BHIPP Bulletin

Volume 9, Issue 2

August 2023

This month's BHIPP Bulletin is a contribution from

Rheanna Platt, MD, Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine and BHIPP Consultant.

As the summer comes to a close and the new school year approaches, it’s a good time for primary care providers to review strategies for supporting youth who experience anxiety at school. While it is normal to experience some anxiety during the significant transition that comes with returning to school, here we will review more significant and/or problematic presentations of anxiety in the school setting, sources of anxiety in the school setting, and tips for managing school-related anxiety.

Sources of Anxiety in the School Setting

Anxiety and anxiety-related disorders are among the most prevalent psychiatric disorders in youth (Merikangas et. al., 2010). Anxiety disorders encompass a range of conditions, including generalized anxiety disorder (GAD), school phobia, social phobia, and panic disorder. Not surprisingly, this also means that anxiety can manifest itself in multiple ways in the school setting, from refusal to attend school, to inattention, to disruptive behavior, to somatic complaints, to selective mutism.

School refusal – perhaps the most severe form of school-related anxiety, has an estimated prevalence of 2% and can present as temper tantrums or behavioral difficulties in the morning in an effort to delay or avoid going to school, leaving or running away from school, difficulty separating from parents to go to school, and/or frequent somatic complaints before or at school (Elliott & Place, 2019). 

Other presentations of school-related anxiety can include:

• Perfectionism in school: this can occur in the context of GAD and can present as difficulty starting or failure to finish assignments or tests in school for fear of making mistakes, failure to turn in homework (if not completed to the student’s liking) and falling behind in school, performance anxiety around tests, or sleep disruption.
• Inattention: while typically thought of as a symptom of ADHD, inattention can also be a presentation of anxiety, as ruminating or worrying can affect one’s ability to attend to tasks or the discussion at hand.
• Physical symptoms: anxiety can manifest as physical complaints, including headaches, nausea, palpitations, and shortness of breath. These can occur in the context of panic attacks, which are usually brief/self-limited, but can be more chronic; in either case, symptoms can significantly interfere with school attendance and function. Frequent visits to the school nurse are common.
• Selective mutism: this can present as difficulty speaking or refusal to speak in certain settings (e.g., school). Similarly, children with social anxiety may avoid speaking in class or engaging in group activities.
• Tantrums or aggression: with extreme anxiety or distress, a child’s fight-or-flight response may lead to aggressive behavior.

Importantly, children may experience anxiety due to external challenges. In these cases, addressing the source of anxiety is critical. For example, a child with a learning disability and insufficient school supports may experience anxiety around school performance, and a child who is experiencing bullying at school may experience anxiety around peer interactions. In these cases, interventions at the school level (e.g., advocacy for appropriate school supports, filing complaints about bullying) are of paramount importance.

Strategies to Support Children Experiencing Anxiety at School

As strategies to support children may vary based on the source or presentation of anxiety, a first step is clarifying the source/nature of the anxiety. In addition to history-taking, the Screen for Child Anxiety Related Emotional Disorders (SCARED) is a broad-band screening instrument that assesses for multiple sources of anxiety (e.g., panic, GAD, social anxiety, school avoidance). While there are differences in approaches based on the nature of the anxiety, an important component of treatment for most types of anxiety is exposure, or “facing your fears”. As avoidance (e.g., not attending school because school is feared; not turning in homework for fear of handing in something imperfect) reinforces anxiety, breaking the cycle of avoidance is essential. Here are some suggestions for intervention:

• For anxiety related to social interactions/situations, encourage families to arrange play dates with select peers before school starts. This allows children to practice skills on a smaller scale prior to the resumption of school. Other strategies include encouraging the child to practice social interactions (i.e., with siblings, parents, or other family members).
• Assess whether parents are accommodating or reinforcing the child’s anxiety. Parents may instinctually want to alleviate a child's acute distress by removing the fear or stressor. For example, parents may remove the child from school or attend to their somatic complaints in an effort to protect them. This may unintentionally lead to an increase in anxiety.
• Coordinate with the child’s school. This may be required in the event of bullying or identification of learning difficulties requiring education supports. Similarly, some anxious children may benefit from behavioral plans in school. In cases where a child is avoiding school, developing a plan for gradual school re-entry may also be required.

Relevant BHIPP Newsletters:

1. School Refusal and Specific Interventions

2. Highlights Regarding the Medication Management of Pediatric Anxiety Disorders

3. Back to School Routines: Resources for Families

4. Back to School Tips and Resources

5. Bullying

6. Educational Services: Know Your Rights and Resources

7. Goodbye Summer, Hello School (Refusal)

Related Resources:

1. Child Mind Institute resources on Back to School Anxiety, How Does Anxiety Affect Kids in School, and Treating Anxiety in Kids by Working With Parents.

2. The Anxiety and Depression Association of America (ADAA) offers information for parents about accommodations for their children in the classroom.

3. The American Academy of Pediatrics has tips for parents regarding school avoidance and links to related content (e.g., signs of bullying)

4. This article offers 5 Tips to Ease Back to School Anxiety

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

BHIPP Announcement

Register for the BHIPP ECHO Beyond the Basics Series!

Join our multidisciplinary team of child behavioral health experts starting October 12th at 12:00pm for virtual case-based learning and didactic presentations. This series is great for providers who have already participated in BHIPP ECHO, or who feel like they are experienced in treating behavioral health in their practice setting and are looking to explore advanced topics.