase the frustration of those attempting to care for and teach the student.

Inside the Classroom

Keeping in mind the possibility that a student may be suffering with one of these disorders, teachers can be aware—and not dismissive—of students who experience intense anxiety. Fear is immensely distracting, and students who are constantly trying to keep their anxiety at bay are not likely to be efficient academic performers. To this end, teachers might take careful note of situations that appear to provoke the most anxiety and help the student avoid these situations.

For example, if public speaking is absolutely necessary, the teacher can ask the student in private how best to accomplish this task. Some students will prefer to "get the assignment over with" by going first, whereas others might prefer the relative anonymity of speaking after the class has heard a number of presentations. Giving the student a choice conveys a sense of control and mastery and might help alleviate some of the dread. Taking care to avoid the student's public humiliation and respecting, as much as possible, a student's wishes to remain more distant is important, as is making every attempt to create an environment in which anxious students feel more comfortable contributing to the class as a whole.

Empathic and careful teaching goes a long way toward helping the anxious student. As with all teaching, helping students feel more at ease with themselves is among the most important roles that an educator can play.