Anxiety Disorders & Non-verbal Learning Disabilities

What’s a Teacher to Do?

Nonverbal Learning DisabilitiesNLD is a controversial diagnosis – some

believe it is simply on the autism spectrum; others argue it is its own disability

Characterized by problems with non-verbal tasks (understanding non-verbal cues, pictures, space and time relationships etc.)

In older students other characteristics emerge

NLD presents similarly to Aspbergers in some ways. Certainly the anxiety that students with Aspbergers experience is similar to that of students with NLD

Characteristics of NLDImpaired ability to organize the visual spatial

field and thus respond to new or novel situations.

Has difficulty producing in situations where speed and adaptability are required

May have physical difficulties and look awkward when moving

May appear confused much of the timeOften has an exceptional memory for rote

materialVery concrete in understanding of

conversation – misses metaphors, figures of speech; does NOT understand irony or sarcasm

Characteristics of NLDOften perceived as a “smart alek” or smart

mouthMay talk a lot – cocktail talk (little content) or

talk about how something works or is done, rather than do it

May have excellent oral reading skills but this may hide weak comprehension

In spoken or written language they tend to talk/write about every minute detail – not ever getting to the main point

Written work is difficult because of motor difficulties as well as the difficulty in seeing/getting to the main point

Characteristics of NLD – High SchoolDo not see the whole pictureCan be confused by their surroundings Confused by or missing social interactions –

not getting the teen communication stylesDifficulty anticipating what comes nextMay have perfectionist and/or

obsessive/compulsive tendencies

Older students with NLDEarly compensatory behaviors do not work as

effectively Rote memory fails when the shift occurs to

application and interpretationProne to developing depression and/or

anxiety disorders

Accommodations for students with NLDExtra time to get places; verbal support and

explanation of how to get to to placesExtra assistance to organize selfBecause of strong verbal skills they present

as much more able than they are – remember 65% of communication is non-verbal and chances are, this student has missed it

Tell them how to do things – don’t show them (give running verbal descriptions when you are showing – for example when solving a math problem)

Anxiety Disorders…Is anxiety bad?When is anxiety bad?What is the difference between normal and

abnormal anxiety?Childhood Anxiety disorders are

characterized by: Pattern of excessive worry or uneasiness Interferes with development and day-to-day

functioning at home, school or in the community Frequency, duration and intensity

Types and Subtypes

• Separation Anxiety Disorder (SAD)• Generalized Anxiety Disorder (GAD)• Social Phobia• Panic Disorder (with or without

Agoraphobia)• Agoraphobia• Specific Phobia• Obsessive-Compulsive Disorder• Posttraumatic Stress Disorder• Acute Stress Disorder

Developmental Considerations

• Some anxiety is normal so must be careful to determine if anxiety is age appropriate

• Lack of communication skills can mean that some children and adolescents are unable to express what is bothering them

• Anxiety can manifest as somatic symptoms, anger, frustration or escapist behaviors

Developmental Considerations

Disorder Differences from Adults

Separation Anxiety Disorder

Must begin before 18. As children age fears may become more specific

Generalized Anxiety Disorder

Concerns with quality of performance or competence at school/sports. May be overly conforming, perfectionists and tend to redo task. Require excessive reassurance.

Social Phobia May not be able to avoid the situation; unable to identify nature of anxiety. Must occur with peers as well as adults and must have capacity for social relationship with familiar people.

Specific Phobia Specific types of onset come in childhood

Developmental Considerations

Disorder Differences from Adults

Panic Disorder Unusual to begin in childhood

Obsessive-Compulsive Disorder

Similar to adult presentation but more common in boys

Posttraumatic Stress Disorder

May exhibit repetitive play with themes or aspects of event; frightening dreams w/o recognizable contact; trauma specific reenactment

Acute Stress Disorder Few differences exhibited

Epidemiology

Waddell et al(2002) study suggests 6.4% of children experience Anxiety Disorders at any one time.

The Costello et al (2003) study – 3% of all children affected by anxiety disorders at any one point – 3 month point 9% - estimated occurrence for children of 1 event by age 16 was 3X higher – so 30% of children by age 16 will be affected by Anxiety Disorders

Equal number of boys and girls when young; by adolescence, more prevalent in girls.

Types of Anxiety Our Students Experience

May be anticipatoryMay be situational

Comorbidity among Anxiety DisordersConcurrent mental health problems such as

depression and other anxiety disorders are common

Highest comorbidity with depression is anxiety disorder

Childhood Anxiety disorders manifest first, before depression

Separation Anxiety often leads to adult onset Panic Disorder

Drug and alcohol misuse in adolescents is often comorbid with anxiety disorders

Treatment and PreventionProtective factors include:

Emotional stability Secure attachment Positive parenting Ability to use effortful control Perceived control Self-esteem and self-efficacy Coping strategies Defense mechanisms Emotional regulation Social supports

Supports for Students with Anxiety Disorders

• Recognize and honor the need for safe place to go when anxiety is high (requests to leave classroom etc.)

• Some students benefit from listening to music or loosing themselves in another activity (reading etc.)

• Ask the student to identify interventions they find helpful and work hand in hand with Student Support to find ways to offer those interventions to students in a non-obtrusive manner

Supports for Students with Anxiety Disorders

• Decrease situations that induce stress (allow alternative assignments if presentations are stressful – ie: record and play the presentation; do a taped powerpoint/breeze presentation)

• Discuss strategies and possible solutions PRIVATELY with the student (and possibly with a parent/advocate) – ensuring no other students are around

Supports for Students with Anxiety Disorders

• Follow a daily routine in the class so students know what to expect. If there is to be a change (field trip etc.) let the student know well in advance

• Help students break assignments into smaller segments to prevent feelings of being overwhelmed (offer to take in the smaller segments as they are completed)

Specific Questions to Ask the Student/Parent

• Is there a preferred seating location• Are there concerns about getting directions wrong

(if so, develop a signal or way of having them indicate they don’t understand directions)

• Are there concerns about having to participate• Are there concerns about class presentations• Are there concerns re: doing questions on the

board• Are there concerns regarding testing conditions

Specific Questions to Ask Student

• What can help after a return from illness • Are field trips a stressor (if so, excuse the student)

Recommended Readings/Viewing Kendall, P.C., Compton, S.N., Walkup, J.T., Birmaher, B.,

Albano, A.M., Sherrill, J., …Piacentini, J. (2010). Clinical characteristics of anxiety disordered youth. Journal of Anxiety Disorders, 25, doi:10.1016/j.janxdis.2010.01.009

Manassis, K., Hudson, J.L., Webb, A. & Albano, A.M. (2004). Beyond behavioral inhibition: Etiological factors in childhood anxiety. Cognitive and Behavioral Practice, 11, 3-12. Downloaded University of Calgary, September 29, 2011.

Pediatric Playbook – Anxiety – Dr S.. Goldman, Children’s Hospital, Boston http://youtu.be/xHzrcGZyEtc

Dr. Arlene Young, Simon Fraser University http://www.youtube.com/watch?v=loRC9T8qUGk&feature=youtu.be

www.worrywisekids.org

References

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Erlbaum.

Anderson, E. R., & Hope, D. A. (2008). A review of the tripartite model for understanding the link between anxiety and depression in youth. Clinical Psychology Review, 28(2), 275-287. doi:10.1016/j.cpr.2007.05.004

Albano, A.M., Chorpita, B.F., & Barlow, D.H. (2003). Childhood Anxiety Disorders in E.J. Mash & R.A. Barkley (2003). Child Psychopathology, 2nd ed. (pp. 279-329). New York: Guilford Press.

Bar-Haim, Y., Dan, O., Eshel, Y., & Sagi-Schwartz, A. (2007). Predicting children's anxiety from early attachment relationships. Journal of Anxiety Disorders, 21(8), 1061-1068. doi:10.1016/j.janxdis.2006.10.013

Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press.

References

Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., et al. (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 545–553.

Brown, T., & Barlow, D. (2005). Dimensional versus categorical classification of mental disorders in the fifth edition of the diagnostic and statistical manual of mental disorders and beyond: Comment on the special section. Journal of Abnormal Psychology, 114(4), 551-556. doi:10.1037/0021-8743X.114.4.551

Brumariu, L. E., & Kerns, K. A. (2008). Mother–child attachment and social anxiety symptoms in middle childhood. Journal of Applied Developmental Psychology, 29(5), 393-402. doi:10.1016/j.appdev.2008.06.002

Clark, D. M. and Wells, A. (1995). A cognitive model of social phobia. In Heimberg, R. G., Liebowitz, M. R., Hope, D. A. and Schneier, F. R. (Eds.), Social Phobia: diagnosis, assessment and treatment (pp. 69–93). New York: Guilford Press.

References

Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100(3), 316-336. doi:10.1037/0021-843X.100.3.316

Costello, E.J., Egger, H.L., & Angold, A. (2004). Developmental epidemiology of anxiety disorders. In T.H. Ollendic & J.S. March (Eds.). Phobic and anxiety disorders in children and adolescents: A clinicians guide to effective psychosocial and pharmacolgoical interventions. (pp. 61-91). New York:Oxford University Press. downloaded October 2, 2011 from University of Calgary ebook collection.

Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A.(2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60(8), 837–844. doi:10.1001/archpsyc.60.8.837.

Dallaire, D. H., & Weinraub, M. (2007). Infant–mother attachment security and children's anxiety and aggression at first grade. . Journal of Applied Developmental Psychology, 28(5-6), 477-492. doi:10.1016/j.appdev.2007.06.005

References

De Bolle, M., & De Fruyt, F. (2010). The tripartite model in childhood and adolescence: Future directions for developmental research. Child Development Perspectives, 4(3) 174-180. doi: 10.1111/j.1750-8606.2010.00136.x

Eley, T.C. & Gregory, A.M. (2004). Behavioral genetics. In T.L. Morris & J.S. March (Eds.). Anxiety disorders in children and adolescents. (pp 71-97). New York:Guilford Press.

Guy, W. (1976). The clinical global impression scale. The ECDEU assessment manual for psychopharmacology—revised (Vol DHEW Publ No ADM 76-338), Rockville, MD:  U.S. Department of Health, Education, and Welfare, Public Health Service, Alcohol Drug Abuse, Mental Health Administration, NIMH Psychopharmacology Research Branch, Division of Extramural Research. pp. 218–222.

Higa-McMillan, C. K., Smith, R. L., Chorpita, B. F., & Hayashi, K. (2008). Common and unique factors associated with DSM-IV-TR internalizing disorders in children. Journal of Abnormal Child Psychology, 36(8), 1279-1288. doi:10.1007/s10802-008-9250-8

References

• Kiff, C. J., Lengua, L. J., & Bush, N. R. (2011). Temperament variation in sensitivity to parenting: Predicting changes in depression and anxiety. Journal of Abnormal Child Psychology. doi 10.1007/s10802-011-9539-x

March, J., Parker, J., Sullivan, K., Stallings, P., & Conners, C. (1997). The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 554–565.

Muris, P.R. (2007). Normal and abnormal fear and anxiety in children and adolescents. Burlington, MA:Elsevier Science and Technology. Downloaded October 2, 2011, from University of Calgary ebook collection.

Muris, P., & van der Heiden, S. (2005). Anxiety, depression, and judgments about the probability of future negative and positive events in children. Journal of Anxiety Disorders, 20(2), 252-261. doi:10.1016/j.janxdis.2004.12.001

Roelofs, J., Meesters, C., ter Huurne, M., Bamelis, L., & Muris, P. (2006). On the links between attachment style, parental rearing behaviors, and internalizing and externalizing problems in non-clinical children. Journal of Child and Family Studies, 15(3), 319-332. doi:10.1007/s10826-006-9025-1

References

RUPP Anxiety Study Group. (2002). The Pediatric Anxiety Rating Scale (PARS): development and psychometric properties. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 1061–1069.

Shamir-Essakow, G., Ungerer, J. A., & Rapee, R. M. (2005). Attachment, behavioral inhibition, and anxiety in preschool children. Journal of Abnormal Child Psychology, 33(2), 131-143. doi:10.1007/s10802-005-1822-2

Shelton, R. C. & Hunt, A. J., 2008. Anxiety disorders. In S. H. Fatemi, & P. J. Clayton (Eds.), The medical basis of psychiatry (pp. 133-159). Totowa, NJ: Humana Press, Inc. doi:10.1007/978-1-59745-252-6

Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. Boulder, CO: Graywind Publications Incorporated

van Brakel, A. M. L., Muris, P., Bögels, S. M., & Thomassen, C. (2006). A multifactorial model for the etiology of anxiety in non-clinical adolescents: Main and interactive effects of behavioral inhibition, attachment and parental rearing. Journal of Child and Family Studies, 15(5), 568-578. doi:10.1007/s10826-006-9061-x

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References

van Brakel, A. M. L., Muris, P., Bögels, S. M., & Thomassen, C. (2006). A multifactorial model for the etiology of anxiety in non-clinical adolescents: Main and interactive effects of behavioral inhibition, attachment and parental rearing. Journal of Child and Family Studies, 15(5), 568-578. doi:10.1007/s10826-006-9061-x

Waddell, C., Hua, J., Godderis, R., McEwan, K. & Wong, W. (2004). Preventing and treating anxiety disorders in children and youth. Vancouver, BC:Children’s Mental Health Policy Research Program. Downloaded October 1, 2011, from University of Calgary ebook collection.

Waddell, C. Offord, D.R., Shepherd, C.A, Hua, J., & McEwan, K. (2002). Child psychiatric epidemiology and Canadian public policy-making: The state of the science and art of the possible. Canadian Journal of Psychiatry, 47, 825-832.

• Wood, J. J., McLeod, B. D., Sigman, M., Hwang, W., & Chu, B. C. (2003). Parenting and childhood anxiety: Theory, empirical findings, and future directions. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 44(1), 134-151. doi:10.1111/1469-7610.00106

References

• Wood, J. J., McLeod, B. D., Sigman, M., Hwang, W., & Chu, B. C. (2003). Parenting and childhood anxiety: Theory, empirical findings, and future directions. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 44(1), 134-151. doi:10.1111/1469-7610.00106