Anxiety by liwenting

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									                            CHAPTER 11. ANXIETY DISORDERS
Within everyday language are the words ‗fear,‘ ‗worry,‘ and ‗anxiety.‘ How are they different?
Fear is a physiological response to specific threatening events/persons; worry is related to
thoughts of future danger or threat. Anxiety involves both the physiological and cognitive
components, as well as, behavioral avoidance (Ollendick, Grills, & Alexander, 2001). Thus,
anxiety is a behavioral response to stress that is accompanied by an ―unpleasant state involving
subjective apprehension and physiological arousal‖ (Coleman, 2001). It is state-based or
dependent upon threat within in the setting and upon the age of the student.

Similar to the traits of activity and intelligence, anxiety falls within a normal distribution.
Anxiety is important for our adaptation as individuals and as a species to anticipate and handle
stressful and often extreme conditions of danger. Anxiety is the body‘s natural reaction and
serves as a warning sign to prepare for these conditions. For example, physiological arousal
prepares us to physically respond to an impending threat (e.g., to escape or attack).

However, when anxiety involves a response to unreasonable dangers and is so intense and
chronic that it interferes with functionality, it can be described as a disorder. Trait anxiety
appears to be related to differences in inherited temperament and to accumulated life
experiences. Children with high trait anxiety have difficulty damping down the large amount of
anxiety they feel; they are also overly responsive to situations or ‗states‘ of possible threat from
the environment (e.g., evaluative feedback). In early years, children with trait-anxiety will be
more inhibited, physiologically aroused, and anxious than other children in new situations, with
new people, or with unpredictable events (Ollendick et al., 2001).. Over time, the focus of their
anxiety may change or spread, for example from fear of new situations to fear of leaving the
house (agoraphobia). [Note, at the opposite end of the continuum are some children who have
too little anxiety and too little guilt. Their lack of anxiety makes it difficult for them to learn
from negative experiences and from social consequences.]

High levels of anxiety can be broad-based across a number of situations (Generalized Anxiety
Disorder), specific to settings (e.g., school, social exchanges), or to specific stimuli (e.g., spider
phobias or other phobias). Each of these types of anxiety disorder has in common, distressing
internalizing symptoms, avoidance behavior, and for older students, a cognitive understanding of
the exaggerated nature of their own anxiety. These commonalities are addressed in this chapter,
followed by similarities and differences related to specific types of school-related anxieties (e.g.,
school and social phobias). There is an overlapping of vocabulary presented at the beginning of
the chapter and implications for intervention across subtypes presented at the end of the chapter
(i.e., rather than following each type of anxiety disorder).

Some of the questions discussed in this chapter are:
   1. School phobia is often triggered by what kinds of events in a child’s life?
   2. What is the cognitive distortion that is involved in anxiety more generally and
      specifically in school phobia?
   3. What is the probable cognitive distortion of social phobia?
   4. What kinds of tasks are more difficult for children with high anxiety?

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   5. How might poor school attendance be related to later employment and vocational
   6. How does shyness differ from social phobia?

A. Vocabulary for all Anxiety Disorders
Conditioned fear      Learned from observing another person’s fearful or
                        avoidant response or from direct experience with a
                        traumatic event (e.g., dog bite).
Behavior              Strategies that involve the application of learning
modification            principles, such as the use of reward consequences
                        when the child engages in small steps related to the
                        feared object, person, or setting.
Cognitive Behavior    In cognitive behavior modification the child uses self-
Modification            talk to modify his/her own behavior (e.g., “I am brave”
                        “I am not afraid”)
Failure oriented      The child is punished for trying and not succeeding and
classroom:              punished for not trying. As well, there may be a
                        predominate use of strategies that involve making
                        comparisons among children‘s performance (e.g., by
                        posting children‘s graded work) or focusing on what is
                        wrong, rather than on what is correct.
Global fears          Anxieties attached to a wide range of related objects,
                        experiences, animals, or events
Internalizing         Somatic symptoms (stomachaches, insomnia, nausea);
symptoms                mood symptoms: worrying, depression, and behavioral
                        symptoms: crying, withdrawal, phobias
Modeling              A child observes an adult or another child with similar
                        characteristics interacting with the feared object or in the
                        feared situation, either in real life or on video.

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Morro reflex               The inherited startle reflex
Nature                     Biology and inherited factors
Neophobia                  Fear of new things
Nurture                    Environmental influences
Performance-               Includes (1) high physiological arousal in performance-
Anxiety                     based or graded contexts, (2) excessive fear of negative
                            evaluations, and (3) escape or avoidance from these
                            situations (Faust et al., 1996).
Phobia                     Irrational fears, such as fear of snakes and the dark,
                            which are not based on direct or observed experiences
                            with an event—may be symbolic, associated with, or
                            representative of a past experience that was fear-
                            inducing. Some phobias are temporary and specific to a
                            normal developmental period (e.g., going into the attic).
Post traumatic stress      Post Traumatic Stress Disorder (PTSD) is a continual,
                            reexperiencing of an earlier traumatic experience,
                            involving death or serious injury or threat to the self or
                            others. In addition, for children there is a behavioral
                            response to this trauma that includes agitation or
                            disorganization (APA, 2000). In a sense, this is
                            rationally-based anxiety and might be considered an
                            example of conditioned responding.
Relaxation                 Strategies designed to reduce anxiety (e.g., slow
techniques:                 breathing)
School phobia:             A specific disorder of school refusal, wherein children
                            avoid school in favor of staying home. An irrational fear
                            of separation from parents or caregivers.
School refusal:            A general category of children who chronically avoid
Separation anxiety         Separation anxiety is the intense fear of separation
                            from a parent or surrogate (guardian or parent
                            substitutes). It is used interchangeably with school
                            anxiety (Kearney, 2003).
Specific anxiety           Fears of an event, experience, animal, or object (e.g.,
disorders                   spiders, escalators).
Systematic                 The gradual exposure of an individual to their feared
desensitization             objects/experience/person/animal in a pleasant or
                            relaxed context, until the phobic can tolerate exposure
Truancy                    A specific case of school refusal, in which the child
                            leaves the school but does not go home; s/he goes into
                            the community. Truancy is used mainly for children
                            who miss school without parental consent (Kearney,

B. Definition

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IDEA. All anxiety disorders would fall within the category of Emotional disturbance:
―exhibiting one or more of the following characteristics over a long period of time and to a
marked degree that adversely affects a child's educational performance: (A) An inability to learn
that cannot be explained by intellectual, sensory, or health factors. (B) An inability to build or
maintain satisfactory interpersonal relationships with peers and teachers.(C) Inappropriate types
of behavior or feelings under normal circumstances. (D) A general pervasive mood of
unhappiness or depression.(E) A tendency to develop physical symptoms or fears associated with
personal or school problems.(ii) Emotional disturbance includes schizophrenia. The term does
not apply to children who are socially maladjusted…‖[Code of Federal Regulations, Title 34,
Section 300.7(c)(4)(i)] (underlining added for relevance to this chapter).
DSM-IV-TR is more specific, defining Generalized Anxiety Disorder Criteria (APA, 2000).
   A. ―Excessive anxiety and worry (apprehension expectation), occurring more days than not
       for at least 6 months, about a number of events or activities (such as work or school
   B. The person finds it difficult to control the worry.
   C. The anxiety and worry are associated with one or more [in children] of the following six
       symptoms (with at least some symptoms present for more days than not for the past 6
       months): (1) Restlessness or feeling keyed up or on edge, (2) Being easily fatigued, (3)
       Difficulty concentrating or mind going blank, (4) Irritability, (5) Muscle tension, and (6)
       Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
   D. The focus of anxiety and worry is not confined to a particular situation or event (as in
       other anxiety disorders).
   E. The anxiety, worry, or physical symptoms cause clinically significant distress or
       impairment in social, occupational, or other important areas of functioning [school or

   1. Prevalence
   Anxiety disorders are among the most common childhood emotional disorders. Studies have
   found prevalence rates from 10-21% in school age populations (Dadds & Barrett, 2001) and
   as high as 45% in clinical populations (Wenar & Kerig, 2006).

   2. Co-occurrence
   Approximately 33% of children with anxiety disorders have met the criteria for two or more
   different types of anxiety disorders (Tannock, 2000). Depression is another commonly co-
   occurring condition; for students who have a past history of LD, there is a 92% incidence of
   anxiety disorders (Levinson, 1989). This is related to the fact that it is not simply inheritance
   but also negative life experiences. That is, failure experiences increase students‘ worries
   about future possible threat or failure.

   3. Differential Diagnosis
    ―Anxiety seems best characterized as a future-oriented emotion‖ (Silverman, 2005, p. 300).
   We might describe children who are anxious as those who ―worry forward‖ anticipating
   something dangerous or difficult for them, in contrast, to children with depression, who
   ―worry backwards,‖ anticipating that past actions, events, or persons can continue to hurt or
   have hurt them. Although both groups feel negative emotions, students with anxiety worry

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   about themselves and others‘ reactions to them, whereas students with depression have an
   already formed negative self-concept (for review see Wenar & Kerig, 2006).

   4. Age, gender, and cultural factors
   Age. Rates by age level have been reported for types of fears, beginning with an infant‘s
   startle response, to fears of separation, followed by fears of imaginary creatures, animals, and
   the dark. When entering school, fears are related to school events, and during adolescence,
   fears are related to social and evaluative settings involving potential embarrassment
   (Ollendick et al., 2001). In other words, specific fears are more common in young children
   and social/evaluative fears more common in older students. Overall, anxiety disorders
   become more easily identifiable as children reach middle childhood and older. That is,
   prevalence rates increase from 8% (11-year-olds) to 20% (21-year-olds) (Wenar & Kerig,
   Gender. By the age of 6, females were twice as likely to have an anxiety disorder as were
   males; this difference increased over age levels, with differences between boys and girls not
   appearing until adolescence (Ollendick et al., 2001; Wenar & Kerig, 2006).
   Culture. ―Race, culture, ethnicity, or a combination of these may account for differences in
   the manifestation of anxiety disorders.‖ For example, ―African Americans experience more
   phobias, panic disorders, and isolated sleep paralysis relative to the general population‖
   (Lambert, 2004, p. 248). Asian cultures may express more anxiety of the somatic form (e.g.,
   muscle tension) rather than of the cognitive form (worrying) (see Wenar & Kerig, 2006).

C. Subtypes—observed in children are generalized anxiety disorder, post-traumatic stress
   disorder, panic disorder (with and without agoraphobia), social phobia (social anxiety
   disorder), specific phobia (school phobia), and obsessive-compulsive disorder (see Chapter
   12). Within some of these categories (e.g., social anxiety disorders), there are additional
   subtypes (e.g., selective mutism).
 1. Generalized anxiety disorder is chronic anxious behavior, even when there is a little to no
     stress at hand that is marked by irritability, fatigue, headaches, excessive sweating, hot
     flashes, etc
 2. Post Traumatic stress disorder is the result of some devastating event with the following
     DSM-IV criteria:
       a. Experiencing or witnessing or being confronted with an event involving actual or
           threatened serious injury or death and person‘s response involved intense fear,
           helplessness, or horror
       b. Event is re-experienced through at least 1 of following:
           i. recurrent and intrusive distressing recollections of event
           ii. recurrent distressing dreams of event
           iii. acting or feeling as if traumatic event were recurring
           iv. intense psychological distress at exposure to internal or external cues that
                symbolize/resemble aspect of event
           v. physiological reactivity on exposure to same
                The symptoms may be immediate or delayed:
                  i. At least 3 associated with the avoidance of stimuli associated with the

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                 ii. At least 2 persistent symptoms indicating high arousal that were not present
                      before the trauma
                 iii. Duration more than 1 month
                 iv. Causes significant distress or impairment in social, occupational, or other
                      important areas of functioning (APA, 2000)
       Re-experiencing these events may be triggered by sounds, smells, or visual details
       associated with the event, and re-experiencing the event might occur in symbolic form
       during nightmares. These children are hyper-vigilant (very sensitive to possible threat)
       and may show startle reactions in response to unexpected sights or sounds. Although
       repetitive behavior (e.g., seen in compulsive disorders) usually relieve anxiety, re-
       enactments of trauma through play do not reduce and may increase the level of anxiety
       for students with PSTD unless there is an element of repair or healing that is imposed
       (Wenar & Kerig, 2006).
   3. Panic Disorder. Panic is defined as the abrupt onset of an episode of intense fear or
      discomfort, which peaks in approximately 10 minutes and includes a feeling of imminent
      danger or doom and the need to escape, with physical/somatic symptoms: palpitations,
      sweating, shortness of breath or feelings of smothering or of choking, chest pain or
      discomfort, nausea or abdominal discomfort, dizziness or lightheadedness, tingling
      sensations, chills or hot flushes, trembling, with a sense of things being unreal
      (depersonalization), and a fear of losing control, "going crazy," or dying. There are three
      types of panic attacks: (1) Unexpected - the attack "comes out of the blue" without
      warning and for no discernable reason, (2) Situational - in which an individual always has
      an attack, for example, upon entering a tunnel and (3) Situational Predisposed - situations
      in which an individual is likely to have a Panic Attack, but does not always have one. An
      example of this would be an individual who sometimes has attacks while driving.

D. Etiology
There is cyclical relationship between the child‘s negative experiences with the world and the
child‘s more sensitive physiological reactions to these experiences, which accounts for anxiety
disorders (i.e., temperament plus learning history).
  Biogenetic. For all individuals there are normal developmental stages of anxiety, described
    above. Differences from the norm are inherited differences in temperament (inhibited/shy
    and avoidant of novelty and challenge), which are relatively stable for about 10% of the
    population. This overall heritability of anxiety disorder accounts for one-third of the
    variance, with many of these children‘s parents also reporting anxiety disorders (Wenar &
    Kerig, 2006). For these children there is higher physiological arousal, and they are more
    easily stimulated or stressed.
  Environmental. These are fears based on one‘s own past life experiences, for example, failure
    in school can lead to anxiety in anticipation of future failures, as previously stated. Social
    observations (e.g., of a dog biting another person) or of another‘s response to dogs (parental
    fear) can also create a specific focus of anxiety. In other words anxiety is contagious and
    ―children often ‗catch it‘ from their parents‖ (Webb et al., 2005, p. 91). These would be
    called conditioned fears and not phobias, as they are rationally based on prior experience.
  Functional. In a functional assessment, we would expect anxiety disorders to be worse under
    conditions of stress. However, for different children there may be different stressors (e.g.,
    family problems, abuse, bullying, academic difficulties). The behaviors that children show in

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   an attempt to cope with these stressors (e.g., by avoiding them directly or through somatic
   problems, such as upset stomachs or headaches, or externalizing them through anger or
   aggression) usually work in the short term.

E. Characteristics
   1. Academic Characteristics
   To know that anxiety affects learning is important to know. ―Research suggests that
   approximately 10%-21% of children report clinical levels of anxiety that can impact overall
   functioning [in] academic achievement‖ (Kendall, 2004, p. 277). These children may be
   reporting temporary responses to possible failure. Differently, are students with chronic
   anxiety. Academic failure is 4 times greater in such a highly anxious group who have lower
   grades and possible grade retention. It is also well known that anxiety-associated failure
   depends on task-complexity. Simple tasks are improved by anxiety, but complex tasks are
   made worse. Complex tasks are defined as those with multistep problems or more required
   reading and those that are group- or teacher-paced, require communication, and where
   incidental learning is possible or needed. NEED REFS

   2. Behavioral Characteristics
    Young children may have tantrums when confronted with exposure to anxiety-producing
   stimuli. Older children more often show repetitive verbal or nonverbal behaviors. That is,
   they are more likely to repeat statements or topics that relate to their concerns and/or to show
   nervous twitches/tics, habits, rituals, and routines. There are some relatively positive coping
   responses to anxiety, such as excessive talking, physical exercise, sleeping, and emoting
   (laughing, crying, cursing) and some negative coping responses, such as, eating, chewing
   gum, drugs (alcohol, smoking), pointless pacing, scratching, finger-tapping, hand rubbing,
   and retreating into fantasy and daydreaming to resolve problems (Menninger et al., 1963).

   3. Social Emotional Characteristics
   ―Research suggests that approximately ―10%-21% of children report clinical levels of
   anxiety that can impact…social and peer relations, and future emotional health‖ (Kendall,
   2004, p. 277).

 3. Cognitive Characteristics
 There is evidence of cognitive and memory distortions or cognitive biases in anxious children.
    Intellectual. Although children with anxiety do not differ from their peers in their positive
      thinking, they are more likely to interpret ambiguous situations in a negative way by
      overestimating danger and underestimating their ability to cope (Bogels & Zigterman,
      2000). Compared to typical children, anxious children are more likley to attend to
      threatening cues, become distracted by worry, focon on negative outcomes, and interpret
      ambiguous information as threatening (Eisen et al., 2001). A potentially threatening event
      (giving a speech) is often accompanied by exaggerated negative self-statements (be
      careful of this, don‘t do that, talk loud enough, look at the crowd/make eye contact). For
      these students, this initial event (giving a speech) will be broadened to encompass more
      than just the original experience to other kinds of performance (Bogels & Zigterman,
      2000; Kopecky et al., 2004).

                                                                    C11. Anxiety Disorders p.     7
     Memory. Anxiety is associated with preferential recall for threatening over non-threatening
      information. ―The preferential processing of threatening information during encoding
      may lead to the disproportionate recall of such information‖ (Daleiden, 1998, p. 216).
      That is, these children selectively attend to threat, recall threatening experiences, and
      form a cognitive picture of the world as a dangerous place.

   5. Communication Characteristics
   Children who are behaviorally inhibited would be less likely to initiate or maintain
   conversational exchanges with others. Research evidence suggests that high levels of anxiety
   are related to statements about the self that are negative (e.g., ―I thought I would fail‖) as
   well as overall negative statements (―Life is terrible‖) (Ollendick et al., 2001, p. 10).

F. Outcomes
The avoidance of risk/challenge, which is often the pattern of behavior that characterizes anxiety
disorder, creates a whole set of new problems that decreases social and academic competence in
the long term. For this reason, it is important to understand what the stressors are for the child,
so that accommodations and interventions can be designed before anxiety spreads (e.g., from a
specific area like reading to all of schoolwork, including riding the school bus). ―The sequelae
of childhood anxiety disorders, if left untreated, can include chronic anxiety, depression, and
substance abuse‖ (Kendall, 2004, p. 277).

Many children avoid school occasionally, but children with school phobia avoid school, due to
an irrational fear of separation from parents/caregivers, school-related stimuli, or some other
unknown source (Kearney et al., 1995).

A. Definition
There is an interesting definitional history of the terms school phobia and truancy, with
confusion still existing today about the best terms. That is in (1) the 19th century, United States
enacted compulsory school attendance laws and therefore created ‗truancy,‘ (2) in the 1930‘s a
distinction between ―delinquent‖ and ―non-delinquent‖ truancy was made. The non-delinquent
was called neurotic delinquency and identified children who missed school due to anxiety or
depression, (3) in the 1940‘s the term school phobia replaced neurotic delinquency, (4) in the
1950‘s, separation anxiety was described as an intense fear of separation and was equated by
some researchers with school phobia (Kearney, 2003).

IDEA Chronic anxiety disorders would be listed under emotional disorders (see definition under
  anxiety disorders at the beginning of the chapter).

DSM-IV-TR Diagnostic criteria for 309.21 Separation Anxiety Disorder (APA, 2000, p.
A. Developmentally inappropriate and excessive anxiety concerning separation from home or
from those to whom the individual is attached, as evidenced by three (or more) of the following:
   (1) recurrent excessive distress when separation from home or major attachment figures
       occurs or is anticipated

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    (2) persistent and excessive worry about losing, or about possible harm befalling, major
        attachment figures
    (3) persistent and excessive worry that an untoward event will lead to separation from a
        major attachment figure (e.g., getting lost or being kidnapped)
    (4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation
    (5) persistently and excessively fearful or reluctant to be alone or without major attachment
        figures at home or without significant adults in other settings
    (6) persistent reluctance or refusal to go to sleep without being near a major attachment
        figure or to sleep away from home
    (7) repeated nightmares involving the theme of separation
    (8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or
        vomiting) when separation from major attachment figures occurs or is anticipated
B. The duration of the disturbance is at least 4 weeks.
C. The onset is before age 18 years.
D. The disturbance causes clinically significant distress or impairment in social, academic
    (occupational), or other important areas of functioning.
E. The disturbance does not occur exclusively during the course of a Pervasive Developmental
    Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not
    better accounted for by Panic Disorder With Agoraphobia.
    Specify if: Early Onset: if onset occurs before age 6 years

    1. Prevalnce
   School phobias represent about 1-8% of school age children and 5% of a clinically referred
   group (Berry, Injejikian, & Tidwell, MISSING DATE (Lee et al., 1996).

   2. Co-occurrence
   Social anxiety and shyness co-occur with school phobia (Kearney et al., 1995). Refusal to go
   to school may be symptomatic of or co-occur with oppositionality or depressive symptoms.

   3. Differential Diagnosis of School Phobia vs. Truancy
   School phobia can be confused with truancy. Differently from truants, children with school
   phobia refuse to attend or stay at school regardless of pressure, punishment, or blame from
   parents or school administration (Chitayo & Wheeler, 2006).

                                                                     C11. Anxiety Disorders p.        9
       school phobia                          truancy
        Typically a good student              Typically not a good student
        Avoids school and stays home          Avoids school and home
        May stay out of school for            Typically misses school for less
          weeks                                  extended periods of time
        Child’s parents are aware of          Truant’s parents are most often not
          the absence                            aware

4. Age, gender, and cultural factors
   Age. School phobias are found in 5-15 year-olds that most commonly affecting 5, 6, 10, and
   11 year olds (Freemont, 2003).
   Gender. There are more males than females (Kearney et al., 1994).
   Culture. Anxiety is more common in single parent/divorced families (Akande et al., 1999;
   Lee et al., 1996). Males are typically from higher economic backgrounds than females;
   females are often younger, more emotionally disturbed, and from lower socioeconomic
   environments and labeled with separation anxiety (see Wenar & Kerig, 2006).

B. Subtypes
School phobia can be classified as an internalizing disorder with children who seek the comfort
of their home. This group is relatively small (i.e., 10% of school refusal cases have school
phobia). Truants can be classified as an externalizing disorder with children who avoid school
and home.

C. Etiology
 Environmental. The behavioral theory suggests school phobia consist of two separate factors—
   an extreme fear of school maintained by various secondary reinforcements, mostly attention
   from parents, siblings, and counselors (Davidson, Lazarus, & Polefka, 1965). Related family
   contributors are that parents can have unrealistic expectations of academic success (Jenni,
   1997), and mothers are more likely to be diagnosed with anxiety disorders (Phelps et al.,
   1992). As well there are often life changing events at home, such as death in the family, birth
   of a sibling, a move to a new house or school, a parent losing a job, or an unstable or
   divorced family (Akande et al., 1999; McAnanly, 1986; Paul, 1998). Related school factors
   for both school phobics and truants are stressful classrooms, for example, a failure oriented
   classroom in which a child is punished for trying and failing and punished for not trying
   (Pilkington et al., 1991).
 Functional. Following from the above environmental factors, a functional analysis would find
   that the characteristics of school phobia function to avoid and to get. That is, some children

                                                                    C11. Anxiety Disorders p. 10
   attempt to avoid negative school stimuli, such as specific teachers or peers, bus rides,
   cafeterias, specific social situations or academic areas or tasks (e.g., presentations, tests)
   (Akande et al., 1999; Evans, 2000). Entering these negative setting-conditions is especially
   difficult, such as, starting kindergarten, junior or sr. high school (Brulle et al., 1985), and
   transitions that involve returning to school after school breaks, holidays, or after summer
   vacation (Evans, 2000). In addition to avoiding, some children with school phobia are trying
   to get attention from parents or siblings by staying at home or going with parents to work or
   access to special activities, such as sleeping in, watching television, playing games. The
   behavior of truants also appears to involve get payoffs when they attempt to participate in
   delinquent behavior or substance use (e.g., for truants) (Kearney, 2006). A method called the
   School Refusal Assessment Scale-Revised can be used to assess these four functions; it
   includes 24 questions, measuring the strength of each function. (Kearney, 2006)

D. Characteristics
   1. Academic Characteristics
   These children want to go to school but are just unable to do so. Their psychosomatic and
   avoidance symptoms are worse on Sunday evenings and Monday mornings. About half of
   school phobic children underachieve academically (Bernstein, 2001). This underachievement
   is related to anxiety (lack of concentration) and to high rates of absence that involve
   incomplete assignments or missing out on essential school tasks and important parts of

   2. Behavioral Characteristics
   Younger children physically cling to their parents (Pilkington et al., 1991); older students
   may cry and hide before and during school, or may use aggression or non-compliance to get
   expelled (Kearney, 2001; Schirduan et al., 2002). At home children may have nightmares or
   somatic complaints (Evans, 2000).

   3. Social-Emotional Characteristics
   Social. School phobia predicts social problems (Kearney et al., 1995), which includes
   withdrawal from peers and isolation and difficulty making and keeping friends (Evans, 2000;
   Kearney et al., 1995; Paccione-Dyszlewski et al., 1987; Pilkington et al., 1991). However,
   with adults these students are eager to please, manipulative in order to avoid school, and
   conscientious conformers (McAnanly, 1986; Want, 1983). Some of these children wield too
   much power, showing willful domination and manipulation of their parents.
   Emotional. For these students there is acute panic and apprehension, feelings of terror,
   depression, hopelessness, and shame (Chitayo & Wheeler, 2006). They are more likely to
   have a sensitive personality with a negative self-image and low self-esteem. For these
   reasons they fear and do not respond well to criticism or reprimands (Akande et al., 1999;
   Jenni, 1997).

   4. Cognitive Characteristics
   Intellectual. Children with school phobia have average or above average intelligence
   (Akande et al., 1999), and they recognizes that their fears are unreasonable (Phelps et al.,
   1992). Still they cannot go to school, which may be related to the strength of their cognitive
   distortions that follow this sequence of thought: (1) ―If I go to school, everyone will make

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   fun of me.‖ (expects negative outcomes), (2) ―I am not able to go to school. I can‘t do it.‖
   (negatively evaluates personal abilities) (3) ―If I can‘t leave school right now, I will go crazy.
   I have to get out of here.‖ (needs to escape situation), and (4) ―I will be a failure in life. I
   can‘t even go to school.‖ (Akande et al., 1999).

   5. Communication Characteristics (no information located)

   6. Motor, Physical, and Somatic Characteristics
  Intense anxiety produces somatic complaints, which are non-existent during weekends,
  breaks, and vacations (Evans, 2000). These reactions are diarrhea, dizziness, nausea,
  headaches, vomiting, drowsiness, abdominal pain, headaches, and stomach-aches, which are
  similar to those who experience stage fright (Pilkington et al., 1991). However, these
  children are not faking illness, and they feel as if they have no control over their feelings of
  terror or their physiological reactions (Jenni, 1997).

E. Outcomes
Family outcomes. Parents see school phobia as more debilitating than conduct disorder,
depression or separation anxiety (Phelps et al., 1992). Parents may have to quit jobs, because
they may have to stay home with their child or constantly pick their child up from school. There
is often parental disagreements over how to best help their child go back to school and long term
marital problems (Kearney et al., 1994; Evans, 2000), as well as, short-term worry, guilt,
impatience and frustration that increases the anxiety in the child and causes the school phobia to
become worse (Cerio, 1997). Siblings are also affected as parents‘ attention is focused primarily
on the child with school phobia (Cerio, 1997).
Child long–term outcomes. If school phobia is not treated, it can lead to emotional outcomes of
increased anxiety, depression, or other phobic disorders. Around 50% of adolescents with school
phobia meet the criteria for an anxiety or depressive disorders or other psychiatric disorders later
in life (Kearney, 2006). During the school years there may also be behavioral outcomes, such as
dropping out of school (Evans, 2000) or suicidal behavior (Jenni, 1997; Kearney et al., 1994). In
later life, school phobia can predict agoraphobia (Jenni, 1997) and difficulty maintaining
employment (Kearney et al., 1995).

SOCIAL PHOBIA (as previoulsly labeled, Avoidant Personality Disorder)
Children with Social Phobia are described as "shy," "timid," "lonely," and "isolated" (APA,
2000, p. 719). Social phobia is considered to be one of the most painful anxiety disorders,
because it is isolating and infrequently recognized in school contexts. These children have low
self-esteem and difficulty being assertive; they are especially sensitive to apparent criticism and
rejection. Their fears are observed across social settings. However, there are specific fears
commonly associated with the disorder, such as, a fear of speaking in public or to strangers,
meeting new people, and specific types of performance that could be embarrassing, such as
writing, working at the board, eating or drinking in public.

                                                                     C11. Anxiety Disorders p. 12
A. Definition
   IDEA Social Phobia would be listed under emotional and behavioral disorders (see anxiety
   disorders above)

   DSM-IV-TR labels social phobia a social anxiety disorder, which is:
   A. ―A marked and persistent fear of one or more social or performance situations in which
      the person is exposed to unfamiliar perople or to possible scrutiny by others. The person
      fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating
      or embarrassing. Note: In children, there may be evidence of the capacity for age-
      appropriate social relationships and the anxiety must occur in peer settings, not just in
      interactions with adults.
   B. Exposure to the feared social situation almost invariably provokes anxiety, which may
      take the form of a panic attack. Note. In children, the anxiety may be expressed by
      crying, tantrums, freezing, or shrinking from social situations with unfamiliar people
   C. The person recognizes that he fear is excessive or uncontrollable. Note. In children, this
      feature may be absent.
   D. The feared social or performance situations are avoided or else are endured with intense
      anxiety or distress.
   E. The avoidance, anxious anticipation, or distress interferes significantly with the person‘s
      normal functioning, social activities, or relationships, or there is marked distress about
      having the phobia.

   1. Prevalence
   An estimated 1-2% of the elementary level and 6% of adolescents from a community
   population, and 27-32% of children who are referred to clinics are socially phobic (Sweeney
   & Rapee, 2001; Wenar & Kerig, 2006).

   2. Co-occurrence

                                                                   C11. Anxiety Disorders p. 13
   Around 90% of children with social phobia also had another anxiety disorder (Curtis, 2004),
   in addition to depression (10%), substance abuse, speech and language LDs, and ADHD
   (Sweeney & Rapee, 2001).

   2. Differential Diagnosis
   It can be challenging to separate social phobia from normal shyness. Shyness and brief
   periods of social anxiety are common in childhood and adolescence but the symptoms tend to
   be outgrown as children age (Webb et al., 2005). Shyness is discomfort and/or inhibition in
   interpersonal situations that interferes with pursuing personal or professional goals. Shyness
   often involves excessive self-focus, a preoccupation with one's thoughts, feelings and
   physical reactions, which may be chronic and considered a personality trait or it may be
   specific to social performance situations that are evaluative. Social phobia involves fear of
   most social situations, which can be identified in late childhood or early adolescence.
   Children with social phobias can be oppositional, with a ‗will of iron‘ or aggressive with off-
   putting negative behavior (see Behavioral Characteristics). There is, as well, an avoidant
   personality disorder (APA, 2000, p. 720), wherein the person exhibits a pervasive pattern of
   social discomfort, fear of negative evaluations, and timidity, which begins by early
   adulthood. Although these subtypes are more similar than different (Widiger, 1992), children
   are classified as socially phobic younger and may be classified with an avoidant personality
   disorder at later ages. Children with giftedness can develop social phobias—fearing external
   criticism, because they have early and easy successes and have not learned to cope with
   failure. Alternatively, they may become perfectionistic (see Chapter 12), with fears of failing
   to meet their own overly high internal expectations and standards (Webb et al., 2005).

   4. Age, Gender, and Cultural Factors.
   Age. Social phobia is typically identified in the teen years, but some individuals may become
   increasingly shy and avoidant during adolescence and early adulthood and go on to develop
   Avoidant Personality Disorder (APA, 2000, p. 719).
   Gender. Social phobia is more common in women -- 3 to 2 ratio (Hollander, 2005)
   Culture. Social phobia is identified across all levels of SES.

B. Subtypes
Within the category of social phobia, there are specific fears of performance-evaluation in public
settings, examples are in restrooms and speaking. There are also general fears in public settings,
for example, in groups, crowds, hallways or transitions. Elective or Selective Mutism (SM) is a
relatively rare subtype of social phobia that is somewhat more common in females than in males
and is manifested as a persistent failure to speak in certain settings, persisting for more than one
month. Children with SM understand spoken language and have the ability to speak and to learn
age-appropriate skills and academics. In typical cases, children with SM speak to their parents
and a few selected others, but not necessarily to all individuals in the home. Most do not speak at
school or in other large social situations, even though they express a desire to speak; they are
unable to do so due to anxiety, fear, shyness and embarrassment. Many do participate in
activities non-verbally, and they can make their needs known by nodding their heads, pointing,
or by remaining expressionless or motionless until someone guesses what they want ―or, in some
cases, by monosyllabic, short, or monotone utterances, or in an altered voice‖ (APA, 2000, p.
126). Their inability to speak interferes with their ability to function in educational or social

                                                                     C11. Anxiety Disorders p. 14
settings, but their withdrawn behavior and lack of verbalizations are not usually disturbing until
the child begins school. By the time SM is recognized, the child has usually had several years in
which non-verbalization has become a pattern and several years exposed to teasing by peers.
―Immigrant children who are unfamiliar with or uncomfortable in the official language of their
new host country may refuse to speak to strangers in their new environment. This behavior
should not be diagnosed as Selective Mutism.…. It is also not diagnosed if the disturbance is
better accounted for by embarrassment related to having a Communication Disorder (e.g.,
Stuttering) or if it occurs exclusively during a Pervasive Developmental Disorder, Schizophrenia,
or other Psychotic Disorder‖ (APA, 2000, p. 125-126).

C. Etiology
 Biogenetic. More than half of these children have at least one shy parent in contrast to 5% of
   comparison children. There is a high rate of psychiatric disturbance in families (i.e., leading
   to communication difficulties within home, Cline & Baldwin, 1994; Harris, 1996).
 Environmental. Mothers-form an abnormally strong bond with their child. There is a close
   alliance with one parent, usually mother, who is seen as seen as overprotective and a home
   atmosphere that does not welcome the expression of feelings. Fathers tend to communicate in
   the home on a limited basis and may react to situations with angry outbursts (Cline &
   Baldwin, 1994)
 Functional. A functional assessment of behavior will document antecedent settings that trigger
   social phobia, which are: one-on-one interactions, opposite gender interactions, intimacy,
   authorities, strangers, having to assert oneself in a group, and in unstructured settings with
   social interactions expected (transitions, such as in hallways and at the beginning and endings
   of classes).

D. Characteristics
   1. Academic Characteristics
   School is a social situation and because of this, there is a high drop out rate (Rappaport,
   2005). In addition, specifically for social phobia there is test anxiety and impairment in
   academic performance (Sweeney & Rapee, 2001).

   2. Behavioral Characteristics
   The behavioral responses associated with anxiety in children are crying, tantrums, freezing,
   or pulling away from social situations, rather than the panic that characterizes adults
   (Sweeney & Rapee, 2001). Avoidance behaviors are relatively easy to understand. However,
   some children show ―off-putting‖ behavior to keep people away, such as growling and
   grumbling, negative statements to others, lacking in cleanliness, poor teeth hygiene, or
   speaking only in a foreign language when others attempt conversation. They may also show
   oppositional behavior of refusing to participate in activities suggested by teachers or adults,
   and unresponsive or negativistic behavior (manipulative, spoiled, stubborn, passive-
   aggressive). They can be sulky with strangers and aggressive at home.

   3. Social-Emotional Characteristics
   Children with social phobia respond emotionally to attention and especially to the criticism
   of other children and adults with blushing or crying, apathetic, or timid/anxious fearful
   responses (Kearney, 2005; Morris, 1998). Socially phobic children will typically have low

                                                                     C11. Anxiety Disorders p. 15
   self-esteem (Hollander, 2005), fewer interpersonal relationships and fears of being viewed as
   ―awkward‖ (Walsh, 2002). They are less likely, therefore, to learn social skills, because they
   do not practice these skills. Finally, they are more likely to be ignored by their peers than
   other children (Sweeney & Rapee, 2001).

   4. Cognitive Characteristics
   Intellectual. The majority of these children fall within the normal range of IQ (Lumg & Wolf,
   Memory. Children with social phobia can learn, retain, and use skills in a normal way (Lumg
     & Wolf, 1988)

   5. Comunication Characteristics
   Students with social phobia avoid communication and conversations (Kearney, 2005), use
   fewer words in role-play settings (Sweeney & Rapee, 2001) and may be mislabeled with
   selective mutism (Hollander, 2005). There is also lack of eye contact (Kearney, 2005;
   Morris, 1998) but not in structured role play contexts (see Sweeney & Rapee, 2001).

   6. Motor, Physical, and Somatic Characteristics
   For this group there is increased heart rate documented (Leary, 1995) and more somatic side
   effects (e.g., sweating, trembling, dizziness) (Curtis, 2004).

G. Outcomes
Lower occupational functioning has been reported.

Anxiety Disorders Implications for:
  1. Intervention
  Anxiety disorders have a high rate of recovery if treated appropriately (Jenni, 1997) and
  early. School phobia should be treated right away, since the child‘s fear will continue to
  build. The longer the student avoids school, the more difficult it is to go back to school.
  Even if the problem arises near the end of the semester, it should be treated then, as the
  child‘s fear will continue to build (Kearney et al., 1994).

   However, avoidance behavior should never be punished, because punishment increases
   avoidance. Unfortunately, anxious mothers were more critical of the inhibited behavior of
   their own children. The evidence also suggests that pushing children too hard toward
   challenges or toward the objects of their fears or by being overly protective were not useful
   (for review of family effects, see Wenar & Kerig, 2006). Major interventions for anxiety
   disorders in general are:
     a. Reconditioning through role play, reinforcement for facing object of fear, matter-of-fact
         statements that child will ―go back to school‖ for instance, removal of reinforcers for
         avoiding object of fear (e.g., can‘t watch TV if at home)
     b. Guided participation or practice--introduce other persons as models with the feared
         stimulus (e.g., videotapes of person with a dog and then with a dog under highly
         supervised conditions).
     c. Flooding or implosion-- high frequency exposure to feared objects

                                                                    C11. Anxiety Disorders p. 16
 d. Systematic desensitization-gradual and repeated exposure to the fear-producing stimuli
    (either in real life or in guided fantasy) and in an activity that is incompatible with
    anxiety (relaxing in a favorite chair, eating ice cream).
 e. Self-control training--may learn relaxation, self-reinforcement, self-punishment, self-
    instruction, visual imagery, or problem solving strategies. Children are taught to
    recognize anxious feelings and physical reactions, modify cognitions and
    misperceptions that contribute to anxiety, and reinforce themselves for making change
 f. Expressive Therapies of art, music, drama, dance, and bibliotherapy where books are
    used to provide models of coping (i.e., for specific types of anxiety-inducing situations,
    such as divorce, moving).
 g. Cognitive-Behavioral Approaches. behavioral and cognitive treatments for school
    phobia are 93% successful while only 37% of the hospitalized group and 10% of the
    home school/psychotherapy group were successful. The behavioral component
    involves contracting for baby steps in the fear provoking setting, using gradual
    reintroduction into school. The pace of returning to school may be slow, so teachers
    may need to focus more on long-term goals, like the ability to attend school full time,
    rather than on immediate academic concerns. This includes reinforcing attendance but
    not crying or complaints of physical symptoms. (If a student complains of a physical
    ailment, send him/her to the nurse; if there is no verifiable illness, return the student to
    class and ignore his/her complaints. Be firm but gentle, Evans, 2000). The gradual
    reintroduction into school may be staying for an hour at first. On Sunday afternoon, the
    child may be walked to school to look at the front doors and the parking lot, then walk
    back home. On Monday, the child may be walked to school again, this time with
    children around, walked to the door of their classroom, then taken back home. On
    Tuesday the child may walk to school, stay for the first hour of class, with his/her
    counselor, buddy, sibling, or parent, then return home. Slow progress may be made
    through the week, or through an extended period of time. At one point the child could
    be left alone in the classroom for a short time. This process would increase steadily
    until the child is ready to attend all day, or the majority of the school day (King &
    Ollendick, 1997). Teachers and staff should reinforce these early efforts, but not call
    too much attention to the student, as he/she may be embarrassed (Evans, 2000).

   Similarly, but for social phobia, a School Based Multidisciplinary Individualized
   Treatment Plan targeted adolescents, using sessions consisting of realistic thinking, social
   skills training, exposure to social interactions, and relapse training (Masia et al., 2001).
   There were also two additional unstructured meetings (pizza parties) that were included
   for practice of social skills. Fear and avoidance ratings decreased significantly.

2. Accommodations
The school environment may be causing anxiety, so investigate the child‘s fears. A good
relationship with the teacher can make a big difference helping the student return to school
just as a bad relationship can keep the child away (Paul, 1998). When fears are associated
with school performance, it will be important to reduce pressure and give practice tests and
practice relaxation techniques in the classroom (Jenni, 1997; Paul, 1998). It is important to
allow these children to have extra-curricular activities even when they miss school to reduce
their isolation from peers and make returning to school easier, and allow the child to sit by

                                                                 C11. Anxiety Disorders p. 17
   the door, so he/she can leave the room or go to a quiet space in the classroom when feeling
   anxious (Jenni, 1997). Use music in settings for individuals with anxiety or depression,
   which has been documented to reduce symptoms, as physiologically recorded by the body,
   even though the child may not report differences in emotion (Field et al, 1998).

A. Chapter Questions
 1. School phobia is often triggered by what kinds of events in a child’s life?
 2. School phobics can be manipulative of adults. Does this indicate that they are able to
    control their own fears?
 3. What is the cognitive distortion that is involved in anxiety generally and in school
    phobia specifically?
 4. What is the probable cognitive distortion of social phobia?
 5. What kinds of tasks are more difficult for children with high anxiety?
 6. How might poor school attendance be related to later employment and vocational
 7. How does shyness differ from social phobia?
 8. Identify Brittany’s possible anxiety disorders. Brittany is a Caucasian female, 11 years
    old, from a two-parent household; with one younger brother. She is labeled
    Emotionally Disabled and was placed in a self contained ED classroom, for yelling
    inappropriate words. Brittany fails to speak in social situations, specifically in
    academic settings; she is chatterbox at home. Her educational achievements are of
    concern and her relationships with others are minimal. She does have a few close
    friends and is considered compliant, although she can be verbally aggressive when
    pressed. Brittany has good verbal language. She enjoys school, is eager to attend, is
    quiet and nondisruptive, and smiles occasionally. She sings in the school choir and
    has a good relationship with school principal.
       Will do                                  Won’t do
       1. Copy                                  1. Read aloud to teacher
       2. Draw                                  2. Verbalize answers to questions
       3. Listen                                3. Write answers to recall questions (short
                                                    answer, essay)
       4. Write on a self-selected topic        4. Rarely verbalizes in academic settings
       5. Select answers to recognition type    5. Rarely verbalizes to adults
           questions (multiple choice, T/F,
                                                6. Verbalizes with peers in nonacademic
                                                7. Participate in specials
                                                8. Lunch in the cafeteria
                                                9. Little personal investment in doing
                                                    well; Poor grades

                                                                  C11. Anxiety Disorders p. 18
Her payoffs are to avoid tasks (33%), get self-determination (47%) and avoid failure (11%), and
get stimulation (8%) (adapted from a report submitted by Heather H-N.

B. Crossword Puzzle


                                    4   3

                                                                  C11. Anxiety Disorders p. 19
ACROSS (grayed bars with #s at the end)      DOWN (bolded numbers on top of blank bars)
1.Both social phobia and truancy are a       1. A neurotransmitter involved in many
  type of school ________________               anxiety types of disorders
2.Anxiety leads to average or better         2. Anxiety involves a high state of
  performance on ________tasks, like            physiological ________
3. Extremely high expectations for a         3. One of the earliest innate fear responses of
  child for success can lead to both            infants is called the Morro -__________
  Passive Aggressive Personality Disorder
  as well as to a type of phobia. Which
4. An irrational fear                        4. ___________Anxiety is specifically tied to
                                                being evaluated in a social comparison with
5. School refusal that involves              5. Repetition and exposure to feared
  externalizing types of behavior and           experience does not help children with ____
  avoiding school to be with friends or to
  have access to drugs

C. Cases
1. Case „P‟, subtitled: “I‟m not smart at all. I didn‟t get 100%. I‟m not smart at all.”
(adapted from an assignment submitted by Joy C.). This 9-year old boy is in a general education
classroom with 20 other students. The female teacher has more than 20 years of experience, all
in the 4th grade. P has been previously diagnosed as Asperger Syndrome (AS) and a
communication disorder. His IEP was written at the end of third grade. Now as a fourth grader
in a different school, he is having problems adjusting, for example, he seems to be having
problems following directions. Could this be an auditory processing problem?
His original IEP states the following:
    1. He can spend 0-20% of his day in the resource room.
    2. He avoids fine motor skills (FMS) and his cursive is more legible than print.
         (Observation shows that he prefers to print.)
    3. He finds noisy and busy environments challenging and is not to use the gym for inside
         recess due to sensory overload.
    4. He loves attention, and is down on himself frequently.
    5. He is very literal.
    6. He is to have a paraprofessional in the classroom in the afternoon to help him understand
         social language cues.
    7. He has excellent verbal skills.
    8. He can take short sensory breaks as needed.
                             Behavioral Log shortened from the original
Unless otherwise noted, there was no response made to any inappropriate behavior by the
teacher, paraprofessional, classmate(s), or this observer.
 1. Reading/Language Arts, am, teacher lead – interactive
      Sitting alone in comfy chair, quietly chewing his nails.

                                                                    C11. Anxiety Disorders p. 20
    Asked me to sit next to him.
    Walked around 2X
    Left class with permission to get Band-Aids, missed instruction.
    Raised hand and was called on.
    Didn‘t follow along with book.
    Put Band-Aids on nails, both thumbs and index fingers – ―These are my worst targets.‖
    Teacher instructed him to get a book.
2. Students reading a play from English book in front of class, roles assigned by teacher
    Continued chewing other nails
    Followed play with book in comfy chair; Teacher checks on him occasionally.
    Turns page with everyone else without prompt.
    Not disturbed by students on stairs making noise within his sight (lockers slamming
       several times).
    Turns page again with everyone else without prompt and without seeming to pay
    Volunteers to read for both scenes, but not called on.
    After teacher explanation (disruption), knew exactly where he was in reading.
    Got drink from water fountain in classroom.
    Reading ahead in the play during explanation.
    Didn‘t raise hand to answer questions.
    Followed in book when play continued.
    Turned page when hearing other students turning page. Started following along again.
    Question and Answer after play, didn‘t seem to pay attention at first.
    Reminded the teacher of going to art. Got in desk chair ready to go.
    Listening because he turned in book when teacher instructed class to do so.
    Got in line when instructed.
    Followed teacher to art at head of line, quietly, still chewing nails. Waited quietly in
       hall for art teacher.
    Engaged me in conversation – Am I a paraprofessional for him? Am I a teacher?
3. Art, am, teacher lead – interactive, then individual work time with some socialization.
    Chewing nails, kicking shoes off and on for several minutes.
    Listened during instruction, but kept saying teacher‘s ideas were ―boring!‖
    Raised hand with question – idea for joke of the day.
    Talked to boy at next table, out of chair, social interaction.
    Started drawing, working quietly by himself.
    Not distracted by neighbors conversation.
    Went to next table to interact with same boy.
    Talked to boy at his table – no response.
    Chewing nails both when drawing and not drawing.
    Went back to next table, not disruptive.
    Semi-standing, semi-kneeling on chair
    Went to teacher with practice drawing for approval to start final. Has positive
       interaction with teacher.

                                                                 C11. Anxiety Disorders p. 21
      Worked independently, traveled to other tables, drew there, some interaction with
    Starts work on final drawing.
    Given time warning – 15 minutes.
    Still working intently, sitting quietly
    Tablemates wanted to see his drawing – got positive feedback/interaction.
    Started to color in with markers.
    Stood ~50% of time to work.
    Received individual instruction from teacher on how to make drawing better. Had help
       from teacher, copying over students pencil marks.
    Still chewing nails when he‘s not working
    Sought out social interaction, received positive peer experiences.
    Moved around (roamed) more than other, stood to work.
    Teacher colored edges of drawing – helping or doing for? Why?
    Followed instruction well.
    Checked on me, showed me drawing and explained it to me.
    After finishing, talks to teacher.
    Left class after turning in drawing and cleaning up space.
    Came back in and explained Pokeman to me (about drawing).
    Stood in line with the girls for several minutes.
    Walked up the hall quietly, holding a boy‘s hand
4. Math, going over test, interactive.
    Teacher assigned homework from skills book, 2 pgs, front and back.
    He told another student that his parents get mad when he has homework.
    Showed me his math test, got an A. Not happy because he‘ll ―never get them all right.‖
    Sat at desk to go over math test, but the test was on the floor, back to chewing his nails.
    Looked at the test when questions were asked.
    Moved from desk to comfy chair.
    Told me, ―I‘m not smart at all. I didn‘t get 100%. I‘m not smart at all.‖
    Told me, ―I got 2 0‘s for turning in work late. I‘m not smart at all.‖
    Hugged pillow in comfy chair
    Leaned forward to see his math test for the reading of each problem.
    Volunteered for several questions early on, not called on, stopped volunteering.
    Called on for last question, got it right, positive feedback from teacher, but didn‘t
       respond positively to himself.
    He was asked to help his seatmate with a problem.
    Corrected other mispronunciations while they were reading the problems.
    Told me he got 100. I said good job, he said he got 100 wrong.
    Told me his job is class medic, ―my job is boring.‖
5. Science, am, mostly teacher instructing
    Sat up to listen to explanation of seasons (teacher writing on the board.)
    Still chewing on his nails.
    Teacher told all students in the back half to sit in front on the floor to see explanation
       with model.

                                                                   C11. Anxiety Disorders p. 22
       Stayed sitting when bell rang for aLEbout 30 sec., then went to back of class to wait at
        the door, still listening to teacher.
       He was worried because, ―we‘re losing recess.‖
       Left classroom when instructed.
        [eliminated 6-10, see ABC-P Table)

11.Individual computer and stress reduction instruction with Occupational Therapist in resource
room. (The OT was someone he‘s never worked with before.)
      Wanted me to carry his computer, I said he was able.
      He was instructed to open a document and complied.
      Said that he was scared of new things.
      OT would say, ―Show me how to . . .‖ and he would follow directions.
      Made grunting noises.
      Told the OT, ―I‘m furious. You‘re making fun of me because of my fears.‖ She
        responded that she wasn‘t making fun, just commenting that those where things they
        could work on.
      Told the OT, ―There‘s just so many problems with me.‖
      Yelled at P, resource room teacher told him to be quiet.
      Yelled again, received positive reinforcement from OT.
      Seemed to have run out of patience to do what was asked on the computer.
      Kicked a trashcan next to the desk.
      Ran out of the room in anger. When the OT followed, he ran further down the hall.
      Slapped at OT‘s hands several times as she tried to get him to come back into the
        resource room.
      Drug back into the classroom by the OT.
      When back in the resource room, he commented that he ―Could just destroy myself.
        That‘d be the best way.‖
      Left classroom.

Observation of this student showed some behavioral parallels to statements made in his IEP,
   1. He displayed an avoidance of fine motor skills, but that avoidance wasn‘t consistent to all
      areas of use (pencil, scissors) or subjects.
   2. He didn‘t seem to be disturbed by the noise and busyness of the cafeteria, nor the noise of
      students in the stairwell and at their lockers just outside his classroom during instruction.
   3. While there were times when he seemed to love attention, there were certainly other
      conditions when he wanted to be socially invisible. He was frequently down on himself.
      (―I‘m not smart at all.‖, ―I can‘t do it, it‘s timed.‖, ―There‘s just so many problems with
   4. He wasn‘t as literal as one would expected for AS. He seemed to understand nuances
      and nonverbal expressions. Once, the teacher asked him if she was serious in a statement
      she had made to him, and he responded correctly that no, she was not.
   5. Specifically noted were his excellent verbal and reading skills.

Overall, this student spends almost all of his time displaying competence, avoiding failure, or
avoiding the social attention he might receive as a result of his failure. He spends just less than

                                                                      C11. Anxiety Disorders p. 23
half of the time showing competence and a little more than half avoiding failure and social
Total Payoffs for All Evaluative Settings




  10%                                                                       5%

         Get competence     Avoid failure     Avoid social attention   Get relatedness


 -40%                          -35%

To better understand these settings the data will be presented according to the following flow

                                            Evaluative Settings

                      Nonsocial                            Social
                    (Without Peers)                 (Peer involvement)
                       (Table 1)

                                                    Perceived                    Perceived
                                                  100% success                 <100% success
                                                     (Table 2)                    (Table 3)

Table 1: Evaluative Setting in a Nonsocial Environment.
Antecedent Behavior                           Result                                 Payoff
Art         Went to teacher with practice     Positive interaction                   Get competence
            drawing for approval to start     with teacher.
Art         Received individual               Positive interaction                   Get competence
            instruction from teacher on       with teacher.
            how to make drawing better.
Science/IN Started labeling map, sitting                                             Get competence
History     quietly, no complaints
Science/IN Wanted me to cut it out for        Told it didn‘t have to                 Avoid failure
History     him, then asked the teacher.      be perfect.
            (Now a social setting, see

                                                                               C11. Anxiety Disorders p. 24
              Table 3)
Transition,   Told teacher ―I‘m just too sad‖ Given choice to work        Avoid failure
math          to be doing his homework.       on math in class or
homework                                      spend rest of day in
                                              resource room.
Individual    He was instructed to open a     Positive reinforcement      Get competence
instruction   document and complied.          from OT.
with OT
Individual    Seemed to have run out of        Positive reinforcement     Avoid failure
instruction   patience to do what was asked    from OT.
with OT       on the computer.
Social        Sat at desk to take the test.                               Get competence
SS            Asked if the test was timed      Told no.                   Avoid failure
SS            Asked teacher about printing     Told to write what‘s       Avoid failure
              or cursive.                      easier.
SS            Worked on test quietly.                                     Get competence

When given an evaluative task without possible peer judgments of his competence, he will either
perform well because he feels competent or he will ask specific questions in order to avoid
failure at the task. Overall, he wants Competence about half the time and to avoid failure or get
clarification the other half.

Table 2: Evaluative Setting in a Social Environment With Perceived 100% Success
(Notes in italics were made with a paraprofessional in the classroom. P signifies
Antecedent            Behavior                            Result              Payoff
Reading/Language Raised hand to answer question.          Called on.          Get competence
Reading/Language Volunteers for reading for both          Not called on.      Get competence
Arts                  scenes
Reading/Language Didn‘t raise hand to answer              Ignored.            Get competence
Arts                  questions
Art                   Raised hand with question – idea Positive feedback Get competence
                      for joke of the day                 from teacher.
Art                   Tablemates wanted to see his        Positive
                      drawing                             interaction with
Art                   Showed me drawing and               Positive            Get relatedness.
                      explained it to me.                 interaction with
Math                  Showed me his math test, got an     Gave positive       Get relatedness
                      A. Not happy because he‘ll          encouragement
                      ―never get them all right.‖         for doing well.
Math                  Volunteered for several questions Not called on.        Get competence
                      early on.

                                                                      C11. Anxiety Disorders p. 25
Math                 Corrected mispronunciations by         Ignored.             Get competence
                     classmates while they were
                     reading the math problems.
Science              Talked to P                            P told him to be     Get relatedness
Science              P took notes while he played with                           Avoid failure (see
                     the pipe cleaners.                                          explanation
Science              Looked around the classroom                                 Avoid failure
                     while a peer was reading
Science              Corrected the teacher.                 Shushed by P.        Get competence

Science              Told P to build his DNA.                                    Avoid failure
Science              Told P, “All I care is that I get an                        Get competence
Science              Answered teacher’s questions           Ignored, he          Get competence
                     correctly.                             wasn‘t called on.

IN History           Answered questions.                    Positive             Get competence
                                                            reinforcement by
IN History           Started labeling map, sitting                               Get competence
                     quietly, no complaints
Chess Club           Match ended in a stalemate, he         Told good match      Get competence
                     was glad he didn‘t lose.               by classmates.
Science (video)      Answered question by teacher                                Get competence
                     during pause.
Science              Answered question                      Teacher gave         Get competence
                                                            positive feedback

When a social evaluative setting can be met with a perceived 100% success rate, the student was
comfortable showing his competence. In the presence of the paraprofessional, he perceived that
success was guaranteed. So in order to avoid failure and guarantee that success, he let the
paraprofessionals do the work for him. He took little or no responsibility for his learning during
their presence in the classroom. Instead he used this time to socialize with his classmates. Notice
also that there were 2 incidents of relatedness with the paraprofessionals. This follows the line
of thinking that he will be successful with minimal or no effort. For what paraprofessional will
let him fail when they are in the classroom? Again, according to his theory, they‘re ―supposed to
do it‖ (a comment made on multiple occasions) for him.

Table 3: Evaluative Setting in a Social Environment With Perceived Less Than 100% Success.
(Notes in italics were made with a paraprofessional in the classroom.
P signifies paraprofessional)
Antecedent         Behavior                    Result of behavior     Payoff
Math               Told me, ―I‘m not smart at I didn‘t respond.
                   all. I didn‘t get 100%. I‘m

                                                                       C11. Anxiety Disorders p. 26
                not smart at all.‖
Math            Told me, ―I got 2 0‘s for      I didn‘t respond.
                turning in work late. I‘m
                not smart at all.‖
PE              Performed shot put, but        Encouragement from       Avoid social
                immediately down on            classmates.              attention.
                himself for not doing well
PE              Ran away from class            Encouragement from       Avoid social
                                               classmates.              attention.
PE              Yelled at classmates for       Encouragement from       Avoid social
                encouraging him 3X             teacher.                 attention.
PE              Ran into wall of building      Classmates yelling at    Avoid social
                6X                             him not to, he‘d get     attention/rejection.
PE              He said he has to be the       I had conversation       Get competence
                best.                          with him about
                                               Michael Phelps.
PE              Ran off screaming in           Ignored.                 Avoid social
                frustration.                                            attention/rejection.
PE              Stayed outside an extra 5                               Avoid social
                minutes after class went in.                            attention.
PE              Went in, didn‘t join class     Teacher asked for his    Avoid social
                on floor.                      scores.                  attention.
PE              Walked away from class         Ignored.                 Avoid social
                2X.                                                     attention.
PE              Ran loudly across gym,         Ignored.
                away and back.
IN History      (Continued from Table 1)       Asked to be quiet.       Avoid failure.
                Said he has to cut it out
                perfectly, repeated 4X.
IN History      Said he can‘t do it         Teacher said he could       Avoid failure.
                                            – that it doesn‘t have
                                            to be perfect.
IN History      He said he can‘t repeatedly She reiterated that it      Avoid failure.
                and argued with the teacher didn‘t have to be
                about his ability.          perfect.
IN History      Told me, ― I have to be     I didn‘t respond.           Get competence.
                right all the time.‖
Timed writing   He went into the hall – ―I  Finally had him call        Avoid failure.
activity        can‘t do it, it‘s time.‖ He his mom to get him to
                wouldn‘t even try.          calm down.
Math            He wanted someone to        Teacher said no.            Avoid failure.
                write the answers for him.
Individual      Yelled at P                 Resource room               Avoid failure.
instruction                                 teacher told him to be
with OT                                     quiet.

                                                                    C11. Anxiety Disorders p. 27
Individual       Yelled again                  Received positive        Avoid failure.
instruction                                    reinforcement from
with OT                                        OT.
Individual       Kicked a trashcan next to     Told to relax.           Avoid failure.
instruction      the desk.
with OT
Individual       Ran out of the room in        When the OT              Avoid failure.
instruction      anger.                        followed, he ran
with OT                                        further down the hall.
Individual       Slapped at OT‘s hands                                  Avoid social
instruction      several times as she tried to                          attention.
with OT          get him to come back into
                 the resource room.
Individual       Drug back into the            OT asked if there was    Avoid social
instruction      classroom by the OT.          a behavior plan in       attention.
with OT                                        place. Told no.
Individual       When back in the resource Positive                     Avoid social
instruction      room, he commented that       encouragement from       attention.
with OT          he ―could just destroy        OT and P.
                 myself. That‘d be the best
Individual       OT gave him and a             Encouraged by OT to      Avoid failure.
instruction      classmate squeeze balls to    try.
with OT          relieve frustrations, anger.
                 He wanted nothing to do
                 with it.
Individual       Began trying to hit the OT Told that wasn‘t            Avoid failure.
instruction      as she attempted to work      appropriate behavior.
with OT          with him.

Table 3 shows that, in social settings with perceived less than 100% success, this student
responded predictably in one of two ways based on whether the evaluation had already occurred
or was to occur presently. When he felt he had already failed, his response was to avoid the
social attention his failure might bring. When the evaluation was imminent and he perceived his
success to be less than 100%, he responded by avoiding the task to avoid failure. Graph 3 shows
the payoffs of his behaviors during social evaluative settings where he perceived his success to
be less than 100%.

                                                                  C11. Anxiety Disorders p. 28
           Graph 3: Evaluative Setting in a
          Social Environment With Perceived
              Less Than 100% Success.

            Avoid social                               Avoid failure
             attention                                    46%


Another problem this student has is with directions, specifically direct commands given by the
teacher, whether to him individually or to the class as a whole. While many children choose to
disregard requests from authority figures from time to time, this student disregards those requests
on a regular basis. Table 4 is a list of these behaviors, responses, and the payoffs for those
responses. Please note: this is not a list of his ability to listen to class instruction, but to direct
requests for specific behaviors.

Responses to Direct Commands by the Teacher (Notes in italics made when paraprofessional
was in classroom. P signifies paraprofessional)
Antecedent          Behavior                            Result       Payoff
Reading/Language Teacher instructed to get book,                     Get preferred activity
Arts                complied.
Reading/Language Got in line when instructed                         Get preferred activity
Arts                (going to Art)
Assigned            He told another student that his    Student      Get relatedness
homework from       parents get mad when he has         asked him if
skills book         homework.                           they were
                                                        mad at him
                                                        or teacher.
Math                He was asked to help his                         Get competence
                    seatmate with a problem, did as
Science             Told to sit down after walking                   Avoid failure
                    away from P, complied.
Science             Ignored P when she asked him                     Avoid failure
Science             Told by P to sit after leaving seat              Avoid failure
                    to look at classmate’s mutated

                                                                       C11. Anxiety Disorders p. 29
                   marshmallow, complied.
Science            Followed directions from P in                            Get relatedness
                   getting supplies.
Science            Didn‘t follow instruction until                          Avoid failure (of
                   after the 3rd time                                       task)
IN History         Knew what to do even thought he                          Get competence
                   had looked like he wasn‘t paying
                   attention as the instructions were
IN History         Didn‘t listen to instruction until it                    Avoid failure (of
                   was repeated.                                            task)
IN History         Told to sit, complied
IN History         Was jumping around in from of           Ignored by       Was trying to get
                   me, didn‘t listen to teacher            teacher and      relatedness
IN History        Sat after being told many times to                        Still trying to get
                  do so.                                                    relatedness
Chess Club        May not have heard the                                    Get preferred activity
                  instructions to reset the board                           (peer relatedness)
                  before leaving or may have been
                  ignoring them.
Math homework     Teacher gave verbal instructions,                         Avoid failure
                  rest of kids complying, he
Math homework     Didn’t follow directions                                  Get preferred activity
Math homework     Supposed to return to seat, but    P tried to             Avoid failure
                  didn’t follow directions 3X.       rationalize
                                                     with him
                                                     about doing
                                                     as told.
Independent work. Didn‘t follow instruction.         Ignored.               Avoid failure
Science           Followed directions as asked                              Get preferred
End-of-day         Followed instructions to return to                       Avoid boredom
cleanup            desk, then started to wander.
End-of-day         Followed directions to get                               Avoid failure
cleanup            backpack
Science            Teacher told him to sit up (he                           Get preferred
                   was laying), complied.                                   activity.
Science            Picked up computer off floor
                   when asked.
Science            Went to teacher to ask question         Told to sit      Get preferred activity
                                                           2X before
Social Studies     Tried to give the test to the           Told to put it
                   teacher (not following previous         in the basket

                                                                     C11. Anxiety Disorders p. 30
Social Studies       Went to desk to follow teacher‘s                     Avoid failure
                     instructions about putting
                     worksheet in specific folder.
End-of-day           Listened and started listing                         Avoid failure
cleanup              homework
                     Left room when dismissed to get                      Avoid failure (miss
                     backpack                                             bus)

Table 4 shows that when given a direct command from the teacher, almost half of his responses
result from his wanting to avoid failure. This could be in choosing to listen as homework is
being listed or, more often, choosing not to respond appropriately so that he can avoid failure of
a task. Many times when the paraprofessional was present, he choose not to comply because, as
previously commented, he can guarantee success with their performing the task, requiring
minimal effort on his part. Often it seemed that the paraprofessional took care of the
activity/assignment simply because it seemed easier to do so than fight to get him on track.
The main antecedent for many of his inappropriate behaviors is his perceived level of success in
evaluative settings. When he feels he can be totally successful, he displays competence, whether
it is in answering whole class questions from the teacher (social setting) or taking a test
(nonsocial). However, when he feels that his success at the task at hand will be anything less
than 100%, he responds as if he will fail and avoids the task at all costs (whether cutting out
continents in science in a social setting or working on a timed writing activity in a nonsocial
setting). Whether his peers will be aware of his grade or not, he won‘t try if he believes he can‘t
succeed to begin with; he‘s unwilling to even attempt without a good bit encouragement from the
teacher and/or paraprofessional.

While his willingness to try may be a problem, a bigger one exists in his definition of success.
For him anything less than 100% is a failure. This can be seen directly in comments such as
―I‘m not smart at all. I didn‘t get 100%. I‘m not smart at all.‖ And ―I have to be right all the
time.‖ Another example would be the math test he scored an A on, but he wasn‘t happy because
it wasn‘t 100%. While most students view grades as a sliding grayscale from A to F, this student
sees grades as black and white, white being a 100%, black being everything else. So his
comment ―All I care is that I get an A.‖ really means, ―All I care is that I get 100%‖.

This skewed definition of success can also be shown to cause problems for the teacher in getting
him to comply with commands. While there seems at first glance to be no rhyme or reason as to
when he chooses to comply or ignore commands requiring a specific response, his payoffs of
those responses provide a clearer picture of what he is thinking. When he feels he has a chance
at evaluative success, he pays close attention and gives the expected response. Examples of this
would be listening to the list of homework reviewed at the end of the day to make sure he has all
the needed books and getting his backpack from the hall when instructed in order to not miss the
bus, a point of great anxiety for him. Other times when he shows a great ability to respond as
requested is when the request involves reading. When given a choice, his preferred activity
would be reading and he will typically do as requested when the response will give him the
chance to read, even if from a text. Most of the time when he ignores requests for specific

                                                                    C11. Anxiety Disorders p. 31
behavior, he does so because it would require that he perform or get ready to perform an activity
he feels he will fail at. Once again, he will ignore any request that brings him closer to
performing a task at which he‘s destined to fail.
As noted this child has a previous diagnosis of Asperger Syndrome (AS), a subtype of Autism
Spectrum Disorders. However, the child seems to only display the characteristic related to
anxiety. He has close friends, interacts well with peers, and generally shows appropriate social
behavior. The students in his class seem to like him and respond to him in a positive manner. If
AS were ruled out, another possibility would be ADHD-I. From this list, he displays a failure to
give close attention to details and makes careless mistakes in schoolwork (he doesn‘t review his
work before turning it in), doesn‘t seem to listen to what is being said to him (although he often
knows the answer to questions asked during his time of seeming inattentiveness), doesn‘t follow
through on instructions and fails to finish schoolwork (according to the teacher, he finishes the
homework; he just doesn‘t turn in it when requested), and has difficulty organizing tasks and
activities (his desk is typically in a state of disarray, but he doesn‘t have to clean it because the
paraprofessional does this for him). However, a he doesn‘t have enough of the characteristics of
ADHD-I. In addition, his defiance to direct commands could potentially be a problem as well,
and result in a label of ODD. Children with ODD have difficulty controlling their tempers,
appear frequently to be angry, and often have temper tantrums. They have persistent
stubbornness, resistance to directions, and deliberate testing of limits by ignoring, arguing, and
refusing blame. However, he was defiant only when he felt destined to fail.

That is, an analysis of his payoffs tell a more interesting story. For example, his seemingly
inattentive behaviors indicated that he was avoiding failure and having the paraprofessional do
the work for him. From the inappropriate behaviors noted in the observation, the best conclusion
is that this student has a form of performance anxiety, specifically in social settings where he
perceives his success rate to be less than 100%. One can see generalized anxiety play out
minute-by-minute in the constant finger and fingernail chewing. While he was never observed to
draw blood, his fingers were in his mouth constantly, a probable sign of anxiety. In addition to
this, he displayed a fair amount of defiance in the face of direct commands to avoid those tasks
with which he felt certain to fail. Since the defiance seemed to be secondary to performance
anxiety, it is assumed that if the anxiety problems were dealt with, the defiance problems would
as well.A diagnosis of performance anxiety seems too simple to describe the multiple behaviors
observed, but looking at the payoffs he is getting, this makes the most sense. While 4th grade
may seem early to be displaying this type of anxiety, it is possible that his internal dialogue is
actually making the anxiety worse. His mind is now trained to feel threatened by all evaluation,
timing, and grading experiences, especially when he isn‘t 100% sure of himself.

Accommodations and Interventions
Outside of a possible diagnosis for this student, specific problems need to be addressed. The
most obvious one is his wanting to avoid failure. First, an intervention is needed to change his
perception of what success is and what failure is. Currently, he sees this as black and white;
even an A isn‘t deemed a success unless it‘s 100%. He needs to be taught about shades of gray
on the success continuum. One possible way of doing this would be to have a grayscale line, one
end A and white (which Michael Phelps would represent) and going more and more gray (and
marked at each grade B through D) until the line is black, signifying an F. Having the student

                                                                      C11. Anxiety Disorders p. 32
compare his score to the line to determine how gray the grade really is may teach him that even a
C isn‘t a failure. Also related to his perceived social failure, an accommodation the teacher could
make for him would be to change his class job to being ―the paper pusher‖. If he has a problem
with turning in his homework because someone else will see his grade, taking away the social
embarrassment would hopefully decrease his anxiety with the situation and increase his chances
of turning in the assignment. If this is really the source of his anxiety, the teacher should see a
rapid turn-around in his failure to turn in his homework.

C. Case Questions
      P Question 1. Why does this case-writer not see P as asperger syndrome?
      P Question 2. What might the teacher do to increase P‟s compliance?
      P Question 3. Does this child have any „insight‟ into his own fears? What is your
      P Question 4. Does this child receive positive attention for his low self-esteem
                       statements and behavior? What is your evidence?
      P Question 5. When children do not follow instructions or apparently „listen‟, what
                       several possible interpretations of this lack of response?

                                                                    C11. Anxiety Disorders p. 33

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