Oct. 1, 2018

Are your dreams over if you fail that exam? Finding ways to overcome anxiety disorders in schoolkids

Anxiety disorders in children are often difficult to detect, but they can have profound effects on academic performance, social well-being, and self-esteem. UCalgary researchers study the causes of anxiety disorders, how to treat them, and how to prevent them in the first place.

A certain amount of anxiety is perfectly normal in the classroom. Stressing about a test or worrying about fitting in with friends is part of any child’s healthy development. A normal level of anxiety can even be a powerful motivator to try harder. But for some kids, their worries and fears take over their emotional well-being and can even cause serious physical symptoms.

While we know that anxiety disorders are one of the most prevalent mental health issues in children and adolescents, there’s no precise statistic that tells us just how many may be struggling with an anxiety disorder in any given classroom across Canada.

That's because identifying kids who may be coping with a disorder is an “inexact science,” says Dr. Kelly Schwartz, PhD, a psychologist and associate professor in the School and Applied Child Psychology program in UCalgary's Werklund School of Education.

“Anxiety disorders are particularly hard to identify because they are the non-disruptive mental disorder of children," says the former school psychologist, also a member of the Alberta Children’s Hospital Research Institute (ACHRI) in UCalgary's Cumming School of Medicine. "It tends to start with withdrawal, what looks like shyness, a lot of separation anxiety where kids pull away or they don’t engage."

Children and teenagers with anxiety disorders generally don’t cause problems in the classroom. Rather, they sit quietly and can easily go unnoticed. “I hear from teachers when kids are unruly, aggressive or oppositional,” says Schwartz. “They stand out for very overt reasons whereas children with anxiety disorders almost ‘stand in.’”

Kids with anxiety disorders tend to be diagnosed a little later — when they have to start doing class presentations, begin to deal with more peer group pressure or when they can start skipping school and their attendance record becomes an issue. “The prevalence of anxiety disorders and depression really starts to increase in the teenage years and the rates steadily go up until the early to mid-20s,” says Dr. Daniel Kopala-Sibley, PhD, an assistant professor in the Department of Psychiatry in the Cumming School of Medicine and a member of ACHRI, the Mathison Centre for Mental Health Research and Education, and the Hotchkiss Brain Institute. “We know that if you’re going to become depressed or anxious at any point in your life, about 75 per cent of people will do so before the age of 24.”

It’s important to try to diagnose and help people as soon as possible — long before that first episode of anxiety or depression occurs (the two disorders are often associated). The longer someone has issues, “the harder it is to treat them,” says Kopala-Sibley. “These are treatable problems, help is out there. If children can be spotted and treated sooner rather than later, it’s generally related to a better prognosis and a better outcome down the road.”

Related: Mental Health Matters, a special publication from UCalgary Alumni magazine

Researchers are working to better understand the complex matrix of factors from both nature and nurture that can lead to anxiety disorders in children and teenagers. “We know it’s a combination of genetics they inherit from their parents, the things they experience in their family, peer and romantic relationships, and how they do at school,” says Kopala-Sibley “It’s not as simple as saying that if you have a certain set of genes you’re definitely going to become anxious. It’s a combination of genes and adverse experiences in your life that seems to promote risk for anxiety and depression.”

That combination is not easy to pin down. “This is not a yes/no type of identification,” says Schwartz. “Anxiety disorders have a lot of moving parts.” And, he stresses the need to understand the difference between a child exhibiting perfectly normal anxious behaviour or having a shy temperament with a child who may have an anxiety disorder. “It’s really important that we differentiate between the two. Is this a child having some adjustment issues, they have some changes going on their lives that is causing some stress versus a child who has a clinical anxiety disorder that’s persistent and pervasive.”

Schwartz, Kopala-Sibley and other scholars in disciplines including psychology, psychiatry and education are researching anxiety disorders in kids to better understand the risks and causes, how to potentially intervene to prevent a disorder from occurring and how to develop effective treatments if it does. The research covers a lot of ground, from First Nations communities outside Calgary to hyper-competitive classrooms in China, and it offers much insight.

Dr. Kopala-Sibley's lab is recruiting for a study that examines how parenting, personality, and brain development influence adolescents’ vulnerability to depression or anxiety. Parents and teens in our study will be asked to complete questionnaires and interviews, participate in an interaction task, and teens will be asked to have an fMRI and EEG. 

You may be eligible for this study if you have experienced, or suspect you have experienced, anxiety or depression in your past, and if you have a child between the ages of 12 and 17 who has never been diagnosed with depression or anxiety. Participation will require two visits to the Foothills Medical Centre in Calgary.

Anxiety disorder more common in girls

Canadian longitudinal research indicates that while anxiety disorders tend to peak in boys around age 12, they keep increasing in girls for several years, to the point where the disorders occur about 50 per cent more often in teenage girls than boys. Researchers believe there are a number of reasons for this gender difference.

A figure representing anxiety threatens a young girl

Girls are more susceptible to anxiety in school.

“Social pressures are heavier for females than males in terms of inclusion and exclusion, and the importance and meaning of relationships can breed more opportunities for girls to be more anxious about their social standing and their peer status,” says Schwartz. Furthermore, young women can have “more dramatic and noticeable” physical changes than boys and that can cause body image issues that are associated with anxiety. “It’s a combination of neurology, social pressures and physiology,” he says.

Anxiety in girls can have real impact on their performance in the classroom. In a study of students in both elementary and junior high school, researchers found that academic engagement decreases as students get older. “In this study girls in junior high had higher levels of anxiety and specifically for girls, higher levels of anxiety was related to lower levels of academic engagement,” says Dr. Gabrielle Wilcox, PsyD, an associate professor in the Werklund School of Education and a member of the Cumming School of Medicine's Hotchkiss Brain Institute. “We found there are some gender differences in that process of transitioning from elementary to junior high with engagement and anxiety as the girls in junior high school had higher levels of anxiety than those in elementary.”

Who is at risk? Studying temperament and families

Temperament — the way a child tends to act, think, and feel — may be one of the factors determining which kids are more at risk for developing anxiety disorders or depression. “You can imagine two children or adolescents experiencing the exact same thing — maybe they both fail a test in school and one of these kids becomes really anxious or depressed whereas the other kid shakes it off and moves on,” says Kopala-Sibley. “I am interested in the difference between those two kids. What is making one react one way and the other react another way?”

During longitudinal research of small children on the U.S. eastern seaboard, an area devastated by Hurricane Sandy in 2012, Kopala-Sibley and his colleagues found they could use the children’s temperament profiles to predict which kids would experience more anxiety and depression after the natural disaster.

“Some children are particularly prone to fear, anxiety, sadness and anger and together we refer to that as negative emotionality, also known as neuroticism in adults,” he says. “It can potentially identify children who are particularly vulnerable to anxiety following a major stress in their life. If we can identify these kids well in advance of the actual stressor, in theory, one could intervene to reduce vulnerability and prevent future mental health issues.”

Children with negative emotionality may be at risk whether or not they live through a natural disaster such as a flood or a hurricane. Children who show low levels of positive emotions may also be at greater risk. “These kids are not very sociable, they don’t react very strongly when something good happens to them,” says Kopala-Sibley. “For example, some kids are overjoyed when they get the present they want and some kids are a little more muted about it.”

Kopala-Sibley is launching a major study in the Calgary area in which he and his colleagues are recruiting a group of teenagers and their families to follow throughout adolescence. The families will each have a parent that has a history of depression and anxiety disorders. “We know that children of parents who have these mental health problems are several times more likely to develop them themselves. These are essentially high-risk kids. We are going to recruit families where the teenager themselves has not yet experienced an episode of depression or anxiety,” he says.

The goal is to further identify factors that may predict whether a teenager will develop depression or anxiety disorders and to be able to intervene earlier and prevent the disorders from emerging. “Right now the current state of the field is not such that we could say with any certainty who is going to develop anxiety or depression but we can say at least that we think this kid versus that kid is probably more at risk.”

Lessons from high-risk kids

One way to help children and teenagers with anxiety disorders is to better understand the millions of children who don’t have these issues. Data shows that 70 per cent of Canadian kids are doing well — they're succeeding at school, are involved in their communities and participate in sports, music and other activities.

“I want to find out what’s working for kids and why,” says Schwartz. “What are their relationships, what are the identity issues that are strong for them, what are the social supports, how’s school and teacher engagement and attachment? We’re constantly trying to figure it out. We want to find out what those factors are that need to be nurtured early on so that we can promote mental health and prevent mental disorders from happening.” While there has been much research into these questions amidst the mainstream population of children and teenagers, Schwartz is studying “pockets” of other kids who may be unrepresented or ignored in more general studies. This work has taken him to the Stony First Nation, just west of Calgary.

“Even amidst what we could consider to be one of the populations most at risk here in Canada, there are some strengths that we’ve left untapped that need to be identified,” he says. “We’re finding that for kids in Indigenous communities their cultural and social heritage is absolutely vital to their well-being.” Learning about their history and spending time with elders and other mentors “is a powerful source of strength for kids,” he says. “It gets clouded over when you consider all the other factors that are going against this population, but for the kids that are not only adjusting well, but thriving, those social and intergenerational connections are huge.”

The study is also revealing that children and teenagers with a strong sense of identity — that is, how they see themselves and their value in the world — can negate some of the familial, economic and societal challenges they face. “A healthy identity not only reduces some of the power of the negatives, it actually neutralizes them, it takes it right of the mix,” he says. “We’re trying to parse out how kids develop that healthy identity.”

Schwartz and his colleagues have also studied children of first responders; another group considered high risk for mental health issues because of the nature of their parents’ stressful occupations. One such subset is the children of parents in the Canadian military. Their parents are likely to be deployed to dangerous situations, leave the family for extended periods of time to serve and they may come home with post-traumatic-stress-disorder issues. Military families also tend to move from base to base every few years, leaving friends and support networks behind. All of this adds up to a “potentially toxic family environment,” says Schwartz.

The researchers assessed a small group of kids and their preliminary results indicate that rather than having low scores of “positive development assets,” the children of parents in the Canadian military exceeded the general population in some measures. “One of the things that’s really coming through is the power of friendship and the role that friendships play in being a healthy distraction for kids as they go through lots of change with parents in these high-stress occupations,” says Schwartz. “These friendships can be a real source of strength for them.”

And these days those friendships are aided by the “instantaneous connections” afforded by Facebook, Instagram and other social media platforms. “Social media has great power to do harm and great power to do good,” says Schwartz. “In this case, it could be a real source of strength for these kids because when they move to a different town or city they can still stay virtually in touch with their close friends and that’s a big support for them.” Parsing out the factors behind the power of friendship — self-disclosure, intimacy and having a reliable ally — could help moderate stressful or anxiety-causing situations for children and teenagers with anxiety disorders.

On the other hand, a theory gaining “some empirical momentum” is that too much social media — and the 24/7 social pressure it brings — is causing heightened anxiety and anxious behaviour in children and teenagers. Schwartz and his colleagues are studying how screen time impacts very young children, three- and four-year-olds, and whether too much time on the phone, tablet or desktop computer may affect their ability to develop executive functioning skills. Executive functioning is a child’s ability to manage their lives, make good decisions and self-regulate, and it’s “heavily associated with how you cope with stress,” says Schwartz. “It’s not a far stretch that if we see kids with lower executive functioning that are high technology users, those kids might be more at risk for demonstrating those anxious behaviours that we’re starting to see in schools.” In another study that’s just getting underway, Schwartz and his colleagues will look at the correlation between a parent’s heavy use of technology and their children’s use.

Setting kids up for success

It’s no surprise that children and teenagers who live in different cultures face different sorts of threats that may contribute to anxiety disorders. But wherever kids are in the world, their mental health issues can often stem from “children fearing whether they measure up to success,” says Dr. Xu Zhao, EdD, assistant professor, director of research in Chinese Youth Mental Health and Well Being at the Werklund School of Education and author of Competition and Compassion in Chinese Secondary Education. “Despite huge differences in the education system and culture, what’s common in North America and China is the weight we give to individualistic competitive success,” she says. “For some children, anxiety is about competitive academic success; for others, it is about acceptance and popularity.” In both cases, it is important to foster confidence and resilience by promoting positive development.

Zhao is researching that positive development and how schools and families can foster cognitive and emotional capacities to help children and teenagers deal with the “normal psychological needs to be competitively successful” without leading to developing anxiety disorders and other mental health issues. One culprit, she says, may be a “check box approach to learning” where students are taught to perform tasks in a particular in way to ace the exam. “Teachers tell the students that they are learning to meet certain standards or assessment requirements so learning is about meeting those requirements not about learning and growing,” says Zhao.

Rather, she suggests teachers and schools allow students to take the time to become immersed in a topic. “Be patient, let the students spend time and enjoy themselves and get fully engaged in the activities,” she says. “Let them fully explore something so they can concentrate. Research shows concentration is associated with low levels of anxiety.”

And at home, parents need to love their kids unconditionally and be aware of how they may be unknowingly impacting their children’s mental health. “Parents can consciously and unconsciously show more affection, love and excitement when their kids perform well,” she says. “And they can show disappointment or disapproval when they aren’t performing as well.” When a family shares unconditional love, acceptance and support, children and teenagers feel more secure and don’t live in fear of disapproval from their parents.

Psychologists have long understood that certain parenting styles are risk factors in a child developing depression or anxiety disorders. Children in homes where they are neglected or abused are at a higher risk and so are kids with parents who are overly critical or harsh. “Generally when parents send the message to kids that their care, regard or love for them is contingent on how that kid acts, that tells the kid that you are only a good person if you’re meeting other people’s standards,” says Daniel Kopala-Sibley. “That really sets them up for depression and anxiety in the face of failures or bad things happening in their life because it makes them fundamentally question their self-worth.”

Young people who develop anxiety disorders can suffer academically when they move on to post-secondary education. In a study of first-year students at the University of Calgary, researchers screened for anxiety and depression and asked the students about their grades and factors that interfered with their success. “One of the things that we found was that anxiety accounted for 32 per cent of the variance in academic achievement in their first year in university,” says one of the researchers, Gabrielle Wilcox. “If they have high levels of anxiety it interferes with their ability to succeed academically.”

Aside from the impact of anxiety on their academic performance, students reported high levels of loneliness, depression and anxiety in general — in all faculties and across all disciplines. The eye-opening results led to the development of UCalgary's Campus Mental Health Strategy, designed to support students, faculty and staff who may be struggling with mental health issues that affect their performance and their well-being overall. 

When issues such as anxiety begin to affect performance, it can create a cycle that's hard to break — the more that performance is impacted, the more anxiety you experience. 

That's why, at home and at school, rather than focusing on children and teenagers being stronger, smarter and more successful, Zhao and other educational experts emphasize encouraging creativity, communication, connection and contribution. “These four Cs will help students build confidence and resilience in a competitive world,” she says. “And the key is to emphasize these messages in the day-to-day practice of teachers and parents.”

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Dr. Kelly Schwartz, PhD, is a psychologist and associate professor in the School and Applied Child Psychology program in UCalgary's Werklund School of Education. His current research interests centre around the social-developmental factors related to child and adolescent development, family and ecological systems theories, identity and positive youth development, and spiritualiy/religiosity across the lifespan. Read more about Kelly

Dr. Daniel Kopala-Sibley, PhD, is an assistant professor in the Department of Psychiatry in the Cumming School of Medicine and a member of ACHRI, the Mathison Centre for Mental Health Research & Education, and the Hotchkiss Brain Institute. His research pertains to the influence of developmental experiences on change over time in personality and brain functioning in youth, and how these factors interact to influence risk for depressive and anxiety disorders. Read more about Daniel

Dr. Gabrielle Wilcox, PsyD, is an associate professor of school and applied child psychology in UCalgary’s Werklund School of Education and a member of both the Mathison Centre for Mental Health Education & Research and the Hotchkiss Brain Institute. Her research focuses on improving our understanding of how to support student learning and preparation for post-school requirements. Specific areas of research include neuropsychology for intervention, mental health in schools, transition planning, and university-level instruction. Read more about Gabrielle

Dr. Xu Zhao, EdD, is an assistant professor and director of research in Chinese Youth Mental Health and Well Being at the Werklund School of Education. Her research aims to examine cultural ideologies and assumptions related to child development and education, challenge social structures that support hegemony and injustice, and engage in social actions to protect youth mental health and promote their long-term social, moral, and civic development. Read more about Xu

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