Students Diagnosed with Anxiety Disorder: A Counselors Views - Essay Example

 Anxiety Disorder: Approach to a Student who has been Diagnosed with Anxiety Disorder: A Counselor’s Views Introduction Anxiety disorders are one of the most prevalent categories of psychopathology in the school children. These disorders are common, especially in school going children with the 3-month estimates ranging between 2.2% to 8.6%. However, the 6-month estimates range from 5.5 to 17.7% (Costello et al., 2005). Although the prevalence rates are less in comparison to those of adolescents and adults, frequently counselors in the school end up getting such patients in the school, and therefore an understanding of the clinical issues related to the presentation and treatment of these disorders becomes important. In this assignment, evidence from current research in this field will be sought in order to explore the subject from the perspective of a middle school counselor based on the following focus areas. Focus Areas of Study A. Descriptions of behaviors or warning signs and risk factors B. Model approaches to prevention or treatment C. TWO detailed strategies for intervention or action plans, appropriate for use with teachers, students, parents, administrators, or siblings. A. Descriptions of behaviors or warning signs and risk factors Anxiety is the experience of fear which has overtaken the sense of `objective' danger. In more recent models, anxiety is understood to arise when the individual has certain beliefs about the dangerousness of situations which hold important individual meaning for that person. Once situations, events, sensations and mental events are seen as dangerous, a complex web of emotions, actions, physiological reactions and thoughts is formed. The central theme of anxiety problems, in contrast to other difficulties, is that anxiety is based on anticipating problems in the future. The theme is that of impending threat and danger. Anxiety is a combination of different elements, cognition, emotion, biology, behaviour and environment, which are linked and trigger one another off (Beck & Averill, 2004). Beck and Averill (2004) comment anxiety is itself an emotion and is strongly related to other emotions. Anxiety can result from other emotions, such as low mood or depression, and can produce many other emotions. Worry is perhaps one of the most characteristic features of anxiety. Given the paucity of research on childhood worry, the current state of knowledge should be considered formative and incomplete. Because of this, researchers on child anxiety have begun a strong and methodologically rigorous journey toward a thorough understanding of childhood worry and anxiety disorders more generally (Beck & Averill, 2004). As indicated about the classification by Last et al. (1996) Anxiety disorders are among the most common mental health conditions affecting youths and include generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), separation anxiety disorder (SAD), selective mutism, specific phobia, and social anxiety disorder (SoAD). Epidemiological studies estimate the prevalence of impairing anxiety disorders at greater than 10%, with four of five large surveys estimating prevalence to be 12% to 20% (Last et al., 1996). Generalized Anxiety Disorder GAD can be perceived as a shared and intrinsic human response that can universally be experienced during times of stress as a threat or challenge. Therefore, assessment and diagnosis of GAD needs to focus on the magnitude, that is, intensity, pervasiveness, and persistence of the worry and anxiety reported. Masi et al (2004) while studying this disease in the referred children comments that at the heart of GAD is excessive anxiety and worry which is known as “apprehensive expectation”, lasting for at least 6 months, occurring more days than not, about a number of events and activities in work, school, and performance. In addition, three of six symptoms need to be present, restlessness, easy fatigability poor concentration, muscle tension, and sleep disturbance to make the diagnosis. The disorder causes significant distress or impairment in functioning. In case of the youth attending school, there is some notable difference that needs to be considered when the diagnosis is made in the adolescent and children. For example, for diagnosing GAD, only one criterion is enough for a diagnosis in them (Masi et al., 2004). Children with GAD are not merely worrying about an upcoming test, for example, but about their personal future, health, performance, and safety and the future, health, performance, and safety of others. A recent study (Masi et al., 2004) of children referred for treatment to an anxiety clinic demonstrated health, school, disasters, and personal harm to be the main domains of worry. Hudson et al. (2005) indicates that the worry is present more days than not, is difficult to control, and is enduring. Additionally, physiological symptoms, such as, restlessness, fatigue, muscle tension, sleep disturbance and cognitive symptoms, such as, irritability and concentration difficulties may accompany the worry. Somatic complaints, such as, muscle tension, stomachaches, and headaches are common. Children with GAD are frequently perfectionistic. They show cognitive distortions in which they believe a small error to be a sign of complete failure. If the task cannot be completed perfectly, it will not be completed at all. It is not uncommon for children with GAD to abandon or avoid activities if they perceive that their performance may fall shy of perfection. In this vein, children with GAD can be excessively self-critical. Additionally, children with GAD may require frequent and excessive reassurances and frequently have marked self-consciousness (Hudson, Deveney, and Taylor, 2005). Childhood anxiety disorders are, as reviewed by Hoge et al. (2004) associated with significant impairment and interfere with school performance, family functioning, and social functioning. They can be as impairing in many ways as disruptive behavior disorders. Moreover, anxiety in childhood predicts adult anxiety disorders, major depression, suicide attempts, and psychiatric hospitalization. Retrospective and prospective studies confirm that anxiety disorders have an early onset and a chronic and fluctuating course through adolescence and into adulthood. Research has identified several risk factors for anxiety disorder, including attachment style, child temperament, parental anxiety, and certain parenting characteristics (Hoge, Oppenheimer, and Simon, 2004). Separation Anxiety Disorder The key feature of separation anxiety disorder (SAD) is excessive anxiety about separation from primary attachment figures such as parents, grandparents. Children with SAD fear that harm will come to themselves or their attachment figures when separated. Other symptoms include distress at the time of separation, somatic complaints when separation occurs or is anticipated, nightmares with themes of separation, shadowing parents in the home, and sleeping with family members. As indicated by Lewinsohn et al. (2008) children with SAD commonly refuse to attend school and are reluctant to go other places without their parents. To be diagnosed with SAD, symptoms must be more intense than expected for the child’s developmental level, be present for at least 4 weeks, have an onset before 18 years of age, and cause significant distress or impairment. A distinguishing feature of SAD is that the child’s anxiety is alleviated when with parents, whereas in other anxiety disorders, the presence of an attachment figure has minimal effect on symptom presentation. In the middle school age group, the prevalence of SAD is 3 to 5%. Children who met full diagnostic criteria for SAD compared with those with subclinical or nonclinical status were more likely to have comorbid disorders and high levels of internalizing symptoms. In addition, parents of children with clinical SAD experienced high levels of internalizing symptoms and general distress (Lewinsohn et al., 2008). As indicated by Masi et al. (2001) the range of emotional, cognitive, somatic, and behavioral symptoms associated with the fear or threat of separation from an attachment figure cripples the child’s enjoyment of life, his or her social and family relationships, and abilities to participate and progress in school and recreational and creative activities. From attachment theory, when infants’ proximity to their caretakers is inadequate such as with separation, an intense affective response is produced, which is termed as separation distress or anxiety. Normal separation distress usually intensifies during early childhood, then gradually subsides at 3 to 5 years of age. It has been known that when children’s separation anxieties persist beyond the developmentally appropriate years, and if the anxieties cause significant distress or impairment in social, academic, family, or other important areas of youths’ functioning, a specific psychological maladjustment as characterized by the diagnosis of SAD may be warranted (Masi, Mucci, and Millepiedi, 2001). Social Phobia Bogels and Zigterman (2000) in their study discuss that the primary characteristic of social phobia (SP) is the same across all ages. Individuals with SP experience fear regarding social and performance situations because of anxiety that they will act in an embarrassing way. Children with SP often have poor social skills and have difficulty initiating and maintaining interpersonal relationships. As expected, children must have the ability to develop age-appropriate friendship. In such situations, there is a problem in ability to make friendship with other children. When socially phobic, they demonstrate anxiety through crying, tantrums, freezing, or shrinking from social situations. SP also seems to have an impact on children’s functioning in the classroom. Higher SP symptoms in children of 10–12 years of age were shown to be associated with poorer general classroom functioning, increased difficulty with peer relationships, and lower self-esteem. Several factors and SP characteristics were found to be associated with an increased risk for subsequent depression. The contributing factors were parental anxiety or major depression, female gender, childhood behavioral inhibition, and having more than two other anxiety disorders. The contributing SP characteristics were increased level of impairment, persistence of symptoms, and greater degree of severity. In addition to the high rate of depressive disorders found in individuals diagnosed with SP, there is also a high rate of comorbidity of SP and substance use disorders. Because of the high comorbidity rates of subsequent depressive and substance dependence disorders, SP places youth at risk for long-term problems across domains of education, social relationships, and employment (Bogels and Zigterman, 2000). Obsessive Compulsive Disorder Stewart et al. (2007) mentions the prevalence of OCD in children and adolescents ranges from 1% to 4%. Common comorbid conditions are tic disorders, other anxiety disorders, ADHD, pervasive developmental disorder, and depression. Almost all children and adolescents with OCD have both obsessions and compulsions. One study showed that 93% of children with OCD experience multiple obsessions and 100% engage in multiple compulsions. In a series of 70 consecutive cases of early onset OCD, the most common obsessions were concern about dirt or germs, danger to self or family, and symmetry; the most common compulsions were excessive washing, repeating rituals, and checking behaviors. Children with OCD present with a variety of obsessions and compulsions. Four factors were identified as strongly associated with the presentation of pediatric OCD and accounted for 60% of the symptom variance, preoccupation with contamination /cleaning /aggressive/somatic, symmetry/ ordering/ repeating /checking, sexual/ religious themes, and hoarding. There is evidence that suggests a similar four-factor structure is applicable across the lifespan. A dimensional approach is useful in understanding the heterogeneity in OCD (Sukhodolsky et al., 2005). Post-traumatic Stress Disorder Carrion and colleagues (2002) assessed the frequency and intensity of PTSD symptoms in children ranging from 7 to 14 years of age. The most frequent symptoms included: 83% engaged in avoidance of thoughts, feelings, and conversations associated with the trauma; 70% had distressing recollections and the inability to recall important aspects of the traumatic event; and 64% reported problems concentrating. Children rated irritability and anger, distressing dreams, and detachment from others as the most intense symptoms. Clinical presentation of PTSD in young children tends to be markedly different than that in older children and adolescents. Young children are less likely to demonstrate emotional numbing and avoidance, which is likely because of the complicated cognitive introspection that is required. Young children are more likely to exhibit overt aggression, destructive behavior, and repetitive play about the traumatic event. Parental psychopathology and family conflict significantly increase the risk of youth experiencing a traumatic event. Other risk factors include history of poor social support and adverse life events, parental poverty, history of childhood maltreatment, poor family functioning, family history of psychiatric disorders, introversion or extreme behavioral inhibition, female gender, younger age, poor health, and history of psychiatric disorder (Carrion et al., 2002). B. Model approaches to prevention or treatment Children and adolescents are not ‘‘little adults’’ and thus require a developmental approach to psychotherapy and modification of the treatment. Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are two types of psychotherapy used in the treatment of children and adolescents. Discussed in Weersing and Brent (2006) CBT is a psychotherapeutic model that posits that individuals with, for example mood and anxiety disorders, have cognitive distortions and behavioral deficits that can be targeted for change in therapy resulting in improvements in emotional, cognitive, and behavioral functioning. DBT, although not used in children is a principle-based psychotherapy developed by Linehan that blends standard cognitive-behavioral therapy with Eastern philosophy and meditation practices and shares elements with psychodynamic, client-centered, gestalt, paradoxical, and strategic approaches . The CBT and anxiety literature for children and adolescents has generally considered anxiety disorders such as social anxiety disorder, generalized anxiety disorder, and overanxious disorder as a single group (Weersing and Brent, 2006). However, there have been several studies that have examined other anxiety disorders such as posttraumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD) specifically. Roblek and Piacentini (2005) in their study state anxiety disorders are among the most common psychiatric disorders in children and adolescents. However, the evidence base for treatment of anxiety in youths is relatively limited. Initial studies of CBT for anxiety showed positive results. More recently there have been several randomized controlled trials (RCTs) that have examined CBT in various formats including individual child, family focused, and group. A number of these studies have demonstrated a significant effect of CBT compared with controls and alternate treatments. In general the reviewed studies have shown benefit for CBT in the treatment of anxiety disorders; however, there have been several methodological shortfalls identified. The most significant of which appears to be difficulties in the process of randomization as well as limited active control comparison groups. In addition, study samples generally included children and adolescents with mild to moderate symptoms of anxiety mostly recruited from community and outpatient populations and did not include severe cases. Therefore, additional studies would be useful to further clarify the efficacy and effectiveness of CBT in treating child and adolescent anxiety disorders (Roblek and Piacentini, 2005). C. TWO detailed strategies for intervention or action plans, appropriate for use with teachers, students, parents, administrators, or siblings. 1. Anxiety disorders are associated with significant impairment in peer relationships, and family and school functioning. There is also an association with suicidal behaviors and comorbid psychiatric disorders such as depression and substance abuse. CBT for adolescents with anxiety can be conducted individually or in groups. The most commonly used treatment manual was developed by Kendall and is called the ‘‘Coping Cat Program.’’ This program typically involves 16 to 20 sessions, which begin with skills training followed by exposure exercises. An acronym used in this program is FEAR, Feeling frightened, Expecting bad things to happen, Actions/attitudes that will help, Review and reward. The adolescent is taught to recognize anxious feelings and bodily sensations, identify and challenge cognitive distortions, develop a coping plan, and, finally, evaluate coping responses and reward themselves appropriately. There are some important developmental differences that may influence the manner in which CBT is performed. First, their ability to recognize and process emotions is still developing, along with their ability to think in an abstract way. Using role-playing, stories and metaphors may be helpful in demonstrating some of the abstract CBT concepts given these developmental limitations. The main difficulty would be working with these children with current difficulties which they fail to visualize would improve in future. This becomes more prominent while doing challenging exposure exercises. These can be avoided through alliance, role of parents, and homework/compliance. Creating an alliance with children are difficult due to their autonomy and individuation. Collaboration in counseling is thus important. Parents and caregivers have important roles. Studies have shown that involving parents is helpful. They usually help in learning coping skills and serve as coaches in exposure exercises and they indeed help developing a behavioral reward system that can motivate the child to work on anxiety. Parents may facilitate maintenance of treatment gains when CBT is terminated. Homework is a key component of CBT. It is well known that teens do not generally love homework, so it is challenging to design homework assignments that they will think worth their while. CBT homework creates opportunities to practice skills to build mastery and enhance capabilities (Cartwright-Huttons et al., 2004). 2. General anxiety and worry are common to many anxiety problems, and it can at times be difficult to distinguish what is going on. The counseling may start with standard techniques such as thought monitoring and challenging. In many cases it is difficult to elicit feelings with the children holding on to their worries at all costs. One of the tasks for the counsellor, therefore, is to maintain a curious and questioning attitude, not only towards the content of the client's difficulties but also towards the process of worry itself. Counselling for worry requires keeping slightly detached from the content, and not getting sucked in, without losing therapeutic empathy. Many clients with worry problems have had bad experiences of not being listened to, of their worries not being taken seriously by others, or being dismissed. On the other hand, to spend a long time in counselling listening to the outpouring of worries can be counterproductive. While clients' worries are real and objectively worth being concerned about, counsellors need to keep in mind the `umbrella' of processes above the concerns, and help form hypotheses about the process. The key adaptations to helping clients with general anxiety problems are, working with the process of worry: identifying and testing out specific beliefs about worry, helping the client build up a repertoire of skills to cope with worry and anxiety, working with underlying assumptions and beliefs, working with ways of dealing with uncertainty, and building up self-confidence. Techniques to reduce worry include, interrupting the process of worry using distraction, physical activity, talking about something else, doing soothing activities, and being kind to oneself (Durham et al., 1999). The central themes of anxiety result from preoccupation or `fixation' with the concept of danger, along with an underestimation of the personal ability to cope. The theme of danger pervades all levels of cognition, thinking and belief, moment-to-moment thoughts, negative automatic thoughts, but also the child's assumptions and schema. The heart of counseling through cognitive therapy comprises of collaboration, conceptualisation, structure and focus, use of a wide range of methods, and its educational and empowering philosophy. The key aims of counselling for anxiety are to gain a clear, empathic understanding of what are the important issues and fears for individual clients, and work with them to find more realistic interpretations of the threats and danger. This involves a process of identifying specific fears and using a spirit of `guided discovery' and `behavioural experiments' to test alternative explanations. This way, clients are able to take on board different appraisals of themselves, others and the world and use these new ways of interpretation as a basis for living their lives, solving problems, or appraising situations. Clinical levels of fear and worry typically distinguish themselves from this common developmental course by an undue persistence and intensity of fearful and anxious reactions. Most fears and anxieties are presumably corrected through disconfirmatory experiences such as corrective information, positive encounters, experience coping with negative encounters, repeated exposures in concert with increases in cognitive-developmental capabilities (Knapp and Jongsma, Jr., 2002). The counseling through cognitive therapy model focuses on problem maintenance. This involves changing what maintains the anxiety, and this is often more the focus of therapy, than is understanding why the child became anxious. Cognitive therapy is based on a collaborative therapeutic relationship. Collaboration is a central aspect of the therapeutic relationship within cognitive ways of working. Client and counselor ideally form a team, which then jointly works on the client's main problems. The therapist's role is to provide conceptual and methodological expertise about the nature of psychological problems and how such problems are resolved. There is a teaching element to this but, it is most effectively achieved when geared to the individual client and his frame of reference. Such a therapy is based on conceptualising both the problem and the individual child. The long-term goals of the therapy would be to reduce the overall level of worry and fear. The child would be made to learn techniques to reframe and redirect anxiety-producing stressors. In this way, there would be an attempt to reduce the somatic symptoms and to reduce the impact of anxiety on restful sleep. The counseling must help the child to develop confidence in social skills and to develop resilience in facing stressful situations and participate in various activities leading even to improve test-taking performance (Knapp and Jongsma, Jr., 2002). The first strategy would be identification of areas of elevated anxiety. This is not possible without the development of a positive trusting relationship. Once the empathic discussion about the current worries begins, in most of the cases, the underlying cause can be identified. An objective inventory may be used to assess the level and areas of anxiety, such as, The Revised Children's Manifest Anxiety by Reynolds and Richmond. A therapeutic game can be used to expand the student's awareness of own feelings and their triggers. In the next step, the generalized worries will be prioritized in order to reduce their numbers. This can be done through brainstorming with the child. The child should be encouraged to verbalize the effects of these personal stressors on daily functioning, and during counseling sessions, these can be interpreted with a greater detail with suggestion of coping skills. In the next step, the counseling should focus on anxiety producing situations, and there must be working together with the student to develop problem solving and decision making skills for that situation. This can be accomplished through a reframing process by suggestion of an alternative method of coping and interpretation of each situation that creates anxiety. The student will be taught to list several positive options, keeping a personal record, and deciding to delay any corrective action until a discussion with a trusted adult. The student will be asked to draw a picture "What Serenity and Clam Look Like to Me", and the drawing may be interpreted during counseling with suggestions to accomplish serenity. Moreover, the student will be asked to identify one source of anxiety and work on it to identify possible remedies, so he is able to choose an option to reduce the anxiety level. The outcome of such implementation may be discussed in the next session of counseling (Knapp and Jongsma, Jr., 2002). The counselor should verbalise an understanding that mistakes are a natural part of learning and can strengthen and enrich life. This can be exemplified through an assignment where the student is asked to list 10 mistakes and then to identify how these have contributed to personal wisdom. This can be boosted by stories from real life where people have endeavored to overcome personal problems and become successful. The child can be asked to keep a journal about other people's mistake and their ways to overcome it. The counselor should reframe the situations that have triggered feelings of fear concerning self, parents, family, school, and friends. The parents must be counseled to help the student reframe situations that can trigger anxiety. The parents should be able to discuss events rationally and logically with their child. Rational emotive techniques may be used to reframe worries, where the student will be able to identify situations that have contributed to fearful feelings and through reframing, they will be able to reevaluate these events in a more realistic and positive manner. Anxiety is demonstrated by stress, and stress has physical consequences. The counselor must explore these symptoms with the student. The student will be asked to keep a journal of stressful events leading to physical symptoms such as rapid heartbeat, headache, stomach distress, and sweaty palms. A biofeedback stress patch may be advised. The student would be given an assignment of Physical Response to Stress where the student will identify areas on an image of human body where personal stress is most commonly reflected (Knapp and Jongsma, Jr., 2002). The counselor will then help implement relaxation techniques during the periods of anxiety by teaching the students techniques by alternating relaxation and tightening with special focus on the symptomatic areas. A stress ball may be used for this purpose. A journal will be kept by the student to record periods of relaxation and even breathing. The student will be assigned to practice muscle relaxation and breathing technique. The student will be encouraged to participate in aerobic exercise on a regular basis. The counselor should implement a regular nightly sleep pattern with development of a bedtime routine that reduces anxiety and encourages sleep. The parents will be counseled to provide the student with an environment conducive to peaceful nighttime sleep and to support and/or enforce a bedtime routine. The student will be encouraged to keep a dream journal to be later discussed with the counselor. The student will be referred to a social skills therapeutic group. The teacher of the student should be encouraged to involve the student in cooperative learning groups. The teacher will also recognize the student for success participation in the class. To reinforce or increase appropriate social interaction with others to at least three occasions per day, the student may be supported to join an extracurricular group sponsored by the school. The counselor must implement conflict management skills in daily social interactions through sharing, taking turns, listening, talking the problem over, apologizing, and getting help. The student will be taught to use I messages and reflective listening. To develop social assertiveness and conflict management skills, the peacemaking skills may be used. The counselor would brainstorm with the student the personal and social benefits of sharing feelings with others (Knapp and Jongsma, Jr., 2002). Conclusion Anxiety disorders are commonly diagnosed in children and adolescents. Prevalence rates range from 2% to 27%, depending on the length of the assessment interval. Therefore, it is important to identify and treat pediatric anxiety disorder to reduce the long-term consequences. Although anxiety disorders often have similar clinical presentations in youth and adults, it is critical to understand the differences that may occur across the lifespan. Reference Beck, J.G., & Averill, P.M. (2004). Older adults. In R.G. Heimberg, C.L. Turk, & D.S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice (pp. 409–433). New York: Guilford Press. Bogels, SM. and Zigterman, D., (2000). 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