Umeå universitet / Barn – och ungdomspsykiatri Vt 2014 Självständigt arbete för kandidatexamen i barn- och ungdomspsykiatri, 15 hp

Childhood Test Anxiety Booster, detainer, disability, disorder

Mikaela Nyroos

Handledare Bruno Hägglöf

1

Childhood Test Anxiety – booster, detainer, disability, disorder

Mikaela Nyroos

Bachelor’s degree thesis in child and adolescent psychiatry, 15 ECTS

Department of Clinical Sciences, Umeå University

2

Abstract

In the context of the recently released DSM-5, currently submitted to authorities around the

world for official transcripts prior to adoption, here is discussed the most common emotional

experience among pupils, test anxiety, and demonstrated its multifaceted character. The focus

is on the intersection of those aspects of the test anxiety construct that imply a disorder and its

correlates implying disabilities. Test anxiety seems to be trapped between these two,

terminating eligibility for either one of those appropriate services. But who and what

determines eligibility? Test anxiety represents a considerable personal burden due to its

interfering nature and is associated with a huge range of deleterious life trajectories,

encompassing school failure and health issues. However, it is also a vital mechanism for

improving memory performance and appropriate fear mobilisation. Nonetheless, in many

countries test anxiety has continued to receive little attention in special education provision.

Based on a review of publications from a wide variety of disciplines, measures for theory and

practice in education and care are presented. Although test anxiety seems to be highly

prevalent among studied samples and the pathological symptoms are similar to those of other

childhood anxiety disorders, there is a paucity of research directly related to the issue. Further,

the work to date has produced conflicting findings and no cohesive theory has been developed

for the phenomenon of childhood test anxiety. Thus, there is a need for richer cross-

disciplinary collaborations between the fields of education and medicine. Because only in a

very few cases does test anxiety feature pathological symptoms that warrant clinical

treatment, it is even more important that test anxiety is attended to within the educational

system, e.g., through special educational provision.

Keywords: intersectionality, experience, expression, special educational provision, DSM-5

3

Introduction

It is inevitable within the educational system that pupils attending school will be evaluated

through tests or examinations. There are benefits (e.g., holding schools accountable,

monitoring individual progress) with testing, but there are also drawbacks, one such being test

anxiety (TA) (Fritz, 2007). Owing to the widespread and growing use of high-stakes

standardised tests to track pupils’ academic progress and evaluate candidates for access to

higher education (Oladipo & Ogungbamila, 2013), together with the known stress-inducing

nature of tests or exams (Putwain, 2009a), it is clearly important to advance our understanding

about the nature of TA; especially since the awareness of its existence greatly fails in many

countries. TA is believed to be one of the most common sources of emotional distress in

school-aged children, causing potentially serious academic impairment if occurring at

excessive rates (Harpell & Andrews, 2013). When the intensity, duration or frequency of the

anxiety and its anticipated impact are so severe that they are accompanied by non-productive

overt and covert behaviours, such cases may meet the general criteria for an anxiety disorder

in the Diagnostic and Statistical Manual (DSM: American Psychiatric Association, 2013), and

thus warrant specialist help (Bögels et al., 2010). Because of the importance of addressing

both academic and mental health needs in anxious children, special educators are uniquely

positioned in assisting (Sulkowski, Joyce, & Storch, 2012).

Notwithstanding the rather devastating character of TA described above, it should not be

forgotten that TA can drive each individual to achieve their best performance, an aspect that

has rarely been touched upon in the literature (Hanoch & Vitouch, 2004; Schutz & Davis,

2000). Inasmuch as TA is a problem, worry and anxiety, it is regarded as a normal aspect of

children’s development (Broeren & Muris, 2009). This bias towards its negative elements is

unwarranted and needs urgent consideration. Therefore, this paper strives to shed light on how

TA conceals states associated with incitement, detainment, disability and disorder, interacting

in different ways to affect an individual’s performance and health. Hence, TA is reviewed

from the perspective of it being a typical developmental fear in school, as a prerequisite for

peak performance, through to its anomalies and potential for clinically significant distress.

It has become apparent that how TA is experienced and its effects are not the same in all

cultural- and age-groups, or as regards both sexes (Zeidner & Matthews, 2005). Yet, our

understanding of the roles of culture, age, and gender, as screening scales in TA, and in this

4

perspective, how the behavioural manifestations of TA vary, is still in its infancy (Bodas,

Ollendick, & Sovani, 2008; Nyroos, Korhonen, Peng, Linnanmäki, Svens-Liavåg, Bagger, &

Sjöberg, 2014). While there is a plethora of research regarding TA in adults and adolescents

(Stöber & Pekrun, 2004), few studies have examined these particular aspects in school-aged

children (Aydin, 2012; Nyroos et al., 2014). However, it is undoubtable that the earlier in life

that problems with TA are identified and attended to, the better is the prognosis to obviate and

ameliorate them (Ginsburg et al., 2014; Rapee, Kennedy, Ingram, Edwards, & Sweeney,

2010). Thus, the purpose of the current paper is to review these areas of research and to

stimulate debate about the theoretical and practical issues of TA in children. In recognition of

special educators’ specific skill set and the roles that they assume in school systems, this

paper will highlight how special education provision can support anxious pupils.

In 2013 the working tool for psychiatry, DSM-5, was released, and currently submitted to

authorities around the world for official transcripts prior to adoption. ICF-CY (International

Classification of Functioning, Disability and Health for Children and Youth, adopted in 2001

by the General Assembly of the World Health Organization, WHO), applied in the special

education diagnosis and practice, supplies information about the diagnosis that is provided in

classification of mental disorders, i.e., DSM-5. Given that special educators are the logical

continuation of the psychiatric practice, and that much less is known about the ability of the

ICF-CY components and categories to provide information on children’s difficulties and

strengths and to describe the impact of the environment (e.g., Klang, 2012), in addition ICD-

11 (the International Classification of Diseases), which bases all disabilities on the ICF, are to

be released in 2015, and finally the DSM has a large international influence, the role of DSM

is of particular interest in the present undertaking.

Test Anxiety

The present paper begins with an overview of TA, including a description of the phenomenon,

concept, construct, correlates and manifestation, before discussing the utility of screening

tools for identifying TA in child populations and the functions of non-clinical and clinical

settings. The paper concludes by singling out certain implications of the TA continuum which

merit special consideration.

5

Phenomenon

Even if TA is a subtype of anxiety, the omnipresent nature of anxiety and the typical self-

regulation styles of child anxiety are likely to be similar to those of TA (Keogh & French,

2001; Zeidner & Matthews, 2005). Hence, general child anxiety theories will be discussed

here. Anxiety is among the most prevalent and persistent human experiences (Susa, Pitică,

Benga, & Mircea, 2012). It is a normal phenomenon occurring during the development of

children (Lodge & Tripp, 1995), as well as an adaptive emotion enabling the escape of threat

(Larson, El Ramahi, Conn, Estes, & Ghibellini, 2010). Although childhood fears can be quite

intense, most of them will disappear just as quickly as they have appeared (Broeren & Muris,

2009). Nonetheless, anxiety disorders belong to the most prevalent types of psychopathology

during childhood (Han, 2009).

TA is likewise a common human experience (Ruscio, 2010) that manifests itself during test

situations when a pupil is faced with fearful distracters (Huberty, 2009; Ladouceur et al.,

2009). Within this context, a sensory experience induces an emotion (e.g., fear) which

ultimately is perceived as a feeling (e.g., TA) that varies from pupil to pupil; the explicit

meaning of a stimulus (i.e., higher-order cognition) in conjunction with the implicit emotional

processing result in an individual (stress) response (Liston, McEwen, & Casey, 2009; Purves

et al., 2012).

The most common pattern of problems arising from TA includes unwarranted rates of fear,

worry and apprehension in pre-, intra-, and post-test situations, accompanied by physiological

reactions and concern regarding (the consequences of) poor performance (Beidel, 1988). It is

seen as a typical worry factor during development (Pathak & Perry, 2006) and a normal

reaction that encourages one to perform better (Teigen, 1994). Yet, for some children, this

‘normal’ worry goes beyond an ‘unpleasant state’ and becomes pathological (Salend, 2011).

The phenomenology of TA defines this change from what is considered normal.

Anxiety in generic terms is a mechanism that helps to avoid some kind of threat.

Inappropriate or disproportionate anxiety it is likely due to a biological vulnerability (Barlow

& Durand, 2012; Hettema, Neale, & Kendler, 2001). However, subtypes such as TA are often

argued to be partly learnt and partly socialised (Varela & Hensley-Maloney, 2009; Zalta &

Chambless, 2012). The threat-response systems are complex, redundant and comprehensive.

6

Thus, the number of potential mechanisms and sites accountable for the dysregulation is vast

(Pathak & Perry, 2006). Likewise, the environmental factors and components of social and

physical threat concerns involved in childhood anxiety are hard to identify (Rapee et al.,

2010), particularly in the case of childhood TA (McDonald, 2001).

An idea of the problem of TA can be obtained by comparing statistics on the prevalence rates

from around the world (note that the reported prevalence rates are based on different

assessment scales, see Cartwright-Hatton, McNicol, & Doubleday, 2006). Prior to the age of

16, 9.9 % of all youths in the U.S. are reported to have suffered from a clinically significant

anxiety problem (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Varela and Hensley-

Maloney (2009) reported that 6.9 % of Puerto Rican children aged 4-17 suffer from anxiety,

while at least 3 % of British children are suggested to display symptoms of a serious anxiety

disorder (and exhibit impairment) at any one time (Ford, Goodman, & Meltzer, 2003). Abbo

and colleagues (2013) reported that the prevalence of anxiety disorders among Ugandan

children was 26.6 %. In a study of Chinese children aged 7-13 years, 6 % qualified as having

generalised anxiety disorder (Hansen, Skirbekk, Richter, Oerbeck, & Kristensen, 2011), while

approximately 5-10 % of all Swedish children are reported to suffer from an anxiety disorder

(Serlachius, Thulin, Andersson, Vigerland, & Ivarsson, 2012).

With regards to TA, the present paper refrains from examining any statistics for the simple

reason of its ambiguous signatures, namely as a booster, detainer, disability and disorder,

which will be delineated below, plus the fact that current criteria and thresholds seem to lack

agreement. In line with this, based on Zuriff‘s (1997) proposed clinical criteria to identify

eligibility for accommodations of TA under the Americans With Disabilities Act, Chapell and

colleagues (2005) analysed data on reported TA. Their findings suggested that it was difficult

to define clinical significance for TA because there was only a small difference between the

highest and lowest percentile of TA scores. Additional support for a nonpathological stress

during test is Kofman and colleagues’ (2006) investigation of both physiological and

cognitive consequences of exam stress.

Concept

Different views have been put forward regarding the concept of TA (Carter, Williams, &

Silverman, 2008), as anxiety (Han, 2009). Among scholars, Spielberger’s (1972)

7

conceptualisation of TA is prominently accepted and refers to an unpleasant state

characterised by feelings of tension and apprehension, worrisome thoughts and the activation

of the autonomic nervous system when an individual faces evaluative achievement-

demanding situations. A broader definition of TA adds threats to esteem due to others

derogatory judgement to the focus on fear of failure (Symes, Putwain, & Connors, 2009).

Spielberger’s seminal view of TA stemmed from the work of Freud in 1936, who conceived

the concept of anxiety. Although this theoretical framework still dominates modern opinions

on anxiety (Han, 2009), contemporary research on TA embraces its complexity and attempts

to address its multifaceted character (for more expanded reviews see, for example, Bodas et

al., 2008; Prato, 2009; Stöber, 2004; Zeidner & Matthews, 2005). In children, a behavioural

sub-category has also been assigned (Wren & Benson, 2004).

What is more, the concept of TA has generated different explanations in the literature due to

the multimodal nature of its construct. Hitherto, no model exists that reproduces all the

complexity of TA or matches data from contemporary research (Chapell et al., 2005). In

addition, TA is conceivably better conceptualised by its objective presentation or symptoms,

and how it is subjectively experienced. The invariant experiences and how they relate to

different consequences (i.e., ‘inverted u-curve’) are discussed below.

Construct

TA is predominantly considered to induce physiological (producing sustained hyper-arousal),

emotional (including bodily symptoms and tension) and behavioural (referring to auto-

manipulative-, object-manipulative-, and inattentive-off-task behaviours) responses, as well as

stimulating cognitive systems (e.g., worry and irrelevant thinking regarding a pending exam

or evaluation) (see Carter et al., 2008).

Various theories of anxiety disorders in childhood relate cognitive distortions to the

development and maintenance of anxiety (In-Albon, Klein, Rinck, Becker, & Schneider,

2008; Muris & Field, 2008), and, for example, poor school performance (Ganley &

Vasilyeva, 2014; Putwain & Daly, 2013). However, due to contradictory findings, it is still

not clear what are the main components affected in children (Creswell & O’Connor, 2004).

8

The scientific construct of TA does not define specific norms, or establish any thresholds,

inflection points or standards, even though some scales offer cut-off points or group

individuals into categories of high and low TA based on standard deviation. TA is equally not

a formal clinical diagnosis in the DSM, although it was considered for inclusion as a form or

sub-type of social anxiety disorder (SAD) or general anxiety disorder (GAD) or as a type of

specific phobia (SP) in the revision of the DSM-IV (Andrews et al., 2010; Bögels et al.,

2010).

According to the DSM-5 (American Psychiatric Association, 2013), anxiety disorders follow

trajectories of excessive anxiety and fear paired with behavioural disturbances. Thus, anxiety

disorders do not refer to fears and worries that are normal for a child’s developmental stage

but go beyond these. Given the similarities of TA with GAD and SAD, TA symptoms of

sufficient severity could fall into either type. The key features of SAD and TA bear some

resemblance, wherein individuals’ fear of negative rejection and social humiliation because of

inadequate performance is central. However, in SAD, the fear that anxiety symptoms may

hinder performance is accompanied by social consequences while being observed (e.g., giving

a speech). In TA, the source of fear is linked primarily to rational negative concerns (e.g.,

regarding passing a grade, need for re-examinations, low admission points) but could lead to

social worries about the upcoming situation with new classmates etc. that then becomes the

main worry. With regard to GAD, children’s problem-based activities are associated with

schoolwork (i.e., quality, competence) that the individual may find difficult to control

(American Psychiatric Association, 2013). Due to fact that a likely biological disposition (i.e.,

already high levels of general anxiety) will be exacerbated during evaluations, the general

preference is that GAD be assigned (Andrews et al., 2010; Bögels et al., 2010; Symes et al.,

2009). In line with this, in the DSM-5, a set of associated symptoms are listed to distinguish

individuals with GAD from high worries (Comer, Pincus, & Hofmann, 2012). Given that only

one symptom is required to be met in children, i.e., “Difficulty concentrating or mind going

blank” (American Psychiatric Association, 2013, p. 222), and that “difficulty concentrating”

was identified in a meta-analysis by Comer and colleagues (2012) to be strongly associated

with GAD diagnosis, TA, classified as GAD, should merit clinical attention.

It is conceivable that TA could also be designated as other specified anxiety disorder (OSAD)

if symptoms show some characteristics of an anxiety disorder but fall outside diagnostic

9

classification. Reasonably, TA could be presented as ‘OSAD generalised anxiety not

occurring for more days than not’ (Comer, Gallo, Korathu-Larson, Pincus, & Brown, 2012).

Considering TA as an atypical worry factor in middle childhood (ages 6-12) (Pathak & Perry,

2006), age inappropriate content may induce ‘OSAD beyond developmental appropriates’

(Lewis-Fernández et al., 2011; Reuschel, 2011).

Correlates

The correlates of TA are many and span several fields, but its name alludes to the main

activity it refers to. TA can range in intensity, frequency and consequent effects between and

within groups. As anxiety, TA can be viewed as ‘fight-or-flight/freeze arousal’ but the

‘flight/freeze’ response, in its original form, serves pupils and students rather poorly in our

modern society and schooling. Instead the flight/freeze response has taken the form or

expression of ‘cognitive and/or affective’ escape (Hanoch & Vitouch, 2004). In an aversive

somatic and emotional state (e.g., as accompanies high TA), which occurs naturally during the

process of fear confrontation, the individual copes by worrisome thoughts, negative feelings

and physical reactions to avoid suffering (Behar, DiMarco, Hekler, Mohlman, & Staples,

2009). These regulated reactions are learnt during specific situations and then henceforth

triggered (Schlöglmann, 2003). In the short term, they appear as functional (inner and outer)

behaviour as the unbearable state is avoided, but the negative effects could worsen in the long

term (Fentz et al., 2013). The consequences of the ‘flight/freeze’ strategy is that the pupil’s

ability to function during the test, or even in the days and weeks leading up to a test, may be

reduced, resulting in poor test achievements and possibly also poor social functioning. Thus,

in the context of TA, this immediate functional-contextual copying presents a bias that may

conceal the true potential of pupils (Symes et al., 2009), independent of their

ability/intelligence (Keogh & French, 2001).

Besides poor academic outcomes, negative associations between TA and pupils’ school-

related motivation, academic self-concept, career advancement, personality development and

health, self-confidence, self-esteem, mental states and sense of emotional stability have also

been found (Carter et al., 2008). Association studies have shown a significant relation

between TA and anxiety and/or depression (e.g., Owens, Stevenson, Hadwin, & Norgate,

2012). Similarly, disability is reported to contribute to the severity of TA in some individuals

(Bishop, 2006; Fulk, Brigham, & Lohman, 1998).

10

As an actual, critical and for some chronic condition, pervasive TA in the most severe cases

meets the general DSM diagnostic criteria for an anxiety disorder (Bögels et al., 2010).

Likewise, TA has been found in several studies to be highly correlated with formally

diagnosable anxiety disorders in the DSM-IV (Bodas & Olledick, 2005; Kumke, 2008). In

children, e.g., TA has been shown to co-occur with SAD (predominantly) and GAD (Bögels

et al., 2010).

The ‘fight’ response, by contrast, can prove an advantage for making achievements if kept at

adequate levels (Hanoch & Vitouch, 2004). Individuals seem to perform best under

intermediate levels of TA (Hopko, McNeil, Zvolensky, & Eifert, 2001; Kofman, Meiran,

Greenberg, Balas, & Cohen, 2006). In a study by Chamberlain, Daly and Spalding (2011), the

vast majority of participants perceived a degree of TA as useful and motivational. This is

often illustrated by the general psychological principle known as the ‘inverted u-curve’ or the

Yerkes-Dodson Law, which addresses both the facilitative and debilitative effects of anxiety

on performance. A moderate amount of anxiety is seen as beneficial to performance as it

motivates the individual to apply an adequate effort to reach their full potential (Salthouse,

2012; Schwabe, Joëls, Roozendaal, Wolf, & Oitzl, 2012). In other words, the drive to excel

oneself may imply elevated levels of TA (Mattarella-Micke, Mateo, Kozak, Foster, &

Beilock, 2011). In contrast, Owens et al. (2012) recently proposed that this beneficial aspect

might be conditional and only valid for individuals with sufficient working memory capacity.

However, research on the factors that govern the switch between these two states and how

individual differences in emotionality and psychopathology affect performance has been

relatively scarce and largely based on small and/or biased samples (Sahlei, Cordero, & Sandi,

2010) or hampered by a lack of ecological rationality (Hanoch & Vitouch, 2004). Schwabe

and colleagues (2012) showed that the point where anxiety switches from being a mere

nuisance to debilitating to education also varies from individual to individual and depends on

the nature of the task (Sahlei et al., 2010) or ability to persevere with the examination at hand

(Putwain, 2009b). Some researchers have claimed the capacity for task-focused attention

rather than levels of TA to be related to performance (Harris, 2011).

11

In keeping with this, Stankov (2010) suggested the possibility that the switching point varies

between cultures, e.g., European compared to Confucian Asian peoples showed a lower

optimum level of anxiety. In corroboration with this, higher levels of social anxiety symptoms

in East Asia (compared to the U.S. and Europe) do not correlate with higher epidemiological

rates of SAD (Lewis-Fernández et al., 2011).

Thus, it seems that symptoms of TA vary between groups, epidemiology or impairment

criteria also differ between populations and causes of distress depend on a number of factors

(Pathak & Perry, 2006). Too often though, experience and expression are lumped together and

measured as a composite measure and findings from country or age group are uncritically

assumed to be universal (Nyroos et al., 2014).

Manifestation

Despite few studies, and disparate findings on the prevalence and manifestation of TA in

different groups (e.g., gender, age), theories on variation have generally been based on North

American and Western European studies (Nyroos et al, 2014). With few exceptions, these

theories have assigned females, older students, Asian cultures (compared to Anglo and

European cultures) and high stakes testing to be accompanied by higher levels of TA.

Females, children and Asian people are further mentioned to manifest TA by more autonomic

reactions. However, other studies into the cultural and age diversities have provided

conflicting results and revealed a significant interaction of genetic factors and environmental

demands (e.g., Riley, 2003; Wang et al., 2005). Young anxious children may also be less

prone to respond emotionally in an appropriate cultural manner (Hesketh et al., 2010; Suveg,

Jacob, & Thomassin, 2009; Thabet & Vostanis, 1998).

In addition, children with anxiety disorders tend to differ in their clinical presentation

compared to adults (Pathak & Perry, 2006). Thus, as is the case with sex disparity in child

anxiety symptoms, the findings of linkage and association studies are inconsistent and

conflicting (Creswell & O’Connor, 2004; Field, Cartwright-Hatton, Reynolds, & Creswell,

2008).

Leaving the genetic factors aside while attending to the identified ‘learning’ factor that is

assumed to be involved in childhood anxiety (Field et al., 2008; Walkenhorst & Crowe,

12

2009), social and cultural influences are known to be important, but when in time these

footprints start to emerge is still unclear.

Hence, in terms of ‘learning’ TA during education, a number of factors appear to be

important. For example, Bodas and colleagues (2008) reported that cultural commandments

and characteristics of the educational setting have a significant effect on experiences of TA

across cultures. In line with this, Nyroos and colleagues (2014) compared two rather extreme

national learning situations and found powerful cultural and contextual impacts on grade 3

children’s expression and experience of TA, as displayed by gender differences. Their

findings raise concerns about the current construct and conceptualisation of TA, which does

not seem universal, neither in feeling, manifestation or gender divergence.

In conclusion, levels and dimensions of TA seem to vary with gender and age, but there is

currently no agreement of the levels or nature of TA in a given context, age or gender group.

Screening and Assessment Measures

For the validation of generalisations, it is essential that scales and factor structures for

assessing TA account for cultural and contextual effects (Lowe & Ang, 2012) and have a

solid conceptual foundation (Sud, 2011). However, of the huge number of assessments that

have been developed for measuring TA (Cizek & Burg, 2006, estimated over two dozen

assessment measures), few are explicit measures of TA but scales comprised of items

indicative of TA. For example, the Test Anxiety Scale for Children (TASC) was developed to

assess fears generated in school settings for children in grades 1 through to 8 (Cizek & Burg,

2006). The majority of scales were developed for adolescent and adult populations, e.g., the

Test Anxiety Inventory (TAI) and FRIEDBEN Test Anxiety Scale (FTAS) (Cizek & Burg,

2006).

To the best of the author’s knowledge, there is no scale for TA for which the objectivity

reliability, equivalence and construct validity has been documented across groups. However,

attempts have been made to translate and use scales from other cultures. For example, Bodas

et al. (2008) translated and culturally adapted the TAI and FTAS to Indian grades 5 to 9.

However, the reliability coefficients were in a moderate range and lower than those reported

for the original instruments. Nevertheless, several important issues regarding cross-cultural

13

research on TA, i.e., the importance of considering the educational system and ecological and

social characteristics of the specific nation, were raised in the article.

At present, only one measure is available for assessing TA in children in grades 3-6, the

Children’s Test Anxiety Scale (CTAS: Wren & Benson, 2004). The CTAS has been verified

to be psychometrically sound for various ethnic groups, genders and grades. In contrast, the

Test Anxiety Inventory for Children and Adolescents (TAICA), which covers grades 4-12

(Lowe et al., 2008), is not available for public use and has not been shown to be valid for

different ethnic groups. Lowe and Ang (2011) examined the Test Anxiety Scale for

Elementary Students (TAS-E) in grades 2-5 across the U.S. and Singapore cultures and

genders. The reliability coefficients for the subsamples were strong to very strong and their

findings provided evidence for construct validity across the different groups, but again, this

scale is not available for public use.

To improve knowledge about how to prevent or reverse anxiety as well as the mechanisms

that contribute to its development and dimensions, Creswell and O’Connor (2004) have

argued that assessment measures of different conceptualisations of TA emanating from

various theoretical issues are needed. In terms of the general criterion variable (i.e., specifier)

of TA, i.e., reduced academic performance, TA measures seldom address this aspect (Gregor,

2005). That leaves ample opportunity for growth in this area.

Conclusion

Despite the saliency of TA in younger pupils, childhood TA seems to be relatively neglected,

both in terms of concrete interventions and research into its variance and variety. Yet, the

immediate impact and persistent effects of TA are a reality for some primary age pupils.

Therefore, the present paper focuses specifically on childhood TA and its multifaceted

meanings.

Drawing on both previous research and TA theories, the pathological uncertainties of TA and

the nebulous character of its phenomena make it difficult to gain a clear understanding of the

true breadth and depth of the TA syndrome in the general population. As a consequence, the

urgent need for programmes targeting a reduction in symptoms of TA falls between the two

stools of psychological treatment and (special) educational provision. An additional problem

14

is that the development of theories and interventions for childhood anxiety has lagged behind

other areas (Cartwright-Hatton, McNicol, & Doubleday, 2006; Reuschel, 2011). On top of

this, educational and mental health researchers, like special educators and clinicians, seldom

collaborate, which hampers the emotional well-being and academic attainment of pupils

(Stephan, Weist, Kataoka, Adelsheim, & Mills, 2007). Studying clinical issues in non-clinical

samples provides invaluable clues into the causal mechanisms underlying the development of

anxiety (Field et al., 2008) and helps to identify how to advance measures in this area (e.g.,

Lowe & Ang, 2012; Sud, 2011).

The multidimensionality of TA means it is also imperative to discuss whether TA should be

included among the anxiety disorders in the DSM-5 or if it even has an undesirable academic

effects, i.e., result in lower achievement outcomes. At first glance, TA seems to falls between

both camps. But then, from this perspective, a grave concern is the potential disability and

impairment implications. Special educational provision attempts to help pupils experiencing

difficulties that interfere with learning and performance (Howlin, 2008). Its broader aim is to

further social, emotional and behavioural development by eliminating all segregated

schooling. This latter objective lies at the very heart of educational equity, that is, to provide

for all pupils that in some form are disadvantaged (Grant & Ladson-Billings, 1997). Thus, it

could be argued that pupils who appear to be proficient or score highly in exams but are

nonetheless restricted by, for example, TA, should also be included.

It is conceivable that pupils who are detained or impaired by TA may attend teaching without

their difficulties being recognised or help being provided. For schools to meet the needs of all

pupils and maximise their entitlements, as given to special needs pupils, some corrective

measures may therefore needed. A major benefit then is the huge number of potential

sufferers (i.e., nearly total population of children) that could be helped within the school

setting (Misfund & Rapee, 2005).

School settings provide unique opportunities for detecting, preventing, and reversing mental

illness (Domitrovich, Weare, Elias, Greenberg, & Weissberg, 2005; Lundin & Belfrage,

2012), including anxiety (Battaglia et al., 2010; Isomaa, Väänänen, Fröjd, Riittakerttu, &

Marttunen, 2013). Information about a pupil’s mental condition could easily be employed

within the ordinary realms of school health and special education, i.e., incorporated into

15

routine educational screening to detect potential anxiety disorders. Thus, the adoption of

assessment measures encompassing TA could avert unintended consequences of delayed

anxiety diagnosis and treatment (Battaglia et al., 2010; Curtis, 2009) and, as discussed below,

unravel and alleviate precursors to reverse developmental trajectories (Creswell & O’Connor,

2004).

Detainer

The elucidation of TA and its manifold causes, i.e., as a booster, detainer, disability or

disorder, should focus on addressing its more harmful effects. From the viewpoint of

educational equity, TA as a ‘soft’ detainer is a concern that needs to be considered at policy

level and by educational stakeholders. In particular, different kinds of preventive actions

should be investigated to reduce the high anxiety associated with high stakes testing (Nyroos

et al., 2014) and the validity of using the results of such tests to make important educational

decisions should be appraised (Bishop, 2006).

Over time, pupils scoring high in examinations and putting a great deal of effort into high

achievement may put their health (e.g., resulting in low affective well-being, stress and

hopelessness) at risk (Chamorro-Premuzic, Gorkan, & Furnham, 2008; Eum & Rice, 2011;

Roslander, 2013). Educators therefore need to de-emphasise the outcome of examinations,

sending out the message that a ‘failure’ is also an opportunity and that no one will be

‘destroyed’ by poor results (Cuijpers, Sijbrandij, Koole, Huibers, Berking, & Andersson,

2014; Fentz et al., 2013; McMillan & Lee, 2010).

In support of this, a comparison study between Swedish and Finnish grade 3 pupils showed

that exposure to sound testing regimes had an impact on reported levels of TA (Nyroos,

Korhonen, Linnanmäki, & Svens-Liavåg, 2012). Finnish pupils sit tests on a regular basis

from grade 1 onwards, whereas Swedish pupils by comparison have fewer tests, especially in

the lower grades. Thus, Finnish pupils exposed to possible worry and fear in testing might

gain an insight into the non-rationality of avoidance behaviour. Hence, by exploring and

staying in a fearful testing situation, pupils may learn that worry is controllable and can be

used to advantage (Fentz et al., 2013; Mattarella-Micke, Mateo, Kozak, Foster, & Beilock,

2011).

16

Disability

The view of TA as a disability has important implications for special educational efforts and

treatment for the management of symptoms. Disabilities have some purchase through

conventions and acts that prescribe the provision of support and complementary strategies

(Howlin, 2009; UNESCO, 1994). To proceed with these directives, special educational efforts

ought to be part of the curricula and specifically address pupils’ responses to TA. Linked to

this, research should focus on intervention programmes to reduce TA. In a study by Liston

and colleagues (2009), the stress levels of healthy students preparing for a high stake test for a

month was found to reduce back to baseline levels four weeks after cessation of the stressful

period. On the other hand, if pupils susceptible to anxiety and/or TA are repeatedly exposed to

stress, they are more likely to develop chronic stress-related neuropsychiatric diseases (Liston

et al., 2009).

Disorder

TA accompanied by clinical symptoms of distress or impairment in social, occupational, or

other important areas of life is eligible for mental health services that aim to relieve such

disease symptoms. Severe TA also bears some relation to other formal anxiety disorders.

Therefore, clinicians are advised to expand their screening battery and attend to TA as a

forerunner to a severe trajectory of anxiety disorders or as a symptom of such anxiety. In

addition, group programs addressing anxiety problems conducted in schools, for example,

“Cool Kids” (Lyneham & Rapee, 2005), could be provided to a greater degree. In this respect,

it should be noted that classification according to the DSM is in many cases the qualifier for

services through the state or municipality. Despite being an ancillary aim of special

educational provision, efforts to address childhood anxiety in school settings display

considerable promise and applicability to common practice. Thus, while considering

childhood anxiety in school settings the needs of many pupils who would otherwise be

disenfranchised from receiving intervention are addressed (Neil & Christensen, 2009).

Booster

Lastly, from the perspective as a booster, tests need to be reconsidered and upgraded to also

constitute a vital aspect of schooling. There is broad support for testing to be a valuable

pedagogical tool. On the one hand, it can assist pupils in learning (e.g., by encouraging pupils

to study more continuously and prepare for class, enabling pupils to adapt their learning based

17

on feedback, informing them about what they have and have not learned and providing

guidance for future study, giving them the opportunity to acquire test-taking skills and

become familiar with different question formats, increasing motivation, generating more

positive attitudes about class and instruction; Karpicke & Roediger, 2007; McDaniel,

Anderson, Derbish, & Morrisette, 2007). On the other hand, it is a robust technique for

improving pupils’ memory for content (i.e., the ‘testing effect’ – promoting unique processing

of target material that improves retention; Dunlosky, Rawson, Marsh, Nathan, & Willingham,

2013; Pennebaker, Gosling, & Ferrell, 2013). In the light of current criticism that too much

testing results in excessive stress and worry in school children, testing on the contrary has

been found instead to alleviate this syndrome (Leeming, 2002; Roediger, McDaniel, &

McDermott, 2006).

Discussion

The general aim of psychiatric diagnosis, to articulate the meaning of patient’s experiences

and find ways out of the problems (Alarcón, 2009), is in harmony with the essence of

educational screening. Whereas practice in special educational provision still seems to be

largely driven by phenomenology (i.e., identifying phenomena through how they are

perceived by the subjects in a situation using inductive, qualitative methods such as

interviews, discussions and participant observation: Karpicke & Grimaldi, 2012; Lester, 1999;

Packer & Goicoechea, 2000), the predominant reliance on etiology in medical treatment (i.e.,

determining causality of phenomena using careful sampling and measurement, comprising

experimental interventions and often statistical analysis: Murrihy, Kidman, & Ollendick,

2010), has begun to extend beyond this.

Contemporary diagnostics (e.g., DSM-5) have come to recognise and accept cultural, gender

and age considerations (Hoffman, Asnaani, & Hinton, 2010). In the DSM-5 (American

Psychiatric Association, 2013): “key aspects of culture relevant to diagnostic classification

and assessment have been considered” (p.14), “potential differences between men and women

in the expression” (p.15) are incorporated, and “Age-related factors specific to diagnosis (e.g.,

symptom presentation and prevalence differences in certain groups) are also included in the

text” (p. xlii). Thus, in the search for practical and feasible modes of action, researchers in the

field of childhood anxiety should move towards each other, that is, clinical research should

examine the specific processes involved (e.g., the role of parents, transient fears) (Reuschel,

18

2011; Varela & Hensley, 2009), and special educational research should employ biologically

determined models (e.g., interventions in specific sample groups compared to control groups)

(Brorson, Numan, Pettersson, & Schollin, 1999; Kadesjö & Kadesjö, 1999).

TA is not a diagnosis, and even if it was termed as such, clinicians never assign TA based on

any single TA measure. Nevertheless, TA measures ought to be designed to provide clinically

useful information, and clinically significant levels need to be established (Chapell et al.,

2005). However, this should not preclude the development of an independent assessment

measure and classification of TA as an impairment or disability.

Programmes targeting a reduction in symptoms of anxiety and TA for young people in

schools have shown promising results (e.g., Keogh, Bond, & Flaxman, 2006; Mitra, Ferguson,

& Sapolsky, 2009). In addition, school health implications of investigations have the potential

to go beyond their impact on the groups targeted (i.e., deficits and disabilities). Thus, it is

conceivable that focusing on the reduction of excessive concerns connected with testing, and

thereof improving test performance, may result in an overall better health situation

(Gustafsson et al., 2010; Petersen et al., 2010). Likewise, children with elevated TA may not

seek or receive help from clinicians. The requirements for specialty psychiatric care are rigid

compared to special educational provision, i.e., the presence of distress and disability governs

the perceived need for treatment (Lehman, Alexopoulos, Goldman, Jeste, & Üstün, 2002).

Moreover, children diagnosed with an anxiety disorder often do not receive the treatment they

require (Olfson, Gameroff, Marcus, & Waslick, 2003; Sawyer et al., 2000). For these reasons,

it seems appropriate that TA remains uncoupled from constituting a diagnosis in the revised

DSM-5.

Then again, individuals with high levels of TA represent a group at particular risk of negative

outcomes associated with TA (Carter et al., 2008). In the long-term, childhood anxiety is also

a risk factor that seems to predispose adult mental-health problems, depression, and substance

misuse (Field et al., 2008; Grillo & da Silva, 2004). Thus, school children reporting high

levels of TA may be indicative of more pervasive anxiety problems (Carter et al., 2008).

To summarise, the ideal psychiatric method considers the “best estimate diagnosis”

procedure, i.e., administers a variety of tests or scales and uses information from observations

19

and parent interviews (Roy et al., 1997). Diagnosis then helps to make an assessment of

abilities, treatment and prognosis, which is just as crucial for clinical work as research

(Alarcón, 2009). In education, a corresponding approach may be found in “formative

assessment”, i.e., different activities that the teachers undertake in teaching to moderate

pupils’ learning processes (e.g., Black & Wiliam, 1998). Hence, the perfected mainstream

schooling articulates accomplishment by such “best academic practice”, i.e., a number of

specific teaching strategies (Howlin, 2008; see also Hattie, 2009). Unfortunately, local and

state authorities are prone to embrace organisational and policy strategies, and in so doing

hinder the development of ‘best practice’ and establishment of praxis.

Thus, even if both fields concur in recognising the importance of a wide but consensus-based

approach to identify opportunities for enhancement through the use of an array of tools and

from multi-perspectives, the educational field falls short in this respect due to restriction of

the teaching-learning scope. Therefore, to implement the models advocated for and to foster a

vigorous agenda, authorities in education need to take this into account and provide adequate

advice to local school agents. As regards educators, with a thoughtful attitude and frankness,

the vitality inherent in TA and corresponding potential for enhancing the performance of

persons exposed to tests, can be turned into a resource.

Special educators do not provide treatment or cures for medical problems; they provide

intervention to allow children with special needs to access the curriculum. Considering the

breadth of learning and school difficulties associated with childhood anxiety (Visu-Petra,

Cheie, Benga, & Packiam Alloway, 2011), providing services in school settings allows for the

needs of anxious children to be addressed across a continuum of services.

Acknowledgements

This research was supported by the Umeå School of Education, Umeå University, Sweden.

The author gratefully acknowledges the knowledge and expertise of staff at the Department of

Clinical Sciences, Unit Child and Adolescent Psychiatry, Umeå University.

20

References

Abbo, C., Kinyanda, E., Kizza, R. B., Levin, J., Ndyanabangi, S., & Stein, D. J. (2013). Prevalence, comorbidity and predictors of anxiety disorders in children and adolescents in rural north-eastern Uganda. Child and Adolescent Psychiatry and Mental Health, 7(21), doi:10.1186/1753-2000-7-21

Alarcón, R. D. (2009). Culture, cultural factors and psychiatric diagnosis: Review and projections. World Psychiatry, 8(3), 131-139.

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Arlington, Va.: American Psychiatric Association.

Andrews, G., Hobbs, M. J., Borkovec, T. D., Beesdo, K., Craske, M. G., Heimberg., R. G., … Stanley, M. A. (2010). Generalized worry disorder: a review of DSM-IV generalized anxiety disorder and options for DSM-V. Depression and Anxiety, 0, 1-14.

Aydin, S. (2012). The effects of young EFL learners’ perception of tests on test anxiety. Education 3-13. International Journal of Primary, Elementary and Early Years Education, 40(2), 189-204.

Barlow, D. H., & Durand, V. (2012). Abnormal Psychology: An Integrative Approach (6th ed). Wadsworth: Cengage Learning.

Battaglia, M., Zanoni, A., Ogliari, A., Crevani, F., Falzone, L., Bertoletti, E., & Di Serio, C. (2010). Identification of gradually changing emotional expressions in schoolchildren: The influence of the type of stimuli and of specific symptoms of anxiety. Cognition and Emotion, 24(6), 1070-1079.

Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23(8), 1011-1023.

Beidel, D. C. (1988). Psychophysiological assessment of anxious emotional states in children. Journal of Abnormal Psychology, 97(1), 80-82.

Bishop, N. S. (2006). Implementation and Assessment of Test Anxiety Reduction Program Presented to 10th Graders and their Subsequent Performance on the Montcas Criterion References Test. Doctoral thesis, The University of Montana Missoula, MT.

Black, P., & Wiliam, D. (1998). Assessment and classroom learning. Assessment in Education: Principles, Policy & Practice, 5(1), 5-25.

Bodas, J., & Ollendick, T. H. (2005). Test anxiety: A cross-cultural perspective. Clinical Child and Family Psychology Review, 8(1), 65-88.

Bodas, J., Ollendick, T. H., & Sovani, A. V. (2008). Test anxiety in Indian children: A cross-cultural perspective. Anxiety, Stress, and Coping, 21(4), 387-404.

Bögels, S. M., Alden, L., Beidel, D. C., Clark, L. A., Pine, D. S., Stein, M. B., & Vomcken, M. (2010). Social anxiety disorder: Questions and answers for the DSM-V. Depression and Anxiety, 27(2), 168-189.

Broeren, S., & Muris, P. (2009). The relation between cognitive development and anxiety phenomena in children. Journal of Child and Family Studies, 18(6), 702-709.

Brorson, L-O., Numan, E., Pettersson, L-E., & Schollin, J. (1999). Barn som kräver särskilt stöd får hjälp av olika kompetenser. Pedagoger, psykologer, socialarbetare och medicinare samverkar i Örebro. Läkartidningen, 96(45), 4934-4935.

Carter, R., Williams, S., & Silverman, W. K. (2008). Cognitive and emotional facets of test anxiety in African American school children. Cognition and Emotion, 22(3), 539-551.

Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children. Clinical Psychology Review, 26(7), 817-833.

21

Cassady, J. C. (2001). The stability of undergraduate students’ cognitive test anxiety levels. Practical Assessment, Research and Evaluation, 7(2), 38-50.

Chamberlain, S., Daly, A. L., & Spalding, V. (2011). The fear factor: students’ experiences of test anxiety when taking A-level examinations. Pastoral Care in Education: An International Journal of Personal, Social and Emotional Development, 29(3), 193-205.

Chamorro-Premuzic, T., Gorkan, A., & Furnham, A. (2008). Little more than personality: Dispositional determinants of test anxiety (the big five, self-evaluations, and self-assessed intelligence). Learning and Individual Differences, 18(2), 258-263.

Chapell, M. S., Blanding, B. Z., Silverstein, M., E., Takahashi, M., Newman, B., Gubi, A., & McCann, N. (2005). Test anxiety and academic performance in undergraduate and graduate students. Journal of Educational Psychology, 97(2), 268-274.

Cizek, G.J., & Burg, S. S. (2006). Addressing Test Anxiety in a High-stakes Environment: Strategies for classrooms and schools. Thousand Oaks, CA: Corwin Press.

Comer, J. S., Gallo, K. P., Korathu-Larson, P., Pincus, D. B., & Brown, T. (2012). Specifying child anxiety disorders not otherwise specified in the DSM-IV. Depression and Anxiety, 29(12), 1004-1013.

Comer, J. S., Pincus, D. B., & Hofmann, S. G. (2012). Generalized anxiety disorder and the proposed associated symptoms criterion change for DSM-5 in a treatment-seeking sample of anxious youth. Depression and Anxiety, 29(12), 994-1003.

Costello, J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60(8), 837-844.

Creswell, C., & O’Connor, T. G. (2004). Interpretation bias and anxiety in childhood: Stability, specificity and longitudinal associations. Behavioural and Cognitive Psychotherapy, 39(2), 191-204.

Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorders: A meta-analysis. Clinical Psychology Review. doi: 10.1016/j.cpr.2014.01.002

Curtis, C. A. (2009). The Relationship between Anxiety, Working Memory and Academic Performance among Secondary School Pupils with Social, Emotional and Behavioural Difficulties: a test of processing efficiency theory. Doctoral thesis. University of Southampton, Faculty of Medicine, Health and Life Sciences School of Psychology.

Domitrovich, C., Weare, K., Elias, M., Greenberg, M., & Weissberg, R. (2005). Enhancing resilience and reducing risk behaviour in schools. In C. Hosman, E. Jané-Llopis and S. Saxena (eds) Prevention of Mental Disorders: Effective interventions and policy options. Oxford, Oxford University Press.

Dunlosky, J., Rawson, K. A., Marsh, E. J., Nathan, M. J., & Willingham, D. T. (2013). Improving students’ learning with effective learning techniques: Promising directions from cognitive and educational psychology. Psychological Science in the Public Interest, 14(1), 4-58.

Eum, K. U., & Rice, K. G. (2011). Test anxiety, perfectionism, goal orientation, and academic performance. Anxiety, Stress, and Coping, 24(2), 167-178.

Fentz, H. N., Hoffart, A., Jensen, M. B., Arendt, M., O’Toole, M. S., Rosenberg, N. K., Hougaard, E. (2013). Mechanisms of change in cognitive behaviour therapy for panic disorder: The role of panic self-efficacy and catastrophic misinterpretations. Behaviour Research and Therapy, 51(9), 579-587.

Field, A. P., Cartwright-Hatton, S., Reynolds, S., & Creswell, C. (2008). Future directions for child anxiety theory and treatment. Cognition and Emotion, 22(3), 385-394.

22

Ford, T., Goodman, R., & Meltzer, H. (2003). The British child and adolescent mental health survey 1999: The prevalence of DSM-IV disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 42(10), 1203-1211.

Fritz, G. K. (2007). Learning disabilities predict dimensions of test anxiety. Journal of Learning Disabilities, 40(4), 360-376.

Fulk, B. M., Brigham, F. J., & Lohman, D. A. (1998). Motivation and self-regulation: A comparison of students with learning and behaviour problems. Remedial and Special Education, 19(5), 300-309.

Ganley, C. M., & Vasilyeva, M. (2014). The role of anxiety and working memory in gender differences in mathematics. Journal of Educational Psychology, 106(1), 105-120.

Ginsburg, G. S., Becker, E. M., Keeton, C. P., Sakolsky, D., Piacentini, J., Albano, A. M., Compton, S. N., Iyengar, S., Sullivan, K., Caporino, N., Peris, T., Birmaher, B., Rynn, M., March, J., & Kendall, P. C. (2014). Naturalistic follow-up of youths treated for pediatric anxiety disorders. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.4186

Grant, C.A., & Ladson-Billings, G. (1997). Dictionary of Multicultural Education. Arizona: The Oryx Press.

Gregor, A. (2005). Examination anxiety: Live with it, control it or make it work for you? School Psychology International, 26(5), 617-635.

Grillo, E., & da Silva, E. J. M. (2004). Early manifestations of behavioral disorders in children and adolescents. Journal of Pediatric (Rio Journal), 80(2), S21-S27.

Gustafsson, J-E., Allodi, M., Westling, A., Äkerman, B., Eriksson, C., Eriksson, L. … Persson, R. S. (2010). School, Learning and Mental Health. Stockholm: Health Committee.

Han, H-R. (2009). Measuring anxiety in children: A methodological review of the literature. Asian Nursing Research, 3(2), 49-62.

Hanoch, Y., & Vitouch, O. (2004). When less is more: Information, emotional arousal and the ecological reframing of the Yerkes-Dodson Law. Theory & Psychology, 14(4), 427-452.

Hansen, B. H., Skirbekk, B., Richter, J., Oerbeck, B., & Kristensen, H. (2011). Comparison of sleep problems in children with anxiety and attention deficit disorders. European Child and Adolescent Psychiatry, 20(6), 321-330.

Harpell, J. V., & Andrews, J. J. W. (2013). Relationship between school based stress and test anxiety. International Journal of Psychological Studies, 5(2), 74-84.

Harris, R. (2011). The Confidence Gap: A guide to overcome fear and self-doubt. Boston, U.S.A.: Shambhala Publications, Inc.

Hattie, J. A. (2009). Visible Learning: A synthesis of over 800 meta-analyses relating to achievement. London: Routledge.

Hesketh, T., Zhen, Y., Lu, L., Dong, Z. X., Jun, Y. X., & Xing, Z. W. (2010). Stress and psychosomatic symptoms in Chinese school children: Cross-sectional survey. Archives of Disease in Childhood, 95(2), 136-140.

Hettema, J. M., Neale, M. C., & Kendler, K. S. (2001). A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry, 158, 1568-1578.

Hoffman, S. G., Asnaani, A., & Hinton, D. E. (2010). Cultural aspects in social anxiety and social anxiety disorders. Depression and Anxiety, 27(12), 1117-1127.

Hopko, D. R., McNeil, D. W., Zvolensky, M. J., & Eifert, G. H. (2001). The relation between anxiety and skill in performance-based anxiety disorders: A behavioral formulation of social phobia. Behavior Therapy, 32(1), 185-207.

23

Howlin, P. (2008). In M. Rutter, D. Bishop, D. Pine, S. Scott, J. Stevenson, E. Taylor, and A. Thapar Rutter’s Child and Adolescent Psychiatry (5th ed) (pp. 1189-1206). Massachusetts, US: Wiley-Blackwell.

Huberty, T. J. (2009). Test and performance anxiety: Good communication and support can help minimize its negative impact. National Association of Secondary School Principals, 10, 12-16.

In-Albon, T., Klein, A., Rinck, M., Becker, E., & Schneider, S. (2008). Development and evaluation of a new paradigm for the assessment of anxiety-disorder-specific interpretation bias using picture stimuli. Cognition and Emotion, 22(3), 422-436.

Isomaa, R., Väänänen, J-M., Fröjd, S., Riittakerttu, K-H., & Marttunen, M. (2013). How low is low? Low self-esteem as an indicator of internalizing psychopathology in adolescence. Health Education & Behavior, 40(4), 392-399.

Kadesjö, B., & Kadesjö, C. (1999). DAMP och ADHD ’’osynliga’’ funktionshinder Genomtänkt omhändertagande av riskbarn främjar optimal utveckling. Läkartidningen, 96(12), 1455-1462.

Karpicke, J. D., & Grimaldi, P. J. (2012). Retrieval-based learning: a perspective for enhancing meaningful learning. Educational Psychology Review, DOI 10.1007/s10648-012-9202-2

Karpicke, J. D., & Roediger, H. L. III (2007). Repeated retrieval during learning is the key to long-term retention. Journal of Memory and Language, 57(2), 151-162.

Keogh, E., Bond, F.W., & Flaxman, P. E. (2006). Improving academic performance and mental health through a stress management intervention: Outcomes and mediators of change. Behaviour Research and Therapy, 44(3), 339-357.

Keogh, E., & French, C. C. (2001). Test anxiety, evaluative stress, and susceptibility to distraction from threat. European Journal of Personality, 15(2), 123-141.

Klang, N. (2012). Applicability of the ICF-CY to Describe Functioning and Environment of Children with Disabilities. Doctoral thesis. Örebro University: Trycksaker.

Kofman, O., Meiran, N., Greenberg, E., Balas, M., & Cohen, H. (2006). Enhanced performance on executive functions associated with examination stress: Evidence from task-switching and Stroop paradigms. Cognition and Emotion, 20(5), 577-595.

Kumke, P. J. (2008). The Adolescent Test Anxiety Scale: Initial scale development and construct validation. Madison: ProQuest LLC.

Ladouceur, C. D., Silk, J. S., Dahl, R. E., Ostapenko, L., Kronhaus, D. M., & Phillips, M. L. (2009). Fearful faces influence attentional control processes in anxious youth and adults. Emotion, 9(6), 855-864.

Larson, H. A., El Ramahi, M. K., Conn, S. R., Estes, L. A., & Ghibellini, A. B. (2010). Reducing Test Anxiety Among Third Grade Students Through the Implementation of Relaxation Techniques. New York: Eastern Illinois University Press.

Leeming, F. C. (2002). The exam-a-day procedure improves performance in psychology classes. Teaching of Psychology, 29(3), 210-212.

Lehman, A. F., Alexopoulos, G. S., Goldman, H., Jeste, D., & Üstün, B. (2002). Mental disorders and disability: Time to reevaluate the relationship? In D. J. Kupfer, M. B. and D. A. Reiger (eds.) A Research Agenda for DSM-V (pp. 201-218). American Psychiatric Association Washington, D.C.

Lester, S. (1999). An Introduction to Phenomenological Research. Taunton UK, Stan Lester Developments. Downloaded 131110 from www.sld.demon.co.uk/resmethy.pdf

Lewis-Fernández, R., Hinton, D. E., Laria, A. J., Patterson, E. H., Hofmann, S. G., Craske, M. … Liao, B. (2011). Culture and the anxiety disorders: Recommendations for DSM-V. Focus – the Journal of Lifelong Learning in Psychiatry, IX(3), 351-368.

24

Liston, C., McEwen, B. S., & Casey, B. J. (2009). Psychosocial stress reversibly disrupt prefrontal processing and attentional control. Proceedings of the National Academy of Sciences of the United States of America, 106(3), 912-917.

Lodge, J., & Tripp, G. (1995). Anxiety in children: Testing the role of cognition. New Zealand Journal of Psychology, 24(2), 29-36.

Lowe, Lee, Witteborg, Prichard, Luhr, Cullinan, … Janik, (2008). The Test Anxiety Inventory for Children and Adolescents (TAICA): Examination of the psychometric properties of a new multidimensional measure of test anxiety among elementary and secondary school students. Journal of Psychoeducational Assessment, 26(3), 215-230.

Lowe, P. A., & Ang, R. P. (2012). Cross-cultural examination of test anxiety among US and Singapore students on the Test Anxiety Scale for Elementary Students (TAS-E). Educational Psychology, 32(1), 107-126.

Lundin, N., & Belfrage, E. (2012). Skolan kan skapa hälsa. Läkartidningen, 109(16), 821-823.

Lyneham, H. J., & Rapee, R. M. (2005). Evaluation and treatment of anxiety disorders in the general pediatric population: A clinician’s guide. Child and Adolescent Psychiatric Clinics of North America, 14(4), 845-862.

Mattarella-Micke, A., Mateo, J., Kozak, M. N., Foster, K., & Beilock, S. L. (2011). Choke or thrive? The relation between salivary cortisol and math performance depends on individual differences in working memory and math-anxiety. Emotion, 11(4), 1000-1005.

McDaniel, M. A., Anderson, J. L., Derbish, M. H., & Morrisette, N. (2007). Testing the testing effect in the classroom. European Journal of Cognitive Psychology, 19(4/5), 494-513.

McDonald, A. S. (2001). The prevalence and effects of test anxiety in school children. Educational Psychology, 21(1), 89-101.

McMillan, D., & Lee, R. (2010). A systematic review of behavioural experiments vs. exposure alone in the treatment of anxiety disorders: A case of exposure while wearing the emperor’s new clothes? Clinical Psychology Review, 30(5), 467-478.

Misfud, C., & Rapee, R. M. (2005). Early intervention for childhood anxiety in a school setting: Outcomes for an economically disadvantaged population. Journal of the American Academy of Child & Adolescent Psychiatry, 44(10), 995-1004.

Mitra, R., Ferguson, D., & Sapolsky, R. M (2009). SK2 potassium channel overexpression in basolateral amygdala reduces anxiety, stress-induced corticosterone secretion and dendritic arborization. Mol. Psychiatry, 14(9), 847-855.

Muris, P., & Field, A. P. (2008). Distorted cognition and pathological anxiety in children and adolescents. Cognition and Emotion, 22(3), 395-421.

Murrihy, R., Kidman, A., & Ollendick, T. (2010). Clinical Handbook of Assessing and Treating Conduct Problems in Youth. Springer: New York.

Neil, A. L., & Christensen, H. (2009). Efficacy and effectiveness of school-based prevention and early intervention programs for anxiety. Clinical Psychology Review, 29(3), 208-215.

Nyroos, M., Korhonen, J., Linnanmäki, K., & Svens-Liavåg, C. (2012). A cross-national comparison in Swedish and Finnish grade 3 pupils: Measured by the CTAS. Education Inquiry. 3(4), 615-636.

Nyroos, M., Korhonen, J., Peng, A., Linnanmäki, K., Svens-Liavåg, C., Bagger, A., & Sjöberg, G. (accepted). A cross-cultural analysis of test anxiety among Chinese, Finnish and Swedish pupils. International Journal of School & Educational Psychology.

Oladipo, S. E., & Ogungbamila, A. (2013). Demographic predictors of test anxiety among undergraduates. International Journal of Learning & Development, 3(1), 62-66.

25

Olfson, M., Gameroff, M. J., Marcus, S. C., & Waslick, B. D. (2003). Outpatient treatment of child and adolescent depression in the United States. Archives of General Psychiatry, 60(12), 1236-1242.

Owens, M., Stevenson, J., Hadwin, J. A., & Norgate, R. (2012). Anxiety and depression in academic performance: An exploration of the mediating factors of worry and working memory. School Psychology International, 33(4), 433-449.

Packer, M. J., & Goicoechea. J. (2000). Sociocultural and constructivist theories of learning: Ontology, not just epistemology. Educational Psychologist, 35(4), 227-241.

Pathak, S., & Perry, B. (2006). Anxiety disorders. In C. E. Coffey (ed.) Pediatric Neruopsychiatry (pp. 285-305). Philadelphia: Lippincott Williams & Wilkins.

Pennebaker, J. W., Gosling, S. D., & Ferrell, J. D. (2013). Performance while reducing achievement gaps. PLOS ONE, 8(11), 1-6.

Petersen, S., Bergström, E., Cederblad, M., Ivarsson, A., Köhler, L., Rydell, A-M, … Hägglöf, B. (2010). Barns och ungdomars psykiska hälsa i Sverige. En systematisk litteraturöversikt med tonvikt på förändring över tid. Stockholm: Hälsoutskottet.

Prato, C. A. (2009). Biofeedback assisted relaxation training program to decrease test anxiety in nursing students. UNLV Theses/Dissertations/Professional Papers/Capstones. Paper 81. Downloaded 120109 from: http://digitalcommons.library.unlv.edu/thesesdissertations/81

Purves, D., Augustine, G. J., Fitzpatrick, D., Hall, W. C., LaMantia, A-S., & White, L. E. (Eds.) (2012). Neuroscience (5th ed.). Sunderland, Massachusetts U.S.A.: Sinauer Associates, Inc.

Putwain, D. W. (2009a). Assessment and examination stress in Key Stage 4. British Educational Research Journal, 35(3), 391-411.

Putwain, D. W. (2009b). Situated and contextual features of test anxiety in UK adolescent students. School Psychology International, 30(1), 56-74.

Putwain, D. W., & Daly, T. (2013). Do clusters of test anxiety and academic buoyancy differentially predict academic performance? Learning and Individual Differences, 27(1), 157-162.

Rapee, R. M., Kennedy, S. J., Ingram, M., Edwards, S. L., & Sweeney, L. (2010). Altering the trajectory of anxiety in at-risk young children. American Journal of Psychiatry, 167(12), 1518-1525.

Reuschel, L. M. (2011). Generalized Anxiety Disorder in Children and Adolescents: Implications for research and practice. Illinois State University, Department of Psychology.

Riley, P. J. (2003). The Relationship Between Parental Warmth and Parental Pressure to Achieve Adolescent Depression and Anxiety in China. Maryland: Faculty of the Graduate School of the University of Maryland at College Park.

Roediger, H. L. III, McDaniel, M., & McDermott, K. (2006). Test enhanced learning. APS Observer, 19(3), 29-39.

Roslander, P. (2013). The importance of personality, IQ and learning approaches: Predicting academic performance. Doctoral thesis, Lund University: Media-Tryck.

Roy M-A., Lanctôt, G., Mérette, C., Cliche, D., Fournier, J-P., Boutin, P., … Maziade, M. (1997). Clinical and methodological factors related to reliability of the best-estimate diagnostic procedure. American Journal of Psychiatry, 154(12), 1726-1733.

Ruscio, A. M. (2010). The latent structure of social anxiety disorder: Consequences of shifting to a dimensional diagnosis. Journal of Abnormal Psychology, 19(4), 662- 671.

Sahlei, B., Cordero, I., & Sandi, C. (2010). Learning under stress: the inverted-U-shape function revisited. Learning and Memory, 17(10), 522-530.

Salend, J. S. (2011). Addressing test anxiety. Teaching Exceptional Children, 44(2), 58-68.

26

Salthouse, T. A. (2012). How general are the effects of trait anxiety and depressive symptoms on cognitive functioning? Emotion, 12(5), 1075-1084.

Sawyer, M. G., Kosky, R. J., Graetz, B. W., Arney, F., Zubrick, S. R., & Baghurst, P. (2000). The national survey of mental health and wellbeing: The child and adolescent component. Australian and New Zealand Journal of Psychiatry, 34(2), 214-220.

Schlöglmann, W. (2003). Can neuroscience help us better understand affective reactions in mathematics learning? Proceedings of the Third Conference of the European Society for Research in Mathematics Education, Bellaria, Italia. Downloaded 140204 from: http://www.mathematik.uni-dortmund.de/~erme/CERME3/Groups/TG2/TG2_schloeglmann_cerme3.pdf

Schutz, P. A., & Davis, H. A. (2000). Emotions and self-regulation during test taking. Educational Psychologist, 35(4), 243-256.

Schwabe, L., Joëls, M., Roozendaal, B., Wolf, O. T., & Oitzl, M. S. (2012). Stress effects on memory: An update and integration. Neuroscience and Biobehavioral Reviews, 36(7), 1740-1749.

Serlachius, E., Thulin, U., Andersson, G., Vigerland, S., & Ivarsson, T. (2012). Ångeststörningar hos barn och ungdomar – hjälp finns att få. Läkartidningen, 43-44(109), 1946-1949.

Spielberger, C. D. (1972). Anxiety as an emotional state. In C. D. Spielberger (ed.) Anxiety: Current Trends in Theory and Research (pp. 33-46). New York: Academic Press.

Stankov, L. (2010). Unforgiving Confucian culture: A breeding ground for high academic achievement, test anxiety and self-doubt? Learning and Individual Differences, 20(6), 555-563.

Stephan, S. H., Weist, M., Kataoka, S., Adelsheim, S., & Mills, C. (2007). Transformation of children’s mental health services: The role of school mental health. Psychiatric Services, 58(10), 1330-1338.

Stöber, J. (2004). Dimensions of test anxiety: Relations to ways of coping with pre-exam anxiety and uncertainty. Anxiety, Stress, and Coping, 17, 213-226.

Stöber, J., & Pekrun, R. (2004). Advances in test anxiety research. Anxiety, Stress, and Coping, 17(3), 205-211.

Sud, A. (2011). Test anxiety research in India: Twentieth century in retrospect. Psychology and Developing Societies, 13(1), 51-69.

Sulkowski, M. L., Joyce, D. K., & Storch, E. A. (2012). Treating childhood anxiety in schools: Service delivery in a response to intervention paradigm. Journal of Child and Family Studies, 21(6), 938-947.

Susa, G., Pitică, I., Benga, O., & Mircea, M. (2012). The self regulatory effect of attentional control in modulating the relationship between attentional biases toward threat and anxiety symptoms in children. Cognition and Emotion, 26(6), 1069-1083.

Suveg, C., Jacob, M. L., & Thomassin, K. (2009). Generalized anxiety disorder in youth. Behavioural Psychology, 17(1), 41-66.

Symes, W., Putwain, D., & Connors, L. (2009). If I can’t answer this question, I’ll fail the whole exam: examination anxiety, GCSE achievement and tendency to draw the worst possible conclusion. Paper presentation at the British Educational Research Association Conference.

Teigen, K. H. (1994). Yerkes-Dodson: A law for all seasons. Theory and Psychology, 4(4), 525-547.

Thabet, A. A. M., & Vostanis, P. (1998). Social adversities and anxiety disorders in the Gaza Strip. Archives in Diseases in Children, 78(5), 439-442.

27

UNESCO (1994). The Salamanca Statement and Framework for Action on Special Needs Education. Adopted by the World Conference on Special Needs Education: Access and Quality. Salamanca, Spain, June 7-10.

Varela, E. R., & Hensley-Maloney, L. (2009). The Influence of Culture on Anxiety in Latino Youth: A Review. Clinical Child and Family Psychology Review, 12, 217-233.

Walkenhorst, E., & Crowe, S. F. (2009). The effects of state worry and trait anxiety on working memory processes in a normal sample. Anxiety, Stress, and Coping, 22(2), 167-187.

Wang, Y., Hui, Z., Xin-rong, L., Su-fen, C., Wei, X., Man-li, Q., & Hui-jie, L. (2005). Gender differences of test anxiety in secondary school students. Chinese Journal of Clinical Rehabilitation, 9(40), 24-26.

Visu-Petra, L., Cheie, L., Benga, O., & Packiam Alloway, T. (2011). Effects of anxiety on memory storage and updating in young children. International Journal of Behavioral Development, 35(1), 38-47.

Wren, D. G., & Benson, J. (2004). Measuring test anxiety in children: Scale development and internal construct validation. Anxiety, Stress, and Coping, 17(3), 227-240.

Zalta, A. K., & Chambless, D. L. (2012). Understanding Gender Differences in Anxiety: The Mediating Effects of Instrumentality and Mastery. Psychology of Women Quarterly, 36(4), 488-499.

Zeidner, M., & Matthews, G. (2005). Evaluation anxiety: Current theory and research. In A. J. Elliot and C. S. Dweck (eds.) Handbook of Competence and Motivation (pp. 141-166). New York: The Guilford Press.

Zuriff, G. E. (1997). Accommodations for test anxiety under ADA? Journal of the American Academy of Psychiatry and the Law, 25(2), 197-206.