Testing Anxiety Toolkit

Testing Anxiety Toolkit

This toolkit offers a collection of materials, primarily for practitioners, with some handouts for parents
and teachers to help students manage anxiety related to testing.
2. Anxiety And Anxiety Disorders In Children: Information For Parents

Thomas J. Huberty, PhD, NCSP Indiana University
6. Test and Performance Anxiety

Thomas J. Huberty, PhD, NCSP Indiana University
11. Research-‐Based Practice Assessing and Treating Childhood Anxiety in School Settings
Savannah Wright & Michael L. Sulkowski
17. Cognitive Behavioral Strategies For Working With Anxious Youth In Schools (PowerPoint Slides)
Elana R. Bernstein, PhD Morgan J. Aldridge, MS Jessica May, MS
28. Anxiety: Tips For Teens

Patricia A. Lowe, PhD, Susan M. Unruh, EdS, & Stacy M. Greenwood University of Kansas
32. High Stakes Testing & Children’s Well-‐Being: A Guide for Parents
NYASP
35. High Stakes Testing & Children’s Well-‐Being: A Guide for Teachers
NYASP
38. Reducing Test Anxiety to Increase Academic Performance (PowerPoint Slides)
Peter Faustino PhD and Tom Kulaga M.S.
104. Utilizing Video Self-‐Modeling and Reattribution Training to Alleviate Test Anxiety (PowerPoint
Slides) Shahrokh-‐Reza Shahroozi, B.S.

ANXIETY AND ANXIETY DISORDERS IN
CHILDREN: INFORMATION FOR PARENTS
By Thomas J. Huberty, PhD, NCSP
Indiana University
Anxiety is a common experience to all of us on an almost daily basis. Often, we use terms like jittery,
high strung, and uptight to describe anxious feelings. Feeling anxious is normal and can range from very
low levels to such high levels that social, personal, and academic performance is affected. At moderate
levels, anxiety can be helpful because it raises our alertness to danger or signals that we need to take
some action. Anxiety can arise from real or imagined circumstances. For example, a student may
become anxious about taking a test (real) or be overly concerned that he or she will say the wrong thing
and be ridiculed (imagined). Because anxiety results from thinking about real or imagined events,
almost any situation can set the stage for it to occur.
Defining Anxiety
There are many definitions of anxiety, but a useful one is apprehension or excessive fear about real
or imagined circumstances. The central characteristic of anxiety is worry, which is excessive concern
about situations with uncertain outcomes. Excessive worry is unproductive, because it may interfere
with the ability to take action to solve a problem. Symptoms of anxiety may be reflected in thinking,
behavior, or physical reactions.
Anxiety and Development

Anxiety is a normal developmental pattern that is exhibited differently as children grow older. All of
us experience anxiety at some time and cope with it well, for the most part. Some people are anxious
about specific things, such as speaking in public, but are able do well in other activities, such as social
interactions. Other people may have such high levels of anxiety that their overall ability to function is
impaired. In these situations, counseling or other services may be needed.
Infancy and preschool. Typically, anxiety is first shown at about 7–9 months, when infants
demonstrate stranger anxiety and become upset in the presence of unfamiliar people. Prior to that time,
most babies do not show undue distress about being around strangers. When stranger anxiety emerges,
it signals the beginning of a period of cognitive development when children begin to discriminate
among people. A second developmental milestone occurs at about 12–18 months, when toddlers
demonstrate separation anxiety. They become upset when parents leave for a short time, such as going
out to dinner. The child may cry, plead for them not to leave, and try to prevent their departure. Although
distressing, this normal behavior is a cue that the child is able to distinguish parents from other adults
and is aware of the possibility they may not return. Ordinarily, this separation anxiety is resolved by age
2, and the child shows increasing ability to separate from parents. Both of these developmental periods
are important and are indicators that cognitive development is progressing as expected.
School age. At preschool and early childhood levels, children tend to be limited in their ability to
anticipate future events, but by middle childhood and adolescence these reasoning skills are usually well
developed. There tends to be a gradual change from global, undifferentiated, and externalized fears to
more abstract and internalized worry. Up to about age 8 children tend to become anxious about specific,
identifiable events, such as animals, the dark, imaginary figures (monsters under their beds), and of
larger children and adults. Young children may be afraid of people that older children find entertaining,
such as clowns and Santa Claus. After about age 8, anxiety-producing events become more abstract and
less specific, such as concern about grades, peer reactions, coping with a new school, and having
friends. Adolescents also may worry more about sexual, religious, and moral issues, as well how they
compare to others and if they fit in with their peers. Sometimes, these concerns can raise anxiety to
high levels.
Helping Children at Home and School II: Handouts for Families and Educators S5–1
Anxiety Disorders present to a significant degree, can indicate anxiety that
When anxiety becomes excessive beyond what is needs attention. As a parent, you may be the first person
expected for the circumstances and the child’s to suspect that your child has significant anxiety.
developmental level, problems in social, personal, and
academic functioning may occur, resulting in an anxiety Relationship to Other Problems
disorder. The signs of anxiety disorders are similar in Although less is known about how anxiety is related
children and adults, although children may show more to other problems as compared to adults, there are some
signs of irritability and inattention. The frequency of well-established patterns.
anxiety disorders ranges from about 2 to 15% of Depression. Anxiety and depression occur together
children and occurs somewhat more often in females. about 50–60% of the time. When they do occur together,
There are many types of anxiety disorders, but the most anxiety most often precedes depression, rather than the
common ones are listed below. opposite. When both anxiety and depression are present,
Separation anxiety disorder. This pattern is there is a higher likelihood of suicidal thoughts, although
characterized by excessive clinging to adult caretakers suicidal attempts are far less frequent.
and reluctance to separate from them. Although this Attention Deficit Hyperactivity Disorder. At times,
pattern is typical in 12–18-month-old toddlers, it is not anxiety may appear similar to behaviors seen with
expected of school-age children. This disorder may Attention Deficit Hyperactivity Disorder (ADHD). For
indicate some difficulties in parent-child relationships example, inattention and concentration difficulties are
or a genuine problem, such as being bullied at school. In often seen in children with ADHD and with children who
those cases, the child may be described as having have anxiety. Therefore, the child may have anxiety
school refusal, sometimes called school phobia. rather than ADHD. Failing to identify anxiety accurately
Occasionally, the child can talk about the reasons for may explain why some children do not respond as
feeling anxious, depending on age and language skills. expected to medications prescribed for ADHD. The age
Generalized anxiety disorder. This pattern is of the child when the behaviors were first observed can
characterized by excessive worry and anxiety across a be a useful index for determining if anxiety or ADHD is
variety of situations that does not seem to be the result present. The signs of ADHD usually are apparent by age
of identified causes. 4 or 5, whereas anxiety may not be seen at a high level
Post-Traumatic Stress Disorder. This pattern often until school entry, when children may respond to
is discussed in the popular media and historically has demands with worry and needs for perfectionism. A
been associated with soldiers who have experienced thorough psychological and educational evaluation by
combat. It is also seen in people who have experienced qualified professionals will help to determine if the
traumatic personal events, such as loss of a loved one, problem is ADHD or anxiety. If evaluation or
physical or sexual assault, or a disaster. Symptoms may consultation is needed, developmental information
include anxiety, flashbacks of the events, and reports of about the problem will be useful to the professional.
seeming to relive the experience. School performance. Children with anxiety may
Social phobia disorder. This pattern is seen in have difficulties with school work, especially tasks
children who have excessive fear and anxiety about requiring sustained concentration and organization.
being in social situations, such as in groups and crowds. They may seem forgetful, inattentive, and have difficulty
Obsessive-compulsive disorder. Characteristics organizing their work. They may be too much of a
include repetitive thoughts that are difficult to control perfectionist and not be satisfied with their work if it
(obsessions) or the uncontrollable need to repeat does not meet high personal standards.
specific acts, such as hand washing or placing objects in Substance use. What appears to be anxiety may be
the same arrangement (compulsions). manifestations of substance use, which may begin as
early as the pre-teen years. Children who are abusing
Characteristics of Anxiety drugs or alcohol may show sleep problems, inattention,
Although the signs of anxiety vary in type and withdrawal, and reduced school performance. Although
intensity across people and situations, there are some substance abuse is less likely with younger children, the
symptoms that tend to be rather consistent across possibility increases with age.
anxiety disorders and are shown in cognitive, behavioral,
and physical responses. Not all symptoms are exhibited Interventions
in all children or to the same degree. All people show Anxiety is a common experience for children, and,
some of these signs at times, and it may not mean that most often, professional intervention is not needed. If
anxiety is present and causing problems. Most of us are anxiety is so severe that your child cannot do expected
able to deal with day-to-day anxiety quite well, and tasks, however, then intervention may be indicated.
significant problems are not common. The chart at the
end of the handout demonstrates behaviors that, if
S5–2 Anxiety and Anxiety Disorders in Children: Information for Parents

Does My Child Need Professional Help? anxiety will be removed; rather, the goal should be
Answering the following questions may be helpful in to get the anxiety to a level that is manageable.
deciding if your child needs professional help: • Teach your child simple strategies to help with
anxiety, such as organizing materials and time,
• Is the anxiety typical for a child this age? developing small scripts of what to do and say,
• Is the anxiety shown in specific situations or is it either externally or internally, when anxiety
more pervasive? increases, and learning how to relax under stressful
• Is the problem long term or is it recent? conditions. Practicing things such as making
• What events may be contributing to the problems? speeches until a comfort level is achieved can be a
• How are personal, social, and academic useful anxiety-reducing activity.
development affected? • Listen to and talk with your child on a regular basis
and avoid being critical. Being critical may increase
If the anxiety is atypical for the child’s age, is long pressure to be perfect, which may be contributing to
standing, does not seem to be improving, and is causing the problem in the first place. Do not treat emotions,
significant problems, then it is advisable to talk with a questions, and statements about feeling anxious as
professional, such as the school psychologist or silly or unimportant. They may not seem important to
counselor, who might recommend a referral to a you but are real to your child. Take all discussion
community mental health professional. Individual seriously, and avoid giving too much advice and
counseling, or even group or family counseling, may be instead be there to help and offer assistance as
used to help the child deal with school, family, or personal requested. You may find that reasoning about the
issues that are related to the anxiety. In some cases, a problem does not work. At times, children may
physician may recommend medication. Although realize that their anxiety does not make sense, but
medication for childhood disorders is not well researched are unable to do anything about it without help.
and side effects must be monitored, this treatment may • Do not assume that your child is being difficult or
be helpful when combined with counseling approaches. that the problem will go away. Seek help if the
problem persists and continues to interfere with
How Can I Help My Child? daily activities.
Although professional intervention may be
necessary, the following list may be helpful to parents in Conclusion
working with the child at home: Untreated anxiety can lead to depression and other
problems that can persist into adulthood. However,
• Be consistent in how you handle problems and anxiety problems can be treated effectively, especially if
administer discipline. detected early. Although it is neither realistic nor
• Remember that anxiety is not willful misbehavior, advisable to try to completely eliminate all anxiety, the
but reflects an inability to control it. Therefore, be overall goal of intervention should be to return your
patient and be prepared to listen. Being overly child to a typical level of functioning.
critical, disparaging, impatient, or cynical likely will
only make the problem worse. Resources
• Maintain realistic, attainable goals and expectations Bourne, E. J. (1995). The anxiety and phobia workbook
for your child. Do not communicate that perfection (2nd ed.). Oakland, CA: New Harbinger. ISBN: 1-
is expected or acceptable. Often, anxious children 56224-003-2.
try to please adults, and will try to be perfect if they Dacey, J. S., & Fiore, B. (2001). Your anxious child: How
believe it is expected of them. parents and teachers can relieve anxiety in children.
• Maintain a consistent, but flexible, routine for San Francisco: Jossey-Bass. ISBN: 0-78796-040-3.
homework, chores, and activities. Manassis, K. (1996). Keys to parenting your anxious
• Accept mistakes as a normal part of growing up, child. New York: Barrons. ISBN: 0-81209-605-3.
and that no one is expected to do everything
equally well. Praise and reinforce effort, even if Website
success is less than expected. There is nothing Anxiety Disorders Association of America—www.aada.org
wrong with reinforcing and recognizing success, as National Mental Health Association—www.nmha.org
long as it does not create unrealistic expectations
Thomas J. Huberty, PhD, NCSP, is Professor and Director
and result in unreasonable standards.
of the School Psychology Program at Indiana University,
• If your child is worried about an upcoming event,
Bloomington, IN.
such as giving a speech in class, practice it often so
that confidence increases and discomfort © 2004 National Association of School Psychologists, 4340 East West Highway,
Suite 402, Bethesda, MD 20814—(301) 657-0270.
decreases. It is not realistic to expect that all
Types of Anxiety Disorders
Cognitive Behavioral Physical
• Concentration difficulties • Shyness • Trembling or shaking

• Overreaction and • Withdrawal • Increased heart rate
catastrophizing relatively • Frequently asking questions • Excessive perspiration
minor events • Frequent need for • Shortness of breath
• Memory problems reassurance • Dizziness
• Worry • Needs for sameness • Chest pain or discomfort
• Irritability Avoidant • Flushing of the skin
• Perfectionism • Rapid speech • Nausea, vomiting, diarrhea
• Thinking rigidity • Excessive talking • Muscle tension
• Hyper vigilant • Restlessness, fidgety • Sleep problems
• Fear of losing control • Habit behaviors, such as
• Fear of failure hair pulling or twirling
• Difficulties with problem • Impulsiveness
solving and academic
performance
S5–4 Anxiety and Anxiety Disorders in Children: Information for Parents

student services student services student services
Test and
S
amantha’s story: Fourteen-year-old Samantha went to the school nurse
on a weekly basis, complaining of stomach aches and being nervous and
Performance worried about school. The nurse referred her to the school psychologist,
who talked with her about the visits to the nurse’s office. Samantha reported
Anxiety
that when taking tests or having to speak in public, she became anxious and was
not able to do well, although she thought that she knew the material. When
describing her anxiety, she said, “My mind goes blank,” “I get shaky,” and “I get
sweaty and red.”
Anxiety is a normal Upon further discussion, the school psychologist found that Samantha also
human emotion that felt anxious often when not at school and that her mother had high expectations
can be detrimental in for her schoolwork. The school psychologist talked to her mother, who indicated
that she had high expectations of Samantha, but she also described her daughter
a school setting, but as being anxious, fearful, and a “worrier” since she was a small child.
good communication
and support can help Anxiety in Adolescents tends to generalize to many evaluative
minimize its negative Cases like Samantha’s are more situations, contributing to more per-
common in school settings than vasive underachievement. Additional
impact. most school professionals realize. In consequences of chronic test anxiety
the majority of cases, test and per- can include lowered self-esteem,
By Thomas J. Huberty formance anxiety is not recognized reduced effort, and loss of motiva-
easily in schools, in large part because tion for school tasks. Other forms of
adolescents rarely refer themselves for anxiety that can be seen in the school
Thomas J. Huberty (huberty@indiana.edu) emotional concerns. Not wanting to include generalized anxiety, fears, pho-
is a professor and the director of the School
risk teasing or public attention, anx- bias, social anxiety, and extreme social
Psychology Program at Indiana University.
ious adolescents suffer in silence and withdrawal.
underperform on school-related tasks.
Student Services is produced in collaboration with Anxiety is one of the most basic Characteristics of Anxiety
the National Association of School Psychologists human emotions and occurs in every The central characteristic of anxiety
(NASP). Articles and related handouts can be
person at some time, most often is worry, which has been defined by
downloaded from www.nasponline.org/resources/
principals. when someone is apprehensive about Vasey, Crnic, and Carter (1994) as
uncertain outcomes of an event or set “an anticipatory cognitive process
of circumstances. Anxiety can serve involving repetitive thoughts related
an adaptive function, however, and to possible threatening outcomes and
is also a marker for typical develop- their potential consequences” (p. 530).
ment. In the school setting, anxiety is Although everyone worries occasion-
experienced often by students when ally, excessive and frequent worry can
being evaluated, such as when taking impair social, personal, and academic
a test or giving a public performance. functioning. It can contribute to feel-
Most adolescents cope with these ings of loss of control and perhaps
situations well, but there is a subset of depression, especially in girls.
up to 30% of students who experience When people become highly
severe anxiety, a condition most often anxious, they tend to view more situ-
termed “test anxiety.” ations as potentially threatening than
When test anxiety is severe, it can do most of their peers. They have an
have significant negative effects on irrational fear that a catastrophe will
a student’s ability to perform at an occur and feel that they are unable
optimal level. Over time, test anxiety to control outcomes. Often, there is
12 z Principal Leadership z Se pt e m be r 2009 Copyright National Association of Secondary School Principals, the preeminent organization for middle level and high
school leadership. For information on NASSP products and service, visit www.principals.org.
a rational basis for the anxiety, but will worsen an adolescent’s anxiety,
it is greatly disproportionate to the further impairing performance, self-
circumstances. esteem, and motivation.
Anxiety is manifested in three
ways: cognitively, behaviorally, and Types of Anxiety
physiologically. Often the symptoms There are two forms of anxiety that
are apparent in all three areas, such as are pertinent to understanding the
worry, increased activity, and flushing formation and maintenance of anxiety.
of the skin. (See figure 1.) Many of “Trait anxiety” refers to anxiety that is
the behaviors exhibited by anxious chronic and pervasive across situations
children and youth reflect attempts and is not triggered by specific events.
to control the anxiety and minimize Trait anxiety is the basis for a variety
its effects. The majority of adolescents of anxiety disorders, including general-
who are anxious are not disruptive ized anxiety and social phobia. “State
and are more likely to withdraw and anxiety” refers to anxiety that occurs
avoid anxiety-producing situations. In in specific situations and usually has
extreme cases, they may be seen by a clear trigger. Not all people who
teachers as unmotivated, lazy, or less have high state anxiety have high trait
capable than their peers. On the other anxiety, but those who have high trait
extreme, some students with perfor- anxiety are more likely to experience
mance anxiety may act out, con- state anxiety (Spielberger, 1973). Although everyone
sciously or unconsciously, as a way of While taking tests, state anxiety
worries occasionally,
avoiding the risk of being embarrassed may occur, although the student may
or failing. School personnel should be also have tendencies toward trait excessive and frequent
aware of students whose disruptive or anxiety. Therefore, if a student shows
worry can impair
negative behavior aligns with upcom- high state anxiety, it is possible that
ing performance-based assignments. he or she has high trait anxiety. It is social, personal, and
important to identify adolescents with academic functioning.
Causes of Anxiety high trait anxiety, because it can be
The specific conditions and mecha- a sign of significant emotional prob- It can contribute to
nisms that cause anxiety are not well lems and may be a precursor for the feelings of loss of control
understood, but there is evidence that development of depression, especially
youth who are test-anxious tend to in adolescent girls. In cases of severe and perhaps depression,
have high levels of general anxiety anxiety, referral to a school psycholo- especially in girls.
that are exacerbated during evalua- gist for more extensive evaluation is
tions. There is considerable research recommended. In Samantha’s case, the
evidence that some children have school psychologist concluded that
biological predispositions to high she had high levels of trait anxiety,
levels of general anxiety, making which worsened her test/state anxiety.
them more susceptible to the effects High parental expectations likely also
of being evaluated (Huberty, 2008). contributed to both her trait and state
Repeated difficulties with test-taking anxiety.
or other performances tend to lower
self-confidence, which in turn can cre- High-Stakes Testing
ate conditions for more frequent and Over the last several years, graduation
intense experiences of anxiety. Also, has come to depend on passing stan-
excessive pressure or coercion likely dardized tests. As a consequence, more
September 2009 z Principal Leadership z 13

students are likely to have anxiety abilities, may find those examinations at risk for developing it. Some sugges-
when taking such tests and their abil- especially challenging, increasing their tions include:
ity to do their best will be impaired. anxiety. Therefore, schools should n Communicating that test anxi-
Consequently, some students may consider screening all students who ety is a real psychological issue
fail sections of these exams despite fail those examinations. and does not reflect laziness,
knowing the material. Although there lack of motivation, or lack of
is little research to suggest that high- School-Based Interventions capability by the student
stakes testing causes anxiety disorders If test anxiety is not complicated by n Communicating to staff
in adolescents, it is likely that students other problems, such as anxiety dis- members and parents that test
with high trait or test anxiety are orders or depression, it is treatable in anxiety should be a priority for
more vulnerable to underperform- the school setting by properly trained schools to address
ing. A key indicator that test anxiety mental health specialists (e.g., school n Providing inservice training
may occur in students is when they psychologists) and teachers with the about how to recognize and
do not do well, despite indications to help of principals and parents. Each treat anxiety and to consider it
the contrary (e.g., current achieve- of the following groups has a role to to be a genuine and pervasive
ment). School personnel should be play in identifying and supporting problem
alert to this possibility and follow up students. n Leading efforts to identify spe-
with students who unexpectedly fail cialists in the school to identify
parts of an examination to check for Principals performance- and test-anxious
the possibility of trait or state anxiety. Principals can be instrumental in students and provide support
Moreover, students who struggle in working with staff members to help to them (Huberty, in press).
school, particularly those with dis- students who have test anxiety or are
School Mental Health
Practitioners
Primary Characteristics of Anxiety Mental health specialists, such as
school psychologists, social workers,
Cognitive Behavioral Physiological and counselors, can work singly and
Concentration problems Motor restlessness Tics collaboratively to develop and imple-
ment interventions for students and
Memory problems Fidgets Recurrent, localized pain
to consult with teachers about how to
Attention problems Task avoidance Rapid heart rate identify and work with students in the
classroom. There are several interven-
Oversensitivity Rapid speech Flushing of the skin
tions that can be used in the school
Difficulty solving Erratic behavior Perspiration setting to help students prevent and
problems control test and performance anxiety.
Irritability Headaches
These strategies include:
Worry
Withdrawal Muscle tension n Providing relaxation training
Cognitive dysfunctions n Using test-anxiety hierarchies
Perfectionism Sleeping problems
—Distortions for assessments and public
—Deficiencies Lack of participation Nausea performances using variations
Failure to complete tasks Vomiting of systematic desensitization
Attributional style
n Using pretask rehearsal
problems Seeking easy tasks Enuresis n Using practice tests
n Reviewing task content before
Source: Huberty, T. J. (in press). Performance and test anxiety. In L. Paige & A. Canter (Eds.),
examinations
Helping children at home and at school III. Bethesda, MD: National Association of School n Modifying tasks, such as break-
Psychologists. ing them into smaller units
14 z Principal Leadership z Se pt e m be r 2009

What Parents Can Do
n Be consistent in how you
handle problems and administer
discipline.
n Be patient and be prepared to
n Developing mnemonic devices Although anxiety and depression
listen.
to help recall often are considered and treated as
n Using cognitive-behavioral separate and distinct problems, they n Avoid being overly critical,
techniques to reduce charac- frequently occur together with an disparaging, impatient, or cynical.
teristics often associated with overlap of symptoms. Often adoles- n Maintain realistic, attainable goals
test anxiety, such as “cognitive cents meet the clinical criteria for and expectations for your child.
scripts” for students to use both disorders simultaneously. The n Do not communicate that
when taking tests or perform- overlap has been reported to be perfection is expected or is the
ing, self-monitoring techniques, as high as 50% in clinical samples. only acceptable outcome.
positive self-talk, and self- Further, if both disorders are present
n Maintain a consistent but flexible
relaxation simultaneously, anxiety most likely
routine for homework, chores,
n Relaxing grading standards or preceded depression. Consequently,
activities, and so forth.
procedures if it is possible to the school psychologist must be pre-
n Accept mistakes as a normal part
do so without lowering perfor- pared to identify the presence of and
of growing up and let your child
mance criteria provide intervention and prevention
know that no one is expected to
n Recognizing effort as well as for both problems (Huberty, 2008).
do everything equally well.
performance
n Avoiding criticism, sarcasm, or Parents n Praise and reinforce effort,
punishment for performance Parents can be highly instrumental in even if the outcome is less than
problems working with their test-anxious ado- expected. Practice and rehearse
n Using alternative forms of lescents. In some cases, parents may upcoming events, such as a
assessment benefit from consulting with school speech or other performance.
n Modifying time constraints and personnel to help determine whether n Teach your child simple strategies
instructions high expectations are contributing to to help with his or her anxiety,
n Emphasizing success, rather the problem. If that is the case, the such as organizing materials and
than failure (Huberty, in press). school psychologist or other mental time, developing small “scripts” of
Mental health specialists can also health professional can help parents what to do and say when anxiety
provide inservice training to school develop realistic expectations of their increases, and learning how to
personnel and parents. This training children. Parents can also help their relax under stressful conditions.
can include information about: students better prepare for examina- n Do not treat feelings, questions,
n The characteristics of anxiety tions and performances by working and statements about feeling
n The types of cognitive prob- with them at home. anxious as silly or unimportant.
lems experienced by perfor-
n Often, reasoning is not effective
mance-anxious students Teachers
in reducing anxiety, so do not
n The task conditions that can In addition to providing inservice
criticize your child for being
affect the experience and training to school personnel and direct
unable to respond to rational
expression of anxiety services to students, school psycholo-
approaches.
n The nature, types, and causes gists and other mental health profes-
of anxiety sionals can consult with teachers to n Seek outside help if the problem
n The tendency of test-anxious help them identify and work with persists and continues to interfere
adolescents to have high trait test-anxious students. Consultation with daily activities.
anxiety and the need for some can include: Source: Huberty, T. J. (in press).
students to receive such inter- n Providing education and infor- Performance and test anxiety. In L. Paige
ventions as social skills training mation to the teacher about & A. Canter (Eds.), Helping children
n A description of interventions test anxiety at home and at school III. Bethesda,
that can be used (Huberty, in n Interviewing students, teachers, MD: National Association of School
press). and parents Psychologists.
September 2009 z Principal Leadership z 15

n Assessing individual stu- are key to identifying students who Samantha learned how to relax, plan
dents to determine cognitive, have text anxiety. for examinations, rehearse public
behavioral, and physiological Effective intervention begins with performances, and develop test-taking
symptoms school administrators, who can cre- strategies. The psychologist worked
n Training teachers, students, ate an awareness of the problem and with the teachers of the classes in
and parents in how to use commit to providing resources and which Samantha was most anxious to
rehearsal, relaxation, and other leadership for mental health special- help them become aware of her anxi-
techniques at home and at ists and teachers so that they can help ety. The teachers helped Samantha
school students. Mental health specialists and develop test-taking strategies, such as
n Helping teachers plan, imple- teachers can be strong advocates who organizational skills, practice exercises,
ment, and evaluate interven- help anxious students improve school and study guides.
tions (Huberty, in press). performance and reduce the risk of Finally, the psychologist talked
the development of other problems, with Samantha’s mother to help her
Leadership Commitment particularly depression. Properly ad- better understand Samantha’s anxiety,
Test and performance anxiety are dressed, test and performance anxiety how her expectations contributed to
common problems for adolescents can be significantly reduced in the her daughter’s problems, and how to
in the school setting and can impair school setting. help prepare Samantha at home to
achievement in as many as one-third take tests and give oral presentations.
of students. Because adolescents may Returning to Samantha Samantha’s anxiety was reduced and
not be aware of the problems, do The school psychologist worked with she performed better, with a signifi-
not know what to do, or do not refer Samantha directly, consulted with her cant reduction in visits to the nurse’s
themselves for help, school personnel teachers, and talked with her mother. office. Although there was little effect
on her trait anxiety, her state anxiety
was reduced to help her improve her
school performance. PL
References
n Huberty, T. J. (2008). Best practices
in school-based interventions for anxiety
and depression. In A. Thomas & J. Grimes
(Eds.), Best practices in school psychology:
Vol. 5 (pp. 1473–1486). Bethesda, MD:
National Association of School Psychologists.
n Huberty, T. J. (in press). Performance
and test anxiety. In L. Paige & A. Canter
(Eds.), Helping children at home and at
school III. Bethesda, MD: National Associa-
tion of School Psychologists.
n Spielberger, C. A. (1973). State-Trait
Anxiety Inventory for Children [Manual].
Palo Alto, CA: Consulting Psychologists
Press.
n Vasey, M. W., Crnic, K. A., & Carter, W.
G. (1994). Worry in childhood: A develop-
mental perspective. Cognitive Therapy and
Research, 18, 529–549.
16 z Principal Leadership z Se pt e m be r 2009

Assessing and Treating Childhood Anxiety Page 1 of 6
Research-Based Practice
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.
http://www.nasponline.org/publications/cq/41/8/anxiety.aspx 10/17/2013
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)
Teacher Parent Self Teacher Parent Self
OMNIBUS
BASC-2 Anxiety Problems 17 17 13 .88 .84 .82
Anxiety Problems, Internalizing Scales
CBCL 112 112 112 .89 .80 .82
(Anxious/Depressed)
CAB Internalizing Behaviors Scale 70 70 — .99 .97 —
Generalized Anxiety Disorder; Separation
CCBRS Anxiety Disorder; Social Phobia; Obsessive- 204 203 179 .84 .82 .85
Compulsive Disorder
NARROW
Physiological Anxiety; Worry; Social .79
RCMAS-2 — — 49 — —
Anxiety; Defensiveness –.92
.80
STAI-C State Anxiety, Trait Anxiety — — 20 — —
–.90
.86
BYI-II Anxiety — — 20 — —
–.96
Generalized Anxiety, Panic/Agoraphobia,
Social Phobia, Separation Anxiety, .69
Spence — 38 44 — .80–.91
Obsessive Compulsive Disorder, Physical –.93
Injury Fears
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).
Conclusion
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.
National Association of School Psychologists, 4340 East West Highway, Suite 402, Bethesda, MD 20814
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NASP Convention School-Based CBT for Anxiety
1 2
Presentation Overview
COGNITIVE BEHAVIORAL 1. Anxiety: Overview, prevalence & long-term impact
2. School-based services for anxiety
STRATEGIES FOR WORKING WITH 3. Case examples
ANXIOUS YOUTH IN SCHOOLS 4. CBT: Overview, theoretical underpinnings, & important concepts
5. CBT: The nuts & bolts
a) Affective
National Association of School Psychologists b) Cognitive
Seattle, WA c) Behavioral
February 12th 2013 6. A typical CBT session presented through a case example
7. School-based implementation of CBT: Challenges & pitfalls
Elana R. Bernstein, PhD 8. School-based implementation of CBT: Application at multiple tiers
Morgan J. Aldridge, MS 9. Questions
Jessica May, MS
3 4
Prevalence Costs & Consequences

• Anxiety disorders have the highest prevalence rates of • $42.3 billion spent nationally on the treatment of anxiety.
mental health problems occurring in children and • Children who suffer from anxiety are more likely to
adolescents. experience:
• Estimated overall lifetime prevalence rates of 8-27% • School drop-out
• Rates are estimated to be higher when children with subclinical • Lower quality of life
symptoms (not meeting criteria for a diagnosis) are considered
• Psychopathology in adulthood
• Children with internalizing disorders are often overlooked
• Unsuccessful peer and family relationships
• Median age of onset is 11 years old. • Comorbid diagnoses
• Anxiety is among the earliest developing psychopathologies. • Substance use
• Anxiety disorders are chronic and persist into adulthood. • Low self-esteem
• Social rejection
• Academic failure
Costello, Egger & Angold (2005); Fox, et al. (2012); Kendall, Aschendrand, & Hudson (2003); Greenberg et al. (1999); Kendall et al. (2003); Kendall (2012); Menutti, Christner, & Freeman (2012)
Mennuti, Christner, & Freeman (2012) Ramirez et. al (2006); U.S. Department of Health and Human Services (2001)
5 6
Anxiety In The Schools The Importance of Early Intervention

• Despite high prevalence • When schools provide mental • “The longer students suffer with unidentified anxiety problems,
rates, anxiety is often health services to students, the more adverse the effects of anxiety can have on children’s
overlooked in schools results include: development…which are difficult to reverse” (Ramirez et al.,
• Difficulties in recognizing • Lower costs 2006, p.273).
internalizing symptoms • Less mental health stigmatization
• Children encounter anxiety • More accessibility to mental • Research shows that 75% of children who receive mental
triggers in school health services
health services do so in school.
• Academic pressure, social • Lower school drop out rate
interactions, test anxiety, • NCLB (2001) emphasizes the
perfectionism, school refusal, use of evidence-based • When mental health services are provided in schools, common
frequent trips to nurse, etc.
interventions in schools. barriers that prevent youth from receiving care are removed
• School-based treatment has
“ecological validity” – the • Schools provide an ideal and (Mychailyszyn, et al., 2011).
benefits can be realized in the “least restrictive environment”
environment that is clinically & to provide mental health
services. • Services are most effectively provided within a multi-tiered
practically meaningful. system of support (MTSS).
Tomb & Hunter (2004); Ramirez et al. (2006)
Allen (2011); Doll (2008); Herzig-Anderson et al. (2012); Merikangas et al. (2011); Mychailyszyn et al. (2011)
Bernstein, Aldridge, & May (2013) 1

7 8
ASSESSMENT PREVENTION/INTERVENTION
Indicated Assessment Few Indicated Prevention

Anxiety: Important Concepts and
~5% Definitions
Some • Anxiety: disproportionate • DSM-IV Symptoms:
Selected Assessment ~15% Selected Prevention
fear response to a • Difficulty falling asleep/staying asleep
perceived threat. • Irritability/outbursts of anger
• Overwhelming sense of • Difficulty concentrating
fear that can be • Hypervigilance

characterized by physical • Exaggerated startle response
Universal Assessment symptoms (e.g., sweating, • Motor restlessness
Universal Prevention
tension, increased pulse). • Anxiety disorders most commonly
seen in schools:
• The Core of Anxiety: • Specific phobias
• School refusal
• Negative affectivity
The only way to • Separation Anxiety
• Perception of Control
move through the
tiers is with DATA!
ALL • Specific Life Examples
• Social Phobia
• Selective Mutism
~80% of Students • Anxious Thinking • Generalized Anxiety Disorder
Multi-Tiered System of Support (MTSS) Chorpita (2007); DSM-IV-TR (2000); Dozois & Dobson (2004)
Source: www.pbis.org
9 10
Case Examples
• Vivi, Preschooler
See Handout #1
• Allison, 3rd grader
• Bryan, 11th grader

WHAT CAN WE DO TO
HELP THESE STUDENTS?
Cognitive-Behavioral Therapy (CBT): An Overview
11 12
CBT: Overview CBT: Empirical Support

• Multifaceted; can be applied to multiple problem areas in • A growing body of evidence over 20 years supports the
school-based practice. efficacy and effectiveness of CBT with children and
adolescents.
• Cognitive behavioral therapy (CBT) has been noted to be an efficacious
• The therapist’s role in CBT is to improve the cognitive treatment for childhood anxiety according to guidelines set forth by the APA
Task Force on Psychological Interventions:
information processing of clients in social contexts and 1) It has been shown to be more effective than all of the following
attend to the client’s emotional state(s) by using scenarios: no treatment, a placebo, or an alternate treatment
structured behavioral practice. 2) Multiple trials have been conducted
3) The trials were conducted by different investigative teams
• The strategies in CBT are designed to produce changes • Note: Studies are mainly limited to clinical (not school) settings or
in thinking, feeling, and behavior have utilized outside providers who implement the treatment in a
school setting.
Kendall, Aschenbrand, & Hudson (2003); Mennuti & Christner (2012)

13 14
CBT in the Schools: Empirical Support CBT: Theoretical Underpinnings

• Recently we are seeing more research on the school-based Cognitions (Thoughts)
implementation of CBT for a range of mental health
diagnoses. These facets are
examined as they
• School services are often reactive and considered pertain to the child’s
successful if the problem goes away. social/ interpersonal
contexts & situations.
• We need to teach coping skills/strategies to prevent
problems, such as anxiety, from re-emerging down the road. There is often a trigger
• CBT is a framework for teaching these skills. or threatening situation
that sets the child down
• Can be used in a reactive and preventive manner. an anxious path.
• Can address problems both in school and those outside of school that
impact school functioning.
Physiological Behaviors/
Feelings/Emotions Actions
The relationship among
Allen (2011) these variables is multi-
directional, not linear.
15 16
CBT: Theoretical Underpinnings

Cognitions (Thoughts):
“I am definitely going to fail this test!” • “Cognitive problem solving strategies are not
transmitted magically from parents to children…they
Social/ interpersonal
contexts & situations: are acquired through experience, observation, and
-Suburban School District interaction with others” (Kendall, 2012, pg. 4).
-Supportive home life
-Overachieving friends
• We can increase the use of these strategies through
Trigger/Threat: intentional intervention/instruction.
-Test in class
• Information processing affects how individuals make sense
of the world.
Physiological Behaviors: • We can intervene by correcting (challenging) faulty
Feelings/Emotions: • Crying
• Upset/anxious
information processing (distorted thinking).
• Avoidance
• Headache Allison • Goes to
• Stomach ache Nurse’s office
17 18
The “C” in CBT: What do we mean by

What do we mean by ‘cognitive’?
‘cognitive’?
– attributions – are the resulting
• Cognitive structures cognitions that emerge from the interaction of information,
• Memory (accumulation of experiences), aka ‘cognitive cognitive structures, content, and processes.
schemas’ • These vary considerably across individuals.
• Related back to temperament
• Cognitive content
• Can shape how individuals perceive and respond to environmental
• Stored information (the contents of the structure) events (either real or imagined!)
• Cognitive processes • Psychopathology (such as anxiety) may be due to

problems in any or all of these.
• How we perceive/interpret experiences Kendall’s dog
@#$t example  • In CBT, we attend to all of these (through the child’s self-
talk, processing style, & attributional preferences).
• Challenging the child’s current way of thinking
• Building a more beneficial cognitive structure/template
Kendall (2012)

19 20
Cognitive Distortions vs. Deficiencies The “B” in CBT: Changing Behavior

• Cognitive processing deficiencies = an absence of • Specifically, we are changing anxious (avoidance)
thinking (when it would be helpful), i.e., minimal behavior.
forethought/problem-solving skills. • And what about emotions?
• ADHD, aggression (often externalizing) • Anxious youth demonstrate a lack of understanding of how to hide
and change their emotions.
• Cognitive distortions = dysfunctional thinking processes. • They struggle to modify their emotional states.
• They lack coping skills for a range of emotions.
• Depression, anxiety, eating disorders (often internalizing)
• They experience more intense emotions.
• CBT can improve an anxious child’s knowledge of and ability to
• CBT does not aim to remove existing cognitive structures, regulate emotional states.
but rather help clients develop new templates for making • Helpful when anxiety and depression are comorbid.
sense of future experiences.
Southam-Gerow & Kendall (2000); Suveg, Sood, Comer, & Kendall (2009); Suveg & Zeman (2004)
21 22
CBT: Primary Components Features of CBT

AFFECTIVE COGNITIVE • Time-limited
- Psychoeducation - Coping Modeling (verbalizing)
- Developing a fear hierarchy - Cognitive Restructuring (changing • Present-oriented
self-talk; identifying and disputing
• Solution-focused
dysfunctional ideas)
• Can be implemented at multiple tiers
• School-wide prevention, groups, classroom-based and individual
BEHAVIORAL OTHER interventions
- Role-play activities (teaching - Therapeutic Relationship
problem-solving techniques)
- Practice
- Exposure & Homework
- Contingency Management
- Reinforcement of positive
behavior and skill mastery
(Self-reward)
23 24
Affective (Feelings)
• Anxious youth demonstrate a heightened sensitivity to
negative or threatening events, things, and information.
• Anxious youth have more difficulty regulating their
emotions.
CBT: • Somatic (physical) complaints are common with anxious
children (e.g., stomachaches, headaches, etc.).
AFFECTIVE COMPONENTS • We treat this through psycho- (affective) education.
• Has positive effects in behavioral, emotional, and social functioning
Psychoeducation & Developing a Fear Hierarchy in children and adolescents
• Is a frequent element in most evidence-based anxiety interventions
Kendall (2012)

25 26
Psychoeducation: Teaching about Anxiety Developing a Fear Hierarchy

• Also known as social and emotional learning (SEL) • “A list of all related, fear-producing situations or objects,
• Explain what anxiety is ordered from least to most anxiety producing” (Merrell, 2008,
• Teach youth about the connection between physical, cognitive, &
behavioral components of anxiety. pg. 175).
• Use the “false alarm” metaphor • Used to uncover the specific fear-provoking stimuli/
• Normalize the fear/anxiety circumstances for the child
• Teach recognition of somatic responses
• “Where do you feel anxiety?”
• Help the child rank fears from least to most anxiety
• Teach feelings identification producing
• Feelings faces
• Feelings charades See Handout #2
• Feelings collage
• Feelings bingo
• “How do you know when…?”
• Use role plays, videotapes, magazine pictures, bibliotherapy, etc.
Merrell (2000)
27 28
Fear Hierarchy Example

My Fear = School
0 = playing in the yard with friends at home
1 = going to bed on a school night
2 = going to school w/ mom (no students present) Let’s look at fear
3 = spending time with my teacher in the classroom when
no students are there
hierarchy examples for
Vivi, Allison, & Bryan. CBT:
4 = getting ready for school in the morning See Handout #1
5 = riding the bus to school COGNITIVE COMPONENTS
6 = walking to the classroom • Modifications for Vivi
7 = staying in class ½ day (allowed to call home)

• Shorten from 10 to 5 Modeling, Building a Cognitive Template, & Cognitive
8 = staying in class whole day (allowed to call home)
• Utilize pictures, index Restructuring
cards, social stories, etc.
9 = staying in class ½ day (not allowed to call home)
10 = staying in class whole day (not allowed to call home)
29 30
Examples of Cognitive Distortions In

Cognitive (Thoughts)
The School Setting
• Cognitive Processes: the procedures by which the
cognitive system operates • Dichotomous Thinking • Personalization
• How we perceive/interpret experiences • Overgeneralization • Should/Must Statements
• Mind Reading • Comparing
• Our cognitive interpretation of the world shapes how we
• Emotional Reasoning • Selective Abstraction
view situations, events, and interactions
• Disqualifying The • Labeling
Positive
• Cognitive distortions: dysfunctional thinking processes
• Catastrophizing
See Handout #3
Kendall (2012)
Menutti & Christner (2012)

31 32
CBT: Building a Cognitive Coping Template Teaching Children To Problem-Solve

• Help children identify and modify negative self-talk • Problem-Solving: it’s what we do best!
• But, remember: school psychologists should not solve students’
• Recognize and challenge the student’s misinterpretations
problems for them, but instead teach them how to problem-solve.
• Example: “If you fail this one test, does that definitely mean that you won’t get • Help children develop confidence in their ability to overcome problems
into college?” and use their experiences to problem-solve in the future
• Help students recognize that other perceptions of the same situation exist • Model brainstorming skills by pointing out plausible and
• Assist students in building new perceptions that encompass appropriate impossible situations
coping strategies • Teach students the five-step problem-solving process:
• The goal: when anxiety provoking events occur, the student will (1) What is the problem?
(2) What are all the things I could do about it?
view the stressful event through the new coping template and be
(3) What will probably happen if I do those things?
reminded to use appropriate coping strategies (4) Which solution do I think will work best?
• The goal is not to overload the anxious student with positive self- (5) After I have tried it, how did I do?
talk, but to reduce the negative self-talk
• “The power of non-negative thinking” (Kendall, 1984). Vivi’s refusal to get out of her
mom’s car when she arrives to school.
Kendall (2012) Kendall (2012)
33 34
Coping Modeling The Steps of Cognitive Restructuring

• Based on social learning theory (Bandura, 1986) • Identify negative self-talk
• “Everyone is going to laugh at me when the teacher calls on me
• Observational or vicarious learning. and I answer her question wrong.”
• May occur through a live model or a video model. • Examine the list of common errors in thinking together.
• Use detective thinking to examine the evidence
• Coping Modeling (verbalizing): • Past Experience:
• Having a problem similar to the client, demonstrating strategies to • “Has anyone laughed when you have been called upon in the past?
overcome the problem, and then demonstrating successful • Alternative possibilities:
performance
• “If so, could they have been laughing at something else?”
• Rather than saying, “Watch me – I’ll show you how to do it,” model
the same fears and strategies to overcome the situation. • General Knowledge:
• Verbalizing Coping Model: a coping model who talks out loud • “How often do you get answers wrong? How about the other students?
through the steps and gives specifics (think aloud). What does the teacher do when other students get the answer wrong?”
• Example: School psychologist pretends as if he or she was the one who • Different Perspective:
was nervous and the student walks the school psychologist through the • How do others feel about answering the teacher’s questions?
fear plan.
35 36
Thought Bubbles Activity: What are they thinking?

The Steps of Cognitive Restructuring
• Identify a positive replacement thought
• “I usually do pretty well in school.”
• “If I don’t know the answer, I’ll just say so.”
• Use realistic thinking in some situations
• Ask: “What if someone laughs?”
• “I’ll just ignore it.”
: Techniques/Strategies
• Group Activity – “Changing Maladaptive Thoughts to Coping
Thoughts”
See Handout #4
• Thought bubbles activity (see the following slide)

• Use magazines and have students fill in ones for anxious thoughts .
• Using a thought record

37 38
Using a Thought Record

Where Emotion/ Negative Evidence that Evidence that Alternative/ Where Emotion Negative Evidence that Evidence that Alternative/
were Feeling Automatic supports the does not support Coping were Feeling Automatic supports the does not support Coping
you? Thought thought the thought Thought you? Thought thought the thought Thought
Chemistry Worried, “Girls were I was stuttering They may have I don’t really
Class stomach laughing in and stumbling been laughing at know why
hurt the back of on my words each other or the they were
the room,
while I was teacher. laughing
they must
have been presenting. and I am
laughing at confident in
me” my project.
What was
What error the What error Modifications for younger
in thinking situation? in thinking children like Vivi:
did I make? did I • Use only 3 columns:
Getting up make? (feelings, negative thought,
_________ to present positive thought)
my project Selective • Use pictures
Abstraction
39 40
Role Play
• We need to practice doing things, we can’t just talk about it!
• Practicing can be different for different kids
• Role play is an opportunity to practice in private before you
perform in public.
• Give the child an opportunity to be active in the session.
CBT: • We role play cognitive, behavioral, and problem-solving
strategies with the child.
BEHAVIORAL COMPONENTS • Role plays should be situations relevant to the child (derived
from his/her fear hierarchy)
Role-play, Exposure, Contingency Management, Self- • Is the child resistant to role play?
reward, & Relaxation Training • Be silly, act out something first and then let the child join in.
: Bryan’s anxiety about calling a

friend on the phone.
41 42
Exposure Exposure: Evidence Base

• “Placing the child in a fear-evoking experience, either • Exposure strategies are a critical component in CBT.
imaginally or in vivo to help him/her acclimate to the distressing
• Consistently shown to be an indispensable component of anxiety
situation and to provide opportunities to practice coping skills interventions (Chorpita, 2007).
within simulated or real-life situations” (Kendall, 2012, p. 160).
• Graduated exposure vs. flooding & response prevention • “Hundreds of clinical trials and dozens of meta-analytic reviews
• An important distinction!
have helped establish (exposure) as the most empirically
supported psychological intervention for the anxiety disorders”
• Remember the fear hierarchy? Here is where we will apply it. (Deacon, 2012, p.10).
• The exposure plan is crafted with the child’s input.
• Chorpita, Daleiden, & Weisz (2005) found that of the studies
• Explain the purpose (treatment rationale) to the child. evaluated, successful treatment of anxiety disorders and specific
• Consider developmental level as an important factor here. phobia always included exposure.
• Remember there is an art to exposure- you have to keep tasks
• The National Institute for Clinical Excellence (2011) recommends
challenging, but not so challenging that they are impossible to exposure-based CBT as a first line in anxiety treatment.
accomplish!

43 44
Challenges with Exposure What should you do during exposure?

• Before
• Failure to reach within-trial habituation
• Remind the child of the purpose of exposure
(a decrease in reported fear during a practice session) • Reinforce the idea that exposure is a learning experience
• Solution: Extend the exposure session (preferred method) or start • It is meant to test whether their anxiety is “real” or a “false alarm”
with an easier stimulus next session • During
• Be quiet, observe, and take notes of the child’s behavioral response –
• Failure to reach between-trial habituation do they demonstrate avoidance? Outward anxiety?
• Only speak if a corrective prompt is needed- avoid reinforcing or
(a decrease in reported fear between practice sessions) distracting the student
• Solution: Schedule more exposure sessions to reduce time • After
between sessions; Include practice sessions at home • Praise the student, using specific statements when possible
• “I really like how you stuck with it and whispered to your friend.”
• Encourage the student to share their success with a parent
• Use this time to review and ask questions about the experience
Chorpita (2007)
Chorpita (2007)
45 46
Relaxation Training Relaxation Training

• Teaches youth how to develop awareness and control over • Techniques/Strategies
their somatic reactions to anxiety. • Progressive Muscle Relaxation (Jacobson technique)
• Research has shown that relaxation training is most effective • The Benson Technique (cue-controlled)
when combined with exposure (particularly in vivo)
interventions. • Guided Imagery
• Elevator Breathing
• Dosage is important!
• Mindful Meditation
• Research shows that you need more than four relaxation sessions to
show an effect • Robot/Ragdoll
• Typically implemented as part of systematic desensitization;
has demonstrated positive effects on its own. • What about teens who are reluctant to participate?
• A study done 3.5 years post-treatment asked kids what they • Work with their interests (golf example).
remembered:
• Provide reinforcement for relaxation.
1. Therapist name
2. You made me do things I didn’t want to do • “Wait ‘em out.”
3. Take a deep breath when I get nervous  • Most of their life they’ve had people talk for them.
• Let them sit.
Kendall (2012); Merrell (2008); Morris & Kratochwill (1998); Ollendick & King (1998)
47 48
Exposure + Relaxation = “I can do

Systematic Desensitization this...take
deep
To teach Allison relaxation strategies it is breaths!”
helpful to have a script or recording, for • Gradual exposure to
example, “Allison, I want you to… • Modifications for feared stimuli
Fear
Hierarchy
1) Find a comfortable position in a quiet setting. younger children such
2) Close your eyes. as Vivi:
3) Pay attention to your breathing. Take a deep • Shorter script
breath in and let it out slowly. • Less muscle groups
4) Imagine your worries leaving with your breath. • Use developmentally • Challenging
5) Tense and tighten your muscles, one by one appropriate metaphors maladaptive
starting with your feet and moving up to your such as the robot/ragdoll. thoughts Cognitive Systematic
head/neck. Then release them and notice how • Thought stopping Strategies Desensitization
• First pretend with an • Utilize coping
you feel.
inanimate object like a thoughts/positive
6) Allow your entire body to relax and keep self-statements
teddy bear.
taking deep breaths in and slow breaths out.
• Demonstrate it first for her.
7) Imagine a comforting place, perhaps your
favorite place. • Bryan would likely be able
8) Continue these steps for several minutes and to do the full progressive • Relaxation
sit peacefully a bit longer.” muscle series. Strategies
Behavioral
Strategies
• Reinforcement/
Reward

49 50
The Importance of the Therapeutic

Contingency Management
Relationship in CBT
• Based on operant conditioning; focuses on the
• The therapeutic relationship is essential in CBT.
consequences of behavior
• Focuses less on anxiety reduction and more on facilitating • Establishing trust with and demonstrating warmth and
approach responses through appropriate reward/ reinforcement positive regard for the client must precede any strategy
• For anxiety, we typically use: implementation.
• Shaping, Fading
• In CBT the therapist acts more as a “coach”
• Positive Reinforcement
• The therapist does not have all the answers.
• Emphasis on self-reward for effort and (partial) success
• Perfection is not expected! • The therapist collaborates with the client in problem-solving.
• Graduated practice leads to a developing confidence (social-cognitive theory; • In sessions = practice; Real life = the game
self-concept).
• Extinction
• Effective at reducing multiple anxiety-related behaviors
(i.e., selective mutism, social phobic behaviors, etc.)
McGivern, Ray-Subramanian, & Bernstein (in press)
51 52
What about Parents? What Does CBT Look Like in Practice?

• An important part of CBT. • Case conceptualization (as opposed to diagnosis)
• Helps the practitioner make decisions regarding the sequence and
• Parents are consultants, not co-clients. selection of particular treatment components.
• In essence, a modular approach (e.g., Chorpita, 2007)
• It is helpful to collaborate with parents on the intervention
• Base the treatment on the child’s age, developmental level, and
plan and maintain their cooperation and support.
presenting problem(s).
1. Examine family dynamics that maintain anxiety.
 Parents often model anxious behavior themselves, or deal • Consider verbal/cognitive abilities.
with anxiety in a maladaptive way. • If the child is particularly sensitive to physical symptoms, you may begin
 Parent-child interactions contribute to anxiety. with deep breathing or progressive muscle relaxation.
2. Solicit their help in developing the fear hierarchy. • If the child first identifies catastrophic thinking patterns, you may start
3. Have the child teach their parent(s) the skills (i.e., relaxation, with labeling cognitive distortions.
positive self-talk, etc.) to help generalize the intervention effects. Vivi
4. Teach parents basic behavioral parenting strategies such as
positive/negative reinforcement, planned ignoring, modeling, etc.) • We would emphasize behavioral versus cognitive components
based on her developmental level.
53 54
A Typical CBT Session CBT: Challenges in School-Based

Session Components: Practical Application:
1. Set the agenda 1. “Here is what we are going to do today…” (write it out) Implementation “…the school context is complex and
(Check in on the relationship) (utilize empathy; engage in “parlor talk”) dynamic, making delivery of services
• Time, time, time… a challenge” (Allen, 2011).
2. Review status and events since 2. “Last week we talked about the physical sensations
• Resources
last session you feel when you are anxious…”
• But wait! You don’t need a packaged program, you need a collection
3. Solicit feedback re: last session 3. “Did you think more about what you learned?” of evidence-based strategies.
• Schools are unpredictable
4. Review “homework” 3. “Did you notice these sensations during the week and
- Examples write it down in your journal?” • Scheduling constraints
• Familial factors
5. Focus on main agenda item (e.g., 5. “Today we are going to talk about how our thinking
cognitive restructuring) impacts how we feel and what we do…” • Parents maintaining anxiety
• Soliciting parent involvement
6. Develop new homework for 6. “I want you to take some time this week to use the
between-session thought record…”
• Child factors
• Comorbidity, symptom severity, developmental delays, language/
7. Progress Monitoring, Praise, & 7. “How anxious do you feel today on the fear processing difficulties, etc.
Self-Reward thermometer (from 1 to 10)? What have you
accomplished on your fear ladder?” “Great job!” (self Davis, Whiting & May (2012)
reward)

55 56
CBT: Challenges in School-Based Maintaining Treatment Integrity &

Implementation, cont. Acceptability
• Common concerns reported by practitioners when treating kids • Measure it!
with anxiety in the school:
• Even if you are the intervention agent, use a formal
• Youth with severe anxiety (e.g., vomiting due to anxiety)
• Make outside referrals when appropriate measure of treatment integrity
• Not having enough time to reduce the child’s anxiety before returning • Solicit input from the child, parents, and teachers on
them to the classroom.
• Save 5-8 minutes at the end of a session to engage in a pleasant activity.
treatment acceptability
• Ensure that their self-reported ratings of anxiety following exposure are • Ongoing measures of acceptability allow you to make adjustments
reduced by ~50%. to the treatment
• Schedule longer sessions for exposure or even after school.
• Higher acceptability yields higher compliance with treatment
• Logistics of conducting exposure tasks in school.
• We need to step back and look at exposure differently.
: How could we craft an in vivo exposure

task for Bryan’s anxiety? Let’s look at his fear hierarchy on Handout #1.
Mychailyszyn, et al. (2011)
57 58
Outcome Evaluation CBT Applications at Multiple Tiers

• Is it working? How can we measure outcomes? • Evaluate what level of intervention is needed within a
• Set measurable goals & monitor progress
multi-tiered system of support (MTSS).
• Goal Attainment Scaling (GAS) • Tier 1: Preventative intervention implemented class or
• Transfer the fear hierarchy into a GAS school-wide
• Use pre-post measures (e.g., MASC-2) • Tier 2: Small group intervention targeting sub-clinical
• Review extant data
levels of anxiety
• School attendance, office referrals, etc. • Tier 3: Targeted intervention for students experiencing
high-risk and clinical levels of anxiety
59 60
ASSESSMENT PREVENTION/INTERVENTION
Indicated Assessment:
- Rating scales
Few
~5%
Indicated Prevention:
- Individual counseling with Manualized Interventions
- Behavioral observations anxious youth utilizing a
- Interviews CBT framework.
Some • Highly structured
~15% Selected Prevention:
Selected Assessment:
- Small groups for youth • Allows for more methodological control
- Teacher/Parent referral/
at risk focused on
nomination
cognitive-behavioral • More easily able to assess treatment integrity
- Screening tools
skill acquisition
• Flexibility is a concern
Universal Assessment:
Universal Prevention: • Evidence-based manualized interventions:
- Outcome evaluation for
- School- or class- • Coping Cat (Kendall & Hedtke, 2006)
programs selected
wide programs to teach
relaxation/stress • Camp-Cope-A-Lot (CCAL; Kendall & Khanna, 2008)
reduction
• Computer-based CBT modeled after Coping Cat
• FRIENDS for Children Program (Barrett, et al., 2000)
The only way to
move through the
system is with
ALL • Cognitive-Behavioral Intervention for Trauma in Schools (CBITS;
Jaycox, 2003)
DATA! ~80% of Students
Kendall & Southam-Gerow (1995); Weisz, Wiess, & Donenberg (2011)
Multi-tiered System of Support (MTSS) for Anxiety
Source: www.pbis.org

61 62
Modularized Interventions
• Case conceptualization approach
• Problem-solving framework
• More flexibility and individualization
• Maintains a level of structure
• Evidence-based modularized intervention:
• Modular Cognitive-Behavioral Therapy for Childhood Anxiety
Disorders (Chorpita, 2007) QUESTIONS
Murphy & Christner (2012)

ANXIETY: TIPS FOR TEENS
By Patricia A. Lowe, PhD, Susan M. Unruh, EdS, & Stacy M. Greenwood

University of Kansas
… Robin has trouble concentrating in her chemistry class because she’s getting so little
sleep at night. She lies awake for hours worrying, and, when she does get to sleep, she’s
jerked awake by nightmares.
… Liz is starting to skip school and her grades are suffering. She had a blow up with her
friends and now she’s afraid of being rejected socially whenever she’s at school.
… Kendrick saw an exchange of gunfire between rival gangs in his neighborhood and now,
whenever he hears a loud noise, his palms get sweaty and he has a hard time catching his
breath. Except for school, where he feels safe, he avoids going out of his house.
Anxiety is one of the most common problems facing teenagers in schools today. Worry and anxiety
are normal reactions to concerns about what might happen in the future. Most teenagers worry at times
about school performance, classmates and friends, family, appearance, health, and personal harm.
A certain amount of anxiety is healthy, especially when it results in productive action, such as when
we worry about getting a bad grade on a test and, consequently, we study extra hard. We all know what it
means to have butterflies in our stomach and to feel restless and tense from time to time. For some of
us, though, anxieties and worries begin to control our lives. We may turn to drugs and alcohol in an
attempt to reduce our anxieties or we may avoid participating in regular activities. These actions limit
our enjoyment of life.
Approximately 1 out of 11 teenagers is diagnosed with anxiety severe enough to be considered a
disorder, with girls being more likely to develop an anxiety disorder than boys. Common anxiety
symptoms that can affect people at any age tend to increase during the adolescent years.
Anxiety Affects Us in Different Ways

Our feelings. The emotions commonly associated with anxiety are discomfort, fear, and dread. We
may feel irritable and angry with others or we may feel that everyone is judging us and we can never
quite measure up to others’ expectations.
Our body’s response. Sweating, nausea, shaking, headaches, muscle tension, fatigue, and generally
being on edge are among the body’s physiological responses to anxiety. Some of us may also experience
dizziness, shortness of breath, and an accelerated heartbeat.
Our behaviors. Some of us who are anxious often engage in behaviors of avoidance and withdrawal,
such as missing school and avoiding social gatherings.
Our thoughts. Some of us have difficulty concentrating when we are worried and anxious. Thoughts
may be negative and unrealistic, and consequently events may be misinterpreted. For example, Mike may
be worried about his acne. When he walks by a group of girls in the hallway and they are laughing, he is
certain that they are laughing at him. In reality, they were not talking about him and did not even notice
that his face broke out, but he starts to avoid talking to girls and keeps his head down whenever his skin
breaks out.
Causes of Anxiety
There are many different causes of anxiety. Anxiety appears to develop from an interaction among
different factors rather than from any single cause. In general, we are more likely to experience anxiety if
one or both parents exhibit anxiety symptoms. That is, anxiety tends to run in families.
Behavioral inhibition, a temperament style, has also The attack usually lasts 10–15 minutes. There is
been linked to anxiety in children and teens. Infants with intense fear and a shortness of breath, shakiness,
this type of temperament are described as shy, timid, dizziness, sweating, heart palpitations, and chest
and wary, and seem to be at a greater risk for pain. These people live in fear that they are going to
developing an anxiety disorder when they are older. have another panic attack and will avoid situations
We can learn to be anxious as a result of our that may bring on another attack, such as avoiding
experiences or conditioning. This is especially true for school and social situations they associate with
those who have excessive fears (phobias) for certain ob- panic attacks.
jects or situations. For example, a frightening experience • Phobia: People who experience a specific phobia
such as being chased by a dog can become associated have an intense, persistent, and maladaptive fear of
with any dog, resulting in an unreasonable fear of all dogs. a specific object such as an animal or insect or of a
Certain styles of thinking also contribute to devel- situation such as standing on a tall ladder or being
oping anxiety. Those of us who experience excessive in an enclosed space. They avoid the feared object
worries and anxieties tend to develop a pattern of or situation leading to interference with their daily
negative and unrealistic thinking. We can misinterpret routines.
harmless situations as threatening and focus our • Post-traumatic stress disorder: People with a post-
attention on what we perceive as threatening. traumatic stress disorder experience severe anxiety
Other environmental factors that may cause anxiety symptoms in response to a traumatic event. The
include exposure to a stressful environment or a trau- traumatic event may involve a natural disaster such
matic event, observing others’ anxious behavior, having as a tornado, a violent act such as a school shooting
overly protective and controlling parents, and learning or abuse, or a frightening act such as a car accident
to avoid certain situations to relieve anxiety symptoms. in which they were either a witness or a victim. The
traumatic event may be re-experienced over and
Types of Anxiety Disorders over again in nightmares, flashbacks, thoughts, or
What follows are the most common types of anxiety memories. These people avoid anything associated
disorders experienced by teens: with the trauma. They startle easily, have difficulty
concentrating and doing their school work,
• Generalized anxiety disorder: People with a general- experience sleep disturbances and irritability, and
ized anxiety disorder experience excessive, unrealistic, have problems getting along with their friends.
and persistent worry about everyday life events and • Separation anxiety disorder: People with a
activities such as their school performance. They separation anxiety disorder experience excessive
find it difficult to control their worrying. They may worry or anxiety when separated from their parents
worry about their school work all the time and spend or primary caregivers. The excessive worry or fear is
hours doing and redoing their work because it is not in response to routine separations such as their
perfect. Their worry causes a tremendous amount of leaving home and going to school for the day. They
distress. They may experience physical symptoms may have physical complaints, such as stomach-
including headaches, stomachaches, fatigue, and aches and headaches, refuse to attend school, do
muscle tension. Other symptoms may be restless not like to sleep alone or away from home, and
and irritable behaviors, difficulty concentrating, and experience unrealistic worry that harm will come to
problems sleeping. themselves or their parents.
• Obsessive-compulsive disorder: People with an obses- • Social phobia or social anxiety: People with a social
sive-compulsive disorder have repetitive thoughts phobia or social anxiety show intense fear in
(obsessions) or behaviors (compulsions) that seem situations in which they may experience criticism,
impossible to control. They realize that their obses- embarrassment, or humiliation in public. They may
sions and compulsions are excessive and meaning- also experience anxiety in social situations when
less, but the repetitive thoughts and behaviors are there is no identifiable stressor to others. Common
difficult to stop and cause distress. Common social phobias include intense fear associated with
obsessions include fear of contamination and public speaking and avoidance of strangers. They
thoughts of harm to themselves or family and friends. avoid feared situations, and their avoidance beha-
Common compulsions include washing and cleaning viors restrict their daily lives. Isolation and possibly
rituals, and checking and rechecking behaviors. depression may follow as a result of their behaviors.
• Panic disorder: People who experience a panic
disorder have recurrent, unexpected panic attacks.
S10–6 Anxiety: Tips for Teens

What You Can Do • Be optimistic: Try to be optimistic. View a problem
The following suggestions may be helpful to combat or a situation as a challenge that can be overcome
anxiety and worry: instead of an obstacle to be avoided or a situation
that causes distress. Use positive self-talk to meet a
• Social support network: Develop a social support problem or a situation directly. This will put you in a
network. It is important to have someone to talk to, better position to resolve your problem or situation
a friend, a parent, an uncle or aunt, when you are with less distress.
feeling anxious or worried, and just talking it out
can sometimes help reduce whatever anxiety or Who You Can Contact for Help
worry you may be experiencing. Sometimes you may need help in dealing with your
• Exercise: Exercise on a regular basis. A 20- to 30- anxieties and worries, especially if anxiety increases in
minute workout three to five times a week can be severity and interferes with your everyday life. Do not be
energizing, and can make you more alert and can calm embarrassed about seeking help. Almost everybody
you. However, before beginning any exercise program, needs help at one point in their lives. And those who
it is important to be sure you are in good health. Ask have not sought help probably should have done so. So,
your family doctor if this is a good idea for you. here are a few people you can contact to help you
• Eat a healthy diet: Eating a healthy diet is important. through this difficult time.
A balanced diet low in sugar and caffeine and junk
foods is highly recommended. Eating well can • Parent or primary caregiver: They care. They are
increase your mental and physical energy and may there with you and know about you. Talk to them.
lessen your anxiety. Tell them your worries and anxieties. Maybe they
• Sleep: Quality and quantity of sleep are important. can help.
Fatigue wears on our emotions. Sleep requirements • School psychologist, school social worker, guidance
vary, though. If you get enough sleep and if you counselor, or school nurse: Sometimes it is good to
have a regular sleep schedule (a specific time to go speak to people who are not related to you and who
to bed at night and a specific time to get up in the are trained to help you. They can provide you with
morning) you will feel more refreshed and are in a information about anxiety and can possibly treat or
better frame of mind to tackle worries and concerns. make a referral to another mental health profession-
• Learn to relax: Different activities are relaxing to al who specializes in the treatment of teens with
different people. If you are feeling anxious or anxiety problems.
worried you can go for a long walk to relax or you • Family physician: Visit your doctor. Your doctor can
can listen to soft music, read a book, draw or paint, rule out other possible medical causes for the
do yoga or martial arts such as tai chi or tae-kwon- symptoms you are experiencing and can help
do, take a nice warm bath, listen to relaxation tapes, determine if you have an anxiety disorder and can
practice deep breathing and muscle relaxation then help refer you to someone who specializes in
exercises, or do anything that you find relaxing. teens with anxiety problems.
• Prepare ahead of time: If you feel anxiety before or
during a test, for instance, it is a good idea to What Help Is Available
develop good study habits, time management skills, Anxiety problems are serious but treatable. Possible
and organizational skills. Being well prepared may treatments include individual or family therapy, parent
give you a sense of confidence and reduce anxiety. training, and medication. These treatments may be used
If you are concerned about public speaking or if you alone or in combination.
have to talk in front of others during a public forum, Two approaches to therapy include changing the
practice parts of the speech beforehand and prepare way we think and behave, and changing specific
well. This may be easier said than done, but give it a behaviors by replacing ineffective behaviors with more
try. Being prepared does help. desirable behaviors.
• Set realistic goals: It may not be a good idea to set Therapists can help you sort out your thoughts,
goals that are too unrealistic because if you do not feelings, and problems and may come up with solutions
reach them then you may feel that you have failed to resolve your problems. A relationship of trust and
yourself and have failed those who count on you. Be rapport first has to be established with the therapist.
more realistic. You know what you can accomplish You have to speak honestly with the therapist, and the
and what you cannot. Be patient. Feel good about therapist has to discuss with you and your family limits
what you have accomplished and can accomplish. on confidentiality, or information that will and will not
be shared with others. You have to set ground rules with
your therapist about what can and what cannot be
discussed with your parents, for instance, or with
anybody else.
Parents should also learn to use techniques that may The National Association of School
help you lessen your worries and anxieties. A therapist Psychologists (NASP) offers a wide
can work with several members of your family or the variety of free or low cost online
resources to parents, teachers, and others
entire family to address issues that relate to your anxiety. working with children and youth through
And, finally, sometimes medication prescribed by the NASP website www.nasponline.org
your physician can be used in addition to therapy. If and the NASP Center for Children & Families website
medication is prescribed, be sure to take it exactly as www.naspcenter.org. Or use the direct links below to
access information that can help you improve outcomes
instructed and let your parents or school nurse know if
for the children and youth in your care.
you are experiencing any side effects—feeling sick,
being more anxious or extra sleepy or having trouble About School Psychology—Downloadable brochures,
sleeping. You are the best judge. Medication does not FAQs, and facts about training, practice, and career
work for everyone and sometimes it takes a while to find choices for the profession.
www.nasponline.org/about_nasp/spsych.html
the right medication or the right dose.
Crisis Resources—Handouts, fact sheets, and links
Resources regarding crisis prevention/intervention, coping with
Davis, M., Robins-Eshelman, E., & McKay, M. (1995). The trauma, suicide prevention, and school safety.
www.nasponline.org/crisisresources
relaxation and stress reduction workbook. Oakland,
CA: New Harbinger. ISBN: 1572242140. Culturally Competent Practice—Materials and resources
Greenberger, D., & Padesky, C. A. (1995). Mind over promoting culturally competent assessment and
mood. New York: Guilford. ISBN: 0898621283. intervention, minority recruitment, and issues related to
Hipp, E. (1995). Fighting invisible tigers: A stress cultural diversity and tolerance.
www.nasponline.org/culturalcompetence
management guide for teens. Minneapolis, MN: Free
Spirit. ISBN: 0915793806. En Español—Parent handouts and materials translated
Powell, M. (2003). Stress relief: The ultimate teen guide into Spanish. www.naspcenter.org/espanol/
(It happened to me, 3). Lanham, MD: Scarecrow.
IDEA Information—Information, resources, and advocacy
ISBN: 0810844338.
tools regarding IDEA policy and practical implementation.
Seaward, B. L., & Bartlett, L. K. (2002). Hot stones and www.nasponline.org/advocacy/IDEAinformation.html
funny bones: Teens helping teens cope with stress
and anger. New York: Health Communications. Information for Educators—Handouts, articles, and
ISBN: 0757300367. other resources on a variety of topics.
www.naspcenter.org/teachers/teachers.html
Patricia A. Lowe, PhD, is on the faculty of the School Information for Parents—Handouts and other resources
Psychology program at the University of Kansas. Susan a variety of topics.
M. Unruh, EdS, is a doctoral student in School Psychology www.naspcenter.org/parents/parents.html
at the University of Kansas. Stacy M. Greenwood is an
Links to State Associations—Easy access to state
EdS student in School Psychology at the University association websites.
of Kansas. www.nasponline.org/information/links_state_orgs.html
© 2004 National Association of School Psychologists, 4340 East West Highway, NASP Books & Publications Store—Review tables of
Suite 402, Bethesda, MD 20814—(301) 657-0270.
contents and chapters of NASP bestsellers.
www.nasponline.org/bestsellers
Order online. www.nasponline.org/store
Position Papers—Official NASP policy positions on

key issues.
www.nasponline.org/information/position_paper.html
Success in School/Skills for Life—Parent handouts that

can be posted on your school’s website.
www.naspcenter.org/resourcekit
S10–8 Anxiety: Tips for Teens

New York Association of School Psychologists
August 2013
High Stakes Testing & Children’s Well-Being:

A Guide for Parents
As the pressures and demands of “high stakes” testing and assessment
increase, so too do the worries of parents. Aside from concerns regarding a child’s
academic progress and performance on these measures, more and more parents are
worried about the emotional toll and overall impact these experiences have on their
children’s well-being. With this in mind, the New York Association of School
Psychologists has created the following list of suggestions to help parents.
Handling Stress Before, During, & After the Assessment:
Before:
 Make sure your child gets plenty of sleep, not only the night before, but
several days leading up to the assessment
 Provide a high quality breakfast (and lunch if your child brings lunch from
home- some tests are given in the afternoon)
 Try to keep a normal routine at home, but consider temporarily scaling back
on after-school activities if your child’s evenings tend to be heavily scheduled
 Allow plenty of time for physical activity, free play and opportunities to unwind
 Be positive with your child and point out all of the things your child does well
 Remind the child that he or she is well prepared for the test and will likely do
well
 Be patient and be prepared to listen to your child’s concerns. Answer all
questions honestly, but with short answers
 Monitor your own anxiety; kids quickly pick up on the anxieties of the
important adults in their lives
 Maintain realistic, attainable goals and expectations for your child.
 Do not communicate that perfection is expected or is the only acceptable
outcome. Accept mistakes as a normal part of growing up and let your child
know that no one is expected to do everything equally well
 Teach a few specific relaxation and stress management strategies, not just to
minimize anxiety around the tests, but as a general life skill. Strategies could
include:
o Deep controlled breathing
August 2013
o Mindfulness exercises
o Listening to relaxing music
o Asking what things might help them relax - this sends the message
that there are concrete things they can do to manage stress and
anxiety, which are normal parts of the human experience
 Share a time when you felt anxious and how you coped with the feeling
 Often, reasoning is not effective in reducing anxiety, so do not criticize your
child for being unable to respond to rational approaches.
 Seek help from the school if the problem persists and continues to interfere
with daily activities. Start with the classroom teacher, but you may also
consult with the school psychologist, counselor, or social worker.
If your son or daughter becomes anxious during testing, you can give them
strategies to use ahead of time, such as:
 Deep breathing, breathing in through the nose and out through the mouth in a
smooth motion.
 “Calming statements,” such as simply saying “relax” quietly to self.
 Shifting negative thoughts to more positive coping thoughts, such as “I will do
the best that I can” or “I prepared well for this test.”
 Focusing on the problems that are easier first, and then go back to more
difficult problems.
After:
 Ask one or two general questions about the test, such as “how did it go?”
 Do not ask questions such as “How many do you think you got wrong?” or
“Do you think you did better than the other kids?”
 Ask what your son or daughter learned in school?
 Ask what he or she did that was fun?
 Help your child keep the testing in perspective. You can say things like, “Sure,
the test are important and you need to do the best that you can, but
remember tests aren’t the only things that matter, and they aren’t the things
that are the most important”
Understanding and Learning from Challenging Experiences:
Research on motivation (Dweck, 2006) has found that how a person responds to
academic challenges, not grades or intellectual ability, is one of the best predictors of
later success in life. A child can view a failure or a challenging experience as a
reflection of either their lack of ability, or as a reflection of the strategies and effort that
were used during this experience. Those with the latter view tend to perceive these
challenges as something to “master” or have a “mastery orientation.” They tend to face
the next challenge with greater determination, a more positive outlook, and ultimately
experience greater learning and success. They will seek out more challenges in
learning and in life and tend to be willing to stretch themselves beyond where they are
comfortable. Because of this approach, in the end, they achieve more. Parents should
understand this and explain it to their children. Ultimately, we may find that it is how the
August 2013
child understands his or her success or difficulty that is the best predictor of his or her
future success.
There are certain vulnerable groups of children, who are more easily emotionally
impacted by high stakes testing. These may include students with learning difficulties or
English Language Learners, who tend to have a negative perception of tests in general.
However, even students at the opposite end of the education spectrum, to whom good
grades, high achievement, and academic accomplishment have come relatively easy,
are vulnerable to test anxiety. While at first, this may seem counter-intuitive, upon closer
analysis, it quickly becomes clear that their anxiety is a result of their own perception of
the test determining their academic status or their “demand” to perform well on all tests.
For all of these children, it is important to remind them:
 Ability and knowledge can be demonstrated in many ways, not just

through standardized testing – providing examples of the many ways they
have been successful and have demonstrated their talents
 Their worth is greater than the sum of their achievement. They are loved
for who they are, and not for what they achieve
 The value in some activities is not in the outcome, but in initiating a task
and knowing that your gave it your all
Things to Watch For:
If your child seems to have a preoccupation with the tests (e.g., talks about them
constantly, comes to you with “what if” scenarios, etc.) or has an extreme reaction (e.g.,
unable to sleep, becoming sick, refusing to go to school the day of the test, etc.) and
your attempts to reassure him or her have not alleviated the anxiety, it may be helpful to
speak with other caring adults in your child’s life. You may wish to speak with your
child’s teacher, school psychologist, or principal. School employed mental health
personnel should be able to provide information regarding your child’s presentation in
school and give you additional strategies and support to help your child.
In this new era of reliance on data and ever increasing levels of accountability,
standardized testing will not go away. Furthermore, when used correctly, as part of
(rather than the sum of) a child’s educational experience they can provide useful
information to educators. With this in mind, it is incumbent upon parents and educators
to minimize the unintended negative effects on the overall well-being of the child.
Additional Resources:
NYASP Resources for Families - http://www.nyasp.org/forfamilies/

Scholastic.com - search for “high stakes testing” in the “parent” section for ideas,
resources, and printable material, www.scholastics.com
August 2013
High Stakes Testing & Children’s Well-Being:

A Guide for Teachers
As the pressures and demands of “high stakes” testing and assessment
increase, so too do the worries of teachers. Aside from concerns regarding a child’s
academic progress and performance on these measures, and how scores are tied to
teacher evaluation, teachers are also worried about the emotional toll and overall impact
these experiences have on their students’ well-being. With this in mind, the New York
Association of School Psychologists has created the following list of suggestions to help
teachers.
Handling Stress Before, During, & After the Assessment:
 Recommend that the students get enough sleep the night before and have
breakfast the morning of the test. This could be their only “homework
assignment.”
 Consider having a “bagel breakfast” the morning of the test to lighten the
mood in class, but also to ensure that the children have had some nutrition.
Local bagel shops/bakeries will often donate items for these events.
 Keep to the normal routine as much as possible, but build in plenty of physical
movement, self-directed time, or socialization
o Give students a chance to unwind after taking the test
 Tell the students what to expect the day of the test, even if they have taken it
before. You can say things like, “When you come in tomorrow, your desks will
be in rows and not in our usual groups.” Or “Mr. Smith will be here tomorrow
to help us with the test.”
 Have extra supplies available if the students are supposed to bring their own
materials. Testing days are not the time for lessons in personal responsibility
or materials management
 Help your students keep the testing in perspective. You can say things like:
“Sure, the test are important and you need to do the best that you can, but
remember tests aren’t the only things that matter and they aren’t the things
that are the most important”
 Select class read alouds that tell stories about testing for younger students
(e.g., The Big Test by Julie Danneburg or Testing Miss Malarkey by Judy
Fincher and Kevin O’Malley). For older students hold brief class meetings,
that give students a chance to speak about their feelings if they wish. By
August 2013
simply acknowledging that the stress is out there, helps to reduce the
pressures that some students feel.
 Point out previous student successes
 Remind the students that they are well prepared for the test and are likely to
do well on the test
 Acknowledge that the test may contain questions that are meant to be
challenging; if they are struggling with an item, it is probably because it is a
hard question, not because there is something that is wrong with them
 Never add pressure to the students by telling them that “your job depends on
their scores”
 Monitor your own anxiety; kids quickly pick up on the anxieties of the
important adults in their lives
 Throughout the year, teach specific relaxation and stress management
strategies, not just to minimize anxiety around the tests, but as a general life
skill. Strategies could include:
o Deep, slow, controlled breathing
o Mindfulness exercises
o Progressive muscle relaxation or simple Yoga poses
o Listening to relaxing music
o Share a time when you were anxious and how you managed those
feelings
o Empower your class by asking what things might help them relax - this
sends the message that there are concrete things they can do to
manage stress and anxiety, which are normal parts of the human
experience
 Utilize the services of the school employed mental health professionals
(school psychologists, counselors, social workers) to consult with you on
classroom-based strategies or actually come into your class to talk about test
anxiety and stress management
Understanding and Learning from Challenging Experiences:
Research on motivation (Dweck, 2006) has found that how a person responds to
academic challenges, not grades or intellectual ability, is one of the best predictors of
later success. A child can view a failure or a challenging experience as a reflection of
either their lack of ability, or as a reflection of the strategies and effort that were used
during this experience. Those with the latter view tend to perceive these challenges as
something to “master” or have a “mastery orientation.” They tend to face the next
challenge with greater determination, a more positive outlook, and ultimately experience
greater learning and success. They will seek out more challenges in learning and in life
and tend to be willing to stretch themselves beyond where they are comfortable.
Because of this approach, in the end, they achieve more. Teachers should understand
this and explain it to their students. Ultimately, we may find that it is how the student
understands his or her success or difficulty that is the best predictor of his or her future
success.
August 2013
Students who are mastery-oriented think about learning, not about proving how
smart they are. When they experience a setback, they focus on effort and strategies
instead of worrying that they are incompetent. This leads directly to what teachers can
do to help students become more mastery-oriented: Teachers should focus on students'
efforts and not on their abilities. When students succeed, teachers should praise their
efforts or their strategies, not their intelligence. Contrary to popular opinion, praising
intelligence backfires by making students overly concerned with how smart they are and
overly vulnerable to failure. When students fail, teachers should also give feedback
about effort or strategies -- what the student did wrong and what he or she could do
now. This has been shown to be a key ingredient in creating mastery-oriented students.
In other words, teachers should help students value effort.
In a related vein, teachers should teach students to relish a challenge. Rather

than praising students for doing well on easy tasks, they should convey the joy of
confronting a challenge and of struggling to find strategies that work. Finally, teachers
can help students focus on and value learning. Too many students are hung up on
grades and on proving their worth through grades. Grades are important, but learning is
more important.
There are certain vulnerable groups of children, who are more easily emotionally
impacted by high stakes testing. These may include students with learning difficulties or
English Language Learners, who tend to have a negative perception of tests in general.
However, even students at the opposite end of the education spectrum, to whom good
grades, high achievement, and academic accomplishment have come relatively easy,
are vulnerable to test anxiety. While at first, this may seem counter-intuitive, upon closer
analysis, it quickly becomes clear that their anxiety is a result of their own perception of
the test determining their academic status or their “demand” to perform well on all tests.
For all of these children, it is important to remind them:
 Ability and knowledge is demonstrated in many ways, not just through

standardized testing – providing example of the many ways they have
been successful and have demonstrated their talents
 Their worth is greater than the sum of their achievement. They are loved
for who they are, and not for what they achieve
 The value in some activities is not in the outcome, but in initiating the task
and knowing that your gave it your all
In this new era of reliance on data and ever increasing levels of accountability,
standardized testing will not go away. Furthermore, when used correctly, as part of
(rather than the sum of) a child’s educational experience they can provide useful
information to educators. With this in mind, it is incumbent upon parents and educators
to minimize the unintended negative effects on the overall well-being of the child.
Additional Resources:
Reducing Test Anxiety To
Increase Academic Performance
Peter Faustino & Tom Kulaga

When an elementary
school teacher heard
we were doing a
presentation on test
anxiety, she ran to
her classroom and
returned with a book.
We’d like to start off

with her suggested
reading.
This book is great…
Really, we didn’t
make it up. It’s a real
book.
Note the attention to

test security pictured
here.
… and here.
Also note the

expressions on the
children’s faces.
Do they seem a bit

anxious?
In the
classroom we
see the usually
nice Miss
Malarkey
acting a little
weird while
talking to her
class about …
THE TEST
This boy, who
is playing a
video game,
explains (to a
parent) that
“Miss Malarkey
said THE TEST
wasn’t that
important.”
A student
reminds the
teacher, “Miss
Malarkey, you
shouldn’t bite
your nails.”
This student
reports playing
Multiplication
Mambo and
Funny Phonics
at recess. He
quotes his
teacher, “You
never know
what’s going to
be on THE
TEST.”
We’re not
sure exactly
what’s going
on here.
Maybe Miss
Malarkey is
supposed to
be teaching
to THE TEST.
TEST DAY
approaches
and things get
weirder and
weirder.
Principal
Wiggins is
yelling about
pencils.
“I want the
good No. 2
pencils. Not
the kind with
the crumbly
erasers…”
The
cafeteria
lady, Mrs.
Slopdown,
took away
the potato
chips and
served only
fish.
In art class,
students
make
posters
about THE
TEST and
are shown
how to color
in little
circles.
In gym, Mr.
Fittanuff
explains to
students that
they have to
prepare their
minds and
bodies for
THE TEST.
“When mom
read me my
bedtime story, I
had to
complete a ditto
and give the
main idea
before I could
go to sleep.”
Dr. Scoreswell
answers
questions at the
PTA meeting.
“How will the

test scores
affect real estate
prices?”
TEST DAY
More teachers
than kids were
waiting for the
nurse.
Principal
Wiggins
waves the
flag to start
THE TEST.
Something
happens to
his hair.
Morgan got a
stomachache
and when
Miss
Malarkey
said to erase
all your
pencil marks,
Janet erased
her whole
test.
After THE
TEST
everybody
got prizes
and extra
recess.
The
teachers
were
happy.
WHAT IS ANXIETY?
•  Anxiety is a very complex human reaction that
has both physical and mental elements to it. The
physical elements include things such as sweaty
palms, accelerated heartbeat, and a queasy
stomach.
•  The mental elements include self-doubts and
constant worry about things. To control your test
anxiety you will need to deal with both of these
elements.
WHAT IS ANXIETY?
•  One way to define anxiety is to say that it
is a fear-like arousal, when the situation
really isn't that threatening.
•  Granted, a test can be threatening to your
grade point average, but it is not a
physical threat and doesn't warrant a full-
blown physical reaction.
WHAT IS TEST ANXIETY
& HOW DID I GET IT?
•  Have you ever had any of the following types of
reactions?
•  "I felt I was ready for the test, but when it started
my mind just went blank."
•  "Before the test started I felt sick. I just wanted to

get out of there."
WHAT IS TEST ANXIETY
& HOW DID I GET IT?
•  "I kept thinking to myself what would happen if I
did poorly on this test, I just knew it would be
awful because I was going to fail again."
•  "I thought I did just fine, but when the grade

came back it was a 'D', I don't know what
happened."
•  "I am always feeling under pressure, my life is

just too hectic."
WHY DO I FEEL THIS WAY?
•  Sympathetic. (The part that gets us
"pumped up")
•  Our heart starts to beat rapidly, and blood

pressure increases.
•  The blood goes to our muscles and less to
the thinking part of our brain (which is why
we go blank when nervous).
•  Digestion is slowed down.
•  Breathing rate increases.
•  Blood sugar is released to give us energy
(also depleting energy reserves).
•  The rate of perspiration increases (you
sweat!).
•  Adrenalin is released in the body giving an
overall excited effect.
•  Parasympathetic. (the part that calms you
down)
•  Breathing is slowed down.

•  Digestive processes increase.
•  Heart rate slows down and blood pressure
decreases.
•  Perspiration returns to normal.
IS A LITTLE ANXIETY GOOD?
There is a myth that all anxiety is bad, but a little
bit of sympathetic arousal might be good for
times when you have to take a test because it
will get you "up" for the test and make you more
alert.
IS A LITTLE ANXIETY GOOD?
However, too much of this type of reaction will
make it hard to concentrate. One explanation is
that all the body's energy is being focused into
the large muscle groups and the brain-stem
(which controls the automatic functions of your
body), and not enough is being brought to the
cerebral cortex which is responsible for thinking.
This explains why you go "blank" when you are
real nervous, then everything comes back to you
when you relax later.
What are the effects?
WHAT IS ANXIETY?
•  Attitudes and beliefs help determine how we
react. One way we look at these attitudes and
beliefs is through what is called, self-talk. Self-
talk is literally what we say to ourselves. The
following are examples of self-statements that
students may be making:
•  "Boy that assignment sounds like fun, I will learn

something new."
WHAT IS ANXIETY?
•  "Give me a break, he knows we won't have time
to do all that."
•  "That is my worst area, what will I do? I'm sure I

can't get that done."
•  "Well, I guess that is what I expected."

The Five Causes Of Test Anxiety
•  Unfamiliarity.
•  Preparation.
•  General Lifestyle.
•  Conditioned Anxiety.
•  Irrational Thinking.
Twelve Myths Of Test Anxiety
•  Students are born with test anxiety.
•  Test anxiety is a mental illness.
•  Test anxiety cannot be reduced.
•  Any level of test anxiety is bad.
•  All students who are not prepared have test
anxiety.
•  Students with test anxiety cannot learn math.
•  Doing nothing about test anxiety will make it
go away.
Twelve Myths Of Test Anxiety
•  Students who are well prepared will not have
test anxiety.
•  Very intelligent students and students taking
high level courses, such as calculus, do not
have test anxiety.
•  Attending class and doing all my homework
should reduce all of my test anxiety.
•  Being told to relax during a test will make you
relaxed.
•  Reducing test anxiety will guarantee better
grades.
How To Reduce Test Anxiety
RELAXATION
TECHNIQUES
THE TENSING AND THE

DIFFERENTIAL DEEP
PALMING
RELAXATION BREATHING
METHOD METHOD
The Tensing And Differential
Relaxation Method
1.  Put your feet flat on the floor.

2. With your hands, grab underneath the chair.
3. Push down with your feet and pull up on your
chair at the same time for about five
seconds.
The Tensing And Differential
Relaxation Method
4. Relax for five to ten seconds.

5. Repeat the procedure two or three times.
6. Relax all your muscles except for the ones
that are actually used to take the test.
The Palming Method
1. Close and cover your eyes using the center of
the palms of your hands.
2. Prevent your hands from touching your eyes

by resting the lower parts of your palms on your
cheekbones and placing your fingers on your
forehead. Your eyeballs must not be touched,
rubbed or handled in any way.
The Palming Method
3. Think of some real or imaginary relaxing

scene. Mentally visualize this scene. Picture the
scene as if you were actually there, looking
through your own eyes.
4. Visualize this relaxing scene for one to two

minutes.
Deep Breathing
1.  Sit straight up in your chair in a good

posture position.
2.  Slowly inhale through your nose.
3.  As you inhale, first fill the lower section
of your lungs and work your way up to
the upper part of your lungs.
Deep Breathing
4.  Hold your breath for a few seconds.

5.  Exhale slowly through your mouth.
6.  Wait a few seconds and repeat the cycle.
Long- Term Relaxation Techniques
Learning long-term relaxation techniques can be

helpful in conquering test anxiety permanently.
After sufficient practice of such techniques you

can induce your own relaxation.
Long- Term Relaxation Techniques
•  The best long-term relaxation technique is cue-

controlled relaxation response. This form of
relaxation involves the repetition of cue words,
such as: “I am relaxed,” “I can get through
this,” or “Tests don’t scare me.”
•  It is essential to avoid use of negative cue words

or self-talk and to concentrate on more positive
phrases.
Discussion
What relaxation technique do you use?
What works at different ages/grades?

RATIONAL THINKING
Albert Ellis discovered that many of his patients

said things to themselves that contributed to
their problems.
It was their irrational beliefs (beliefs not based on

the facts or reality) that were contributing to
strong emotional reactions and negative
behaviors.
RATIONAL THINKING
By helping his patients think in a more rational
(based on the facts) manner, many of their
problems were eliminated or reduced.
From this experience he built a very simple

explanation of this mental and emotional
sequence, and called it his A-B-C method:
RATIONAL THINKING
•  A - Activating Event. Something that triggers the
whole sequence. It could be something inside
our minds or bodies, or it could be in our
environment.
•  B - Belief. These are the thoughts we have

regarding the activating event.
•  C - Consequences. This is what happens as a

result of A and B.
RATIONAL THINKING
An example of a sequence of thinking follows:
•  A - Activating Event. While taking a difficult test a

student begins to feel physically tense.
•  B - Belief. When I feel this way I always get into

trouble, and I can't stop it.
•  C - Consequences. The student gets a full blown

anxiety attack and goes completely blank.
CHANGING IRRATIONAL
BELIEFS
•  Negative self-talk (cognitive anxiety) is defined
as the negative statements you tell yourself
before and during tests.
•  These statements cause students to lose

confidence and give up on tests.
•  Positive self-talk can build confidence and

decrease test anxiety.
CHANGING IRRATIONAL
BELIEFS
Changing negative into positive self-talk:
Neg: “No matter what I do, I will not pass
this test.” to Pos: “I studied all of the
material, I will do great on this test.”
Neg: “I am no good at math, so why

should I try?” to Pos: “I’ve worked hard
and I will try my best on this test.”
Thought-Stopping Techniques
•  Some students have difficulty stopping

their negative self-talk.
•  In order to prevent these negative

thoughts from causing anxiety students
should practice silent shout.
•  Silent shout is a thought-stopping
technique.
•  Silently shouting to yourself “Stop!” or

“Stop thinking about that,” interrupts the
worry response before it can cause high
anxiety.
•  After you eliminate the negative thoughts
immediately replace them with positive
self-talk or relaxation.
•  This will enable the student to think more

clearly and concentrate more on the test.
The Test Monster
The Test Monster is a fun activity that help
younger children get rid of test anxiety.
Children may be given an outline print of a

monster and instructed to draw facial features as
well as thoughts associated with test anxiety.
The Test Monster
Once the details of the monster are

completed, students can crumple up the
drawing and secure it in a box,
symbolizing the elimination of anxiety.
Discussion
What cognitive restructuring technique do

you use?

MANAGING THE TEST
SITUATION
There are no magic tricks to reducing the anxiety

in the middle of a test, because what works for
one person may not work for another person.
Below are some things that you might try.

MANAGING THE TEST
SITUATION
1. Plan to Use the Entire Time.

2. Stop, Pause, and Relax.
3. Start Skipping Around.
4. Ask for a Change of Location.
5. Do Something.
Discussion
What study technique do you use?

Coping Strategies - A Review
•  The coping strategies approach assumes that
you cannot totally eliminate all the anxiety in a
testing situation, you have to accept it as a
normal part of life.
•  By anticipating the anxiety and planning what

you are going to do, you will keep it at a
manageable level.
Physical Relaxation
Positive Self-Talk
Managing the Test Situation
It is not easy to change how you think overnight,
it has taken you quite a few years to establish
the patterns that you have and habits are hard to
break.
But by attacking and challenging a few of the

negative thoughts that you have, you begin the
process of change.
Thank You
August 2013
NYASP Resources for Educators - http://www.nyasp.org/foreducators/

NYASP Resources for Families - http://www.nyasp.org/forfamilies/
NYSED Engage – Information on Common Core Curriculum and Standardized Testing,
http://www.engageny.org/
Scholastic.com - search for “high stakes testing” in the “teacher” section for ideas,
resources, and printable material, www.scholastics.com
Utilizing Video Self-Modeling
and Reattribution Training
to Alleviate Test Anxiety
CALIFORNIA STATE UNIVERSITY,

LONG BEACH
SHAHROKH-REZA SHAHROOZI, B.S.
NASP Convention February 24th, 2011

Acknowledgments
  Thesis Committee:

¡  Brandon Gamble, Ph.D.
¡  Bita Ghafoori, Ph.D.
¡  Simon Kim, Ph.D.
  CSULB
¡  Kristin Powers, Ph.D.
¡  Kristi Hagans, Ph.D.
¡  James Morrison, Ph.D.
¡  Judy McBride, Ph.D.
  Non-Public School Staff

¡  Sabrina Schuck, Ph.D.
¡  Joe Newkirk
¡  Sue Schecter-Keir
  The 4th through 6th grade students who participated.

Abstract
  The present study examined the effectiveness of video self-

modeling of appropriate test-taking strategies and
reattribution training on elementary students at a non-public
school. In a mixed-methods and non-experimental design, pre
and post-treatment quantitative and qualitative data was
collected through a series of interviews, anxiety rating scales,
and two videoed testing sessions.
  It was hypothesized that the participants would report feeling

more positively about their test-taking experience as a result of
the treatment. Post-treatment results suggest that students
who identified themselves as test-anxious felt more at ease and
confident in a testing situation, whereas students who did not
identify tests as anxiety-inducing reported little to no benefit.
Introduction
  Researchers such as Spielberger (1962) and

Hembree (1988) have detailed the effects of test
anxiety on students and how exam performance
can be significantly impaired as a result.
  Current modifications that instructors may

provide include providing “second chances” post-
test, familiarizing students with test format and
grading scheme, and lowering the impact of any
one test (McKeachie & Svinicki, 2005).
What is Test Anxiety?
  Test anxiety is an affliction that in excess impairs our

capacity to think, plan, and perform on tests.
  The current emphasis placed on high-stakes testing

à increased pressure on students to perform
  This pressure may lead to maladaptive behaviors in

any child, especially those with disabilities.
Test Anxiety Theory
  In the early days, theorists defined test anxiety in

motivational terms, believing that it was an
expression of one’s general anxiety in evaluative
situations (Spence & Spence 1966).
  There came a shift to a cognitive approach to the

problem. Test anxious students were thought to be
splitting their time between task relevant and task-
irrelevant thoughts (Wine, 1971).
Test Anxiety Theory Pt. 2
  The 80s brought about the test taking and study skills
paradigm
¡  Students with poor study skills have difficulty encoding classroom
material à fail repeatedly on tests à onset of test anxiety
(Benjamin et.al 1981)
  Self-regulation, self-worth, and transactional process

models dominated the 90s (Carver, Scheier, Covington,
Spielberger & Vagg)
¡  Self regulation: self-defeating thoughtsà task irrelevant behavior
¡  Self worth: doing poorly is a reflection of my incompetency
¡  Transactional: situational anxiety (testing is threatening)
Test Anxiety Model
Engel (1977) & Schwartz (1982)

Statement of the Problem
  Presently, there is limited research on evidence-

based interventions to treat test anxiety, and none of
the currently available studies target self-awareness
skills.
¡  Self awareness on two levels:
1.  Externally with regard to physical symptoms/behaviors
2.  Internally with regard to attributions
  There are many studies documenting the effects of

attribution on academic achievement, but very few
discuss their effects on test anxiety.
Purpose of the Study
  Research Questions:

¡  How do students perceive test anxiety having an effect on
their test performance?
¡  What are students’ existing methods of coping with test
anxiety?
¡  How do students perceive attribution training and video
modeling of test taking skills as having an effect on their
levels of test anxiety?
¡  Is a combined treatment of video self-modeling and
reattribution training effective in reducing test anxiety?
Purpose Pt. 2
  Research Hypotheses:

¡  Students equate their perceptions of self-worth with test
performance, which creates pressure and anxiety
¡  Many existing coping strategies of test anxious students only

serve to exacerbate their symptoms.
¡  Students will gain an insight into their internalizing and

externalizing behaviors as a result of VSM and reattribution
training.
¡  It was hypothesized that the treatment condition would result

in improved test performance and the perception of a decrease
in test anxiety exhibited by subjects.
Recent Studies
•  In the summer of 2007, Laura E. Johnson proposed

a 9-week intensive course of progressive muscle
relaxation and systematic desensitization for
students identified as being test-anxious.
•  She found that this intervention resulted in better

test scores among research participants.
•  She further proposed that PMR and SD be used as a

preventative measure, as opposed to a reactive one.
Rationale for Video Self-Modeling
  Many appropriate test-taking behaviors are implicit.

¡  These are just a few of the test behaviors expected of our
students:
q  Positive thinking/ Self-belief
q  Regulating breathing
q  Working efficiently
q  Focusing on one’s own progress
q  Self-advocacy
q  Clarification
q  Physical Needs
●  Do all kids come with this built-in blueprint?

Benefits of VSM
  Time and cost effective

  Effects tend to generalize
  Skills are maintained
  Videos/clips portable to enhance maintenance
  Documented social validity
  Successfully combined with other interventions
  Targets self-awareness and emotional regulation
Bellini, 2010
Materials Needed for Video Modeling/Editing
 Flip Recorder (or

smartphone)
 Computer
 Television
Definitions
  Self-Observation: Viewing oneself performing at present

levels – good, bad, ugly – e.g. athletes watching game
film.
  Self-Modeling: Allowing people to view themselves

performing a skill or task that is slightly beyond their
present ability. = All positive.
Two Forms of Self-Modeling
1.  Positive Self-Review: Going over and reinforcing

already known skills to improve performance/fluency
2.  Feedforward: Video of skills not yet learned.

Introducing a new skill or behavior.
Dowrick, 1977
Video Self-Modeling Procedures
  Video Modeling Procedures

¡  Picking a target behavior (Before Video)
¡  Picking a target setting
¡  Pre-teaching/Frontloading
¡  Adult models the skill
¡  Child models the skill w/assistance
¡  Video Editing
¡  Priming child with video prior to activity

Why Video Modeling?
Albert Bandura’s modeling research:
  Most effective peers are those closest to attributes and

abilities of observer - including ability (Bandura).
  Self-Efficacy = If you think you can, you are more likely to
succeed
!
Necessary Requisites for Successful Modeling
(Bandura)
1.  Attention
2.  Memory
3.  Imitation/Behavioral Production
Bandura
Attention
  Without attention there will be no learning
  Often times the break down in perspective is from

inattention
Bellini, 2007
Memory
  Remembering what you have done
  Can be facilitated through scheduled viewings of the

video to promote retention of the skill
Bellini, 2007
Imitation and Behavioral Production
  The priorities of video modeling are behavioral

imitation and production.
  The Zone of Proximal Development (ZPD) is what

the child can do autonomously
(Vygotsky, 1978).
  Important to pick behaviors that are within the child’s

skill level.
¡  Increases the child’s feelings of self-efficacy
¡  Increases the likelihood for the behavior to be reproduced
Vygotsky, 1978
An Example of the ZPD at Work
Vince Carter Me
Attribution (Weiner, 1986)
  In general, people can attribute success or failure to

one of four things:
1)  Luck
2)  Ability
3)  Effort
4)  Difficulty
  Internal vs. External Locus of Control

(Rotter, 1954)
Weiner, 1986
Two Types of Student Theorists (Dweck, 1999)
Fixed IQ theorists: Untapped Potential

Theorists:
  These students believe   These students believe
that their ability is that ability and success
fixed, probably at birth, are due to learning,
and there is very little if and learning requires
anything they can do to time and effort. In the
improve it. case of difficulty one
must try harder, try
another approach, or
seek help etc.
What type of student performs best?
  In 1978, Cassandra Whyte found a correlation

between high locus of control and academic success
in students enrolled in higher education courses.
  This suggests the need for parents and educators

alike to foster this belief in their students as early as
possible.
Whyte, 1978
Setting
  The study was originally intended to be conducted

in a public school with students identified as having
demonstrated test or performance anxious behavior.
¡  Approval was denied by the school board due to academic time
to be missed during treatment sessions.
  The study took place in a non-public school

specializing in the treatment of ADHD and related
behavioral and learning disorders.
¡  Treatment was a more seamless process, as it served to
support the therapy and reinforcement systems that were
already in place.
Participants (Males)
  Student #1
¡  12 year old male in the 6th grade
¡  Dx: ADHD and Generalized Anxiety
¡  History of limited academic production , poor writing skills, low self-
esteem, and performance anxiety
  Student #2
¡  Dx: ADHD and sleep disorder
¡  Challenges with low self-esteem and motivation
  Student #3
¡  Dx: ADHD combined/ODD
¡  History of distractibility, low work-productivity, dependence on
assistance
Participants (Female)
  Student #4
¡  12 year old female in the 6th grade
¡  Dx: ADHD and Anxiety Disorder
¡  Difficulties with sustaining attention, completing work, and

regulating mood ( social anxiety)
  Student #5
¡  11 year old female in the 5th grade
¡  Dx: Asperger’s syndrome
¡  History of non-compliance, low-work productivity, and social

anxiety.
Procedures
1.  Teacher consultation

1.  Identifying target students
2.  Matching exam type (math, writing, reading comp, etc.) to the
student
2.  Video Recorded Initial Exam (30 minutes)
3.  Individual Counseling Session (30-45 minutes)
1.  Interviews
2.  Reattribution training
3.  Review of video
4.  Teaching of replacement behaviors
4.  Video Priming ~10 minutes before Final Exam
5.  Video Recorded Final Exam (30 minutes)
6.  Final Counseling Session (30-45 minutes)
Multidimensional Anxiety Scale for Children
(MASC)
  Self-report instrument that assesses the major

dimensions of anxiety in young people aged 8 to 19
years.
  Analyses show high validity and reliability (1996 and

1997)
¡  Test-Retest Reliability Coefficient (0.93)
÷  3 weeks and 3 months
  Pre and post-treatment measures taken

over the course of 3 weeks
John S. March, M.D.

Interview Questions
  15 open-ended questions ranging from:

¡  Test Anxiety
÷  Helpful/Harmful?
÷  Why?
¡  Feelings before, during, and after a test
¡  Current strategies being used?
¡  What could you have done differently?
¡  What could teachers do to help?
¡  What do tests measure?
¡  Describe any sources of pressure.
¡  How video self-modeling impacted their 2nd exam, if at all?
¡  Perceptions of the treatment (pre and post)
Reattribution Training:
Shifting Schemas
Existing Schema Reformed Schema
  I’m just bad at math,   I have the ability, but I
writing, etc. and that need help accessing it.
will never change.   The effort I put into my
  I have no control over work is what I’ll get out
how I do, even if I try. of it
  Tests are trials that are
  If I do poorly on a test,
intended to measure
I’m a bad student. My what we know and what
parents and teachers we need to work on (no
will think I’m stupid. more and no less).
Maladaptiveà Functional Test-Taking Strategies
(VSM)
Maladaptive Strategies Functional Strategies
  Poor body language   Positive body language

¡  Slumped shoulders ¡  Sitting up straight
¡  Staring up at the ceiling ¡  Eyes on your paper
  Verbal and physical   Positive self-talk

expressions of   Controlled breathing
frustration   Moving at your own
  Comparing progress on pace
test to others
Student # 1 (12 year old male, 6th grade)
Notable Comments
  Effects of Test Anxiety:

¡  Positive
÷  It can help you concentrate.
÷  It makes you want to get it done.
¡  Negative
÷  It
can cause you to get fed up with it, and you can't concentrate at all.
Gets you upset.
  What do tests measure?
¡  They measure your IQ…what you’re capable of.
  Pressures?
¡  When I first hear that I'm going to take a test I feel pressure. The
second I hear that I jump into mental panic mode.
¡  I think about how the teacher will think about me depending on how
good or bad I do.
Student #1
Notable Comments Pt. 2
  Things teachers can do?

¡  I would like them to kind of walk me through it (frontloading)
¡  I want them to motivate me somehow
÷  Give me some kind of goal to shoot for
  Thoughts about Reattribution:
¡  My feelings definitely changed about tests for sure, because I never
really thought about it like that.
  Thoughts about VSM:
¡  I thought it definitely helped. I knew what to expect. Like I learned
not to get frustrated when someone else finishes before me.
  Overall thoughts:
¡  I think it helped, and in the classroom I had to do another test later
in the day, and I referred back to this and I think it helped.
Student #5 (11 year old female, 5th grade)
Notable Comments
  Effects of Test Anxiety:

¡  Positive
÷  It gets you going
¡  Negative
÷  You start getting all worried and it's like oh my gosh, time is running out, oh
no.
  Thoughts about Reattribution:
¡  I just thought that “that’s cool.” It don’t think it changed anything, but
it was something I hadn’t thought of before.
  Thoughts about VSM:
¡  It felt kind of good to see me being good at taking tests, but I was pretty
good before.
  Overall thoughts:
¡  It made me think about some new things, but nothing really changed,
although it definitely didn’t hurt!
Results Pt.1 (Rating Scale Data)
Student # MASC Overall MASC Overall Performance Performance

(Pre) (Post) Scale (Pre) Scale (Post)
1 T=52 T=49 Raw=5 Raw=3
2 T=33 T=32 Raw=2 Raw=0
3 T=45 T=45 Raw=2 Raw=0
4 T=37 T=48 Raw=4 Raw=6
5 T=27 T=26 Raw=0 Raw=0
• Paired samples t-test (MASC Overall)
• t = 0.4804 df = 4 P=0.650
• standard error of difference = 2.498
• Difference was not statistically significant
• Paired samples t-test (Performance Scale)

•  t = 1.0000 df = 4 P=0.3739
• standard error of difference = 0.800
• Difference was not statistically significant
Results Pt.2 (Interview Questions)
  The research yielded several salient patterns:

¡  Students place lots of value on exam performance.
÷  Parental,teacher, and self-satisfaction
÷  Some feel it is a measure of their intellectual standing in the class
¡  They also seemed aware of their behaviors, but saw them in a
different light when shown the video.
÷  They
consciously tried to change their behavior in the 2nd
examination.
¡  They regarded test anxiety as negatively impacting their test
performance.
÷  Moststudents agreed that a little bit of anxiety helped spur them
into action, but after a certain point it would be to their detriment.
Limitations/Areas for Future Development
  Non-experimental design

  Very small sample size (3 males, 2 females)
  Only anecdotal teacher feedback, though generally positive
  Non-typical school setting
¡  Highly reinforcing behavioral program
¡  Small class sizes (~ 15 students in a class)
¡  Non-typical population (students without disabilities?)
  MASC is not very sensitive to change in the specific area of
test anxiety
¡  More targeted scales are being developed (TAICA, WTAS)
  Retention of learned skills?
  Vital to look at the impact of test anxiety on ethnic minorities
and English Language Learners.
¡  Stereotype threat?
Implications
  Parents and school staff alike need to be very

mindful of the impact of test anxiety on their
students.
¡  Important to push our students (facilitating anxiety), but they
should not be made to feel that test performance is a measure
of their self-worth (debilitating).
  The current push with high stakes testing (e.g.: CST,
GATE, CAHSEE) is inevitably going to rouse
tensions in certain students.
¡  Highlights the importance of a preventative curriculum to
address student concerns
Proposed Test Anxiety Treatment
Model Under RTI
Intensive:
•  Video Self-Modeling of Test Taking Skills
•  Individual Counseling
• Reattribution Training
• Continued progress monitoring
Targeted:
• Students identified as being test
anxious
Tier 3 • Group Counseling/Talk Therapy
Tier • Progress monitoring to note positive
2 or negative change
Tier 1
Universal:
• Universal Screening (TAI,
WTAS, TAICA)
• Preventative curriculum
addressing test-taking skills
• Environmental modifications
The Role of the School Psychologist
Triad of School Mental Health
Academic Behavioral
Performance Output
Social/Emotional
Health
Are we responsible for all 3 elements?
Shahroozi, 2011
Advocacy Groups and More Information…
  www.gotanxiety.org. A website directed towards college students and the

unique anxieties they experience, developed by the Anxiety Disorders
Association of America.
  www.adaa.org. The official website of the Anxiety Disorders Association
America (ADAA), the leading non-profit organization whose mission is to
promote the prevention, treatment and cure of anxiety disorders and to
improve the lives of all people who suffer from them.
  http://kidshealth.org/teen/school_jobs/school/test_anxiety.html. A website
dedicated to improving the health and spirit of children and teens, developed by
the Nemours Foundation.
  www.dartmouth.edu/~acskills/success/stress.html. A website for the Academic
Skills Center at Dartmouth College that focuses on test anxiety.
  My contact info:
¡  Reza Shahroozi
¡  sshahroo@student.csulb.edu
Questions
IF YOU SEE OTHER THAN TWO
DOLPHINS IT’S TIME FOR A BREAK

Testing Anxiety Toolkit

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2. Anxiety And Anxiety Disorders In Children: Information For Parents

6. Test and Performance Anxiety

28. Anxiety: Tips For Teens

Anxiety and Development

S5–2 Anxiety and Anxiety Disorders in Children: Information for Parents

Cognitive Behavioral Physical

• Concentration difficulties • Shyness • Trembling or shaking

S5–4 Anxiety and Anxiety Disorders in Children: Information for Parents

September 2009 z Principal Leadership z 13

14 z Principal Leadership z Se pt e m be r 2009

September 2009 z Principal Leadership z 15

16 z Principal Leadership z Se pt e m be r 2009

Why Treat Anxiety in School Settings

Assessing and Treating Anxiety in School Settings

Assessing Anxiety in Students

Table 1. Omnibus and Narrow Measures of Childhood Anxiety

Treating Anxiety in School Settings

Conners, C. K. (2009). Conners: Manual. North Tonawanda, NY: Multi-Health Systems.

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Prevalence Costs & Consequences

Anxiety In The Schools The Importance of Early Intervention

Bernstein, Aldridge, & May (2013) 1

Indicated Assessment Few Indicated Prevention

• Overwhelming sense of • Difficulty concentrating

fear that can be • Hypervigilance

• Bryan, 11th grader

CBT: Overview CBT: Empirical Support

Kendall, Aschenbrand, & Hudson (2003); Mennuti & Christner (2012)

Bernstein, Aldridge, & May (2013) 2

CBT in the Schools: Empirical Support CBT: Theoretical Underpinnings

CBT: Theoretical Underpinnings

The “C” in CBT: What do we mean by

• Cognitive processes • Psychopathology (such as anxiety) may be due to

Bernstein, Aldridge, & May (2013) 3

Cognitive Distortions vs. Deficiencies The “B” in CBT: Changing Behavior

CBT: Primary Components Features of CBT

Bernstein, Aldridge, & May (2013) 4

Psychoeducation: Teaching about Anxiety Developing a Fear Hierarchy

Fear Hierarchy Example

7 = staying in class ½ day (allowed to call home)

Examples of Cognitive Distortions In

Bernstein, Aldridge, & May (2013) 5

CBT: Building a Cognitive Coping Template Teaching Children To Problem-Solve

Coping Modeling The Steps of Cognitive Restructuring

Thought Bubbles Activity: What are they thinking?

• Thought bubbles activity (see the following slide)

Bernstein, Aldridge, & May (2013) 6

Using a Thought Record

: Bryan’s anxiety about calling a

Exposure Exposure: Evidence Base

Bernstein, Aldridge, & May (2013) 7

Challenges with Exposure What should you do during exposure?

Relaxation Training Relaxation Training

Exposure + Relaxation = “I can do

Bernstein, Aldridge, & May (2013) 8

The Importance of the Therapeutic

What about Parents? What Does CBT Look Like in Practice?

A Typical CBT Session CBT: Challenges in School-Based

Bernstein, Aldridge, & May (2013) 9

CBT: Challenges in School-Based Maintaining Treatment Integrity &

: How could we craft an in vivo exposure

Mychailyszyn, et al. (2011)

Outcome Evaluation CBT Applications at Multiple Tiers

•  "Before the test started I felt sick. I just wanted to

•  "I thought I did just fine, but when the grade

•  "I am always feeling under pressure, my life is

•  Our heart starts to beat rapidly, and blood

•  Breathing is slowed down.

•  "Boy that assignment sounds like fun, I will learn

•  "That is my worst area, what will I do? I'm sure I

•  "Well, I guess that is what I expected."

1.  Put your feet flat on the floor.

1.  Sit straight up in your chair in a good

4.  Hold your breath for a few seconds.

•  The best long-term relaxation technique is cue-

•  It is essential to avoid use of negative cue words

•  B - Belief. These are the thoughts we have

•  C - Consequences. This is what happens as a

•  A - Activating Event. While taking a difficult test a

•  B - Belief. When I feel this way I always get into

•  C - Consequences. The student gets a full blown

•  These statements cause students to lose

•  Positive self-talk can build confidence and

•  Some students have difficulty stopping

•  In order to prevent these negative

•  Silently shouting to yourself “Stop!” or

•  This will enable the student to think more