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The School Counselor and Group Counseling (ASCA)

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The School Counselor and Group Counseling (ASCA)

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ASCA's position statement on the School Counselor's role in School Counseling is an important document to review before beginning the groups. It emphasizes that School Counselors can provide interventions such as psychoeducation and skill building to address general mental health challenges that impact a student's school performance and functioning outside of the classroom such as anxiety. Further, it states that School Counselors provide short-term interventions rather than long-term counseling to address specific psychological disorders. This will be important for us to keep in mind as different issues arise and information is shared throughout the group process.

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The School Counselor and Group Counseling

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Group counseling, which involves a number of students working on shared tasks and developing supportive relationships in a group setting, is an efficient, effective and positive way of providing direct service to students with academic, career and social/emotional developmental issues and situational concerns.

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"The Effect of Solution-Focused Brief Group Counseling on Adolescents' Basic Need Satisfaction and Wellness"

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"The Effect of Solution-Focused Brief Group Counseling on Adolescents' Basic Need Satisfaction and Wellness"

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This article supports the rationale for using a solutions-focused brief group counseling as an intervention for adolescents experiencing anxiety and other mental health challenges. The authors found both quantitative and qualitative data supporting the effectiveness of this type of intervention. For example, participating students reported statistically significant improvement in perceived relatedness, competence and well-being. Furthermore, in a qualitative interview following the intervention, students reported that the group had helped them develop responsibility and self-efficacy, helped increase their happiness and positive thinking, and contributed to their social relationships.

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"A Systematic Review and Meta-Analysis of School-Based Stress, Anxiety, and Depression Prevention Programs for Adolescents"

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"A Systematic Review and Meta-Analysis of School-Based Stress, Anxiety, and Depression Prevention Programs for Adolescents"

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This article further supports the rationale for the group. The authors found that school-based anxiety prevention programs resulted in a statistically significant reduction in participating students' anxiety symptoms. Another helpful finding was that the results of the interventions in the study did not seem to last long-term. This is important for us to keep in mind so that we focus our group sessions on helping students build skills and change their mindsets so that the group intervention has a longer-lasting impact.

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Thought distortions are very common, especially for people who experience anxiety. It will be important for students to learn to recognize their own thought distortions to begin challenging and reframing these unhelpful thoughts to help decrease anxiety.

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Video for Thought Distortion Group Activity

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Video for Thought Distortion Group Activity

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Students will watch this video to learn about 9 common thought distortions and how they impact their feelings, moods and behavior.

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9 Cognitive Distortions that can Cause Anxiety and Depression

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Challenging Negative Thoughts Worksheet (Thought Distortion Group Activity)

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Challenging Negative Thoughts Worksheet (Thought Distortion Group Activity)

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Students will use this worksheet to practice challenging and reframing inaccurate/unhelpful thoughts

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Three Good People Worksheet for Strengths Spotting Group

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Three Good People Worksheet for Strengths Spotting Group

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Students will use this worksheet to practice recognizing strengths in others as well as themselves to begin using a strengths-based mindset to boost self-esteem and confidence.

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Self-esteem is often a challenge for adolescents, especially those experiencing anxiety. This group activity focuses on recognizing strengths in ourselves and how we use those strengths to overcome challenges.

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This article describes five different options for closing rituals that our group could utilize. Giving students choices is one way to improve group engagement and ownership so it may be effective to give students a choice in which closing ritual they think would be best for the group.

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When I plan for group counseling, I always think about how we'll wrap things up in the end as well. Some of this develops organically throughout the group as the students get to know each other and create their own bonds. I always want to end our time together in a meaningful way that is reflective of the growth and relationships that took place in group. Keep reading to find 5 group counseling closing rituals that you can use in your groups!

Group Counseling Closing Rituals

1. Group Motto

If you have a group motto or group affirmation that students have developed or said together throughout the group, using this to end the group is a great way to wrap up. Students can simply stand or sit in a circle and say the motto or affirmation in unison as the last group activity before leaving the space.

2. Leave Your Mark

For this activity, students can leave a handprint or thumbprint to make something as a group. You could use their thumbprints to make a bundle of balloons, a flower, a caterpillar or something else. Or you could use handprints to make something your students choose. This is just something to leave behind that they can see when they come back to the counseling office as a reminder of their time in group. I leave students' names off of this so I can hang them on the wall.

3. My Hope for You

This closing ritual takes some time, but it's so meaningful! Students take turns sharing their hopes for group members. They can say something to each group member or you can draw names so that each person shares their hope for one other person. Students simply say, "My hope for you is..." and share what they hope for the group member after group ends. You can also have students write these so that group members have a tangible take-away after group.

4. Pass the Peace

In this ritual, students can stand in a circle and hold hands or just face each other. If students are holding hands, one student begins by gently squeezing the hand of the person to their left. They say, "I pass the peace to you." This continues around the circle as a way to pass peace to each group member before they leave the group. If students not holding hands, one student can begin by making eye contact with someone and giving them a wink or a smile and saying, "I pass the peace to you." This continues until everyone has received the peace.

5. You Impacted Me

In this ritual, students take turns sharing how other group members impacted them during group. It could be something they said, something they shared, or a way they treated others. It's a nice way for students to hear how they have had an impact on others to remember and take away from group.

What are your favorite group counseling closing rituals? Leave them in the comments below!

Want step-by-step guidance for group counseling planning? Sign up for Group Counseling Game Plan!

Ready to print-and-implement group counseling curriculum:

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Looking for meaningful ways to end group counseling? Check out these 5 group counseling closing rituals to use with your students!

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Video for breathing through Anxiety group activity.

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Video for breathing through Anxiety group activity.

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Students will watch this video to learn different breathing exercises to help when encountering difficult situations. Students will identify which relaxation skill works best for their anxiety and identify ways to implement their new skill.

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Relaxation Skills for High School Students: How to Cope with Stress & Anxiety | Child Mind Institute

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Group Anxiety Activity: Coping Skill practice

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Group Anxiety Activity: Coping Skill practice

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The goal of this activity is to identify the things you can and cannot control. Students will understand their impact in the circle of life. Students will achieve acceptance; understanding; coping skills and problem skills. Students will gain the skill of inner strength.

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Circle Of Control Activity For Kids - Good Mental Health And Stress Management

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Fun and interactive way to introduce coping skills to High school students. Each category encourages conversation and engagement.

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Snowball Activity: Will be used in Session Two

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Snowball Activity: Will be used in Session Two

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It can be difficult to get students to open up, especially those in higher grades but we know how critical it is for wellbeing to be able to manage and release emotions. If you're looking for fun stress relieving activities for students, I can guarantee that this one will be a hit!

If you'd like a variation of this crumpled paper lesson for younger students, I have one in my pack that teaches students to manage anger and anxiety.

While playing the Grumpy Paper Toss, kids are asked to write down things that worry them or make them feel grumpy. They take a moment to consider why these things are upsetting and promise to allow themselves to let the little things go. After scrunching their paper into a ball, they get to shoot for a goal in the rubbish bin!

The Snowball Toss is a step up which allows older students the opportunity to unpack their worries and learn about the effects of stress. It's a great segway into discussions around mental health, compassion, understanding and supporting others.

Transcript of snowball toss video

Teacher: All right, gentlemen, what have we learned about stress from the week's discussion?

Student: Today we did an activity in my classroom where we talked about stress.

Teacher: We're going to do the snowball activity, okay?

I'm trying to get them to know how to identify stress and then know how to be able to adapt and cope and work with that.

Okay, go ahead and take one minute to finish up.

After they wrote down their stress, they balled up the paper. I asked them, "What should you do with stress?" and they said, "Get rid of it." "So let's get rid of the stress," and we had a snowball fight.

Student: Everybody ready?

Students: Yeah.

Student: Go.

Teacher: The idea is that we're moving around, we're able to have fun, laugh, scream, be loud, and then have that discussion about stress.

Everybody get a snowball.

Afterwards, they unwrap the snowball and they read what their peer was stressed about.

Who'd like to begin?

Student: I learned that stress can cause many things, like depression.

Teacher: They got up, it was interactive and it was hands on. They were able to have a conversation with
each other about things that they were dealing with.

Student: I haven't felt good about myself in such a long time.

Teacher: Which is promoting interpersonal skills and learning during the process.

If you want an effective lesson for bullying, the " Wrinkled Heart Activity" is very popular among students and teachers.

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Snowball Toss Activity - Teach Students How to Relieve Stress

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Take a 60-second brain break to relieve stress and anxietyIt can be difficult to get students to open up, especially those in higher grades but we know how critical it is for wellbeing to be able to manage and release emotions.

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High school students Battling ADHD and Anxiety

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High school students Battling ADHD and Anxiety

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This article highlights exercises you can conduct with students who have a learning disability. The goal of the exercises is to be proactive and create different skills to combat anxiety. Students will learn the importance of journaling and exercising to create balance.

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Adults with attention deficit hyperactivity disorder (ADHD or ADD) lead anxious lives. The nature of ADHD often makes day-to-day life stressful, creating situations and environments fraught with uncertainty - anxiety's primary fuel.

That is why ADHD cannot be discussed without bringing up anxiety, whether that means pesky, troublesome bouts of worry that present only in specific contexts (like meeting work deadlines or making difficult back-to-school decisions), or full-fledged anxiety disorder. Either way, the link between the two is direct, so much so that anxiety is the most common comorbid diagnosis with adult ADHD.

This ADHD-anxiety link is magnified today by an almost universal and unprecedented stressor: the pandemic. A giant, unfamiliar cloud of uncertainty hovers indefinitely over us, raining down feelings of discomfort and anxiety that make this relationship impossible (and unhealthy) to ignore.

Is Anxiety a Symptom of ADHD?

Although anxiety alone is not included in the diagnostic criterion for ADHD, the link between the two conditions is strong. Individuals with ADHD are more likely to have an anxiety disorder than are individuals without the condition, with rates approaching 50 percent. ¹

Anxiety refers to our mental and physiological response to a perceived risk or threat. Anxiety disorders, which range from social anxiety disorder to panic attacks to post-traumatic stress disorder (PTSD) and more, are characterized by constant feelings of worry and fear that interfere with daily life.
[Could You Have Anxiety? Take This Symptoms Test]
Some symptoms - like fidgeting and trouble concentrating - are hallmarks of both ADHD and anxiety. As a result, clinicians must rule out anxiety and other mental disorders when diagnosing ADHD, and vice versa.

Does ADHD Make Anxiety Worse?

Individuals diagnosed with ADHD and anxiety disorders tend to have more severe anxiety symptoms than do those without ADHD. ² But even adults with ADHD who do not meet the diagnostic criteria for anxiety may experience occasional and situational anxiety in their daily lives - precisely because of ADHD, which may cause time blindness, poor working memory, and exaggerated emotions, among other anxiety-producing symptoms.

In one study on adults with ADHD, researchers noted that problems stemming from ADHD - such as tardiness, procrastination, and the prospect of social stigma - all led participants to experience anxiety at many points in their lives, "and once they were anxious, their ADHD symptoms worsened." ³

Other ADHD Symptoms That Exacerbate Anxiety

"Consistent Inconsistency"

Inherent uncertainty about how an event or a task will play out is at the core of anxiety. Understanding "consistent inconsistency," a common element of life with ADHD, is key to understanding the persistent anxiety of living with ADHD. "Consistent inconsistency" describes the distrust and uncertainty in yourself that builds up after years of experiencing ADHD symptoms such as inattention, overwhelm, memory lapses, and more. "Consistent inconsistency" is knowing, for example, that a task needs to be accomplished, but doubting the ability to get it done.
[ADHD Directory: Find an ADHD Specialist or Clinic Near You]
ADHD as a Performance Problem

Individuals with ADHD know what they need to do, but they have problems with implementation - a tension that begets anxiety. This is a big part of what makes ADHD maddening, particularly in adulthood. Barriers to implementation include the following:

Self-regulatory efficacy: "I know I can do this, but I'm not sure if I can resist distraction or focus."

Incautious optimism: Otherwise known as distorted positive thoughts. "I work best at the last minute."

Front-end perfectionism: "I have to be in the mood/have enough energy to do something." These unlikely standards are by far the most common distorted automatic thought within adults with ADHD.

Emotional dysregulation: While not included in the DSM-5, emotional intensity is a central feature of ADHD. Part of managing anxiety is being able to change and control our emotional states so that we can readily engage in a task. Failing to manage discomfort effectively can lead to avoidance and procrastination, which exacerbates and is exacerbated by anxiety.

How Do You Treat Both ADHD and Anxiety?

Both ADHD and anxiety are treated through medication and/or psychosocial therapy. Often, treatment that focuses on one condition actually improves symptoms in both, though that depends on the individual. Still, clinicians always attempt to treat the most severe condition first.

Stimulant medications used to treat ADHD generally do not worsen anxiety symptoms, and non-stimulants are considered second-line pharmacological treatments for comorbid ADHD and anxiety. A combination of medicine and therapy, however, has been found to be most beneficial for individuals with ADHD and anxiety. ⁴

General feelings of anxiety can also be quelled through healthy coping mechanisms.

ADHD and Anxiety During the Pandemic

With ADHD minds experiencing so much overwhelm and so many new stressors - like working remotely from home, assuming the role of teacher, navigating disorienting routines, and treating health problems - it's important, more than ever, to develop skills to effectively manage anxiety and achieve resiliency.

Regulate Emotions, Behaviors & the Mindset

To effectively manage your anxiety, begin by using your feelings and behaviors as information. Anxiety or an otherwise troubling feeling can signal the question, "What's this discomfort telling me?" Good follow-up questions include:

What am I feeling?

What is the problem?

What was the trigger?

Is the problem really a problem? If so, how can it be managed?

What's the best, worst, and most likely outcome of the issue?

Pursue this disentanglement exercise through writing. Making notes on your phone or computer is fine, but there is something more therapeutic and engaging about using pen and paper to write out stressors and worries. Either way, moving the issue out of your head and seeing it take shape as text can help you clearly see what's in your control, and what's not. The exercise is also one of exposure - coming face-to-face with the problem.

Here's the exercise in action: Suppose you find yourself self-medicating through alcohol or binge eating during quarantine. How can you manage these urges?

Ask: "What am I feeling? What is the benefit of this behavior? What am I getting out of it?" These behaviors are typically associated with reducing anxiety, numbing oneself to stress, or feeling in control. Labeling the feeling (anxiousness, overwhelmed, out of control) is also a form of acknowledging the situation, in turn an action that calms us.

Identify the triggers or problems that gave rise to the bingeing or self-medicating behavior. This varies according to the individual, but common ones include boredom, loneliness, worries about meeting obligations, unrest or tension at home, work-related stress, and even the news cycle.

Think hard about these triggers and problems. Are the listed problems truly problems? Maybe you gave yourself an unrealistic deadline to meet the obligation you're stressing over. What are the best- and worst-case scenarios, and what's most likely to happen? Thinking through these can help us dwell in the probabilities rather than the possibilities - the problem may not be a problem after all.

That said, self-medicating on alcohol and bingeing are problems that need addressing. One way to handle both is through stimulus control - removing temptations in the household - and looking for replacement behaviors, like swapping in healthy foods or replacing alcohol with another liquid or stimulus, like tea or listening to calming music. Of course, if these or any other issues feel completely out of control, it may be best to get in touch with a licensed mental health clinician.

Other Coping Mechanisms for ADHD and Anxiety Today

1. Structure unstructured time. There's no way around it: Creating routine is a must, especially one that's highly visible. That could be an appointment planner, a calendar on the wall, or a digital planner kept open on a tablet. Think of planners as time machines that allow us to look hours, days, and weeks into the future, priming us for what we plan to do. Breaks must be worked into any schedule, including making room for...

2. Exercise and movement. We underestimate the loss of "stealth" movement during the course of the traditional workday (walking down hallways, to the parking lot or train station, etc.). As basic as it sounds, movement helps. This is especially true when cooped up and working from home. Movement can be its own form of meditation, allowing us to remove ourselves from work or home and reset.

3. Maintain healthy habits. Many individuals, ADHD or not, are experiencing chronic stress and general feelings of overwhelm with no one particular stressor. Better exercise, sleep, and diet - like limiting physical anxiety triggers like caffeine and alcohol - are effective at reducing overall stress.

4. Specify tasks. Avoid vaguely defining activities, and instead fill your calendar with task- or time-based items. Reviewing a report for work can be a 15-minute of 15-page task, and checking emails can be a 5-emails or 5-minute activity. Clearly laying out tasks helps combat front-end perfectionism and becomes an easy way to engage in a task for which you are not "in the mood." Discomfort fades soon after engagement.

5. Organize physical spaces. Define where work, leisure, sleep, study, and other activities will be done around the home to help with behavioral priming and habit formation. Combat "sight pollution" by resetting and preparing your spaces for the next day, which also helps with transitions.

6. Stay on ADHD medication and continue to attend psychotherapy sessions if applicable. Medications help reduce ADHD symptoms and improve coping and functioning, helping adults with ADHD feel more efficacious and, overall, less anxious. Same goes for psychotherapy, now widely available remotely.

7. Lower the bar on expectations. We can't expect the same performance in this pandemic world as before. That's a recipe for entrapment. Instead, we can reframe tasks into do-able terms and take on a sufficiency mindset. Being good enough is better than expecting to be perfect, and this mentality alone can get you unstuck and to a less anxious state. Now's probably not the time to embark in radically new endeavors, but it can be for new opportunities, like attending to deferred projects around the house.

8. Decatastrophize. Maintaining perspective and practicing gratitude is needed to get through all of this, even if loss, in any way, has touched the household. One way to modify thoughts is to disengage with the inflexible "should" mindset -- as in things "should" only work out one way and are no good if they don't. We can also "defuse" by accepting some negative thoughts for what they are - just thoughts.

[Read This Next: How to Stop Anxiety and Its Triggers] The content for this webinar was derived from the ADDitude Expert Webinar "Coping with Anxiety and Adult ADHD in the Pandemic World" by J. Russell Ramsay, which was broadcast live on June 25, 2020.
THIS ARTICLE IS PART OF ADDITUDE'S FREE PANDEMIC COVERAGE
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View Article Sources
¹Kessler, R. C., Adler, L., Barkley, R., Biederman, J., et.al. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. The American Journal of Psychiatry. 163(4), 716-723. https://doi.org/10.1176/ajp.2006.163.4.716 ² Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3 ³ Managing ADHD in children, adolescents, and adults with comorbid anxiety in primary care. (2007). Primary Care Companion to the Journal of Clinical Psychiatry, 9(2), 129-138. ⁴ Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatric Disease and Treatment, 4(2), 389-403. https://doi.org/10.2147/ndt.s6985

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ADHD and Anxiety: Symptoms, Connections & Coping Mechanisms

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ADHD and anxiety are closely connected. Anxiety disorder is ADHD's most common comorbidity - in no small part because the ADHD experience makes for a life characterized by stress and worry. This is especially true in the time of the pandemic, when new coping mechanisms are required.

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Students will complete test before group. Counselor will divide students by stress level and encourage students to discuss some of their stressors and how that has effected their everyday lives. The goal is for students to find a connection and with their peers and discover different skills to lower their stress.

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I am unable to concentrate on my studies.

I get distracted easily.

The thought of upcoming tests makes me extremely anxious.

Sometimes I feel like I don't deserve to be in the university, to begin with.

Some assignments seem so overwhelming that I just give up on them.

My relationships with my fellow students are complicated.

I feel awkward around my peers.

I have fallen behind in my studies and can't catch up.

I fear criticism.

Random questions and spontaneous assignments make me feel uncomfortable.

I tend to overthink test questions.

I don't have the willpower to study.

I feel extremely anxious before tests, even if I studied.

I am terrified of being excluded from university.

Sometimes I have to speak in front of an audience, and that makes me very anxious.

I am bullied by my peers or professors/lecturers.

I struggle to complete tasks on my to-do list.

I can't fall asleep before an important exam.

I am very concerned about my future.

My mood depends on how well I do in exams.

The minimum score is 0.
The maximum score is 100.
The higher the score, the higher the stress level.

Student stress can negatively affect your mental and physical wellbeing, as well as academic performance. If an undesirable event occurs, such as a bad grade, your cortisol spikes high and remains high unless you know how to relax and let things go. Being in a state of constant stress may lead to a weakened immune system, anxiety, and depression.

Additional contributors to student stress are:

financial struggles

living far from home

living with roommates

romantic relationships

Mild stress can be managed by

eating well

sleeping well

taking a walk

exercising

spending time with family and friends

learning time management techniques

getting more organized

realizing that academic intelligence can be developed

talking to others about your difficulties

journaling

developing optimism

However, if you experience any of the below symptoms, you must talk to a mental health professional:

violent outbursts

uncontrollable crying

anxiety

panic attacks

substance abuse

suicidal thoughts

abnormal social withdrawal

What makes you the way you are? Take THIS TEST to find out "

Related Posts:

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This quick test is designed to measure student stress levels. Student stress can negatively affect your mental and physical wellbeing, as well as academic performance.

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Opening, First, Second, and Third Sessions

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Opening, First, Second, and Third Sessions

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The 5-4-3-2-1 Method: A Grounding Exercise to Manage Anxiety

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Everyone experiences anxiety. It is a natural and important emotion, signaling through stirrings of worry, fearfulness, and alarm that danger or a sudden, threatening change is near. Yet sometimes anxiety becomes an exaggerated, unhealthy response.

Given the array of changes and uncertainties facing a normal teenager, anxiety often hums along like background noise. For some teenagers, anxiety becomes a chronic, highpitched state, interfering with their ability to attend school and to perform up to their academic potential. Participating in extracurricular activities, making and keeping friends, and maintaining a supportive, flexible relationship within the family become difficult. Sometimes anxiety is limited to generalized, free-floating feelings of uneasiness. At other times, it develops into panic attacks and phobias.

Identifying the Signs
Anxiety disorders vary from teenager to teenager. Symptoms generally include excessive fears and worries, feelings of inner restlessness, and a tendency to be excessively wary and vigilant. Even in the absence of an actual threat, some teenagers describe feelings of continual nervousness, restlessness, or extreme stress.

In a social setting, anxious teenagers may appear dependent, withdrawn, or uneasy. They seem either overly restrained or overly emotional. They may be preoccupied with worries about losing control or unrealistic concerns about social competence.

Teenagers who suffer from excessive anxiety regularly experience a range of physical symptoms as well. They may complain about muscle tension and cramps, stomachaches, headaches, pain in the limbs and back, fatigue, or discomforts associated with pubertal changes. They may blotch, flush, sweat, hyperventilate, tremble, and startle easily.

Anxiety during adolescence typically centers on changes in the way the adolescent's body looks and feels, social acceptance, and conflicts about independence. When flooded with anxiety, adolescents may appear extremely shy. They may avoid their usual activities or refuse to engage in new experiences. They may protest whenever they are apart from friends. Or in an attempt to diminish or deny their fears and worries, they may engage in risky behaviors, drug experimentation, or impulsive sexual behavior.

Panic Disorder More common in girls than boys, panic disorder emerges in adolescence usually between the ages of fifteen and nineteen. Feelings of intense panic may arise without any noticeable cause or they may be triggered by specific situations, in which case they are called panic attacks. A panic attack is an abrupt episode of severe anxiety with accompanying emotional and physical symptoms.

During a panic attack, the youngster may feel overwhelmed by an intense fear or discomfort, a sense of impending doom, the fear he's going crazy, or sensations of unreality. Accompanying the emotional symptoms may be shortness of breath, sweating, choking, chest pains, nausea, dizziness, and numbness or tingling in his extremities. During an attack, some teens may feel they're dying or can't think. Following a panic attack, many youngsters worry that they will have other attacks and try to avoid situations that they believe may trigger them. Because of this fearful anticipation, the teen may begin to avoid normal activities and routines.

Phobias Many fears of younger children are mild, passing, and considered within the range of normal development. Some teenagers develop exaggerated and usually inexplicable fears called phobias that center on specific objects or situations. These intense fears can limit a teenager's activities. The fear generated by a phobia is excessive and not a rational response to a situation. The objects of a phobia usually change as a child gets older. While very young children may be preoccupied with the dark, monsters, or actual dangers, adolescents' phobic fears tend to involve school and social performance.

Several studies have revealed an increase in school avoidance in middle-school or junior-high years. With school avoidance, excessive worries about performance or social pressures at school may be at the root of the reluctance to attend school regularly. This leads to a cycle of anxiety, physical complaints, and school avoidance. The cycle escalates with the worsening of physical complaints such as stomachaches, headaches, and menstrual cramps. Visits to the doctor generally fail to uncover general medical explanations. The longer a teenager stays out of school, the harder it becomes for him to overcome his fear and anxiety and return to school. He feels increasingly isolated from school activities and different from other kids.

Some youngsters are naturally more timid than others, As their bodies, voices, and emotions change during adolescence, they may feel even more self-conscious. Despite initial feelings of uncertainty, most teens are able to join in if given time to observe and warm up. In extreme cases, called social phobia, the adolescent becomes very withdrawn, and though he wants to take part in social activities, he's unable to overcome intense self-doubt and worry. Gripped by excessive or unreasonable anxiety when faced with entering a new or unfamiliar social situation, the adolescent with social phobia becomes captive to unrelenting fears of other people's judgment or expectations. He may deal with his social discomfort by fretting about his health, appearance, or overall competence. Alternatively, he may behave in a clowning or boisterous fashion or consume alcohol to deal with the anxiety.

Because so much of a teenager's social life gets played out in school, social phobia may overlap with and be hard to distinguish from school avoidance. Some teens with social phobia may try to sidestep their anxious feelings altogether by refusing to attend or participate in school, Classroom and academic performance falls off, involvement in social and extracurricular activities dwindles, and, as a consequence, self-esteem declines.

Some teens may experience such a high level of anxiety that they cannot leave the house. This disorder, agoraphobia, seems to stem from feelings about being away from parents and fears of being away from home rather than fear of the world. In fact, a number of children who demonstrate severe separation anxiety in early childhood go on to develop agoraphobia as adolescents and adults.

Causes and Consequences
Most researchers believe that a predisposition towards timidity and nervousness is inborn. If one parent is naturally anxious, there's a good chance that their child will also have anxious tendencies. At the same time, a parent's own uneasiness is often communicated to the child, compounding the child's natural sensitivity. A cycle of increasing uneasiness may then be established. By the time this child reaches adolescence, his characteristic way of experiencing and relating to his world is tinged with anxiety. Some research suggests that children who are easily agitated or upset never learned to soothe themselves earlier in life.

In many cases, adolescent anxiety disorders may have begun earlier as separation anxiety, the tendency to become flooded with fearfulness whenever separated from home or from those to whom the child is attached, usually a parent. Adolescents can also have separation disorders. These teens may deny anxiety about separation, yet it may be reflected in their reluctance to leave home and resistance to being drawn into independent activity. Separation anxiety is often behind a teen's refusal to attend or remain at school.

School avoidance can follow a significant change at school, such as the transition into middle school or junior high. It may also be triggered by something unrelated to school, such as a divorce, illness, or a death in the family. Some youngsters become fearful about gang activities or the lack of safety in school.

A worried teenager performs less well in school, sports, and social interactions. Too much worry can also result in a teenager's failing to achieve to his potential. A teen who experiences a great deal of anxiety may be overly conforming, perfectionistic, and unsure of himself. In attempting to gain approval or avoid disapproval, he may redo tasks or procrastinate. The anxious youngster often seeks excessive reassurance about his identity and whether be is good enough.

Some teenagers with anxiety disorders can also develop mood disorders or eating disorders. Some teenagers who experience persistent anxiety may also develop suicidal feelings or engage in self-destructive behaviors; these situations require immediate attention and treatment. Anxious teens may also use alcohol and drugs to self-medicate or self-sootheor develop rituals in an effort to reduce or prevent anxiety.

How to Respond
If your teenager is willing to talk about his fears and anxieties, listen carefully and respectfully. Without discounting his feelings, help him understand that increased feelings of uneasiness about his body, performance, and peer acceptance and a general uncertainty are all natural parts of adolescence.

By helping him trace his anxiety to specific situations and experiences, you may help him reduce the overwhelming nature of his feelings. Reassure him that, although his concerns are real, in all likelihood he will be able to handle them and that as he gets older, he will develop different techniques to be better able to deal with stress and anxiety.

Remind him of other times when he was initially afraid but still managed to enter into new situations, such as junior high school or camp. Praise him when he takes part in spite of his uneasiness. Point out that you are proud of his ability to act in the face of considerable anxiety. Remember, your teenager may not always be comfortable talking about feelings that he views as signs of weakness. While it may seem at the moment as though he's not listening, later he may be soothed by your attempts to help.

If fearfulness begins to take over your teenager's life and limit his activities, or if the anxiety lasts over six months, seek professional advice. His doctor or teacher will be able to recommend a child and adolescent psychiatrist or other professional specializing in treating adolescents.

Managing anxiety disorders - as with any adolescent emotional disturbance - usually requires a combination of treatment interventions. The most effective plan must be individualized to the teenager and his family. While these disorders can cause considerable distress and disruption to the teen's life, the overall prognosis is good.

Treatment for an anxiety disorder begins with an evaluation of symptoms, family and social context, and the extent of interference or impairment to the teen. Parents, as well as the teenager, should be included in this process. School records and personnel may be consulted to identify how the teen's performance and function in school has been affected by the disorder.

The evaluating clinician will also consider any underlying physical illnesses or diseases, such as diabetes, that could be causing the anxiety symptoms. Medications that might cause anxiety (such as some drugs used in treating asthma) will be reviewed. Since large amounts of caffeine, in coffee or soft drinks, can cause agitation, a clinician might look at the youngster's diet as well. Other biological, psychological, family, and social factors that might predispose the youngster to undue anxiety will also be considered.

If a teenager refuses to go to school, a clinician will explore other possible explanations before labeling it school avoidance. Perhaps the teen is being threatened or harassed, is depressed, or has an unrecognized learning disability. He may also be skipping school in order to be with friends, not from anxiety about performance or separation.

If the teenager has engaged in suicidal or self-endangering behavior, is trying to self medicate through alcohol or drug use, or is seriously depressed, these problems should be addressed immediately. In such cases, hospitalization may be recommended to protect the youngster.

In most cases, treatment of anxiety disorders focuses on reducing the symptoms of anxiety, relieving distress, preventing complications associated with the disorder, and minimizing the effects on the teen's social, school, and developmental progress. If the problem manifests in school avoidance, the initial goal will be to get the youngster back to school as soon as possible.

Cognitive-Behavioral Therapy In many cases, cognitive-behavioral psychotherapy techniques are effective in addressing adolescent anxiety disorders. Such approaches help the teenager examine his anxiety, anticipate situations in which it is likely to occur, and understand its effects. This can help a youngster recognize the exaggerated nature of his fears and develop a corrective approach to the problem. Moreover, cognitive-behavioral therapy tends to be specific to the anxiety problem, and the teen actively participates, which usually enhances the youngster's understanding.

Other Therapies In some instances, long-term psychotherapy, and family therapy may also be recommended.

Medications When symptoms are severe, a combination of therapy and medication may be used. Antidepressant medications, such as nortriptyline (Pamelor), imipramine (Tofranil), doxepin (Sinequan), paroxetine (Paxil), sertraline (Zoloft), or fluoxetine (Prozac), or anxiety-reducing drugs, such as alprazolam (Xanax), clonazepam (Klonopin), or lorazepam (Ativan) may be prescribed in combination with cognitive or other psychotherapy. When tricyclic antidepressant medications such as imipramine are pre-scribed, your teen's physician may want to monitor for potential side effects by conducting periodic physical exams and occasional electrocardiograms (EKGs).
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See also;
Anxiety Disorders Resource Center
Facts for Families #47, The Anxious Child
Glossary of Symptoms and Illnesses; Anxiety
AACAP's Practice Parameter for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders

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Your Adolescent - Anxiety and Avoidant Disorders

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Everyone experiences anxiety. It is a natural and important emotion, signaling through stirrings of worry, fearfulness, and alarm that danger or a sudden, threatening change is near. Yet sometimes anxiety becomes an exaggerated, unhealthy response. Given the array of changes and uncertainties facing a normal teenager, anxiety often hums along like background noise.