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Sulkowski, M. L., Joyce, D. K., & Storch, E. A. (2012). Treating childhood anxiety in schools: Service delivery in a response to intervention paradigm. Journal of Child and Family Studies, 21, 938–947.

Summary by Dr. Amie Grills


Anxiety is a normal emotional response that everyone experiences from time to time. However, for some children, anxiety becomes excessive and they become fearful of situations or objects that are not truly dangerous. The type of situations or objects that bring out anxiety in children may vary with age. For example, younger children often show signs of separation anxiety, such as fearing being away from caregivers, whereas older children more commonly have social anxiety concerns, such as fearing speaking in class or eating in the cafeteria. Specific phobias, like fearing spiders, heights, thunderstorms, or some other object or situation, are also common. Several other anxiety disorders can be diagnosed in youth (e.g., generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder).

Children may display anxiety in ways such as "freezing," crying, screaming, or refusing to engage in an activity (e.g., refusing to go to school because of separation fears). Because many children keep these anxious feelings to themselves, the feelings may go unnoticed. For other children, an observer might notice the outward signs as the child's body reacts to the anxiety (e.g., sweating, shaking). Some children appear distracted or inattentive because they focus on the anxiety and not the task at hand. Other children may act up or seem oppositional in an attempt to avoid the things that make them feel anxious.

Anxiety is among the most common childhood disorders, with alarmingly high prevalence rates and an early age of onset (e.g., Kessler, Berglund, Demler, Jin, & Walters, 2005; LaVigne, LeBailly, Hopkins, Gouze, & Binns, 2009). In fact, as many as one in three children experience significant (subclinical) anxiety, with roughly 8% to 19% of children receiving a diagnosis in their lifetime.

Child anxiety has been well studied over the past several decades, resulting in a wealth of information on consequences and treatment approaches. Consequences of childhood anxiety include social (e.g., peer victimization), emotional (e.g., poor self-esteem), and academic (e.g., poor achievement) domains (see Grills-Taquechel & Ollendick, 2012, for review). Fortunately, several interventions, all of them from the cognitive and/or behavioral theoretical domain, have been developed and shown through strong evaluation criteria to effectively treat child anxiety difficulties (e.g., Reynolds, Wilson, Austin, & Hooper, 2012). Such interventions have been applied in typical individual therapy (i.e., one-on-one), as well as in group-based approaches and those conducted within school or other (e.g., medical) settings, typically by trained counselors but also by trained personnel (e.g., teachers, nurses).

Multitiered response to intervention (RTI) models can be applied with emotional and behavioral issues in the same manner that they have now increasingly been applied with learning difficulties. For instance, at tier 1, universal prevention skills can be integrated as part of a school-based program that targets all students and also allows for screenings to determine students considered at risk for or presently experiencing significant emotional difficulties. Students who do not respond to the universal tier 1 program, or those determined to be at risk, would then progress to the second tier, which would include more targeted intervention, perhaps in a group format. Finally, a third tier could be designed for students who had not responded to either of the previous tiers, focusing on individual or, perhaps, family cognitive-behavioral psychotherapy.

Key Points

This article specifically considers child anxiety and how a child with such difficulties might qualify for school-based services, using a multitiered model consistent with the RTI approach. The authors highlight the important role schools can serve in providing services to children with socioemotional difficulties like anxiety and discuss the different ways through which a child with anxiety might qualify for such services. For example, a child may (1) receive special education services, typically following classification as having either an "other health impairment" or "emotional disturbance," based on the most recent (2004) Individuals with Disabilities Education Act; (2) receive services through a Section 504 plan (though the school system must pay all expenses for such plans, which may be a limiting factor); or (3) receive increasingly intensive services through an RTI model. Importantly, the authors also note that the specific language and requirements for these laws and statutes can vary by state.

The second half of this article focuses on what a multitiered model for anxiety difficulties could look like, specifically highlighting empirically supported assessments and interventions that might be part of such a model. This model includes universal screening with broad-based socioemotional measures (that is, those that examine a variety of symptom areas, including anxiety, depression, behavior, and attention) and services at tier 1 and suggested interventions that could include other areas of focus (e.g., bullying prevention). The authors propose that 5% to 10% of kids would need a tier 2 intervention, which could include small-group or computer-based anxiety interventions. Finally, it was suggested that 1% to 5% of kids could need tier 3 intervention, which would involve more intensive, individualized intervention approaches. For tiers 2 and 3, several interventions have already demonstrated strong empirical support.


As is highlighted in this article, several laws and regulations are involved in qualifying a child with anxiety for school-based mental health services. Varying by state and school resources, the process can be complicated. Parents often report feeling confused and frustrated by a lack of understanding and knowledge about the potential resources available for their child. Therefore, it is recommended that educators and other individuals involved in school-based service provision (e.g., teachers, guidance counselors, school psychologists, clinical psychologists) work together to ensure that information is accessible and understandable for parents and guardians. It may be that some children do not receive services because of a lack of appreciation for what is available and that others seek outside services when a school-based approach would better serve the child and family’s needs.

Similarly, school systems need to evaluate their preparedness for integrating an RTI model focused on specific mental health issues into their existing service provision. For instance, a school system may lack individuals with expertise in the requisite evidence-based interventions (particularly tiers 2 and 3). In such cases, outside professionals could provide such services or specialized training for school providers (i.e., school psychologists) who would subsequently provide the services. As another example, some schools may need to consider even more basic logistics—such as where, when, and how universal screenings and services would be provided—before initiating the tier 1 program. Further, it is recommended that in developing such programs, special consideration is given to determining how to assess for anxiety. Although it may be easiest to rely on teacher nominations, for example, of at-risk students in need of tier 2 services, this approach may miss children because the experience of anxiety is not always well known. Therefore, including multiple informants and nomination methods in the determination of at-risk students is recommended. Such an approach could use critical cut-off points on anxiety assessment tools administered to the child and his or her parents, as well as the nomination of teachers or other school personnel who work with the child.

Also noteworthy is the lack of empirical research on tier 1 interventions for socioemotional issues like anxiety. This area represents a critical need for future research because initial interventions have the potential to universally reach students and alleviate distress in a large proportion of them. This fact is of particular importance for anxiety and related internalizing concerns, which can be more easily overlooked than externalizing problems like hyperactivity or disruptive behaviors. Moreover, given that well-supported tier 2 and tier 3 interventions exist for child anxiety disorders, focusing on the development, implementation, and evaluation of tier 1 interventions is especially pertinent.

Finally, it is recommended that school-based RTI models for child anxiety begin to be applied and studied to provide more evidence for their utility. Further, although the authors present several examples of potential tools and interventions, they do not provide an exhaustive list, and alternative approaches could be considered to best fit the needs of the school and its resources. Fine-tuning such RTI models is important future work—for example, determining the best time frames and grades for administering universal programs.


Grills-Taquechel, A. E., & Ollendick, T. H. (2012). Phobic and anxiety disorders in children and adolescents. Boston, MA: Hogrefe.


Lavigne, J., LeBailly, S., Hopkins, J., Gouze, K., & Binns, H. (2009). The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. Journal of Clinical Child and Adolescent Psychology, 38, 315–328.


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