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Dear teacher(s),

I am here to write a letter offering advice on how to help students who struggle with anxiety and panic attacks. I've been in the same position as they have. Trust me when I say it's not easy to deal with. So many people are under the false assumption that anxiety is a cry for attention or a "fake" issue. Neither are usually the case. In fact, anxiety is a very scary condition and often times support is greatly needed and appreciated.

Please, take some time to read over these suggestions on how to help those who have anxiety and panic attacks. Thank you!
1. If you see someone who appears anxious, ask what's wrong and what you can do to help.
Each individual struggles with anxiety in different ways and not every method has the same results. The best way to know how to help someone is to ask.
2. Don't force someone to do something just because you think it will help.
Because everyone deals with anxiety in different ways, some methods may be helpful to some but not to others. Therefore, the best thing to do if someone says that something won't help them is to find another way to help.

Here's an example: I was once told over and over again to drink water to make myself feel better. I told the individual that it wouldn't help, but they practically forced me to drink the water. This honestly just made me more anxious!
3. Be understanding, and don't make us feel like we're being a nuisance.
This also applies to school nurses. I can't tell you how many times I was made to feel like I was a burden in high school because of my anxiety. The school nurse made it like I was faking it. Every time I went to see her, I felt her eyes rolling at me. Having anxiety is a legitimate issue. We don't enjoy it. So please, don't act like we do!

4. Talk to us!
Ask us how we're doing. Check in. You don't have to ask 24/7, but once in awhile, see how we're doing. Sometimes getting our feelings of our chest makes us feel better and helps us know we are supported.
5. Don't talk down to us, patronize us or treat us like we're silly.
It's hard enough going through something that's so misunderstood, let alone being treated like we're insane or childish. In my opinion, it's crucial that teachers try to understand what their students are going through. I had so many teachers who showed me a great deal of respect. It was these teacher who made a real difference in my life.
6. Share your own issues with us and help us feel less alone.
Be honest and if you have similar experiences with anxiety, share them with us. I had a teacher who told me about one of his fears and honestly, it helped. By sharing something he went through, he helped me realize I wasn't alone and that it was possible to get through what I was going through. I also knew there were people who cared for me.
7. If a student has to leave school due to anxiety, then don't make them feel guilty.
In high school, I left school several times due to my anxiety. I always felt awful. Additionally, there were times when school officials or the school nurse made me feel guilty about leaving because I wasn't physically sick.

Anxiety is a very difficult issue to deal with. People who go to school and deal with anxiety have to try extremely hard to get through the day and sometimes, anxiety makes it seem like an impossible task. However, with the help and support from teachers and staff, students can feel supported and get through school with a sense of accomplishment.

Crippling.
If I'm being quite frank, it has the power to destroy my day. It has the power to send it reeling into the depths, with no hope for return and for no apparent reason at all. It will shut me down completely. The only option is to succumb to it, to get it over with and move on. I let my mind run rampant with fallacies, just long enough to mute it for a little while.
A nightmare.
I dread falling asleep because the night is dangerous. My day is done, and there's time now to review what I'd done, who I interacted with and all I've said. There's time now to consider all of the possible outcomes of my actions, primarily the negative ones. Perhaps, I upset my boss, and I'll be fired tomorrow. Perhaps, I've disappointed my parents.

I have always been close with my family. Now, I feel like I can no longer be. What if they don't accept my anxiety? What if they call me weak or dramatic or tell me to suck it up? What if they cannot understand that I cannot control what goes on inside of my head? What if I upset them? What if it's this way for the rest of my life?
Living.
Both in the past and the future, but never the present. I reminisce on days when I felt the utmost joy, no worries, no anxiety back when days like those existed. They are the most beautiful thing in my mind. They are also the most torturous. I can't go back, no matter how hard I try. So, I try to look toward the future and imagine how wonderful things will be, and I can't get there fast enough. That's exactly the problem. I am not there. I am here, and I can't be. I don't want to be.

Illogical.
I am consistently fearing the worst in every situation, regardless of how nonsensical it may be. Even if I know the outcome will be positive, there is (at the very least) a sliver of me that worries the tables may turn. Some may call it protecting themselves, but not to this extent, not to this frequency.
A gift.
My anxiety is a lesson. I am constantly learning things about myself and about others that amaze me. I've learned I am strong. I am more than strong. I am a warrior, and I am a survivor.

I've learned I can relentlessly fight every single day. I can wake up, fight again every morning and go to sleep knowing I survived another day. I've learned my relationships are stronger than my anxiety. I am hopeful to learn of my family's support, despite the plaguing doubts. You cannot change your family, so you love them despite the differences.

I am able to decipher when I am being unreasonable, when my mind has carried me too far yet again. While I am still unable to stop it, I am able to recognize it. That is more than I could ask for from myself.

Anxiety is like a bad roommate. Sometimes it's quiet, and we live together without a hitch. We live together but our lives don't intertwine, it's a good deal. Every once in a while it keeps me up late, banging pots and pans inside my brain making it difficult to co-exist. When my Anxiety has a bad day, it comes into the apartment raring to bring me down with it's passive aggressiveness. It takes over the space, changing the atmosphere from calm to totally haywire.

We've all felt anxious. That uncomfortable feeling in the pit of your stomach when you enter an exam, your sweaty palms when you meet a new group of people, or the knot in your throat right before you tell someone you like them. These things are normal, but when does it cross a line?

Something I'm trying to figure out is: When does every day worrying become so uncontrollable and unrealistic it can hold you back and make you feel helpless? And what can I do to feel more in control when that happens?

I'm going to be totally honest. When I came up with the idea for a video on SoulPancake, I knew it wasn't going to be easy. What I didn't know was that the creative process would cause panic attack after panic attack. I anticipated struggling, but I didn't anticipate having to book a last minute flight home to be with my family because I wasn't equipped to deal this caliber of anxiety.

I made this video after spending a month in the U.S., traveling with my fellow New Age Creators. I found myself alone for the first time in 30 days. Without the voices of my friends surrounding me, distracting me, an anxiety filled white noise flooded my bedroom.

I became acutely aware of all of my deadlines and responsibilities. Video due on Monday, rent due on the first, university starts in a month, what do I do after I graduate? Am I any good at this YouTube thing anyways? All of the things that would normally end up on a long term to-do list in my pocket became one of those billboards you hate, but can't seem to get away from.

When you look at me, you see someone who willingly talks about personal ideas and opinions on the internet. Online and off, I'm confident, sarcastic and I usually look like I have everything under control and planned out to a T. You might even say:"It comes easy to her" this whole, "life" thing. While all of those things are true to an extent, you don't see my brain constantly go fuzzy with worry about something I've said, you don't hear my second-guessing thoughts say "Why on earth did you do that?" or "Is anyone going to actually care that I uploaded this video?"

It's easy to feel like the end of the world is impending - but as much as I feel like panic and anxiety can make me weak at times, I know my strength to keep going will outlast it. I know that it'll pass and I have found ways that help me cope:

When I'm restless, I take the pacing outside and walk it off.

I listen to playlists of nature sounds or songs that calm me down

I exercise. Taking care of all the excess energy from my fight or flight reflex.

I call someone I trust and I don't hang up the phone until I feel myself relax.

Anxiety and panic can make you feel alone and misunderstood - and I'm not OK with that. That's why I made this video. If one person can share this with their friends to explain how it feels, or just look at it and find that "me too" feeling, then it has all been worth it. Together, we can create an environment where it is safe to talk about our worries, and open up about the bad days. You are not alone, I am right there with you, and so are so many other amazing people who sometimes panic, too.
You can find Marie on SoulPancake this summer, and all year long on The New Age Creators , and her personal YouTube Channel.

I am living a life that, at first glance, is exactly the life I had dreamed of as a child. I live by myself, in a condo in a fantastic location. I have several good friends. I have exactly the job I want. I have an amazing boyfriend. I have a car I love. I have multiple hobbies I enjoy immensely, and I am incredibly happy and loving life.

At the same time, however, there is a secret side to my life, a side most people don't know about - a dark side. My beautiful condo usually looks like a tornado ripped through it. I don't see my friends often. My relationships at work are strained because I frequently have trouble focusing and doing what I need to. My relationship with my boyfriend terrifies me. My car takes me places I don't want to go for fear of them. My hobbies require effort, focus and talent, which I tend to either lack or believe I lack.

You see, inside of me I have two things that desperately hate me: a voice and a dragon. The voice also hates the dragon. The dragon is a terrible scaly, black creature that sleeps on a shelf right above my stomach. I spend most of my time trying to ensure he does not wake up. When the dragon wakes, he brings with him full blown panic attacks. As long as he sleeps, the anxiety will, at worst, mean nausea and heart palpitations. I can still breathe through it and usually, I am fairly good at keeping him asleep.

However, that voice in my head exists. The voice hates me and hates the sleeping dragon. It fights constantly with me in the hopes of waking the dragon. The voice says horrible things, over and over.

You're fat, and your skin is disgusting. Your eyes are different sizes, and you look atrocious. How can you possibly go out in public like that? You aren't funny, and anyone who says you are is lying to you. Don't bother trying to write, draw, embroider or create anything. You're not any good at it and you'll fail miserably. No one is ever going to want any of it. You know one day he's going to wake up and realize what an awful human being you. Then, he's gonna be gone in a flash, right? No one is ever actually going to want you because you are so repellent.Living with a voice like this is so incredibly difficult. To have part of your brain constantly telling you how worthless you are, how little value you have and how no one in their right mind would ever care about you is horrible. Fighting against that voice is one of the hardest things to do. To come out and say, "You are wrong, and I am magnificent," is easier said than done. However, that doesn't mean it can't be done. I have spent years trying to master it.

I have worked so hard on ignoring the voice. I have worked on asserting my own belief that I am amazing, I have loads of talent and humor. I am a kind and loving human being and I deserve to be loved and respected by others. On the one hand, I have succeeded. I truly believe those things, and I do not tolerate other people treating me as if those things are not true. I do not tolerate others giving me less than I deserve. I refuse to accept others limiting me.

After all, the voice exists, just as loud as ever. Believing I am amazing, worthy and valuable does not make the voice go away. It does not shut it up. It does not make ignoring it any easier. It does not mean that sometimes I don't believe the voice nor doubt how amazing, worthy and valuable I am. I do.

The voice still limits me. It prevents me from keeping my beautiful home neat and clean. It prevents me from seeing the people I love. It prevents me from doing things I love. It damages my relationship with my boyfriend. It limits me every day. I still try to ignore it, to assert what I know about myself over it, but it is an ongoing struggle. It will continue to be. The voice tells me I will never get rid of it entirely. To me, that's just a challenge, and I am more than happy to take it on.

Last week, I read my worst nightmare in headline form: " Stop Whoring Out Your Undiagnosed 'Mental Illness. '"

Gut-punch. Straight where it hurts.

The piece is essentially a message to people who claim they have " anxiety or depression online and IRL (in real life) based on their own self-diagnosis." The author's thesis is people who haven't been diagnosed by a doctor with a mental illness share "relatable" anxiety and depression videos just to get attention.

She then suggests those people should see a professional to find out one of three scenarios: 1) You're having normal thoughts and everything is fine with your mental health; 2) You have an anxiety disorder or depressive disorder; or 3) You you have a completely different mental illness you have been wrongfully labeling as anxiety and depression.

It's never a bad thing to encourage someone to seek professional help.

But if only it were that simple.

As someone who lives with and writes about living with anxiety, I question the validity of my mental health issues every day. Every time I open up, I pay for it later in the form of mean, bullying thoughts: Your problems aren't that bad. Who are you to be writing about this? You're being dramatic, exaggerating. There are so many people who have it worse.

When a piece I wrote about living with high-functioning anxiety went somewhat viral, I (ironically) had a really bad few weeks. I couldn't shake the thoughts that told me I was a fraud, an attention-seeker. When I expressed this concern to my boyfriend, he laughed, kissed my forehead and said, "Trust me, Sarah. You're that anxious."

I don't have a certificate that says I have an anxiety disorder. I've only had one therapist, who I decided wasn't for me after a few months. I haven't found another one yet. I'm 23, and many people develop mental illnesses in their early 20s. I'm new to this and so are a lot of people who are maybe just experiencing mental health issues for the first time.

But I write about my anxiety. I share about my anxiety. I relate to articles about anxiety.

When I see, "stop whoring out your undiagnosed mental illness..." I'm brought back to a time before I was open about living with anxiety. Before I was calling anxiety by its name. It wasn't because I wasn't familiar with mental illness - my brother has obsessive-compulsive disorder (OCD), and I watched him go through what I thought was the "classic" (and therefore only) trajectory for having a real, valid mental illness: have a mental health crisis, get hospitalized, get a diagnosis, get some medication, figure out "recovery." Of course, it was was little more complicated, with more hospitalizations, treatment centers and medication changes in between.

Even though looking back I can see I was struggling, I never reached out to my peers because I thought I knew what a "real" mental illness looked like. I didn't reach out for support because I thought it would seem like I was complaining, attention-seeking. I was afraid of people, like the author of this piece, scoffing at me and my "undiagnosed" mental illness.

The author writes: "The average person wouldn't say they have cancer and then ask for support from friends and family without being diagnosed. So why is it socially acceptable to do this with a mental illness?"

While I'm all on board the "we should treat mental illnesses like physical illnesses" train, we can't pretend we can diagnose every mental illness like we can cancer. Many mental illnesses, especially anxiety and depression, exist on scale of severity. It isn't as clear cut as getting diagnosed with cancer. It just isn't. It often begins with you pretty much saying, "that's so me" to a list of symptoms. Other people, including professionals, can verify your behavior, but you're the only one who knows what's going on in your head.

The people the author berates, the ones "whoring" out their undiagnosed mental illnesses online to garner attention - we don't know where they are on their journeys.

I'm sure people do exaggerate their mental health issues online to get attention. People do things for attention all the time. Take selfies, make statuses about their accomplishments, write articles... and sometimes it's annoying. But to make such a strong statement, to assume everyone who has not yet pursued an "official" mental illness is only talking about mental health for, as the author says, a "like, a share, a comment, or a reblog," makes people like my past self - who want to share an anxiety article because they relate to it but aren't ready to make the big leap to ask for help - want to crawl back into our holes where our problems aren't "big enough," "important enough" or "official enough" to talk about.

Sound familiar? It's classic mental health stigma being thrown back into our faces.

Seeing a professional could be a prerequisite for sharing a "relatable" anxiety video in a world where mental health services were cheap and accessible. But that's not the world we live in. Today you get put on a waiting list. All the professionals in your area are out of your network. Sometimes you see a professional and get the wrong diagnosis anyway. It's a messy process, and it is not our job to judge how people approach or handle it. If someone is writing or talking about anxiety or depression before they get the chance to see a mental health professional, we shouldn't discourage them. For all we know, that online support system might be all they have.

The author also claims those with "undiagnosed" mental illnesses make people with "real" mental illnesses seem like fakers. If anything, I think the opposite is true. Embracing my own mental health issues and being active in the community helps me empathize with others who have more severe anxiety than I do. Because I know I can't control when I'm in a spiral, I know someone whose anxiety is more severe than mine can't control it either. I get that depression can't be cured by just going for a walk. I get that people with bipolar disorder aren't just "moody." I don't know exactly what it's like - but I understand the nature of the beast enough to know it isn't their fault.

I don't think we should be giving out mental illness diagnoses like free samples or that people should be using diagnoses incorrectly. For example, I hate when people misuse OCD ("I'm so OCD about my closet."), but those statements usually come from a place of ignorance. Instead of berating people you think don't actually have anxiety or depression, we need to educate people about what these conditions are really like. And although the author accuses these people of stealing "resources and support," I say there isn't enough resources and support to go around. Instead of demanding people who might have anxiety see a doctor so they can either get a diagnoses or "get over it" - we should be encouraging people to seek help because they need and deserve help. Maybe a few will learn their anxiety or depression is situational or not severe enough to be clinically diagnosed, but that still doesn't mean they don't have a right to use services and post about their mental health issues online. There is no suffering competition, and sharing an anxiety video doesn't take away the severity of what you go through. It's possible to care and advocate for people with serious mental illnesses while talking about your own mental health issues as a form of self-care. One does not cancel out the other.

It's easy to hate something because it's "popular." I get it. I roll my eyes every time an article is written about a celebrity mentioning the word "anxiety," thinking really? Do you really have anxiety? But at the end of the day, it isn't my place to judge. I'd rather mental health be "trendy" or "basic" if it means people aren't struggling alone. There's so much mental health content being produced right now. We may even get saturated with it. But d on't demand people don't share it - ask for a more accurate representation of mental illnesses. Don't claim people are stealing your services - demand services should be available for anyone who needs them. Because if the end goal is that mental health is treated just like physical health, we want people getting mental health checkups like they go to the dentist. We want mental health support available for people who have a whole range of issues. We want people to have such a great understanding of what mental illnesses are that it becomes universally unacceptable how many people with severe mental illnesses aren't getting the support they need.

It doesn't end with writing a silly blog post or sharing a video about anxiety. I know that. But it can start there. And I know personally if I hadn't been so afraid to identify with an article about anxiety, I might have reached out to my friends sooner. I might have gotten help sooner. And I don't want to live in a world where that's a bad thing.

With mental health issues, it sometimes feels like you can't ask for help until you've "lost it." Like if you're still getting out of bed, still putting pants on, still going to work and still keeping your life somewhat in order, you must be fine. Everything's fine, and therefore anything that's not fine must be your fault - like it's you who's being dramatic, unable to handle the stress of everyday life.

That is simply not true.

There was 40 million adults in the U.S. who live with anxiety disorders, and these anxiety disorders present themselves in different ways. Just because someone seems fine doesn't mean their anxiety disorder is less valid. And just because you're good at hiding your anxiety doesn't mean you don't deserve help.

We asked people in our mental health community who feel like they live with hidden anxiety to tell us one thing they wish others understood.
Here's what they had to say:
1. "My body is in constant fight-or-flight mode, and after it passes, I'm left exhausted. On the outside I'm so happy and likable, but on the inside I over-evaluate each and every word I speak and I worry about what you think." - Kelsie W.

2. "My reaction to you or my demeanor is not a reflection of how I feel about you. It is my mind struggling inside. I may not laugh, smile or say hello, but it's not because I don't like you or don't care. It's because I can't right now." - Jeanine H.

3. "I may be less than my normal self on days panic is washing over me with 10-foot waves. I am not a bitch, I am just trying not to drown." - Chriss T.

4. "I wish people understood the times it seems like nothing's wrong and I look the most capable and 'fine,' are the times I'm fighting the hardest. Sometimes it takes all I have to keep from falling apart inside even though I look OK from the outside." - Alyssa C.

5. "I am a confident person with a diagnosed anxiety disorder. I enjoy acting and love being onstage, but I can't make a phone call or knock on a door. I am a confident person, but the smallest things like a teacher shouting at me or having to make a phone call can trigger a panic attack. I wish people understood you can be both confident and anxious. It's really difficult for me to explain to people." - Danni-Mae K.

7. "I'm not just a loner. I really want to fit in and go out with friends or go on a date. But this anxiety I have makes me overthink and second guess every move I make. Decisions that are easy for most people to make take me twice as long because I have to outthink every possible outcome." - Shannon R.

13. "I defiantly wish people understood anxiety isn't just a switch; I can't turn it off and on whenever I want. It can happen at anytime during the day/night. It can happen when I'm happiest or when I'm saddest. It comes and it goes. You have your bad days and your good days. I just wish people understood it isn't something I can control, even if I'm on medications." - Jessica N.

15. "You have no idea what's going on in my head." - Nicole D.

18. "I have the tendency to dress up more when I feel really anxious. I put makeup on and dress well, as that's how I try and convince myself I'm OK." - Neelam A.

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7 Ways Teachers Can Help Students With Anxiety

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Dear teacher(s), I am here to write a letter offering advice on how to help students who struggle with anxiety and panic attacks. I've been in the same position as they have. Trust me when I say it's not easy to deal with.

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Although anxiety does not necessarily impact a child's academic abilities, it can affect their ability to learn. Parents and teachers can work together to help a child succeed in the classroom. There are a number of ways teachers can make the school day easier and less stressful for a child with anxiety:

Create a "safe" place for the child to go when anxiety symptoms are high or during stressful times. This may be the nurse's office or a staff member's office. Establish rules for the use of the "safe" place. These rules should include items such as, the student must inform the teacher they need a few minutes to calm down, and a set time limit.

Be aware of physical symptoms of anxiety and provide activities to distract the child. Calming activities, such as, reading or listening to music may help to alleviate some of the physical symptoms and allow a child to return to class work after a period of time.

Allow a few minutes at the beginning of the day for the child to transition into the school day. Additional transitional periods might be necessary for other times when routine is disrupted. This can be providing five to ten minutes for the child to prepare their papers and school supplies or simply a few minutes for the child to sit quietly before the school day begins. If the time before school is difficult for the child, it may be beneficial for them to either enter the classroom a few minutes before or a few minutes after the rest of the class arrives.

Talk to the student about what interventions they would find helpful. Having the student discuss strategies may help them to be involved in reducing their anxiety symptoms. This also provides the child an opportunity to talk about situations that cause anxiety symptoms as well as for them to be more aware of their symptoms.

Teach the child relaxation techniques they can do at school, such as deep breathing exercises. Talk with parents about the techniques used at home and try to incorporate them into the classroom.

For children avoiding school because of anxiety, offer suggestions such as coming to school for a shorter day. The longer the child avoids going to school, the more difficult it is for them to return. Allowing them to come to school for shorter periods will give them a chance to face their fears but may make it easier if they know they will be able to return home at lunchtime.

Use small group activities throughout the day. Children with anxiety may be better able to cope with small groups of a few students rather than large classroom study. Have the class break into small groups to complete class work to encourage participation.

Reward effort by a student with anxiety. When a child shows effort or is able to control their anxiety symptoms through interventions, let them know you have noticed and are proud of their efforts.

Create group activities that role-play appropriate behaviors. Teach young children what to do in specific situations. This can help all students learn how to handle situations such as anger management, stress reduction, test anxiety. Providing instruction to the entire class will decrease the focus on the child with anxiety.

Decrease situations that induce stress. Teachers can restructure assignments to decrease the amount of stress for a student. For example, instead of having a child stand in front of the class to read a report, find creative ways to complete reports. Allow students to make posters or record presentations at home on a tape recorder.

Discuss anxiety symptoms privately with the student. Never single out a child or call attention to their anxiety in front of the class. This can cause humiliation or embarrassment and increase anxiety symptoms.

Discuss alternative ways of handling situations. Talk to the student after an anxiety attack about how the situation could have been different or what strategies could have been used (by both the student and the teacher) to make the situation better.

Find books that address children with anxiety. Incorporate these books into reading curriculum. This not only helps the child with anxiety to feel better about their anxiety but also can help the other students in the class be more understanding of the condition.

Teach positive self-talk to the entire class. Helping children to be aware of the negative way they talk to themselves, such as the use of "I can't" and help them to develop a more positive way of talking to themselves.

Post the daily routine in the classroom and let students know in advance any changes in the schedule. Letting students know exactly what is expected will help lessen anxiety. For a student with anxiety, a sudden change can cause a panic attack. Knowing in advance what the day will be like will help in transitions.

Help students break assignments down into smaller segments. This can help to decrease feeling overwhelmed by large assignments and help a student work on each section.

Play soothing music during down time. Many times playing soft music can help children to calm down and can relieve stress. During quiet activities or seatwork, use soothing music.

Incorporate exercise into the school day. Stop lessons for a few minutes or do stretching exercises in between lessons. This can help reduce stress.

Use computerized reading programs. Allowing children time to work on their own rather than in a large group can reduce stress and anxiety.

Discuss what sections of a book will be read aloud with a student before calling on them to read. If reading aloud in the class causes stress and anxiety, plan ahead of time and let a student practice a small selection the night before.

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20 Classroom Interventions for Children with Anxiety Disorders

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Although anxiety does not necessarily impact a child's academic abilities, it can affect their ability to learn. Parents and teachers can work together to help a child succeed in the classroom.

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Sometimes anxiety is easy to identify - like when a child is feeling nervous before a test at school. Other times anxiety in the classroom can look like something else entirely - an upset stomach, disruptive or angry behavior, ADHD, or even a learning disorder.

There are many different kinds of anxiety, which is one of the reasons it can be hard to detect in the classroom. What they all have in common, says neurologist and former teacher Ken Schuster, PsyD, is that anxiety "tends to lock up the brain," making school hard for anxious kids.

Children can struggle with:

Separation anxiety: When children are worried about being separated from caregivers. These kids can have a hard time at school drop-offs and throughout the day.

Social anxiety: When children are excessively self-conscious, making it difficult for them to participate in class and socialize with peers.

Selective mutism: When children have a hard time speaking in some settings, like at school around the teacher.

Generalized anxiety: When children worry about a wide variety of everyday things. Kids with generalized anxiety often worry particularly about school performance and can struggle with perfectionism.

Obsessive-compulsive disorder: When children's minds are filled with unwanted and stressful thoughts. Kids with OCD try to alleviate their anxiety by performing compulsive rituals like counting or washing their hands.

Specific phobias: When children have an excessive and irrational fear of particular things, like being afraid of animals or storms.

Here are some tips for recognizing anxiety in kids at school, and what might be causing it.

Inattention and restlessness

When a child is squirming in his seat and not paying attention, we tend to think of ADHD, but anxiety could also be the cause. When kids are anxious in the classroom, they might have a hard time focusing on the lesson and ignoring the worried thoughts overtaking their brains. "Some kids might appear really 'on' at one point but then they can suddenly drift away, depending on what they're feeling anxious about," says Dr. Schuster. "That looks like inattention, and it is, but it's triggered by anxiety."

Attendance problems and clingy kids

It might look like truancy, but for kids for whom school is a big source of anxiety, refusing to go to school is also pretty common. School refusal rates tend to be higher after vacations or sick days, because kids have a harder time coming back after a few days away.

Going to school can also be a problem for kids who have trouble separating from their parents. Some amount of separation anxiety is normal, but when kids don't adjust to separation over time and their anxiety makes going to school difficult or even impossible, it becomes a real problem. Kids with separation anxiety may also feel compelled to use their phones throughout the day to check in with their parents.

Disruptive behavior

Acting out is another thing we might not associate with anxiety. But when a student is compulsively kicking the chair of the kid in front of him, or throws a tantrum whenever the schedule is ignored or a classmate isn't following the rules, anxiety may well be the cause. Similarly, kids who are feeling anxious might ask a lot of questions, including repetitive ones, because they are feeling worried and want reassurance.

Anxiety can also make kids aggressive. When children are feeling upset or threatened and don't know how to handle their feelings, their fight or flight response to protect themselves can kick in - and some kids are more likely to fight. They might attack another child or a teacher, throw things, or push over a desk because they're feeling out of control.

Trouble answering questions in class

Sometimes kids will do perfectly well on tests and homework, but when they're called on in class teachers hit a wall. There are several different reasons why this might happen.

"Back when I was teaching, I would notice that when I had to call on someone, or had to figure out who's turn it was to speak, it was like the anxious kid always tended to disappear," says Dr. Schuster. "The eager child is making eye contact, they're giving you some kind of physical presence in the room like 'Call on me, call on me!' " But when kids are anxious about answering questions in class, "they're going to break eye contact, they might look down, they might start writing something even though they're not really writing something. They're trying to break the connection with the teacher in order to avoid what's making them feel anxious."

If they do get called on, sometimes kids get so anxious that they freeze. They might have been paying attention to the lesson and they might even know the answer, but when they're called on their anxiety level becomes so heightened that they can't respond.

Frequent trips to the nurse

Anxiety can manifest in physical complaints, too. If a student is having unexplained headaches, nausea, stomachaches, or even vomiting, those could be symptoms of anxiety. So can a racing heart, sweaty palms, tense muscles, and being out of breath.

Problems in certain subjects

When a child starts doubting her abilities in a subject, anxiety can become a factor that gets in the way of her learning or showing what she knows. Sometimes this can be mistaken for a learning disorder when it's really just anxiety.

However anxiety can also go hand in hand with learning disorders. When kids start noticing that something is harder for them than the other kids, and that they are falling behind, they can understandably get anxious. The period before a learning disorder is diagnosed can be particularly stressful for kids.

Not turning in homework

When a student doesn't turn in her homework, it could be because she didn't do it, but it could also be because she is worried that it isn't good enough. Likewise, anxiety can lead to second guessing - an anxious child might erase his work over and over until there's a hole in the paper - and spending so much time on something that it never gets finished. We tend to think of perfectionism as a good thing, but when children are overly self-critical it can sabotage even the things they are trying their hardest at, like school work.

You might also notice that some anxious kids will start worrying about tests much earlier than their classmates and may begin dreading certain assignments, subjects, or even school itself.

Avoiding socializing or group work

Some kids will avoid or even refuse to participate in the things that make them anxious. This includes obvious anxiety triggers like giving presentations, but also things like gym class, eating in the cafeteria, and doing group work.

When kids start skipping things it might look to their teachers and peers like they are uninterested or underachieving, but the opposite might be true. Sometimes kids avoid things because they are afraid of making a mistake or being judged.

Dr. Schuster notes that when kids get anxious in social situations, sometimes they have a much easier time showing what they know when teachers engage them one-to-one, away from the group.

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How Does Anxiety Affect Kids in School? - Child Mind Institute

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Sometimes school anxiety is easy to identify - like when a child is feeling nervous before a test at school. Other times anxiety in the classroom can look like something else entirely - an upset stomach, disruptive or angry behavior, ADHD, or even a learning disorder.

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Trouble concentrating. An upset stomach. Sleeplessness. Anxiety can show up in a lot of ways. And anxiety can be one of the most debilitating challenges that students face in classrooms today. Yet, it can also be one of the most hidden and unknown.

According to the Child Mind Institute, health-care providers have seen a 17 percent increase of anxiety in children over the past 10 years . But there aren't really that many more students seeking help and care. In fact, less than one percent of kids will seek anxiety treatment the year their symptoms begin. And even though anxiety will affect about 30 percent of all children at some time in their lives, more than 80 percent will never receive care for it.

Chances are you've seen the increase in anxiety in your classroom and school, maybe around testing season, or even kids experiencing trauma. You know anxiety is more than just "worries." Anxiety can influence classroom performance just as much as any other learning disability.

Kids who are worried and anxious aren't doing it on purpose. The nervous system acts automatically, especially when it comes to worry (which often stems from fight or flight reflexes). That's why phrases like "just relax" or "calm down" aren't helpful. But with practice, kids can learn to slow down their anxious brains, and teachers can learn to help them. Here are a few ways you can help anxious kids in the classroom.

1. Practice those deep breaths.

[embedyt] https://www.youtube.com/watch?v=O29e4rRMrV4[/embedyt]

When people slow down their breathing, they slow down their brain. When I notice that one of my kids is struggling with anxiety, I'll often lead the whole class in a breathing exercise. It helps the child who is overwhelmed and usually a few other kids too. Sometimes, I'll do it just because the whole class is squirrelly and we need to focus. Slow, deep breaths are the key. This article about belly breathing describes the process I like to use with my kids. It works every single time.

2. Take a break and go outside.

Being out in nature can also calm an anxious brain. Sometimes just a change of scenery is what makes the difference. Breathing the cool air or making time to notice chirping birds can also calm an overactive worrier. Asking students to carefully observe their environment can help them turn the focus away from their worries and toward something more tangible: How many different kinds of trees do you see? How many different bird songs do you hear? How many different shades of green are in the grass?

3. Talk about anxiety openly.

Don't set anxiety up as something you want (or should) get rid of. It's part of life, and it's not realistic to think it'll go away completely. You can help students see and understand this in your own actions. Check out this great article of what you should (and shouldn't) do when working with kids dealing with anxiety.

4. Get kids moving.

[embedyt] https://www.youtube.com/watch?v=sZfe2hjlEwE[/embedyt]

Exercise helps anyone who is feeling anxious. Anxiety can end up looking like anger, so if you see this, try taking a movement break. You probably already have some favorite ways to do this, but if you're looking for some ideas, check out our video above. You can also get the free set of printables for that right here.

5. Try walking and talking.

Building on the moving idea, if you have a student that needs some one-on-one attention, try the walk-and-talk method. I used to have a student who struggled a lot with anxiety, and this worked great with her. After a couple of loops around the playground with me, everything would feel a little better. Our walk served three purposes: 1. It removed her from the situation. 2. It gave her a chance to explain the issue to me. 3. It got her blood pumping, which clears out the anxiety-producing energy and brings in the positive exercise endorphins.

6. Think positive by having students keep a gratitude journal.

[embedyt] https://www.youtube.com/watch?v=TxFRx-87-Qo[/embedyt]

The brain is incapable of producing anxious thoughts while it is producing positive thoughts stemming from gratitude. If you can trigger a positive train of thought, you can sometimes derail the anxiety. I knew a teacher who had his fifth graders keep gratitude journals, and every day they would record at least one thing they were thankful for. When his students seemed overwhelmed by negativity or mired in anxiety, he'd encourage them to reread their journals. Check out the video above for another inspiring teacher.

7. Remind kids to eat healthy and stay well.

For the most part, teachers don't really have a lot of control over what students eat and how much they sleep, but these things do matter when it comes to managing anxiety. Not surprisingly, a healthy diet and plenty of sleep make a difference in how well a student is able to handle situations that could be overwhelming. It's one of the reasons that snack and rest time were an essential part of the day when I was teaching preschool. (It probably would have benefited my older students too, even if they might not have admitted it!)

If you can find a way to work these things into your school day, they could make the difference for your kids who tend to worry. Even if you can't control these things, you can still remind them by talking about healthy food choices, or wrapping it into the curriculum when you can.

8. Share a story with your students.

Often, when one of my kids is struggling, the school counselor will come and share a picture book about managing anxiety with the entire class. Some kids may not be receptive to direct, one-on-one, intervention, but they will respond beautifully if they know the whole class is receiving the same information. Check out this list from WeAreTeachers about great books for kids with anxiety.

9. Try creating a space where kids can express their anxiety.

You've probably heard of classroom safe spaces, and this is a great option to offer if you have students dealing with anxiety. Another idea, which can stand on its own or be part of your safe space, is offering classroom fidgets. Sometimes this can work wonders in just giving kids an outlet. Here are some of our favorite classroom fidgets.

10. Offer individual accommodations.

For older students, accommodations can make all the difference. Many students struggle with performance anxiety, especially when it comes to tests. When a student is feeling anxious, their brain simply can't function as effectively. When we can set up our tests and assignments so anxious kids are less stressed, they'll likely perform better. Extended time and cue sheets could help kids who suffer from test anxiety. For other accommodations for kids who struggle with anxiety, check out this list from Worry Wise Kids.

The good news about anxiety is that it is one of the most manageable mental-health struggles that children face in the classroom. With the right support and strategies, most children are able to develop strategies that help them manage their anxiety.
Check out our article on how to help kids dealing with test anxiety. Teachers also deal with anxiety. Take a look at the realities of Sunday night anxiety and what you can do.

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10 Ways to Help Students Who Struggle With Anxiety

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Trouble concentrating. An upset stomach. Sleeplessness. Anxiety can show up in a lot of ways. And anxiety can be one of the most debilitating challenges that students face in classrooms today. Yet, it can also be one of the most hidden and unknown.

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Depression, Anxiety at School and Self-Esteem in Children with Learning Disabilities

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Educational research places emphasis on the fact that pupils with Learning Disabilities may develop depressive and anxiety symptoms characterized by lower levels of self-esteem. Th..

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This article is a follow up from our first article: Strategies for Parents to Help Their Child with Separation Anxiety. This intro is the same, but as you go further down the article, you will see strategies for schools to use to Help children with separation anxiety.

What is Separation Anxiety Disorder?
According the American Psychiatric Association, a person with separation anxiety disorder is excessively fearful or anxious about separation from those with whom he or she is attached. The feeling is beyond what is appropriate for the person's age, persists (at least four weeks in children and six months in adults) and causes problems functioning. A person with separation anxiety disorder may be persistently worried about losing the person closest to him or her, may be reluctant or refuse to go out or sleep away from home or without that person, or may experience nightmares about separation. Physical symptoms of distress often develop in childhood, but symptoms can carry though adulthood. Children with separation anxiety disorder may be at-risk for school refusal in the future. Behaviors related to school refusal may include:

severe emotional distress about attending school (e.g., anxiety, temper tantrums, depression, or somatic symptoms - such as pain or fatigue)

the child often tries to persuade parents to allow him or her to stay home

the child often attempts to conceal absence from parents

child stays home during school hours because it is safe and secure

child expresses willingness to do schoolwork and complies with completing work at home

Some separation anxiety, which may manifest itself as clinging to parents, crying, and resistance when going to another caregiver (e.g., school, daycare, babysitter, etc.) is typical in young children such as those ages three and four. However, if the anxiety seems severe (in young or older children) in that it is causing extreme distress and interfering with daily functioning, parents should consult with a child therapist.

Some children may receive a diagnosis of separation anxiety disorder from a child psychologist or psychiatrist. Other children may manifest symptoms that are never officially diagnosed. Regardless of where there is an official diagnosis, there are strategies we can put into place to assist a child with symptoms of separation anxiety. As previously stated, some children would benefit from therapy with a child psychologist or counselor, but in addition to that, there are ways that schools can provide support to children with symptoms of separation anxiety. For parent strategies see Strategies for Parents to Help their Child with Separation Anxiety.

How Can Schools Help?
When examining therapeutic options for treating separation anxiety disorder, research indicates that psycho-educational interventions, which include, education of child and parents, collaboration with school personnel, and training to increase child's autonomy and competence, are effective methods of treatment. For more on this research see Separation Anxiety in Children and Adolescents.

One of the most commonly recommended strategies by mental health professionals aims to teach parents/caregivers and school personnel how to provide the child with a flexible and supportive environment to overcome his/her separation anxiety symptoms. Below is a list of suggestions for school management strategies. Remember that for some children this is not enough, and they may need psychological or psychiatric intervention. If the school is concerned that a child may need more than what the school can offer, it is important to arrange a meeting with parents to discuss your concerns. When working with a therapist, the most effective/research-based non-pharmacological (not involving medication) method for reducing separation anxiety in children is cognitive-behavioral therapy (CBT). To read more about CBT and how it has effectively been utilized to treat separation anxiety, see Separation Anxiety Disorder in Youth: Phenomenology, Assessment, and Treatment.

Remember to see Part 1: Strategies for Parents to Help their Child with Separation Anxiety

Strategies Schools Can Use to Assist Children with Separation Anxiety

Have a trusted, familiar school staff present when the child arrives at school if possible, preferably the same person every time, at least until the anxiety is reduced.

For younger children, who are not in kindergarten yet, they may benefit from a shorter school day that is increased gradually.

Identify a safe place where the child can go to reduce anxiety during stressful periods. Some children benefit from taking some time to adjust in the counselor's office or other safe space before going to the classroom.

Identify a safe adult to whom the child can go to during times of stress. This adult should speak to the child with empathy, being understanding of their feelings. However, they should encourage the child to return to their class or activity once they are calm, and review self-calming strategies that the child can use when anxiety arises. Self-calming strategies may include deep breathing, counting, muscle relaxation, holding an object that provides comfort (e.g., picture of parent, favorite item from home), drawing a picture, writing down their feelings, thinking of a funny time, thinking of another time that they had anxiety but got through it and it turned out fine, reminding themselves that they will be okay and they will be going home at a certain time.

If a child asks questions like, "will I be okay, is my mom coming back, when am I going home," it is okay to reassure them one time, but stay away from reassuring them over and over, as this could just prolong the time they stay away from the classroom or class activity, and feed into the anxiety. You can say something like, I am here if you need me, but I am confident that you will be okay. At three o'clock your mom will pick you up. If they keep asking questions seeking more reassurance, remind them the you already reassured them once, and it is not effective to reassure over and over.

For more on the topic of reassurance as it related to separation anxiety see: Home Management Strategies for Separation Anxiety Disorder

Educate children about anxiety. Talk about what anxiety feels like (e.g., knot in stomach, pounding heart, sweating) so children know how to recognize it when it occurs. Remind them that everyone experiences some anxiety sometimes and it is completely normal. Some anxiety is good because it is our body's way of warning us of potentially dangerous situations. However, sometimes anxiety occurs due to a perceived fear that may be highly unlikely or non-existent. When anxiety tells us to stay away from non-dangerous situations and causes us to avoid experiences that may actually be good for us or when normal anxiety becomes so intense that it is hard to focus, get through an activity, or interact with others, we need to learn coping strategies to get through these times, rather than avoiding these situations.

Promote practicing relaxation techniques developed at home...see Part 1: Strategies for Parents to Help their Child with Separation Anxiety for suggestions regarding relaxation techniques that can be taught by a parent or school counselor.

Provide alternative activities to distract the child from physical symptoms associated with the anxiety (e.g., draw a picture, write feelings down, join a preferred classroom activity).

Encourage/model small group interactions (e.g., games, art projects, discussions). This can start with only one classmate. With time, if the child increases his competency, the group may be enlarged gradually. This is something that can be done in the counselor's office or when students are paired up with peers for classroom activities.

Give positive feedback when the child makes efforts to get through anxiety provoking situations or uses strategies he/she has learned to cope with anxiety.

Help the child prepare for transitions. For instance, give the child time to prepare that a change is coming (e.g., in five minutes we will be going to music class, or after math is over we will be working on an art project). Children with anxiety may be apprehensive to change from one activity to the next, especially if they are unprepared for the change.

If the child has been staying out of school, initiate a plan to promote the child´s return to school as soon as possible (the school team including the school counselor, teacher, and principal, can talk to the parents/and therapist if applicable, to come up with a plan for when the child will return and how to facilitate this return). The school may need to help the parents come up with a plan. See suggestions for how parents can encourage their children to return to school in Part 1: Strategies for Parents to Help their Child with Separation Anxiety.

Maintain frequent meetings with parents, in order to collaborate regarding what type of support is appropriate for their child to have while in school. It is important for parents and school to handle problems related to separation anxiety in a consistent way using a team approach. Expectations for how the child copes with his/her anxiety should be similar in school and at home.

If the child is refusing to attend school, assess what may be the trigger for the refusal and work with the child to address the concern if possible (e.g., are there problems with friends, fear of a teacher, etc.?).

Two research-based programs for treating Separation Anxiety Disorder include the Coping Cat Program and the FRIENDS Program. These programs are intended to be utilized by mental health professionals treating children for anxiety related conditions such as separation anxiety disorder. For more on the research regarding the effectiveness of these programs see Separation Anxiety Disorder in Youth: Phenomenology, Assessment, and Treatment.

Related Article: Evidence Suggests That the Coping Cat Program Reduces Anxiety in Children and Teens

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Strategies for Schools to Help Children with Separation Anxiety - educationandbehavior.com

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This article is a follow up from our first article: Strategies for Parents to Help Their Child with Separation Anxiety. This intro is the same, but as you go further down the article, you will see strategies for schools to use to Help children with separation anxiety. What is Separation Anxiety Disorder?

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Abstract

We examined trends in publications on childhood anxiety disorders over the past 25 years. A PsycINFO search was carried out to find relevant research articles published between 1982 and 2006. Results indicated a gradual and significant rise in the frequency of publications on childhood anxiety disorders during the past 25 years, and this increase was particularly strong for post-traumatic stress disorder, obsessive-compulsive disorder, social phobia, and multiple anxiety disorders. Most studies concerned the phenomenology of childhood anxiety disorders (i.e., >50%). Considerable less research has been conducted on the etiology, intervention, and assessment of these disorders in youths. Nevertheless, the conclusion seems warranted that the research on childhood anxiety disorders has made significant advancements during the past decades. This notion is supported by a selective review of the literature, which highlights important developments in this field of study.

Keywords: Childhood anxiety disorders, Publication trends, Review

Introduction

Anxiety disorders constitute a common psychiatric problem. For example, in their large-scale epidemiological study, Kessler et al. ( 2005b) noted that with a 12-months prevalence of 18.1% anxiety disorders were by far the most prevalent DSM-IV disorders in a representative sample of American adults. Not surprisingly, anxiety disorders have attracted a considerably amount of research attention, which has led to clear advancements in our knowledge of the phenomenology, etiology, assessment, and treatment of this type of disorders (e.g., Barlow 2002).

Meanwhile, researchers have neglected to investigate childhood anxiety disorders for a long time. This was probably due to the fact that fear and anxiety are fairly common in youth, which has led many psychologists to the conclusion that these phenomena were of less interest from a clinical point-of-view (Cartwright-Hatton et al. 2006). During the last two decades, this opinion has gradually changed as it has been demonstrated that a substantial minority of children and adolescents do suffer from such high fear and anxiety levels that a diagnosis of an anxiety disorder is clearly warranted. In fact, community studies have indicated that anxiety disorders are among the most frequent forms of psychopathology among youths (Costello et al. 2003; Ford et al. 2003). Moreover, there is evidence indicating that a significant proportion of the childhood anxiety disorders have a chronic course, and even last into adulthood (Keller et al. 1992; Roza et al. 2003).

A recent analysis of publication trends in individual anxiety disorders (Boschen 2008) has demonstrated that research on this psychiatric disorder has steadily grown during the past 25 years. Obviously, publication trends are one method to determine the health of a research field (e.g., Pincus et al. 1993), and on the basis of Boschen's results it can be concluded that the anxiety research in adults has substantially increased over the past decades. However, it remains to be seen whether such a conclusion is also true for the research on childhood anxiety disorders. With this issue in mind, the present study was conducted. More precisely, it was examined whether the understanding that childhood anxiety disorders represent a serious psychiatric problem has led to an increase of activity in research. Furthermore, an attempt was made to typify the research and to provide a selective review of the literature, which highlights some of the major research advancements in the past 25 years as well as avenues for future studies on childhood anxiety disorders.

Method

The method closely followed the procedure employed by Boschen (2008; see Mendlowicz et al. 2006) in his investigation of publication trends on anxiety disorders. The most popular database of psychological literature, PsycINFO, was used to search for articles on childhood anxiety disorders. For each year in the period 1982-2006, we looked for original research articles in peer-reviewed journals that focused on childhood anxiety disorders. Searches were conducted employing the following search terms in the title of the articles from the database, in combination with the term CHILD* OR ADOL*, which could appear anywhere: (1) PANIC OR AGORAPHOBI* for panic disorder/agoraphobia, (2) SOCI* PHOBI* OR SOCI* ANXI* OR AVOID* DISO* for social phobia, (3) SPECIFIC PHOBI* OR SIMPLE PHOBI* OR PHOBIA for specific phobia, (4) OBSESSI* OR COMPULSI* OR OCD for obsessive-compulsive disorder, (5) SEPA* ANXI* for separation anxiety disorder, (6) POST-TRAUM* OR POSTTRAUM* OR PTSD for posttraumatic stress disorder, and (7) GENERALI* ANXI* OR GAD OR OVERANXI* DISO* for generalized anxiety disorder. Note that although we employ the current nosologic terms for anxiety disorders as listed in the more recent editions of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 1994, 2000) throughout this article, our search terms also covered relevant diagnoses that were used in previous editions of this classification system (American Psychiatric Association 1980, 1987). To prevent that we would miss articles devoted to multiple childhood anxiety disorders, an additional search was carried out with ANXI* DISO* as search term in the title. These searches yielded 467 hits for panic disorder/agoraphobia, 454 for social phobia, 780 for specific phobia, 1240 for obsessive-compulsive disorder, 258 for separation anxiety disorder, 1522 for post-traumatic stress disorder, 106 for generalized anxiety disorder, and 517 for multiple anxiety disorders. The abstracts of all these hits were visually inspected in order to remove non-relevant articles. Commentaries, letters, review articles, dissertation abstracts, books, and book chapters were excluded, and we also encountered quite a large number of false positives (e.g., articles on childhood antecedents of adult anxiety disorders).

For relevant publications, a number of study characteristics were determined: (1) Did the study include clinically referred children? (2) Did the study investigate the pertinent anxiety disorder(s) in children (aged 0-12 years), adolescents (aged 13-18 years), or both age groups? (3) What was the main topic of research? The latter question had four response categories: (a) Phenomenology: the study is examining the anxiety disorder(s) on a descriptive level by investigating symptomatology, epidemiology, severity of the disorder, clinical correlates, and comorbidity with other psychiatric disorders, (b) Etiology: the study is investigating variables that play a role in the development and maintenance of the anxiety disorder(s), (c) Assessment: the study describes the development and/or psychometric evaluation of an instrument for measuring specific or more general aspects of anxiety disorders, and (d) Intervention: the study examines the effectiveness of a psychological or pharmacological intervention that aims to reduce or prevent anxiety disorders. As it is recognized that in particular the judgment of the study topic may be rather subjective, a reliability analysis was carried out. Two-hundred articles retrieved from the psychological literature were categorized into the four categories by two judges. The percentages of agreement were 89.1% for phenomenology, 76.9% for etiology, 89.7% for assessment, and 96.8% for intervention, yielding an overall kappa of 0.82.

Results

Our analysis of the literature eventually yielded a total of 1394 relevant articles on childhood anxiety disorders: 99 of these were on panic disorder/agoraphobia, 177 on social phobia, 83 on specific phobia, 367 on obsessive-compulsive disorder, 51 on separation anxiety disorder, 377 on post-traumatic stress disorder, 34 on generalized anxiety disorder, and 206 on multiple anxiety disorders. From this, it can be concluded that the research on childhood anxiety disorders has been dominated by posttraumatic stress disorder and obsessive-compulsive disorder, followed by multiple anxiety disorders and social phobia, whereas studies on panic disorder/agoraphobia, specific phobia, separation anxiety disorder, and generalized anxiety disorder are clearly less frequent. Further, a comparison of these frequency figures with those of Boschen ( 2008) indicated that childhood anxiety disorders reflect only a small proportion of the total publications on anxiety disorders ( N = 13614), namely 10.2%.

Figure displays the mean frequency of publications per year averaged for each 5-year period for various categories of childhood anxiety disorders. An 8 (anxiety disorders category) × 5 (time period) analysis of variance with the last factor being a repeated measure, yielded a significant main effect of anxiety disorders category [ F(7,160) = 65.26, p < .001, η ² = .74], which indeed confirmed the observation that some childhood anxiety disorders were more frequently investigated than others. Bonferroni-corrected post hoc comparisons indicated that there were significantly more publications on post-traumatic stress disorder and obsessive-compulsive disorder than on multiple anxiety disorders and social phobia (all ps < .001), which in turn were more often examined than the other anxiety disorders (all ps < .05). Furthermore, the analysis yielded a significant main effect of time period [ F(4,160) = 90.26, p < .001, η ² = .69]. As shown in Fig. , there was a significant increase in the number of publications on childhood anxiety disorders over the past 25 years. Post hoc analyses indicated that the increase of publications occurred gradually from one 5-year period to another (all ps < .01); only between 1987-1991 and 1992-1996 no significant change in the number of publications was observed ( p > .05). Finally, the interaction of anxiety disorders category and time period was also significant [ F(28,160) = 10.34, p < .001, η ² = .64], suggesting a differential course in the frequency of publications on various childhood anxiety disorders. To explore this finding, correlations were computed between year of publication and the number of publications per year for each anxiety disorder category (Table ). For reasons of comparison, similar correlations as obtained by Boschen ( 2008) are also shown (for this reason, only the years 1982-2005 were used in the statistical analysis). For all anxiety disorders, correlations were positive and significant, indicating an increase of publications for all anxiety disorder categories during the past 25 years. However, tests for comparing correlation coefficients indicated that the increase for some anxiety disorders [i.e., post-traumatic stress disorder ( r = 0.91), obsessive-compulsive disorder ( r = 0.90), social phobia ( r = 0.88), and panic disorder/agoraphobia ( r = 0.80)] was significantly stronger than for others [i.e., separation anxiety disorder ( r = 0.46) and specific phobia ( r = 0.33); all t(48)s ≥ 2.99, ps < .01]. A statistical comparison between the correlations as found in the current study and those reported by Boschen ( 2008) indicated that the increase in number of publications in the childhood anxiety disorders literature was similar to that observed in the general anxiety literature. The only exception was generalized anxiety disorder, for which the increase in publications was significantly smaller among children and adolescents [ t(50) = 3.80, p < .001].

Table 1

The characteristics of the research on childhood anxiety disorders are shown in Table . Note that a substantial proportion of the studies (65.9%) included clinical patients, although the percentages differed across various disorders [ F(7,162) = 15.96, p < .001]. Research on obsessive-compulsive disorder, specific phobia, and generalized anxiety disorder most often included clinically referred youths, while studies on social phobia, post-traumatic stress disorder, and panic disorder/agoraphobia least frequently focused on youths in clinical settings. There were also significant differences between various anxiety disorders with regard to the inclusion of children [i.e., 0-12 years; F(7,162) = 13.43, p < .001] and adolescents [i.e., 13-18 years; F(7,162) = 4.81, p < .001]. Research on generalized anxiety disorder, specific phobia, multiple anxiety disorders, and separation anxiety disorder quite often investigated children, while studies on panic disorder/agoraphobia and obsessive-compulsive disorder most frequently relied on adolescent populations.

Table 2

An inspection of the distribution of the research across various topics revealed that studies on the phenomenology of anxiety disorders were clearly most common (50.8%), followed by research on etiology (22.7%) and intervention (20.9%), whereas research on assessment was least prevalent (11.2%) [except for the comparison between etiology and intervention; all differences were significant with Zs ≥ 4.06, ps < .001]. ANOVAs indicated that only the frequency of publications on the etiology of childhood anxiety disorders has changed significantly over the past 25 years [ F(4,165) = 3.69, p < .01]: inspection of the mean percentages of publications per 5-year period revealed a gradual increase from 15.1% in 1982-1986 to 32.6% in 2002-2006 ( p < .05).

Further, there were no differences between various anxiety disorder categories regarding the frequencies of studies on phenomenology and etiology [both F(7,162)s ≤ 1.66, p > .05]. However, significant variation in research on assessment and intervention was found across various anxiety disorders [ F(7,162)s being 3.39 and 4.84, respectively, both p s < .01]. As can be seen in Table , studies on assessment instruments for social phobia were fairly prevalent, whereas few investigations addressed the measurement of panic disorder/agoraphobia, specific phobia, obsessive-compulsive disorder, and post-traumatic stress disorder. With regard to intervention, specific phobia was most commonly investigated, with relatively few studies on the treatment of post-traumatic stress disorder.

Selective Review of Research Advancements and Future Directions

Although the quantitative analysis of the literature on childhood anxiety disorders as presented above yields interesting information on publication trends in this research domain, it may also be worthwhile to perform a more qualitative review on the studies that have been published in order to highlight some of the advancements in this field of study. For this purpose, we will employ the four topics of research that were also used in the publication trends analysis (i.e., phenomenology, etiology, assessment, and intervention). For each topic, we will also indicate possible directions for future research.

Phenomenology

As mentioned earlier, epidemiological studies have indicated that childhood anxiety disorders are quite prevalent. For example, Costello et al. ( 2003) report a cumulative prevalence rate of 9.9% for anxiety disorders by the age of 16 years, which means that 1 out of 10 youths in this study had suffered from an anxiety disorder at some point during their childhood. Specific phobia, social phobia, generalized anxiety disorder, and separation anxiety disorder are most common, with mean prevalence rates between 2.2 and 3.6%. Agoraphobia (1.5%) and post-traumatic stress disorder (1.5%) are less prevalent, whereas panic disorder and obsessive-compulsive disorder are relatively rare (i.e., <1%; Costello et al. 2004). Girls more frequently suffer from phobias and other anxiety disorders as compared to boys (i.e., the sex ratio is about 2:1), and there is clear evidence indicating that this difference in prevalence already emerges at a very early age (Lewinsohn et al. 1998). Findings concerning the course of childhood anxiety disorders indicate that anxiety disorders are transitory phenomena in most children and adolescents (Last et al. 1996). Yet, in a subgroup of youths, pathological manifestations of fear and anxiety become chronic, causing significant problems and interference with daily functioning for many years (e.g., Kessler et al. 2005a). Childhood anxiety disorders also show considerable comorbidity with other psychiatric problems, in particular depression. For example, Costello et al. ( 2004) noted that depression is more than 8 times as likely in youths with anxiety disorders than in youths without anxiety disorders.

Although current classification systems (e.g., American Psychiatric Association 2000) adopt highly similar criteria for defining anxiety disorders in youths and adults, child psychologists have questioned whether this is all correct (e.g., Weiss and Last 2001). There is emerging evidence indicating that the symptomatology of anxiety disorders may vary from one age group to another (Geller et al. 2001; Kendall and Pimentel 2003). Some authors have even proposed that developmental shifts may herald periods in which children are particularly prone to develop anxiety disorders (e.g., Westenberg et al. 1999). As such, it seems important to further examine the exact manifestations of specific anxiety disorders in youths of various ages and to explore the possible influence of developmental factors.

Etiology

In the past decades, a range of variables have been identified that are thought to play a role in the etiology of childhood anxiety disorders (Muris 2007). First of all, behavioral-genetic research has shown that there is clear support for the genetic transmission of childhood anxiety disorders, with some studies showing that up to 50% of the variance in anxiety problems can be explained by heritability (Eley and Gregory 2004). It is assumed that the genetic influence on childhood anxiety is rooted in the biologically substrate of the temperament trait 'neuroticism', which already manifests itself at a very early age as 'behavioral inhibition' (Craske 1997). Behavioral inhibition can be defined as the tendency of some children to interrupt ongoing behavior and to react with vocal restraint and withdrawal when confronted with unfamiliar people or settings (Kagan 1994). Evidence coming from cross-sectional and prospective studies has shown that children who clearly display the signs of this temperament characteristic are at increased risk for developing anxiety disorders (Fox, Henderson et al. 2005). Second, there are also environmental variables which may increase children's vulnerability to develop anxiety disorders. Examples are overprotective parental rearing behaviors (Rapee 1997), an insecure attachment relationship (Warren et al. 1997), direct (i.e., conditioning) and indirect (i.e., modeling, negative information transmission) learning experiences (King et al. 1998), and negative life events (Tiet et al. 2001). Third, research has identified various types of cognitive biases that are thought to play a role in the development and maintenance of childhood anxiety disorders. More precisely, there is clear evidence showing that anxious children typically display hyperattention towards potentially threatening material (i.e., attentional bias) and more frequently interpret ambiguous stimuli and situations in a threatening way (i.e., interpretation bias; Vasey and MacLeod 2001).

While genetic-based vulnerability, environmental influences, and maintaining factors have been predominantly studied in isolation, it is clear that an "understanding of the pathways by which childhood anxiety disorders develop, persist and remit is likely to require consideration of a wide range of influences and, most importantly, their potential for complex, dynamic, transformational interactions (i.e., transactions) across development" (Vasey and Dadds 2001, p. 3). More longitudinal studies are urgently needed that include multiple vulnerability (as well as protective) factors to further expand our knowledge on the etiology of this highly prevalent type of psychopathology.

Assessment

Although our publication trend analysis suggests that research on the assessment of childhood anxiety disorders is relatively sparse, it is positive to note that several questionnaires and interview instruments have become available in the past decade that classify and quantity symptoms of anxiety disorders in terms of the prevailing diagnostic system, i.e., the DSM (Silverman and Ollendick 2005). Good examples are the Spence Child Anxiety Scale (Spence 1998) and the Screen for Child Anxiety Related Emotional Disorders (Birmaher et al. 1999), which can be used to measure anxiety disorders symptoms from the child's and parents' point-of-view, and the Pediatric Anxiety Rating Scale (Research Units on Pediatric Psychopharmacology Anxiety Study Group 2002), which is a clinician rating scale. As for interview instruments, the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (Silverman and Albano 1996) is the gold standard. This semi-structured interview has been developed specifically to assess child and adolescent anxiety disorders as well as a number of frequent comorbid disorders (e.g., mood disorders, disruptive behaviour disorders).

Research has specifically addressed the development of instruments for measuring social phobia (see Table ), including the Social Anxiety Scale for Children-Revised (LaGreca and Stone 1993) and the Social Phobia and Anxiety Inventory for Children (Beidel et al. 1995). This does not mean that specific instruments are lacking for other childhood anxiety disorders, but these simply need more psychometric evaluation.

Intervention

Various methodologically sound treatment outcome studies have appeared in the literature, which have evaluated the effectiveness of psychological and biological interventions for youths with phobias and anxiety disorders (e.g., Barrett 1998; Birmaher et al. 2003; Kendall 1994; RUPP Anxiety Study Group 2001). This research has demonstrated that Cognitive Behavior Therapy (CBT) and pharmacotherapy are effective in reducing anxiety symptoms in children and adolescents of various ages. Given that the empirical evidence for CBT is more substantial than that for pharmacotherapy, cognitive-behavioral interventions should still be regarded as the treatment of choice for childhood anxiety disorders. However, pharmacotherapy (in particular Selective Serotonin Reuptake Inhibitors or SSRIs) can be employed during the acute phase of treatment (when symptoms are very severe) or when children or adolescents do not respond adequately to a CBT intervention (American Academy of Child and Adolescent Psychiatry 1997).

Although the field has made considerable progress in the treatment of youths with anxiety disorders, it is also true that there is a substantial proportion of the children and adolescents who do not respond to psychological and pharmacological interventions. By means of research on the mediators and moderators of treatment, we may learn more about how to use various interventions more effectively, which may improve our therapeutic approach of individual children and adolescents with anxiety disorders.

Discussion

In this article, we present an analysis of publication trends on childhood anxiety disorders during the past 25 years as well as a selective review of the literature on this type of psychopathology. With regard to the publication trend analysis, a number of remarks can be made. First of all, we observed a gradual and significant increase in publications during the past 25 years for all childhood anxiety disorders. This trend was highly similar to that observed in the adult literature (Boschen 2008), and particularly strong for post-traumatic stress disorder, obsessive-compulsive disorder, social phobia, and multiple anxiety disorders, for which, if this tendency continues, even a greater amount of research can be expected in the near future. Second, the results indicated that post-traumatic stress disorder and obsessive-compulsive disorder were most frequently examined (see also Boschen 2008), which of course is not in keeping with the fairly low prevalence rates of these anxiety disorders in youths. Meanwhile, it is quite surprising to note that separation anxiety disorder, which is quite prevalent and a disorder specifically diagnosed in particular among children, has received relatively little research attention (Silverman and Dick-Niederhauser 2004). Third, most studies have investigated the phenomenology of childhood anxiety disorders (i.e., >50%). Considerable less research has been devoted to the etiology, intervention, and assessment of childhood anxiety disorders. In spite of the observation that scientific advancements are not evenly distributed across various anxiety disorders and several research topics, we think that the conclusion is still justified that the research on childhood anxiety disorders has shown various important advancements as illustrated by our selective review of the literature.

Childhood anxiety disorders are best viewed from a developmental psychopathology perspective, which assumes that normal and abnormal manifestations of fear and anxiety are part of one and the same continuum (Vasey and Dadds 2001). This implies that it is equally relevant to study clinical as well as non-clinical populations of youths. Not surprisingly, then, although our literature search focused on childhood anxiety disorders, about one-third of the studies was found to rely on non-clinical children and adolescents and it is obvious that this proportion would have increased if we had employed more liberal search terms (e.g., FEAR OR ANX* in combination with CHILD* OR ADOL*). In other words, it should be kept in mind that the publication trend analysis was not based on the definitive total of research output in the field of childhood anxiety (disorders), but rather focused on a representative sample of relevant studies.

As it is increasingly acknowledged that the foundation of many adult anxiety disorders is already laid during childhood (Craske 2003), it is good to note that researchers have picked up this notion and more and more investigate this type of problems in youths. In the past decades, the research domain of childhood anxiety disorders has made significant progress, as evidenced by an increasing amount of empirical articles in scientific journals. We hope that this publication trend analysis and review may guide researchers in their future work in this rapidly expanding and intriguing research area.

Acknowledgment

Mark J. Boschen is thanked for providing us with his data set on publication trends in anxiety disorders.

Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

References

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005b). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry,62, 617-627. doi:10.1001/archpsyc.62.6.617. [
PMC free article]

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Twenty-five Years of Research on Childhood Anxiety Disorders: Publication Trends Between 1982 and 2006 and a Selective Review of the Literature

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We examined trends in publications on childhood anxiety disorders over the past 25 years. A PsycINFO search was carried out to find relevant research articles published between 1982 and 2006. Results indicated a gradual and significant rise in the frequency of publications on childhood anxiety disorders during the past 25 years, and this increase was particularly strong for post-traumatic stress disorder, obsessive-compulsive disorder, social phobia, and multiple anxiety disorders.