School Counselor, That's Not Anxiety. Here's How to Prove It.

In this episode, I’m challenging a common habit in school counseling: labeling student distress as “anxiety” before it actually meets clinical criteria.

You’ll hear the research behind "prevalence inflation," how DSM standards separate normal worry from clinical anxiety, and the four-question test that will change how you approach 504 plans, school refusal, and all your anxiety-related counseling referrals.

Because when we mislabel discomfort, exclusion, or instability as anxiety, we don’t just miss the root issue. We build an entire intervention around the wrong problem.

Run the four-question test before you write the accommodation.

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All names, stories, and case studies in this episode are fictionalized composites drawn from real-world circumstances. Any resemblance to actual students, families, or school personnel is coincidental. Details have been altered to protect privacy.

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This work is part of the School for School Counselors body of work developed by Steph Johnson, LPC, CSC, which centers role authority over role drift, consultative practice over fix-it culture, adult-designed systems and environments as primary drivers of student behavior, clinical judgment over compliance, and school counselor identity as leadership within complex systems.

Transcript

The Anxious Fifth Grader Setup

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Picture this. You're sitting in a student support team meeting. The teacher is there, parent, assistant principal, and you're talking about a fifth grader. We're gonna call her Josie. The teacher opens the meeting the way these things almost always start. She's really anxious. She won't raise her hand in class. She gets stomach aches before math tests. She asks to go to the nurse every time we do group work. And she started saying that she doesn't want to come to school. And you watch every head in that room start nodding. The parent nods, the AP nods, you nod, because everyone heard the word anxious. And everyone thinks they know exactly what they're dealing with, and exactly which person in that room needs to jump into action. That's you, by the way. Every eye in that room just landed on you. So what do you do? You might start talking about accommodations, safe passes, a check-in schedule, maybe a calming down area. And if you listen to last week's episode, you already know where that road leads. Those are exactly the kinds of avoidance-based accommodations that research says can strengthen anxiety when it's truly present. But here's what I want you to consider. Even if you had designed the perfect plan, you still might have been wrong. Because nobody, not one person in that room, including you as the school counselor, stopped to ask the question that should have come first. Does this student actually have anxiety? Or is there something else going on that nobody's even considering? I've been in that exact meeting. And the framework I'm gonna walk you through today is the one I built because of it. Hey there, school counselor. Welcome back. Last week's episode on anxiety accommodations changed how a lot of you were thinking about your 504s. But here's what's been sitting on my heart. What if we mislabel it in the first place? Wrong label, wrong plan, wrong outcome. And a student carrying a label that never belonged to them. Today I'm gonna give four questions I now ask before I call anything anxiety. So if you're ready for some straight talk, my friend, some clarity on your work and maybe a little bit of rebellion, you are in the right place. I'm Steph Johnson, and this is the School for School Counselors Podcast. All right, so before we dive in, I have to tell you something. The response to last week's podcast episode has been unlike anything that I have seen in over a quarter million downloads so far. My inbox, my DMs, my mastermind community were just exploding. And all of you got fired up in the best kind of way. That response tells me that we're on to something that our profession needs to hear. So thank you for that. And if you haven't listened to that last episode yet, go back and start there because today is going to build directly on it. Last week was, does the accommodation help them do the thing or avoid the thing? This week is, are we even sure the thing we're addressing is anxiety? All right. Let me set this up because these four questions did not come out of nowhere. I did not dream them up in the drive-thru line at the Dunkin' Donuts. They came out of a problem that I started seeing everywhere once I knew to look for it. Normal worry is real. It's expected and it's developmentally appropriate. Separation fears in early childhood, fear of the dark at five and six, school performance worries in elementary, social evaluation fears in middle school and high school. Y'all, that's not pathology, that's typical development. For example, a study in the Journal of Abnormal Child Psychology found the most common worries in kids ages 7 to 12 or school, health and personal harm. Now, if a student told you that, that they were worried about school, health, and personal harm, you'd think anxiety, wouldn't you? But these are the most common worries for every kid in that age range. And here's where it gets complicated. Two researchers, Lacey Falkes and Jack Andrews, published a paper in 2023 introducing the prevalence inflation hypothesis. The basic idea was this: mental health awareness campaigns improve recognition of genuine disorders, but they also lead some young people to interpret normal distress as clinical anxiety. Our students are scrolling TikTok where our creators diagnose anxiety from a list of five symptoms. I believe that I have true blue anxiety. Then when I feel nervous about a test, I don't think this is normal nervousness. I think my anxiety is acting up. And what do you do when your anxiety is acting up? You avoid, you make excuses for yourself. And then that avoidance makes the next situation harder, which confirms the label. The label creates the behavior, the behavior reinforces the label. Y'all, we are running anxiety awareness groups for kids who are already primed to over-identify with the symptoms. Now, this is not an argument against awareness, it's an argument for precision. Falks herself doesn't say pull back. She says help young people understand the difference between a normal emotional response and a clinical condition. And that's exactly what my four questions are designed to do. But before I walk through them, let me just say one more very important thing. I'm going to reference the DSM a couple of times. And some of you are going to be thinking, I don't diagnose. That's not my role. And you're right, it's not. But I'm not going to be asking you to diagnose anyone. Here's what I will ask. The DSM is the clinical standard for what anxiety actually is. It denotes the line between this is a clinical condition and this is a normal human experience. And every time we use the word anxiety about a student in a meeting, on a referral, in a 504 plan, or in a small group, we're making a little bit of a clinical claim, whether we realize it or not. We are saying that this student's experience crosses that line. So if we're going to use clinical language, we should at least understand what the clinical standard actually requires. Not so that we can diagnose, but so we can be precise about what we're seeing before we build a plan around it. And that starts with a distinction that I think a lot of people forget to say out loud. There is a difference between having anxiety and feeling anxious. Having anxiety is a clinical condition. It's persistent, it's pervasive, it shapes how a student moves through the world. Feeling anxious is a temporary emotional state. It's a response to something specific and it resolves. Every human being on the planet feels anxious sometimes. That doesn't mean that every human being has anxiety. But right now in our schools, we're kind of treating those two things like they're the same, and they're not. So we're not talking about this idea of you treating generalized anxiety disorder. Okay. But what we are talking about is whether or not you've confirmed that what you're looking at is actually anxiety before you intervene, like it is. That's all these four questions are. Okay. Just a way to check before you act. So, question one: is this showing up across settings or just in one? Clinical anxiety tends to be pervasive. It bleeds across different settings. A student with generalized anxiety isn't just anxious in math. They're anxious at home, at practice, at the dinner table, or in the car on the way to school. So when a teacher tells me a student is really anxious, the first thing I want to know is, is this everywhere? Or is it just right here? Because a kid who's only struggling in one class with one teacher doing one type of activity, that's not a picture of generalized anxiety. That's a picture of something specific happening in that environment. And the list of the things that could be is pretty long. A skill deficit they're embarrassed about, a social dynamic in their seating group, a sensory issue with the room, a conflict with the teacher, a transition they haven't adjusted to, something happening at home that only services under pressure, and on and on and on. None of these are anxiety. All of them look like anxiety if you're not asking this question. And this isn't just my opinion or instinct. The DSM V requires that anxiety shows up across a number of events or activities, not just one. If it's isolated to a single setting, the diagnostic criteria are already telling you to look elsewhere. Here's what I do now. When I hear this kid is anxious, I check with at least two other settings before I move forward. What does this look like in other classes? What do they look like when they're at lunch? At home? At recess? If the picture changes across settings, the label probably needs to change too. Question two. Does the reaction match the situation? This one is all about proportionality. And it's the DSM distinction I think that we tend to skip over the most often. The DSM 5 says the worry has to be out of proportion to the actual likelihood or impact of the anticipated event. That's not my interpretation. That's the diagnostic language. So when you're trying to decide if a student's reaction is clinical or situational, the DSM is telling you to measure the size of the response against the size of the stressor. A student who's nervous before a big state test, that's proportional. A student who's nervous before a presentation in front of their whole grade, proportional. A student who throws up every morning for two weeks before a routine spelling quiz, that's disproportionate. The size of the response relative to the size of the stressor matters. And here's where I think we've kind of gone off course in schools. We've gotten so attuned to student distress, which is a good thing, that we sometimes forget to ask whether the distress makes sense for the situation. The kid who cries their first week in a new school isn't having a clinical episode. They're having a completely normal human reaction to a genuinely nerve-wracking event. And what they need is not a coping plan. They need someone to say, yeah, that's scary. But you know what? You got this. I'll give you a really good rule of thumb for this one. If you describe the student's reaction to a colleague and told them what the stressor was, would they say, that makes sense? Or would they say, ooh, that seems like a lot? If it makes sense, it's probably not clinical anxiety. It's just hard. I had a counselor come to me for consultation once. She had an eighth grader who had great grades, good friendships, no history of any real concerns. But one day he started refusing to go on the cafeteria, just flat out refuse to go. So the teacher says, Well, he's anxious. And the school counselor's first instinct was to look for the situational explanation. Is somebody messing with him? Is there a social issue? Did something happen in the cafeteria? But no, nothing. The cafeteria was fine. But then she found out through some more investigation that he'd also stopped wanting to go to his uncle's house. He started avoiding car rides and he'd been checking all the locks on the front door before bed. The reaction didn't match any single situation because it wasn't about a situation. That was anxiety. And the proportionality question is what flagged it, because the response had detached from any identifiable stressor and had kind of taken on a life of its own. Question three: Does it resolve when the stressor resolves? This is the persistence test. And this is one that I wish I had known to use years ago. The DSM requires anxiety symptoms to be present more days than not for at least six months before it meets criteria for generalized anxiety disorder. Six months. And the stress research backs this up. Shankhoff's work at Harvard Center on the Developing Child shows that a healthy stress response is designed to return to baseline once the stressor is removed. When it doesn't, when the system stays activated even after the threat is gone, that's when we know we're talking about a different animal. Normal stress responses have an off-switch. The test is over, the kid bounces back by lunch. The friendship fight gets resolved, and the stomach aches stop. The recital is done and they're fine the next day. That's the stress response doing exactly what it's designed to do: ramping up for a challenge and then standing down. Clinical anxiety doesn't have a clean off switch. The test is over and they're already worrying about the next one. The stressor resolves, but the symptoms don't. Or new worries rush in to fill the space. That's what the DSM means by persistent. So here's what I ask. What happened after? If the event passed and the student reset, I'm a lot less concerned about clinical anxiety and a lot more interested in what made that specific situation so activating. If the event passed and they're still struggling days later, or they've moved on to worrying about something else entirely, now I'm thinking differently. This question also requires something that's way harder than it sounds. It is following up. We are good at catching the moment. We see the student in distress, we respond, we document, and we start building supports. But how often do we circle back a week later and say, is this still happening? Because if the stressor resolved and the student bounced back, that tells us something important. It tells us the system worked. The stress response did its job. And what looked like a clinical anxiety concern in the moment may actually have been a student navigating something hard and getting through it. I'll tell you where this question saved me recently. I had a student, primary grade, who was struggling to get in the building. And I don't mean dragging her feet. I mean physically fighting her mom at the car door. It looked severe, it looked clinical, it looked like school refusal. It felt very urgent, and every adult in that building was looking and talking to me like, what are you gonna do? But here's what I realized that they didn't. Her teacher had been out on maternity leave since the fall. And this student had been cycling through a parade of substitute teachers for months. So instead of jumping straight to a referral or a 504 conversation, I treated it like what it was: a stress response to an unstable environment. We worked on coping skills for the hard mornings. We built in some incentives to help push her through the door. And we developed consistency with other people on campus where we could. And notice that's a different intervention than what I would have used for clinical anxiety. I wasn't building a graduated exposure plan. I wasn't targeting avoidance patterns. I was helping a kid get through a temporary situation that was genuinely hard. I didn't do nothing, I just didn't label it. And when her teacher came back after Christmas break, the student was fine, completely fine, walking in the school building like nothing had ever happened. If we built a whole anxiety intervention around those car door moments, we would have pathologized what was actually a very valid concern for a primary grade student. She didn't have anxiety, she had instability, and her nervous system was telling her so. Question four. Is it impairing or is it just uncomfortable? This is a big one. And this is one that I think our profession has the most trouble with right now. Because somewhere along the way, we started treating discomfort like it's the same thing as impairment, and it's not. A student can be uncomfortable and still participate. A student can be nervous and still perform. A student can have sweaty palms and a racing heart and still walk into that classroom, sit down and do the work. That's not impairment. That's courage. And just like we talked about in the last episode, if we swoop in with accommodations every time a student is uncomfortable, we're teaching them that discomfort is a signal to stop, not a signal to push through. Impairment means they can't function. They're not sleeping, they're not eating, they're missing school consistently, their grades have dropped and they can't recover them. Their friendships have fallen apart. Their daily life has narrowed to the point where they're avoiding more than they're engaging. That's impairment. A student who doesn't want to give a speech is uncomfortable. A student who hasn't been to school in three weeks because they can't stop thinking about what might happen if they go, that's impaired. And those require fundamentally different responses. I've had to reckon with this in my own mind. Every time that I treated discomfort as impairment, I undermined that student's belief in their own ability to handle the hard things. I sent the message that I didn't think they could do it without a safety net. And that is the opposite of what I was trying to do. And the research backs this up. Michelle Kraske's work on inhibitory learning, and she's one of the leading exposure researchers in the world, found that the goal of exposure isn't to reduce distress, it's to increase distress tolerance. The student learns that they can feel uncomfortable and still function. That's the mechanism of change, which means every time we treat discomfort as a reason to pull a student out of a situation, we're not just being overprotective. We're actively interfering with the process that builds resilience. So let's go back to Josie and run her through these four questions. I told you at the beginning of this episode that I've been in that exact meeting. That is true because Josie was my student. And here's what happened when I finally slowed down and worked through these questions. Question one, is this showing up across settings? When I finally asked that question, the answer was no. Josie was fine in every other class. Fine at recess, fine at home. The distress was isolated to one setting, her math class, specifically during group work. Question two, does the reaction match the situation? On the surface, stomach aches and nurse visits seemed disproportionate for math class. But once I understood that the girls at her table had ostracized her, they'd stopped talking to her. And all of a sudden, that reaction made perfect sense. It was completely proportional to what was actually happening. It's just that we didn't know what was actually happening. Question three, does it resolve? Josie didn't worry about math on weekends. She didn't worry about school in general. The distress showed up on a predictable schedule. The days and times when she had group activities, that's situational. That's not persistent. Question four, is it impairing or uncomfortable? Josie was functioning everywhere else. She was doing her work, playing with friends at recess, participating in other classes. This wasn't pervasive impairment. This was a student trying to avoid one specific painful situation. Four questions, four answers that pointed away from anxiety and toward exclusion. Because that's what was actually happening. Josie would try to participate in group work. She'd offer an answer, and the other girls would talk right over her. If she pushed through and got the answer right, they'd mock her for it anyway. She wasn't avoiding math. She was avoiding humiliation. If we kept calling it anxiety, we might have accommodated her right past the actual problem with a safe pass to leave the room, which is exactly what the girls at her table would have wanted. Or we would have worked up this graduated exposure plan to group work that really wouldn't have fixed the root of the issue. Mislabeling leads to misintervention, which leads to reinforcement. That's the cycle. And it changes student identity over time. So here's the framework. Pin this thing to your wall, bring it to your next meeting. When somebody says, this kid has anxiety, four questions before you move forward. One, is it showing up across settings or just in one? Two, does the reaction match the situation? Three, does it resolve when the stressor resolves? And four, is it impairing or is it just uncomfortable? Or if you want it even simpler, if it's not pervasive, not persistent, not impairing, and not out of proportion, stop calling it anxiety. That doesn't mean the student isn't struggling. It just means that we need to respond to what's actually happening. And I know some folks are going to be thinking, okay, Steph, if it's not anxiety, then what do I do instead? The good news is you already know. If it's one setting, you investigate the setting. If the reaction makes sense, address the situation. If it resolved, document and watch. If they're uncomfortable but functioning, coach them through it. The framework doesn't just tell you what it's not, it points you toward what it is. And that's where your training and the art of counseling really starts to matter. Slow it down. Get curious and don't label it just yet. Because the wrong label doesn't just lead to the wrong intervention, it changes how that student sees themselves. And that is a very hard thing to undo. If you want this information in a format you can actually use, I've got a free action guide for this episode at schoolforschoolcounselors.com. Because knowing the framework is one thing, but actually implementing it, that is the harder thing, right? So go grab this for some quick on-the-fly reference. My friend, anxiety is real. Anxiety disorders are serious, and you are doing the important work by paying attention to your students' emotional well-being. None of that is going to change. But precision matters as much as compassion. Because when we call everything anxiety, the word itself starts to mean nothing. So this week, carry these four questions with you. And before you label anxiety, consider what else it could be. Because our students deserve more than just a generic label. They deserve the label that's right. And I'll tell you this: if we are this imprecise with a word as common as anxiety, a word that we probably use every single day in our buildings, if we're being honest, imagine what is happening with bigger labels. Labels like trauma. That conversation is coming, and it is another one we need to have. Now, if this episode is making you rethink how you approach anxiety on your campus, I want you to know this is the kind of work we're doing inside the School for School Counselors mastermind every single month. We go way deeper than what I can cover in a podcast episode. We look at the research, we look at the protocols, we have the conversations that nobody else in this industry is having. And in fact, we have an entire rethinking anxiety masterclass inside the mastermind that goes even further. You can check out all the details at schoolforschoolcounselors.com slash mastermind. You can join just for a month, explore what we've got, see if it's a good fit. I think you're gonna love it, and I'm gonna invite you to take that chance and see what it's all about. All right, my friend, I'll be back soon with another episode of the School for School Counselors podcast. In the meantime, your students don't need you to be fast. They need you to be right. The next time someone in your building says this kid is anxious, run the four questions before you run the intervention. Take care.