Topic: Generalized Anxiety Disorder
Researched and written by:  Flora K. lee
                                                I attest that the following report is a product of my own original work.

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Generalized Anxiety Disorder In the Classroom   “I’m always on edge,” “I can’t sleep at night, it’s as though as soon as my head hits the pillow, my brain just goes on overdrive,” “I dread being alone at night, “ “Will I ever be myself again?” “What if I don’t get the promotion?”  These questions, that is, questions that are in the “what if” form, are the epitome of the thought processes that plague the adult with Generalized Anxiety Disorder.   The same chronic “what if” worrying is also in the mind of the child with Generalized Anxiety Disorder, only the questions are more similar to “Will I pass this test?”  “What if I am not picked for kickball?”  “What if I am picked for kickball, but I mess up in front of everyone?”  “Will I freeze in front of my class when it is my turn to present again?”  Again, the “what if’s?” are there, only the questions and worries are applicable to the child’s life. Generalized Anxiety Disorder (GAD) is one of the six major classifications of Anxiety Disorder, which is the most common childhood disorder.  The other classifications include eating disorder (anorexia and bulimia), obsessive-compulsive disorder, panic disorder, phobia, and post-traumatic stress disorder.  GAD is characterized by an excessive and overwhelming worry that is not the result of any recent experience (Turnbull, Turnbull, Shank and Smith 2004). Considerable impairments in academic functioning, as well as familial and social functioning, are associated with pathological anxiety.  Other characteristics that define the disorder include difficulty to relax, stomachaches, headaches, self-doubt and fear of failure.  The most important detail to keep in mind with GAD is that the characteristics are chronic and beyond the control of the patient (Schlozman, 2002). Childhood and adolescent GAD was once referred to as “over-anxious disorder” and was considered a childhood syndrome.  The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) indicated a clear continuity between the characteristics of the childhood syndrome and those of the adult disorder.  The anxiety and/or worry in both adults and children are self-referent, and rarely, if ever, are related to the well being of others.  Adult patients with GAD have reported be “worriers” all their lives, and that the onset of the disorder developed mostly in adolescence.  Very few studies have been conducted upon anxiety in children and adolescents, even though GAD is the most prevalent of the anxiety disorders to have an onset before the age of 18 (Leger, Ladouceur & Dugas 2003).   Statistics GAD is one of the most commonly found disorders among people in the United States, affecting three to four percent of the population, most of which are female  (NMHA, 2004; Richards, 2004). Not only does the disorder have a dramatic impact on the general population, it has an even more devastating influence on our youth.  An estimated three to ten percent of school-aged children suffer from GAD (Manassis & Hood 2002). In a study conducted by Dr. Peter Muris, et al, seventy percent of children in the study claimed to worry every now and then.  The sample was a nonclinical group of children between the ages of eight and thirteen (N=193).  The study found that just over six percent of the children in the group met the DSM-III-R criteria for GAD (Muris, Meesters, Mercklebach and Sermon, 1998). Characteristics               GAD can be characterized by excessive physiologic symptoms and difficulty with coping skills and cognitive processes (Gliatto, 2000).  Those who suffer from GAD are not only inundated with worry and fear, but also with possible twitching, trembling, headaches, and insomnia.  Additionally, people with GAD are overly irritable, frustrated, and have an inability to concentrate (Richards, 2004).  These symptoms have highly detrimental affects on the patient’s lifestyle.  There is a high comorbidity rate for GAD in both adults and children (Kendall, Brady, Verduin, 2001). In reference to school-aged children, school refusal symptoms are directly associated with GAD.  School refusal symptoms include, but are not limited to, the student’s lack of attendance, and can cause emotional distress at the mere thought of going to school (King, Tonge, Turner & Heyne, 1999).  Previous studies have shown connections between environmental factors and childhood GAD.  These environmental factors include prenatal problems, developmental difficulties, family conflict, and psychosocial adversities (Manassis and Hood, 1998).   Classroom Issues               The pressures that a child is put under in a classroom setting are both numerous and varying.  There are pressures to succeed in the class itself, pressure to be successful on standardized testing, pressure to be able to accomplish a skill successfully – and even more pressure to be as successful as one’s peers.  On top of the pressures that are created from academics, there is also the pressure to be socially successful.   Being picked last for kick ball or not being asked to the Homecoming dance can be extremely devastating to a student.   In addition to these pressures, there can also be pressure that is applied from home.  These are issues that many children have to cope with as students, and to the majority of these students, life will continue (Richards, 2004).  However, for the student with GAD, the ability to cope is not nearly as strong as it is in those students without the disorder.  While these pressures to a “normal” student may seem like a small weight on his or her shoulders, these pressures to a student with GAD can feel like a life or death situation.             In terms of GAD and the classroom, the disorder and the setting are part of a reciprocal relationship.  GAD has negative influences upon students in the classroom, just as the classroom is often times the catalyst of anxiety for the student with GAD.  Thus, the vicious cycle begins.   Students with GAD can often have school-phobic behaviors.  Either academic or social situations, or both can cause these phobias. However, cognitive-behavioral treatments have been proven successful in the modification of school-phobic behaviors (Deluty and DeVitus, 1996).             Contingent reinforcement is one of the many cognitive-behavioral treatments that have been successful in curbing the reactions to worrying situations.  This occurs when an event that follows a response increases the probability that the response will reoccur.  Cognitive reinforcement is frequently a treatment used in coalition with other treatments, such as relaxation training.  Relaxation training is a technique that involves the mind and body.  The student learns to relax different major muscle groups through a variety of tension-release exercises.  This is a progressive treatment that helps the student to gain control over his or her body by using his or her mind to concentrate on the specific muscle groups.  Through exercising the different muscle groups the student learns to identify sensations of tension, and thereby use these sensations as stimuli to relax (Deluty and DeVitus, 1996).  This treatment puts the student in a situation where he or she is in control and concentrating.   The feeling of being in control and the ability to concentrate are foreign skills to the student with GAD, therefore making the successful completion of this treatment positive on many levels.             The utilization of outside specialists who do not work directly with the students can also be helpful to the GAD-classroom relationship.  Traditionally, with GAD a mental health specialist will work with the school staff as opposed to the student.  This method is more to the benefit of the staff in the sense that they are gaining more information directly from the specialist as to how they can better the classroom environment.  The specialists suggest appropriate treatment regimens, make referrals as necessary, and show the teachers how to translate clinical techniques into classroom management techniques (Schlozman, 2003).             As with many other disorders that impact student learning, medication is a possible route for treatment.   Positive correlations between the use of antidepressants for the treatment of GAD have been made.  There were more side effects than there were with a placebo, but not to the extent that treatment had to be cancelled. Antidepressants have only been proven to be successful on a short-term basis (Flynn and Chen, 2003). One fact to keep in mind with any drug use is that the side effects are unique to the user.  Antidepressants can be helpful for some, but they may be unhelpful to others.  Side effects of the drugs have the ability to cause even more problems in the classroom.  The student may become physically ill because of the drug, and therefore cause the student to miss class more often than before.  These results can also lead the student to be apprehensive towards other forms of treatment, possibly even causing treatment to be yet another stimulus of anxiety.  However, the use of medication can be beneficial, especially at the beginning of treatment, but a pill alone is not the cure-all for GAD.   Treatment Issues Related to the Classroom               Just as there are treatment options available outside of the classroom for GAD, there are many in-classroom treatments that can be conducted by the teacher with and/or without the assistance of a psychological professional.  Teachers can begin by utilizing a stress intervention model.  First, the teacher appraises the situation by identifying the stimuli that cause the stress or fear in the student.  Is it taking a test?  Is it public speaking?  Is it reading aloud?  The stimuli are identified best through documented observations conducted by the teacher and/or instructional assistant.  Second, an assessment of the student reaction to the stimuli is conducted.  This assessment measures the level of stress or fear that is caused by the identified stimuli.  Next, a background check on the student’s psychological status is made.  Looking at notes that were made by previous teachers, or inquiring about the child’s family history can complete this task.  A decision is then made as to whether or not intervention is necessary, and this can be a very grey area at times.  In general, intervention should be considered when there is a significant change in student behavior, where the behavior is either extremely severe or minimal in relation to the anticipated response.  If intervention is decided upon, the teacher monitors the concrete behaviors of the student and the impact the intervention has upon him or her (Deluty and DeVitus, 1996). Cognitive restructuring is another cognitive-behavioral treatment that can also be implemented by the classroom teacher.  This treatment involves the reduction or removal, if possible, of any misinterpretation of environmental events.  The student needs to feel safe and comfortable in the classroom, therefore the student needs to know that he or she does not need to worry about his or her peers making fun of him or her.  A positive classroom environment must be established.  The teacher needs to challenge faulty logic and irrational self-statements that the student makes.  Students with GAD suffer from extreme self-doubt, and this will come through in the comments he or she makes.  In this situation it is impertinent that the teacher replace such comments with statements that will build up the student, as opposed to shut him or her down.  It is also very important that the teacher not go overboard in this situation as well, for this can cause the student to feel on the spot, thus causing more anxiety.  Finally, the teacher progressively constructs a frame of reference with coping strategies for the student. The ability to cope with situations that may seem “everyday” to others is highly challenging for the student with GAD, the construction of these coping skills will improve the student’s ability (Deluty and DeVitus, 1996). Similar to how coping strategies need to be developed in the student with GAD, so do problem-solving strategies.  This is where problem-solving training comes into play.  The teacher helps the student to establish a problem-solving sequence.  First, the student must learn to prepare for the solution of the problem.  Instead of becoming overwhelmed with worry when a problem should arise, the student must see that every problem has a solution, and that he or she can in fact find that solution.  Once the student is prepared, he or she will then define the problem and the possible goals of the solution.  An important factor in this step is that the goals that are defined must be attainable.  The student creates alternative solutions, and then the decision making process occurs.  Once the decision is made, it is implemented.  The student must finally verify the success of the decision, and this can be done with the help of a teacher or peer.  This treatment may feel unnatural and possibly excessive at first, but this process will eventually become more natural to the student (Deluty and DeVitus, 1996). Any decent teacher knows that it is one of their greatest responsibilities to show a good example to their students.  This is important in the success of cognitive-behavioral treatment called “modeling”.  Modeling is a teaching technique that is naturally utilized by many teachers, hence, teaching by example.  In the case of modeling as treatment for a student with GAD, the teacher models non-fearful responses in fearful situations.  This is accomplished by demonstrating adaptive responses to stimuli that cause fear.  Instead of tensing up, freezing, worrying, or shying away from an experience that causes anxiety, find a way to cope with those feelings and take the situation head on.  Construction of skills or references as to what to do in a certain situation will help the student to react more calmly to situations that otherwise would make him or her anxious.  Appropriate behaviors are eventually acquired, and fears are reduced (Deluty and DeVitus, 1996). If the student with GAD sees that these situations occur for others, especially a teacher, and that others find ways to cope with these situations, this will ease the process of being able to cope.  Adversely, if the teacher demonstrates that when he or she is put into a stressful or fearful situation that the way to handle it is to tense up or shy away, what kind of example will this provide for the student?  Not that the “do as I say, not as I do” approach is ever appropriate for teaching, but especially in the case of the student with GAD.  This student needs concrete evidence that if coping and problem-solving techniques are used in reaction to a stressful situation, he or she will make it through that situation with success.  The modeling treatment option coincides with imaginary and “in vivo” exposure.  This technique exposes the student to his or her fears.  The student is placed in a fear-inducing situation until he or she acclimatizes.  Fear-reduction occurs when the student can discriminate between the stimuli that cause stress, and the stimuli that do not.  (Deluty and DeVitus, 1996)  The student must face his or her fears in order to overcome them.  Through modeling, the student can see that coping and problem-solving skills can be used to help dissolve these fears.   Summary   Generalized Anxiety Disorder is a disorder that can be severely harmful to their academic and social functioning of a child or adult.  However, as with many disorders, early detection and treatment can keep the symptoms under control.  In reference to GAD in the classroom, the student with GAD can be helped through a combination of professional and pedagogical treatments.  The goal of the treatments is to get the student in control.  When the student is out of control, academic, social, and familial dysfunction become highly probable.  Intensive behavioral treatments have been proven to be highly effective in the treatment of Generalized Anxiety Disorder.

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Muris, P., Meesters, C., Mercklebach, H., Sermon, A.  1998. Worry in normal children. Journal of the American Academy of Child and Adolescent Psychology, v 37, 7, 703-710.

National Mental Health Association. 2004.  Fact sheet: anxiety disorders: generalized anxiety disorder.  http://www.nmha.org/infoctr/factsheets/31.cfm retrieved 11/9/04

Richards, T. A.  2004. What is generalized anxiety disorder?  http://www.anxietynetwork.com/gawhat.html retrieved 11/9/04

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