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School- Based Interventions for Students with Generalized Anxiety Disorders

Christina Majcher

University of Calgary

ANXIETY INTERVENTIONS
Most teachers agree that every classroom has students with varying degrees of anxiety.
Many children manage their anxiety with minimal support. However, some children suffer with
anxiety that affects their ability to manage their day-to-day lives. Children with ongoing,
excessive anxiety and worry may be diagnosed with generalized anxiety disorder (GAD).
Commonly manifested through school refusal, somatic complaints of stomachaches and
headaches, inhibition and excessive shyness, the internalizing symptoms of anxiety are often
overlooked and misunderstood by adults (Peacock & Collett, 2010). Fortunately, there has been
a recent surge of research and literature on effective school-based interventions for challenges
associated with GAD. However, not all interventions have the same effect. Professionals within
the school environment can help ensure successful interventions by identifying quality
indicators. Upah and Tilly (2002) present a 12-step quality indicator model as a best practice
standard when designing, implementing and evaluating interventions. This beneficial model can
help review interventions for children with GAD within the problem-solving framework. This
paper will examine characteristics associated with GAD, the etiology of the disorder, common
interventions or strategies of support, and an overview of Upah and Tillys model followed by its
relation to the evidence based intervention program, Coping Cat.
Anxiety disorders are the most common psychiatric disorders affecting children and
youth (Albano, Chorpita & Barlow 2003). GAD is a chronic anxiety disorder that affects up to
5% of people at some point in their lives and is diagnosed two times more in females than males
(Brown, OLeary & Barlow, 2001; Witchen & Hoyer, 2001). Often described as little
worriers, children with GAD display excessive and unrealistic worry about adult concerns,
over-exaggerate the likelihood of unrealistic events, place high standards on themselves to the
point of perfectionism, require frequent reassurance and feel anxious for longer periods of time
than children with age appropriate anxieties or concerns (Brown et al., 2001; Albano et al.,
2003). According to the DSM-IV (APA, 2000), GAD is characterized by excessive and hard to
control worry that must occur for a period of at least six months. This worry causes clinically
significant functional impairment and has at least three of the following symptoms: restlessness,

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being easily fatigued, difficulty concentrating, irritability, muscle tension and sleep difficulties
(APA, 2000).
Many theories help explain the origin of GAD in children. The etiology of this disorder
is currently believed to result from a combination of genetic, biological and psychosocial risk
factors that interact and combine to produce this complex genetic condition (Brown et al., 2001;
Schienle, Hettema, Caceda & Nemeroff, 2011). Numerous family and twin studies have been
conducted to help determine if GAD has a familial pattern. Recent research indicates a general
heritability of traits is often correlated with anxiety and anxiety disorders (Rygh, Sanderson,
2004). GAD is considered a moderately familial disorder with heritability rates estimated
between 20-30 percent (Brown et al., 2001; Rygh, Sanderson, 2004; Schienle et al., 2011).
Although the genetic link is clear, the modest correlation is likely the result of the diagnostic
poor validity and reliability associated with GAD (Shienle et al., 2011).
Links are being researched between anxiety and possible brain systems. A study by
Paulesu and his colleagues (2009) identified specific neural correlates for high worriers with
GAD (Paulesu et al., 2009). The study indicates that people with and without GAD have worry
triggered in the same locations of their prefrontal and anterior cingulate regions, areas commonly
associated with mentalization and introspective thinking (Paulesu et al., 2009). Individuals with
GAD demonstrated persistent activation in these areas, indicating possible neurotransmitterbased dysregulation (Paulesu et al., 2009).
Recent research into the neurobiology of GAD echoes this previous discovery, linking
GAD to the amygdala and the bed nucleus stria terminals (Yassa, Hazlett, Stark & Hoehn-Sari,
2012; Schniele et al., 2011). The amygdala has long been known to regulate emotional
responses whereas the bed nucleus of the stria terminals influences behaviour well after the
stimulus has been removed (Yassa et al., 2012). It is believed that these two systems diminish
the response of the amygdala as well as an enhancement in the response of the bed nucleus of the
stria terminals during unpredictable or stressful times that prolong an individuals anxious state
(Yassa et al., 2012). Similar to the study by Paulesu and his colleagues (2009), activation was

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persistent (Yassa et al., 2012). While the data regarding adults with GAD has always indicated
increased amygdala volume, the data for children with GAD has been inconsistent, likely related
to challenges associated with diagnosing pediatric GAD (Schniele et al., 2011).
The origins of GAD are interconnected with environmental and psychosocial factors.
There are a large number of theories ranging from parental psychopathology to attachment
issues, stressful life events, abuse, helicopter parenting, parental avoidance and the modeling of
anxious behaviour (Nordahl, Wells, Olsson, & Bjerkeset, 2010). Evidence indicates that
childhood GAD is more common with parental overprotection, parental pressures and inadequate
supervision and control (Nordahl et al., 2010). Although these can all be contributing factors,
most theories emphasize the parallel relationship and interactions between a childs temperament
and environmental factors (Rapee, Kennedy, Ingram, Edwards & Sweeney, 2010). Children who
display inhibited behaviours early in their lives tend to elicit an overprotective and controlling
behaviour style, often linked to the parents own anxiety (Rubin, Burgess, Kennedy & Stewart,
2003). This interaction appears to enhance the childs inhibition throughout their development,
resulting in an increased risk for an anxiety disorder (Rubin et al, 2003; Hudson & Rapee, 2004).
Regardless of the origin of a childs diagnosis of GAD, this disorder can be debilitating.
Without intervention and support, children risk the likelihood of comorbid disorders, particularly
depression and substance abuse (Campbell, 2003; Roemer, Orsillo & Salters-Pedneault, 2008).
Research over the last 20 years has proven that the prognosis for individuals who receive
treatment for anxiety is significantly better than those who are left untreated (Campbell, 2003;
Albano et al., 2003; Hoffmann, Sawyer, Witt & Oh, 2010). Current intervention strategies used
to treat anxiety disorders include exposure techniques, pharmacological support, play therapy,
psychodynamic or family therapy, psychoeducation regarding anxiety and a wide variety of
cognitive behaviour therapy programs and mindfulness training (Campbell, 2003; Evans,
Ferrando, Findler, Stowell & Haglin, 2008). Over the past couple of decades, these approaches
have been widely researched to explore their benefits and impact on reducing anxiety (Roemer,
Lee, Salters-Pedneault, Erisman, Orsillo & Mennin, 2009).

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The most studied contemporary treatments for GAD are those that follow a cognitivebehavioural framework (Peacock & Collet, 2010). Cognitive behavior interventions (CBT),
delivered individually or in group settings, are problem specific and focused on symptom
reduction (Peacock & Collett, 2010, p.112). Evidence-based programs such as Timid to Tiger,
Friends for Life, Cool Kids and Coping Cat focus on teaching positive self-talk, adaptive coping
skills, and teaching behaviour strategies to reduce symptoms of anxiety (Peacock & Collett,
2010). Although CBT continues to be the most common form of intervention to treat anxiety,
the concept of mindfulness-based stress reduction has come to the forefront in recent years.
Some researchers believe that cognitive behaviour therapy does not address the psychological
processing difficulties of emotional regulation and mindfulness that are typical symptoms
associated with GAD (Roemer et al., 2009).
A large number of classroom-based strategies are available to teachers and school
professionals to help reduce anxiety in the classroom. Teachers can help children with GAD by
providing a routine and predictable classroom environment, watching for behavioural cues that a
childs anxiety might be rising and working with the student to determine strategies for reducing
anxiety such as a quiet working environment, relaxation exercises, or using humour to distract.
Despite all of the strategies and interventions available to children with GAD, many
students struggle to manage with reduced symptoms in a typical classroom. Although
internalizing disorders such as GAD are commonly observed problems in the school system, they
have historically received less attention than externalizing disorders (Peacock & Collett, 2010).
In addition, as Upah and Tilly (2002) indicate, most students do not receive quality interventions.
Further compounding the problem is lack of access to resources. Finally, many teachers have
minimal knowledge of anxiety disorders and lack understanding of what constitutes anxiety
compared to age-appropriate worries.
Applying a problem-solving model to monitor and guide the intervention process helps
increase the quality of interventions. Upah and Tillys (2002) 12-step model has specific
standards for designing, implementing and evaluating interventions. This model is divided into

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four stages: problem solving identification, problem analysis, plan implementation, and problem
evaluation. The remainder of this paper will review Upah and Tillys (2002) model to explore
the efficacy of procedures and strategies to support and reduce symptoms in children with GAD.
Furthermore, this model will be discussed in reference to the evidence-based intervention of
Coping Cat.
The first step in the process is problem identification, which identifies, defines and
validates a problem (Upah & Tilly, 2002). This phase has three intervention components known
as behavioural definition, baseline data and problem validation. The first intervention
component is determining a clear behavioural definition that includes a complete description of
specific actions that the student is demonstrating (Upah & Tilly, 2002). This definition should
indicate what a student does in external actions using both examples and non-examples (Upah &
Tilly, 2002). This is a crucial step for supporting children with GAD as it may be difficult to
view external signs of their anxiety. A behavioural definition to describe target behaviour for a
child with GAD may include examples such as rapid breathing, tense posture, absence of
eye contact or leaving room as well as non-examples such as calm breathing, relaxed
posture or calm voice. This definition helps identify which behaviours are occurring when the
child is experiencing anxiety.
The second intervention component is to obtain baseline data by identifying a childs
current level of functioning. Necessary aspects of the challenging behaviour must be identified
and measured in the natural setting before the successful implementation of any intervention
(Upah & Tilly, 2002). A systematic method of measuring data must be established, outlining the
behaviour to be measured, how it will be collected, necessary materials, who will collect the data
and where and when the data should be collected (Upah & Tilly, 2002). Review and clarification
of these variables is important as data is collected throughout the course of the intervention
(Upah & Tilly, 2002). Changes in variables can affect the entire process. The measurement of
data must be appropriately linked with identified behaviours in the environment where the child
is demonstrating anxiety and collected over several days until a relationship between symptoms

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of anxiety and environmental variables can be established (Upah & Tilly, 2002). When
collecting baseline data on anxiety, behaviour may be different dependent on the environment or
proceeding events. Also, methods of collecting data need to be realistic and feasible for teachers.
Many of the core symptoms of anxiety are subjective and not observable, which can overwhelm
busy teachers (Peacock & Collett, 2002). A realistic method of data collection for teachers could
include gathering information and tracking the intensity of a childs anxiety. Information could
also be collected on the latency, or elapsed time of anxious symptoms as well as the setting and
perhaps antecedent event (Upah & Tilly, 2002).
The final intervention component in problem identification is problem validation. This
assesses the scale of problem by determining the difference between a students baseline, or
current level of function, in comparison to the typical functioning of his or her peer group (Upah
& Tilly, 2002). School professionals can then determine any discrepancy between the identified
problem and the standard behaviour and whether the problem requires intervention (Upah &
Tilly, 2002; Peacock & Collett, 2010). All children experience worry and anxiety. This stage of
the process helps identify if the anxiety and worry warrants intervention.
The second problem solving stage is problem analysis steps. Upah and Tilly identify it as
perhaps the most complex and most critical to the selection of appropriate interventions
(p.488). This step begins with identifying what is known about the problem and what is
unknown through the process of collecting data to determine why the problem is occurring
(Upah & Tilly, 2002). Assessment information is linked to the intervention by generating a
hypothesis and predictive statement to logically explain the behaviour and guide intervention
(Upah & Tilly, 2002). One method used to help determine the function of a childs anxious
behaviour is a functional behaviour assessment (FBA). A childs anxious behaviour might be
connected to attempts to escape or avoid uncomfortable situations and/or to escape aversive
situations (Peacock & Collett, 2010). A childs anxiety may be linked to multiple antecedent
events and consequences (Peacock & Collett, 2010). Problem analysis includes manipulating
and observing the behaviour by implementing the intervention or manipulating the environment

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(Upah & Tilly, 2002; Peacock & Collett, 2010). This helps empirically test and validate the
hypothesis and predictive statement. If the hypothesis and predictive statement are validated,
then the plan moves towards the design and implementation of the intervention (Upah & Tilly,
2002). The goal is a meaningful and effective intervention plan that matches the intervention to
the needs of the student of concern (Upah & Tilly, 2002).
The third problem solving stage in Upah and Tillys (2002) model is plan
implementation. This includes the intervention components of goal setting, intervention plan
development, measurement strategy and a decision-making plan. The intended outcome or goal
of the intervention needs to be identified in a measurable, clear, and realistic manner with a
distinct time frame for expected change in behaviour (Upah & Tilly, 2002). This identifies core
features and logistics of the plan, as well as roles for each individual to help the successful
implementation and overall integrity of the intervention (Upah & Tilly, 2002). Measurement
continues to play an important role throughout the intervention process. To help make valid
comparisons with baseline data, the overall method of data collection must remain the same
throughout the intervention (Upah & Tilly, 2002). The scale created in the data collection phase
could be used throughout the plan to help ensure a common language.
The final problem solving stage in Upah and Tillys (2002) model is program evaluation.
This includes the intervention components of progress monitoring, formative evaluation,
treatment integrity and summative evaluation. Progress must be monitored on an ongoing basis
and interventions must provide support to ensure adequate mental health and a safe learning
environment (Peacock & Collett, 2010). Data collected throughout the intervention can be used
to help guide decisions, to modify strategies as needed and to ensure that data changes are the
result of growth with student performance rather than changes with the measurement (Upah &
Tilly, 2002).
Formative evaluation must occur throughout a planned intervention to help make changes
as needed (Upah & Tilly, 2002). For example, a child with GAD working on a cognitive
behaviour therapy program may be better suited to mindfulness stress based therapy instead

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(Upah & Tilly, 2002). Graphing the data can be a helpful way to visually summarize
information about a students progress and to help keep all of the individuals involved with the
plan on track. This can also be useful during formative evaluation to help compare progress to
the baseline data (Upah & Tilly, 2002). For example, a teacher implementing a cognitive
behaviour therapy intervention would be collecting, tracking and charting data to determine if
there has been a decrease in signs of anxiety that is following a trend over time and if the data
indicates an increase in coping strategies. (Upah & Tilly, 2002; Peacock & Collett, 2010).
Treatment integrity checks help ensure that the intervention is being implemented as
intended (Upah & Tilly, 2002). Having this part of the process directly built into the progressive
intervention plan is effective, perhaps in the form of a teacher completing a checklist as part of
their observation time (Upah & Tilly, 2002). The integrity of the plan depends on clear
interventions that target the area of greatest concern and include the teacher and parents as part
of the collaborative process. This collaboration can, increase the impact of the intervention as
well as increase positive relationships between parents and school personnel (Peacock & Collett,
2010, p. 18).
Summative evaluation provides an opportunity to determine the success of an
intervention to change student behaviour positively. Data collected throughout the plan is
reviewed to guide further decisions. If the outcome of the intervention is positive, efforts should
be made to help maintain gains and generalize behaviour gains to other settings (Upah & Tilly,
2002). If the outcome of the intervention is negative, changes to the intervention plan need to be
considered beginning with a reanalysis of the problem (Upah &Tilly, 2002).
Coping Cat, created by Philip Kendall, is an evidence-based intervention that has been
proven to reduce symptoms of GAD in children (Beidas, Benjamin, Puleo, Edmunds, Kendall,
2010; Mychailyszyn et al., 2011). This cognitive behavioural treatment program is a series of 16
sessions that teach children methods to recognize anxious feeling and their reactions, reframe
thoughts in anxiety provoking situations, develop plans to cope with challenging situations,
evaluate performance and administer self-reinforcement as needed (Beidas et al., 2010).

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Although the skills taught are similar to typical CBT programs for adults, Coping Cat provides
developmentally appropriate lessons that increase a childs ability to relate to the concepts.
Coping Cat meets the majority of the criteria outlined in Upah and Tillys (2002) model
for designing, implementing and evaluating quality interventions. This program supports
problem identification with the interventionist establishing a rapport and collecting information
from the child about times and situations when they feel anxious as well as their typical response
(Mychailyszyn et al., 2011). This helps the interventionist establish a behavioural definition,
collect baseline data and determine problem validation. This information can be examined to
meet Upah and Tillys (2002) second stage of problem analysis. When delivering Coping Cat, a
meeting is held after the third session with a childs parents to encourage parental involvement,
review treatment goals, share ideas and to receive parental input (Mychailyszyn et al., 2011).
This stage allows the interventionist to review the data provided by their own observations as
well as information from the child and parents to create a hypothesis and predictive statement to
help guide the intervention. Plan implementation includes implementing the lessons outlined in
Coping Cat. This program allows for flexible implementation without compromising fidelity to
ensure the intervention is individualized to the students needs (Beidas, Benjamin, Puleo,
Edmunds, Kendall, 2010). In terms of program evaluation with Coping Cat, children evaluate
their own performance and reward themselves as they move through the lessons. However, it is
also necessary that the interventionist monitors student progress, ensures treatment integrity and
has methods to conduct formative and summative evaluation.
Over the years, children with externalizing behaviours have received attention and
support within the education system. Children with internalizing disorders such as GAD have
often gone unsupported leading to increased risks for life-long mental health concerns and school
dropout. Children with GAD must have the same access to quality school-based interventions
designed and implemented by school psychologists and other school professionals (Upah &
Tilly, 2002). Although research into childhood anxiety disorders is increasing, many teachers
are ill equipped to support these children or to provide effective interventions. School

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psychologists can play a crucial role in helping educate schools, parents and children about
generalized anxiety disorders. Evidence-based interventions such as Coping Cat can have
positive effects on reducing anxiety in children. Efforts, such as Bell Mobilitys (2013) nation
wide Lets Talk campaign, are being made to remove the stigma associated with mental health
concerns. Wouldnt it be wonderful if those efforts were echoed in the elementary school
classroom?

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References
Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood Anxiety Disorders. In
Barkley, R. A. & Mash, E. J. Editor (Eds.)., Child psychopathology, 2nd edition, 279329. New York: Guilford Press.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders, 4th edition. Washington, DC: Author
Beidas, R. S., Benjamin, C. L., Puleo, C. M., Edmunds, J. M., & Kendall, P. C. (2010). Flexible
applications of the coping cat program for anxious youth. Cognitive and Behavioral
Practice, 17(2), 142-153.
Bell Let's Talk. (2013). Retrieved June 16, 2013, from http://letstalk.bell.ca
Brown, T., OLeary, T. A., & Barlow, D. H. (2001). Generalized Anxiety Disorder. In Barlow,
D. H. Editor (Ed.)., Handbook of psychological disorders, 3rd edition. New York:
Guilford Press.
Campbell, M. A. (2003). Prevention and intervention for anxiety disorders
in children and adolescents: A whole school approach. Australian Journal of
Guidance and Counselling, 13(1), 47-62.
Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulnessbased cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders,
22 (4), 716-721.
Hoffman, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness based
therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and
Clinical Psychology, 78 (2), 169- 183.
Nordahl, H. M., Wells, A., Olsson, C. A., & Bjerkeset, O. (2010). Association between
abnormal psychosocial situations in childhood generalized anxiety disorder and
oppositional defiant disorder. Journal of Psychiatry, 44, 852-858. Doi:
10.3109/00048674.2010.489504

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Paulesu, E., Sambagaro, E., Torti, T., Danelli, I., Ferri, F., Scialfa, G., Ruggiero, G. M., Bottini,
G. & Sassaroli, S. (2009). Neural correlates of worry in generalized anxiety disorder and
in normal controls: A functional MRI study. Psychological Medicine, 40, 117-124.
doi:10.1017/S0033291709005649
Peacock, G. G., & Collett B. R. (2010). Collaborative home/school interventions: Evidencebased solutions for emotional, behavioural, and academic problems. New York: Guilford
Press.
Hudson , J. L., Rapee, R. M., (2004). From anxious temperament to disorder: an etiological
model of generalized anxiety disorder, in Generalized Anxiety Disorder: Advances in
Research and Practice. Edited by Heimberg, R.G., Turk, C.L. & Mennin D. S. New
York: Guilford Press.
Mychailyszyn, M. P., Beidas, R. S., Benjamin, C. L., Edmunds, J. M., Podell, J. L., Cohen, J. S.
& Kendall, P. C. (2011). Assessing and treating child anxiety in schools. Psychology in
Schools, 48, 223232. doi: 10.1002/pits.20548
Rubin K. H., Burgess, K. B., Kenned, A. E., & Stewart S. L. (2003) Social withdrawal in
childhood, in Child Psychopathology, 2nd ed. Edited by Mash E. J. & Barkley R. A. New
York: Guilford Press.
Rygh, J. L. & Sanderson, W. C. (2004). Treating generalized anxiety disorder: Evidence-based
strategies, tools and techniques. New York: Guilford Press.
Roemner, L., Orsillo, S.M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based
behavior therapy for generalized anxiety disorder: Evaluation in a randomized controlled
trial. Journal of Consulting and Clinical Psychology, 76 (6), 1083-1089.
Roemner, L., Lee, J. K., Salters-Pedneault, K., Erisman, S. M., Orsillo, S. M., & Mennin, D. S.
(2009). Mindfulness and emotion regulation difficulties in generalized anxiety disorder:
Preliminary evidence for independent and overlapping contributions. Behavior Therapy,
40, 142-154.

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Schienle, A., Hettema, J. M., Caceda, R., & Nemeroff, C. B. (2011). Neurobiology and genetics
of generalized anxiety disorder. Psychiatric Annals, 41 (2), 113-123. doi:
10.3928/00485713-20110203-10
Yassa, M. A., Hazlett, R. L., Stark, C. E., & Hoehn-Saric, R. (2012). Functional MRI of the
amygdala and bed nucleus of the stria terminalis during conditions of uncertainty in
generalized anxiety disorder. Journal of psychiatric research, 46 (8), 1045-1052. doi:
10.1016/j.jpsychires.2012.04.013
Wittchen, H. U., & Hoyer, J. (2001). Generalized anxiety disorder: nature and course. Journal of
Clinical Psychiatry, 62, 15-21.