Tarnow Articles

Academic Anxiety Syndrome and It's Treatment By Anxiety Task Force

Introduction

A Message from the Director
In the past five years, we have observed that many children, adolescents, and adults who have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) have not responded as well as would be expected to the typical treatments. The interdisciplinary team at the Center began to study these patients in detail by pooling our data.

The Center convened a task force to investigate this issue. It became clear that many of these students experience academic anxiety that interferes with their functioning in the school setting. Multiple problems can be confused with, or complicated by, underlying anxiety. These include ADHD, Conduct Disorder, Oppositional Defiant Disorder, Mood Disorders and learning disabilities. Many of these students appeared to be "distractible," "glazed over," or "daydreaming," and unavailable for learning. They often complained about knowing the material and then "going blank," "spacing out," or becoming confused on tests.

Parents and teachers sometimes notice that these students avoid academic work, become oppositional, procrastinate, and get stuck or overwhelmed, rush through work or shut down, become physically ill, or miss school because of illness or because of frequent visits to the nurse.

Incomplete success with previous treatment may in part be related to looking only at a specific part of the individual. Our task force has determined that it is important to conduct a comprehensive interdisciplinary evaluation. This includes assessment of the biological, psychological and social (school, family relationships), aspects of a problem (Biopsychosocial Model ).

Anxiety is an understandable response when students experience failure day after day. Understanding the process by which a student develops academic anxiety is essential for successful treatment. The most successful treatment comes from specialists working closely together, intervening on all three levels of the individual - biological, psychological, and social.

This newsletter is devoted to Academic Anxiety Syndrome. We will delineate the basis of this problem, how it develops, how to evaluate it, and finally, the optimal treatment approach. Please feel free to share your thoughts with us at our website www.tarnowcenter.com. Sincerely,

Jay D. Tarnow, M.D.

What Is Anxiety?

Anxiety is an essential, physical response that communicates the need to pay attention to something in the environment. This reaction has been essential for animals to survive, and is also important for people. It starts as a biochemical change in your brain and body with the release of adrenalin. This chemical increases heart rate and increases your attention to the source of the anxiety. High levels of anxiety or fear cause your body to prepare to fight or run away (fight or flight response) (see Figure 1).

When an animal cannot escape from an overwhelming stress, the next response is the freeze response (see chart 1). This is a physical and mental shutdown, like "a deer caught in the headlights." It is the most severe anxiety response. The survival purpose of this response is to fool the predator into believing that the animal is dead, thereby causing the predator to let go or release the animal. This freeze response is an instinctual, unconscious reflex, just like the fight or flight response. Anxiety is necessary for survival. Some anxiety can motivate or mobilize us to change and to accomplish goals. However, too much anxiety impairs our functioning and can cause Anxiety Disorders. When worry accumulates over a long period of time and becomes a preoccupation, it can lead to psychophysiologic conditions such as migraine headaches, irritable bowel syndrome, insomnia, hypertension, fibromyalgia, and other conditions.

Anxiety can also interfere with academic functioning. From birth, young children are geared to learn. As they learn, pathways of brain cell fibers develop to connect different parts of the brain. These pathways allow children to respond quickly, without conscious thought, to learning situations. (see figure 2) When children confront a learning situation and fail to learn, the automatic nervous system responds with stress and anxiety (fight or flight response). Repeated failure leads to the development of an anxiety response pathway. Thus, an anxiety response pattern is created when the student confronts a difficult learning situation.

Severe anxiety disturbs the capacity to pay attention, increases the motor activity level, sets the mind racing, and can lead to impulsivity. This pattern can look just like ADHD. Children learn how to avoid the painful stress of learning by a variety of behavior patterns, much of which can be unconscious and automatic, just like the fight or flight response. The fight or flight response can be expressed as "acting out", such as being oppositional and aggressive. Stressed elementary students in grades two through four may cry, throw tantrums, wet themselves, or vomit. Children avoid eating, homework and studying, and even develop physical symptoms such as headaches, stomachaches, and even asthma attacks. These students may be spending large amounts of time at home sick or going to the nurse at school throughout the day. Adolescents are more likely to rebel by refusing to participate, cutting classes, using drugs to ease their anxiety, or even deliberately failing a test. When all these methods do not work, some children develop the freeze response. These children will explain, "My mind went blank when I saw the test." These behaviors are unconscious learned responses that help individuals to escape anything that provokes uncomfortable feelings of anxiety. These patterns can continue into adulthood as in the story of the professional who became so anxious about reading as a young child in the stressful school situation that he was unable to read for pleasure.

Sometimes the slightest thing can trigger an emotional overreaction, completely out of proportion to the event itself. This is more likely to happen when we are under pressure and vulnerable. The way we perceive and evaluate our problems determines how much anxiety we experience. While we cannot always control the stressors in our environment, we can change how we think and feel about these stressors, thereby changing the extent to which we feel anxious or threatened. All of us are biological, psychological, and social beings. We cannot separate the brain, mind, and body. Consequently, comprehensive management of anxiety requires an interdisciplinary approach including psychotherapy, biofeedback therapy, cognitive retraining, and/or medication.

The Tarnow Center Approach to Academic Anxiety

Assessment
The Tarnow Center's Academic Anxiety Program is unique, focusing on our combined skills as a team. Our assessment consists of psychiatric, psychological, and learning style evaluations integrated into a comprehensive evaluation. Using a biological, psychological, and social approach, the Tarnow Center obtains a picture of the student through an interdisciplinary team assessment. The team approach is critical for assessing academic anxiety, which is often easy to miss because symptoms of academic anxiety and general anxiety can sound similar to those of Attention Deficit-Hyperactivity Disorder (ADHD) and other disorders. In addition, 30-50% of cases, academic anxiety can co-exist with ADHD, as well as with a learning or language disorder.

Prior to the first appointment, each family participating in the program is sent a battery of questionnaires to be completed by the parents, the child, and the teacher. Thus, we begin the process of understanding the whole child and assessing for the possibility of anxiety, depression, attention problems, and other difficulties that could interfere with learning and daily functioning.

The family then meets with a psychiatrist who obtains a detailed medical history, a history of the student's response to medication, and a complete mental status exam.

A clinical interview by the psychologist helps the team learn more about the specific concerns of the family, as well as possible family dynamics that may be related to anxiety. The clinician obtains a thorough understanding of the history of the child's problems, prior attempts to address them, specific anxiety regarding homework and tests, coping strategies, and other difficulties. Assessing the strategies that families and schools have used in the past allows the team to generate and develop new, more helpful techniques and methods than those previously used.

In addition to the clinical interview, the psychologist performs various kinds of assessment. Through cognitive testing, the clinician develops a good sense of a child's areas of strength and challenge. The psychologist also has the opportunity to observe how the student responds to the demands of a testing situation. Social and emotional assessment helps the clinician obtain a better sense of the student's drives, emotions, approach to stress, worries, distractions, and personality conflicts.

Each student also meets with a learning specialist to evaluate the student's strengths and weaknesses. Determining how the child learns best will help the team develop a treatment plan based on the student's strengths. Some parents are concerned about which tests will be administered. More important than the specific battery of tests is the information that needs to be obtained to understand the strengths and weaknesses of the learner. The Tarnow Center uses those tests, which will best accomplish this for each individual student. An assessment should evaluate underlying processing skills, academic skills, and should determine how well a student compensates for weaknesses. Our job is to best explain why the difficulties are occurring and how these struggles can be minimized. One can only accomplish this by individualizing the evaluation and testing to each student's needs.

After testing is completed, the assessment and treatment team, which includes all members of the Tarnow Center clinical staff, convenes once more to formulate impressions and to clearly define strengths and deficits. The clinicians generate specific recommendations to address the student's needs in the context of the home, the school, and the clinic. At times, when the evaluation uncovers specific problems, the assessment and treatment team may want to include additional testing as part of the evaluation.

Treatment

Once the full evaluation is completed, a critical step in the process occurs: the collaborative Family Feedback Session. Understanding of a student's strengths and weaknesses is an essential first step to improving all aspects of academic and emotional performance. A clinician meets with the family to present their impressions and to obtain feedback from family members. Then the clinician and the family formulate a treatment plan to address the biopsychosocial and cognitive needs of the child and family.

This feedback session is therapeutic for both the student and the family. Family interactions are often improved when everyone realizes that what was previously assumed to be lack of motivation or even defiance on the part of the student is actually a learning difficulty or an effort to cope with anxiety.

Both student and parents are empowered. Understanding both the student's strengths and the treatment plan to address the challenges gives hope to the family that the student's situation can be addressed. This realization is often a strong boost to the student's self-esteem. At this time, the effort put forth by the student, family, and team finally comes together to form a thorough and effective treatment plan.

The treatment plan usually begins with counseling and biofeedback. Counseling with the psychologist helps the parents support the student as he or she learns stress management. For example, parents and student practice identifying problems and learn how to ask for help in solving those problems. The psychologist guides the parents in developing strategies to manage their own anxieties. In this way, the parents are able to model for their children strategies for breaking old patterns and developing new ones.

Biofeedback therapy is a technique for reducing anxiety. For many children, this is a first step in recognizing how they have been reacting to a stressful event. Biofeedback training teaches a combination of deep breathing, muscle relaxation, and visualization skills, which are strategies to calm the system when anxious. Additionally, during the Tarnow Center specialized biofeedback therapy sessions, the student is taught to identify the negative thinking that accompanies anxiety-producing situations and replace it with positive thinking. Through practicing these strategies during sessions, at home, and eventually, at school, the student gradually becomes competent at managing anxiety.

If the student's anxiety is so overwhelming that it interferes with the ability to benefit with other types of treatment, the psychiatrist on the team may recommend a medication to help reduce the student's anxiety level. This is done only if absolutely necessary and is temporary.

The learning specialist helps the student and parents develop intervention strategies that address the student's learning skills and needs. (See chart 2)

The team works with the teachers to develop and implement an IEP (Individualized Educational Plan) for the student. They also support the teachers and the school by decreasing their anxiety in working with the student, and by empowering them. The teachers learn how to help the student practice relaxation skills in the classroom.

GOALS OF THE ACADEMIC ANXIETY PROGRAM

The Case of Anne

Questionnaires from Anne's parents revealed that although her development in infancy seemed typical, she was colicky and severely allergic to dairy products. The worsening of this allergy led to recurrent ear infections. Clinical documents from her pediatrician and school records were also made available. Both the parents and the school suggested that Anne's problems included anxiety and lack of attentiveness.

The medical history taken by the psychiatrist indicated possible tics. Anne also had a history of frequent headaches and stomach pains that may have been related to her allergies or ear infections. The psychiatrist reviewed Anne's history of medications with the family, including the fact that she had developed a throat-clearing habit while on Ritalin for ADHD. The psychiatrist concluded that the Ritalin had increased anxiety and compulsive behavior.

The clinical interview by the psychologist revealed details about Anne's early temper tantrums and limited interest in reading. Her academic functioning was impaired by frequent "spacing out," daydreaming, temper tantrums, and increasing frustration in learning situations. Battles at home over homework had affected the parent-child relationship and increased Anne's feelings of failure and resignation.

Through the testing process, the psychologist noted that Anne had an average I.Q. Testing also revealed multiple fears, tantrums, compulsive habits, sleep difficulties, poor appetite, and moodiness. The learning specialist noted Anne's history of marginal hearing loss and concluded that Anne had a central auditory processing problem and a language-based learning disorder.

When the entire Academic Anxiety Team convened to discuss the case, all three clinicians agreed that Anne did not have ADHD. Instead, she had an Anxiety disorder resulting from her learning problems. This Anxiety Disorder made it very difficult for her to pay attention.

In the feedback session, these impressions were presented to the family along with a more detailed explanation of the results of the testing. Together, the team and the family developed a treatment plan to address Anne's anxiety and the learning disorder. This included changes in medication, as well as language therapy and biofeedback. The team would also assist the teachers in developing an IEP (Individual Educational Plan) that was suited to Anne's particular needs.

The psychiatrist prescribed a small dose of an anti-anxiety medication that helped calm Anne's body so that she could participate in her treatment plan, but only until she developed self-calming skills.

The Center's specialized biofeedback therapy sessions helped Anne identify signs that she was becoming anxious and develop strategies to relax. These included deep breathing and muscle relaxation exercises, which strategies that Anne could practice at her desk in school without attracting attention. The therapist also helped Anne identify her negative thoughts about herself in school. Instead of labeling herself as stupid when she couldn't do a school task, Anne learned to recognize her skills so she could view herself as smart and capable.

The psychologist met with Anne and her parents to help them recognize when she needed them to be calm and reassuring. With their help, Anne learned ways to manage her anger with words instead of tantrums.

The learning specialist contacted Anne's teacher to explain the anxiety she experienced when approaching her schoolwork and the strategies she was learning to help her relax. The teacher implemented the recommended IEP developed by the team. The team continues to communicate with the teacher to insure that Anne is using her relaxation and coping strategies.

*Not based on any one person

Summary

Although anxiety is a normal, even healthy part of our lives, it can be counterproductive when not managed well. Academic anxiety in children and adolescents can be challenging to recognize since it can have much in common with other disorders. However, a good interdisciplinary biopsychosocial evaluation allows us to differentiate between the anxiety and co-occurring difficulties that may accompany it. The ultimate goal is to provide the best individualized treatment for students and their families so that they can more easily learn without anxiety interfering.

* Anxiety Task Force/Editors: Lynn Ayres, M.Ed., Debra Clough-Stokan, MD, Sophia Havasy, Ph.D., Linda Narun, M.A., CCC-SLP, Diane N. Roche, Ph.D., Meredith Sargent, Ph.D., Lesley Solomon, L.P.C., Jay D. Tarnow, MD, Lourdes Valdes, Ph.D.