Today, being GAAD (Global Accessibility Awareness Day), I would like to share an article of mine that was published yesterday. The article is actually a slight modification of the full text at the request of the editor as the publication's focus is on Universal Design for Learning.
Here is the link to the published article:
Universal Design for Learning (pdf) from the Design for All Institute of India
The following is the full text of the article:
Living Afraid:Impacts of Anxiety and UDL with WCAG Solutions
By Valorie Sundby, CPACC, PCWA
Introduction
The day dawns bright with a clear sky and a warm temperature. Getting out of bed is easy. The night's sleep was restful and long enough. Waking up in a good mood is the best way to begin any day.
The dog pulls himself out from under the bed, his favorite place to sleep. He stretches, stumbles a bit and then limps over to say good morning. The limp is new. The endless stream of questions begins like water cascading over a cliff: What happened to him? How bad is it? Was it something I did? Did I not hear him in the night? Should I make an appointment with the vet? How can I fit a vet visit in to the day's schedule? Should I call in a PTO day? How much will this cost? What if it’s cancer? What if he needs to be put down?
The questions spiral down to ever-increasing depths of unfounded possibilities and settles into a full rolling boil of panic. Blood pressure rises. Heart rate soars. All this physical and mental reaction occurs before the dog even makes his way over for morning scratches. This is how the day may start for a person living with an anxiety disorder.
Anxiety Explained
The reaction in the introduction is called a panic attack – "an intense fear response to aroused sympathetic activity is manifested in the absence of actual danger." (Jieun E Kim, 2012). Panic attacks can happen to anyone and are estimated to occur in about 28.3% of the people at least once during their lifetime. (Jieun E Kim, 2012)
What happens to the body and brain in the introductory example is called an Amygdala Hijack. (Goleman, 1995) When a threat is perceived, the amygdala triggers a flood of stress hormones that are released into the body, the physical source of the elevated heart rate and blood pressure.
Most people learn to recognize and evaluate perceived threats and respond in more controlled methods. In the case of the dog, before reacting, one person may watch the dog's movements for a while to see if they persist; another person may bend down to examine the dog's leg closely for injury; another may dismiss the limp temporarily and file it away as something to consider at the end of the day (wait and see).
People with anxiety disorders, specifically Panic Disorder, may not have the ability to react in a controlled manner. "Unlike the general belief that ’cognition rules over emotion,’ there is evidence that emotion modulates cognition from perception and attention to higher domains of judgment and reasoning." (Jieun E Kim, 2012)
The frontal cortex in humans performs a function to sooth unwarranted fears. As children grow, they learn skills to calm anxiety. Studies of brain activity show that people who use self-talk in upsetting situations have an increased activity in the prefrontal cortex with decreased activity in the amygdala. The amygdala response does not go away completely. Even with well-practiced skills, when the cortex is otherwise occupied with other stress when a perceived threat arises, the Amygdala Hijack can come back at full-force. (Cain, 2013)
For people living with an anxiety disorder, the incidence of panic attacks may be frequent. The person may stay in a hyper-alert state anticipating the next attack. The panic attacks and hyper-vigilance both manifest in physical and mental reactions. The elevated heart rate and blood pressure may be accompanied by lowered cognitive ability, slower processing times, and slower reactions. Reading is slower. Understanding is slower. Deciding is slower. Reacting is slower. To compensate for the internal slowness, the person may speed up their physical movements. They may become clumsy, exhibit tics, or make repetitive motions.
Anxiety Disorder Defined
Anxiety disorders include GAD (Generalized Anxiety Disorder), PTSD (Post Traumatic Stress Disorder), OCD (Obsessive Compulsive Disorder) and PD (panic disorder), among others. Anxiety disorders may be mild to severe. Milder cases may not disrupt daily life but may require structure, such as the rituals of those with Obsessive Compulsive Disorder needing to have a perfectly tidy bath and bed room before leaving the house, for instance. Severe cases can cause the person to withdraw from daily social activities, impair work, and create major distress.
GAD (Generalized Anxiety Disorder) may be diagnosed when a person is unable to evaluate perceived threats properly and stay on high alert excessively." Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role." (Anxiety and Depression Association of America, n.d.)
OCD (Obsessive Compulsive Disorder) is an anxiety disorder where the person, over time, develops recurring and unwanted thoughts, ideas or sensations that cause them to do something repetitively (compulsions). These compulsions become persistent and rigid to the point that they disrupt daily life and cause great distress. (American Psychiatric Association, n.d.)
PTSD (Post Traumatic Stress Disorder) is an anxiety disorder caused by experiencing or witnessing a traumatic event. People with PTSD may relive the traumatic event through flashbacks or nightmares. The impact includes irritability, feelings of guilt (survivor’s guilt included), lowered ability to concentrate, and social isolation. Sufferers of PTSD may also develop insomnia. (NHS Choices, n.d.)
Panic Disorder (PD), though also not fully understood, is emerging to be associated with dysfunction of the hypothalamic-pituitary-adrenal axis. The amygdala, it has been suggested, may play a critical role. Panic Disorder is often accompanied by anticipatory anxiety, fear of losing control or sanity and other behaviors associated with fear. (Jieun E Kim, 2012)
Spectrum of Impact
It is easy to conceptualize sight and hearing impairment being on a spectrum from minimal impairment (hearing loss, tinnitus, presbyopia) to full impairment (deaf, blind). When it comes to anxiety and the resulting cognitive impairment, the spectrum is harder to understand. The strides in Autism Spectrum Disorder (ASD) research and publicity have helped in recent years to build public awareness of the oft-times hidden disability and the breadth of its spectrum of impact. Anxiety disorder spectrum may be like that of ASD, in that the disorder is often a hidden one and the spectrum of impact is variable based on a combination of environment and personal perception.
With sight and hearing impairments, the impact is stable. With anxiety, the impact to cognition can change very rapidly. Someone with a sight impairment, for the most part, puts on their glasses each morning and is confident that they can see all day until they take their glasses off to go to bed at night. The individual goes to bed confident that the same pair of glasses will work tomorrow. An annual checkup may be all that is needed to accommodate change.
We often overlook the fact that a person who wears glasses is not considered to have an impairment because the accommodation is stable and consistent, and the impact to daily function is low. The person with an anxiety disorder, however, may not share their impairment with others and may do very well. So well, in fact, that the impairment may be forgotten or overlooked, forgetting that an impairment may even exist. The disorder may have only vague impacts such as irritability or forgetfulness that is easily explained by an "off day." When an Amygdala Hijack occurs, it not only catches the individual who is impacted off guard, but also people around them who may know nothing of the anxiety.
One parent of a child with an anxiety disorder was heard saying, "She does so good that people forget. I forget. When she has an event, it becomes a crisis." This is a very different challenge than a person with a vision impairment losing the screw to the earpiece of their glasses. It is easy to fit an earpiece on glasses with a paperclip for a few days until it is replaced. Workarounds for cognitive lapses are not so easy or obvious. The individual is often left to cope by themselves, and within themselves, as they try to hide the distress. The impact may also have long-lasting effects.
There is little shame in losing a screw to the earpiece on glasses. It may even become a fun event where everybody searches for the screw and the finder becomes the hero. However, the person who suffers a panic attack can suffer extreme shame. Reentry to a classroom or work group can also bring on additional anxiety. Workers who once thought of the person as smart and inventive may suddenly see the person as unstable and unreliable. People may act cautiously around the person and withhold humor, assignments or forthrightness, the very things that may help the individual cope.
UDL as a Method to Prevent and Dispel Anxiety
When the Universal Design for Learning (UDL) Guidelines are used to design content, there are several benefits for learners with anxiety disorders. Because UDL is about providing opportunities, the learner with an anxiety disorder and their teachers have built in avenues to prevent heightened anxiety or dispel existing anxiety, so these students can continue to learn and succeed.
Providing options allows the learner with anxiety to select the method that is best in situations they do not have controls over. When anxiety is high regardless of the situation, having options may allow them to continue learning and can be instrumental in decreasing or dispelling the anxiety. The following examples from Guideline 1 explore some common situations:
Guideline 1: Provide options for perception (UDL: Perception, n.d.)
- Checkpoint 1.1 Offer ways of customizing the display of information
Being able to personalize the perceptual features can prevent the anxiety trigger of losing study time. Modifying the background color of learning materials to individualized colors can reduce eye strain and allow the learner to study for longer periods of time. When a learner must take time away from study for eye strain, this can trigger anxiety as the learner thinks about the study time that is being lost.
- Checkpoint 1.2: Offer alternatives for auditory information
Text equivalents are used by many learners and is not limited to those with low vision and blindness. For learners with anxiety, have text alternatives provides a way to learn and review the content when they are in environments where audio would be difficult to hear and where audio is not an option such as when siblings are sleeping in a shared room.
For all learners, having technology fail can bring on anxiety. For those with anxiety disorders, technology failure can be derailing. Knowing that an alternative is available when the earbud wires are cut from the family pet biting them or if the wires get accidentally closed in the car door, can mean that the learner with anxiety stays the course and continues with their learning.
- Checkpoint 1.3: Offer alternatives for visual information
When opportunity for additional time to study is given to a learner with anxiety, it can dispel the anxiety of not having enough time. For the learner with anxiety, having alternatives for visual information, especially text-to-speech, provides opportunities to study by listening to lessons in places where reading would not be easy. Listening to lessons from a lightweight audio player on a bumpy bus or train ride home is easier than carrying a large book and trying to focus on the content that moves with every bump.
The benefits of UDL also extend to the teacher of the student with an anxiety disorder or any student who may find themselves with an Amygdala Hijack. Having choices to present to students during times of high anxiety, can help the student focus on what they can handle now. Starting the student with an audio lesson with eyes closed, may help them focus when visual stimulation is disturbing them. Having a student read a lesson, when anxiety is heightened because a video is being presented at too fast a pace for them to digest, can help them continue without an anxiety attack.
Teachers can work with students during times when anxiety is low to develop strategies for times of high anxiety. Preparing ahead of time can help both the teacher and student to employ the strategy so that it does not bring undo focus on the student. Curriculum designed with UDL makes development of strategies much easier than curriculum designed without the choices inherent in UDL.
Web Accessibility as a Method to Prevent and Dispel Anxiety
Applying the Web Content Accessibility Guidelines (WCAG) 2.0 Success Criteria (SC) can also be helpful with anxiety disorders. Combining Universal Design practices along with ensuring access by following WCAG 2.0 provides people with anxiety an improved chance of success. The following are specific examples of how applying WCAG 2.0 SC is helpful.
- SC 1.4.2 (A) Audio Control – Unexpected audio can be a source of anxiety for some people. Those with PTSD may associate certain sounds with a traumatic event. Being able to control “when” and “how” loud audio plays can be critical in preventing an Amygdala Hijack. Fortunately, devices have user-controlled settings for volume.
- SC 2.2.1 (A) Timing adjustable – Time limits add undue stress on people with anxiety disorders, people who know they process information slower, those who use assistive technology, or use alternate formats. When timeouts are encountered, providing a clear method to turn off or extend time is important to prevent anxiety. (SC 2.2.3 (AAA) No timing – is even better!)
- SC 2.2.2 (A) Pause, Stop Hide – Information that is moving on a web page needs a mechanism to stop, pause or hide the motion. I have heard people say that this Success Criteria is for people who are easily distracted. Anxiety is also a valid reason to be able stop motion. For instance, a person who got t-boned in a car may now flinch at information moving across their field of view. With no mechanism to stop a carousel from advancing, people with anxiety disorders may leave the page quickly to avoid a panic attack.
- SC 3.2.3 (AA) Consistent Navigation – The impact of inconsistent navigation can be very distressing. It can cause a person to fail at the task they are trying to perform. The task may be of critical importance, such as signing up for health insurance, filing taxes, banking, or communicating with health providers.
When navigation is inconsistent, people may begin to doubt their own ability to remember the location and order of menus and menu items. Self-doubt can be a big contributor to increased anxiety. It might not occur to the person with an anxiety disorder that the lack of consistency is a result of the design of the website.
- SC 3.3.2 (A) Labels and Instructions – having enough information to complete a task successfully the first time is important. This may seem self-explanatory, but the following scenario is an example of a person’s experience when the correct labels and instructions are not implemented:
Filling out a form is fast when the form is well designed and developed - Tab, type, tab, type, tab, type, submit!
With submit, errors are identified. The date format is incorrect. Try again. Search for the format instructions. There are none to be found – even in the error message (SC 3.3.3 (A) Error Suggestion). It takes three or more attempts to finally enter the date in the correct format.
Anxiety mounts as the task takes longer to complete and the user is told repeatedly by the web page that they are wrong. For the person with anxiety, having an inanimate web page pointing out their mistakes can have a profound impact to self-esteem.
Of course, the polite thing to do is to provide format instructions to begin with. It is polite and conforms with 3.3.2.
Looking ahead to WCAG 2.1, SC (AA) 1.3.5 Identify Input Purpose and SC (AAA) 1.3.6 Identify Purpose may help diminish anxiety by providing support for inputs, User Interface Components, icons and regions (such as input customization, autocomplete, and symbol mapping to user agents). (W3C, 2018) (W3C, 2018) (W3C, 2018) Saving time and having additional cognitive support are both strategies for success for people with anxiety disorders.
Conclusion
Anxiety is often the companion of other disabilities and can take a backseat, not getting diagnosed and treated. Or, it may be treated as symptomatic relief and not diagnosed on its own standing. This article does not address the process of diagnosis, treatments, and therapy. Those topics are highly individual and should be addressed with health professionals.
Anxiety disorders have long been ignored in many modern cultures or have been fraught with shame and humiliation as a sign of immaturity or a conscious choice. The shame and humiliation of being identified with the disorder and accepting treatment is not trivial. Anxiety is not something to "get over." It is something to accept, work with and share so that others experiencing the same, or similar, disorder will hopefully experience a smoother path to success.
UDL provides choices and they provide relief to both student and teacher. Having options is good for planning strategies, helping the student focus during difficult times and helps the student discover what works best for them. Students with an anxiety disorder who have the benefit of a learning career developed under UDL, may be able to succeed throughout their years in school. When the person gets into the workforce, they will have the benefit of knowing what works best for them and can work with colleagues and managers to develop strategies for a successful career. The benefits can also carry into their adult home life with strategies to building strong partnerships and raising their own children.
Anxiety is something most human beings experience at one time or another. It should not be difficult for people to understand how having an anxiety disorder is difficult at best. Our cultures and societies, however, have not provided an easy way for this understanding to occur. We are getting better – that is the good news. As cultures continue to adopt and strengthen the use of guidelines such as UDL and WCAG 2.0 (2.1), the world will become an easier place for people with differences to succeed at the same levels and opportunities as those who are considered normal.
Works Cited
American Psychiatric Association. (n.d.). What Is Obsessive-Compulsive Disorder? Retrieved from American Psychiatric Association: https://www.psychiatry.org/patients-families/ocd/what-is-obsessive-compulsive-disorder
Anxiety and Depression Association of America. (n.d.). Generalized Anxiety Disorder (GAD). Retrieved from Anxiety and Depression Association of America (ADAA): https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad#
Cain, S. (2013). Quiet: The Power of Introverts in a World That Can't Stop Talking. New York: Random House.
Goleman, D. (1995). Emotional Intelligence. New York: Bantum Books.
Jieun E Kim, S. R. (2012, 11 20). The role of the amygdala in the pathophysiology. Retrieved from Biology of Mood & Anxiety Disorders: https://biolmoodanxietydisord.biomedcentral.com/articles/10.1186/2045-5380-2-20
NHS Choices. (n.d.). Post-traumatic stress disorder (PTSD). Retrieved from NHS.UK: https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/
UDL: Perception. (n.d.). Retrieved from CAST: http://udlguidelines.cast.org/representation/perception
W3C. (2018, 4 20). Understanding Success Criterion 1.3.5: Identify Input Purpose. Retrieved from Understanding WCAG 2.1: https://www.w3.org/WAI/WCAG21/Understanding/identify-input-purpose.html
W3C. (2018, 04 20). Understanding Success Criterion 1.3.6: Identify Purpose. Retrieved from Understanding WCAG 2.1: https://www.w3.org/WAI/WCAG21/Understanding/identify-purpose.html
W3C. (2018, 04 24). Web Content Accessibility Guidelines (WCAG) 2.1. Retrieved from Web Content Accessibility Guidelines (WCAG) 2.1: https://www.w3.org/TR/WCAG21/