Fear and Loathing in Public Schools

What is Anxiety? Anxiety is an emotional state similar to fear.  Fear can be defined as a normal (adaptive) emotional and physiological response to perception of an external threat.  Anxiety is the pathological or irrational persistence of fear in the absence of threat.   When symptoms associated with anxiety are frequent, intense, numerous, and durable (FIND) enough to cause significant distress or impairment of functioning, an Anxiety Disorder can be diagnosed. 

How common are Anxiety Disorders?  According to Massachusetts General Hospital (MGH) “Anxiety disorders are one of the most common mental health conditions in children and adolescents.” 

What are the consequences of Anxiety Disorders:  Research has shown that if left untreated, children with anxiety disorders are at higher risk to perform poorly in school, to have less developed social skills and to be more vulnerable to substance abuse.  Anxiety disorders are often associated with avoidance, a coping mechanism that temporarily lowers distress, but also shrinks the size of the individual’s zone of comfort.  The anxious person’s world tends to become smaller and smaller.  Anxiety disorders can become chronic and debilitating. 

How do Anxiety Disorders present in childhood?  Physiological and behavioral responses to fear are primitive survival mechanisms carefully selected for by evolution.  Immature human animals tend to act on their feelings rather than talk about them.  Because youngsters are still developing skills for self-observation and have may have a limited vocabulary for feelings, behavior does the talking for them.  Behavioral responses to fear and anxiety can be overt/intuitive or covert and counterintuitive. 

 How are anxiety disorders defined and differentiated?

 Distinctions between anxiety disorders are largely artificial.  Individuals often have symptoms that meet criteria for multiple disorders.  Differential diagnosis is attempted for research and specificity treatment approaches, but treatments tend to be the same regardless of the name.

1.       Specific phobia - fear of a particular object (for example, spider) or situation (for example, airplane travel)

2.       Generalized anxiety disorder  (GAD), characterized by fluctuating levels of apprehension, tension, and worry, that may “float freely” between stimuli.  GAD affects approximately three to four percent of children. 

3.       Social phobia or social anxiety - fear of meeting new people or of embarrassing oneself in social situations.  Socially phobic people may have panic attacks triggered by the stress of being around others.  This is a common cause of anxiety-based school refusal and selective mutism (persistent failure to speak in specific social situations)  

4.       Separation anxiety disorder - fear of separating from familiar people or places (similar to agoraphobia, which is avoidance of public places where panic attacks might be embarrassing or dangerous). 

5.       Panic disorder – spontaneous, unpredictable and repeated attacks of intense fear and physical symptoms.  Panic attacks are often experienced as physical illness, prompting emergency medical assessment. 

6.       Obsessive-compulsive disorder – intrusive and unwelcome repetitive thoughts or images, often accompanied by repetitive behaviors (rituals, non-functional routines) intended to prevent the fears from being realized. 

7.       Post-traumatic stress disorder:  complex behavioral responses to stresses that are “beyond the scope of usual human experience” characterized by re-experiencing (intrusive memories, flashbacks, nightmares), avoidance of reminders, emotional outbursts and/or blunted emotions, and sometimes “repetition compulsions” (re-enactment of the traumatic events). 

Alcohol, pain-killers, marijuana:   Many (most) individuals go without professional treatment and often “self-medicate." 

Skills-based psychotherapy (CBT, DBT, relaxation training, stress management):  support is essential but will not address anxiety effectively.  Most anxious people have already sought and failed to respond adequately to support, reassurance, proximity, etc.  Research supports specific therapeutic approaches, especially exposure-based treatments.  These forms of therapy use gradual de-sensitization or abrupt “flooding” exposure to feared situations but erect obstacles to the usual avoidant responses to anxiety.  Eventually, the stimulus loses the power to produce overwhelming symptoms.  Cognitive approaches, which supportively confront errors in thinking common to anxious people are most useful for older teenagers and adults whose intellect is mature enough to utilize logical arguments.  Parent guidance is an essential part of any psychotherapy intervention for children. 

Medications: (antidepressants, benzodiazepines, antihypertensives, buspirone, anticonvulsants, antipsychotics) are not well studied, especially for children.  They are in common use, however, and are considered safe and relatively effective.  The Food and Drug Administration has not approved any drug for the treatment of generalized anxiety disorder in the pediatric population.  FDA indications are limited to treatment of OCD and PTSD. 

Check out All About Meds for more information about this option. 

What can be done at school to help the youngster with an Anxiety Disorder?

The school counselor must establish an alliance with the anxious student.  To be effective the counselor-student relationship must be insulated. Alliance is extremely difficult to accomplish if the counselor has a administrative/disciplinary administrative role in the school.. 

MGH at www.schoolpsychiatry.org suggest the following:

Pearls of Wisdom:

Anxiety disorders can be caused by biological factors (stimulants, caffeine, thyroid, alcohol withdrawal)

Anxiety disorders are the great imitators (tantrums, aggression, suicidality)

Anxiety disorders can hide (like a pebble in a shoe)

Anxiety disorders complicate or cause other conditions (ADHD, mood disorders, personality disorders, alcoholism, coronary artery disease)

Consider anxiety when: 

 Disclaimer:  The information in this educational material was adapted and enhanced from a number of publically-available sources, which are attributed when possible.