This week’s blog was contributed by Carrie Champ Morera, PsyD, NCSP, LP. Carrie is a licensed school psychologist and the lead project and content director at PAR.
The increased use of telehealth—including teleassessment—has changed psychological assessment practices. Although many of us have adjusted our assessment practices to keep up with the times, we have to keep in mind that, when engaging in teleassessment, our practices must be ethical—just as if we were providing in-person assessment services.
Here are 10 ethical considerations for practitioners to consider when providing services via teleassessment.
1. Obtain informed consent. Just as you would do with in-person assessment practices, obtain informed consent prior to providing telehealth services. Informed consent is more than a form—it’s a process.
2. Train and practice. Carefully review standardization procedures for the assessment. Practice the assessments several times using the technology and platforms with which you plan to administer them.
3. Consult with colleagues. Talk about ethical dilemmas with colleagues, consult the literature, and continue to update your ethical guidelines. It’s important to lean on one another for practice, support, and guidance.
4. Follow the publisher’s guidelines. PAR developed a statement on telehealth that addresses test security and measurement concerns. The integrity and security of the tests must always be maintained.
5. Keep forms and data secure. Make sure paper protocols and electronic forms are stored securely. Consider password protections, encryption, and malware protection and keep backups.
6. Establish and maintain professional boundaries. It can be tempting to relax your professional boundaries in a telehealth setting. Dress professionally, reduce distractions, and set clear expectations with your clients.
7. Consider cultural factors. Consider the implications for clients from traditionally marginalized backgrounds or various socioeconomic and ethnic backgrounds or those with less computer experience.
8. Document the use of digital and remote assessments. Include a statement in your report that assessment was conducted via telehealth. Record any technical issues, and disclose any modifications or alterations of standardized procedures.
9. Consider the psychological effects of the pandemic in digital and remote assessment. We’ve seen a general increase in anxiety, depression, grief and loss, and isolation. Go beyond scores and evaluate individual item responses. Stressors all contribute to these psychological effects, perhaps now more than ever.
10. Take advantage of PAR resources. We have many teleassessment resources and a wide selection of products available for administration, scoring, and/or interpretation on PARiConnect—and we are always adding more! Need to brush up on your teleassessment skills? Check out this video from PAR’s Director of Customer Support, Daniel McFadden, or visit the PAR Training Portal for more insight. You can use PAR products via telehealth technology while retaining the integrity and security of the measures. PAR has several tools available to help you navigate this challenge.
Digital options to help us complete the work we do are increasingly important as digital interactions become more common in psychological assessment. We at PAR are committed to helping you serve your clients and recognize your increasing need for digital materials. Digital assessment options (like online and remote products, e-Stimulus Books, and e-Manuals) offer several benefits, including improved flexibility and support for your practice—whether you work in school, hospital, private practice, or other settings. Digital solutions can also provide increased accessibility and security in addition to environmental benefits like reduced use of paper.
We want to provide you with more options for test administration (e.g., on-screen vs. paper-and-pencil) while reducing the number of materials you need for administration and addressing concerns about hygiene with printed materials. We are expanding our library of e-Manuals, e-Stimulus Books, and remote assessment tools and adding more products offering administration, scoring, and interpretation via PARiConnect. We now offer more than 100 e-Manuals, which are easily accessed from our new Digital Library in PARiConnect. These digital versions of PAR professional manuals are also downloadable (limited to a single user and device). See our full list of e-Manuals.
Our In-Person e-Stimulus Books allow for easy, safer administration of stimuli via tablet and are designed for in-person testing sessions. Convenient and user friendly, these digital tools provide flexibility and confidence in testing and are hygienic and easy to clean. Visit parinc.com/e-stim to see what’s new. We also offer remote tests designed to be administered via videoconferencing. Learn more about our remote assessment solutions.
Finally, our online assessment platform, PARiConnect, allows you to administer and score tests from most internet-connected devices. Designed in strict adherence with HIPAA, this flexible tool is adaptable for any organization, from small, solo practitioners to large, multilocation groups. More than 75 assessment tools are currently available, and we are continually adding new products. New to PARiConnect? Get three free uses just for signing up.
No matter your setting, we have a digital solution that can help take your practice beyond paper and pencil!
This week’s blog was contributed by Maegan Sady, PhD, ABPP-CN. In addition to being a licensed psychologist and board-certified neuropsychologist, Maegan is a project director in PAR’s research and development department. She worked as a pediatric neuropsychologist for nearly a decade before joining PAR.
Psychological assessment allows for three types of clinical decisions: diagnosis, treatment planning, and measuring change over time. Assessment involves integrating information from multiple sources—tests, rating scales, observations, and interviews—to answer a given referral question and provide recommendations.
To best serve clients and patients, providers should engage in evidence-based assessment (EBA; related terms include evidence-based medicine, evidence-based practice, empirically based assessment, and evidence-based instruments). EBA relies on scientific knowledge to help providers make clinical decisions. Although EBA has been a longstanding goal in psychology, clear documentation of EBA standards has been in place for only the past 15–20 years.
Choosing reliable, valid assessment tools is the foundation of EBA. Basic psychometric strengths include representative normative samples, strong internal consistency, sound construct validity, and test–retest statistics (built-in change metrics are a bonus!). Because validity applies to the use of a test for a specific presenting problem in a particular individual, studies using discriminant function analyses and base rates identify the clinical utility of tests for given populations.
To use an EBA approach, ask: What tools can I use to rule the proposed diagnosis in or out? For which related conditions do I need to screen? What else do I need to know about this client to recommend an appropriate treatment? Which tests are sensitive to change in the constructs being targeted?
Increasingly more tools are available to providers to address real and perceived barriers to practicing EBA. Special issues of journals are devoted to using EBA for various conditions, books contain systematic reviews of instruments, and professional organizations have position papers on topics including serial neuropsychological assessment and effort/malingering.
To keep up with advances in research relevant to your practice, create Google Scholar or PubMed alerts to generate periodic emails (use search terms like “evidence-based assessment,” “meta-analysis,” or “systematic review,” along with key disorders) and organize the literature in a free citation manager. For an informal approach, follow known researchers and EBA gurus and join social media groups for your clinical interests. Subscribe to professionally focused podcasts and queue up relevant episodes for your next commute, walk, or hammock session.
At PAR, we aim to propel the growth of EBA by working with our customers to make it easier to search for information about tests and to collaborate on clinical data repositories. Visit the PAR data collection page for more information.
Browse parinc.com/resources for training and supplemental materials, put our products to the test in your clinical research, and reach out to us if you have data on clinical samples. Though the initial adoption of EBA practices takes time and effort, you’ll see the results via more precise decision making and buy-in from clients. It’s never too late to jump on the bandwagon!
June is Alzheimer’s and Brain Awareness Month, and it’s a great time to shed light on the impact of Alzheimer’s in our communities. About 6.5 million Americans age 65 years and older—or 1 in 9 people in this age group—live with Alzheimer’s dementia (i.e., dementia due to Alzheimer’s disease). This number is expected to grow as the baby-boom generation ages.
Alzheimer’s is a progressive disease that causes problems with memory, thinking, and behavior in primarily older people. Average survival after diagnosis in people age 65 years and older is 4 to 8 years, but some individuals live up to 20 years with the disease. This takes a huge toll on both those living with Alzheimer’s and those who care for them.
There are many ways to support people in your community who are dealing with the daily effects of Alzheimer’s disease:
Learn about the risk factors and incidence rates of Alzheimer’s. Visit alz.org to read facts and figures, find resources for help, and learn about advocacy.
“Go purple” in June to raise awareness. Wear purple, turn your Facebook page purple, and share your story on social media using the hashtags #ENDALZ and #GoPurple.
Contribute your time or money to organizations that support people living with Alzheimer’s, like the Alzheimer’s Association, the Alzheimer’s Foundation of America, or a local group.
For more information about what you can do in June to highlight Alzheimer’s disease, visit https://www.alz.org/abam/overview.asp.
Looking for products to assess dementia or Alzheimer’s disease? Learn more.
This week’s blog was contributed by Sierra Iwanicki, PhD. Sierra is a clinical psychologist and project director in the research and development department at PAR.
In the mid-20th century, humanistic psychology emerged in direct response to perceived limitations of psychoanalysis and behaviorism. Contrary to those earlier theories, humanism focused on the individual as a whole person, with the cardinal belief that perceived experiences fundamentally shaped us as human beings. In the 1940s and 1950s, clinicians began to encourage the collaborative use of projective instruments (e.g., drawings, Rorschach, TAT) to develop insight with clients.
A few decades later, clinicians began to write about the use of psychological assessment within a humanistic frame. Ray A. Craddick criticized the approach of treating a “person primarily as a series of building blocks of traits, factors, habits, etc. [calling] the separation of man into parts…antithetical to both the humanistic tradition and to personality assessment.” Drawing from a phenomenological perspective, researchers like Constance Fischer first wrote about the “testee as a co-evaluator,” and later articulated a model of collaborative, individualized psychological assessment. In subsequent years, clinicians continued to write about the therapeutic benefits and collaborative approaches of assessment.
In 1993, Stephen Finn coined the term therapeutic assessment to describe a semi-structured, systemized method for using assessment in a collaborative, therapeutic fashion. Since then, he and psychologists like Constance Fischer and others have promoted collaborative methods to conduct assessments.
According to Finn and colleagues, defining elements of collaborative and therapeutic assessment include:
• Having respect for clients (e.g., providing them with comprehensible feedback)
• Taking a relational view of psychological assessment (e.g., acknowledging the vulnerability of clients in the assessment situation)
• Maintaining a stance of compassion and curiosity rather than judgment and classification (e.g., fully understanding clients in all their complexity, not just summarizing them in terms)
• Having a desire to help clients directly (e.g., not just providing helpful information to other stakeholders)
• Taking a special view of tests (e.g., viewing tests as tools and results as ways to understand and help clients)
• Staying flexible (e.g., conducting a home visit as part of an assessment)
Fast forward to 2021: A multidisciplinary database search yielded more than 4,000 peer-reviewed journal articles related to psychological assessment as a therapeutic intervention, therapeutic assessment, or collaborative assessment. However, Kamphuis et al. note that the treatment utility of assessment has long been controversial, stipulating a broader view of relevant outcome metrics, more powerful research designs, and use of stepped assessment, taking into account the complexity of the patient’s psychopathology. Nevertheless, there is consensus that therapeutic assessment tends to yield more useful psychological assessment data as well as increase the effectiveness of assessment feedback.
In fact, a meta-analysis found the therapeutic benefits of individualized feedback following psychological assessment yielded a notable effect size of .42. More recently, a meta-analysis compared well-defined therapeutic assessment compared to other forms of intervention and showed three areas where it was superior: 1) decreasing symptoms (effect size .34), 2) increasing self-esteem (effect size .37), and 3) fostering therapeutic alliance and engagement and satisfaction with treatment (effect size .46). Overall,
research has shown that collaborative and therapeutic assessment is effective for adults, couples, children, adolescents, and families. According to the Therapeutic Assessment Institute, more than 35 studies have demonstrated that collaborative/therapeutic assessment is generally effective at improving outcomes for a wide range of clients with diverse clinical problems across various settings.
The Therapeutic Assessment Institute was formed in 2009 to promote and coordinate training in Therapeutic Assessment. Learn more.
This week’s blog was contributed by Maegan Sady, PhD, ABPP-CN. Maegan is a project director in PAR’s research and development department in addition to being a licensed psychologist and board-certified neuropsychologist. She worked as a pediatric neuropsychologist for nearly a decade before joining PAR.
As we emerge from the pandemic, the need for flexibility in assessment is here to stay. The only way to begin to combat socioeconomic and technological disparities is to offer more options, but how do we do it? Several themes on flexible assessment have emerged from what we learned during the pandemic, and PAR is ready to help.
Shifting formats
Many psychologists have adopted a hybrid, in-person/telehealth assessment model, necessitating careful deliberation over personal and professional implications. Which tests can be given remotely, and what evidence is needed to make that decision? Which clients are a good fit for teleassessment? Which tests can be given while wearing personal protective equipment (PPE)? If we sit six feet away from our client, how do we indicate where to start on the response page? How do we assess patients who cannot travel and do not have high-speed internet? In essence, how can we answer every referral question without compromising our ethical obligations to our tests, our patients, and each other?
Thankfully, timely guidelines emerged from the American Psychological Association; the Inter Organizational Practice Committee, which focuses on neuropsychology; and a new book, Essentials of Psychological Tele-Assessment. More recently, journal articles are beginning to present viable models for teleassessment and hybrid practice, both generally and for special populations (e.g., older adults, pediatric medical patients, historically underserved populations). Evidence is building that testing remotely or with PPE can be valid for many tests and within many populations. A few articles even address the impact of teleassessment on trainees, with recommendations for supervisors.
Digital tools are more flexible
Whether you’re testing someone face-to-face, from the next room, or fully remotely, electronic materials make life easier. Digital versions of more than 150 test manuals allow you to access administration and normative information from your home office and clinic any day of the week. Digital stimulus books, available for some of PAR’s most popular tests, allow you to cut back on the number of items you’re transporting and cleaning. They also make it easier to switch to a new test in the moment. To provide full remote administration options, we modified or specially designed eight performance-based tests for remote administration, and indirect evidence supports the remote utility of multiple others.
To use these tools most effectively, you can find white papers and video demonstrations for digital and remote administration on our website. Our digital materials do not confine you to a single device type, and our E-stimulus books do not require Wi-Fi or Bluetooth.
Screening as a model of care
With longer waitlists, pressure to assess more patients in less time, and more complex presenting problems, screening approaches are becoming more valuable. Screening can assist with triage, and doing so within a telehealth format has been shown to reduce wait times, increase satisfaction, and lead to more timely intervention and referral. Questionnaire-only assessment can be an efficient way to make treatment recommendations for patients with primarily emotional or behavioral concerns. More than 60 rating scales are available on PARiConnect as well as in print, meaning this evaluation approach can save time whether it’s executed remotely or in-person.
Screening in the context of a full evaluation allows you to cover more domains in less time. With 15 screeners/short forms of rating scales available on PARiConnect and several more in print, you can quickly add a measure of suicide risk, substance abuse, trauma, or depression to your battery. You can also use one of our performance-based screening tests to efficiently determine whether mental status, intellectual ability, or academic performance requires a closer look.
New presenting problems
In addition to new formats, testing is also changing in terms of content. Psychologists know all too well that the past two years have magnified or introduced multiple forms of stress and trauma, including anxiety, grief, effects of systemic racism, and food and housing insecurity. As a result, experiences of PTSD, depression, substance abuse, and parenting stress have increased. Adding a few extra measures to your test library is a good way to ensure you’re able to assess for a wide range of presenting issues.
Validity
With new procedures come new potential threats to validity. Practitioners must consider the integrity of testing remotely, in PPE, and under the general stress of a pandemic, in addition to more traditional considerations around effort and applicability of tests. There are creative ways to mitigate these threats, and we must document our efforts in our reports, citing limitations in interpretation where necessary.
Poised for success
In spite of challenges, psychologists have persisted. Testing settings are fluid, clinical conclusions have more caveats, and the list of areas for future research is longer than ever—but patients continue to depend on you. We have our work cut out for us, but together we can make psychological assessment more accessible, meaningful, and innovative.
Learn more about our digital assessment options.
April is Autism Acceptance Month, a time to not only recognize, but to open up and accept individuals with autism.
Up until last year, this had been referred to as Autism Awareness Month. The Autism Society of America suggested by the name change to encourage people to move beyond awareness and into acceptance of those affected by autism. This change in mindset can help drive positive changes for individuals and families affected by autism.
According to the Centers for Disease Control and Prevention, 1 in 44 children are diagnosed with autism. More than 7 million people in the U. S. are on the autism spectrum across all racial, ethnic, and socioeconomic groups. There is a growing need for first responder training and employer advocacy programs. For more information regarding these and other types of autism support, please visit the Autism Society.
If you’re treating a child you suspect may have ASD or another developmental disorder, remember that PAR has products to assist you, such as the PDD Behavior Inventory™ (PDDBI™), the PDDBI-Screening Version, and the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2).
There are additional free resources on the PAR Training Portal for those who specialize in assessing and treating autism or other learning disorders. Located under the Achievement/Development header, you can find a recorded webinar on how to use the PDD Behavior Inventory (PDDBI) on PARiConnect as well as an interactive course on the PDDBI family of products.
This week’s blog was contributed by Theo Miron, PsyS. Theo is a licensed specialist in school psychology and a nationally certified school psychologist. He spent nearly 18 years providing psychological services to public school students in Minnesota, Arizona, and Texas.
School psychologists in the U.S. report that completing student assessments is the task they perform most frequently. These psychoeducational and psychological tests are based on the basic principles of measurement theory, standardized testing, and normal distributions. Practitioners receive extensive training in measurement theory—maybe even to the extent that their dreams are filled with visions of the normal or bell curve.
The normal curve is a fundamental concept psychologists use to help measure and explain student performance; that is, how a student functions in comparison to other children of the same age or grade level. We psychologists love to throw around the numbers associated with standard scores, percentile ranks, T scores, and scaled scores, knowing our fellow psychologists and well-versed teachers will know exactly what we’re talking about. Unfortunately, though, measurement theory is a relatively obscure field, so this type of language may puzzle parents, students, and clients.
During my first few years as a school psychologist, I struggled to find an effective way to explain these types of results. As a visual learner, I thought adding visual aids to my results meetings might help explain the information more clearly. So one year, I harnessed my inner artist and drew a nice normal curve with standard deviations clearly marked out. I then headed to the copy machine and generated a hundred more. During results meetings, I’d break out my box of colored markers and a ruler and start mapping out the standard scores from the different tests I had given, with the normal curve as the back drop. Once done, I’d have a few marked-up normal curves for each measure the student had taken.
Using these visual aids during results meetings helped both parents and teachers start to understand what the different scores meant. Not only did I receive some nice compliments on my “art projects,” but I also started noticing that more parents had questions and comments about the results. One parent explained she’d sat through several of these types of meetings over the years, but mine was the first one where she completely understood what the scores meant and how her child compared to other students his age.
These days, you can keep your art supplies in your drawer. Simply log on to PARiConnect, our online assessment platform, scroll to the Quick Links section in the bottom right corner, and click Interactive Bell Curve.
This new interactive tool allows you to enter relevant student data, and then add scores for up to three different tests on the same normal curve. You can enter the name of the specific assessment, the type of score you’d like to report (standard, scale, T score, or percentile), and up to 10 index or subtest raw scores. The system plots each score across the normal curve using vertical lines color-coded to the specific tests entered. When finished, you have a few options to explain results to parents, teachers, and clients: present “as is” on-screen, print out a paper copy, or print to a PDF file that can be presented (and shared) digitally.
The interactive bell curve is a free feature available to every PARiConnect user, and it can be used for any test on the market—not just those published by PAR. So put those markers away, log on to PARiConnect, and try it out yourself.
Learn more.
Interested in or have questions about other assessment products for schools? Visit our school resources page.
This week’s blog was contributed by Carrie Champ Morera, PsyD, lead project and content director, and Theo Miron, PsyS, regional manager–educational assessments.
Why should psychologists and other clinicians assess for emotional disturbance (ED) in the school setting? Parents and caregivers of 8.3 million school-aged children (ages 4 to 17 years) have sought help from school staff or mental health professionals about their child’s emotional or behavioral difficulties. Approximately 7.5% of children ages 6 to 17 years used prescribed medication during the past 6 months for emotional or behavioral difficulties. Assessment of ED is necessary in the school setting to help children obtain the emotional and behavioral support services they need to be successful.
Over the past 20 years, the number of students served within special education has steadily increased, while the number of students being served under ED eligibilities has steadily decreased. For example, during the 2000–2001 school year, 6.29 million students received special education services with 7.6% of those students identified as having an ED. Although the population of students receiving special education services grew by almost one million children to 7.13 million over the next 18 years, only 5% were identified as having an ED during the 2018–2019 school year.
How can we improve ED identification and help children obtain the services they need to be successful in school? It is the school’s responsibility and a school psychologist’s professional role to find children who are struggling emotionally and behaviorally, identify them through the evaluation process, and then connect them with appropriate services and interventions so they can begin to heal and make educational, social, emotional, and behavioral progress.
When completing assessments for ED, we need to carefully consider and adhere to specific eligibility criteria while distinguishing the difference between social maladjustment (SM) and ED. Practitioners also need to consider DSM-V-related diagnoses as well as the impact of trauma, adverse childhood experiences (ACES), and the pandemic on the child’s functioning. It is also imperative to be cognizant of racial disproportionality in determining eligibility for ED services (see NASP Position Statement: Racial and Ethnic Disproportionality in Education).
Assessments of ED need to be comprehensive and include multiple tests and information from a variety of sources. Clinical interviews with the student, caregivers, and teachers, as well as observations of the student in the natural environment are paramount. Trauma, ACES, and the pandemic also need to be considered in the assessment of ED. Childhood adversity is a broad term that refers to a wide range of circumstances or events that pose a serious threat to a child’s physical or psychological wellbeing, including child abuse, neglect, divorce, bullying, poverty, and community violence. Adverse experiences can have profound consequences, particularly when they occur early in life, are chronic, and accumulate over time. Trauma is an outcome of exposure to adversity while adversities are the cause of trauma. Trauma affects everyone differently, depending on individual, family, and environmental risk, as well as protective factors.
Repeated or prolonged trauma in addition to the effects of the pandemic can have a litany of adverse outcomes on our children in the areas of cognition, brain development, behavior, emotions, mental health, physical health, and relationships. These factors need to be considered in a comprehensive evaluation for ED.
Since the start of the pandemic, we have seen a significant increase in kids struggling with both emotional and behavioral difficulties. This increase may lead to an uptick in the number of ED-related assessment referrals that come across our desks and the number of students who require special education services. This leads us into how we assess children for an ED and the benefits of using the Emotional Disturbance Decision Tree (EDDT).
Dr. Bryan Euler, the author of the EDDT, has worked as a school counselor, diagnostician, lead school psychologist, and a clinical psychologist. While working in the Albuquerque public schools, Dr. Euler teamed up with PAR to create the EDDT to provide a standardized approach to the assessment of ED. It was designed to directly address the framework of the federal ED eligibility criteria; for every component of the federal ED criteria, there’s a corresponding EDDT scale or cluster. The scales within the assessment are written to address these broad domains thoroughly, then help school psychologists apply the specific criteria to make informed decisions on both eligibility and programming.
The EDDT includes all the relevant aspects of the federal ED criteria. It contains scales and clusters that address each of the specific ED criteria. The structure of the EDDT walks the practitioner through each area of the federal ED criteria.
Bryan Euler, PhD, describes the benefits of the EDDT and the importance of multiple informants, including the student’s perspective, here.
There are several best practices to keep in mind with the EDDT: Include the viewpoint of multiple raters (teacher, parent, and/or self) from different settings (school, home, and community). Use the EDDT as part of a comprehensive evaluation to determine ED eligibility. In addition to the EDDT, be sure to include qualitative information such as interviews (from the student, parents, and/or teachers) and observations across school settings to supplement the data received on the EDDT.
Carrie Champ Morera, PsyD and Theo Miron, PsyS will present on the EDDT at the National Association of School Psychologists (NASP) annual convention in February. In their presentation, Assessing Emotional Disturbance in Schools Using the Emotional Disturbance Decision Tree (EDDT), they will explore the features and trends in ED and investigate the structure and use of the EDDT. If you attend NASP, feel free to stop by the PAR booth to learn more about how PAR can meet your assessment needs.
This week’s blog was contributed by Jeremy Sharp, PhD, licensed psychologist and clinical director at the Colorado Center for Assessment & Counseling and the host of the Testing Psychologist Podcast. Dr. Sharp earned his undergraduate degree in experimental psychology from the University of South Carolina and earned his master’s degree and doctorate in counseling psychology from Colorado State University. He specializes in psychological and neuropsychological evaluation of children and adolescents and provides private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. He lives in Fort Collins, Colorado with his wife (also a therapist) and two kids.
Upon returning to school in fall 2021, my 8-year-old daughter started showing signs of separation anxiety almost immediately. She would not go into the classroom on her own and developed a compulsive habit of checking the weather before school each day to see if it was going to rain. Over the course of a couple of weeks, we spent hours on the playground before (and during) school, attempting to cajole her into feeling safe. We eventually enlisted the help of the fantastic school psychologist who helped our daughter get over her fears and go in on her own within another two to three weeks.
Though her separation anxiety seemed to come out of nowhere, hindsight would say otherwise. The biggest clue was that she started a new, much bigger school this year. She was also having trouble making friends, which was different for her. The final piece of the puzzle was learning that a classmate had shared information about a flood warning with my daughter, and she became scared that there might be a flood while she was at school—hence the checking of the weather every morning.
Related post: Jeremy Sharp on trauma-informed assessment
My daughter is not alone. Depending on what you read, estimates on prevalence of anxiety disorders in kids ages 3–17 range from about 2% to more than 30%, with a recent meta-analysis settling on about 7%. That’s two kids in your average classroom who are experiencing clinical anxiety, with even more who have subthreshold anxiety.
There are many reasons that kids might feel anxious at school, but let’s break it down into three areas for the sake of simplicity. Those areas are:
Separation from caregivers
Social interaction
Academic demands
Separation anxiety is the most common form of anxiety in kids under 12. The core theme of separation anxiety is “excessive distress” when separated from or thinking about separating from a primary attachment figure or caregiver. At school, this looks like unwillingness to get out of the car, clinging to a parent’s leg, not leaving the caregiver to go into the classroom, and other similar situations. As in my daughter’s case, it can also show up as a fear of an event that would cause separation from the primary attachment figure. Separation anxiety often ramps up after breaks, like when returning to school after the holidays or summer vacation. Even a typical Monday can increase anxiety, as kids have gotten used to being with caregivers over the weekend.
Social interaction is another area of potential distress in kids. The clinical diagnosis of social anxiety disorder is estimated to occur in about 9% of adolescents (ages 13–18 years). Social anxiety is characterized by the fear of being judged by others paired with avoidance of certain situations that cause anxiety. An example is eating lunch alone due to a fear of saying something “dumb” while sitting with peers.
Lastly, academic demands can lead to anxiety in kids. Research suggests that around 20% of students experience test anxiety overall, though it differs depending on several demographic factors. For instance, female-identifying students and ethnic minority students are more likely to experience test anxiety. Regarding personality factors, there is a consistent negative relationship between self-esteem/self-concept and test anxiety. Students with disabilities (i.e., ADHD) are more likely to experience test anxiety than students without an identified disability. Additionally, test anxiety’s negative impact on performance is highest in middle school and decreases in high school. It’s important to note that text anxiety is not the only form of performance anxiety in school, however. Some students feel a variation of social anxiety or fear of being called on in class as well.
This information confirms what we already intuitively know: as “front line” workers in pediatric mental health, school staff plays a very important role in kids’ social and emotional wellbeing. Indeed, the research is clear that kids learn better when they also have skills to manage their emotions. But it’s not always easy to know which students need help! Anxiety is an internalizing disorder, meaning that kids tend to feel it in their minds or bodies without necessarily expressing it overtly to others. What we do know is that kids from lower income homes and ethnic minority kids are at greater risk of “flying under the radar” and not receiving the support that other kids get. We also know that school is a great place to implement interventions given that so many barriers to accessing treatment are removed when kids are already there.
So, what school-based interventions actually work? A recent meta-analysis of prevention programs showed that cognitive-behavioral strategies make up the vast majority of interventions in the academic environment. The effect sizes across all forms of intervention were small but statistically significant, indicating that prevention programs are certainly helpful in addressing anxiety. The study looked deeper into whether the type of program (universal vs. targeted) made a difference and found that it did not. Similarly, it didn’t matter whether school staff (i.e., teachers, school counselors) or an external mental health professional delivered the intervention. The research suggests, however, that intervention be delivered as early as possible, in a preventative context, given the relatively early age of onset of anxiety.
To summarize, a substantial minority of kids will experience some form of anxiety at school before finishing high school, but there are ways to help. School counselors and teachers are in a great place to do so. Being mindful of anxiety as an internalizing disorder and paying attention to kids who tend to fly under the radar are excellent places to start. Knowing the different types of anxiety and the places they show up are valuable as well. On a broader scale, prevention programs are helpful and effective, especially when delivered earlier rather than later.
Catch up with the Testing Psychologist podcast on their website, via Apple Podcasts, Google Podcasts, or on Spotify.
Related: School resources to help you address trauma, anxiety, and more.