The invisibility of anxiety in young,traumatised South African children

Abstract

The high prevalence of anxiety in young traumatised children has been well established in literature. However, the body of literature that explores how anxiety manifests in classroom settings in the South African context is still growing. The ways in which it presents at the personal level for individual children, in particular, need to be examined in greater depth. The current study posed the question, ‘How does anxiety manifest in young, traumatised South African children in classroom settings?’ The researchers adopted an interpretive phenomenological approach and used a combination of intervention and vignette research. Data were collected from individualised, intuitive, and integrative psychotherapeutic processes. Primary participants (n = 5) ranged in ages from 8 to 14 years, while secondary participants included parents and teachers. An analysis of parental and teacher interviews as well as vignettes for each participant revealed high levels of anxiety invisibility in classroom settings for all the study participants. This finding was triangulated from the teacher interviews, parental interviews, therapeutic engagement, and vignettes. The study identified the need for capacity development in teachers in terms of mental health and wellbeing, and recommended that additional support mechanisms be provided for young, traumatised children suffering from anxiety.

Children with a history of trauma typically suffer from at least one anxiety, or from an additional mood or behaviour disorder (Brink & Wissing, 2012; DePierro et al., 2019). Moreover, affected children frequently exhibit difficulties in self-regulation across various areas (e.g., emotional, behavioural, mental, intellectual, and relational). They frequently display deficient bonding, anxiety, mood swings, substance abuse difficulties, an inability to focus, impulsivity, persistent medical issues, and poor academic achievement (Abraham et al., 2022; Brink & Wissing, 2012; Cook et al., 2005; DePierro et al., 2019; Spinazzola et al., 2018; Sunderland, 2020). Fernandes and Osório (2015) suggest that childhood trauma is associated with various negative adult outcomes and warn that negative childhood experiences can permanently affect an individual’s life. Traumatic experiences may typically involve physical, emotional, or sexual abuse; detachment from a primary caregiver; domestic violence; and widespread trauma. Such events can promote and reinforce inadequate and negative self-beliefs, and may result in higher anxiety levels in response to new stressors. This increases the likelihood of developing an anxiety disorder (AD), panic attacks, generalised anxiety, and social anxiety disorders.

Epidemiological research

Epidemiological research on the prevalence and impact of mental health disorders among South African children and adolescents should be expanded significantly. According to Flisher et al. (2012), the prevalence of anxiety disorders specifically is estimated at 17%, with generalised anxiety disorder being the most prevalent. A relationship was found between exposure to violence and mental health issues such as depression and anxiety (Flisher et al., 2012). Other traumatic events, such as exposure to abusive behaviour, loss, relationship difficulties, and psychological and social pressures, have also been linked to mental health issues troubling the South African population (Skeen et al., 2022). Results from the South African Depression and Anxiety Group (SADAG) (2018) show that 17% of children and adolescents suffer from anxiety that hinders them from living their lives, and in 2017, 16.5% of South Africans suffered from prevalent mental disorders such as depression and anxiety. One third of adolescents and children experience a mental disorder at some point during their lifetime. Anxiety disorders constitute the most prevalent mental illness among children and include childhood overanxious disorder and separation anxiety disorder.

According to research by Schmitt (2019), anxiety is on the rise among elementary school children, but indications are that they can overcome it with appropriate support. Support from other professionals is essential for empowering educators to maintain strong, supportive relationships with traumatised children and to manage their classroom behaviour. Phasha (2008) suggests that the question in the South African context is how traumatised children can be supported optimally.

Practitioners and researchers working with young children consistently contribute to understanding trauma and childhood mental health. Kaminer and Eagle (2010) admit that South African trauma intervention models have been created, but argue that significant information gaps still exist.

Problem statement

There is a need for more studies on childhood anxiety and trauma to be conducted in the African and South African context. Above and beyond gathering statistics, it is important for researchers and practitioners to understand the ways in which anxiety manifests at a granular level in the lives of individual children to optimise the efficacy of support interventions.

Method

This study was conducted in Fairland, Gauteng, South Africa, at a public primary school with approximately 1200 students and 71 teachers. The research took place in a therapy room at the primary school and a private practice in Honeydew. Both therapy settings were situated in safe areas and furnished to accommodate a range of children served by educational psychologists.

Aim of the study

The study aimed to explore how anxiety manifests in young traumatised South African children. To be able to identify how anxiety manifests in young traumatised South African children, we conducted an interpretive phenomenological study using vignettes as a descriptive and narrative structure.

The research question

The research question that guided the study was, ‘How does anxiety manifest in young, traumatised South African children in classroom settings?’

Participants

The primary participants included five children, their parents, and their teachers. The children were from different grades and were aged 8, 9, 10, 11, and 14 respectively. Children with possible symptoms of anxiety were identified with the help of their teachers who used a basic screening questionnaire formulated by a group of professionals at the school (site of study). These professionals consisted of psychologists, occupational therapists, remedial teachers, and speech therapists. Subsequently, a full emotional assessment and a background interview were conducted by a registered educational psychologist to screen for trauma. The emotional assessment included the Draw-A-Person (DAP), the Draw-A-Person-in-the-Rain Test (DAP-R), and the Kinetic Family drawing. In addition, emotions were also identified and assessed through a facilitated drawing activity in which emotions were drawn, explained in terms of causality, and ranked in order of frequency of occurrence by each participant. Trauma markers included acrimonious parental divorce, high conflict marital relationships, loss of significant others, parental illness, disruption in schooling due to Covid-19, and having to nurse both parents during the Covid-19 pandemic. Participant names were anonymised. Participants who did not meet the selection criteria for trauma still received intervention from the psychologist who conducted the emotional assessments.

Instruments

Data were collected during individually tailored interventions wherein an intuitive approach towards implementing integrative psychotherapeutic techniques was designed for each participant. In other words, other than some selected psychotherapeutic techniques, no specific intervention programme was formulated before the intervention period started. The intervention process was semi-structured and accommodating. It needed to be open and flexible due to the different forms of anxiety presenting and differences in the participants’ specific needs during the therapy session.

Every session adopted a format that contained the details of each participant and their presenting problem, followed by the specific theme, goal, activity, specific materials, or instruments needed during the session. At least 10 sessions were scheduled per participant, with an additional one or two sessions, depending on the child’s specific needs. The intervention sessions consisted of drawings, semi-structured and structured questionnaires, observations of the children, artefacts, field notes, and video recordings of each assessment and therapy session (Finlay, 2012). An emotional assessment of the identified children was made to gain in-depth insight into their anxiety (Van Manen, 2016a). Vignette data were collected during the interventions and classroom observations. Parental and teacher interviews were conducted, and voice recordings were made of the classroom observations and interviews held with the teachers.

To increase our understanding of the complexities during a therapy session and what arose in the classroom, vignettes were crafted for each participant. Vignettes serve the dual purpose of magnifying individual experiences while providing insights into the specific phenomenon under study.

Procedure

The study commenced in February 2021 when teachers were asked to identify learners with anxiety symptoms by means of administering a basic screening questionnaire. The questionnaire was formulated by a group of professionals at the school consisting of psychologists, occupational therapists, remedial teachers, and speech therapists. The screening questionnaire covered various areas of development, including psychological, occupational, speech, and remedial challenges that the learner might encounter. For this study, we focused on the psychological wellbeing of the child and possible psychological challenges they might encounter.

The parents of three of the five participants reported that their children had anxiety and reported it to their class teachers for support and to ask for referrals. The teachers used the screening questionnaire to identify all learners with possible anxiety symptoms. The psychological part of the questionnaire gathered information on interpersonal, behavioural, and socialising skills to assist teachers in identifying learners displaying the following possible anxiety symptoms:

• Low activity levels – passive class participation or apathy

• Tearful, anxious, or afraid

• Shy, withdrawn, or apathetic

• Excessively active or noisy in class

• Low frustration tolerance or angry outbursts

• Teased or bullied, or he or she teases and bullies others

• Ineffective socialisation with peer groups

The above symptoms were linked with the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 476) symptoms that specify diagnostic criteria for 300.02 (Generalised Anxiety Disorder):

• Excessive anxiety and worry (apprehensive anticipation), occurring on most days for at least 6 months, about various events or activities (such as work or school performance).

• The individual struggles to control their anxiety.

• The anxiety or worry is accompanied by at least three of the following symptoms (with at least some symptoms present for more days than not, for the past six months): [Note: Only one item is necessary for children.]

• ii. Being quickly exhausted

• iii. Trouble concentrating and a blank mind

• iv. Irritability

• v. Muscle tension

Sleep disturbances (difficulty falling asleep or staying asleep, or restlessness) are common.

Anxiety and worry are not restricted to features of an Axis 1 disorder. For example, anxiety and worry are not about having a panic attack (as in panic disorder) or being embarrassed in public (as in social phobia).

The anxiety, concern, or physical symptoms cause clinically significant impairment or distress in important social, occupational, or other areas of functioning.

The disturbance is not caused by the direct health consequences of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism), nor is it unique to a mood disorder, psychotic disorder, or pervasive developmental disorder.

If the teacher identified a child with a potential anxiety challenge or anxiety-specific need when completing the child’s screening questionnaire, the screening form was given to the parents, whose responsibility it was to respond to the request from the teacher and to give their written consent for further intervention. The emotional assessment to identify the most critical cases then commenced. As stated, the emotional assessment used drawings as projective techniques accompanied by semi-structured questionnaires for the parental interviews. Participants were selected equitably and gave every child, regardless of age, gender, language, race, context, or socioeconomic status, a fair opportunity to receive the necessary support. All relevant ethical considerations were explained to the participants, after which interviews were scheduled at convenient times for all parties involved.

The assessment and intervention with the five children took place once a week for 8 to 10 weeks. During the intake and the feedback session, open and semi-structured interviews were conducted with the parents. Open and semi-structured interviews with the teachers were also conducted at the beginning and end of the sessions with the children. The emotional assessment took place within the first 4 to 5 weeks. The intervention process occurred between Weeks 6 and 10, involving various positive psychological and psychotherapeutic techniques. The initial data collection during the intervention sessions comprised drawings, semi-structured and structured questionnaires, observations of the children, artefacts, field notes, and video recordings of each assessment and therapy session. The vignette research allowed a member of the research team to co-experience teaching and therapeutic situations in and out of a classroom and therapy room. The vignette researcher thus tried to capture learning or therapeutic experiences as authentically as possible, describing one moment in time. It was about pausing, creating an atmosphere, creating a new awareness, sensitising participants, making the invisible visible, and paying attention to time, space, and body language (Eloff, 2020).

The observations from the therapy room were supplemented with field notes and video recordings of every session. During classroom observations, voice recordings were made. The participants were observed in the transformation of their experiences of actual situations as they underwent therapy.

An emotional assessment of the identified children was made to gain in-depth insight into their anxiety (Van Manen, 2016a). By using the phenomenological approach, the ways in which anxiety resulting from trauma presents as a phenomenon for these participants could be investigated. Phenomenological research includes visual methodologies like art in the form of drawings, creations out of clay, paintings, and photos within an unstructured interview context that permit children to articulate their lifeworld experiences in meaningful and original ways. (Finlay, 2012).

Concomitantly, a set of raw vignettes was written for each participant. The raw vignettes were presented at resonance readings and finalised based on the feedback from the resonance reading groups. Resonance reading groups consisted of other health professionals, parents, and teachers.

Ethical considerations

The study obtained ethics approval (EDU207/20) from the University of Pretoria, and all participants provided informed consent and assent.

The study aligned to ethical conduct in research as outlined in the Terre Blanche and Durrheim’s (1999) statement, which stipulates that moral concerns should be integrated with the planning and execution of research. The foremost principle in research is the best practice interest, which includes the participants’ safety and wellbeing. Participants in this study were asked to provide written informed assent. The parents and teachers participating in the study also provided informed written consent. Detailed ethical consent forms were provided to secondary participants to make rational, consensual, and informed decisions about their potential participation.

Aspects such as the research goals, the nature of the assessment and intervention, and the credentials of the researcher were explained to the children in understandable language and at their level (McMillan & Schumacher, 2014). It was essential to be aware of the ethical challenges posed by the research because of the researcher’s emotional and personal involvement in the study (Sanjari et al., 2014). The researcher committed to upholding the impartiality and autonomy of all participants. The voluntary nature of participation allowed participants to withdraw from the process at any point without penalty or repercussion (Aggarwal & Gurnani, 2014). This was explained to each participant at their specific level of development.

In terms of the ethical agreement, participants could choose not to respond to a question or participate in an activity presented. They were reminded of this throughout the entire process, and yet there were no withdrawals from primary or secondary participants in the study. The ethical requirement of confidentiality demanded that the identities of all individuals involved and any gathered information or data be sorted and compiled to preserve their anonymity and privacy.

Data analysis

The data analysis was conducted based on the interviews with the parents and teachers, and the vignettes of the child participants. To interpret the data from a place of empathy, the researcher aimed to be objective when interpreting the data, to stay truthful to the information and to remain true to what it revealed (Holland, 2014).

Audio recordings of interviews with both parents and teachers were transcribed and analysed using Van Manen’s (2016b) six interactive approaches for interpretive phenomenological inquiry and data analysis. These included locating the researcher to the phenomenon of interest and elaborating on presumptions and preconceived notions; investigating life experience as obtained through informal discussions rather than as we truly understand it; trying to reflect; performing thematic analyses that define the phenomenon; analysing through dialogues; and explaining the occurrence through the procedure of repetitional writing (rethinking, reflecting, recognising) to generate in-depth understanding (Leone et al., 2013).

Results

The study revealed high levels of anxiety invisibility at school for young traumatised children. Evidence of invisible anxiety emerged across all the data sets, prominently in all the teachers’ interviews and in some parental interviews, as illustrated in extracts from their interviews.

In the first section, it is clear from the teachers’ interviews that the anxiety the parents referred to was not ‘visible’ to the teachers.

Teachers’ interviews

• There are no actual signs of anxiety that I notice in him. (Interview 1, Pieter’s teacher, line 11)

• Not at all, no anxiety. He speaks comfortably in front of the class. He plays with all the mates. (Interview 1, Pieter’s teacher, line 17)

• Then he can tell me exactly what to do without any signs of anxiety. (Interview 1, Pieter’s teacher, line 44)

• I have never even experienced her nearly aggressively or anxious. Not at all, I cannot see it in her either. (Interview 2, Doné’s teacher, line 39)

• I’m Pieter’s remedial teacher. He comes to me twice a week for extra help with schoolwork. I do not experience that he is anxious with me. He acts spontaneously and shows confidence when he does the work. (Interview 3, Pieter’s remedial teacher, line 1)

• I was shocked when the mom told me they were struggling with anxiety at home with Karné. (Interview 3, Karné’s teacher, line 2)

• So, when the mother told me there had been problems with her at home, I could not believe it. (Interview 4, Karné’s teacher, line 14)

• Well, if she’s anxious, she’s hiding it well. She stands . . . she speaks . . . she speaks a little softly, but most girls speak a little softly. She talks nicely, she holds her speech cards nicely. She actually looks comfortable. Sometimes with the girls, I see they are a bit tense, because they are holding their dresses. (Interview 1, Karné’s teacher, lines 36–40)

• His attention can sometimes wander a bit and sometimes he struggles to organise his table, but emotionally he is doing very well, not that it has ever been a problem in class with him. (Interview 3, Pieter’s teacher, line 5)

The parents confirmed that the teachers did not observe visible symptoms of anxiety in their children. This is illustrated in the following extracts from the parents’ responses.

Parents’ interviews

• But his teacher also tells me that he functions very well in class. He gets his work done. He talks with his friends in class. (Interview 1, Pieter’s mother, line 156)

• In other words, when he experiences stress, he can handle it well. You do mention that he will “vomit” at home, but when he comes to school, he handles it very well. His teacher does not notice anything. Really!! Are you serious? I cannot believe it! (Interview 2, Pieter’s mother, line 225).

• Was he anxious in the class when he had to do his speech? Not at all! (Interview 2, Pieter’s mother, line 460)

• Behavioural problems at home, yes. Not at school at all. People think I’m crazy when I’m struggling with her at home. The previous therapist said that there is an underlying fear. (Interview 1, Karné’s mother, line 119)

• It feels to me like people think I’m totally cuckoo. No one sees this stuff except us at home. She does everything at school one hundred percent. (Interview 1, Karné’s mother, line 665)

• No not at school, the teacher has not yet mentioned anything about anxiety or anger outbursts at school. She’s just struggling with her schoolwork. At home, yes, a lot. She was very aggressive until my dad put a punching bag on for her so she could vent her emotions on it. (Interview 1, Doné’s mother, line 327)

Vignettes

This invisible anxiety is also present in relevant vignettes that were developed during the course of the study. The anxiety is illustrated in the following three vignettes, which were developed on the basis of observational data during classroom visits. The vignettes confirm the absence of visible signs of anxiety in the school context.

Third vignette, Pieter – 28 May 2021, Session 5. Phenomenon: Subjective wellbeing

It’s a winter morning at my school. The morning sun peeks through the classroom window while we just came to sit down after the break. I get the smell of sandwiches still hanging in the air. I hear the noise of tables as the children sit down at their seats. The friends are still talking about the excitement of the break and then my teacher says that we should sit in our seats and calm down because in a minute or two she will start listening to our speeches. I try to whisper one last word to my friend before it suddenly becomes very quiet in class. We each now get busy with our work while the children give their speeches, and we sit quietly and listen. Some of us are learning spelling for the next day and others are sitting and reading. Then the teacher calls my name to do my speech. I get up very excited from my chair and with my furry dinosaur mask on my face I step forward and stand in front. I peek in Aunt Jani’s direction just to make sure she’s watching and listening too. She is. Then I smile and look down with a shy laugh before I start. The teacher says that the friends who speak can take off their masks so that she can hear us clearly. I pull my mask up to my chin and tell the class about my pet puppy ‘Snoekie’. While talking lovingly about my puppy, I quickly peek in the direction of Aunt Jani again. She smiles kindly at me because she can see that I enjoy every moment. I end my speech by showing pictures of my puppy, and each child responds with an aah or oee or so cute! It makes me happy when my friends react like that. I think Aunt Ingrid and my teacher can see the happiness on my face! When I finish, my teacher compliments me on my beautiful speech and here and there a child also agrees. While the rest of the children continue their speeches, I take out my books and quietly write down my spelling words and learn them. Every now and then I look up, nod my head as I listen to the speeches and then I get busy with my ruler. After the last child has spoken, one of my friends walks up to Teacher’s table and says that he has just pulled his tooth. The teacher says that he has to wrap his tooth in a piece of tissue and take it home so the tooth mouse can come and visit. When Teacher instructs us to take out our reading cards and reading books, I do so immediately. I suddenly rub my eyes and quickly stretch my one arm in and out. Then Teacher says we should open our workbooks and write the date. She starts by asking what type of farm animals one finds on a farm. We each call out a different kind of animal. The class becomes restless and a boy shouts from behind, ‘Shoot!’ Teacher says, ‘Guys, listen to me now, quickly put down everything in your hands for me. Where should your eyes be’? We shout, ‘On the board!’ Teacher says she is doing revision to help us because we are now going to have to write sentences. Then she asks, ‘What do you call a male horse and a female horse’? The children answer excitedly: ‘A stallion and a mare!’ When she asks what one calls a female chicken, I raise my hand and reply, ‘A hen, Teacher’. Teacher is impressed with my quick answer and says, ‘Mooi, Pieter!’ We all sound cheerful and it’s really fun in our class! Lastly, teacher asks what you call a baby horse. Then she asks if I know the answer, and I answer, ‘A filly!’ Teacher says that the class should clap their hands for me because I remembered so beautifully. I smile proudly.

Vignettes present an experience from the perspective of the other. The vignette above presents an experience of excitement, spontaneity, and contentment. It was evident that Pieter enjoyed every moment while performing his speech. After the speeches, he also participated in the class discussion about farm animals. Even though this vignette presents an interpreted version of his classroom experience, the invisibility of anxiety reported by the study’s teachers is confirmed in the depiction of his behaviour.

Third vignette, Karné – 26 August 2021. Class visit. Phenomenon: Subjective wellbeing

It’s a cold Thursday morning and Aunt Jani walks into our class right after break. She’s coming for a class visit today. The kids in the class are also excited to see her, and everyone greets her kindly. My teacher is also very kind to her and introduces her to the class. The friends cannot wait to recite their poems in front of the class. As this is my first time performing in front of Aunt Jani, I am a little anxious. I step in and immediately sit down at my table. I take my books out of my suitcase and then keep a close eye on Aunt Jani. Every now and then she looks in my direction and then winks at me. I feel a bit shy and then rather look down. Every child now sits at his place, and it becomes quiet. Then the teacher starts calling children forward to recite their English poems. Some children bring props, and some do not. I also did not bring anything with me. I do not think it is necessary because I know my poem well enough. Some children know the words fluently and others struggle, and then my teacher helps them. We laugh because some children brought nice props. While listening, I play with my fingers on the table. I rather do not look at my teacher or Aunt Jani, because I know it’s almost my turn to stand in front. Every now and then I peek at Aunt Jani and then look away. Suddenly the teacher calls me forward. I get up quickly and step forward. I stand against the class board with my hands behind my back. I look straight ahead and start speaking expressionlessly. Fortunately, I know my words well. I do not look left or right. I say my poem and walk back to my desk. As I walk back, the class claps hands, and Aunt Jani and my teacher complimented me on a good effort. I quickly look in their direction and give a slightly shy laugh before I sit down. I focus intently on the work in my book. I feel Aunt Jani’s eyes on me. I look up again and she points a thumbs-up in my direction. After everyone has spoken, Aunt Jani congratulates us on our performances and says that we were very sweet. When she gets up to walk out, one of the girls in the class comes up to her and gives her a bright pink shiny beaded necklace that she used as a ‘prop’ in her poem. Aunt Jani looks surprised and thanks her for the gift. I’m glad Aunt Jani came to visit and especially listened to my poem!

When reading the above vignette, the reader can sense Karné’s slight nervousness. However, it can be argued that it is normal to feel a bit exposed and nervous when performing in front of the class and that the experience does not depict anxiety. The vignette does, however, indicate that there is a sense of excitement in the air. Interview 1 with Karné’s teacher (lines 36–40) which underpins the vignette, also showed that the teacher could not observe any severe feelings of anxiety during Karné’s performance.

Fourth vignette, Doné – 16 September 2021. Phenomenon: Subjective wellbeing

Today Aunt Jani comes to visit the class. I feel a little nervous, because I do not know what to expect. When she walks in, she greets the class kindly and sits down at the table right next to mine. My teacher suggested it because she says then Aunt Jani can keep a good eye on the class, and on me of course. I greet her kindly behind my mask and sit down immediately. I take out my books and the teacher says that we must open our books because she wants to see if we have done our homework. My work is done neatly. Aunt Jani glances quickly at my book and smiles. I smile back. The teacher walks through and stops for a moment when she comes to me, looks at my work and then nods her head as a sign that she is satisfied. The class goes on quietly as if no one is visiting us. We are now wearing our summer clothes again. I am neatly dressed with a tight ponytail on my head, rounded off with a black mask. My appearance looks as neat as my book. As we mark the work, the teacher asks the children to read their answers aloud. I know she’s going to ask me soon because Aunt Jani is sitting here. My mind is not yet cold from the thought, and she asks me. Luckily, I know my answer is correct and I read it with confidence. The teacher says thank you and continues. Aunt Jani smiled quickly in my direction. It feels quite nice, and I smile back. After marking the language work, we begin to discuss the poems and mark the work we also got for homework. The teacher works quickly and is sometimes a little impatient if the children do not give their answers soon enough. Then she simply answers on their behalf. It makes me a little nervous. ‘Oh no! She’s asking me!’ I give my answer, but it’s not right. She asks the question in a different way. While I am still hesitating, she calls out the answer. I feel a little embarrassed because Aunt Jani’s eyes are on me now. She smiles reassuringly. It’s not nice. Next time I will have to answer right. Luckily, the air conditioning in the class is on which cools me down a bit, as I can feel the heat rising against my neck. When the teacher asks me the last question, I am ready and answer with certainty. Teacher answers: ‘Very good answer Doné!’ I blush a little, but now I feel better! When the bell rings for the second Afrikaans period, Aunt Jani stands up and says that we are a very well-mannered class that works very well together. She smiles at me and then greets the class and walks out. It is nice that she came to visit!

From the above vignette, it is evident that Doné composed herself very well when the teacher asked her the first question and she could answer it correctly and with confidence in her voice. When Doné answered the second question incorrectly, she stayed calm until she answered the last question correctly. As illustrated in this vignette, the theme of ‘Invisibility of anxiety at school’ is substantiated across the data sets of this study.

Discussion

It can be deduced that the invisibility of anxiety at school makes it very difficult for teachers in a classroom context to identify children with anxiety or to respond to their needs. This challenge may also lead to inappropriate referrals (Cvinar, 2010). Therefore, it is crucial for future research to investigate how teachers define anxiety and to raise awareness when children’s anxiety becomes excessive. In this study, the teachers did not identify three out of the five participants who were experiencing anxiety. This may be because the symptoms of anxiety are not always recognisable or because of how children present behaviourally in class. Headley and Campbell (2013) suggest that because these children are typically well behaved and may internalise symptoms of anxiety, teachers fail to recognise the manifestation of anxiety. Therefore, early mental health intervention and teacher training in children’s psychological health are essential tools to maximise positive outcomes for children.

Prior to making a referral, a challenge must be identified. Teachers play a crucial role in identifying children with mental challenges. According to Reinke et al. (2011), 75% of teachers who were surveyed about their contribution to promote children’s psychological wellbeing in schools had worked with and referred children with mental health challenges within the past year. In their framework of defining the variables that influence how children with psychological challenges obtain psychological care, Stiffman et al. (2010) identified these educators as entry-point suppliers: non-mental-health professionals who direct or initiate treatment access. Despite their crucial role in assisting children and supporting their right to receive psychological support, classroom teachers rank recognising and comprehending children’s mental health challenges as among the top three areas for which they require training (Narainsamy et al., 2024; Reinke et al., 2011).

There is a particularly pressing need to equip teachers to identify psychological health challenges in the classroom. The invisibility of anxiety in children at school highlights the need for support services to be established at all district levels in South Africa. A school-based support team (SST) must be established where educational psychologists and other professionals can provide support services to children, teachers, and parents. This team will act as a link with district support services. The appointment of suitable personnel, the active solicitation of advice, and the presentation of workshops and in-service training will help to accommodate all children with learning difficulties and psychological challenges (Babatunde et al., 2020; Donald et al., 2014; Kajtaz, 2020; Taipale, 2016). Psychologists and other professionals should be trained to work with teachers in supporting children with anxiety in the classroom. In addition, tailored workshops for educators and parents on wellbeing interventions for children can be developed. Workshops for parents can focus on teacher-parent engagement and how to support children with anxiety as they negotiate the various educational spaces in their lives.

In addition to capacity development in educators and health professionals, the range of coping skills for children with anxiety who have experienced trauma can also be strengthened. By expanding coping skill repertoires at the individual level during childhood, children may potentially be equipped with lifelong strategies to deal with anxiety.

Limitations

While this study clearly suggests the need to develop teacher capacity for dealing with invisible anxiety in children in their classrooms, it should be noted that a danger exists of teachers over-reacting in terms of their supportive role. In this regard, the roles and responsibilities of health professionals in relation to teachers should be clearly delineated. A further limitation of the study is that the data for this study were collected through teacher interviews, parental interviews, and vignettes. While interviews can provide in-depth data, their inherent subjectivity is acknowledged. Vignettes, in turn, are highly individualised, but they can potentially bridge subjectivity in that they report from the perspective of the other (Agostini et al., 2024). Finally, this study was conducted within a bounded system, and therefore its findings cannot be generalised to other settings.

Conclusion

This study elucidated a disjuncture between the high prevalence of anxiety in young traumatised South African children, and the low levels of visibility of anxiety in classroom settings within the same population. The study presented a call for increased screening procedures for anxiety at school level, a need for capacity development in teachers, as well as the need for expanded support mechanisms for young, traumatised children with anxiety.