Symptoms/characteristics:

• Worries excessively
• Headaches, stomachaches, nightmares
• Avoids anxiety-provoking situations
• May manipulate, defy, or tantrum to avoid feared object or situation.
• May be hypervigilant.
• Worry may interfere with concentration.  Child may get “stuck” in worry or obsessions.

Different types --  (Note:  people often have several anxiety disorders.  Anxiety disorders are  often accompanied by a mood disorder.)          

Generalized Anxiety Disorder (GAD) – Worries excessively and unreasonably about many things.  Tense, irritable, needs frequent reassurance.  May lie awake worrying. 

Separation anxiety –Desperate and miserable when separated from primary caregiver.  May refuse to go to school or sleepovers.  May follow parent from room to room, insist on sleeping near parent.   Worries that parent will be harmed or die.

            Performance anxiety – dreads tests or other high-stakes events to the extent of becoming physically ill, trembling, unable to think, frozen.

            Panic disorder – Attacks with intense fear, pounding heart, sweating, dizziness, breathlessness, trembling, terror.  Child worries s/he’s “crazy” or dying. 

            Social anxiety – Dreads and tries to avoid social interactions and situations.

            Post-traumatic Stress Disorder – following extreme or repeated trauma, child relives it, has nightmares, may re-enact during play.  Reminders of event trigger strong emotions or numbness (dissociation).

            School refusal often results from anxiety disorders.  For example, a child fears having a panic attack or losing control while at school.  A child with separation anxiety worries that parent will die while s/he’s at school.   Or, school refusal may result from avoidance of performance or social situations.

            Obsessive-Compulsive Disorder – repetitive rituals provide temporary relief from sense of impending doom.  Rituals may involve washing, counting and numbers, checking, evening-up, hoarding.    Child may be perfectionist about writing, erasing repeatedly until there are holes in the paper.  Intrusive thoughts and mental rituals may disrupt school work. 

Often occurs with:  Tourette’s Syndrome, Trichotillomania (hair-pulling), skin-picking, eating disorders, ADHD.

Brain biology:   Overactive or hair-trigger threat-sensing system.  Amygdala signals a threat.  Another deep-brain structure, the hippocampus, is smaller in people who get Post-Traumatic Stress Disorder.  Basal ganglia and striatum are implicated in obsessive-compulsive disorder (OCD).  OCD can be caused by autoimmune response to strep infection damaging basal ganglia.

Treatment:  Cognitive behavior therapy, relaxation skills, deep breathing, anxiety management, gradual desensitization, medication.

Classroom applications:

• Provide calm, encouraging support, predictability, routine.
• Work closely with parents and therapist, with a unified plan for gradual improvement.
• Follow therapist’s instructions regarding what situations the child can handle and how to respond to refusals. 
• Avoid “buying into” the anxiety, but on the other hand, don’t push too hard.
• For school refusal, plan pleasurable, stress-relieving activities or interactions when the student first arrives at school – providing an immediate reward for coming.  Schedule de-stressing and debriefing times throughout the day to avoid build-up of anxiety.

Advice for parents/care givers

·        Name the fear and help your child objectify it – draw it, for instance.  Encourage child to go to battle with the fear and refuse to let it control his/her life.

·        Find a therapist trained and experienced in treating anxiety disorders.  Exposure and ritual prevention is effective therapy for OCD.

·        Don’t participate in rituals; don’t try to forcibly interrupt them.

Book for children:

• Up and Down the Worry Hill:  A Children's Book about Obsessive-Compulsive Disorder and Its Treatment, by Aureen Pinto Wagner, Ph.D. and Paul A. Jutton

Books for teachers and parents:

• Worry by Edward M. Hallowell, M.D., especially “The Worried Child” chapter.
• Teaching the Tiger: A Handbook for Individuals Involved in the Education of Students with Attention Deficit Disorders, Tourette Syndrome, or Obsessive- Compulsive Disorder by Marilyn Dornbush and Sheryl Pruitt.
• The Boy Who Couldn't Stop Washing:  the Experience and Treatment of Obsessive-Compulsive Disorder by Judith Rapoport, M.D.
• Freeing Your Child from Obsessive-Compulsive Disorder by Tamar E. Chansky, Ph.D.
• School Refusal:  Assessment and Intervention within School Settings by Mary B. Wimmer, Ph.D.

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