Panic Anxiety Disorders in Middle School Students

Informed educators can have a positive impact on students who are struggling

By: Rick Wormeli


In her 1994 book of poetry, Something Permanent, writer/poet Cynthia Rylant gets inspiration from the photographs of Walker Evans, a photojournalist who documented rural America during the Great Depression in the 1930s for the Farm Security Administration. In one photo, a young boy sits barefoot on a chair in a small room of a struggling family. The thin wooden walls are decorated with pictures cut from magazines, and the furniture, curtains, and boy's clothing seem old and tired. The boy sits up in his chair, though, interested at the prospect of having his picture taken. The last line of Rylant's companion poem for this photograph reads:

It gave him, briefly,
some sort of feeling
of just being
enough.

There are volumes spoken in these spare, few lines. What are all those factors in his life that convinced him he wasn't enough, what is lost because he never felt like he was enough, and where will this lead as he grows up?

Leaping forward 80+ years, do our students today feel like they are never enough for those around them? Almost hourly our students wonder if they are pretty enough, smart enough, normal enough, connected online enough, Hispanic/Black/Muslim/Jewish/Christian enough, athletic/creative/funny enough, male/female enough, or whether or not they are worthy of friendship/trust/respect/love. And what do we do as teachers to assure students that they, as they are right now and without conditions, are enough, that no apologies are needed for who they are or where they've been, that they are ceaselessly valued, legitimate individuals in their own right?

Fear of being enough is one of the many concerns that students identified with anxiety and panic disorders feel intensely. And this fear is often accompanied by real depression, though it may not be immediately identified as such, which can lead to unnecessarily long and painful recovery if not treated. And here's the thing, anxiety and panic disorders among students in middle school through college years are on the rise nationwide, but mental health training for teachers and the number of counselors assigned per school has not kept pace with the increasing demand.

If we have not experienced severe anxieties or panic ourselves, we may not appreciate the level of despair and real fear our students feel. For some of our students, we're talking about the involuntary heart-wobbling, muscle trembling, chilled (or warming) skin, sweaty palms, nausea inducing, let me out of this plastic bag before I suffocate, my toddler brother just ran into the street in front of a speeding car and I'm too far away to save him with my cement legs, my mouth is open but no scream will come kind of fear. This is the kind of fear that is only abated by pulling our limbs into the center of our bodies, closing our eyes, placing our face against a cool surface, and talking ourselves down from the precipice.

Some research suggests that your body's natural fight-or-flight response to danger is involved in panic attacks. For example, if a grizzly bear came after you, your body would react instinctively. Your heart rate and breathing would speed up as your body prepared for a life-threatening situation. Many of the same reactions occur in a panic attack. But it's unknown why a panic attack occurs when there's no obvious danger present.
www.healthline.com/health/panic-attack-vs-anxiety-attack#takeaway

To this day, I still wake up at night from time to time with the willies and cold sweats, recalling the stories of my cousins growing up and caving in Texas. They would crawl face forward, then wiggle, inch by inch to the very end of severely narrowing crevices deep in the earth while their headlamps faded in the heavy darkness. Soon their arms were pinned to their sides due to the now tight confines of the shaft, their faces wedged against the floor of the crevice, inhaling ancient dirt, because their skulls were jammed tightly against the rock ceiling above, leaving only six inches of breathable volume before the solid stone wall they can barely see. And now, before the oxygen depletes and panic sets in, they have to somehow communicate with their toes to the three climbers who lay end to end on their bellies in the crevice directly behind them to start backing up, and to do it pretty darn fast. I imagine the welling anxiety and crossing threshold for panic in students is something akin to this.

The weird thing about panic attacks is that they occur any time and without cause, and they can last just a few minutes to something much longer. Imagine driving a car at 65 mph on a busy highway and such an attack occurs—heart-racing, sweaty hands, dissociation from reality, feeling complete incompetence at the task, sucking oxygen like it's your last, unable to assimilate all the incoming data into your mind, and feeling like you've missed something vital, and you're three lanes over from the shoulder. You pray someone will let you over quickly and that there's a safe place to stop and pull over to let the panic subside.

This actually happened to a member of my own family who suffers from panic-anxiety disorders. This person misses work from time to time, struggles to maintain some conversations, can be significantly challenged navigating the grocery store, suffers from depression, and is exhausted by all of it much of the time—yet the person is brilliant, happy, extremely capable, and contributes mightily to the world. What a trapped feeling! For others I know, they feel ashamed of this condition, living in fear others will find out, which in turn can trigger panic. Many, including my family member, have these attacks in moments of great happiness as well. Anything can trigger it, and that's scary. Many of our students become anxious to an unhealthy degree just worrying about whether or not they will become too anxious to function.

The International Board of Credentialing and Continuing Education Standards (IBCCES) reminds us that anxiety in students is quite normal. It becomes an issue, they say, when it prevents students from participation in class and extracurricular activities, and when it affects their learning, test performance, and social interactions. In their blog, they elevate a big concern, as well: "Often, anxiety in students goes unnoticed and their unpredictable behavior, such as missing class, might be assumed to be lazy or irresponsible (ibcces.org/blog/2019/05/08/signs-student-anxiety-classroom/).

IBCCES says that anxiety and panic disorder students can obsess over perfectionism, feel "on edge," irritate easily, make out-sized emotional responses to non-threatening comments, refuse to go to school, isolate themselves, ceaselessly procrastinate, have difficulty focusing on simple tasks, and experience, "…derealization or feeling as if they are dying or going crazy."

In their online piece, "Panic Disorder: When Fear Overwhelms," the National Institute of Mental Health (NIMH) includes the following as indicators of panic disorders:

  • Sudden and repeated panic attacks of overwhelming anxiety and fear
  • A feeling of being out of control, or a fear of death or impending doom during a panic attack
  • Physical symptoms during a panic attack, such as a pounding or racing heart, sweating, chills, trembling, breathing problems, weakness or dizziness, tingly or numb hands, chest pain, stomach pain, and nausea
  • An intense worry about when the next panic attack will happen
  • A fear or avoidance of places where panic attacks have occurred in the past
    www.nimh.nih.gov/health/publications/
    panic-disorder-when-fear-overwhelms/
    index, downloaded December 4, 2019

Other indicators of anxiety and panic disorders include feeling helplessness in daily activities, insomnia, difficulty dealing with transitions, cutting one's skin, constantly feeling threatened, alcohol/drug use, unhealthy fear of failing, problems interacting with peers or family members. Doctors add that too much caffeine, thyroid problems, phobias, stressful work, financial worries, and experiencing or witnessing trauma can spark anxiety and panic attacks as well (www.healthline.com).

This is a lot for an already insecure middle school student to handle. Unfortunately, it's becoming more prevalent in our schools.

Anxiety and Panic Disorders on the Rise

I work with thousands of teachers each year to improve grading practices, and grading, of course, causes a lot of anxiety and sometimes panic in students. The number of teachers and principals—whether or not they work in urban, suburban, rural, affluent, underserved, well-served, diverse, homogeneous, faith-based, public, international, or charter schools—who report serious spikes in mental health referrals for anxieties and panic disorders in the past five years is stunning, disconcertingly so. They describe it as a tsunami.

Officially, the National Institute of Mental Health (www.nimh.nih.gov/health/statistics) reports that 31.9% of adolescents have some sort of anxiety disorder, with 8.3% having severe impairments as a result. They say that anxiety disorders are higher in females than in males.

In her March 28, 2018 (updated March 2019) NEA Today article, "The Epidemic of Anxiety Among Today's Students," Mary Ellen Flannery writes,

[A] Pew survey found that 70 percent of teens say anxiety and depression is a "major problem" among their peers, and an additional 26 percent say it's a minor problem… "Honestly, I've had more students this year hospitalized for anxiety, depression, and other mental-health issues than ever," said Kathy Reamy, school counselor at La Plata High School in southern Maryland and chair of the NEA School Counselor Caucus. "There's just so much going on in this day and age, the pressures to fit in, the pressure to achieve, the pressure of social media. And then you couple that with the fact that kids can't even feel safe in their schools—they worry genuinely about getting shot—and it all makes it so much harder to be a teenager."
neatoday.org/2018/03/28/the-epidemic-of-student-anxiety/

More disturbing still, Flannery cites a study published in Clinical Psychological Science declaring that between 2010 and 2015, "the number of teens who felt 'useless and joyless' surged 33 percent. The number of 13- to 18-year-olds who committed suicide jumped 31 percent." She follows these statements with reference to the work of San Diego State University Professor Jen Twenge, who says social media has played a significant factor here: "[Teens] say things to a screen that they would never say face to face, things like 'you should kill yourself.' And many studies have found that increased social media use actually makes people feel more socially isolated. It also disrupts sleep, which is related to mental health."

In her own article for The Washington Post in 2017, Twenge writes,

[W]hile conducting research for my book on iGen, I found that teens now spend much less time interacting with their friends in person. Interacting with people face to face is one of the deepest wellsprings of human happiness; without it, our moods start to suffer and depression often follows. Feeling socially isolated is also one of the major risk factors for suicide. We found that teens who spent more time than average online and less time than average with friends in person were the most likely to be depressed ... Teens are also sleeping less, and teens who spend more time on their phones are more likely than others to not be getting enough sleep. Not sleeping enough is a major risk factor for depression…

Interested educators can read more of Twenge's perspective here: www.washingtonpost.com/national/
health-science/teenage-depression-and-suicide-are-
way-up--and-so-is-smartphone-use/2017/11/17/
624641ea-ca13-11e7-8321-481fd63f174d_story.

While many middle school students can develop anxiety and panic disorders, it's becoming even more prevalent in our society as students move into high school and college. In their August 27, 2019, Harvard Health blog, "Anxiety in college: What we know and how to cope," Nicole J. LeBlanc and Dr. Luana Marques claim anxiety in colleges is widespread. They cite the American College Health Association Fall 2018 National College Health Assessment, stating that, "63% of college students in the US felt overwhelming anxiety in the past year ... 23% reported being diagnosed or treated by a mental health professional for anxiety in the past year." They continue their commentary, focusing on the biggest trigger for anxiety:

The sharpest increase in anxiety occurs during the initial transition to college. A recent study demonstrated that psychological distress among college students—that is, their levels of anxiety, depression, and stress—rises steadily during the first semester of college and remains elevated throughout the second semester. This suggests that the first year of college is an especially high-risk time for the onset or worsening of anxiety.
www.health.harvard.edu/blog/anxiety-in-college-what-we-know-and-how-to-cope-2019052816729

What might this mean with students transitioning to middle school, or from middle school to high school? For helpful articles on how to help students transition to middle school and from middle school to high school check out the sections on transitioning at amle.org, "Transitioning Young Adolescents from Elementary to Middle School - Research Summary" by Casey Dianna Gilewski and Monica L. Nunn, and "Preparing Students for the Transition to High School" by Vanessa Scanfeld, Sean Robertson, Leah Weintraub, and Vincent Dotoli. Also see my article, "The Middle/High Years/Movin Up to the Middle," (http://www.ascd.org/publications/educational-leadership/apr11/).

LeBlanc and Marques add that,

In the US, some research shows a decrease in psychological well-being among adolescents over the past several years. It's not entirely clear what is causing this trend, though research shows a strong association between time spent on electronic communication (social media, smartphones) and reduced well-being among adolescents. Electronic communication might interfere with adjustment to college if it replaces healthy coping behaviors like exercise, face-to-face social interactions, and studying.

How Do We Respond to Students Having a Panic Attack at School?

No one policy, program, or act will solve the problems of increasing rates of anxiety and panic disorders among our students or help those who currently experience them. Collectively, however, multiple responses from educators can have a positive impact. Let's look at some of the possibilities:

  • Conduct professional development for faculty on anxiety and panic disorders.
  • If rising anxiety and panic experiences are affecting learning, socialization, test performance, and self-efficacy, or limiting the student's success in significant ways, it is time to seek a professional's help. First, we contact our school counselors, if we have them, and from there, we may need to get the student to see a medical professional.
  • If a doctor diagnoses an anxiety or panic disorder, students may be treated with psychotherapy called, "cognitive behavioral therapy" which teaches students healthy ways to adjust thinking, behavior, and reactions as episodes begin or to keep them from happening in the first place. This may include exposure therapy, too, in which students spend short periods of time in the anxiety-inducing situations, but with support, then the time periods slowly increase over time until the anxieties in those situations subside. In severe cases, doctors may prescribe medications, including benzodiazepines (like Xanax) to calm students.
  • During the anxiety or panic attack, avoid the urge to comfort the student with the phrases, "It's not a big deal," "It's just part of being in middle school," or worse, "Everything is going to be fine." The student knows these are not true and that these attacks aren't normal. And now they've lost trust in you. Empty platitudes aren't balm; they don't comfort or respect the student.
  • Create a hotline texting app that connects the student directly to a school counselor, social worker, or psychologist as available, and promote it to students regularly. If they ever feel out of control, depressed, overly anxious, dysfunctional, suicidal, and need a listening ear and genuine support, they text a simple code to a particular number and a qualified adult advocate will respond within a few minutes.
  • As we can, we help students learn techniques to mitigate and control rising anxiety or panic attacks. We can provide a quiet, private space to do this, if needed, or help them use some of these techniques at their classroom desk as episodes rise. Some of those helpful techniques include:
    • Breathing deeply
    • Recognizing the panic attack and calling it what it is (this helps the person realize that it’s temporary and will pass)
    • Closing eyes to minimize external stimulation
    • Practiced mindfulness, focusing on specific sensations in and around the body
    • Relaxing muscles, focusing on one muscle or small group of muscles at a time
    • Focusing on an object in the room
    • Thinking of a comfortable, soothing place
    • Some forms of light exercise (endorphins release into the bloodstream and calm the mind)
    • Repeating a mantra
    • Smelling lavender (this has a calming effect in some people)
      Paraphrased from www.healthline.com/health/how-to-stop-a-panic-attack

In her article, "Anxiety in the Classroom – Another Learning Disability?," (amle.org/am/prentis), Paula Prentis, a licensed social worker specializing in child and adolescent health, wellness, and development suggests:

Instead of offering security, offer skills. For instance, if a student avoids school, create a context for him that values him being there. In one example, a student became known as the school pet expert. He never missed another day because he was valued for his knowledge of pets, something for which the teachers and many classmates counted on him. He felt "good enough."

  • We teach in a developmentally appropriate way. Middle schools aren't junior versions of high school (see, "Middle School, not Junior High," (amle.org/am/wormeli3), nor are they just extensions of elementary school. They are unique, and teachers should have specific expertise when teaching this age group. This means we spend considerable time and energy on teaming, exploratory programs, and teacher-advisory programs, even when they are not popular with those untrained in middle school research. All three have a strong, positive effect on student emotional growth and sense of belonging.
  • For students who need structure and regular procedures, provide them, but also sit with them ahead of time and talk through those moments in the day or days ahead that will not be as structured and normal. Identify specifically what irregular, unstructured thing is going to happen and the specific steps the student can take to navigate the irregularity constructively.
  • As mentioned above, build and maintain a robust and responsive transitioning program from elementary to middle school and from middle school to high school. Seriously, this is one of those times when thoughtful proactive work on the front end prevents all the unnecessary trauma on the back end for both students and their teachers. Schools with such programs never regret spending the time and energy in developing them.
  • Do not, do not, do not ask students to drop fine and performing arts classes, technology classes, or any other class or extracurricular activity in which they are passionately interested and feel safe in experiencing. Quite often, these are a collective oasis that gets them through the day feeling normal, capable, and invested in life. And yeah, that means we don't take students out of these experiences in order to double-up on math or reading classes in preparation for state or provincial exams.
  • Overtly teach students executive function skills (time management, impulsivity/distractibility control, decision making, moral and abstract reasoning, responding constructively in social situations, and more). Students can't use skills and tools they don't have, and wow, training in executive function sure does help in middle school. Among others you may find helpful, my article with suggestions on how to do this is on my website.
  • Invest the time and energy in all those positive school climate programs and elements, and make sure it's happening in all areas: hallways, classes, buses, bus stops, playgrounds/fields, locker rooms, cafeteria, and online. This includes social-emotional facets as well. Make sure teachers trained in their subject areas see the value of gaining expertise in the emotional development of their students. It's what professionals do, and given what we know about young adolescent development, it is educational malpractice to remain indifferent to it or incompetent in it.
  • Develop a dozen or more constructive descriptive feedback techniques and use them frequently instead of judgement or evaluation. Good descriptive feedback does not invoke ego or self-preservation; no one is threatened. It invites students into their own learning and builds self-efficacy. There are wonderful books just about feedback. Let's read them and assure hope and growth.
  • Pull back from the autocratic/didactic approaches as much as possible and facilitate more student choice. Choice feeds autonomy and the sense that what students want matters to the teacher.
  • Allow students to rehearse tests, speeches, conversations, and presentations a day or two ahead of time in order to visualize and experience what it will be like, where the rocky and smooth parts occur, what they will be seeing from their position in the room, what the materials will feel like in their hands as they recall the things they want to say, etc. It really helps.
  • We can't say this enough: Make recovering from mistakes and failures compelling and doable. Yes, allow re-do's and re-takes for full credit. If we're concerned about how to teach responsibility when we do this, I respond to that concern in Fair Isn't Always Equal, 2nd Edition (Stenhouse Publishers, 2018). I'd also suggest my articles on why students cheat and plagiarize (and how to recover from them), on redo's, on the fallacy of always preparing students for the levels above, and more at www.rickwormeli.com. All articles are free to download and share.
  • Confront and dismantle the systemic racism, sexism, classism, and gender orientation biases that are perpetuated by the unaware majority. Yeah, I know this is a big thing, but it makes you think: If we're spending all this focus on helping students cope with severe anxieties and panic disorders, we should also be thinking about what's at the root of many of those stresses instead of just telling students to deal with them. Looming huge among them are the micro and macroaggressions and structural limitations experienced daily by children of a different color/culture/gender/sexual orientation, or by children who are underresourced, overweight, or the sons and daughters of alcoholics and opioid abusers. What a devastating waste of everyone's time and student potential it is to slap a tiny band-aid on a forefinger when the real issue all along is the massive heart attack. To get started, consider faculty book studies with any of these books:
    • Gullo, Gina Laura; Capatosto, Kelly; Staats, Cheryl; Implicit Bias in Schools: A Practitioner's Guide, Eye on Education, 2019
    • Kay, Matthew R.; Not Light, But Fire: How to Lead Meaningful Race Conversations in the Classroom, Stenhouse Publishers, 2018
    • Mayorga, Edwin; Picower, Bree; What's Race Got to Do With It? How Current School Reform Policy Maintains Racial and Economic Inequity, Peter Lang Publishers, 2015
    • Oluo, Ijeoma; So You Want to Talk about Race, Seal Press (Hatchette Group), 2018
    • Pollock, Mica; SchoolTalk: Rethinking What We Say About – And To – Students Every Day (Laying a Foundation for Equity), The New Press, New York, 2017
    • Stevenson, Howard C.; Promoting Racial Literacy in Schools: Differences That Make a Difference, Teachers College, 2014

  • Finally, let's put information into the hands of students and their parents. If they want to know more, support others, or, if they are afraid they are developing serious issues with anxiety, panic, or depression, get them the support they need. In addition to what the school, district, county, and city services provide, remind them of the following:
    • Call 911 if they or someone they know is in immediate danger
    • National Suicide Prevention Lifeline - 1-800-273-TALK (8255). For Spanish speakers, use 1-888-628-9454
    • Crisis Text Line - Text “HELLO” to 741741

We breathe in and out, aspire to great things, stumble, get insight, learn to forgive, aspire again, stumble again, then rise to greet yet another day. We can do this because we have versatile skills honed from years of experience and the assurance that comes from having made it to our adult years relatively intact: There are grounds for optimism. Young adolescents aren't there yet, however, and their rocky, narrow path along the cliff's edge may fall away at any moment, or so it seems to them.

Let's respect those peaks and valleys of youth and remain empathetic to their journey. Where we cannot be empathetic, let's be informed and helpful, and at the very least, do no harm. At the very best, dismantle that which limits anyone. Let's prove to students daily through word, action, and culture that they are valued as they are, that they are enough. Then, let's show them that the dynamics among learning, anxiety, courage, doubt, happiness, and hope remain throughout life, and they are not alone as they make their way through it. Our belief in them and the power that comes from true connection with others in our lives, especially when we are struggling, never wane. Both are something permanent.


Rick Wormeli is a long-time teacher, consultant, and author living in Herndon, Virginia. His book, The Collected Writings (So Far) of Rick Wormeli: Crazy, Good Stuff I Learned about Teaching Along the Way, is available from www.amle.org/store. His book, Fair Isn't Always Equal (second edition) (Stenhouse Publishers), was released in 2018, and his latest book, Summarization in any Subject: 60 Innovative, Tech-Infused Strategies for Deeper Student Learning, (second edition) (ASCD), co-authored with Dedra Stafford, was just released.
rick@rickwormeli.onmicrosoft.com
@rickwormeli2
www.rickwormeli.com

Published in AMLE Magazine, February 2020.

 
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