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To be a person is to feel anxious from time to time. The physical symptoms are probably familiar: racing heart, trembling hands, sweaty skin, and possibly some gastrointestinal distress. Anxiety’s effects are often emotional and cognitive, too—though these symptoms may be harder to detect.

The National Institute of Mental Health (NIMH) estimates that just over 31% of adults in the U.S. experience an anxiety disorder in their lifetime (NIMH, n.d.). The Centers for Disease Control and Prevention (CDC) reports that around 9.4% of children 3–17 years old have been diagnosed with “an anxiety problem” (CDC, 2023), and the median age at which an anxiety disorder begins is 11 years (Walter et al., 2020). 

Even without a clinical diagnosis, anxiety of varying degrees can influence how well people perform on tests and how people respond to interventions.

Anxiety can exist on its own as a distinct mental health disorder. It can also be secondary, resulting from a health condition, a life experience, or exposure to/withdrawal from a substance or medication. Symptoms may be mild, or they may feel utterly debilitating. An existing anxiety disorder can change how a person performs in an evaluation, and an assessment can cause its own kind of anxiety. That’s why it’s vital for clinicians and educators to understand the complex interactions that take place when anxiety is part of someone’s life experience. 

 

 

Research and Resources:

 

Centers for Disease Control and Prevention. (2023, March 8). Data and statistics on children’s mental health. https://www.cdc.gov/childrensmentalhealth/data.html  

National Institute of Mental Health. (n.d.). Any anxiety disorder. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder#:~:text=Prevalence%20of%20Any%20Anxiety%20Disorder%20Among%20Adults,-Based%20on%20diagnostic&text=An%20estimated%2031.1%25%20of%20U.S.,some%20time%20in%20their%20lives. 

Walter, H. J., Bukstein, O.G., Reese Abright, A., Keable, H., Ramtekkar, U., Ripperger-suhler, J. & Rockhill, C. (2020). Clinical practice guidelines for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10): 1107-1124. https://www.jaacap.org/article/S0890-8567(20)30280-X/fulltext#articleInformation 

 

 

 

Screening and Diagnosing Anxiety Disorders

Difficulties with anxiety are increasing. For that reason, the U.S. Preventive Services Task Force (USPSTF) recommends screening for anxiety among children 8–18 and adults 64 years old and younger—even if they’re not showing any obvious signs of anxiety. Although experts at the USPSTF don’t specify how often screening should happen, they do note that repeated screening may be best for teens with more anxiety risk factors. 

The World Health Organization (WHO) International Classification of Diseases, 11th Edition (ICD-11) describes an anxiety or fear-related disorder as a condition that causes “significant distress or impairment in functioning.” The World Health Organization distinguishes between fear and anxiety, noting that though the two are related, “fear represents a reaction to perceived imminent threat in the present, whereas anxiety is more future-oriented, referring to perceived anticipated threat” (WHO, 2023).

The ICD-11 lists the following anxiety and fear-related conditions:

• Generalized Anxiety Disorder 
• Separation Anxiety Disorder 
• Selective Mutism
• Specific Phobia
• Social Anxiety Disorder
• Panic Disorder
• Agoraphobia

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM 5-TR) includes these additional conditions under the umbrella of anxiety disorders: 

• Substance/Medication-Induced Anxiety Disorder 
• Anxiety Due to Another Medical Condition

This table summarizes the diagnostic features and practical effects of these anxiety disorders: 

 

 

Source: Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR™, American Psychiatric Association 

 

 

What Anxiety Can Feel Like 

 

Woodgate et al. (2021) asked people with anxiety to describe what it feels like. Here are a few of their responses:

• “It’s like when you put a cat inside a bag and they start clawing at it.” 

• “It’s like living in a box and the box keeps on going smaller and smaller every day.” 

• “You’re trapped in this world…you’re screaming for help and no one can hear you.” 

• “Anxiety is like a lot of black sludge.”

• “I guess anxiety is that burden, the heavy, heavy backpack…full of things you don’t even need but they are there.” 

• “It’s like water that keeps rising; it’s at my chin.” 

In other studies, people have said the experience of anxiety is “very much about pain,” whether that pain is physical, emotional, mental, or social (Woodgate et al., 2020). 

When asked to describe the experience of talking about anxiety with others, people with anxiety told researchers:

• “Teachers are still not open to these topics and are not accepting of it at all. The environment and the attitudes of the system play an important role in self-disclosure.”  

• “What really stood out to me as helpful was using art or other forms of expression to communicate, and not just words.” 

• “When I shared my feelings on an online platform, I did feel good. It did have a short-term benefit. But personally, I felt all those feelings again the next day, and the day after as well. So although I felt good initially, it didn’t ‘fix’ anything.” 

• “It is a helpful release of difficult emotions or experiences and gives me a sense of belonging or togetherness.” 

• “The languages people’s stories are shared in matters. Also, how many marginalized voices you have included—the more diverse the voices, the more people will be able to relate.”  

Some people felt comforted “just knowing others have similar experiences,” and others felt it was important to point out that “struggle does not always lead to recovery” (Gonsalves et al., 2023). 

 

Learn more: The WPS Guide to Assessing Depression in Children and Teens 

 

 

Research and Resources:

 

American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). https://ebooks.appi.org/epubreader/diagnostic-statistical-manual-mental-disorders-fifth-edition-text-revision-dsm5tr  

Gonsalves, P. P., Nair, R., Roy, M., Pal, S., & Michelson, D. (2023). A systematic review and lived experience synthesis of self-disclosure as an active ingredient in interventions for adolescents and young adults with anxiety and depression. Administration and Policy in Mental Health, 50(3), 488–505. https://doi.org/10.1007/s10488-023-01253-2  

U.S. Preventive Services Task Force. (2023). Anxiety disorders in adults: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening 

U.S. Preventive Services Task Force. (2022). Anxiety in children and adolescents: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents  

World Health Organization. (2023). Anxiety or fear-related disorders. https://icd.who.int/browse11/l-m/en#http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1336943699 

Woodgate, R. L., Tennent, P., & Legras, N. (2021). Understanding youth's lived experience of anxiety through metaphors: A qualitative, arts-based study. International Journal of Environmental Research and Public Health, 18(8), 4315. https://doi.org/10.3390/ijerph18084315 

 

 

 

 

Risk and Protective Factors for Anxiety and Anxiety Disorders

 

According to the USPSTF, factors that raise the risk for an anxiety disorder could include:

Genetics or family history  Interparental conflict  Parental overprotection  Early parental separation

Poverty Child maltreatment Other adverse childhood events

Adverse childhood events may include historic and societal exposures, such as living in an environment where people are treated poorly because of their race, ethnicity, gender, sexuality, gender identity or expression, or immigration status. There’s evidence that being female raises your risk of having an anxiety disorder (Guimarães et al., 2022). And some studies have linked loneliness and unhealthy dietary patterns to the development of anxiety as well (Pearce et al., 2023; Aucoin et al., 2021).  

 

 

Just as children, teens, and adults can have intersecting risk factors, they can also have protective or resilience factors that may lessen the impacts of anxiety. These include:  

Physical activity  Strong social support networks  Well-developed coping skills  Cultural connection  Spiritual practices

Access to green and blue natural spaces  Self-esteem Self-efficacy and autonomy Community and job-related relationships

 

If you’re working with people who are vulnerable to anxiety, you can strengthen their protective factors by providing supports like these: 

Clear expectations  Psychological safety  Opportunities to engage with others  Opportunities to create art or music

Opportunities to visit natural or cultural sites  Mentors to help build skills and explore interests  Structure and routine

 

 

Discovering all you can about a person’s interests, resources, cultural assets, support networks, and individual strengths can help you plan effective interventions. It can also help you understand where someone’s environment may need to become more equitable, attuned, and supportive. 

 

 

Research and Resources:

 

Aucoin, M., LaChance, L., Naidoo, U., Remy, D., Shekdar, T., Sayar, N., Cardozo, V., Rawana, T., Chan, I., & Cooley, K. (2021). Diet and anxiety: A scoping review. Nutrients, 13(12), 4418. https://doi.org/10.3390/nu13124418

Cherewick, M., Dahl, R. E., Bertomen, S., Hipp, E., Shreedar, P., Njau, P. F., & Leiferman, J. A. (2023). Risk and protective factors for mental health and wellbeing among adolescent orphans. Health Psychology and Behavioral Medicine, 11(1), 2219299. https://doi.org/10.1080/21642850.2023.2219299

Gonzalez, M. B., Sittner, K. J., & Walls, M. L. (2022). Cultural efficacy as a novel component of understanding linkages between culture and mental health in Indigenous communities. American Journal of Community Psychology, 70(1-2), 191–201. https://doi.org/10.1002/ajcp.12594

Guimarães, G. O., D'Angelo, F., Brouillette, K., Souza, L. D. M., da Silva, R. A., Mondin, T. C., Pedrotti Moreira, F., Kapczinski, F., de Azevedo Cardoso, T., & Jansen, K. (2022). Incidence and risk factors for anxiety disorders in young adults: A population-based prospective cohort study. L'Encephale, S0013-7006(22)00212-3. Advance online publication. https://doi.org/10.1016/j.encep.2022.08.012 

MacIntyre, M. M., Zare, M., & Williams, M. T. (2023). Anxiety-related disorders in the context of racism. Current Psychiatry Reports, 25(2), 31–43. https://doi.org/10.1007/s11920-022-01408-2

Masotti, P., Dennem, J., Bañuelos, K., Seneca, C., Valerio-Leonce, G., Inong, C. T., & King, J. (2023). The Culture is Prevention Project: measuring cultural connectedness and providing evidence that culture is a social determinant of health for Native Americans. BMC Public Health, 23(1), 741. https://doi.org/10.1186/s12889-023-15587-x  

Pearce, E., Birken, M., Pais, S., Tamworth, M., Ng, Y., Wang, J., Chipp, B., Crane, E., Schlief, M., Yang, J., Stamos, A., Cheng, L. K., Condon, M., Lloyd-Evans, B., Kirkbride, J. B., Osborn, D., Pitman, A., & Johnson, S. (2023). Associations between constructs related to social relationships and mental health conditions and symptoms: An umbrella review. BMC Psychiatry, 23(1), 652. https://doi.org/10.1186/s12888-023-05069-0 

Zimmermann, M., Chong, A. K., Vechiu, C., & Papa, A. (2020). Modifiable risk and protective factors for anxiety disorders among adults: A systematic review. Psychiatry Research, 285, 112705. https://doi.org/10.1016/j.psychres.2019.112705 

 

 

 

 

Building a Comprehensive Anxiety Evaluation

 

The American Academy of Child and Adolescent Psychiatry (AACAP) offers clinical practice guidelines for assessing children and teens for anxiety disorders. They recommend that practitioners take these steps to create a comprehensive evaluation: 

1. Use reliable, validated diagnostic measures along with your training and clinical judgment to distinguish between an anxiety disorder and periods of anxiety that are typical for a specific developmental stage. For example, some degree of separation anxiety is to be expected in toddlers, and many teens experience some social anxiety. To help you tell the difference, the DSM 5-TR and ICD-11 also include diagnostic criteria focused on how long symptoms have been present and how severe or disruptive they are.
2. Gather information from multiple sources in different settings. The AACAP recommends carefully and sensitively interviewing parents or caregivers, teachers, health care providers, childcare workers, and the child at the heart of the evaluation. When you consider information from a range of sources, you’ll be better informed about any sources of anxiety in the child’s environment.  
3. Minimize or remove language barriers. If you do not speak or understand the language spoken by the family, it’s important to work with an interpreter who does. An interpreter who is also familiar with the cultural background of the family may enable you to understand the family’s concerns and communicate in a way that is helpful and not harmful. 
4. Rule out other explanations for anxiety. Because so many health conditions, medications, substances, and environmental exposures can cause or worsen anxiety symptoms, it’s important to conduct a detailed history to identify any other causes or contributing factors.   
5. Consider a variety of assessments. Structured interview guides and symptom rating scales can give you important information about how the child and family are processing what’s happening. A variety of guides and scales can also help you understand the individual in context—including the historical, health, and social factors that may be adding to the distress. 
6. Evaluate the safety risks. Some people with anxiety disorders may experience suicidal thoughts, self-harm, or impulsive risk-taking behaviors. Others may be experiencing neglect, abuse, or other forms of trauma. Assessing these risks is a difficult but necessary part of a thorough anxiety disorder evaluation.  
7. Identify supports and resilience factors. To create an effective treatment plan, you will need information on the child’s protective resources and assets, which can be reinforced and leveraged to build resilience. You may want to consider educational, cultural, familial, community, and healthcare resources as you plan.

 

 

Research and Resources:

 

Walter, H. J., Bukstein, O.G., Reese Abright, A., Keable, H., Ramtekkar, U., Ripperger-suhler, J. & Rockhill, C. (2020). Clinical practice guidelines for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10): 1107-1124. https://www.jaacap.org/article/S0890-8567(20)30280-X/fulltext#articleInformation 

 

 

 

 

Cultural Considerations When Screening for and Diagnosing Anxiety

As you’re screening for and identifying anxiety disorders, it’s important to be aware of the many ways cultural background can influence the process. Culture can affect: 

• what causes people to feel anxiety; 
• how people view anxiety; 
• which symptoms people are likely to feel; 
• which words people use to describe their experience; and 
• how people seek help in distressing situations. 

While the list below isn’t exhaustive, it’s a good starting place for understanding some of the ways culture can influence both the experience and the evaluation of anxiety: 

• In some cultures, the language of faith or spirituality is useful to people in describing the causes and effects of anxiety. For example, the ICD-11 notes that in some cultures, the source of anxiety could be ascribed to “external forces or factors (e.g., witchcraft, sorcery, malign magic, or envy) and not as an internal experience or psychological state” (WHO, 2023). Understanding a little about a client or patient’s spirituality may also be helpful as you’re planning supports and interventions. Research shows that spirituality (including a person’s sense of purpose, their values, and their ability to cope with hardship and connect with nature, other people, and a spiritual source) mitigates anxiety and its impacts (Shabani et al., 2023).

• The age at which a child might be expected to spend significant amounts of time away from a parent varies from culture to culture and family to family. Those expectations may influence how symptoms of separation anxiety disorder are experienced or interpreted. In one study involving preschool children in China, children who lived in intergenerational homes (defined by researchers as a family in which grandparents cared for children and parents were not present) were more likely to have separation anxiety disorder (Hu et al., 2021) than children with other family structures. The DSM 5-TR points out, “It is important to differentiate separation anxiety disorder from the high value some cultures place on interdependence among family members” (APA, 2022).

• In some places, colloquial terms may best express anxiety symptoms. For example, in some parts of India, study participants described tension as “standing on toes” or “jhuma jhuma”—a vibrating sensation (Sowmya et al., 2023). 

• In some cultures, anxiety is more likely to be experienced or expressed physically (somatic symptoms), including sore necks or stomachaches, than it is in cognitive or emotional symptoms (Kim et al., 2019). Researchers point out that in some cultures, somatic complaints are more acceptable than psychological ones—but also note that in many cultures mind and body are considered more interconnected than they are in Western cultures.

• The source of anxiety can also vary between cultures. Personal achievement may be a source of worry in individualistic cultures, whereas in collectivist cultures, people may worry more about familial or community concerns (WHO, 2023).

• In addition to culture, gender norms may shape people’s specific fears, symptoms, expression, and help-seeking behaviors. Panic disorder, for example, is nearly twice as common among women as it is among men. In addition, women having panic attacks are more likely to experience shortness of breath and nausea, while men are more likely to experience sweating (APA, 2022).  

 

 

 

 

Research and Resources:

 

Hu, H., Wu, T., Wang, S., Chen, P., Zhang, J., & Zhao, X. (2021). Association between family structure and anxiety disorder among pre-schoolers: A cross-sectional study in urban Chongqing, China. Frontiers in Psychiatry, 12, 626377. https://doi.org/10.3389/fpsyt.2021.626377 

Kim, J. H. J., Tsai, W., Kodish, T., Trung, L. T., Lau, A. S., & Weiss, B. (2019). Cultural variation in temporal associations among somatic complaints, anxiety, and depressive symptoms in adolescence. Journal of Psychosomatic Research, 124, 109763. https://doi.org/10.1016/j.jpsychores.2019.109763

Ren, Q., & Jiang, S. (2021). Acculturation stress, satisfaction, and frustration of basic psychological needs and mental health of Chinese migrant children: Perspective from basic psychological needs theory. International Journal of Environmental Research and Public Health, 18(9), 4751. https://doi.org/10.3390/ijerph18094751 

Shabani, M., Taheri-Kharameh, Z., Saghafipour, A., Ahmari-Tehran, H., Yoosefee, S., & Amini-Tehrani, M. (2023). Resilience and spirituality mediate anxiety and life satisfaction in chronically Ill older adults. BMC Psychology, 11(1), 256. https://doi.org/10.1186/s40359-023-01279-z

Siddiqui S. M. (2022). Acculturative stress, everyday racism, and mental health among a community sample of South Asians in Texas. Frontiers in Public Health, 10, 954105. https://doi.org/10.3389/fpubh.2022.954105

Sowmya H R, Ghani, S., Sreedaran, P., Sahu, M. K., Mysore, A., & Sharan, P. (2023). Cultural expression of anxiety symptoms in Kannada language: A qualitative study. Indian Journal of Psychological Medicine, 45(5), 496–502. https://doi.org/10.1177/02537176221140742 

 

 

 

 

Co-occurring Conditions

 

It is very common for people to have more than one anxiety disorder at the same time. In addition to overlapping anxiety disorders, some people may also have other co-occurring health conditions that cause, contribute to, or mimic the symptoms of anxiety. 

Here’s a look at some common conditions that may raise the risk of anxiety: 

  

Attention Deficit/Hyperactivity Disorder (ADHD)

Anxiety is not uncommon for people with ADHD. Between one quarter and one half of children and teens with ADHD also have an anxiety disorder—and many others experience anxiety because of their ADHD symptoms, even if they don’t meet diagnostic criteria for a disorder (Leon-Barriera et al., 2023; Gair et al., 2021).  

For some children with ADHD, anxiety symptoms begin as early as preschool and may persist for years. In a longitudinal study involving children ages three through eight, researchers found that ADHD symptoms in preschool increased the risk for anxiety later in childhood. In the same study, researchers noted that around one third of children with ADHD at 8 years old also met the diagnostic criteria for an anxiety disorder or depression at the same time. They offered this recommendation: “[C]linicians should ask parents about anxiety and depressive symptoms and ask teachers about anxiety symptoms, both in children with and without co-occurrent ADHD symptoms. They should be aware that anxiety and depressive symptoms are easily overlooked in young children” (Ingeborgrud et al., 2022).

During the teen years, there’s some evidence that having ADHD and an anxiety order together may increase the risk of suicidal thoughts and behaviors—but more research is needed to confirm this risk, since some studies have arrived at different conclusions (Austgulen et al., 2023). 

Some other effects to consider:

• Some studies show that anxiety may lessen the effects of ADHD on some kinds of assessment tasks, including those that require sustained attention, emotion recognition, and response inhibition (Manoli et al., 2021).

• In the teen years, researchers say, anxiety may increase working memory deficits in people with ADHD (D’Agati et al., 2019).

• Some researchers have suggested that what appear to be ADHD characteristics in early childhood may instead be early symptoms of anxiety (Gair et al., 2021).  

 

Learn more: The WPS Guide to Assessing for Attention-Deficit/Hyperactivity Disorder 

 

 

Specific Learning Disorders

When you’re evaluating a student who has difficulty with reading, math, or writing, it’s important to rule out anxiety disorders as a cause. It can be hard to distinguish anxiety symptoms from the effects of a specific learning disorder (SLD)—especially because anxiety can interfere with the assessment process.  

 

When a student has significant anxiety, you may notice signs like these during an assessment: 

Giving up or fatiguing easily  Answering too quickly  Answering after a long hesitation  Using very simple sentences  Rushing  Avoiding tasks like writing

Having trouble with organization  Processing at a shallow level Being unable to clarify answers Being forgetful Marking answers randomly (Shah et al., 2019)

Conducting a comprehensive evaluation can help you clarify which behaviors are driven by anxiety and which stem from a learning disorder. Experts recommend that you include these elements in an SLD evaluation: 

• Review of school records, including behavioral, academic, and attendance data 
• Family and personal history of anxiety, neurodevelopmental conditions, or academic difficulties (including a language history if more than one language is spoken) 
• Review of health records if available 
• Conversation with the child, the family or caregivers, and educators to shed light on their concerns and goals 
• Observations in classrooms and other school settings 
• Assessment with validated measures to identify or rule out potential causes for academic difficulties 
• Screening for co-occurring conditions such as ADHD and anxiety 

Students with SLDs have a higher risk for anxiety than typical students do. Predictably, they’re more likely to experience that anxiety in school, where they meet with:

• difficult tasks; 
• frequent demands; 
• fear of failure; and 
• unfavorable comparisons with other students (Aro et al., 2022).

In a review of 86 peer-reviewed journal articles and other sources, researchers found that these factors influenced mental health in children with dyslexia, the most common specific learning disorder:

• Social experiences can act as either a risk or protective factor. Friendships, for example, have a protective effect, while bullying is a risk factor for mental health concerns.
• Poor reading self-concept raises the risk of anxiety and depression.
• Low levels of self-efficacy led to more headaches, stomachaches, and other physical symptoms of anxiety.
• People who have dyslexia can feel disconnected from school, largely because they feel dyslexia isn’t well understood or adequately supported. When students with a learning disorder feel understood and supported by teachers, their anxiety decreases (Wilmot et al., 2023). 

 

Learn more: The WPS Guide to Dyslexia Assessment 

 

  

Autism

Experts estimate that between 20% and 50% of autistic adults have a co-occurring anxiety disorder, compared to 8.7 % of the general population (Ezell et al., 2019). The risk of anxiety is higher for autistic people without intellectual disability (ID). In a large population-based study in Sweden, researchers found that autistic adults without ID had higher risks of panic disorder, generalized anxiety disorder, post-traumatic stress disorder, and specific phobias (Nimmo-Smith et al., 2020).

Anxiety and autism can look the same in some individuals. Both can involve social avoidance. Both can limit interests and lead to repetitive behaviors and reluctance to change. And both can change how people respond to certain stimuli in their environments. Because of this shared territory, it can be challenging to tell which condition underlies a behavior or response—which in turn can make accurate identification a little more difficult (Ezell et al., 2019).

It may be that autistic people have higher rates of anxiety because of these factors:

• Autism and anxiety have shared genetic causes. 
• Autistic people may experience rejection, punishment, or stressful preventive interventions aimed at their interests, behaviors, or communication style. 
• Confusion, uncertainty, and social fears can develop because of misunderstanding other people’s thoughts, feelings, and intentions.  
• Sensory perception differences may cause fear or stress in certain environments.  
• Autistic people may feel pressure to conform to neurotypical expectations. 
• Autistic people may be targeted by bullies (Hunsche et al, 2022.; Nimmo-Smith et al., 2020). 

When autistic children and teens also have an anxiety disorder, it’s especially important to plan early and in cooperation with parents, who may also be experiencing some distress (Guerrera et al., 2022). 

 

Learn more:  The WPS Guide to Autism Assessment 

 

  

Developmental Language Disorder

Developmental language disorder (DLD) is a neurodevelopmental condition that leads to difficulties with both expressive and receptive language. It’s estimated that children with DLD have lower self-esteem, difficulties in social relationships—and a rate of anxiety that is six times higher than in typically developing children their age (Burnley et al., 2023).

In a study published in 2023, researchers explored the underpinnings of anxiety in children with DLD. Parents in that study said their children felt “an overload of uncertainty on a daily basis due to their language difficulties.” Worry was a logical attempt to control that uncertainty, researchers said (Burnley et al., 2023). 

In a related study, Burnley et al. interviewed parents about their children’s expression of anxiety. Parents said it showed up in several predictable patterns:

Rumination or over-thinking  Preference for “sameness”

Intolerance for uncertainty  Negative interpretation bias

Because anxiety can also influence oral language and social communication and vice versa, it’s important to include a thorough language assessment in an anxiety evaluation.  

 

Learn more: Elevate Your EL Speech–Language Assessments 

 

 

Medical Conditions  

When people have a medical illness, anxiety is often part of the experience. That’s especially true when health conditions are long-term. The ICD-11 classifies such anxiety disorders as secondary anxiety syndrome, noting that the anxiety symptoms are “a direct pathophysiological consequence of a health condition not classified under mental and behavioural disorders” (WHO, 2023). 

Anxiety can make symptoms of the health condition worse, and it can affect general well-being and social relationships (Romanazzo et al., 2022).  

Anxiety disorders are associated with these health conditions: 

• Generalized anxiety disorder is common among people with cardiovascular, respiratory, central nervous system, skin conditions, cancer, and COVID-19 infection.
• Panic disorder has been linked to cardiovascular, respiratory, and skin conditions.
• Social anxiety often occurs alongside cardiovascular, respiratory, and rheumatoid conditions.
• Specific phobias often happen with multiple sclerosis, lupus, certain cancers, irritable bowel syndrome, gastroesophageal reflux, and end-stage kidney disease.

In addition, some medications and substances can also cause anxiety as a side effect, including these:  

Stimulants used to treat ADHD  Corticosteroids used to treat infections  Some over-the-counter decongestants and antihistamines used to treat allergies and cold symptoms

Antidepressants  Thyroid medications  Cannabis  Caffeine

 In the DSM 5-TR, anxiety related to using or stopping the use of a drug or substance is classified as substance/medication-induced anxiety disorder.  Having a clear understanding of a student’s or patient’s medical history can help you schedule assessments when side effects are least likely to interfere with their abilities. 

 

 

Research and Resources:

 

Austgulen, A., Skram, N. K. G., Haavik, J., & Lundervold, A. J. (2023). Risk factors of suicidal spectrum behaviors in adults and adolescents with attention-deficit / hyperactivity disorder - a systematic review. BMC Psychiatry, 23(1), 612. https://doi.org/10.1186/s12888-023-05099-8

Burnley, A., St Clair, M., Bedford, R., Wren, Y., & Dack, C. (2023). Understanding the prevalence and manifestation of anxiety and other socio-emotional and behavioural difficulties in children with developmental language disorder. Journal of Neurodevelopmental Disorders, 15(1), 17. https://doi.org/10.1186/s11689-023-09486-w

Burnley, A., St Clair, M., Dack, C., Thompson, H., & Wren, Y. (2023). Exploring the Psychosocial Experiences of Individuals with Developmental Language Disorder During Childhood: A Qualitative Investigation. Journal of Autism and Developmental Disorders, 10.1007/s10803-023-05946-3. Advance online publication. https://doi.org/10.1007/s10803-023-05946-3

D'Agati, E., Curatolo, P., & Mazzone, L. (2019). Comorbidity between ADHD and anxiety disorders across the lifespan. International Journal of Psychiatry in Clinical Practice, 23(4), 238–244. https://doi.org/10.1080/13651501.2019.1628277 

Ezell, J., Hogan, A., Fairchild, A., Hills, K., Klusek, J., Abbeduto, L., & Roberts, J. (2019). Prevalence and predictors of anxiety disorders in adolescent and adult males with autism spectrum disorder and fragile X syndrome. Journal of Autism and Developmental Disorders, 49(3), 1131–1141. https://doi.org/10.1007/s10803-018-3804-6

Gair, S. L., Brown, H. R., Kang, S., Grabell, A. S., & Harvey, E. A. (2021). Early development of comorbidity between symptoms of ADHD and anxiety. Research on Child and Adolescent Psychopathology, 49(3), 311–323. https://doi.org/10.1007/s10802-020-00724-6

Guerrera, S., Pontillo, M., Tata, M. C., Di Vincenzo, C., Bellantoni, D., Napoli, E., Valeri, G., & Vicari, S. (2022). Anxiety in autism spectrum disorder: Clinical characteristics and the role of the family. Brain Sciences, 12(12), 1597. https://doi.org/10.3390/brainsci12121597

Ingeborgrud, C. B., Oerbeck, B., Friis, S., Zeiner, P., Pripp, A. H., Aase, H., Biele, G., Dalsgaard, S., & Overgaard, K. R. (2023). Anxiety and depression from age 3 to 8 years in children with and without ADHD symptoms. Scientific Reports, 13(1), 15376. https://doi.org/10.1038/s41598-023-42412-7

León-Barriera, R., Ortegon, R. S., Chaplin, M. M., & Modesto-Lowe, V. (2023). Treating ADHD and comorbid anxiety in children: A guide for clinical practice. Clinical Pediatrics, 62(1), 39–46. https://doi.org/10.1177/00099228221111246

Manoli, A., Liversedge, S. P., Sonuga-Barke, E. J. S., & Hadwin, J. A. (2021). The differential effect of anxiety and ADHD symptoms on inhibitory control and sustained attention for threat stimuli: A go/no-go eye-movement study. Journal of Attention Disorders, 25(13), 1919–1930. https://doi.org/10.1177/1087054720930809

Nimmo-Smith, V., Heuvelman, H., Dalman, C., Lundberg, M., Idring, S., Carpenter, P., Magnusson, C., & Rai, D. (2020). Anxiety disorders in adults with autism spectrum disorder: A population-based study. Journal of Autism and Developmental Disorders, 50(1), 308–318. https://doi.org/10.1007/s10803-019-04234-3

Romanazzo, S., Mansueto, G., & Cosci, F. (2022). Anxiety in the medically Ill: A systematic review of the literature. Frontiers in Psychiatry, 13, 873126. https://doi.org/10.3389/fpsyt.2022.873126 

Shah, H. R., Sagar, J. K. V., Somaiya, M. P., & Nagpal, J. K. (2019). Clinical practice guidelines on assessment and management of specific learning disorders. Indian Journal of Psychiatry, 61(Suppl 2), 211–225. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_564_18

Wilmot, A., Hasking, P., Leitão, S., Hill, E., & Boyes, M. (2023). Understanding mental health in developmental dyslexia: A scoping review. International Journal of Environmental Research and Public Health, 20(2), 1653. https://doi.org/10.3390/ijerph20021653 

 

 

 

 

 

Mental Health Assessment Tools

Choosing the best assessment takes careful consideration. The practice guidelines of your profession will provide you with important information to guide your decision-making about which assessments are needed in a comprehensive anxiety evaluation.

For example, the Principles of Professional Ethics of the National Association of School Psychologists (NASP) state that school psychologists should:

• “Select assessment instruments and strategies that are reliable and valid for the examinee and the purpose of the assessment…” (Standard II.3.3) 
• “Choose instruments with norms that are representative, recent, and appropriate for the person being evaluated.” (Standard II.3.4) 
• Use “a variety of different types of information from different sources,” noting that “no single test or measure is used to make broad determinations regarding disability identification or services needed.” (Standard II.3.6)

 

Read more about NASP Professional Standards here. 

 

 

Similarly, the American School Counselor Association (ASCA) National Model encourages school counselors to:  

• “Use data to identify students in need of counseling intervention.” (ASCA School Counselor Professional Standards & Competencies B-SS 3.a) 
• “…Remain acutely aware of how a student’s diagnosis can potentially affect the student’s academic success.” (ASCA Ethical Standards for School Counselors A.1.c.) 
• “Use only valid and reliable tests and assessments with concern for bias and cultural sensitivity.” (ASCA Ethical Standards for School Counselors A.13.a) 

While school counselors don’t diagnose anxiety disorders, they play a critical role in identifying students who may need mental health supports and interventions to succeed personally and academically.  

  

The Importance of a Multidisciplinary Assessment Team

Anxiety has many causes and effects—and they may be different for every person you evaluate. Whenever possible, it’s best to work with a team of professionals to create the clearest possible picture of the person at the center of your evaluation. Clinical psychologists, school psychologists, school counselors, occupational therapists, speech–language pathologists, social workers, educators, and other professionals can each contribute something vital to the process. You may also understand a student or patient better after speaking with that individual, their caregivers, and their family members. 

WPS Assessment Consultants are also available to assist you in selecting the most appropriate tests for the situation. We invite you to consider these assessments as you build a comprehensive mental health evaluation: 

 

Mental Health Assessments 

Revised Children’s Manifest Anxiety Scale, Second Edition (RCMAS™-2)  Conners Comprehensive Behavior Rating Scales (Conners CBRS)  Children’s Depression Inventory, Second Edition (CDI 2) Piers-Harris Self-Concept Scale, Third Edition (Piers-Harris ™ 3)  Risk Inventory and Strengths Evaluation (RISE™ Assessment)

Scales for Assessing Emotional Disturbance, Third Edition (SAED 3)  Trauma Symptom Checklist for Children (TSCC)  Trauma Symptom Checklist for Young Children (TSCYC)  Trauma Symptom Inventory-2 (TSI-2)

Assessments to Measure Cognitive & Functional Effects of Anxiety 

Woodcock-Johnson IV (WJ IV)  Woodcock-Johnson IV Tests of Early Cognitive and Academic Development (ECAD)  Batería IV Woodcock-Muñoz  Woodcock-Muñoz Language Survey  Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2)  Behavior Rating Inventory of Executive Function–Preschool Version (BRIEF-P)  Adaptive Behavior Assessment System, Third Edition (ABAS®-3)  Oral Passage Understanding Scale (OPUS™)

Oral and Written Language Scales, Second Edition (OWLS™-II)  Comprehensive Assessment of Spoken Language, Second Edition (CASL®-2)  Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2)  Test of Word Reading Efficiency, Second Edition (TOWRE-2)  Gray Diagnostic Reading Tests, Second Edition (GDRT-2)  Gray Oral Reading Test, Fifth Edition (GORT-5)  Test of Early Reading Ability, Fourth Edition (TERA-4)  School Motivation and Learning Strategies Inventory (SMALSI™)

Assessments for Co-occurring Neurodevelopmental Conditions 

• Conners Fourth Edition (Conners 4) 
• Autism Diagnostic Observation Schedule™, Second Edition (ADOS®-2) 
• Monteiro Interview Guidelines for Diagnosing the Autism Spectrum, Second Edition (MIGDAS™-2) 
• Tests of Dyslexia (TOD™)

 

 

Research and Resources:

 

American School Counselor Association. (2019). ASCA National Model: A Framework for School Counseling Programs, Fourth Edition. Alexandria, VA. https://www.schoolcounselor.org/getmedia/a8d59c2c-51de-4ec3-a565-a3235f3b93c3/SC-Competencies.pdf

American Speech–Language Hearing Association. (2016). Scope of practice in speech–language pathology. https://www.asha.org/policy/sp2016-00343/#Domains_of_Professional_Practice

National Association of School Psychologists. (2020). The Professional Standards of the National Association of School Psychologists. https://www.nasponline.org/standards-and-certification/nasp-2020-professional-standards-adopted 

 

 

 

 

How Anxiety May Affect Assessment Outcomes

 

Anxiety can affect the people you’re assessing in vastly different ways depending on individual circumstances. Anxiety may boost some people’s performance in subtle ways. For example, research confirms that trait perfectionism, which goes hand in hand with anxiety, may spur some people to outperform others on cognitive tests (Roberts et al., 2023).    

For other people, anxiety hinders performance on cognitive tasks—meaning their true abilities aren’t reflected by their test scores. Here’s a summary of what we know so far about the ways anxiety can change test performance:

 

Anxiety and Executive Function

Executive function (EF) is a set of thinking skills that allows people to plan, set goals, focus, remember, switch tasks, and use self-control. Many cognitive assessments measure executive function capabilities. These skills are often grouped into three categories: working memory, set-shifting, and inhibitory control. 

Anxiety and executive function have a two-way relationship. Executive function deficits can lead to anxiety, and anxiety can interfere with some aspects of executive function. For example, when people have trouble controlling impulsive behaviors, it can cause stress in relationships at school and work—leading to higher anxiety. 

Anxiety can negatively affect people’s executive functioning. In some studies, researchers have found broad executive dysfunction when people are experiencing a heightened state of anxiety called “anxious arousal.” When people are feeling anxious apprehension, they may not be as adept at switching tasks efficiently (Warren et al., 2021). 

In a 2023 study, anxiety disrupted performance on working memory tasks (Suddell et al., 2023), especially those tasks involving verbal working memory. That effect was consistent whether someone was experiencing state anxiety (short-term, situational) or trait anxiety (long-term or chronic).

It's important to point out, however, that anxiety doesn’t always interact with executive function in a negative way. In fact, sometimes anxiety boosts certain executive function skills. In a 2022 review, researchers Zainal and Newman said it’s possible that “higher anxiety levels can dovetail with better inhibition and associated EF domains for some subgroups and under specific settings” (emphasis original). Children with trait anxiety and social anxiety symptoms often show “enhanced cognitive control capacities,” they reported. 

If you are evaluating someone with anxiety, you may want to assess executive function to determine what effect, if any, anxiety is having on the individual’s cognitive abilities. 

 

Anxiety and Language

In studies, anxiety has been linked to oral and written language difficulties. For example, in one Australian study, parents who rated their children as anxious also said their children had trouble with functional language in everyday situations, even when their children had not formally been diagnosed with an anxiety disorder or a language disorder (Pickering et al., 2022).

In a Brazilian study, researchers found that children diagnosed with an anxiety disorder didn’t perform as well on tasks involving oral language comprehension, inference processing, word reading, writing comprehension, copied writing, and semantic verbal fluency. In that study, having more than one anxiety disorder was associated with more severe language-related difficulties (Sbicigo et al., 2020).  

Long-term studies have found that there is a complex relationship between language abilities, internalizing symptoms like anxiety, and externalizing symptoms like physical aggression. They tend to influence each other over time—which is why researchers say a comprehensive assessment is needed to understand the root of an impairment (Tamayo et al., 2023).  

 

 

Anxiety and Math

People with math-specific anxiety generally don’t perform well on math assessments. Some people have a long-term aversion to anything related to math. This chronic math anxiety is sometimes called “trait math anxiety.” By contrast, some people have a temporary anxious arousal when dealing with a specific math-oriented situation—known as “state math anxiety.” Research suggests that people with general anxiety may be more likely to develop math anxiety (Daches Cohen et al., 2021).

In studies, underperformance on math tasks is partly, but not entirely, related to anxiety people feel in anticipation of having to do math. Some researchers theorize that math anxiety leads people to avoid math, resulting in less practice and less proficiency. This explanation is sometimes called the Deficit Theory.

Others have speculated that math anxiety may cause processing difficulties or distracted thinking. Another possible explanation could be that people with math anxiety don’t fully engage with math tasks, as a means of regulating their emotions (Daker et al., 2023). 

A specific learning disability in math, sometimes called dyscalculia, can affect psychosocial quality of life and lead to higher levels of anxiety in students (Saga et al., 2023).

 

Anxiety and Reading

The influence of anxiety on reading hasn’t yet been well studied, especially among students with reading difficulties. While more research is needed, recent studies confirm these connections between anxiety and reading:

• General anxiety and reading anxiety are different, but they can overlap.
• Anxious thoughts and the physical symptoms of anxiety may distract people, making it harder for them to concentrate while reading. For example, reading anxiety could affect the ability to process information efficiently, which may hinder reading fluency for some readers.
• In studies, neither reading anxiety nor general anxiety influenced word reading accuracy. However, anxiety did significantly affect reading comprehension (Macdonald et al., 2021).
• Students with dyslexia have higher levels of both general and reading anxiety than typical readers do (Chung et al., 2023).  

 

Test Anxiety

Test anxiety isn’t a separate diagnosis. Nevertheless, it can be a powerful influence in an evaluation.  

In Strategies for Academic Success: The SMALSI™ Intervention Guide, the authors explain that test anxiety can: 

• be related to poor studying or test-taking skills; 
• cause irrelevant thoughts to keep students from focusing on test questions; 
• cue students to view testing situations as threatening; 
• keep students from efficiently encoding, organizing, or accessing information; 
• trigger self-doubts that interrupt attention and cause students to miss important test cues; and
• lead to lower self-esteem.

If anxiety about an assessment prevents someone from accessing knowledge and demonstrating abilities they normally have, then the test results may not be an accurate reflection of the test-taker’s true strengths and needs. 

Test anxiety seems to disrupt fluid reasoning—the ability to think clearly and quickly in new situations. Researchers think this disruption may be behind reading comprehension problems in testing situations (Sylvia et al., 2023). 

Ultimately, addressing test anxiety is a worthy goal, not just because it affects people’s scores, but because anxiety can eat away at learning motivation and lessen well-being over time (Yatkin et al., 2023). 

 

Learn more about the School Motivation and Learning Strategies Inventory (SMALSI™).

 

 

Research and Resources:

 

Chung, K. K. H., Lam, C. B., Chan, K. S., Lee, A. S. Y., Liu, C., & Wang, L. C. (2023). Are General Anxiety, Reading Anxiety, and Reading Self-Concept Linked to Reading Skills Among Chinese Adolescents With and Without Dyslexia? Journal of Learning Disabilities, 222194231181914. Advance online publication. https://doi.org/10.1177/00222194231181914

Daches Cohen, L., Korem, N., & Rubinsten, O. (2021). Math anxiety is related to math difficulties and composed of emotion regulation and anxiety predisposition: A network analysis study. Brain Sciences, 11(12), 1609. https://doi.org/10.3390/brainsci11121609

Daker, R. J., Gattas, S. U., Necka, E. A., Green, A. E., & Lyons, I. M. (2023). Does anxiety explain why math-anxious people underperform in math? NPJ Science of Learning, 8(1), 6. https://doi.org/10.1038/s41539-023-00156-z

Macdonald, K. T., Cirino, P. T., Miciak, J., & Grills, A. E. (2021). The Role of Reading Anxiety among Struggling Readers in Fourth and Fifth Grade. Reading & Writing Quarterly, 37(4), 382–394. https://doi.org/10.1080/10573569.2021.1874580

Roberts, C., Sahakian, B. J., Chen, S., Sallie, S. N., Walker, C., White, S. R., Weber, J., Skandali, N., Robbins, T. W., & Murray, G. K. (2023). Impact and centrality of attention dysregulation on cognition, anxiety, and low mood in adolescents. Scientific Reports, 13(1), 9106. https://doi.org/10.1038/s41598-023-34399-y

Saga, M., Rkhaila, A., Oubaha, D., & Ounine, K. (2023). The impact of anxiety and life quality on the mathematical performance of dyscalculic middle school children. Applied Neuropsychology Child, 12(4), 318–326. https://doi.org/10.1080/21622965.2022.2105146

Sbicigo, J. B., Toazza, R., Becker, N., Ecker, K., Manfro, G. G., & Salles, J. F. (2020). Memory and language impairments are associated with anxiety disorder severity in childhood. Trends in Psychiatry and Psychotherapy, 42(2), 161–170. https://doi.org/10.1590/2237-6089-2019-0051

Stade, E. C., Ungar, L., Eichstaedt, J. C., Sherman, G., & Ruscio, A. M. (2023). Depression and anxiety have distinct and overlapping language patterns: Results from a clinical interview. Journal of Psychopathology and Clinical Science, 10.1037/abn0000850. Advance online publication. https://doi.org/10.1037/abn0000850

Suddell, S., Mahedy, L., Skirrow, C., Penton-Voak, I. S., Munafò, M. R., & Wootton, R. E. (2023). Cognitive functioning in anxiety and depression: Results from the ALSPAC cohort. Royal Society Open Science, 10(8), 221161. https://doi.org/10.1098/rsos.221161 

Sylvia, A. M., Shear, P. K., Jastrowski Mano, K. E., Guerin, J. M., & Mano, Q. R. (2023). Test anxiety and reading comprehension: the key role of fluid reasoning. Anxiety, Stress, and Coping, 36(6), 781–794. https://doi.org/10.1080/10615806.2023.2169677

Tamayo, N., Wareham, H., Franken, M. C., McKean, C., Tiemeier, H., & Jansen, P. W. (2023). Bidirectional associations between mental health problems and language ability across 8 years of childhood. European Child & Adolescent Psychiatry, 10.1007/s00787-023-02192-x. Advance online publication. https://doi.org/10.1007/s00787-023-02192-x 

Warren, S. L., Heller, W., & Miller, G. A. (2021). The structure of executive dysfunction in depression and anxiety. Journal of Affective Disorders, 279, 208–216. https://doi.org/10.1016/j.jad.2020.09.132 

Yatkin, E., Aral, N., Gunes, L. C., & Tosun, S. (2023). Mental well-being and test anxiety among students preparing for the university admission exam during the pandemic. Frontiers in Psychology, 14, 1184788. https://doi.org/10.3389/fpsyg.2023.1184788

Zainal, N. H., & Newman, M. G. (2022). Executive functioning constructs in anxiety, obsessive-compulsive, post-traumatic stress, and related disorders. Current Psychiatry Reports, 24(12), 871–880. https://doi.org/10.1007/s11920-022-01390-9 

 

 

 

 

Reducing Test Anxiety

 

The strategies described below are aimed at lowering test anxiety. They may not be appropriate for every type of assessment, and they’re not intended to treat anxiety disorders. They may, however, help you create a more welcoming and supportive classroom or clinical environment.

1. Use students’ names and pronouns correctly.
2. Make space for informal, non-content conversations (including stories about any experiences you may have had bouncing back from a poor test performance). 
3. Embed some humor in your tests where appropriate.
4. In a classroom, avoid “cold-calling,” or asking students to share information when they have not volunteered, which has been shown to spike anxiety.  
5. Allow students to choose their own groups for group work. 
6. Consider assigning roles and responsibilities in group work, making sure you clearly explain goals, deadlines, and the rationale for the project.
7. Frame mistakes as a natural part of growth and learning. 
8. Use “microaffirmations” or non-verbal demonstrations of kindness to help people feel accepted and welcomed.
9. Explain “stereotype threat,” intentionally correcting the common misbelief that intelligence and exams are connected.
10. Eliminate high stakes testing whenever possible. When preparing students for standardized tests, avoid describing the negative consequences of a poor test performance. 
11. Encourage students to use metacognition—thinking about their studying, test preparation, and test-taking before and after assessments.
12. Teach evidence-based test-taking strategies to develop a sense of control in students with test anxiety. For a thorough discussion of test-taking and study strategies, as well as a parent guide on reducing test anxiety for students, consult Strategies for Academic Success: The SMALSI™ Intervention Guide. 
13. De-mystify your tests. To minimize fear of the unknown, explain to students how you create a test, emphasizing the opportunities for students to show what they know and can do. 
14. Use language that promotes a growth mindset—the belief that skills and knowledge can be improved over time. In a school setting, you may want to consider grading policies based on mastery, which can reinforce growth mindset.
15. For students with severe test anxiety, consider accommodations that might decrease the stress—extra time, testing spaces with minimal distractions, or a test-reader. It may be necessary to seek a diagnosis that will make the student eligible for a 504 plan that specifies these testing accommodations.  

 

Learn more about ways to make evaluations more trauma-sensitive.  

 

 

Research and Resources:

 

Hsu, J. L., & Goldsmith, G. R. (2021). Instructor strategies to alleviate stress and anxiety among college and university STEM students. CBE Life Sciences Education, 20(1), es1. https://doi.org/10.1187/cbe.20-08-0189

Vannest, K., Stroud, K. & Reynolds, C. R. (2014). Strategies for Academic Success: The SMALSI Intervention Guide. Western Psychological Services. Torrance, CA.

 

 

 

 

 

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