Assessing and Treating Childhood Anxiety in School Settings
By Savannah Wright & Michael L. Sulkowski
Between 2% to 27% of children and adolescents suffer with an anxiety disorder and many more struggle with distressing yet subclinical levels of anxiety (Costello, Egger, & Arnold, 2005; Mychailyszyn, Mendez, & Kendall, 2010). However, only about 6% of youth receive treatment for their anxiety symptoms or related sequelae (Esser, Schmidt, & Woerner, 1990). This service provision deficit is concerning because of the large body of research indicating that anxious youth are at risk for school absenteeism, academic underachievement, low social acceptance, and impaired psychosocial functioning (Kearney & Albano, 2004; McDonald, 2001; Mychailyszyn et al., 2010; Spencer, DuPont, & DuPont, 2003). Furthermore, if they do not receive effective treatment, anxious youth are at risk for developing mental health problems (e.g., depression, substance abuse, anxiety) and impaired occupational functioning (Donovan & Spence, 2000; Kendall, Safford, Flannery- Schroeder, & Webb, 2004; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005; Woodward & Fergusson, 2001).
Fortunately, effective interventions such as cognitive–behavioral therapy (CBT) exist for treating childhood anxiety, and school psychologists can have an important role in implementing these interventions (Sulkowski, Joyce, & Storch, 2012). As professionals who often know the most about psychology in school settings and education in clinical settings and because of the importance of addressing both academic and mental health needs in anxious youth, school psychologists are uniquely positioned to assist anxious students. In addition, due to their specific training (e.g., psychoeducational assessment, progress monitoring, direct intervention, consultation, data-based decision making) and the roles that they assume in school systems, school psychologists possess a dynamic skill set that can be utilized to identify anxious students, ensure that these youth receive evidence-based interventions services, and monitor how students respond to interventions once they are implemented (Wnek, Klein, & Bracken, 2008). In recognition of this skill set and because of the importance of treating childhood anxiety, this article will highlight how school psychologists can support anxious students through using a multitiered framework that can be flexibly applied to fit different types of school settings.
Why Treat Anxiety in School Settings
Obtaining access to mental health services may be a challenge for families that reside in communities with few service providers. Additionally, significant transportation, monetary, and logistical barriers may prevent youth from receiving services. Schools, however, exist in almost all communities and are the most common entry point for accessing mental health services in the United States (Farmer, Burns, Phillips, Angold, & Costello, 2003). Furthermore, research suggests that providing mental health services in schools can reduce disparities in service utilization among high need subpopulations (e.g., Racial/ethnic minority youth; Cummings, Ponce, & Mays, 2010). Therefore, given the large discrepancy between anxious children who need and receive services, treating childhood anxiety in school settings has the potential to address the needs of many youth who would otherwise be disenfranchised from receiving intervention.
Despite being an ancillary aim of many school psychologists and other school-based mental health professionals, efforts to address childhood anxiety in school settings display considerable promise and applicability to common practice. As the most comprehensive evaluation to date, a meta-analysis by Neil and Christensen (2009) suggest that school-based cognitive–behavioral interventions are moderately effective for treating childhood anxiety, with effect sizes ranging from .11 to 1.37 (Mdn = .57). This study also illustrates the utility of using a multitiered service delivery model to address childhood anxiety as 59% of the interventions were universally delivered, 11% were selective or geared toward specific at-risk groups of students, and 30% involved implementing individual interventions or treatment plans. Collectively, these results highlight the potential to address childhood anxiety across different service-delivery tiers, particularly at the universal or school-wide level.
Assessing and Treating Anxiety in School Settings
Time and resource limitations commonly encountered by school psychologists enhance the importance of identifying and remediating student problems with great efficiency. In this regard, a multitiered systems of support (MTSS) such as the multiple- gating approach for identifying social–emotional problems and the responseto- intervention (RTI) service delivery framework can help with determining which students should receive specific interventions as well as the dosage of these interventions. To help with identifying anxious youth and with intervention delivery efforts, a version of a multiple gating approach is discussed below as well as how collected data can inform intervention service delivery. However, a comprehensive review of these procedures is beyond the scope of this article, so readers may wish to review Sulkowski et al. (2012) for a more complete discussion.
Assessing Anxiety in Students
Symptoms of internalizing disorders such as anxiety and depression often are inconspicuous, which can make identifying these symptoms a challenge (Whitcomb & Merrell, 2013). Anxious individuals do, however, display observable characteristics that knowledgeable observers can identify. Some of these observable characteristics include frequently asking for reassurance, being clingy, displaying avoidant behavior, performing checking behavior, hyperventilating when not active, complaining of somatic issues, and engaging in repetitive rituals. In excess, these characteristics might be obvious and suggestive of an anxiety disorder; however, none of them are sufficient by themselves to identify a child who may have anxiety problems. Therefore, as a more objective and thorough approach for assessing childhood anxiety, school psychologists can administer systematic behavior screeners to help identify youth who may have elevated anxiety symptoms.
Currently, two commonly used and commercially available behavior screeners exist. The Behavioral Assessment Scale for Children, Second Edition, Behavioral and Emotional Screening System (BASC- 2, BESS; Kamphaus & Reynolds, 2007) screens for general internalizing and externalizing symptoms. This measure has been incorporated into the AIMSweb data screening, monitoring, and management system. Similarly, the Brief Problem Monitor (Achenbach, McConaughty, Ivanova, & Rescorla, 2011) also allows users to screen for internalizing problems. The Brief Problem Monitor is a new screener and progress monitoring measure that is part of the Achenbach System of Empirically Based Assessment (ASEBA). Although both of these screeners assess internalizing symptoms, neither measure independently assesses anxiety. Assessing anxiety symptoms on behavior screeners requires assessors to inspect students' responses to individual screening items.
Following universal screening for anxiety problems, a multitrait, multisetting, and multi-informant assessment approach can be used to assess for anxiety problems and related concerns in at-risk youth (Whitcomb & Merrell, 2013). In addition to conducting clinical interviews with multiple informants and observations across settings, this process generally involves administering omnibus behavior rating scales that include items that purport to assess anxiety such as the BASC-2, Child Behavior Checklist (CBCL), Clinical Assessment of Behavior (CAB; Bracken & Keith, 2004), and the Conners' Comprehensive Behavior Rating Scale (CCBRS; Conners, 2009), as well as narrow- construct anxiety measures such as the Revised Children's Anxiety Scale, Second Edition (RCMAS-2; Reynolds & Richmond, 2008), State-Trait Anxiety Scale for Children (STAI-C; Spielberger, 1973), the Beck Anxiety Inventory for Youth (BAI-Y; Beck, Beck, & Jolly, 2001), and the Spence Children's Anxiety Scale (Spence, 1997). When analyzing data obtained through this assessment process, consistency in ratings across informants, settings, and identified traits allows the assessor to have greater confidence in the assessment results. For example, if a child was found to be at-risk on the BESS, in the clinically significant range on the BASC-2 for Anxiety Problems, and for any of the anxiety constructs represented on the RCMAS-2 across informants, it is likely that the child is suffering from clinically significant anxiety. Table 1 lists the number of items, types of rating formats, internal consistency estimates, and the constructs that are measured by each of the previously listed behavior rating scales.
|Table 1. Omnibus and Narrow Measures of Childhood Anxiety|
|CONSTRUCTS ASSESSED||NUMBER OF ITEMS||RELIABILITY (α)|
|CBCL||Anxiety Problems, Internalizing Scales |
|CAB||Internalizing Behaviors Scale||70||70||—||.99||.97||—|
|CCBRS||Generalized Anxiety Disorder; Separation Anxiety Disorder; Social Phobia; Obsessive-Compulsive Disorder||204||203||179||.84||.82||.85|
|RCMAS-2||Physiological Anxiety; Worry; Social Anxiety; Defensiveness||—||—||49||—||—||.79–.92|
|STAI-C||State Anxiety, Trait Anxiety||—||—||20||—||—||.80–.90|
|Spence||Generalized Anxiety, Panic/Agoraphobia, Social Phobia, Separation Anxiety, Obsessive Compulsive Disorder, Physical Injury Fears||—||38||44||—||.80–.91||.69–.93|
|Note: BASC -2 = Behavior Assessment System for Children, Second Edition; CBCL = Child Behavior Checklist; CA B = Clinical Assessment of Behavior; CC BRS = Conners' Comprehensive Behavior Rating Scale; RCMAS -2 = Revised Children's Anxiety Scale, Second Edition; STA I-C = State-Trait Anxiety Inventory for Children; BYI-II = Beck Youth Inventories, Second Edition; Spence = Spence Children's Anxiety Scale|
Lastly, to confirm a clinical diagnosis, a school psychologist may wish to conduct the Anxiety Diagnostic Interview Schedule (ADIS; Silverman & Albano, 2004) with a child and a caregiver because of its adherence to Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association, 2000) criteria for assessing all childhood anxiety disorders and many psychiatric disorders that occur in children (e.g., major depression disorder, attention deficit hyperactivity disorder). Although a psychiatric diagnosis is not needed for a student to receive services under RTI, under the Individuals with Disabilities Education Improvement Act (IDEIA), or Section 504 of the Rehabilitation Act, schools that bill for Medicaid may need to include diagnostic information in order to be reimbursed for services. In addition, provisions in the Patient Protection and Affordable Care Act will impact the availability of health insurance and the ability of schools to bill for mental health services. Therefore, the role of school psychologists in diagnosing psychopathology and classifying students to receive interventions may increase.
Treating Anxiety in School Settings
Universal service delivery. Even though the majority of students do not have anxiety problems, all students may benefit from universal programs that can reduce stress and anxiety in schools as well as help foster supportive learning environments. Currently, no anxiety- specific school-based universal prevention or intervention programs exist; however, programs that aim to reduce bullying, school violence, and support healthy and safe school communities also may reduce anxiety because of the relationship between school climate and anxiety in members of school communities (Sulkowski, Wingfield, Jones, & Coulter, 2011). Additionally, as a promising approach to facilitating well-being and reducing anxiety that can be universally implemented, mindfulness-based programs may help students cope better with distress. In a preliminary investigation, Mendelson et al. (2010) found that students (N = 97) from high stress and economically disadvantaged school communities benefited from 12-weeks of a school-wide mindfulness- based intervention program. Active participants in this study displayed lower levels of stress, worrying, and peer relationship problems posttreatment compared to a control group. Thus, although this finding warrants replication before it can be generalized broadly, mindfulness-based programs may be effective universal interventions. Although awaiting future research, a variety of programs, media resources, and practitioner-oriented workbooks have been developed and some of these resources may have applications for school-based practice (Biegel, 2009; Kabat-Zinn, 2012).
Targeted service delivery. Many students do not respond to universal interventions and need more intensive and targeted intervention services. To identify these students, school psychologists can employ behavioral screeners and rating scales to find youth who display elevated internalizing and anxiety scores. Collectively, and consistent with an RTI or a graduated approach to service provision, these students may benefit from targeted interventions that can be delivered to groups of youth who display similar concerns.
Several studies support the efficacy of group-based CBT interventions for treating childhood anxiety (e.g., Barrett, 1998; Flannery-Schroeder & Kendall, 2000; Masia-Warner, Fisher, Shrout, Rathor, & Klein, 2007; Mendlowitz et al., 1999; Silverman et al., 1999). These interventions may be particularly effective because group members can identify with each other, provide and receive social support, and help to facilitate therapeutic engagement and treatment adherence (Masia-Warner et al., 2005). In addition, the mere act of participating in an anxiety treatment group can be therapeutic for youth with social anxiety because interacting with other group members is a form of behavioral exposure, which is an effective component of CBT (Masia-Warner et al., 2007).
Computer delivered CBT programs also may be effective for treating anxious children or students who are at-risk for experiencing anxiety problems. Although research is needed to establish the program's efficacy in school settings, the Camp Cope-A-Lot (CCAL; Khanna & Kendall, 2008) computerized CBT program has been specifically designed to address childhood anxiety. Camp Cope-A-Lot is designed for use with children and young adolescents (ages 7–13 years). It includes six computer-assisted anxiety-reductive therapy sessions that can be followed with six therapist-directed exposure therapy sessions. Results from a randomized controlled clinical trial support the efficacy, feasibility, and likeability of CCAL (Khanna & Kendall, 2010). Specifically, 81% of youth who received 12 sessions of CCAL displayed greater reductions in anxiety posttreatment compared to youth in a control condition.
Intensive service delivery. Anxious students who do not respond effectively to universal (e.g., mindfulness-based intervention) or targeted interventions (e.g., group therapy) likely will need intensive intervention services. These services might involve individualized CBT or CBT combined with pharmacotherapy. These youth can be identified either directly through a MTSS assessment process or through analyzing their response to previously attempted interventions. In general, these youth would be expected to already display functional impairments in their academic, social, and family functioning because of their anxiety problems. For example, they may be reluctant to go to school, be socially withdrawn, or even refuse outright to attend school.
All mental health professionals must be adequately trained to deliver intensive CBT. This training should be obtained through supervised graduate training experiences or through attending CBT workshops and obtaining supervision from experienced colleagues (Mychailyszyn et al., 2011). In school systems that lack experienced CBT therapists, skilled CBT practitioners in the community can be located via databases maintained by the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the Anxiety and Depression Association of America (ADAA). In collaboration with a community-based therapist, school-based mental health professionals can work together to optimize treatment and ensure that treatment gains generalize to the school environment (Sulkowski et al., 2011).
Evidence-based treatment protocols such as the Coping Cat (Kendall & Hedtke, 2006) can help with structuring and delivering CBT to treat childhood anxiety. The Coping Cat program has a 16-session format that aims to teach youth to identify, regulate, and cope with anxiety-provoking thoughts, feelings, and sensations. As a multicomponent treatment program, the Coping Cat involves modeling being calm, relaxation/ self-calming strategies, in vivo exposure tasks, and learning problem solving strategies.
Several studies support the efficacy of the Coping Cat for treating childhood anxiety in a variety of clinical and educational settings (for review, see Kendall and Suveg, 2006). In addition, Beidas and Kendall (2010) report that the treatment program can be flexibly adapted for school settings and applied by school-based mental health professionals. However, this process might involve modifying therapy sessions to accommodate a school's schedule and sessions may need to be scheduled around other important events that occur at school (e.g., exams, field trips). Furthermore, preliminary research suggests that even a brief course of treatment using the Coping Cat (approximately 8 sessions) can be effective for reducing moderate forms of childhood anxiety, which highlights the program's utility and versatility (Crawley et al., 2013).
Many youth suffer with anxiety; however, few receive the treatment they need. Treatment for childhood anxiety often occurs in clinical settings yet school-based interventions for anxiety display considerable promise (Neil & Christensen, 2009). Treating anxiety in school settings can help overcome some extant treatment barriers, and providing services in schools allows for the needs of anxious youth to be addressed across a continuum of services. A multitiered framework was presented in this article that can be flexibly applied to fit different types of school settings and address students' needs across universal, targeted, and intensive levels of service delivery.
Promising universal efforts to assist anxious youth include conducting universal screeners to identify youth with internalizing problems and implementing universal prevention programs that improve school climate and connectedness. At the targeted service delivery level, school psychologists can conduct more comprehensive assessments to identify students who currently display (or are at risk for) anxiety problems, and then help to facilitate the delivery of interventions to address these problems. Lastly, students who display serious anxiety problems can be provided with effective interventions such as CBT, which is an evidence-based intervention that can be effectively translated to school settings (Neil & Christensen, 2009; Sulkowski et al., 2012).
To conclude, school psychologists display unique skills that can help them be key stakeholders in efforts to address childhood anxiety. In addition, resources exist that can help school psychologists obtain advanced training in the delivery of evidence-based interventions for childhood anxiety such as CBT. For example, informational and didactic presentations often are featured at national conferences that are sponsored by the National Association of School Psychologists, IOCDF, and ADAA. However, even if not directly involved in service delivery, school psychologists also can be key stakeholders in efforts to address childhood anxiety through collaborating with other professionals. In this regard, the IOCDF and ADAA provide extensive lists of CBT specialists that school psychologists can refer to or contact to facilitate professional case collaboration. As professionals who often know the most about psychology in school settings and education when communicating with clinical professionals, school psychologists are uniquely positioned to support the needs of anxious youth.
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Savannah Wright is a doctoral student in the school psychology program at the University of Arizona. Her research interests include behavioral disorders and childhood anxiety. Michael L. Sulkowski, PhD, is an assistant professor in school psychology program at the University of Arizona.