Tipping Points: Teachers’ Reported Reasons for Referring Primary School Children for Excessive Anxiety

Teachers’ Decisions to Refer Children for Excessive Anxiety

It is unclear why teachers do not always refer children with suspected excessive anxiety. There is reportedly inconsistency and a lack of teacher understanding regarding how severe any perceived problem should be before teachers believe the threshold, or ‘tipping point’, for when to make a referral is reached (Pearcy et al., 1993; Tilly, 2008). Variation appears to exist in the processes and outcomes of teachers’ referral decisions, regarding both internalising and externalising problems in children (Kingsley, 2011; Trudgen & Lawn, 2011). Different factors have been found to influence referral decisions and tipping points, including attributes of teachers themselves, characteristics of the children they consider for referral, and system-level influences.

Teacher Factors

Teaching experience has been shown to influence referral decisions in some studies (Kingsley, 2011; Powell, Fixsen, Dunlap, Smith, & Fox, 2007) but not in others (Luke, 2009). Perhaps any effect of teaching experience may be explained by an increase in knowledge about students’ emotional and behavioural problems with professional experience; however, personal experience may also account for such an increase in knowledge (Trudgen & Lawn, 2011).

Teachers’ personal beliefs and attitudes relating to the perceived problem may also affect referral decisions (Liljequist & Renk, 2007), such as teachers’ concerns about labelling and stigmatising young children, and about parents’ reactions to their assessment of a child's behaviour (Kingsley, 2011). Research investigating teachers’ attitudes toward the specific behaviour of reporting suspected child sexual abuse (Walsh, Rassafiani, Mathews, Farrell, & Butler, 2010, 2012) revealed three dimensions of teachers’ attitudes that may influence their reporting behaviour: teachers’ commitment to the reporting role; confidence in the system's effective response to reports; and concerns about the consequences of reporting (Walsh et al., 2012). These dimensions may suggest possible attitudinal influences on teachers’ decisions to refer children for suspected excessive anxiety, which could be appropriate targets for intervention to improve referral rates due to the supposition that attitudes may be changed with time, context, experience, and education (Ajzen, 2005; Walsh et al., 2010).

In sum, existing evidence for the influence of teacher factors on referral decisions regarding children's emotional and behavioural problems is mixed, and complicated by potential interrelationships and interaction effects. Clarification of the effect of teacher factors on referral decisions is important, as these factors are potentially powerful targets for intervention to improve referral rates of children with excessive anxiety.

Child Factors

Teachers have been shown to be more likely not to refer girls with internalising problems compared to boys (Green et al., 1996; Kirk, 2013), and more likely to make a referral if a child with emotional or behavioural problems also displays low academic achievement (Abidin & Robinson, 2002; Briesch et al., 2013; Eklund & Dowdy, 2013; Green et al., 1996; Trout, Epstein, & Nelson, 2006). When children have additional actual or perceived risk factors, such as poverty or difficult temperament, teachers were also more likely to make a referral (Kingsley, 2011). Thus, it has been shown that child factors interact with teacher factors such as beliefs and attitudes, to influence teachers’ referral decisions.

System-Level Factors

Aspects of the educational setting's unique environment and referral systems may also influence teachers’ referral decisions (Fantuzzo et al., 1999; Kingsley, 2011; Powell et al., 2007). Awareness of mental health service availability, other staff being a help or hindrance, time pressures, and resourcing in student support teams, as well as relationships with external agencies, have been identified as factors teachers consider when deciding to refer a child for internalising or externalising problems (Fantuzzo et al., 1999; Kingsley, 2011; Trudgen & Lawn, 2011). Referral processes differ between individual schools (Campbell, 2003b) and between preschool, primary and high school contexts, but there is a lack of research about how referral systems operate in practice. There is a need, therefore, to understand how system-level factors interact along with child factors and teacher factors to influence decisions to refer anxious children.

The Current Study

Given that teacher referral is the most common pathway to treatment for children with excessive anxiety, understanding the reasons that teachers decide to refer anxious children, and their tipping point for when to make a referral, is a necessary step towards addressing the existing poor referral rate. Therefore, this exploratory study built on previous research into influences on teachers’ referral of children with suspected excessive anxiety, by: (a) investigating the primary school context specifically; (b) using qualitative interviews with teachers to enable new influencing factors to emerge; (c) gathering school-level data, to enable a consideration of the influence of contextual factors; and (d) asking teachers about specific cases rather than general recollections alone, to improve the validity of responses.

Participants

Participants were 20 primary school staff members (3 male, 17 female) from two participating Catholic primary schools, 14 from School A (21% of staff) and six from School B (24% of staff) in south-east Queensland. Staff were eligible to participate if they met at least one of the following inclusion criteria: (a) had recently been involved in referring a particular child with suspected excessive anxiety; (b) were incidentally involved in identifying and referring anxious children in the course of their role as a teacher; or (c) had detailed knowledge and explicit involvement in the school's process of identifying children with excessive anxiety.

School A participants included the guidance counsellor, a cross-section of seven class teachers from Prep to Year 7, two support teachers for inclusive education, two specialist teachers, the assistant principal, and the assistant principal for religious education. School B participants included the guidance counsellor, a cross-section of three class teachers from Year 2 to Year 7, the support teacher for inclusive education, and the assistant principal for religious education. Participants’ experience in the teaching profession ranged from 2 to 45 years.

Procedure

Ethical approval was gained from both the university ethics committee and the schools’ employing authority. Emails advertising the study were sent to Catholic primary schools in the metropolitan area seeking schools that were planning to offer a school-based group intervention for anxiety in the near future to participate. The study was also advertised via word of mouth between professional contacts, particularly school guidance counsellors. Two guidance counsellors expressed an interest in having their school participate in the study. Approval was granted from each school principal, and the guidance counsellor acted as a liaison person in each school. The guidance counsellor at each school suggested a cross-section of staff in different job positions who met the criteria for inclusion in the study. These staff members were contacted directly by the researcher, provided with information about the study, and invited to participate voluntarily in an interview at a suitable time on their school campus. Before completing the interview, each participant was informed verbally about the study and given the opportunity to ask questions, before providing written informed consent.

Children who had been referred for excessive anxiety by the participating teachers and guidance counsellors in July to August 2013 participated in a school-based group intervention aimed at reducing anxiety and improving social skills between September and November 2013. The intervention was tailored to the needs of the children, and implemented by the guidance counsellor in School A, and by the researcher and a colleague (both psychologists with provisional registration) in School B. No data was collected from the children.

School Characteristics

Contextual information about the size, composition, and policies of each school was collected, to allow for inferences to be made about possible system-level influences on teachers’ referral decisions. Both schools were co-educational, with students enrolled from Prep to Year 7. School A had a total enrolment of 528 students, and School B a total enrolment of 177 students. Both schools had policies outlining the process teachers were expected to follow, to formally refer a child with suspected learning, emotional or behavioural needs to the student support team. In each school, the student support team was comprised of the guidance counsellor, support teacher(s) for inclusive education, and members of the leadership team.

Theme 1: Impact on Learning

A major theme that teachers considered when deciding to refer a child, was whether the child's excessive anxiety was perceived to be impacting their ability to learn. Teachers described both direct impacts on academic learning, as well as indirect impacts due to poor social-emotional wellbeing in their decision to refer a child:

When it's affecting their participation and accessing the curriculum, because that's what we're about, that's what Learning Support always says. Our core role is to help the children access the curriculum, so if they're anxious enough to . . . you know, if it's stopping them from doing their work. A, Year 1 CT, F, 2)

You've got to try and work out, identify, is it something that is going to affect them at school? So we always look at the analogy of the pyramid; we've got the social and emotional skills at the bottom, and as you go up the pyramid it gets to the academic side of things. (A, Prep CT, M, 24)

[My tipping point] probably would have been when things just weren't happening for that child in the classroom. Just when they weren't cooperating, you could see them not moving on, getting by, struggling . . . just everyday learning. And then the impact on others in the classroom as well. (B, Year 4 CT, F, 17)

If they're not learning at their best, if they're anxious . . . that's got to come first — student wellbeing . . . the student wellbeing framework is the basis of everything. (B, Year 5/6/7 CT, F, 26).

Theme 2: Atypical Child Behaviour

While all participants were able to name behavioural indicators and signs of anxiety in children, such as withdrawn behaviour and ‘meltdowns’, seven participants spoke about a child's atypical behaviour as an indicator that the child should be referred for suspected anxiety:

‘If it is multiple concerns, multiple complaints or notices from the teacher that this is beyond what is the norm. (A, ST:IE, F, 36)

You know, if something was happening where I would expect a typical Year 2 child to be able to cope with that . . . if it was out of the ordinary, that would be one of my alarms, and you know, without significant triggers. (A, Year 2 CT, F, 11)

You can find out little bits and pieces to see if that's what is causing it, or whether it's a bigger issue . . . are they sleeping properly, eating properly? You know, all those things. I am seeing this behaviour in the playground, or in the classroom, or in transition times. And that's when, if I think it's a bigger thing, I get [the Guidance Counsellor] or Learning Support to come in. (A, Prep CT, F, 5)

I think we are more likely to pick up a child's anxiety here, because we know them so well . . . whereas in a big school, kids can tend to get a bit lost, I think . . . You get to know them from year to year, so that if something changes, the teachers notice. They think, ‘What's happening?’ and usually we would refer. (B, ST:IE, F, 24)

Theme 3: Repeated Difficulties that Do Not Improve Over Time

A child displaying repeated and persistent difficulties emerged as one of the most prominent reasons that teachers decided to make a referral. A number of teachers described ‘regular meltdowns’ or ‘daily’ issues as the tipping point to refer a child:

I contacted [the Guidance Counsellor] early on, I can't remember when. But because it was regular, like there would be tears! (A, Year 1 CT, F, 2)

I wouldn't [raise] it straight away because all kids have an off day. But if it seems to be happening a lot . . . if it became to the point where it was affecting them every lesson, then I would bring it up with their classroom teacher. (A, PET, F, 13)

She had a really happy first week, but then in week two, she started getting very anxious, and getting upset very quickly. So, I organised an interview with Mum and Dad, and just kept them in the loop through email, and then it was really starting to escalate and happen more regularly, so then I had to — I of course went to [the Guidance Counsellor] and Learning Support. (A, Year 1 CT, F, 14)

Theme 4: Poor Response to Strategies

Teachers spoke about making the decision to refer a child for excessive anxiety when the child does not respond to the strategies they implement themselves:

After the first few times that I've noticed it or they've come to me and I've worked with them, to see it then not improving but recurring, then I'd take the next step and speak with . . . our support team. (B, Year 2 CT, F, 25)

The Student Support Team form that we ask the staff to fill in stops referrals that may not be as big as they really think it is . . . it actually gives us a background, whether staff have exhausted their possibilities in their strategies. (B, APRE, M, 25)

Really good teachers have actually been putting strategies in place long before they've referred them. And certainly teachers here do that. (A, GC, F, 37)

Theme 5: Teachers’ Need for Support

Rather than solely focusing on the child's behaviour and ability to cope, teachers from both schools perceived their own or their colleagues’ need for support as a tipping point for referral:

When we see that this is beyond being managed by a classroom teacher . . . If people have to keep coming back to the support team to say ‘I need help, I need help, I need help!’ (A, ST:IE, F, 36)

Nothing really was happening for him, and I was just getting to my wit's end. ‘I need help [laughs]! I need support. I've got these two children who can't speak English. I've got . . .’ Yeah [sigh]. (B, Year 4 CT, F, 17)

We have a referral system, so if we've reached the point of thinking ‘we need some support with this’, we do have a formal referral system to fill in the form. (B, Year 5/6/7 CT, F, 26)

Theme 6: Information from Parents/Carers

Some teachers described receiving information from parents/carers about a child's functioning at home as a prompt to make a referral for excessive anxiety.

The mum and dad really wanted to target the anxiety, because it wasn't only just at school, he would wake up in the middle of the night. (A, Prep CT, F, 5)

Often also a parent will ring up, and you know, they'll say, ‘There's been problems with my child at home, what are you going to do about it?’ (A, ST:IE, F, 36).

Often the parents will come up and say, ‘They're not sleeping at night’ or ‘They're worrying about their friends’ or this and that, and they'll alert us to something that is happening at home, some worry they've got. (B, ST:IE, F, 24)

Combinations of Themes

Some participants reported considering only one reason before deciding to make a referral, and thus there was little or no delay in deciding to refer a child. In these cases, the referral tipping point was low; these teachers reported needing few perceived reasons to justify making a referral. Other participants reported considering up to four reasons before they decided to refer a child, and so the referral was somewhat delayed in comparison. This reflects a higher tipping point for referral; these teachers waited for an accumulation of reasons before making a referral. However, many teachers were proactive in seeking this additional information; for example, approaching the parents for information about the child's functioning at home, or employing in-class strategies.

Teacher Factors

As expected from the existing literature, teacher factors affected teachers’ decisions to refer children for excessive anxiety. No pattern of results emerged relating teaching experience to referral decisions, which is consistent with previous qualitative studies (Kingsley, 2011; Trudgen & Lawn, 2011). Some recent graduates and some of the most experienced participants likewise indicated they had a low tipping point for referral. Neither did teaching experience appear to be related to knowledge of anxiety in children, as teachers with different levels of experience conveyed an accurate understanding of the signs and consequences of anxiety in children, which strengthens the conclusion that teachers are able to accurately identify children with excessive anxiety (e.g., Headley & Campbell, 2013). Together, this contradicts Powell et al.’s (2007) hypothesis that teaching experience affects knowledge of children's emotional and behavioural difficulties and thus referral decisions, rather suggesting that teaching experience may have little if any effect on referral decisions specific to children with excessive anxiety.

On the surface, some teachers’ perceptions that their own or their colleagues’ need for support was a reason to make a referral may indicate they felt ill-equipped to identify and support children with anxiety. However, this theme was less prominent, and always considered in conjunction with other factors, rather than constituting a tipping point per se. This suggests that rather than reflecting a sense of feeling ill-equipped and thus a low tipping point, this ‘need for support’ factor emerged from participants who had already observed repeated difficulties in a child and implemented in-class strategies, but saw a poor response and lack of improvement.

The ‘poor response to strategies’ theme corroborates with Kingsley's (2011) results, and indicates that many teachers implement in-class strategies and do what they can themselves, then seek help when they see a child needs more support than they can provide. Teachers also revealed their use of proactive strategies to support students’ wellbeing, such as maintaining regular contact with parents, responding to small incidents quickly, gathering data about the child's behaviour, and consulting with their immediate colleagues and teaching team for support and ideas for in-class strategies before making a referral to the student support team.

Child Factors and Interaction Effects

Child factors interacted with teacher factors to influence teachers’ decisions to refer anxious children. A dominant reason that teachers cited for deciding to refer a child was whether the child's suspected anxiety was seen to be impacting on their ability to learn, in line with previous research suggesting teachers are more likely to refer children with low academic achievement (Abidin & Robinson, 2002; Briesch et al., 2013; Eklund & Dowdy, 2013; Green et al., 1996; Trout et al., 2006). Some teachers also considered the effect on the child's classmates’ ability to learn, which matches Kingsley's (2011) findings.

Many teachers’ responses suggested they believed their primary role was ensuring children access the academic curriculum, which may affect their attitudes toward their role in referring children for excessive anxiety by decreasing their commitment and sense of responsibility for identifying and referring students’ emotional difficulties. However, other teachers conveyed their commitment to supporting the overall wellbeing of their students, reflecting and occasionally explicitly referring to, their school's student wellbeing policy or framework rather than concentrating on academic achievement only. Teachers who conveyed a stronger commitment and responsibility to fulfil their role in referring anxious students appeared to be more proactive, or had a lower tipping point for referral.

Receiving information from parents/carers that a child's anxiety was affecting their functioning at home was reported by some teachers as a reason for making a referral. Sometimes parents were aware that their child's behaviour reflected anxiety, but at other times parents mentioned behavioural signs and symptoms without recognising them as indicators of anxiety. This suggests information from parents/carers may be important in assisting teachers’ early identification and referral of children with internalising problems.

System-Level Factors and Interaction Effects

The results revealed how system-level factors interacted with teachers’ perceptions to either encourage teachers to make a referral, or act as a barrier to timely referrals. Some teachers perceived that a small school population was a positive influence that facilitated early identification of anxious students because they were able to develop stronger relationships with students and thus notice symptoms of anxiety earlier. However, barriers to the next step of referral may still exist in small schools, such as limited funding and resource availability.

Availability of funding and resources emerged as a system-level factor that appeared to influence teachers’ referral decisions in two ways. First, the findings suggest that funding and resource availability may affect referral processes. The student support team in the smaller, less-resourced school expected teachers to wait until they had tried their own strategies before making a referral to the student support team. Limited funding and resource availability may create policies where teachers are expected to manage independently using their own in-class strategies, which appears to encourage a higher tipping point for referral.

Second, teachers’ perceptions of service and resource availability may enable or prevent timely referrals. For example, some teachers’ comments suggest they perceived the guidance counsellor to be readily available, which may encourage a low tipping point for action. However, other teachers indicated an awareness that service and resource availability was limited, and this perception seemed to delay their decision to refer a child. The influence of teachers’ perceptions of service and resource availability on referral decisions is consistent with previous research (e.g., Fantuzzo et al., 1999; Kingsley, 2011), such as the finding that teachers do not want to overload their school counsellor colleagues (Trudgen & Lawn, 2011), and the perception that school counsellors are overloaded with assessment cases and do not have time for counselling or intervention work (Bell & McKenzie, 2013).

Implications

The current results suggest that teacher training and professional development may be an effective way to target the identified factors that influence referral decisions, in order to improve the referral rate. As teachers differed in their reported reasons for referring children with excessive anxiety, training could focus on equipping teachers with a decision-making model that guides them through the most appropriate reasons for deciding to make a referral and outlines appropriate tipping points, with the aim of achieving an optimal threshold for referral.

Teachers’ attitudes toward their role in referring children with internalising problems could also be targeted through training both pre-service and inservice, by highlighting the nature and importance of teachers’ role in the identification and referral of children with excessive anxiety, with the aim of increasing their commitment to this role. Teacher training could also include methods to foster strong parent–teacher working relationships, which may encourage parents to raise concerns about their child's wellbeing with teachers and thus promote the early identification and referral of children who are most at risk of not receiving appropriate assistance.

The current results also revealed an interaction between teacher- and system-level factors, particularly the effect of funding and resource availability on school-level referral processes, as well as teachers’ perceptions of resource availability. These findings indicate that to have the greatest impact, system-level factors should be targeted directly. For example, allocation of funding and resources to schools could be needs based rather than enrolment based in order to improve resourcing in small schools with high needs, as in the current funding climate such schools appear to experience additional barriers to referral and service provision. However, such large-scale systemic change is difficult and dictated by political and economic environments. Targeting factors at the teacher level could still promote appropriate referrals of children with excessive anxiety within a context of limited resources. For example, training teachers in implementing effective classroom strategies to support children with symptoms of anxiety could assist them to be better equipped and more effective as a first line of early intervention.

Limitations

Though qualitative interview was the most appropriate methodology to answer the current research question, certain limitations exist. Despite the researchers’ attempts to structure and conduct the interviews to elicit relevant information and ask about actual events that had occurred, some teachers may still have responded in a somewhat socially desirable way, or may have provided incomplete or inaccurate reflections about referrals they had made. Qualitative inquiry acknowledges that results are not intended to be generalisable outside their context, instead allowing rich data to be obtained. Even so, it is worth noting that the current study drew its sample of teachers from two schools. Though the schools differed from each other in their composition and context, recruitment and participation was voluntary, and thus the schools and teachers sampled may be more aware of anxiety, and more invested in the social-emotional wellbeing of their students, compared to the wider population of schools and teachers. As this small comparative study emphasised the referral process in schools, which all staff are involved in, interview data was collapsed and analysed across teachers in different roles within the schools. A further study may survey school staff in different roles, to determine patterns in their differential involvement in the referral process.

Directions for Future Research

The current study and extant qualitative research (e.g., Kingsley, 2011; Trudgen & Lawn, 2011) has helped identify numerous teacher factors that influence teachers’ decisions to refer children for emotional problems. Thus, future research could employ quantitative methods and larger sample sizes to investigate the generalisability of identified influences on teachers’ referral decisions, such as attitudes, experience, knowledge, and gender, and the interactions between these. This could inform the development of teacher training aimed at improving referral rates of internalising problems, particularly excessive anxiety, by confirming the factors that should be targeted to effect change.

Future research could further investigate the effect of system-level factors, such as resource availability and referral processes, on teachers’ referral decisions. Sampling numerous schools could help identify the system-level conditions that promote and hinder teachers’ referral decisions, and thus children's access to mental health services. In addition, more research on encouraging reflective practice of teachers, whether they are proactive in seeking professional learning in this area and whether they seek to link with system-level support teams and outside professionals could assist in changing teacher practice.