Mental health problems are on the rise in schools, but mental events are often hidden, and a teacher may have no idea what turmoil is plaguing a child underneath the surface.
While you are trying to teach them about Of Mice and Men or explaining quadratic equations, the blank face in the class may not indicate a lack of understanding. For a child with anxiety, the blankness may be hiding an internal narrative of spiralling anxious thoughts, leading to catastrophe: “I don’t get this; I’m going to fail my exam; I’ll never get to uni or a job; I’m going to end up on the street.” This may seem far-fetched, but this is the actual thought process of one of my anxious patients who never got anything but As.
Anxiety is the most common mental health difficulty experienced by pupils and, when anxiety levels are very high, it can tip into the public sphere in the form of a panic attack.
Would you know what to do if one of your pupils started to panic in front of you? To answer this question, we should first try to understand what panic is, which will give us a framework to understand how to intervene.
What is a panic attack?
At its most simple, a panic attack is an extreme bout of anxiety, and anxiety is the body’s response to a perceived threat.
In more primitive, hunter-gatherer times, our bodies were primed for fight or flight from a perceived threat. Our core brain releases adrenaline and cortisol, which cause our heart to beat faster, our breathing to quicken, the stomach to turn over more quickly, our sweat glands to start to cool us. Our bodies mobilise internal resources to prepare the energy and oxygen necessary for fight or flight. Were we to come across a wild animal ready to attack us, this would still be an appropriate response. When the perceived threat is quadratic equations, it is definitely a less appropriate response to punch a teacher or run from the classroom.
The spiral of panic
In psychology we understand panic on four interrelated levels:
- What are they thinking that is contributing to this panic?
- What is going on physically for them?
- How are they behaving?
- What is their emotional sensation?
Each level has the potential to be both a reaction and a trigger to the other levels. This can lead to a spiral of anxiety or panic.
For a pupil suffering with anxiety, a relatively innocuous thought, such as, “What if I don’t know the answer?” is perceived by the brain to be a threat, triggering the physical symptoms of anxiety.
As their heart starts beating faster, their mouth goes dry and they start to blush or sweat, the physical reaction feeds back to trigger a second round of negative thoughts, such as, “Oh, my God, I’m panicking. I’m going to make a total fool of myself.” They feel anxious, and want to run away or hide, but are generally prevented from this by social convention, or by the fear of making themselves more conspicuous.
As they sit frozen to their seat, the physical resources their body has mobilised have no outlet. This heightens the awareness of the panic, and the thoughts become more catastrophic: “I’m such an idiot. Nobody is going to want to know me,” or, in those having a panic attack for the first time: “I’m having a heart attack.”
What should a teacher or school nurse do?
Pupils with anxiety and panic are not all the same: they have different things that calm them down. For this reason, no hard or fast rules can be applied to everyone, and it’s important to watch their responses carefully, and adjust accordingly.
The first thing to remember is that emotions are contagious, and so you need to stay super-calm yourself. Speak very calmly, quietly and slowly, and breathe very slowly.
Physiologically, there are two symptoms of anxiety that can be brought under conscious control: breathing and muscle tension. We can also intervene to interrupt the spiralling negative thoughts, which gives us a three-point plan to reduce anxiety.
- Slow down a young person’s breathing, and get them to breathe out
When people are in an anxious state, they tend to gulp in air, and do so too quickly. To calm someone down, you want to encourage them to have a longer out-breath than in-breath, and for their breathing to slow down. Your tone should be calm, gentle and encouraging.
Generally, I find the best way to slow someone’s breathing is to make eye contact, and, if appropriate, hold their hands, and make my breath very slow and obvious. In that situation, people tend to match their breathing level to mine, so we are breathing in unison.
- Talk to them to interrupt their panicky thoughts
Anxiety and panic are a person’s response to a perceived threat, and therefore what you say to them should reassure them that they are going to be OK and that this will pass. It is rarely helpful when someone is in a full-blown panic attack to ask, “What’s the matter?” At that point, the matter is that they are in a panic attack, and they are past discussing it.
Often, naming it as a panic attack is helpful. Try to avoid saying it is “just” a panic attack. But if someone thinks they are having a heart attack, it is a bit of a relief to know that is a panic attack and you are not dying.
- Physical tension
When someone is panicking, they tend to tense all their muscles. Getting them to relax and soften their muscles is the third part in your panic toolbox. Words such as “let go”, “relax”, “drop your shoulders” can help here. Also, if their breathing is slowed down, getting a young person to tense and relax their muscles can aid the relaxation process.
After a panic attack
The most important task after a panic attack is to give the child a chance to relax and recover. They may want to carry on with their day, but they may feel very scared and tired, and it is more likely that they would need to go to the nurse’s office to have a rest and something to eat or drink.
During a panic attack is rarely the time to understand the reason behind it, but afterwards it might be worth exploring this a bit more. Sometimes a panic is triggered by something internal to them (a random thought popping into their head, for example) or it might be something external (such as something someone said).
It is a good idea to help them understand how that trigger event spiralled up into panic, by asking questions such as “And what did that make you think?” or “How did you feel then?” You can be openly curious about the difference between their thoughts and yours: “It’s interesting that you are so worried about answering the question correctly, because as a teacher I don’t mind at all whether someone gets the question right or wrong. I just like it that they tried.”
Finally, a young person who is suffering with panic attacks is likely to need a more specialist intervention, either through child and adolescent mental health services, school counselling or other local services. So do follow up with your local policies and procedures, to involve their parents, and/or the pastoral and safeguarding teams.
Dr Tara Porter is a clinical psychologist at the Royal Free London NHS Trust and Anna Freud National Centre for Children and Families, as well as Tes’ mental health columnist. The views expressed are her own
