Sunday, March 5, 2017

On Rising Anxiety Rates

A couple weeks ago, CBC ran an article about a high-school guidance counsellor, Boyd Perry, concerned with the increase in anxiety in students, and I've been dwelling on it ever since. This is crazy long as I'm just figuring all the angles here. Perry thinks we need to assess anxiety differently because these kids, some of them in kindergarten, aren't disordered but merely ill-equipped due to the bubble parenting that's become a trend, the swooping in to fix every little thing rather than letting kids feel the pain and learn to cope. According to an annual survey of counselling centres, the most common issue raised by students used to be around relationship concerns. In 1996, anxiety took over as number one spot, and it's stayed there gaining a wider lead ever since.

I agree parenting trends and misdiagnoses are an issue, but I also think it's more complicated than that.

I raised a similar concern a year ago; maybe mid-winter is the season to discuss our discontentment. My students last year were quite sure school is significantly harder than ever before regardless my claims to the contrary backed up with binders of old assignments and exams spanning the decades. I don't think they felt like it's harder just because life has been too easy for them because of overprotective parents, though. At the time I said it's also because of their parent's anxiety over the job market, the demands social media have on their time, and everyone's heightened expectations of themselves and their lives including, but not limited to, the quest for a gratifying career that allows them to work to their potential in a field they find fascinating. Today, I'd add the decrease in face-to-face interactions and feelings of community, the umbilical cord of cellphones that prolongs separation anxiety (with friends as well as parents), unceasing change that keeps us in a state of perpetual turmoil, concern with the state of the world, and even pollution. There are numerous societal, environmental, and personal factors intertwined that are pushing this trend.


WHAT IS ANXIETY

But what does anxiety even mean? A separate issue is that 'anxiety' is a word like 'cancer.' Decades ago I saw an interview with an oncologist (and sometimes comedian and philosopher), Robert Buckman, who insisted that we should use the word 'cancer' the way we use the word 'infection'. Both are very broad terms that could mean someone needs a minor procedure or they're on death's door. You might need a benign mole removed or a blister popped, or you might have pancreatic cancer or AIDS. We don't generally gather family together to tell them "I have an infection" because that's meaningless information. We're more specific about it. We need to apply that specificity to cancer discussions always including the location, the spreading potential, and the stage. The word has become too loaded, typically cueing people to think the worst.


His idea didn't take off, but it should. And that same reasoning should be applied to anxiety as well.

Anxiety can be a feeling of nervousness in a specific situation, like before a presentation or test. It can sometimes fog our brain for a bit, or it can actually give us the boost in adrenaline we need to get things done! But it can also be a debilitating condition that can trap a person lingering in the threshold of their bedroom, desperate but unable to cross over. We use it far too broadly. The difference between the terms 'anxiety' and 'cancer' or 'infection', however, is that it's only from an individual's personal self-description that we can even hope to know the intensity of the problem.

I've sat in the doctor's office with my own son who struggled just to get out the door to the appointment. His description of how he was feeling was all the doctor could go on to determine the problem and how to treat it. It was similar to my experience having a concussion. I could easily have taken months off work if I exaggerated a few symptoms or played football that afternoon with just a slight change of word choice and tone. Every diagnosis and form completed depended on, entirely, my descriptions of how I was feeling at each visit. From my limited experiences with my son's anxiety, it seems that how the symptoms are expressed by the patient, the language used and behaviours exhibited, affects the diagnosis dramatically. Try to be cool about it and act like it's just a bit of stress after not being able to leave your room for a week, and it's written off as minor, but burst into tears because a situation was difficult at school that day, and out comes the prescription pad, even if it's your mom who breaks. At a cancer follow up appointment, I could discuss all the ins and out of my experience without so much as a grimace, but the question "How are things going otherwise" showed me the toll mental illness can take on bystanders. I think it's very likely that people who express emotions externally are likely overprescribed, and those who keep it in more are underprescribed much needed medication. It's something that seriously requires further study, as Perry suggests, but I'm not sure how it can be assessed much differently.


SELF-PERPETUATION THROUGH NORMALIZATION

The signs of an anxiety disorder can be ambiguous and easily misunderstood as symptomatic (fatigue, irritability, excessive worrying) by the student, but it also doesn't help that we are highly suggestible and influenced by our surroundings. Studies like the Lost in the Mall experiment show that "misinformation can change people's recollections in sometimes very powerful ways," and way back to William James - "man is essentially the imitative animal" (408) - it's been asserted that our perception of events affects our reaction to them. That is, the very fact that anxiety disorders are increasingly normalized could be increasing them as students think they recognize and experience more symptoms than they might otherwise, had they never heard of them. We want to understand our experiences, and we'll use the words and ideas easily available to us to do so. We're shifted from being nervous about tests, expressed in a giddy, bouncy behaviour with the expectation that it's about to begin, to being traumatized by the thought, expressed in a more mortified and definitive manner, with no expectation of carrying out the task. Tests become another thing added to the list of things we can't do.  

Barring MRIs for the lot, it's impossible to weed out who sits where on this range of disabilities and to what extent this is due to an internal disorder or an externally driven (and therefore potentially reversible) perception of a disorder. It might help, however, if we could generally identify and differentiate feelings of discomfort, nervousness, and fearfulness from more significant anxiety in our everyday lives. We need to remind people that feeling nervous and uncomfortable is a really normal part of the human condition, not something to remedy until we're all placidly languid.

The other factor that might be adding to the numbers, something that some teachers might suspect from time to time, is that claiming an anxiety disorder can be easier than accepting that more effort or ability is necessary to get through a difficult task. Some students might have developed weak work habits from being given inflated marks for less than stellar work in the past. At this point it's not out of the question to consider that some parents or students, disappointed with test results, might be jumping on the anxiety bandwagon rather than recognizing personal shortcomings. It's much easier to digest having a common ailment that's out of their own control and requires accommodations than to accept that a change of behaviour is necessary. Sometimes it can be a case of procrastination leading to anxiety, a perfectly common and ordinary event, but it's now suddenly provoking a demand for a doctor's visit in order to garner accommodations. As I said in the Boyden case, there's a draw to being associated with victims.

And then there's the social end of it. It once may have been a concern that having an anxiety disorder made people weird, but it also made them interesting enough to be mimicked; being angsty might make one worthy of attention. But now this is a common enough condition that people can bond over shared symptoms with some left out of the discussion because they don't have anything clinically diagnosed. To be clear, it's really important that we're accepting of anyone with any kind of anxiety disorder. Absolutely. But it's a double edged sword: If it's socially acceptable, to what extend is it made desirable, a new means to form community, or a sign of having depth? We love conflict in our stories and in our lives. For some, being reasonably, boringly healthy isn't a compelling persona to develop. But I don't mean they fake it so much as they adapt to it. Any little feelings of nervousness are noticed and discussed and attended to just a bit more, and a bit more. When it's something to hide (not that it should be hidden, but stay with me here), then it might be less emulated.


WHEN TO PUSH AND WHEN TO PULL BACK

We can't really know how people are feeling and how serious their situation is. So, the more important question is, when do we push kids and when do we accommodate them? When will challenging kids to do more to help them cope, to get them out of their shell or provoke them to see what they're actually capable of, and when is it going to be pushing too far, seriously distressing and undoing all the baby steps they've taken to that point? Temple Grandin, author of The Loving Push, is a great advocate of demanding that kids learn to manage certain behaviours, manners, and work habits, even when they're difficult for them. A condition or disorder shouldn't give allowances for being rude or selfish or otherwise uncivil, or to miss out on important chores around the house. She writes at length about the problem with parents and teachers who give free rein to children with ASD because learning social cues is difficult for them. If it's difficult, it just means we have to enforce the rules more consistently until they get it. But we can't quite do the same for kids with anxiety.

According to research in Cognitive Behaviour Therapy, the more we avoid a stressful situation, the worse it can get. Avoiding a trigger can reinforce the idea that it's something that needs to be avoided. So we need to approach the triggering stimuli a bit at a time, but in a way that feels reasonably safe. If someone's terrified of water, we'd let them sit beside it, then put their feet in, then encourage them to step in it. Tossing a fearful child into water is, currently, seen as the worst thing to do. The important bit about CBT is having people consider what they're thinking when they're terrified of innocuous events and then having them come up with more realistic thinking to replace the fearful thoughts, and then encouraging more exposure to the difficult situation. But when are we throwing kids into the pool? If we demand that they do the presentation and stand there speechless, or spend an hour not answering any test questions, it doesn't benefit anyone. But for some kids, asking the bare minimum is too much. It's up to the student to decide where the line is even though many people are notoriously bad at doing what's best for them. It's very complicated!

In my day, we pushed everyone. What doesn't kills you makes you stronger! But some people didn't recover well from that kind of pressure (or from old school corporeal punishment). It can be really healthy to be pushed out of our comfort zone, until we're pushed too far. We want kids to try new things, just a bite, but we don't want them made to try something beyond mildly upsetting. It's really difficult finding that sweet spot between harming them when we're too kind and when we're too firm.


THE RESEARCH  

Lots of studies show that we're overprotective in general, but none can tell us what works with the specific person in front of us. When I came home from school with 90% on a test, my dad would focus on that missing 10% in hopes of motivating me to work even harder next time. I ended up dropping out of school. BUT, those two events could possibly have nothing to do with one another, regardless the natural desire to create a causal connection. Now I'm a really hard worker. Couldn't that also be a result of my dad's high standards? We can do all the studies in the world, seeking whatever connections we can manage, but we'll still never really know the very best way to raise our children for sure. They're not a homogeneous lot that will react tidily in uniform ways.

Some studies suggest that resilience in people can come from the luck of having one supportive mentor or from the chance development of an internal locus of control - whether we see events as overwhelmingly stressful or opportunities for growth. Then there are others that suggest the problem is the lack of stressors at all. And another found that even easily excitable infants (which make up about 20% of babies) become confident children if their parents allow them freedom to take risks, adding more credence to more hands-off parenting. Others suggest that kids develop self-regulation when they set and meet goals themselves, and it's not just a problem with bubble parenting, but also cell phones that do the planning for us, which weakens self-regulation. It makes us more easily impatient and less able to work out problems. But even if we can find things that work for the average kid, we can't know what will help each specific case. Dealing with people is always guess work.


SO WHAT DO WE DO?

The studies are all right, but they're not always right for each particular case. We can't ever really know how badly people are managing, and we can't know when to push or when to hold back. Clearly we'll do less significant harm if we err on the side of believing their self-reporting-based diagnosis and resisting the desire to push them beyond whatever they feel they can do. We don't want to do any serious damage by pushing too hard too fast. BUT I'm still going to try. We have to take their anxiety at face value, but we can get them to try just one bite. Just answer the first few questions of the test in the room and see what happens. Just present for a minute or two in front of the class, and I'll stand with you.

I once had a student who seemed completely illiterate. She needed me to read every word to her and then I'd have to write down every answer, even a one word answer on a handout. One day, a professor friend asked if he could do a study on my students. I gathered all the necessary permission forms, and they all eagerly agreed to participate. He came to class with surveys that involved significant writing, passed them out, and said they'd get $10 each for completing them. Suddenly my illiterate student could read fluently and write entire paragraphs without any help. It can be comfortably self-perpetuating to stay in a cycle of anxiety and avoidance. Perhaps we need some kind of rewards to encourage some out, to convince them that doing all the work under their own steam within the typical timelines is actually worth something in terms of their future success. But long-range rewards are far less enticing than a ten dollar bill on the corner of the desk.

There are other things to be aware of. In our schools many teachers use a Google Classroom program that automatically sends students their assignments and can be programmed to remind them if they haven't finished something. I'm one of few that refuses to use it. Based on that last study mentioned above, I think students need to learn to write down and track their own due dates and monitor their own behaviour to meet the timelines. Some can't do it any more, and this year a few have started blaming the fact that I won't use the program that does all their organizing for them for the reason they haven't done any homework. It can be hard to resist the pressure to conform even when you believe it's in their best interest, but I'm pushing back and teaching them to remember to look at my website regularly for the work. It's a little thing, but for one or two of them it might be the thing that improves their chances at success at university. I can only hope it's not harming them somehow. Time will tell.

With some kids, sometimes it's a matter of waiting for the symptoms to abate enough to try a few things, and that can cost them a semester of school because, as much as we accommodate, we won't budge that timeline. Sometimes that's very reasonable, but other times it's questionable. I had a very bright student who was struggling to come to class, and she asked to write the exam at a different time to be able to write alone. It was an effort to get permission to do that, but then she couldn't make it after all. And getting permission to have her write with a proctor in her home would have been reams of paperwork that takes weeks to process, so she lost that credit. She was in the building again a week later, but it was too late. That just feels wrong. If someone has a physical illness that keeps them out of school, they can have their exams deferred; there are still greater barriers for psychological conditions, particularly if their doctor thinks they're fine based on self-reporting done while the student is successfully acting as together as they possibly can!

Some think the solution is to stop talking about all the negative stuff going on in the world - except that's so much of my courses. By high-school, many students have noticed that we're in precarious times. Now, do we keep that from them, or is the political and economic world something they'd be better off acknowledging? Do we shield our charges from bad news? I lean towards being upfront. Otherwise, it's like pretending a dissolving marriage is going swimmingly. Ignoring problems can be an effective way to get through the day, but only once acknowledged and grieved can we actually get on with things with a clear head. And the children always know when something's up.

I wonder how much social media plays into the increase in anxiety. It's my feeling, based on mainly anecdotal evidence, that it's key to this issue, well beyond parenting and schooling problems. It increases their expectations, decreases personal connections, decreases their time alone with their thoughts (if that ever happens anymore), affects their sleep habits, warps their attachment behaviours, and sucks up the time they could use to doing something productive and thereby develop a greater sense of self-efficacy. I wonder if encouraging transitional objects would help to get students more comfortable away from their permanent connectivity to friends and family and mindless information. We need some means to get them to leave their phones at home, not just so they pay attention to us in class, but so they pay attention to their own thoughts, learn how to be bored, and to cope with being alone.

We can't clearly determine who's "disordered or ill-equipped," and we have to be cautious pushing anxious kids more than they might be able to handle, but we can push a bit. And we can help by encouraging different words to express the great variety of feelings that we've lumped together under "anxiety." But beyond that, teachers (and parents) need help. We need solid training in anxiety disorders and the use of CBT. We have kids who identify as trans come to speak at staff meetings to increase understanding and reduce stigma, and the board created a video about some of them. Maybe we need kids with anxiety disorders to do the same. If they can.


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