Children with Anxiety: Role of the School and Health Care Systems

Parents and schools have a responsibility to work together in the best interests of the child. If parents and schools are at odds with each other, they effectively undermine each others efforts and the child is left helpless. Parent’s primary reaction is to protect their child, so they often fall into the trap of nurturing the child’s anxiety, they often will need to be trained as to their role in helping the child deal with anxiety. Staff should also be educated about this issue and taught what to expect and how to react.

If you suspect a child has anxiety, then they need to be seen by a doctor for an evaluation. If the parents don’t understand what you are seeing they will not take the child for an evaluation. It is also important to rule out other medical reasons for symptoms and/or complications. It is important to get the doctor’s impressions and recommendations before a team meeting is called. If he or she is available ask them to attend the team meeting.

Do not rush and try to do something, you need all players on board before any strategies are put in place.

Management of Anxiety in School

The importance of stabilization

This involves setting realistic expectations about what a child can accomplish in a time of crisis.

Until an anxious child has the skills to de-escalate anxiety, the responsibility for defusing the situation is with the adults. Being rigid, inflexible and insistent on rules adds to the child’s sense of being overwhelmed and unable to cope. Crisis should be anticipated and a crisis management plan should be proactively developed. A proactive plan for de-escalation must involve the child and the parents. Do not try and do this when the child and family are in crisis. The child will not hear anything you have to say and the parents will only be focusing on how to protect their child. Wait until everyone is calm and able to think rationally.

When a child’s academic functioning slides, the stress of trying to catch up can be overwhelming and they often give up.

Children should not be punished for behaviours that are clearly driven by anxiety. Rather, being excused temporarily while he or she is learning how to overcome their anxiety is a more helpful response. It helps if all the adults can see and understand the intent behind the behaviour.

Anxiety is a genuine problem over which the child has no control. Anxiety is a legitimate illness that impairs coping and functioning – it is not manipulative or self-serving, children do not derive any pleasure from what they do, they are genuinely scared and do not have effective coping skills. Therefore, children with anxiety type behaviours have a right to appropriate school and health based services.

Any developed plan must filter down to all the people who have contact with this child.

School based intervention must be planned, not developed in haste. It must be practical and feasible at school. It must address the cognitive, physical and behavioural aspects of that child’s anxiety. The goals must be specific, manageable, discrete and progressive. The goal is to build resilience, promote wellness and create a climate of proactive and positive handling of stress.

 

  1. Primary Prevention – educate all children about dealing with anxiety, regardless of their anxious tendency (promote healthy coping with stress, fear and anxiety).
  2. Secondary Prevention – involves identifying children who may be prone to anxious tendencies and teaching them anxiety reduction skills proactively.
  3. Tertiary – children who already have problematic anxiety (reduce the length and severity of recurrences or increase the time between relapse).

 

Primary Prevention

 

  • Educate yourself and all staff about anxious behaviours in children.
  • Educate both the parents and the children about the differences between anxiety and fear, what happens in the brain, possible resulting behaviour and why it happens.
  • Teach both the parents and the children how to proactively plan for these situations and experiment with different types of appropriate coping skills. One skill does not work for everyone and it is important for the children to understand what works for them.
  • This helps to remove misconceptions of anxiety and fear as weakness.

 

Secondary Prevention

 

  • If you think a child is demonstrating anxious behaviours ask him or her; “What is going on or what is happening?” Do not ask them why they are doing what they are doing.       If it is a fear based response then call the parents and set up a meeting. Face to face is better than over the phone. Some parents are extremely nervous about meeting at the school. (There is a genetic link for anxiety.) You can offer to meet them somewhere neutral that is private or at their home if your administration allows.       Gently explain what you have seen and found out from the child’s responses and then ask if they have seen anything similar. This should be a discussion, not one adult telling another adult what to do.
  • Children identified as anxiety prone can participate in group training on various stresses and coping topics. Peer mentors/support also help, especially if the peer has experienced anxiety issues themselves. (Involves removing blame and shame, validating feelings & fostering appropriate problem solving).

 

Tertiary Anxiety

 

  • This is aimed at children who have already displayed problem anxiety and behaviour.
  • Involves being proactive in anticipating potential crises, identifying triggers and preparing the child and the classroom for future episodes of anxiety, and together with the child and the parents developing a planned response.

School plan:

Identify specific concerns:

    1. Focus concerns into precise descriptions of specific behaviours that the child is exhibiting, the specific conditions in which they occur.       When, in what context, and how, and when they interfere with the child’s ability to function academically and socially.

Develop partnerships:

 

    1. School –home
    2. Student – teachers (who is involved and who needs to know)
    3. Establish timelines for effective communication and consistency.       This system needs to be clarified before anything is implemented.
    4. All must respect each others perspectives and contributions.
    5. A NO Blame NO Shame attitude.

Conduct systematic assessment:

 

    1. Understand the child as a person, not as a problem.
    2. Use several methods – observation, interviews, rating scales, questionnaires and psychological tests.
    3. Assessment continues during and after intervention in order to track changes.
    4. Focus on the child’s attempts to change or control the behaviour and not outcomes. Do not focus on just the end behaviour –reward any and all attempts at an appropriate coping strategies with a positive discussion on the child’s commitment to helping themselves. These children, for some reason, can’t handle a reward for behaviour change and I haven’t figured out why yet. If you just reward the behaviour change you will find the child will quickly revert back to the inappropriate behaviour, if you focus on the attempts you will help the child feel successful.

 

You need to know, understand and accept the following:

 

  • Triggers
  • Frequency
  • Severity
  • Duration
  • Interference
  • Peer, parent/teacher responses.
  • Interviews allow a better understanding of the child’s thought process and mood state, insight, motivation and readiness to engage in change. Parents provide information about history, pervasiveness and persistence of the behaviour. School and home reactions can be assessed – do these exacerbate or calm?

 

Define goals & prioritize target behaviours:

 

  • Focus of Interventions
    • Identify fears, worries and anxieties.
    • Identify body changes connected with anxiety.
    • Link thought, feelings and physical symptoms.
    • Identify specific triggers for anxiety.
    • Identify and correct sources of anxiety with possible outcomes.
    • Take charge of feelings and behaviours.
    • Develop realistic self-talk.
    • Learn to self-soothe, take space.
    • Confront fears via gradual exposure.
    • Experiment with and use different problem-solving skills.
    • Build confidence and optimism.
    • Utilize appropriate assertiveness and social skills.
    • Develop self-reliance.

 

Cultivate treatment readiness: (This is an incredibly important step that often gets overlooked because the adults often think they know best.)

 

  • Child might not be motivated or ready to confront fears or in agreement of what behaviour to change.
  • Everyone needs to understand how change can occur. (Worry Hill, Noise at Window are helpful.)
  • They need to see the necessity for change, the possibility for change and believe they have the power to change.
  • Must have collaboration with the child and family.

 

Apply interventions: Before any interventions are undertaken the following issues need to be clarified, agreed upon and communicated among all members of the team.

 

  • What precise steps are involved in each intervention?
  • What resources will be needed to put the plans into action?
  • What specific roles are to be played by the child, parent, teacher, other school staff or other provider?
  • Who is responsible for implementing and monitoring each intervention?
  • Do staff or parents need to be trained before proceeding?
  • Has the child been prepared adequately for each intervention?
  • Where and when will each intervention occur?
  • What exactly will happen when the intervention is carried out?
  • How will the child’s response to each treatment be recorded?
  • How will the plan be evaluated?
  • How will the need for modifications be determined?
  • How will changes be incorporated and executed?

 

Evaluate & Modify

 

  • This is important to determine if the child is meeting the goals (after a predetermined amount of time) using the same methods that were used to obtain the baseline.
  • A 75% improvement is a good indicator of success, if there is less than a 30% improvement then you need to start over again – you have missed something.
  • Indicators of improvement (attempts to control) should be individually considered for each child.
  • Questions for evaluation
  1. Is the child actively trying to control his or her behaviour?
  2. Were interventions implemented as agreed and written?
      • If not, what needs to be corrected?
  1. Have there been obstacles to the application of the plan?
  • If yes, what changes need to be made to eliminate the problem?
  1. If progress is in the right direction, what is the next step?
  2. For how long should the intervention be continued?
  3. When is the intervention to be tapered and stopped to allow the child to utilize the skills he or she has acquired?
  4. What is the follow-up plan? Once the goals are reached then you need a follow up plan – in times of stress this behaviour often will come back.
  5. When and how often will booster sessions be provided?

 

Wagner, A. (2005) Worried No More; Help and Hope for Anxious Children.                   Lighthouse Press, Rochester, NY.

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