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Helping Highly Anxious Students. Dr. Greg Schoepp Chartered Psychologist [email protected] (780) 407-7075 Capital Health Authority University of Alberta Hospital Stollery Children’s Hospital. What is Anxiety?.

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Helping Highly Anxious Students

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Helping highly anxious students l.jpg

Helping Highly Anxious Students

Dr. Greg Schoepp

Chartered Psychologist

[email protected]

(780) 407-7075

Capital Health Authority

University of Alberta Hospital

Stollery Children’s Hospital


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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


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Relationship Between Thoughts and Feelings

Emotions are a direct result of your thoughts and beliefs about an event.

EventThought/beliefEmotional

Reaction

attendingmight be usefulmotivation

anxiety sessioninterest

Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital


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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


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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


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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


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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


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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


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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


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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


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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


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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


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Anxiety ThermometerFor Young children

Small WorryMediumWorryBig worry

123

Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital


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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


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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


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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


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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


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(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


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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


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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


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Simplifying Realistic ThinkingJanice, age 11

Greg Schoepp, Chartered Psychologist Psychology-University of AB Hospital


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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


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Skating competitions10

Away from family, mom 9

Giving speech 8

Getting interviewed10

Going somewhere on

my own10

_____________________________________________

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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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