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Address Student Anxiety
9/1/2016
Mary E. McCormac
Thursday September 01, 2016
by: Mary E. McCormac

Section: Inside Insight


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There is currently a stress and anxiety crisis in our schools. Anxiety, a sense of fear and worry, is the most common mental health challenge facing children, teens and adults. More than a quarter of teens report experiencing extreme stress during the school year. Some stress and anxiety is good, but extreme levels result in students feeling overwhelmed, having health problems related to the release of stress hormones in the body and sometimes even contemplating suicide. Stress is a trigger for anxiety and perfectionism. Without social/emotional education and early intervention, youth often develop unhealthy coping strategies and behaviors to deal with anxiety. These unhealthy behaviors often persist into adulthood.
 
School counselors at all levels encounter students with a variety of types of anxiety and report finding those who also have cognitive rigidity and perfectionism to be among the most challenging to help. Pressure and high expectations now begin in preschool with even kindergarten students feeling anxious and stressed but without the ability to tell adults why they are distressed. More and more school counselors are being asked to help students experiencing severe panic attacks in school and deciding if they need to be sent home from school.

We need to look at anxiety and stress in context. School counselors need to advocate for there to be less pressure on students to take as many accelerated courses as possible, achieve unreasonably high grades and perform at advanced levels on tests. In many communities, the push for excellence seems to be part of the school culture and can come at a cost to students’ mental health and wellness. Today’s students experience additional stress from the digital world, which consumes much of what in the past would have been downtime.

How to Help
Practicing stress-reduction strategies can help students rebuild the damage stress causes to their brains and avoid damage to their bodies, relationships and school performance. Most school counselors agree that helping students develop self-regulation skills works better than trying to make them anxiety-free. Today many add the additional goals of making students “stress smart” and increasing mindfulness. The two research-based counseling approaches shown to be effective in teaching positive ways to cope with anxious behavior are cognitive behavioral therapy and mindfulness-based stress reduction. Mindfulness helps students befriend anxiety rather than see anxiety as the enemy. There is also some evidence that motivational interviewing can help reduce anxiety and in some cases cognitive rigidity and perfectionism.

Because anxiety is an internalizing behavior it can remain hidden or undetected for a long time. By collaborating with students, parents, nurses, teachers, administrators and community mental health providers you can maximize the probability of identifying students with high levels of anxiety and providing a supportive environment for them to practice new ways of coping with anxiety and stress. School nurses are often the first person in a school to recognize that a student making frequent visits to the clinic doesn’t have a physical aliment but rather anxiety. You can also educate teachers about some of the common signs of anxiety such as problems concentrating, missed deadlines, decline in participation, absenteeism and tardy arrivals and urge them to consult with you to determine if intervention for a particular student is needed.

Teachers can also serve as powerful models and think out loud so students realize adults need to be stress smart too. For example, teachers can say, “Let’s just all take a minute to breathe slowly and be aware of our surroundings before we begin our day.” Administrators can help reduce stress by managing the demands that come from an overcrowded calendar and no downtime for students (and staff). We know, for example, that lack of adequate sleep makes anxiety worse, which is part of the argument for later start times for teens. More so than many other mental health challenges, context is key to the level of anxiety and the appropriate intervention.

Whenever possible, school counselors should address aspects of the parent-child dyad or family dynamics, which can lead to increased stress and anxiety for students and the family as a whole. We aren’t trying to blame parents but rather help them understand the big picture and what they can do to reduce their children’s anxious behavior and increase bravery. Parents generally want their children to be happy and will initially respond to an anxious child’s wish to avoid what the child thinks is unpleasant or scary. It’s important to teach parents that the goal in helping their anxious children is to prevent avoidance and learn healthy coping mechanisms to deal with their anxiety instead.

Parents can be critical to helping with systematic exposure or desensitization to the source of their child’s fear (objects, thoughts and situations). For example, if a child is nervous about playing a solo in orchestra in an assembly, parents can have the child practice at home in front of friendly faces. They can then ask if the child can practice at school in the same room as the performance but without an audience and work with the school counselor to devise a cue during the performance to show that the school counselor or parent is there for support the day of the performance. When parents work together with the school to help their child overcome anxiety, it helps the student much more in the long run than when parents e-mail the orchestra teacher and say their child can’t perform the solo.

Parents are often the ones putting the pressure on their children to take challenging courses, earn high grades and participate in multiple extracurricular activities. Although students with a high level of perfectionism frequently put that pressure on themselves, it is often a learned behavior, with parents reinforcing schedules that don’t allow for needed downtime. School counselors can teach parents useful communication skills, such as thinking out loud and modeling to encourage their children to be stress smart. “I could go answer some work e-mails, but I’d rather we take a walk together.” Changing the responses of others to anxious behavior, especially parents, is frequently critical to reducing students’ anxiety. Finally, if parents are dealing with anxiety themselves, encourage them to reduce their own anxiety as yet another way to help their child.

Multitiered Systems of Support
Most schools today have or are moving toward a multitiered system to support students’ academics and behavior. School can address anxiety and stress challenges schoolwide through a mental health awareness day or mental wellness week. Look at the school year, and prepare for peak times of anxiety and stress. For example, the start of a school year or a long break from school can trigger specific behaviors, which can be reinforced by the responses and outcomes that follow the behavior. Pay special attention to students transitioning to a new school, which is a stressor. You may need to implement de-stressing tips and activities during the end of the quarter when many projects are due, tests are given and standardized tests are administered.

For elementary schools these activities could be done in the classroom, and at the secondary level school counselors can set up a play and wellness table in the cafeteria with de-stressing activities, such as coloring mandalas, making stress balls, blowing bubbles, writing positive affirmations on sticky notes and posting them on a bulletin board. Viewing anxiety behaviors as “learned” suggests the school counselor can modify the environmental conditions so problem behavior is less prevalent and occurs less frequently.

Schools are beginning to see the importance of having an evidence-based schoolwide social/emotional program in place. Learn more about these programs at www.casel.org/.

To help prevent anxiety from becoming a concern, teach all students positive self-talk to regulate attention, thoughts and emotions. The best way to teach these skills to all students is through an evidence-based program such as Second Step or MindUp. In these programs all students learn ways to develop emotion regulation through diaphragmatic breathing, accurately identifying feelings and problem-solving skills to handle challenge. By encouraging all students to focus on positive emotions like happiness and teaching them that kindness and compassion make both the giver and receiver more positive, you can help them cope with anxiety. The student, parents and teachers need to reinforce progress toward new, more appropriate skills so they will be repeated. Teachers should try some accommodations and record data on their effectiveness for at least four weeks before referring a student for a Tier 2 intervention.

Some students will need Tier 2 levels of support to learn and implement strategies to cope with stress and anxiety. You can identify these students based on their responses to perception surveys at the end of classroom lessons or from other data such as an increase in absenteeism or decrease in class participation. Screen referred students to determine if Tier 1 interventions have been effective and what more may be needed. Common Tier 2 interventions for anxiety include a behavior plan, structured breaks, morning check-ins and evidence-based skill development such as social skills training and progressive muscle relaxation.

Generally it is more efficient to help students with anxiety in small-group settings. Groups have the advantage of normalizing what a student is experiencing and the opportunity to gain support and learn how peers cope with stress and anxiety. Be sure to screen students first, as some students with anxiety may not be comfortable participating in a group and admitting there is something they need to change.
Some students may need short-term individual counseling first to benefit from a group, and others may be more comfortable with an outside referral to a community mental health provider. By working with these students, you can help them find behavioral strategies such as writing in a journal or listening to music, which may help them lessen feelings of anxiety. Explore cognitive strategies such as changing negative automatic thoughts, correcting unrealistic beliefs and interpretations and encouraging flexible thinking. Most anxious thoughts aren’t factual or actual. To help students keep anxiety in check, teach them to ask themselves, “Is this really true?” Additionally, have students write positive affirmations such as “I am safe in school” on an index card they can keep in their pocket to read when needed. Groups offer the opportunity for students to role-play to practice new skills to use in dealing with their anxiety triggers.

Additionally, teach students the benefits of mindfulness, staying in the moment without judging, to cope with stress and anxiety. Often imagery and metaphors are used with mindfulness (e.g., thoughts and feelings are like clouds that appear and float away). Many students benefit from being taught some grounding techniques such as simply observing their immediate surroundings with all their senses (e.g., name five things you can see right now). Another helpful strategy is to self-monitor anxiety on a simple scale from 1-10 or a feeling thermometer to assess what triggers high levels of anxiety and what coping tools help bring the anxiety to an acceptable level. Some students are helped by being taught to externalize the anxiety and name it (i.e., that is just my “worry brain” talking).

As an extension of your counseling, consider helping students find books or mobile apps for coping with anxiety that address mindfulness, relaxation and sleep.

Next Steps
After receiving Tier 2 interventions for a period of time, a few students will still have such high levels of anxiety that it interferes with cognitive functioning and their ability to do what would be considered developmentally appropriate such as come to school on time. Consider addressing Tier 3 interventions with more intensive research-based groups such as Coping Cat or A Still Quiet Place. Additionally, a daily check in check out (CICO) program may help. CICO is an evidence-based intervention consisting of students checking in with an adult at the start of each school day to retrieve a goal sheet and encouragement. Teachers provide feedback on the sheet throughout the day, and students check out at the end of the day with an adult. The student then takes the sheet home to be signed, returning it the following morning at check in. Although this has been shown to be effective with anxiety, it’s difficult for one school counselor to have more than a few students on CICO at a time. Consider using another trusted adult on staff to help implement this intervention. If after receiving Tier 1, 2 and 3 interventions for a reasonable time students are still struggling to cope, it is time to refer out for additional more intensive intervention. Research has shown that a combination of cognitive behavioral therapy and medication is an effective treatment for severe anxiety.

Some students receiving multitiered interventions in the general education setting also have a 504 plan because they have a diagnosed disability that significantly affects learning or another major life activity. School counselors commonly attend 504 meetings and suggest accommodations an individual student needs such as preferential seating, modified class participation and presentation options, small-group testing, alternative location for unstructured time, warning for fire drills or changes in routine like substitutes, use of a “fast break card” that students simply put on top of the desk when anxiety comes on suddenly and they need to leave the room to go for a break with a pre-arranged safe person in the school. Students can receive multitiered support with or without a 504 plan.

School counselors see students struggling with various levels and types of anxiety and stress daily. We need many tools in our toolbox so we can help the students to become stress smart and develop their own coping tools for anxiety that fits their unique needs.
 
Mary E. McCormac is a school counselor at Nottingham Elementary School in Falls Church, Va. She can be reached at mccormacmb@gmail.com.