Managing Anxiety in the Classroom through Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) Skills: A Curriculum Project by Kaleigh Lamb A project submitted in partial fulfillment of the requirements for the degree of MASTER OF EDUCATION with an emphasis in CURRICULUM AND INSTRUCTION WEBER STATE UNIVERSITY Ogden, Utah 4/11/2023 Approved Stephanie Speicher, Ph.D. Britten Lamb, LCSW Ryan B. Mortensen, M.A. Ed. Table of Contents Abstract 1 Literature Review Prevalence of Anxiety in Adolescents Cognitive Effects of Anxiety Social and Behavioral Effects of Anxiety Therapeutic Techniques to Treat Anxiety Cognitive Behavior Therapy Dialectical Behavior Therapy Therapy Techniques in the Classroom Summary Purpose Method Context Development Procedures Evaluation procedures 3 3 5 6 7 7 9 11 12 13 14 14 14 16 Results Course Layout Table 1 Evaluator Feedback Educational Professionals Therapeutic Professionals Discussion Insights from Evaluator Feedback Recommendations and Disseminations Conclusion 17 17 18 19 19 21 23 23 24 25 References 27 MANAGING ANXIETY IN THE CLASSROOM 1 Abstract Students in the United States are experiencing anxiety/mental health issues at alarming rates. Various research supports that unchecked anxiety results in severe, long lasting effects on education, cognitive development, and self-esteem in adolescents. Several skills and techniques have been developed that mitigate anxiety’s chronic effects, and implementing those methods within educational settings yields decreased long-term impacts. This project explores the designing of a curriculum that teachers of any subject in grades 7-12 can implement within their classrooms. The curriculum was created using cognitive behavioral therapy and dialectical behavior therapy techniques that have been proven effective by the American Psychiatric Association to aid anxiety/mental health issues. Overall, evaluators of the project recognized both the value and effectiveness of integrating therapeutic techniques and curriculum, and found the instruction seamless to implement. Upon first glance, the therapeutic concepts may appear overwhelming or confusing; however, when presented simply, the curriculum becomes easily accessible and implementable. MANAGING ANXIETY IN THE CLASSROOM 2 Today's students are experiencing anxiety/mental health issues at alarming rates. Anxiety is one of the most common mental health issues that affect this vulnerable group (Garcia & O’Neil, 2021; Mohammadi, Ahmadi, et al., 2020; Mohammadi, Pourdehghan, et al., 2020; Parodi et al., 2021). Anxiety rates in the United States appear to be higher than in the rest of the world (Mohammadi, Ahmadi, et al., 2020; Parodi et al., 2021). Throughout the last decade, anxiety rates have been on the incline internationally and within the United States specifically (Parodi et al., 2021). A similar pattern has been seen since the early 2000s (Garcia & O’Neil, 2021). Adolescents are more vulnerable to this type of mental disorder due to factors specific to adolescent populations (Garcia & O’Neil, 2021). Unchecked, anxiety and mental health issues (depression, bipolar disorder, eating disorders, etc.) are detrimental to students in many ways. Anxiety can have severe and long-lasting negative effects on education, self-esteem, and confidence for adolescents (Hendriks et al., 2016; Mohammadi, Pourdehghan, et al., 2020; Waite & Creswell, 2014). These long-lasting effects result from anxiety causing adolescents to have impaired social, cognitive, and behavioral functions (Hendriks et al., 2016; Mohammadi, Ahmadi, et al., 2020; Waite & Creswell, 2014). Some of the time, the negative impact that anxiety has on children’s lives can lead to disability (inability to perform an activity in a manner considered normal) later in life (Hendriks et al., 2016). Adolescents with anxiety disorders are in need of clinical treatment (Waite & Creswell, 2014). Research suggests that anxiety can easily become chronic in many adolescents, but it can decrease over time with effective treatment (Mohammadi, Ahmadi, et al., 2020; Waite & Creswell, 2014). Many skills and techniques have been used to treat the symptoms of anxiety and help prevent the long-term effects that it might cause. Implementing these techniques within an MANAGING ANXIETY IN THE CLASSROOM 3 educational setting can help students see decreased anxiety symptoms and fewer long-term negative effects. While there are therapeutic techniques to support students who deal with these issues, teachers may not be aware of or know how to implement these techniques. Cognitive Behavior Therapy (CBT) techniques can have positive outcomes in treating anxiety (Parker & Waller, 2019; Sigurvinsdóttir et al., 2019). However, these techniques are either under-used or not used as a form of treatment (Parker & Waller, 2019). Dialectical Behavior Therapy (DBT) is also an effective treatment for adolescents with anxiety (Falabella et al., 2021; Malivoire, 2020). On their own, these two therapies can have positive outcomes in the reduction of anxiety symptoms. When used together, there are even more significant changes in anxiety symptoms (Falabella et al., 2021). Literature Review Prevalence of Anxiety in Adolescents Anxiety is a mental health disorder that is classified in the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) as any number of disorders “that share features of excessive fear and anxiety and related behavioral disturbances” (American Psychiatric Association [APA], 2013 p. 189). Anxiety is often associated with feelings of fear or worry. Fear is the body’s response to an actual or perceived threat. When the body senses a threat (whether it is real or not) it reacts biologically through the “fight-or-flight” response (Myers & Dewall, 2015, APA, 2013). This affects the body physiologically as well as mentally. Anxiety is a type of fear that is associated with the anticipation of a perceived threat. Although the threat isn’t actually there, the body still responds, in the same way, putting the same strain on the body as fear would (Myers & Dewall, 2015, APA, 2013). MANAGING ANXIETY IN THE CLASSROOM 4 Anxiety rates throughout the globe are increasing. Even a decade ago, rates of anxiety disorders were on the rise. A study by Bitsko et al. (2018) gathered parental reports on youth prevalence of anxiety. These children were between the ages of six and nineteen. The study showed an increase in anxiety over a nine-year period. In 2003, rates of anxiety and depression in children were 5.4%. This rate increased to 7.8% in 2007 and again showed an increase to 8.4% in 2011-2012. These changes show a 19% increase in anxiety among children ages six to nineteen (Bitsko et al., 2018). Another study was done by Katherine B. Parodi et al. which looked at the rates of anxiety between 2012 and 2018. Their results showed even more of an increase in anxiety than the prior study. Within this six-year period, anxiety rates increased by another 29%. This study found that in the midwestern United States, anxiety was prevalent amongst 34.1% of adolescents. Three years later they found this rate increased to 37.7% in 2015, and then increased again to 44% in 2018 (Parodi et al. 2021). Anxiety rates were already rising throughout the first two decades of the 21st century. These rates were increasing when the world seemed to be running as usual. In 2020, the world was met with the COVID-19 pandemic which changed the way the world ran and the way people interacted with one another. One of the biggest impacts on youth was the disruption of school as it moved to an online environment. A meta-analysis conducted in 2021 found that struggles with mental health among children and adolescents nearly doubled during the COVID-19 epidemic (Racine et al., 2021). Children and adolescents are suffering from anxiety disorders at higher rates than ever before. These statistics are only representative of reported cases of anxiety. There is a significant chance that anxiety rates for all individuals (including adolescents) is underreported. An article MANAGING ANXIETY IN THE CLASSROOM 5 published in the JAMA Psychiatry journal suggests that reports of mental illness through surveys show that calculations of mental health disorders have been underestimated (Takayanagi, et al. 2014). Anxiety rates may be higher and increasing faster than can be measured accurately. Cognitive Effects of Anxiety While anxiety is a disorder frequently associated with stress and fear which can put a strain on an individual’s physical well-being due to the constant state of autonomic hyperarousal (the fight or flight response); it is also associated with negative cognitive effects (American Psychiatric Association, 2013). When an individual worries excessively, they often find it difficult to do things in an efficient or quick manner (APA, 2013). This constant state of worry takes time and energy away from the individual experiencing the disorder which can lead to trouble concentrating, tiredness, and problems with sleep (APA, 2013). All of these factors have an impact on cognitive function and for adolescents, this is seen through difficulties at school. In 2007, a new theory on anxiety was proposed called the Attention Controlled Theory (ACT) which was centered around the idea that the effects of anxiety on cognitive ability are focused on an individual’s working memory. This theory focused on the effects of anxiety in a more specific manner compared to prior theories. The authors of this theory concluded that anxiety does have a negative cognitive effect on individuals, including “(a) reduced ability to inhibit incorrect prepotent responses, (b) increased susceptibility to distraction, (c) impaired performance on secondary tasks in dual-task situations, and (d) impaired task switching performance” (Eysenck et al., 2007, p. 348). Angelidis et al. (2019) did further research on the effects of anxiety, cognition, and working memory and found similar results. That increased anxiety, due to an increase in stressors led to poorer working memory and overall poorer cognitive function (Angelidis et al., 2019). MANAGING ANXIETY IN THE CLASSROOM 6 They compared a control group that was given tasks to complete without any stressors placed on them to an experimental group that at different times experienced different levels and quantities of stressors. Not only did the experimental group perform cognitively poorer, but they also worked much slower as their working memory was taxed (Angelidids et al., 2019). If adolescents are finding themselves anxious during class due to stressors either within that classroom or outside of it, they are more likely to perform poorly on academic tasks. Social and Behavioral Effects of Anxiety Behavior is another factor that can be greatly influenced by anxiety. One of the diagnostic criteria for generalized anxiety disorder (as listed in the DSM-5) is “The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2013 p. 222). Within the adolescent population, behavior is a key component of connecting with people and excelling in a school or any professional environment. A disorder that can reduce or diminish an individual’s ability to behave appropriately for their environment can lead to long-lasting negative effects within social or professional circles. Hendriks et al. conducted a study on anxiety to determine if there are long-term disability effects of anxiety disorders. Their definition of disability was “any restriction or lack of capacity to perform an activity in a manner or within a range considered normal for a human being” (Hendriks et al., 2016). During the study, individuals with anxiety were compared to individuals with depression, and a control group consisted of individuals who did not suffer from a mental disorder. Their findings showed that all types of anxiety disorders were connected to a long-term disability (Hendriks et al., 2016). Certain disorders such as social anxiety disorder (SAD) and generalized anxiety disorder (GAD) were at a greater risk for long-term disability (Hendriks et MANAGING ANXIETY IN THE CLASSROOM 7 al., 2016). If left untreated, today’s youth who suffer from any sort of anxiety disorder are at a higher risk of a long-term disability compared to their peers who do not suffer from anxiety. Social behavior can be greatly influenced by the presence of anxiety in individuals. These individuals tend to avoid social interactions and communications with other people, especially people they are not familiar with (Wu et al., 2013). Lack of social interaction and communication can impede an individual’s ability to respond appropriately to social cues, and misinterpret other people’s behaviors. There are therapeutic techniques that focus on helping individuals with anxiety to understand the importance of socialization and understanding other people. Therapeutic Techniques to Treat Anxiety Two therapeutic approaches to anxiety take the lead as the most effective for the treatment of symptoms and long-term management of these types of mental disorders. Cognitive behavioral therapy (CBT) is the first, with a focus on changing the way an individual thinks. It focuses on the basics of cognition and how to manipulate one’s own thoughts so that they are more manageable and the individual is calmer. The second is dialectical behavior therapy which is an off-shoot of cognitive behavioral therapy. Dialectical behavior therapy uses the same ideas laid out in CBT which focus on changing an individual’s cognition, but provides them with skills to approach different situations within their own life whether it be social, emotional, or mental. Cognitive Behavior Therapy Cognitive behavioral therapy (CBT) is a treatment technique that has been thoroughly researched and tested through clinical trials. It is highly effective in treating many disorders including anxiety. CBT is often found to be as, or more, effective than other psychological therapy or treatments (American Psychological Association, 2017). CBT treatment is aimed at improving individuals' everyday functioning and overall quality of life. MANAGING ANXIETY IN THE CLASSROOM 8 There are many principles that CBT is based on. Three of these principles are, (1) faulty thinking is the basis of psychological problems, (2) The same psychological problems are also based on learned negative behaviors, and (3) individuals who suffer from psychological problems are capable of learning skills that allow them to cope and relieve symptoms (APA, 2017). CBT treatment is focused on the last principle. Its goal is to change thinking and behavioral patterns. Changing an individual’s thinking patterns is not a quick or easy process. However, CBT has several strategies to help with the change. These strategies include but are not limited to (a) recognizing faulty thinking and comparing it to reality to make changes, (b) learning and understanding other people’s behaviors and motivations, (c) gaining good problem-solving skills in order to cope with situations that are difficult to manage mentally, and (d) building one’s own sense of strength and ability to overcome obstacles (APA, 2017). Different strategies are used in order to change behavior. Some of these strategies are (a) no longer avoiding fears, but instead facing them, (b) practicing through role-playing in order to prepare for possible scenarios in the future, and (c) learning skills that work to calm the mind and body and intentionally reducing symptoms of stress or anxiety (APA, 2017). Not every individual is in need of all of the aforementioned strategies. Instead, a therapist works with their client to teach them different strategies and skills. The client and therapist then work together to create a mixture of strategies that benefit the client. The importance of CBT is to give individuals a sense of control over their own mental health disorders. It teaches them how to treat themselves in order to better prepare them for any unknown situation. A key difference between CBT and other therapies is that CBT focuses on an individual's current situation rather than on past events (APA, 2017). MANAGING ANXIETY IN THE CLASSROOM 9 Dialectical Behavior Therapy Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy (CBT) that was created throughout the 1970s and 1980s. This form of therapeutic approach has more of an emphasis on change and acceptance. It was originally created for more difficult to treat psychiatric conditions including borderline personality disorder. However, it became more popular with anxiety disorders. In 2019, Malivoire (2020) suggested that DBT skills should be used more frequently with a generalized anxiety disorder (GAD). She found that the skills taught through DBT therapy were highly effective in treating and managing symptoms of anxiety (Malivoire, 2020). Dialectical behavior therapy focuses on emotion regulation and on an individual’s ability to accept what is happening around them and change their own thinking to better manage their anxiety. The four main skills that Malivoire (2020) found were the most effective for treating GAD include interpersonal effectiveness skills, distress tolerance skills, emotion regulation skills, and mindfulness skills. Interpersonal effectiveness skills are skills that are intended to help an individual build positive relationships with others and maintain those relationships over long periods of time (Malvoire, 2020). This is done through understanding empathy and others' points of view. Interpersonal effectiveness skills can help those struggling with anxiety disorders understand how to communicate effectively with other people and also help them to recognize unhealthy relationships and how to set boundaries within or end those types of relationships (Malvoire, 2020). Distress tolerance skills are extremely valuable to individuals with anxiety disorders. These skills help individuals to accept the situation they are in. It allows them to focus on the MANAGING ANXIETY IN THE CLASSROOM 10 present and on what they can control (Malivoire, 2020). It also gives them the ability to accept their own emotional state and understand that one’s feelings are important and valid. Distress tolerance skills aid in grounding individuals and allowing them to focus on what is important within each situation. Emotion regulation skills build off of distress tolerance skills. While the former encourages individuals to accept what they are feeling, the latter skills are “processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions” (Gross, 1998, p. 275). Individuals with anxiety disorders benefit greatly from emotion regulation skills because most individuals with anxiety have low tolerance for negative or aversive emotions (Malivoire, 2020). Mindfulness skills are intended to help individuals understand where they are, accept it without judgment, and learn flexibility when it comes to their working memory and what they are paying attention to. “Mindfulness skills are core to DBT because they provide foundational skills required for effective implementation of the subsequent DBT skills” (Malivoire, 2020, p. 4). Many individuals who suffer from anxiety disorders focus on future-oriented details and planning which leads to a worry about events that have not or may never occur (Borkovec, 2002). Living in the present moment and practicing skills that can help people achieve this goal is the main focus of mindfulness skills. While cognitive behavioral therapy is the leading therapeutic approach to treating anxiety, on its own, it is not fully effective. Dialectical behavior therapy takes an approach to anxiety that emphasizes the emotional dysregulation piece that accompanies anxiety. Either therapeutic approach can be used individually in an effort to treat anxiety with positive outcomes MANAGING ANXIETY IN THE CLASSROOM 11 (Malivoire, 2020). However, if the two therapy types are used together, there is a higher possibility of more positive and long-lasting outcomes (Falabella et al., 2021). Therapy Techniques in the Classroom There is little literature and research regarding the use and effectiveness of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) within the classroom. This is due to a few factors, (1) educators are not adequately trained to provide effective therapeutic interventions in their classrooms, (2) there is little access to easy-to-use methods and curriculums, and (3) the implementation of CBT and DBT skills within the classroom in the past have not been cost-effective (Stallard et al., 2013). A trial study conducted by Stallard et al. took a look at the cost-effectiveness and overall effectiveness of cognitive behavioral therapy used within the classroom. Of the 5030 individuals who agreed to participate in the study, 392 participants within the high-risk category were allocated to the CBT group (Stallard et al., 2013). Stallard et al. found that the use of CBT in a school setting was effective in increasing students' awareness of self and symptoms (Stallard et al., 2013). However, they also found that this type of academic intervention is not cost-effective for schools to implement (Stallard et al., 2013). Another study by Chugani and Landes looked at dialectical behavior therapy within counseling centers in colleges. They studied 107 employees who work in college counseling centers across 34 states. Their findings concluded that while DBT is effective in helping students, like the previous study it is difficult to implement due to cost and ease of access (Chugani & Landes, 2016). There is a great need for an easy to implement and cost-effective solution for incorporating cognitive behavioral therapy skills directly in the classroom. While MANAGING ANXIETY IN THE CLASSROOM 12 this study focused on colleges, the need is equally as important for adolescents within high school environments Summary Rates of anxiety are on the rise in the United States and throughout the world (Parodi et al., 2021). Today’s adolescents are at a high risk of developing anxiety disorders due to factors that are specific to adolescents (Garcia & O’Neil, 2021). Anxiety is a type of fear that is associated with the anticipation of a perceived threat. Although the threat isn’t present, the body still responds, in the same way, putting the same strain on the body (Myers & Dewall, 2015, p. 620-627, American Psychiatric Association, 2013 p. 189). Adolescents are suffering from anxiety disorders at higher rates than ever before and are in need of intervention. There are significant cognitive effects of anxiety disorders. Studies show that individuals with any levels of anxiety perform poorer on cognitive tasks, have a poorer working memory, and their ability to focus on or switch between different tasks is greatly diminished (APA, 2013; Angelidids et al., 2019; Eysenck et al., 2007). There are also social and behavioral effects of anxiety disorders. Individuals with anxiety disorders are highly likely to obtain long-term disabilities which can lead to long-lasting negative effects within social or professional circles (APA, 2013; Hendriks et al., 2016). Cognitive behavioral therapy and dialectical behavior therapy are both types of therapeutic techniques that are effective in treating individuals who suffer from anxiety disorders. These techniques focus on changing the way individuals perceive their surroundings and their own behaviors in order to provide them with specific skills to create better functioning and quality of life. (APA, 2017; Malivoire, 2020). MANAGING ANXIETY IN THE CLASSROOM 13 The implementation of the following therapy techniques within classrooms can have positive impacts on adolescents. However, these techniques are often underutilized and their presence within schools is difficult to implement and costly ( Chugani & Landes, 2016; Parker & Waller, 2019; Stallard et al., 2013). There is a significant need for a method that is cost-effective and easy to implement and use in order to bring effective techniques into classrooms. Adolescents are in need of techniques and skills. Exposure to them during their education will greatly benefit their success not only academically and socially, but will also prepare them for anxiety provoking situations in day-to-day life. Purpose Rates of anxiety have been on an incline in adolescents for the past twenty years, with a significant increase during the COVID-19 pandemic. Anxiety is a mental health disorder that, if left untreated, can have negative effects on teens. They can suffer from long-lasting effects on education, self-confidence, social abilities, and behaviors. There are therapy types available that can work to decrease levels of anxiety and prevent these long-lasting effects. However, these types of therapy are often underutilized or entirely unknown to the adolescent population, leaving them with increasing rates of stress and worry without a solution to the problem. The purpose of this project will be to create a curriculum that teachers of any subject in grades 7-12 can implement within their classrooms. The intent of this curriculum will first be to raise awareness of anxiety and possible solutions to the problem, secondly, it will provide materials and tools that teachers can offer to their students to help them implement therapy skills and strategies within the classroom, and lastly, it will provide these resources in a simple to use curriculum that can be implemented within any classroom and only take up about five to fifteen minutes of instruction time per lesson. MANAGING ANXIETY IN THE CLASSROOM 14 Method Context This curriculum will be created using cognitive behavioral and dialectical behavior techniques that have been proven to be effective by the American Psychiatric Association. Two different workbooks will be used and referenced, one for CBT called The Anxiety & Phobia Workbook Fourth Edition and one for DBT called The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance. These workbooks are intended to help individuals understand their own emotions better and use skills to help manage them. These books will include valuable information as well as usable worksheets and activities. The curriculum will aid educators in using the workbooks correctly and efficiently while also providing additional context and material. Development Procedures This curriculum will be developed with ten modules. The first module will be intended to teach educators about the two modes of therapy, cognitive behavioral and dialectical behavior therapy. The curriculum can be accessed through Canvas (a web based learning management system). Educators will be required to complete the material and pass the first module before gaining access to the remaining modules which they will be able to use within their own classroom. The curriculum will be in an online format available through Canvas. The remaining modules will provide short (5-15 minute) lessons that align with techniques outlined within CBT and DBT. These lessons are intended to be teacher-led within the classroom or assigned to students in an online setting. The scope of this curriculum is outlined below. ● Module 1: What are CBT and DBT? MANAGING ANXIETY IN THE CLASSROOM ○ CBT ○ DBT ○ Module 1 quiz ● Module 2: DBT - Mindfulness ○ What skills ○ How skills ○ Mindfulness activities ● Module 3: CBT - Activity Scheduling/Behavior Activation ○ Mindfulness ○ Calendar/Planner habits ● Module 4: CBT - Journaling/Thought recording ○ Mindfulness ○ Pen to Paper ● Module 5: CBT - Relaxation and Stress reduction ○ Mindfulness ○ Physical Methods ● Module 6: CBT - Successive Approximation ○ Mindfulness ○ Break it down ● Module 7: DBT - Walking the middle path ○ Mindfulness ○ Living in the gray ● Module 8: DBT - Distress Tolerance 15 MANAGING ANXIETY IN THE CLASSROOM 16 ○ Mindfulness ○ Managing stress in the moment ● Module 9: DBT - Emotion Regulation ○ Mindfulness ○ Recognizing and accepting primary emotions ● Module 10: DBT - Interpersonal Effectiveness ○ Mindfulness ○ Interacting with others while maintaining one’s sense of self and values. Evaluation procedures The writing of this curriculum will be done throughout the 2023 spring semester. The goal is to have the curriculum completed and evaluated by the end of March 2023. I will have four different professionals evaluate the curriculum. Two of those will be educational professionals, and the other two will be therapeutic professionals. They will review the curriculum and provide me with feedback within two weeks on how to better the curriculum either therapeutically or pedagogically depending on their area of expertise. The educational professionals will provide me feedback on the following questions in regard to the curriculum. (1) are the lessons within the curriculum pedagogically sound and clear enough to implement within any classroom environment? (2) What are the strengths and weaknesses of the curriculum? (3) Is the canvas course easy to navigate and understand? (4) If you were to implement this curriculum within your own classroom, what changes would you want to make? (5) Do you think that the curriculum will set children up for success in learning and implementing new skills within their lives and improve their confidence in their abilities? MANAGING ANXIETY IN THE CLASSROOM 17 The therapeutic professionals will provide me feedback by answering the following questions in regard to the curriculum. (1) Are the lessons within the curriculum therapeutically sound and clear enough for non-therapeutic professionals to implement within their classrooms? (2) What are the strengths and weaknesses of the curriculum? (3) Is the canvas course easy to navigate and understand? (4) Are the skills for cognitive behavioral and dialectic behavioral therapy accurate? (5) Do you think that the curriculum will set children up for success in learning and implementing new skills within their lives and improve their confidence in their abilities? (6) If you were to use these lessons with your own therapeutic clients, what changes would you make? The feedback received will be used to improve the curriculum. Additional information, lessons, or materials will be added as needed to successfully match the given feedback. Any parts of the curriculum that the professionals don’t deem helpful or necessary will be removed to ensure the lessons provided are effective and concise. The intent of each lesson will be that it adequately teaches and provides helpful skills, while also taking only a small portion of time. The purpose of the small lessons will be to limit the amount of instruction time that they take from any educator’s required course curriculum. Results Course Layout Using two different handbooks, The Anxiety & Phobia Workbook Fourth Edition for CBT skills and The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance for DBT skills, the course was reduced to an eight module layout rather than the proposed ten. There were two reasons for this change. Two of the modules were combined into a single module MANAGING ANXIETY IN THE CLASSROOM 18 because they were very similar in nature. Originally, mindfulness (a DBT skill) was one module while relaxation and stress reduction (CBT skills) were another module. They were combined in order to reduce redundancy in the lessons. Another one of the modules proposed was titled walking the middle path, this module was cut from the curriculum because it was not available in either of the handbooks chosen for the course. A learning management system called Canvas was used to organize the curriculum. It is set up to include all the information needed for lessons and learning activities. It is possible to use the course without the suggested workbooks, however, it is highly recommended to obtain the workbooks as they enhance the learning experience and provide even more information and skill activities that are not included within the course. It has been made public access for anyone with a canvas account. The following link (https://canvas.instructure.com/enroll/WBJYJB) can be used to access and enroll in the course. There are eight modules available, with the first one intended for use by the educator only. Module one has a lot of suggested reading and slide presentations for educators to use in order to become familiar with the concepts and skills associated with CBT and DBT. The educator is required to pass a quiz summarizing the therapy methods before gaining access to the remainder of the course. From that point, the educator can use modules two through six as a guide for implementing the therapy skills in their classroom. There is no proposed timeline for this course as modules can be repeated as needed. Table 1 is provided below as an outline of the course modules. MANAGING ANXIETY IN THE CLASSROOM 19 Table 1 Module Topic Skill activities 1 What are CBT and DBT (for the educator only) ● ● ● ● ● Suggested readings from handbooks Need for CBT skills Need for DBT skills DBT and CBT Quiz How to navigate the course and prepare lessons 2 DBT- Mindfulness CBT- Relaxation and Stress Reduction ● ● ● ● Inner-Outer Experience Skill Mindfulness Skills Progressive Muscle Relaxation Skill Calming breath exercise Skill 3 CBT- Self-Talk and Mistaken Beliefs ● Mindfulness Skills ● Challenging Negative Self-Talk Skill ● Record Dysfunctional Thoughts Skill 4 CBTJournaling/Thought recording ● Mindfulness skills ● Feeling Journal Skill ● Write a Letter Communicating Your Feelings Skill 5 CBT- Successive Approximation ● Mindfulness Skills ● Break it Down Skill 6 DBT- Distress Tolerance ● Mindfulness Skills ● Radical Acceptance Skill ● Values and Committed Action Skill 7 DBT- Emotion Regulation ● Mindfulness Skills ● Recognizing your Emotions and Behaviors Skill ● Problem Solving Skill 8 DBT- Interpersonal Effectiveness ● Mindfulness Skills ● Identify Your Interpersonal Values Skill ● Knowing What You Want Skill Evaluator Feedback Access to the canvas course was given to four evaluators. Two of the evaluators were educational professionals, and two of the evaluators were therapeutic professionals. They were MANAGING ANXIETY IN THE CLASSROOM 20 given two weeks to explore the course and then provide feedback by answering the questions listed in the evaluation procedures section above. Below is their feedback. Educational Professionals The first question asked of these evaluators was are the lessons within the curriculum pedagogically sound and clear enough to implement within any classroom environment. Both evaluators agreed that the canvas course was sound and easy to navigate. The lessons were very clear and simple to understand. The structure of the course was very organized and could be implemented by a wide range of educators. Secondly, when asked What are the strengths and weaknesses of the curriculum, the evaluators thought that the curriculum had a lot of strengths and thought that it could be effective not only for teens in school but also for a lot of workplaces. The skills provided adequately supported the concept and were simple enough for anyone to understand. The weaknesses found in the curriculum were that it may require more training for teachers initially. The first module does a good job of teaching what CBT and DBT are, but the evaluators felt as though teachers would need a complete run-through of the course by a professional before they would feel comfortable implementing it within their own classrooms. The third question asked, is the canvas course easy to navigate and understand? Evaluators already spoke to this within their feedback in the first question. They also noted the value of adding mindfulness in every module. They are some of the easiest and most beneficial skills to practice in everyday life. If you were to implement this curriculum within your own classroom, what changes would you want to make, this was the fourth question for the educational professionals. One of the evaluators thought it would work best in their class if they were to introduce the whole MANAGING ANXIETY IN THE CLASSROOM 21 curriculum at the beginning of the school year, continue mindfulness activities every day, and revisit the other skills as needed throughout the year. Lastly, they were asked, do you think that the curriculum will set children up for success in learning and implementing new skills within their lives and improve their confidence in their abilities? Both evaluators agreed that it depends on how the topic is presented, who is presenting it, and how regularly it is used. An educator cannot expect to go through this curriculum one time and expect the students to be fluent in the skills. This is a course that needs to be revisited frequently and repeatedly. Therapeutic Professionals The therapeutic professionals were asked to answer six questions. The first one was: are the lessons within the curriculum therapeutically sound and clear enough for non-therapeutic professionals to implement within their classrooms? Both evaluators agreed that the essentials of both CBT and DBT were captured within the course and were in a format that would be easy to follow for educational professionals. One evaluator did ask that the slides introducing the skills had more examples and possibly add videos for a visual aspect of learning. It was decided that it was the role of the educator to review the chapters in the workbook associated with the skills. The lessons are intended to be short in order to take up a minimal amount of classroom time. However, the slides and information presented in module one were expanded upon to help facilitate better understanding for the educators. Next, the evaluators were asked to highlight the strengths and weaknesses of the curriculum. The strengths included thorough, yet easy-to-understand descriptions of the two different therapy techniques, an easy-to-navigate course that is readily available online, a module specifically designed for the educator to learn about the skills before integrating them into a MANAGING ANXIETY IN THE CLASSROOM 22 classroom, and the consistent use of mindfulness skills in the modules. Weaknesses included the need for an assignment for the educators to complete that helped them to organize what skills could be used every day and which skills were more situational and the file section of the course was not organized and they wanted to see it separated by therapy technique. Both of these weaknesses have been addressed and the curriculum has been updated. The third evaluation question was is the canvas course easy to navigate and understand? Both evaluators agreed that the course was separated into helpful modules for clearer navigation and the layout was easy to understand and follow. They also appreciated the page in module one that explained how to navigate the course for classroom use. Are the skills for cognitive behavioral and dialectic behavioral therapy accurate was the fourth question. This is where the evaluators had different responses. One evaluator felt that much thought and energy was required to compile the skills accurately and in a clear format. The other evaluator was worried that the DBT skill distress tolerance and emotion regulation were swapped by definition. The first evaluator disagreed and an additional therapeutic professional and the workbook were consulted to ensure accuracy. It was decided that the original definitions within the course were correct. The fifth evaluation question was do you think that the curriculum will set children up for success in learning and implementing new skills within their lives and improve their confidence in their abilities? Both evaluators wholeheartedly agreed that this course is invaluable and would benefit students in any classroom. One evaluator liked that these imperative skills for self-improvement were presented in a way that greatly minimized the learning curve that deters most people from exploring these topics. The other evaluator thought that this would be equally MANAGING ANXIETY IN THE CLASSROOM 23 as if not more important for the educators to understand and it would increase overall knowledge around mental health. Lastly, the therapeutic professionals were asked if they were to use the lessons with their own clients, and what changes would they make. Overall, they did not think any changes needed to be made if the course was taught in an academic setting, but within a therapeutic setting, it would be more beneficial for all of the assignments and skills to be in one notebook or folder so that their clients could look back on their progress as they moved through therapy. Discussion Insights from Evaluator Feedback Overall, the feedback for this curriculum was very positive. All of the evaluators recognized the need for a curriculum such as this. They all agreed that the design of the course was simple and easy to navigate, even for the evaluators who had never used the LMS Canvas before. The skills and assignments chosen to represent the therapeutic techniques were agreed to be valuable and effective while also presented in a way that made the skills seem less overwhelming and more manageable. The evaluators chosen to review this curriculum were all already familiar with the two therapy techniques that were used to create the course. This allowed them to speak to the legitimacy of the content and its value as they have seen it used within their own work. They did comment on this fact and were happy to see that the first module was set up as a way to teach the educator before they would be expected to implement it within their classrooms. However, it was mentioned a couple of times that for use within a public school setting, there would probably need to be more thorough training given to the educators on top of module one. One suggestion MANAGING ANXIETY IN THE CLASSROOM 24 was to still use the curriculum, but have a therapeutic professional actually teach the first module. All of the evaluators were individuals who work at a residential treatment center. I work with these individuals and was confident that they would be willing to give me honest and thorough feedback. The curriculum was inspired by the work that is done within residential treatment centers where therapy and education are interconnected. For the two weeks that my coworkers took to evaluate the curriculum, it was so well received that they chose to share it with the company's directors. I have since been approached by these directors and asked to sit down with them and create a new training program for our company using the course that I designed. They believe that it would not only benefit our students but would also benefit the employees of the company to manage the daily stressors of working in residential treatment and hopefully avoid burnout. Recommendations and Disseminations Further research could be done to assess the effectiveness of this curriculum. Quantitative research could be used to compare anxiety reports before and after completing the curriculum. Administrators could work with school counselors to administer assessments and then have their educators use the curriculum in a variety of classroom settings. Anxiety ratings could be measured for the students who were provided the curriculum and compared to ratings from students who did not receive any additional anxiety management skills. One major limitation of this research is maintaining every student’s confidentiality and ensuring that all individuals involved in the research adhered to the Health Insurance Portability and Accountability Act (HIPAA). MANAGING ANXIETY IN THE CLASSROOM 25 Qualitative research could also be beneficial to assess the value of the curriculum. This type of research could opt for in-person interviews in order to get a deeper understanding of each person’s beginning-level anxiety and their perception of the effectiveness of the curriculum. The researcher could perform interviews with both students and educators to find any gaps in the course that can be fixed. The validity of the curriculum could also be tested by giving educators different levels of training before implementing the curriculum within their own classrooms. Follow-up interviews with each of those educators could provide the evidence needed for further training. The canvas course that was created for this curriculum is public to anyone with a Canvas account and the enrollment link. It can be easily distributed to a wide range of educators across all forms of schools from public to charter, to private. The course is free to use. However, it is more valuable if the handbooks used to create the curriculum are purchased and educators can have those on hand. The literature suggests that programs intended to help students' mental health are not cost-effective to implement within the classroom (Stallard et al., 2013). The hope for this curriculum is to minimize the cost to schools and provide valuable skills to students. Conclusion There is no doubt that anxiety rates are on the rise in the United States. The literature supports this claim and also supports the effectiveness of different therapy techniques to treat anxiety disorders. CBT and DBT are often used by therapeutic professionals to teach their clients valuable skills to help them understand, cope with, and manage anxiety. Teaching these skills to all adolescents can not only benefit them and their success in school but also their success in everyday life. Upon first glance, the therapy techniques and skills may seem overwhelming or difficult to implement. However, these are simple skills that can be used daily to help any MANAGING ANXIETY IN THE CLASSROOM 26 individual manage anxiety disorders. They just need to be presented in such a way that is easy to digest and implement. Managing anxiety in the classroom will bring more awareness and understanding to mental health disorders and normalize using skills to cope with overwhelming emotions. This curriculum is an attempt to make this possible in a brief, but concise way. The lessons laid out in the curriculum only require five to fifteen minutes of an educator's instruction time. Students with anxiety perform worse in school than their peers who do not suffer from anxiety. Taking the time to use this curriculum will be worth the instruction time that it consumes. The ultimate goal of this curriculum is to provide students and educators with the confidence to manage their own emotions and overcome difficult situations when they arise. I hope to see more awareness around and action is taken to help reduce the rates of anxiety within the United States. MANAGING ANXIETY IN THE CLASSROOM 27 References American Psychiatric Association. (2013). 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