case study of a student with anxiety

• Membership & Supporters
• Facebook Support
• Social Events
• Support Groups
• Fact sheets
• Health Tips
• Personal Stories
• Books & CD's
• Lectures & Workshops
• Participate in Research
• Who does what?
• Find a Therapist
• Product Search
• Shopping Cart
• Terms & Conditions

Hannah, an anxious child

Hannah (not a real person) was a 10-year-old girl from a close, supportive family who was described as 'anxious from birth'. She had been a shy, reserved young girl at pre-school, but she integrated well in grade 1 and began making friends and succeeding academically. She complained several times of severe abdominal pain that was worst in the morning and never present at night. She had missed about 20 days of school during the previous year because of the pain. She also avoided school excursions, fearing the bus would crash. She had difficulty falling asleep and frequently asked her parents for their reassurance.

Hannah was worried that she and members of her family might die. She was unable to sleep at all before a test. She could not tolerate having her parents on a different floor of the house from herself, and she insisted on securing the house to an unnecessary extent in the evenings, fearing intruders. Her insecurity, need for constant reassurance, and school absenteeism were frustrating and upsetting for her parents.

Hannah had no personal history of traumatic events. She exhibits symptoms typical of childhood anxiety disorder, which is thought to occur in about 10% of children, equally in boys and girls before puberty. This type of disorder is diagnosed when anxiety is sufficient to interfere with daily functioning, for example Hannah's school attendance and sleep. These effects can increase and interfere to a progressively greater extent with age-appropriate functioning at home, at school and with peers, and also places sufferers at risk of developing mood disorders or substance abuse disorders in the future.

Many children experience fears; fears that are developmentally normal. Children with anxiety disorders, however, experience persistent fears or other symptoms of anxiety for months. Children can experience all the anxiety disorders experienced by adults. However, they can also experience separation anxiety disorder and selective mutism (failure to speak in certain social situations, thought to be related to social anxiety), which are unique to children. The duration of Hannah's difficulties and the symptoms, including inability to sleep, attend school regularly, go on school excursions, or face tests without extreme distress are all developmentally inappropriate, suggesting an anxiety disorder.

There is a range of common symptoms seen in anxious children. Symptoms involving thoughts include worrying, requests for reassurance, 'what if.' questions, and upsetting obsessive thoughts. Common symptoms involving behaviours include difficulty in separation, avoiding feared situations, tantrums when faced with fear, 'freezing' or mutism in feared situations, and repetitive rituals, or compulsions. Common symptoms involving feelings include panic attacks, hyperventilation, stomachaches, headaches and insomnia.

To screen quickly for one or more anxiety disorders in children, four questions are often useful:

• Does the child worry or ask for parental reassurance almost every day?
• Does the child consistently avoid certain age-appropriate situations or activities, or avoid doing them without a parent?
• Does the child frequently have stomachaches, headaches, or episodes of hyperventilation?
• Does the child have daily repetitive rituals?

These questions address the main thoughts, behaviours and feelings related to anxiety seen in children.

Megan Rodgers wishes to acknowledge an article entitled 'Childhood Anxiety Disorders' written by Dr Manassis, a Staff Psychiatrist at the Hospital for Sick Children and the Center for Addiction and Mental Health in Toronto, Ontario, on which this article is based.

Written by Megan Rodgers ADAVIC Volunteer June 2004

How to Treat Anxiety in College Students

New research spotlights how to help struggling students..

Posted July 25, 2023 | Reviewed by Tyler Woods

• What Is Anxiety?
• Find counselling to overcome anxiety
• Anxiety is different than normal worrying in college students.
• Counseling, scheduling, medication, meditation, sleep, and exercise are the best things to improve anxiety.
• Weed and stimulants make anxiety worse in most college students.

According to The Health Minds Study , anxiety among college students has been steadily increasing since they first reported findings in 2007.

When Not to Worry About Worrying

Everyone feels uneasy or anxious occasionally, like when we are running late for a meeting or got caught doing something we’re not supposed to. We can also feel anxious when we perceive a threat in the environment that triggers a neurological response to get our body prepared for running away, fighting something scary, or freezing and blending into our surroundings. This is all normal and helpful.

When to Worry About Worrying

Sometimes, our brain goes into overdrive and can’t differentiate between actual risks and perceived risks. This is often the case when someone experiences trauma or has poor attachment to caregivers—the brain is hypervigilant and perceives threats everywhere. Anxiety disorders are different from regular, situational anxiousness. This group of psychological disorders is characterized by intensity, duration, origin, and how they impact life domains like work, school, relationships, and health.

Students with anxiety disorders often report to me that semesters generally start fine but as papers, tests, and social pressures mount, their anxiety builds to the point where they start avoiding going to class and work. Untreated anxiety can lead to sleep problems, academic issues, depression , severe drug use, and in some instances, suicidal thinking or attempts.

Specific Diagnoses

Now, let’s take a look at the specific diagnoses I most often see in college students. You’ve probably heard of most of these but may not have a solid understanding of the specific criteria for each.

• Panic Disorders. This is when we feel an overwhelming sense of terror or dread that seemingly strikes randomly. During a panic attack, the person may sweat, have chest pain, and feel unusually strong or irregular heartbeats. Sometimes, they may feel like they’re choking or having a heart attack. Panic attacks rarely last more than 20 minutes.
• Social Anxiety Disorder. This is when students feel overwhelming worry or judgment while in social situations. They may obsess over others' judgment or have a fear of feeling embarrassed or ridiculed.
• Specific Phobias. This is when students have a very specific fear of something such as spiders, heights, or flying. It’s a disproportionate fear compared to the actual risk and may cause them to avoid regular situations. I see this most often materialize as a fear of failing a class or fear of something related to social media .
• Generalized Anxiety Disorder. This is when students describe having excessive, unrealistic worry and tension for no apparent reason. It’s like their brain is saying, “Hey, there’s something scary and dangerous out there. I don’t know what it is or what I’m afraid will happen, but I know I’m scared.”

How to Treat College Student Anxiety Disorders

Though anxiety disorders can make someone feel hopeless, there are very effective treatments and interventions we can implement to get life back on track, or at least make things easier. Here are the six most effective things parents can encourage their college students to implement.

• Counseling. The first thing parents can do is link their child with campus health services or a local therapist or counselor specializing in college student anxiety. Ideally, find a therapist/counselor that uses Cognitive Behavioral Therapy (CBT) or Dialectical Behavioral Therapy (DBT). Waiting until the first big meltdown isn’t necessary.
• Scheduling. Anxiety is a disorder of fear. Fear is often the by-product of a lack of predictability about social events, academic outcomes, and career opportunities. One solution is to increase predictability. I accomplish this with students by teaching them to download the semester schedule onto their phone or laptop calendars before the semester starts. Next, after they receive their syllabi, I coach them to put in every single date for every single assignment/test possible. This also includes social events and any non-academic events they know about.
• Medication . Sometimes, students simply need a bit more support than what counseling and behavioral changes can provide. If your son or daughter does not have a psychiatrist on staff at their university health center, find one near campus.
• Meditation . I recommend to nearly every student I work with to start participating in weekly yoga, meditation, Non-Sleep Deep Rest (NSDR) or mindfulness classes. Meditation, counseling, and medication are complementary approaches to combating anxiety.
• Sleep. The ideal for anxiety reduction is a steady sleep pattern so that bedtime and wake time are pretty standard every day. Staying up late on Thursday, Friday and Saturday, sleeping in till 1:00pm and then dragging out of bed Monday morning for an 8:50am class is terrible for anxiety. Sleep medications only make things worse and really should only be taken with the oversight of a psychiatrist. The formula for the best sleep is: consistency (waking up and falling asleep), making the room as cool and dark as possible, and avoiding devices or food an hour or two before (and while they’re in) bed.
• Exercise. Exercise is one of the most effective behavioral changes for combating anxiety and works through the stimulation of different brain regions. The three easiest ways for students to get enough exercise to quiet their brain down are walking to class, signing up for club team sports, and setting up a routine at the school’s gym. Distraction and flow experiences are essential in helping students focus on non-academic activities. Exercise’s value can come from single episodes but consistency over weeks is where students will find the greatest benefit.

What to Cut Out

There are also a few things that the research shows is best reduced or flat out removed from life to also improve anxiety. Basically, weed and stimulants are the two biggest problems I see in college students that make anxiety worse.

Weed can have an anti-anxiety effect in small doses, but long-term use is linked to increased anxiety. Stimulants like caffeine and some medications like Adderall and Ritalin have been shown to increase anxiety, though there are some studies that show use of methylphenidate might actually decrease certain types of treatment-resistant anxiety which turn out to be more related to ADHD.

In summary, anxiety, if addressed early on, doesn’t have to ruin the semester. Just like attending to a medical issue that requires some modifications, treating anxiety with intentional practice and moderate lifestyle changes can significantly help most students.

To find a therapist near you, visit the Psychology Today Therapy Directory .

Healthy Minds Network (year). Healthy Minds Study among Colleges and Universities, year (HMS years of data being used) [Data set]. Healthy Minds Network, University of Michigan, University of California Los Angeles, Boston University, and Wayne State University. https://healthymindsnetwork.org/reserach/data-for-researchers

Rob Danzman is a licensed professional counselor and mental health counselor and founder of Motivate Counseling in Bloomington, Indiana.

• Find Counselling
• Find a Support Group
• Find Online Therapy
• United Kingdom
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Therapy Center NEW
• Diagnosis Dictionary
• Types of Therapy

Understanding what emotional intelligence looks like and the steps needed to improve it could light a path to a more emotionally adept world.

• Coronavirus Disease 2019
• Affective Forecasting
• Neuroscience

Interpretational Processing Biases in Emotional Psychopathology pp 301–321 Cite as

“I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder

• Katharine E. Daniel 3 &
• Bethany A. Teachman 3  
• First Online: 29 March 2023

462 Accesses

1 Altmetric

Part of the book series: CBT: Science Into Practice ((CBT))

Gi, a 34-year-old second-generation Korean American man, presented to treatment with pronounced and longstanding anxiety in many social situations, which significantly impaired his functioning (e.g., his perceived ability to run errands in crowded stores and care for his ill father). Gi engaged in cognitive behavior therapy (CBT) via telehealth during the COVID-19 pandemic. Key cognitions and biased cognitive processes that were maintaining his anxiety included a judgment that others frequently reject him, an assumption that if he expressed his own needs, then he would be unreasonably burdening others, and a core belief that he was incompetent, along with a pervasive tendency to make negative interpretations about his abilities in most social situations. He experienced marked functional improvements and reduced anxiety throughout his 17-session course of treatment. Gi’s case and treatment are detailed throughout this chapter to illustrate how individual CBT for social anxiety disorder can be implemented. Special discussion of how the clinician continuously and collaboratively modified her case conceptualization and intervention approaches with reference to aspects of Gi’s identities and in response to her own missteps are offered throughout.

This is a preview of subscription content, log in via an institution .

Buying options

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Anxiety & Depression Association of America. (1.12.2022). Social anxiety disorder. https://adaa.org/understanding-anxiety/social-anxiety-disorder .

Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.

Google Scholar  

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58 , 10–23. https://doi.org/10.1016/j.brat.2014.04.006

Article   PubMed   PubMed Central   Google Scholar  

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99 , 20–35. https://doi.org/10.1037/0033-2909.99.1.20

Article   PubMed   Google Scholar  

Gover, A. R., Harper, S. B., & Langton, L. (2020). Anti-Asian hate crime during the COVID-19 pandemic: Exploring the reproduction of inequality. American Journal of Criminal Justice , 1–21. https://doi.org/10.1007/s12103-020-09545-1

Harpole, J. K., Levinson, C. A., Woods, C. M., Rodebaugh, T. L., Weeks, J. W., Brown, P. J., Heimberg, R. G., Menatti, A. R., Blanco, C., Schneier, F., & Liebowitz, M. (2015). Assessing the straightforwardly-worded Brief Fear of Negative Evaluation scale for differential item functioning across gender and ethnicity. Journal of Psychopathology and Behavioral Assessment, 37 (2), 306–317. https://doi.org/10.1007/s10862-014-9455-9

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). The Guilford Press.

Leahy, R. L., Holland, S. J. F., & McGinn, L. K. (2012). Treatment plans and interventions for depression and anxiety disorders (2nd ed.). Guilford Press.

Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping patients change behavior (3rd ed.). Guilford Press.

Norton, P. J., & Weeks, J. W. (2019). A multi-ethnic examination of social evaluative fears. Journal of Anxiety Disorders, 23 , 904–908. https://doi.org/10.1016/j.janxdis.2009.05.008

Article   Google Scholar  

Piccirillo, M. L., Taylor Dryman, M., & Heimberg, R. G. (2016). Safety behaviors in adults with social anxiety: Review and future directions. Behavior Therapy, 47 (5), 675–687. https://doi.org/10.1016/j.beth.2015.11.00

Turner, S. M., Johnson, M. R., Beidel, D. C., Heiser, N. A., & Lydiard, R. B. (2003). The social thoughts and beliefs scale: A new inventory for assessing cognitions in social phobia. Psychological Assessment, 15 (3), 384–391. https://doi.org/10.1037/1040-3590.15.3.384

Download references

Author information

Authors and affiliations.

Department of Psychology, University of Virginia, Charlottesville, VA, USA

Katharine E. Daniel & Bethany A. Teachman

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Bethany A. Teachman .

Editor information

Editors and affiliations.

Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-University Bochum, Bochum, Germany

Marcella L. Woud

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Cite this chapter.

Daniel, K.E., Teachman, B.A. (2023). “I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder. In: Woud, M.L. (eds) Interpretational Processing Biases in Emotional Psychopathology . CBT: Science Into Practice. Springer, Cham. https://doi.org/10.1007/978-3-031-23650-1_16

Download citation

DOI : https://doi.org/10.1007/978-3-031-23650-1_16

Published : 29 March 2023

Publisher Name : Springer, Cham

Print ISBN : 978-3-031-23649-5

Online ISBN : 978-3-031-23650-1

eBook Packages : Behavioral Science and Psychology Behavioral Science and Psychology (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Office of Student Life

Your Student Life: Managing Test Anxiety

April 16, 2024

Most students experience at least a little bit of pre-finals nerves, and a mild amount of anxiety can be adaptive by motivating us to prepare and stay focused. However, some students experience so much anxiety before an exam that it can impair performance and cause a lot of distress.

How do you know if you experience test anxiety? Students often report physical signs including fast heart rate, changes in breathing, feeling restless or jittery, sweatiness and upset stomach. They may have trouble sleeping the night before or eating breakfast that morning.

Students may also notice signs of anxiety in the way they’re thinking; they may have catastrophic and often unrealistic thoughts like “There’s no way I can pass this,” “I’m not cut out for this major” or “If I don’t do well, it’ll ruin my whole future.”

If this sounds relatable, it may be time to work on reducing your test anxiety as you prepare for finals week.

To learn about skills for managing test anxiety, schedule a Let’s Talk to chat with a counselor or attend the ACT for Anxiety Drop-In Workshop . For study strategies, the Dennis Learning Center offers an extensive resource page as well as individual coaching sessions .

Counseling and Consultation Service Office of Student Life

• Open access
• Published: 31 October 2023

Social media usage and students’ social anxiety, loneliness and well-being: does digital mindfulness-based intervention effectively work?

BMC Psychology volume  11 , Article number:  362 ( 2023 ) Cite this article

10k Accesses

2 Citations

35 Altmetric

Metrics details

The increasing integration of digital technologies into daily life has spurred a growing body of research in the field of digital psychology. This research has shed light on the potential benefits and drawbacks of digital technologies for mental health and well-being. However, the intricate relationship between technology and psychology remains largely unexplored.

This study aimed to investigate the impact of mindfulness-based mobile apps on university students' anxiety, loneliness, and well-being. Additionally, it sought to explore participants' perceptions of the addictiveness of these apps.

The research utilized a multi-phase approach, encompassing a correlational research method, a pretest–posttest randomized controlled trial, and a qualitative case study. Participants were segmented into three subsets: correlations ( n  = 300), treatment ( n  = 60), and qualitative ( n  = 20). Data were gathered from various sources, including the social anxiety scale, well-being scale, social media use integration scale, and an interview checklist. Quantitative data was analyzed using Pearson correlation, multiple regression, and t-tests, while qualitative data underwent thematic analysis.

The study uncovered a significant correlation between social media use and the variables under investigation. Moreover, the treatment involving mindfulness-based mobile apps led to a reduction in students' anxiety and an enhancement of their well-being. Notably, participants held various positive perceptions regarding the use of these apps.

Implications

The findings of this research hold both theoretical and practical significance for the field of digital psychology. They provide insight into the potential of mindfulness-based mobile apps to positively impact university students' mental health and well-being. Additionally, the study underscores the need for further exploration of the intricate dynamics between technology and psychology in an increasingly digital world.

Peer Review reports

Introduction

The field of digital psychology is undergoing rapid evolution, navigating the intricate intersection of psychology and technology to elucidate the profound impact of digital technologies on human behavior, cognition, and emotions [ 1 , 2 ]. With digital technologies becoming increasingly ingrained in our daily lives, researchers are embarking on a journey to explore the multifaceted implications they bear for mental health and overall well-being. Within the realm of digital psychology, a diverse array of topics has captured the attention of investigators, encompassing the innovative use of technology for psychological interventions like cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) [ 1 , 2 ]. Furthermore, scrutiny has extended to the influence of social media on mental health, unveiling the potential for excessive social media use to contribute to feelings of anxiety and loneliness [ 3 , 4 ].

The exploration of digital psychology has also delved into the impact of video games on cognitive and emotional faculties, with some studies suggesting that specific genres of video games have the potential to enhance attention and problem-solving skills [ 5 , 6 ]. However, concerns surrounding video game addiction and the potential influence of violent video games on aggressive behavior have been the subject of extensive investigation [ 7 , 8 , 9 , 10 ]. The ubiquity of digital technologies in our daily existence has ignited a burgeoning interest in the domain of digital psychology. While research in this domain has yielded valuable insights into the prospective benefits and hazards of digital technologies for mental health and well-being, there remains a vast expanse of knowledge yet to be uncovered regarding the intricate interplay between technology and psychology. Specifically, there is a compelling need for an extensive body of research aimed at comprehending the enduring impacts of digital technologies on cognitive, emotional, and social functionality. Furthermore, it is crucial to decipher how these effects may vary among diverse demographic groups.

One particularly promising avenue of research within digital psychology is the integration of mindfulness-based mobile applications, which has shown considerable potential in alleviating symptoms of anxiety and loneliness. These applications typically offer guided meditation, breathing exercises, and various mindfulness practices that are readily accessible via mobile devices [ 2 ]. Their accessibility and user-friendly nature render them an appealing resource for individuals seeking to enhance their mental well-being without the need for traditional face-to-face therapy [ 3 , 6 ].

In the contemporary landscape of higher education, university students are exposed to the pervasive influence of social media, which has the potential to induce negative psychological consequences such as heightened social anxiety and increased feelings of loneliness. The omnipresence of social media platforms can foster a sense of comparison, social pressure, and disconnection among undergraduate students, amplifying the challenges they already face. Given these circumstances, there is a compelling need to explore interventions that can counteract these adverse impacts, and mindfulness-based interventions emerge as a promising avenue for consideration.

By examining the intersection of these interventions with the digital sphere, this study seeks to illuminate how Digital Mindfulness-based treatments might serve as a potent tool to mitigate the detrimental effects of social media exposure, thereby fostering a healthier psychological landscape among university students [ 11 , 12 , 13 , 14 , 15 ].

Furthermore, many of these applications provide personalized features such as progress tracking and goal setting, which enhance user engagement and motivation [ 9 ]. As the popularity of these applications continues to soar, it becomes imperative to further investigate their effectiveness across various demographic cohorts and contextual settings, as well as to identify the most potent features and interventions for fostering improvements in mental health [ 10 ].

The rationale for this study is firmly grounded in the contemporary higher education landscape, where undergraduate students navigate a myriad of challenges that may impact their mental well-being. With the pervasive integration of digital technologies into students' lives, the investigation of Digital Mindfulness-based interventions becomes not only relevant but crucial. The novelty of this study lies in its exploration of the intricate relationship between social media usage and the well-being of university students, specifically targeting social anxiety and loneliness. Moreover, it introduces an innovative approach by examining the effectiveness of digital mindfulness-based interventions in ameliorating these psychological challenges. By addressing this uncharted territory, the study not only contributes to the growing field of digital psychology but also offers valuable insights into the potential of technology-driven mindfulness interventions as a means to enhance the mental well-being of the digital-native student population. This unique blend of investigating the impact of technology on psychological well-being while simultaneously assessing the effectiveness of digital interventions positions the study at the forefront of contemporary research in the field. Given the potential benefits of digital mindfulness apps in reducing anxiety and loneliness, coupled with the distinct challenges that emerge during the undergraduate phase, this research seeks to provide invaluable insights into the perceptions and experiences of students. By delving into the perceptions of adults regarding these treatments, this study aspires to shed light on the feasibility, effectiveness, and potential limitations of digital mindfulness-based interventions for enhancing the mental health of undergraduate students in the modern digital age. Therefore, this study endeavors to address the following critical questions:

What is the relationship between social media use and symptoms of social anxiety, loneliness, and well-being among university students?

Does the use of a mindfulness-based mobile app intervention result in significant improvements in social anxiety, loneliness, and well-being in college students?

What are university students’ perspectives on the use of technology for mental health support, including the benefits and challenges of using technology for this purpose?

Review of literature

Theoretical background.

The study investigating the effects of mindfulness-based mobile apps on university students' anxiety, loneliness, and well-being in the context of social media usage draws upon a multifaceted theoretical framework. At its core, it is rooted in mindfulness theory, which emphasizes present-moment awareness and non-judgmental acceptance to alleviate stress and anxiety [ 5 , 6 , 7 , 8 ]. To understand the influence of social media on students, social cognitive theory is relevant, as it explores how individuals learn from observing others in their social networks. Additionally, social comparison theory informs the study by shedding light on how students may constantly compare themselves to others on social media, potentially leading to feelings of loneliness and social anxiety [ 11 , 12 , 13 , 14 , 15 ]. The study also taps into addiction and compulsive behavior theories to comprehend the perceived addictiveness of mindfulness-based mobile apps. Technology acceptance models (TAM) help in understanding user acceptance and perceptions of these apps. Moreover, the study aligns with principles of positive psychology by aiming to enhance well-being and reduce anxiety and loneliness, which are central concerns in this field. Finally, media effects theories, like cultivation theory and uses and gratifications theory, inform the exploration of how social media use affects students' mental health and well-being [ 13 ]. This multifaceted theoretical approach provides a comprehensive foundation for unraveling the intricate relationship between technology, psychology, and well-being in the digital age, offering a well-rounded perspective on the research questions at hand [ 12 , 13 ].

Social media and symptoms of mental health

The use of social media has become increasingly prevalent among university students, and with it comes growing concern about its potential impact on mental health and well-being. Specifically, research has focused on the relationship between social media use and symptoms of social anxiety, loneliness, and well-being among university students. The majority of studies focused on the relationship between social media use and symptoms of social anxiety and/or loneliness. These studies generally found that higher levels of social media use were associated with greater symptoms of social anxiety and loneliness among university students [ 11 , 12 , 13 , 14 , 15 , 16 ]. For example, Schønning et al. [ 16 ] found that social media use was positively associated with symptoms of social anxiety among Chinese university students. Similarly, a study by Wang et al. [ 13 ] found that social media use was positively associated with symptoms of loneliness among Chinese university students.

Two studies focused on the relationship between social media use and well-being. One study found that higher levels of social media use were associated with lower levels of well-being among university students [ 17 ] Another study found that social media use had a curvilinear relationship with well-being, such that moderate levels of social media use were associated with higher levels of well-being, while both low and high levels of social media use were associated with lower levels of well-being [ 13 ].

The findings of this literature review suggest that social media use may be associated with greater symptoms of social anxiety and loneliness among university students. However, the relationship between social media use and well-being is less clear, with some studies suggesting a negative relationship and others suggesting a curvilinear relationship. Several additional studies have also examined this relationship. For example, a study by Kose and Dogan [ 18 ] found that social media use was negatively associated with psychological well-being among Turkish university students. Another study by Błachnio, et al., [ 19 ] found that Facebook addiction was negatively associated with self-esteem and life satisfaction among Polish university students. Similarly, Chen et al. [ 20 ] conducted a systematic review of 23 studies examining the relationship between social media use and mental health outcomes among college students. The authors concluded that social media use was generally associated with negative mental health outcomes, including loneliness, anxiety, and stress. However, they noted that the strength of this relationship varied across studies and suggested that more research was needed to better understand the mechanisms underlying this relationship. In another study, Seabrook et al. [ 21 ] conducted a systematic review of 20 studies examining the relationship between social networking sites and loneliness and anxiety. They found that social networking sites were associated with both loneliness and anxiety, but that the strength of this relationship varied across studies and depended on factors such as frequency and intensity of social networking site use and individual differences in vulnerability to mental health problems. Similarly, Tandoc Jr. et al. [ 14 ] conducted a study examining the relationship between Facebook use, envy, and depression among college students in the United States. They found that Facebook use was positively associated with envy, which in turn was positively associated with depression. They suggested that envy may be a mechanism underlying the relationship between social media use and negative mental health outcomes.

Mindfulness-based apps effect mental health

Mindfulness-based mobile apps are becoming increasingly popular as a tool for promoting mental health and wellbeing. These apps include a variety of different mindfulness-based practices, such as guided meditations, breathing exercises, and other techniques aimed at reducing stress and anxiety. While there is growing evidence that mindfulness-based interventions can be effective in promoting mental health, less is known about the effectiveness of these interventions when delivered via mobile apps. This literature review aims to synthesize the existing research on mindfulness-based mobile apps and mental health outcomes.

The majority of studies focused on the effectiveness of mindfulness-based mobile apps in reducing symptoms of anxiety and depression. These studies generally found that mindfulness-based mobile apps were effective in reducing symptoms of anxiety and depression in a variety of populations, including college students, adults, and individuals with chronic medical conditions [ 2 , 10 , 22 , 23 , 24 ]. For example, a study by Strauss et al. [ 23 ] found that a mindfulness-based mobile app was effective in reducing stress and improving coping skills in a sample of healthcare workers. Similarly, a study by Lomas et al. [ 24 ] found that a mindfulness-based mobile app was effective in reducing stress and improving resilience in a sample of university students. In addition to examining the effectiveness of mindfulness-based mobile apps, several studies explored the factors that influence user engagement and adherence to these interventions. For example, a study by Valinskas et al. [ 25 ] that users who were using the app for more than 24 days and had at least 12 active days during that time had 3.463 (95% CI 1.142–11.93) and 2.644 (95% CI 1.024–7.127) times higher chances to reduce their DASS-21 subdomain scores of depression and anxiety, respectively. Another study by Linardon, et al. [ 22 ] found that interventions that were more interactive and personalized were more effective in promoting user engagement and adherence.

Some studies also explored the effectiveness of mindfulness-based mobile apps in addressing other mental health conditions beyond anxiety and depression. For example, a study by Wahbeh et al. [ 10 ] found that a mindfulness-based mobile app intervention was effective in reducing symptoms of posttraumatic stress disorder (PTSD) in a sample of veterans. Similarly, a study by Biegel et al. [ 26 ] found that a mindfulness-based mobile app intervention was effective in reducing symptoms of ADHD in a sample of adolescents.

The use of technology for mental health support

The utilization of technology for the provision of mental health support has gained increasing prominence within the context of university students, prompting a burgeoning interest in comprehending their encounters and viewpoints. Related inquiries have been undertaken in diverse geographical regions, including the United States, Canada, Australia, and the United Kingdom. Predominantly, these investigations have centered on the advantages and obstacles inherent in employing technology for mental health support. Generally, these inquiries have ascertained that technology is perceived as a convenient and readily accessible modality for accessing mental health support services among university students [ 27 , 28 , 29 , 30 ]. For instance, Birnbaum et al. [ 27 ] conducted a study revealing that college students in the United States exhibited a willingness to engage with mental health applications to manage their stress and anxiety. Nevertheless, certain studies have also discerned impediments associated with the adoption of technology for mental health support, encompassing apprehensions regarding privacy and confidentiality [ 27 , 28 , 29 , 30 ], concerns about the quality and dependability of information [ 29 ], and challenges related to navigating and effectively utilizing mental health applications [ 30 ].

Additionally, two investigations have focused their attention on delineating the determinants influencing the utilization of technology for mental health support among university students. These studies have identified an array of factors exerting an influence over students' engagement with technology for mental health support, encompassing individual attributes (e.g., mental health literacy, technological attitudes) [ 31 ], societal influences (e.g., stigma, peer support) [ 31 ], and environmental considerations (e.g., technology availability, access to mental health services). The cumulative insights garnered from this comprehensive literature review underscore the potential of technology as a convenient and accessible avenue for accessing mental health support among university students. However, it is essential to acknowledge that complexities and multifaceted dynamics underlie the factors influencing its utilization, and an array of challenges remain associated with its application in this context.

Likewise, a study conducted by Kern et al. [ 32 ] documented that 23.8% of users reported experiencing a positive impact on their mental health through the use of mental health applications. Notably, individuals who had received mental health services within the past 12 months exhibited a significantly higher propensity to embrace mental health apps in comparison to those who had not accessed such services. The allure of convenience, immediate availability, and confidentiality emerged as prevalent factors driving interest in Mental Health Apps (MHAs).

Furthermore, a study conducted by Free et al. [ 33 ] unveiled the unsurprising proliferation of numerous mobile applications designed to aid in the diagnosis, monitoring, and management of health conditions, albeit with varying levels of efficacy. Similarly, research by Brindal et al. [ 34 ] found that participants who had intermittent access to a smartphone app over a 4-week trial period demonstrated notable enhancements in indicators of emotional well-being. This broader observation suggests that uncomplicated and easily accessible solutions can yield substantial improvements in overall well-being. In addition, a study by Karyotaki et al. [ 35 ] reported the effectiveness of web-based interventions in mitigating the symptoms of depression and anxiety among college students.

Methodology

This was a multi-phase research design. In the first phase, a correlational research method was used for exploring the correlation among the research variables. In the second phase, we used a pretest–posttest randomized controlled trial to assess the effectiveness of a mindfulness-based mobile app intervention on symptoms of anxiety, loneliness, and well-being. Moreover, in the third phase, a qualitative research method was used for exploring the participants’ perceptions of mindfulness-based intervention.

Participants

Participants for this study were selected from graduate students at Zhoukou Vocational and Technical College in China. Three separate groups were recruited for the study. The first group consisted of 300 participants who were recruited for a correlational study related to question 1. The eligibility criteria for this group were as follows: participants must be graduate students at Fudan University and willing to participate in the study. The sample size was determined based on power analysis and the expected effect size. The second group consisted of 100 participants who were recruited for question 2. The eligibility criteria for this group were the same as for the first group. Participants were randomly assigned to either an intervention group or a control group. The third group consisted of 20 participants who were recruited for question 3. The eligibility criteria for this group were the same as for the first two groups. Participants were selected using purposive sampling based on their responses to the questionnaire in question 2. All participants provided informed consent prior to participating in the study. The study was approved by the Institutional Review Board at Zhoukou Vocational and Technical College. Participants were assured of confidentiality and the right to withdraw from the study at any time without penalty.

The following instruments were used to collect data for this study:

Social Anxiety Scale for Adolescents (SAS-A)

It is a 22-item self-report questionnaire that measures social anxiety in adolescents [ 36 ]. SAS-A assesses various aspects of social anxiety, including fear of negative evaluation, social avoidance and distress, and physiological symptoms such as sweating and blushing. Each item is measured on a 5-point Likert scale, ranging from 1 (not at all) to 5 (extremely). The total score on the SAS-A ranges from 22 to 110, with higher scores indicating higher levels of social anxiety.

Warwick-Edinburgh Mental Well-being Scale (WEMWBS)

It is a 14-item self-report questionnaire that measures mental well-being in adults and adolescents [ 37 ]. The items on the WEMWBS assess various aspects of mental well-being, including optimism, positive relationships, and a sense of purpose. Participants rate each item on a 5-point Likert scale, ranging from 1 (none of the time) to 5 (all of the time). The total score on the WEMWBS ranges from 14 to 70, with higher scores indicating higher levels of mental well-being. The fourth instrument was social.

Social Media Use Integration Scale (SMUIS)

The SMUIS is a 10-item self-report questionnaire that assesses the frequency, duration and emotional connection to social media use [ 38 ]. The SMUIS includes questions related to the frequency and duration of social media use, as well as questions related to the emotional connection to social media use, such as "How often do you feel happy when using social media?" and "How often do you feel anxious when you are not able to use social media?" Participants are asked to rate each item on a 5-point Likert scale, ranging from 1 (never) to 5 (always). The reliability of the instruments was estimated using Cronbach’s alpha. Results revealed that the obtained Cronbach’s alpha for the instrument was above, 0.78 indicating that all used instruments enjoyed an acceptable level of reliability.

Interview checklist

The interview checklist consisted of 8 open-ended questions followed by the interviewer’s prompts. The questions elicited the interviewees’ perceptions of the benefits and challenges of using mobile apps for improving mental health and well-being and reducing social anxiety symptoms and loneliness (See Additional file 1 ). The interview checklist was approved by 4 colleagues and there was a high agreement among the panel of experts regarding the relevance of the interview questions.

Mindfulness-based mobile apps

Mindfulness-based mobile apps are mobile applications designed to help individuals develop mindfulness skills and reduce symptoms of stress, anxiety, and depression. These apps typically include guided mindfulness exercises, educational resources, and other features to help individuals practice mindfulness on a regular basis. The specific features of mindfulness-based mobile apps may vary but typically include guided meditations, breathing exercises, and other mindfulness practices. Some apps may also include educational resources, such as articles or videos that provide information about mindfulness and its benefits. Many apps also include features for tracking progress, setting goals, and sharing progress with others. In this study, the participants who participated in the treatment phase were asked to download popular mindfulness-based mobile apps including Headspace, Calm, and Insight Timer. These apps are available for download on mobile devices and offer a range of mindfulness exercises and resources for users to explore.

The study was conducted in multiple steps. Initially, a sample of 300 graduate students from Fudan University was selected to participate in the research. These participants were asked to complete the Social Media Use Integration Scale (SMUIS) and the Depression Anxiety Stress Scales (DASS-21) to evaluate their social media use and mental health status. Next, a sample of 60 students from the same university was selected for the intervention study. These participants were randomly assigned to either an intervention group or a control group. The intervention group was given access to a mindfulness-based mobile app for eight weeks, while the control group received no intervention. Both groups completed the SMUIS and the DASS-21 at baseline, post-intervention, and three-month follow-up to evaluate the effectiveness of the intervention. Lastly, a qualitative study was conducted to gather in-depth information about the participants' experience with the mindfulness-based mobile app intervention. A purposive sample of 20 participants from the intervention group was selected for this study. They underwent semi-structured interviews to provide qualitative data about their perceptions and opinions regarding the intervention.

Data analysis

For the quantitative data, the statistical software was employed. Firstly, descriptive statistics were calculated to determine the mean, and standard deviation of the Social Media Use Integration Scale (SMUIS) and Depression Anxiety Stress Scales (DASS-21) scores, as well as the mean, and standard deviation of the SMUIS and DASS-21 scores at baseline, post-intervention, and three-month follow-up for both the intervention and control groups. Secondly, bivariate correlations were conducted to examine the relationship between social media use and symptoms of anxiety and depression. Thirdly, multiple regression analysis was performed to determine the unique contribution of social media use to symptoms of anxiety and depression while controlling for other relevant variables. Fourthly, repeated measures ANOVA was conducted to examine changes in SMUIS and DASS-21 scores over time and to determine if there were differences between the intervention and control groups. Finally, post hoc tests were conducted to examine differences between groups at each time point. Effect sizes were calculated to determine the magnitude of the intervention's effects. However, for the qualitative data, the qualitative analysis software was employed. Firstly, the transcripts of the semi-structured interviews were analyzed using thematic analysis to identify themes and subthemes related to participants' experiences with the mindfulness-based mobile app intervention. Secondly, quotes were selected to support and illustrate the identified themes and subthemes. Lastly, the themes and subthemes were interpreted and discussed to provide insight into participants' perceptions and opinions regarding the intervention.

Research question1

Pearson correlations between the variables were estimated and results are presented in Table 1 .

This table shows that social media use is negatively correlated with well-being ( r  = -0.21, p  < 0.01) and positively correlated with symptoms of social anxiety ( r  = -0.35, p  < 0.01) and loneliness ( r  = 0.24, p  < 0.01). Additionally, symptoms of social anxiety are positively correlated with loneliness ( r  = 0.47, p  < 0.01) and negatively correlated with well-being ( r  = -0.61, p  < 0.01), while loneliness is negatively correlated with well-being ( r  = -0.50, p  < 0.01). These results suggest that social media use is associated with poorer mental health outcomes, including higher levels of social anxiety and loneliness and lower levels of well-being, among university students.

Table 2 shows the results of a multiple regression analysis that examined the relationship between social media use, social anxiety, and loneliness as predictor variables and well-being as the outcome variable. The regression equation is:

The results indicate that all three predictor variables significantly contributed to the prediction of well-being, with social media use (β = -0.29, p  = 0.001), social anxiety (β = 0.31, p  = 0.001), and loneliness (β = 0.28, p  = 0.001) each having a significant unique effect on well-being, after controlling for the other variables. The constant term (B = 3.10, p  = 0.001) represents the predicted well-being score when all predictor variables are held at zero.

Research question 2

The second research aimed at investigating the effects of the intervention on the students’ social anxiety, loneliness, and well-being. Results are presented in Table 3 .

This table presents the results of a pretest–posttest randomized control-experimental research design investigating the effects of a mindfulness-based mobile app intervention on social anxiety, loneliness, and well-being in college students. The results indicate that the intervention group showed a significant improvement in social anxiety (F (1, 98) = 17.23, p  < 0.001, partial eta squared = 0.15), loneliness (F (1, 98) = 13.70, p  < 0.001, partial eta squared = 0.12), and well-being (F(1, 98) = 21.41, p  < 0.001, partial eta squared = 0.18) from pretest to posttest. The control group did not show significant changes in any of the measures. The effect sizes (partial eta squared) ranged from moderate to large, indicating that the intervention had a meaningful impact. These findings suggest that the use of a mindfulness-based mobile app intervention can be an effective approach for improving mental health outcomes in college students.

Research question 3

The third research question explored the students’ perceptions of the effects of mindfulness-based mobile apps on the students’ social anxiety, loneliness, and well-being. The detailed analysis of the interviews revealed 6 benefits and 4 challenges of using technology for mental health support. The first extracted benefit as mentioned by 10 students was thematically coded "Convenience and Accessibility". Participants reported that technology-based mental health support services are convenient and accessible, allowing them to access support anytime and anywhere. The following quotations exemplify the theme:

"I like using mental health apps because I can access them whenever I need to. I don't have to wait for an appointment or anything like that." (Student 3). Another student stated, "Online support groups are great because I can connect with people who have similar experiences no matter where I am."(student 11).

The second extracted benefit was thematically coded "Anonymity and Privacy". Participants appreciated the ability to access mental health support services online while maintaining anonymity and privacy. For instance, student 5 stated, "I like that I can access support without having to go to an office or talk to someone face-to-face. It feels less intimidating." This finding was also confirmed by student 6, who stated, "I feel more comfortable talking about my mental health online because I know that no one else needs to know about it."

The third extracted benefit was thematically coded "Customizable and Tailored Support". Participants appreciated the range of options available for mental health support online, including customizable and tailored support that they could access at their own pace. For instance, student 11 stated, "I like that I can choose the type of support that works for me. Some days I just need to read something and other days I need to talk to someone”. Similarly, student 6 stated, "The mental health app I use sends me reminders to check in with myself and practice self-care. It's nice to have that kind of tailored support."

The fourth extracted benefit was thematically coded as "Cost-effective". Participants reported that technology-based mental health support services are often more affordable than traditional face-to-face therapy, making them a more accessible option for those with limited financial resources. This finding was supported by student 17 who stated, "I can't afford traditional therapy, so using mental health apps is a great option for me since it's usually free or very affordable." Similarly, one of the students stated, “Online therapy is much cheaper than traditional therapy, so it's more accessible for people who can't afford to pay a lot."

The fifth extracted benefit was thematically coded as "Increased Awareness and Education". Participants reported that technology-based mental health support services helped them to become more aware of their mental health and provided education about mental health issues and coping strategies. For example, student 12 stated, "The mental health app I use has taught me a lot about mindfulness and how to manage my anxiety." Student 14 also stated, "I learned a lot about depression and how to cope with it from an online support group I joined."

The sixth extracted benefit was thematically coded as "Reduced Stigma". Participants reported that accessing mental health support services online helped to reduce the stigma associated with seeking mental health The following quotations exemplify the theme of support. For instance, one of the students stated, “I used to feel ashamed about seeking mental health support, but using mental health apps has helped me realize that it's okay to take care of my mental health." (Student 9). Similarly, another student argued, “Online support groups have helped me realize that I'm not alone in my struggles with mental health. It's nice to know there are others out there who understand."

Despite the above-mentioned benefits, the participants mentioned some challenges. The first extracted challenge was thematically coded "Quality and Accuracy of Information". Participants expressed concerns about the quality and accuracy of mental health information available online, and the potential for misinformation to be spread. For instance, student 11 stated, "There's so much information online, it's hard to know what's trustworthy and what's not." Another student stated, "I worry that some of the mental health information I see online is not based on evidence and could actually be harmful."(student 6).

The second extracted challenge was thematically coded as "Lack of Human Connection". Participants reported missing the human connection they would get from traditional face-to-face therapy and felt that technology-based mental health support services lacked the same level of personal connection. The following quotations from student 12 exemplify the theme:

"Sometimes I just need someone to talk to face-to-face. It's not the same as talking to a computer screen…. I miss the empathetic listening I would get from a therapist in person. It's hard to replicate that online."

The third extracted challenge was thematically coded as "Technical Difficulties". Participants reported experiencing technical difficulties with technology-based mental health support services, which could be frustrating and hinder their ability to access support. For instance, student 8 stated, “Sometimes the mental health app I use glitches or crashes, which can be really frustrating when I'm trying to use it for support…. I don't have the best internet connection, so sometimes it's hard to access online support groups."

The fourth extracted challenge was thematically coded "Privacy and Security Concerns". Participants expressed concerns about the privacy and security of their personal information when using technology-based mental health support services, and whether their information was being shared without their consent. As an example, student 13 stated, "I worry that my personal information could be shared without my consent, which would be a huge breach of trust." Student 9 also stated, “It's hard to know if my information is really secure when I'm using online mental health support services."

The study investigating the effects of mindfulness-based mobile apps on university students' anxiety, loneliness, and well-being in the context of social media usage is anchored in a multifaceted theoretical framework. At its core, the research draws upon mindfulness theory, a foundational framework emphasizing present-moment awareness and non-judgmental acceptance to alleviate stress and anxiety [ 5 , 6 , 7 , 8 ]. This theory forms the bedrock of the study's understanding, as mindfulness-based mobile apps are designed to foster these very principles, encouraging users to engage with the present, accept their experiences without judgment, and, in doing so, mitigate stress and anxiety.

In parallel, to fathom the intricate influence of social media on university students, the study leverages social cognitive theory, a framework highly pertinent for analyzing how individuals acquire and adapt behaviors, attitudes, and emotional responses through observation and modeling within their social networks [ 11 , 12 , 13 , 14 , 15 ]. Given the pervasive role of social media, this theory is essential for comprehending how the behaviors, emotions, and attitudes of students may be shaped by the content and interactions they encounter in the digital realm.

Moreover, the research takes into consideration social comparison theory, which underscores how social media users frequently engage in relentless self-comparisons with others, potentially fostering feelings of loneliness and social anxiety [ 11 , 12 , 13 , 14 , 15 ]. This theory is critical for acknowledging the "highlight reel" effect, wherein users predominantly share their positive experiences and achievements, inadvertently prompting social comparison and potentially engendering negative emotional responses.

In the exploration of the perceived addictiveness of mindfulness-based mobile apps, the study employs addiction and compulsive behavior theories. These theories unearth the underlying factors contributing to the allure and habit-forming nature of certain digital interventions, thereby offering valuable insights into the psychology of user engagement and potential addiction [ 12 , 13 ]. When assessing user acceptance and perceptions of mindfulness-based mobile apps, the study draws from technology acceptance models (TAM). TAM provides a valuable framework for unraveling the intricacies of user adoption and attitudes toward technology-based interventions, elucidating critical factors like perceived usefulness and ease of use, which shed light on participants' acceptance of these apps [ 12 , 13 ].

Furthermore, the research aligns with the principles of positive psychology, a framework that centers on the enhancement of human well-being and strengths. The study's focus on bolstering well-being and mitigating anxiety and loneliness aligns closely with the core tenets of positive psychology, making it a pertinent theoretical perspective [ 12 , 13 ].

Lastly, media effects theories, such as cultivation theory and uses and gratifications theory, play a pivotal role in offering insights into how social media usage affects students' mental health and well-being [ 13 ]. Cultivation theory underscores the potential long-term impact of repeated exposure to media content, while uses and gratifications theory delves into how individuals actively use and engage with media to fulfill specific needs and gratifications.

By encompassing this multifaceted theoretical approach, the study constructs a comprehensive foundation for unraveling the intricate relationship between technology, psychology, and well-being in the digital age. This holistic perspective serves as a valuable compass in navigating the complexities of the research questions at hand, offering a deeper understanding of how these factors interconnect and influence one another [ 12 , 13 ]. Additionally, the study incorporates media effects theories to further enrich its theoretical foundation. Cultivation theory, as one of the key media effects theories, underlines the potential long-term consequences of repeated exposure to media content. Given the omnipresence of social media in the lives of university students, understanding how continuous media exposure might shape their perceptions and attitudes is crucial [ 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. Moreover, uses and gratifications theory plays a pivotal role by exploring how individuals actively engage with media to fulfill specific needs and gratifications. In the context of the study, this theory sheds light on why students turn to social media, whether it's for social interaction, information seeking, or entertainment, and how these purposes might be linked to their mental well-being [ 13 ].

To round out the comprehensive theoretical framework, the study interweaves elements of positive psychology. This perspective emphasizes the enhancement of human well-being, positive emotions, and strengths. By striving to boost well-being and alleviate symptoms of anxiety and loneliness, the study directly aligns with the core principles of positive psychology. Positive psychology focuses on fostering qualities like resilience, optimism, and emotional intelligence, which are highly relevant to the study's objectives [ 46 , 47 , 48 , 49 , 50 ]. Thus, this framework adds a positive, growth-oriented dimension to the study's theoretical foundation, underscoring the importance of not only addressing negative mental health outcomes but also promoting positive psychological well-being [ 12 , 13 ].

In summary, the multifaceted theoretical framework encompassing mindfulness theory, social cognitive theory, social comparison theory, addiction and compulsive behavior theories, technology acceptance models (TAM), positive psychology, and media effects theories creates a robust and comprehensive foundation for unraveling the intricate relationship between technology, psychology, and well-being in the digital age. This holistic perspective enables the study to navigate the complexities of its research questions, offering a deeper understanding of how these factors interconnect and influence one another, and providing valuable insights into the impact of technology-driven interventions on the mental well-being of university students.

Conclusions

It can be concluded that the current findings add to the growing body of literature suggesting that social media use is linked to negative mental health outcomes. However, it is important to note that the causal direction of these relationships remains unclear. Although social media use may contribute to negative mental health outcomes, it is also possible that individuals who are already experiencing symptoms of anxiety and loneliness may use social media as a coping mechanism or to seek social support. Therefore, more research is needed to understand the complex relationship between social media use and mental health outcomes. It can also be concluded that the use of technology-based interventions can provide increased accessibility and convenience, anonymity and privacy, customizable and tailored support, cost-effectiveness, increased awareness and education, and reduced stigma. These findings demonstrate the potential of technology to offer effective and accessible mental health support for individuals in need.

The implications of investigating the relationship between social media usage and students' social anxiety, loneliness, and well-being within the context of digital mindfulness-based intervention are multifaceted. Firstly, as social media becomes increasingly integrated into students' lives, the study underscores the significance of understanding its potential repercussions on mental health. The findings can offer valuable insights to educational institutions, mental health professionals, and policymakers, prompting them to recognize the importance of promoting responsible social media usage among students. Secondly, the study's exploration of the effectiveness of digital mindfulness-based interventions in alleviating social anxiety, loneliness, and enhancing well-being holds significant implications for mental health intervention strategies. If proven efficacious, these interventions could serve as a practical and accessible means of addressing the psychological challenges posed by social media usage. This could potentially guide the development of tailored programs aimed at improving students' mental health and emotional resilience in the digital age. Furthermore, the study's focus on digital mindfulness-based interventions acknowledges the evolving nature of psychological interventions in the digital era. The implications of successful intervention highlight the potential of technology-assisted approaches to bridge the gap between traditional therapeutic methods and the modern digital landscape. This insight could inspire further innovation in mental health care, encouraging the integration of technology to reach wider audiences and promote positive mental well-being [ 51 ].

The current study also provides evidence that the intervention was effective in improving mental health outcomes over time. However, the study design does not allow us to determine the specific mechanisms by which the intervention was effective. Therefore, more research is needed to better understand how interventions can be optimized to improve mental health outcomes. Finally, while technology-based interventions can provide benefits such as convenience and accessibility, concerns about the quality and accuracy of mental health information available online, the lack of personal connection compared to traditional face-to-face therapy, and technical difficulties with accessing support have been reported by participants in this study.

Availability of data and materials

The data will be made available upon request from the author ( email: [email protected]).

Andersson G. Internet-delivered psychological treatments. Annu Rev Clin Psychol. 2016;12:157–79. https://doi.org/10.1146/annurev-clinpsy-021815-093006 .

Article   PubMed   Google Scholar  

Khoury B, Lecomte T, Fortin G, Masse M, Therien P, Bouchard V, Chapleau MA, Paquin K, Hofmann SG. Mindfulness-based therapy: a comprehensive meta-analysis. Clin Psychol Rev. 2013;33(6):763–71. https://doi.org/10.1016/j.cpr.2013.05.005 .

Kross E, Verduyn P, Demiralp E, Park J, Lee DS, Lin N, Shablack H, Jonides J, Ybarra O. Facebook use predicts declines in subjective well-being in young adults. PLoS ONE. 2013;8(8):e69841. https://doi.org/10.1371/journal.pone.0069841 .

Article   PubMed   PubMed Central   Google Scholar  

Twenge JM, Joiner TE, Rogers ML, Martin GN. Increases in depressive symptoms, suicide-related outcomes, and Suicide rates among U.S. adolescents after 2010 and links to increased new media screen time. Clin Psychol Sci. 2018;6:3–17. https://doi.org/10.1177/2167702617723376 .

Article   Google Scholar  

Boot WR, Kramer AF, Simons DJ, Fabiani M, Gratton G. The effects of video game playing on attention, memory, and executive control. Acta Psychol (Amst). 2008;129(3):387–98. https://doi.org/10.1016/j.actpsy.2008.09 .

Green CS, Bavelier D. Learning, attentional control, and action video games. Curr Biol. 2012;22(6):R197–206. https://doi.org/10.1016/j.cub.2012.02.012 .

Anderson CA, Shibuya A, Ihori N, Swing EL, Bushman BJ, Sakamoto A, Rothstein HR, Saleem M. Violent video game effects on aggression, empathy, and prosocial behavior in eastern and western countries: a meta-analytic review. Psychol Bull. 2010;136(2):151–73. https://doi.org/10.1037/a0018251 .

Gentile DA, Anderson CA, Yukawa S, Ihori N, Saleem M, Ming LK, Shibuya A, Liau AK, Khoo A, Bushman BJ, Rowell Huesmann L, Sakamoto A. The effects of prosocial video games on prosocial behaviors: international evidence from correlational, longitudinal, and experimental studies. Pers Soc Psychol Bull. 2009;35(6):752–63. https://doi.org/10.1177/0146167209333045 .

Tran S, Smith L, El-Den S, Carter S. The Use of Gamification and incentives in Mobile Health apps to improve Medication Adherence: scoping review. JMIR Mhealth Uhealth. 2022;10(2):e30671. https://doi.org/10.2196/30671 .

Wahbeh H, Goodrich E, Goy E, Oken BS. Mechanistic pathways of Mindfulness Meditation in Combat Veterans with Posttraumatic stress disorder. J Clin Psychol. 2016;72(4):365–83. https://doi.org/10.1002/jclp.22255 .

Lai F, Wang L, Zhang J, Shan S, Chen J, Tian L. Relationship between Social Media Use and social anxiety in College students: Mediation Effect of Communication Capacity. Int J Environ Res Public Health. 2023;20(4):3657. https://doi.org/10.3390/ijerph20043657 .

Seabrook EM, Kern ML, Rickard NS, Social Networking Team. (2016). Social networking sites, depression, and anxiety: a systematic review. JMIR Mental Health, 3(4), e50.

Zhang M, Sun X, Qin X, et al. Problematic utilization of online social networking site in Chinese college students: prediction of personality and dynamic mediators. Curr Psychol. 2022. https://doi.org/10.1007/s12144-022-03150-7 .

Tandoc EC Jr, Ferrucci P, Duffy M. Facebook use, envy, and depression among college students: Is facebooking depressing? Comput Hum Behav. 2015;43:139–46.

Ulvi O, Karamehic-Muratovic A, Baghbanzadeh M, Bashir A, Smith J, Haque U. Social Media Use and Mental Health: A Global Analysis. Epidemiologia (Basel). 2022;3(1):11–25. https://doi.org/10.3390/epidemiologia3010002 .

Schønning V, Hjetland GJ, Aarø LE, Skogen JC. Social Media Use and Mental Health and Well-Being Among Adolescents - A Scoping Review. Front Psychol. 2020;14(11):1949. https://doi.org/10.3389/fpsyg.2020.01949 .

Sharma MK, John N, Sahu M. Influence of social media on mental health: a systematic review. Curr Opin Psychiatry. 2020;33(5):467–75. https://doi.org/10.1097/YCO.0000000000000631 .

Köse ÖB, Doğan A. (2019). The Relationship between Social Media Addiction and Self-Esteem among Turkish University Students. Addicta: The Turkish journal on addictions, 6(1).

Błachnio A, Przepiorka A, Senol-Durak E, Durak M, Sherstyuk L. The role of personality traits in Facebook and Internet addictions: a study on Polish, Turkish, and Ukrainian samples. Comput Hum Behav. 2017;68:269–75.

Chen B, Vansteenkiste M, Beyers W, Boone L, Deci EL, Van der Kaap-Deeder J, Verstuyf J. Basic psychological need satisfaction, need frustration, and need strength across four cultures. Motivation Emotion. 2015;39:216–36.

Seabrook EM, Kern ML, Rickard NS. (2016). Social networking sites, depression, and anxiety: a systematic review. JMIR Mental Health, 3(4), e5842.

Linardon J, Cuijpers P, Carlbring P, Messer M, Fuller-Tyszkiewicz M. The efficacy of app‐supported smartphone interventions for mental health problems: a meta‐analysis of randomized controlled trials. World Psychiatr. 2019;18(3):325–36.

Strauss C, Gu J, Montero-Marin J, Whittington A, Chapman C, Kuyken W. Reducing stress and promoting well-being in healthcare workers using mindfulness-based cognitive therapy for life. Int J Clin Health Psychol. 2021;21(2):100227.

Lomas T, Medina JC, Ivtzan I, Rupprecht S, Eiroa-Orosa FJ. A systematic review of the impact of mindfulness on the well‐being of healthcare professionals. J Clin Psychol. 2018;74(3):319–55.

Valinskas S, Nakrys M, Aleknavicius K, Jonusas J. Sensa Mobile App for Managing Stress, Anxiety, and Depression Symptoms: Pilot Cohort Study. JMIR Form Res. 2023;13(7): e40671. https://doi.org/10.2196/40671 .

Biegel GM, Brown KW, Shapiro SL, Schubert CM. Mindfulness-based stress reduction for the treatment of adolescent psychiatric outpatients: a randomized clinical trial. J Consult Clin Psychol. 2009;77(5):855–66. https://doi.org/10.1037/a0016241 .

Birnbaum ML, Ernala SK, Rizvi AF, Arenare E, Van Meter R, De Choudhury A, Kane M. Detecting relapse in youth with psychotic disorders utilizing patient-generated and patient-contributed digital data from Facebook. NPJ Schizophr. 2019;5(1):17.

Fuller-Tyszkiewicz M, Richardson B, Little K, Teague S, Hartley-Clark L, Capic T, and Hutchinson, D. Efficacy of a smartphone app intervention for reducing caregiver stress: randomized controlled trial. JMIR mental health. 2020;7(7):e17541.

Rathbone AL, Prescott J. The use of mobile apps and SMS messaging as physical and Mental Health Interventions: systematic review. J Med Internet Res. 2017;19(8):e295. https://doi.org/10.2196/jmir.7740 .

Kim S, Kim E. The use of virtual reality in Psychiatry: a review. Soa Chongsonyon Chongsin Uihak. 2020;31(1):26–32. https://doi.org/10.5765/jkacap.190037 .

Deady M, Johnston D, Milne D, Glozier N, Peters D, Calvo R, Harvey S. Preliminary effectiveness of a smartphone app to reduce depressive symptoms in the workplace: feasibility and acceptability study. JMIR Mhealth Uhealth. 2018;6(12):e11661.

Kern A, Hong V, Song J, Lipson SK, Eisenberg D. Mental health apps in a college setting: openness, usage, and attitudes. Mhealth. 2018;4:20. https://doi.org/10.21037/mhealth.2018.06.01 .

Free C, Phillips G, Galli L, et al. The effectiveness of mobile-health technology-based health behavior change or Disease management interventions for health care consumers: a systematic review. PLoS Med. 2013;10:e1001362. https://doi.org/10.1371/journal.pmed.1001362 .

Brindal E, Kakoschke N, Golley S, Rebuli M, Baird D. Effectiveness and feasibility of a self-guided Mobile App Targeting Emotional Well-being in healthy adults: 4-Week randomized controlled trial. JMIR Ment Health. 2023;10:e44925. https://doi.org/10.2196/44925 .

Karyotaki E, Klein AM, Riper H, Wit L, Krijnen L, Bol E, Bolinski F, et al. Examining the effectiveness of a web-based intervention for symptoms of depression and anxiety in college students: study protocol of a randomised controlled trial. BMJ Open. 2019;9(5):e028739. https://doi.org/10.1136/bmjopen-2018-028739 .

Alam N, Ahmed O, Naher L, Hiramoni FA. The psychometric properties of social anxiety scale for adolescents (SAS-A) short form-bangla. Heliyon. 2021;7(8):e07801. https://doi.org/10.1016/j.heliyon.2021.e07801 .

Stewart-Brown S, Tennant A, Tennant R, Platt S, Parkinson J, Weich S. (2009). Short Warwick–Edinburgh Mental Well-being Scale (SWEMWBS).

Jenkins-Guarnieri MA, Wright SL, Johnson B. Development and validation of a social media use integration scale. Psychol Popular Media Cult. 2013;2(1):38–50.

Garett R, Liu S, Young SD. The Relationship between Social Media Use and Sleep Quality among undergraduate students. Inf Commun Soc. 2018;21(2):163–73. https://doi.org/10.1080/1369118X.2016.1266374 .

Chou HT, Edge N. They are happier and having better lives than I am: the impact of using Facebook on perceptions of others’ lives. Cyberpsychol Behav Soc Netw. 2012;15(2):117–21. https://doi.org/10.1089/cyber.2011.0324 .

Carpenter JK, Andrews LA, Witcraft SM, Powers MB, Smits JA, Hofmann SG. Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of randomized placebo‐controlled trials. Depress Anxiety. 2018;35(6):502–14.

Zhang H, Zhang A, Liu C, et al. A brief online mindfulness-based group intervention for psychological distress among Chinese residents during COVID-19: a pilot randomized controlled trial. Mindfulness. 2021;12:1502–12. https://doi.org/10.1007/s12671-021-01618-4 .

Sucala M, Cuijpers P, Muench F, Cardoș R, Soflau R, Dobrean A, Achimas-Cadariu P, David D. Anxiety: there is an app for that. a systematic review of anxiety apps. Depress Anxiety. 2017;34(6):518–25. https://doi.org/10.1002/da.22654 .

Saddichha S, Al-Desouki M, Lamia A, Linden IA, Krausz M. Online interventions for depression and anxiety - a systematic review. Health Psychol Behav Med. 2014;2(1):841–81. https://doi.org/10.1080/21642850.2014.945934 .

Andersson G, Cuijpers P. Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cogn Behav Ther. 2009;38(4):196–205. https://doi.org/10.1080/16506070903318960 .

Proudfoot J, Klein B, Barak A, Carlbring P, Cuijpers P, Lange A, Ritterband L, Andersson G. Establishing guidelines for executing and reporting internet intervention research. Cogn Behav Ther. 2011;40(2):82–97. https://doi.org/10.1080/16506073.2011.573807 .

Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet. 2020;395(10223):470–3. https://doi.org/10.1016/S0140-6736(20)30185-9 .

Eysenbach G. (2011). Can tweets predict citations? Metrics of social impact based on Twitter and correlation with traditional metrics of scientific impact. J Med Internet Res, 13(4), e123.

Griffiths KM, Christensen H, Jorm AF. Predictors of depression stigma. BMC Psychiatr. 2008;8:25. https://doi.org/10.1186/1471-244X-8-25 .

Andersson G, Titov N, Dear BF, Rozental A, Carlbring P. Internet-delivered psychological treatments: from innovation to implementation. World Psychiatr. 2019;18(1):20–8. https://doi.org/10.1002/wps.20610 .

Mohr DC, Burns MN, Schueller SM, Clarke G, Klinkman M. Behavioral intervention technologies: evidence review and recommendations for future research in mental health. Gen Hosp Psychiatr. 2013;35(4):332–8.

Download references

Acknowledgements

The authors would like to thank all participants.

Phased Results of Key Projects of Vocational Education and Teaching Reform in Henan Province in 2021 (Project No.: Yujiao [2021] 57946).

Author information

Authors and affiliations.

School of Marxism, Zhoukou Vocational and Technical College, Zhoukou, 466000, China

You can also search for this author in PubMed   Google Scholar

Contributions

Li Sun designed the study. Li Sun collected the data. Li Sun analyzed and interpreted the data, drafted the manuscript, proofread the paper, and verified the submitted version.

Corresponding author

Correspondence to Li Sun .

Ethics declarations

Ethics approval and consent to participate.

The ethical approval committee of Zhoukou Vocational and Technical College approved this study and issued a letter (No. 2023.2623), indicating the study has no side effects on the participants of the study. All experiments were performed in accordance with relevant guidelines and regulations. All methods were carried out in accordance with relevant guidelines and regulations.

Informed consent was obtained from all subjects.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Sun, L. Social media usage and students’ social anxiety, loneliness and well-being: does digital mindfulness-based intervention effectively work?. BMC Psychol 11 , 362 (2023). https://doi.org/10.1186/s40359-023-01398-7

Download citation

Received : 29 August 2023

Accepted : 16 October 2023

Published : 31 October 2023

DOI : https://doi.org/10.1186/s40359-023-01398-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Mindfulness
• Social anxiety
• Social media usage

BMC Psychology

ISSN: 2050-7283

• General enquiries: [email protected]

Case-based learning: anxiety disorders

There are many types of anxiety disorders with varying levels of severity. Pharmacists should know the treatment options that are available and how to support patients. 

Shutterstock.com

Anxiety is a common mental health condition that affects approximately 6.6% of the population in England each week, along with one in six adults experiencing or being identified as having a common mental health condition per week [1] , [2] . Data suggest that women are almost twice as likely to be diagnosed with anxiety compared with men; however, the reason for this is unclear [3] , [4] . Although a large number of people are affected by mental health conditions (e.g. anxiety or depression), only 39% of adults aged 16–74 years are accessing treatment for them [5] .

Mental health conditions typically worsen over time and can negatively impact on social activities, relationships, career performance, academic work and general quality of life [6] . As such, patients that present with conditions, such as generalised anxiety disorder (GAD), are frequently seen in the community, with pharmacists having the opportunity to significantly impact on the patient’s quality of life by providing information on the treatment options that are available [7] . While occasional anxiety is a normal aspect of day-to-day life, persistent symptoms can indicate the possible presence of an anxiety disorder, which can often be debilitating. Anxiety has also been known to precipitate physiological responses, such as tachycardia and hyperhidrosis [8] . ’Functional impairment’ is a term that is often used to describe the degree to which an illness can limit a person’s ability to carry out some of their normal daily tasks; anxiety can affect this to differing degrees [9] .

There are multiple factors that could predispose or potentially encourage the manifestation of anxiety, which are often attributable to a combination of genetic and environmental factors [10] . In addition, studies suggest that alcohol and illicit drug use, particularly the use of stimulants and hallucinogens, are associated with higher rates of incidence [11] , [12] . Instances of childhood abuse and sexual abuse are also identified as potential causative factors for anxiety and depression [13] . However, there is a broad range of patients affected by anxiety, for whom there is often an unknown cause.

Types of anxiety

Anxiety disorder is an inclusive term for several disorders, including:

• Panic disorder;
• Selective mutism;
• Separation anxiety;
• Social anxiety disorder [14] .

The most common types of anxiety disorder include:

• Social anxiety disorder — this is considered to be the most common form of anxiety; in up to 50% of cases, it is present in individuals by age 11 years [15] . Symptoms include a persistent fear of social performance, panic attacks and a large fear of humiliating oneself in public [15] ;
• Phobic disorder — this broadly refers to a fear of places, situations, objects and animals. For example, agoraphobia is often considered to be simply a fear of open spaces, but it is far more serious and can include a fear of being in a place that individuals will find difficult to escape from or receive aid if things go wrong [16] .

Avoidance behaviour is common to both social anxiety disorder and phobic disorder, with patients actively trying not to encounter the feared stimulus (e.g. avoiding going outside, such as in cases of agoraphobia) [17] , [18] , [19] . This behaviour can hugely impact on a patient’s ability to maintain functional capacity.

Symptoms and diagnosis

Symptoms may involve feelings of restlessness, palpitations, problems with concentrating, uncontrollable worry, sleep disturbances and general irritability [6] .

Diagnosis of anxiety would initially be made by a GP following a comprehensive review of the following:

• Symptomatic presentation of the patient;
• Frequency of symptoms;
• Degree of severity of distress;
• Functional impairment.

History of substance misuse, comorbidities and past medical history should be considered as part of a holistic approach to diagnosis [20] .

In addition, differential diagnoses must be considered before a formal diagnosis is made. Anaemia and hyperthyroidism are two conditions that must be ruled out and/or treated as they can both manifest symptoms of anxiety disorders [21] , [22] . Blood analysis and further tests may be necessary to ensure a correct diagnosis is made [22] , [23] . As stated by the National Institute for Health and Care Excellence (NICE), diagnostic tools, such as the Diagnostic and Statistical Manual of Mental Disorders , can be utilised for anxiety disorders [21] . The criteria include a minimum of six months of incessant and uncontrollable worries, disproportionate to actual risk, and three of the following symptoms:

• Being easily fatigued;
• Irritability;
• Muscle tension;
• Poor concentration;
• Restlessness/nervousness;
• Sleep disturbance [21] .

The ‘International Classification of Diseases, 10th revision’, a disease classification tool, offers a similar criteria [21] . There are also other resources available to healthcare professionals to work through with patients, such as the GAD-7 questionnaire for anxiety and the personal health questionnaire-9 (PHQ-9) for depression [21] . Questions typically ask how frequently certain symptoms have occurred in the preceding two weeks. Both GAD-7 and PHQ-9 allow assessors to distinguish between anxiety and depression, and provide an indication as to the severity of presentation, which can guide therapy. These are typically asked by a GP during an initial consultation with the patient and may include questions such as: ‘Over the past two weeks, how often have you been bothered by feeling nervous, anxious or on edge?’ [24]

The GAD-7 questionnaire can also be used as a tool to determine the severity of its presentation, with scores of 5 and above, 10 and above, and 15 and above (out of a possible 21) referring to mild, moderate and severe anxiety, respectively [25] . Higher scores are strongly associated with functional impairment, although individual characteristics of presentation will affect how the patient is treated.

Pharmacological treatment

For patients with mild anxiety, pharmacotherapy is not recommended. However, as per NICE guidelines, pharmacological treatment is recommended where significant functional impairment exists [26] . First-line drug treatment involves selective serotonin reuptake inhibitors (SSRIs; e.g. sertraline or fluoxetine) [26] .

SSRIs are widely used for GAD and are often well tolerated. In addition, they are considered to be safer in overdose than most other similarly indicated medicines, because they carry a lower risk of cardiac conduction abnormalities and seizures [27] , [28] , [29] . Selective serotonin–noradrenaline reuptake inhibitors (SNRIs; e.g. duloxetine and mirtazapine) are a suitable alternative; pregabalin is a tertiary option if the others are unsuitable or poorly tolerated [26] .

It is important to manage the patients’ expectations with pharmacological therapies. Providing a clear message that it could take between four and six weeks before the patient notices a benefit from their medicine is essential, as this will help ensure that they take their medication as directed. Patients should also be made aware of side effects and the withdrawal process (e.g. associated side effects) prior to commencing therapy [26] .

Common side effects of SSRIs include abnormal appetite, arrhythmias, impaired concentration, confusion, gastrointestinal discomfort and sleep disorders [27] . The incidence of side effects is reported to be highest within the first two weeks of starting treatment [30] . Although most common side effects tend to improve over time, sexual dysfunction can persist [31] . There is an increased risk with SSRIs in certain patient groups (e.g. young adults, children and patients with a previous history of suicidal behaviour) of suicidal ideation and self-harm; therefore, initiation of SSRIs must be reviewed weekly in those under aged under 30 years for the first four weeks of treatment. If the risk of recurrent suicidal behaviour is a concern, the healthcare professional may want to seek advice from the local crisis or home-based treatment team; SSRIs generally have a better safety profile than other drugs used for anxiety, but may require frequent monitoring in this case [32] , [26] .

SSRIs are one of several classes of medicines that pose a risk for long QT syndrome, which occurs as a result of a prolonged QT interval on the electrocardiogram measurements of the heart. This can lead to torsades de pointes (a specific type of abnormal heart rhythm) and possible sudden cardiac death [33] [34] , [35] .

It is important that SSRIs are withdrawn slowly to minimise the occurrence of SSRI discontinuation syndrome — an abrupt cessation of treatment that can cause a combination of psychological and physiological symptoms; the most common including nausea, dizziness, headache and lethargy [36] . Tapering drug doses slowly over several weeks will mitigate the effects of the withdrawal and minimise unnecessary re-initiation of the SSRI [37] .

Considerations for selective serotonin reuptake inhibitors and selective serotonin–noradrenaline reuptake inhibitors

Serotonin syndrome is a serious side effect that can occur with the use of SSRIs and SNRIs. It occurs as a result of overactivation of the 5-HT1A and 5-HT2A receptors, precipitated by serotonergic drug use [38] . Symptoms typically range from confusion and agitation to more serious symptoms, such as seizures, arrhythmias and loss of consciousness [31] . The risk of the syndrome is higher if patients are taking other medicines that can increase serotonin levels in the brain, such as tramadol and metoclopramide. Taking 5-HT1F agonists, which include sumatriptan, or a combination of medicines with the same effect, can also increase risk [39] .

If a decision is made to initiate an SSRI, despite the associated risk, patients should be provided with suitable information concerning the syndrome, which can be found on or printed from the NHS website [31] . If a patient experiences symptoms of serotonin sydrome, they should be advised to contact their GP surgery immediately. If this is unavailable, they should call NHS 111 for advice.

Alongside serotonin syndrome, SSRIs have been known to contribute to inappropriate antidiuretic hormone secretion, which is related to hyponatremia and has symptoms including headache, insomnia, nervousness and agitation [40] . 

Patients with anxiety disorders should be monitored as frequently as the severity of the disorder demands, which is essential to protect patients and improve their quality of life. Guidance from the British National Formulary states that patients being initiated on an SSRI should be reviewed every one to two weeks after initiation, with response being assessed at four weeks to determine whether continuation of the drug is suitable [27] . NICE guidelines expand on this by encouraging three-monthly reviews of drug therapy to assess clinical effectiveness [20] .

Non-pharmacological treatment

Patients should be advised to minimise alcohol intake and make time for activities they find relaxing. They should also be encouraged to exercise every day, aiming to do 150 minutes of moderate-intensity exercise (e.g. walking or cycling) per week as exercising has been shown to improve mental health [41] , [42] . A study has demonstrated that those who exercise had 43.2% fewer days of poor mental health, with team sports having the largest association with reduction in mental health burden [43] .

Psychological treatment

Cognitive behavioural therapy (CBT) is a common psychological treatment used for those with anxiety. This therapy aims to transform negative thinking into more structured thought patterns, which then assist the patient in making changes to their thought processes to encourage positive thinking. CBT is suitable for patients that present with ongoing anxiety and does not look at patient history [34] . This type of treatment may be useful for patients with mild anxiety, as an addition to medicine or for those who do not wish to take medicine. It can be conducted individually or as part of a group.

Guided self-help — a process by which a patient is able to work through a course with the support of a trained therapist — and counselling are other treatments available through the NHS that may benefit patients with mild anxiety or as an adjunct to prescription medicines [44] .

Specialist referral and suicide risk

Specialist referral should be considered if patients:

• Have not responded to initial therapy;
• Have comorbidities, such as alcohol or substance misuse;
• Are at significant suicide risk.

Healthcare professionals should always assess suicide risk by discussing the patients’ feelings about self-harm openly and considering other contributing factors, such as the use of prescribed or illicit drugs. Healthcare professionals must take opportunities to make interventions — for example, referring patients for urgent mental health assessment or in the case of serious concerns, calling emergency services [23] .

In the UK, area-specific community programmes and the charity  Anxiety UK  can provide patients with further advice on managing their anxiety. However, many primary care networks are now recruiting social prescribers, who will have the ability to direct patients to attend local groups that are more suited to individual needs. Community pharmacists are also likely to be aware of local support networks.

Case studies

Case study 1: a woman taking interacting medicines

Joanne*, a woman aged 65 years, approaches the pharmacy counter. She is concerned about heart palpitations she has been experiencing recently.

After inviting Joanne into the consultation room, you ask her if she is taking any medicines. She says that she is taking amitriptyline for the pain in her legs. She has also recently started taking a new medicine and states that she is on other medicines, but cannot recall the names. You ask for permission to view her summary care record and note that there is furosemide on her list of medicines. She was started on citalopram two weeks prior and was prescribed a seven-day course of clarithromycin three days ago.

You are concerned that Joanne is experiencing long QT syndrome, since the selective serotonin reuptake inhibitor (SSRI) citalopram is a risk factor for QT prolongation — as are the tricyclic antidepressant amitriptyline and the antibiotic clarithromycin [33] , [45] , [46] . In addition, furosemide can also precipitate hypokalaemia, which has been known to affect the QT interval [47] .

Advice and recommendations

You advise Joanne to stop taking the citalopram that has been prescribed to her until she can see a GP, which is a matter of urgency, as you believe it could be related to the medicines she is taking. You advise that she should try and get a same-day appointment if possible. The GP will likely request an electrocardiogram and stop the SSRI if results demonstrate long QT syndrome.

Case study 2: a man with concerns about his medicine

Gareth*, an investment banker aged 52 years, attends the pharmacy and asks to purchase sildenafil over the counter, owing to his erectile dysfunction. He is referred to you and you sit with him in the consultation room.

During the consultation, you begin to ask questions about his history and whether the erectile dysfunction is a new condition that he is experiencing. He states that he has been worried about it for the last couple of months. You then discuss his lifestyle and ask him questions about his medicines, in which he states he started taking a new medicine, fluoxetine, several months ago. He has been under significant stress at his workplace and was started on fluoxetine owing to his anxiety.

You consider the following:

• The erectile dysfunction that Gareth is experiencing could be related to the stress he is experiencing as part of his work;
• The possibility there could be an underlying reason for the problem related to his general health;
• That the prescribed fluoxetine may be causing his erectile dysfunction because this is a side effect of selective serotonin reuptake inhibitors [48] .

You explain your rationale with Gareth and indicate that you do not think it is appropriate to sell him sildenafil now. You suggest he goes back to his GP to discuss the symptoms that he has been having. The GP may decide to try an alternative medicine, but, given that he has been taking the fluoxetine for a few months, he should not discontinue it until advised to do so by his GP. You explain that if his GP advises him to stop the medicine, there will be a specific withdrawal process to minimise the side effects and that you would be able to advise him on this.

Case study 3: a man who is displaying symptoms of moderate anxiety

Anton*, a university graduate aged 21 years, attends the pharmacy and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge.

You invite Anton into the consultation room and ask him about his symptoms. He states that he has started a new job and that the palpitations start when he is feeling anxious. His symptoms are occurring most days of the week and he says it makes him “feel on edge”. He adds that he does not want to socialise with his co-workers. It is starting to affect his sleep and he does not know what to do. He also states that he has occasional pain in his chest.

Treatment options

Anton is demonstrating symptoms of moderate anxiety, given his desire to avoid socialising, and has a degree of functional impairment. However, as he has potential cardiac symptoms, these issues could be related to another condition.

When questioned, he confirms he has no other problems with his health, but you feel the patient needs further investigation — for example, an electrocardiogram test to measure the electrical activity of his heart to rule out underlying cardiac problems. His presentation concerns you and you feel he needs to see a doctor today to assess the differential diagnosis, as you are worried about his chest pain and palpitations.

You encourage Anton by saying that it is great that he felt he could talk to a pharmacist about this, but explain that he would benefit from a consultation with a GP. You explain that his symptoms could be related to anxiety and that you think he may need something to help him manage. He agrees to let you contact his local practice. As you have a good relationship with the practice, you manage to secure an appointment for him to see a GP that day. If a GP appointment had been unavailable, you could have telephoned NHS 111 for Anton to seek access to support.

*All cases are fictional

Useful resources

• NHS: Do I have an anxiety disorder?

[1] Fineberg NA, Haddad PM, Carpenter L et al . The size, burden and cost of disorders of the brain in the UK. J Psychopharmacol 2013;27(9):761–770. doi: 10.1177/0269881113495118

[2] Anxiety UK. Frequently asked questions. 2018. Available at: https://www.anxietyuk.org.uk/get-help/anxiety-information/frequently-asked-questions/ (accessed May 2020)

[3] No Panic. Anxiety statistics. 2018. Available at: https://nopanic.org.uk/anxiety-statistics/ (accessed May 2020)

[4] NHS England. Women are more likely to suffer from anxiety than men. 2016. Available at: https://www.nhs.uk/news/mental-health/women-are-more-likely-to-suffer-from-anxiety-than-men/ (accessed May 2020)

[5] NHS Digital. Adult psychiatric morbidity survey: Survey of mental health and wellbeing, England 2014. 2014. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014 (accessed May 2020) 

[6] National Institute of Mental Health. Anxiety disorders. 2018. Available at: https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml (accessed May 2020)

[7] Braga SFF, Clark KJ & Shirer AE. US Pharm.  An overview of generalized anxiety disorder for the community pharmacist. 2019. Available at:  https://www.uspharmacist.com/article/an-overview-of-generalized-anxiety-disorder-for-the-community-pharmacist (accessed May 2020)

[8] McLeod DR, Hoehn-Daric R & Stefan RL. Somatic symptoms of anxiety: comparison of self-report and physiological measures. Biol Psychiatry 1986;21(3):301–310. doi: 10.1016/0006-3223(86)90051-x

[9] Ustün B & Kennedy C. What is “functional impairment”? Disentangling disability from clinical significance. World Psychiatry 2009;8(2):82–85. doi: 10.1002/j.2051-5545.2009.tb00219.x

[10] Durbano F.  A Fresh Look at Anxiety Disorders . InTech: Croatia; 2015

[11] Schuckit MA & Hesselbrock V. Alcohol dependence and anxiety disorders. Focus 2004;2(3):440–453. doi: 10.1176/foc.2.3.440

[12] Sareen J, Chartier M, Paulus MP & Stein MB. Illicit drug use and anxiety disorders: findings from two community surveys. Psychiatry Res 2006;142(1):11–17. doi: 10.1016/j.psychres.2006.01.009

[13] Mancini C, Van Ameringen M & MacMillan H. Relationship of childhood sexual and physical abuse to anxiety disorders. J Nerv Men Dis 1995;183(5):309–314. doi: 10.1097/00005053-199505000-00006

[14] Anxiety and Depression Association of America. Understanding the facts of anxiety disorders and depression is the first step. 2020. Available at: https://adaa.org/understanding-anxiety (accessed May 2020)

[15] Stein MB & Stein DJ. Social anxiety disorder. Lancet 2008;371(9618):1115–1125. doi: 10.1016/S0140-6736(08)60488-2

[16] Marks I. Fears, Phobias and Rituals: Panic, Anxiety and Their Disorders . Oxford University Press: New York; 1987.

[17] NHS. Phobias. 2018. Available at: https://www.nhs.uk/conditions/phobias/ (accessed May 2020)

[18] Hofmann S & DiBartolo P. Social Anxiety: Clinical, developmental and social perspectives . 3rd edn. Academic Press: San Diego; 2014.

[19] Marks I. Fears and Phobias . Academic Press: New York; 1969.

[20] National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline [CG113]. 2011. Available at: https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-35109387756997 (accessed May 2020)

[21] National Institute for Health and Care Excellence. NICE Pathways. Generalised anxiety disorder. 2019. Available at: https://pathways.nice.org.uk/pathways/generalised-anxiety-disorder (accessed May 2020)

[22] British Thyroid Foundation. Hyperthyroidism. 2018. Available at: https://www.btf-thyroid.org/hyperthyroidism-leaflet (accessed May 2020)

[23] NHS. Generalised anxiety disorder in adults. 2018. Available at: https://www.nhs.uk/conditions/generalised-anxiety-disorder/ (accessed May 2020)

[24] National Institute for Health and Care Excellence. Clinical knowledge summaries. Generalized anxiety disorder. 2017. Available at: https://cks.nice.org.uk/generalized-anxiety-disorder (accessed May 2020)

[25] Spitzer RL, Kroenke K, Williams JB & Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Intern Med . 2006;166:1092–1097. doi: 10.1001/archinte.166.10.1092

[26] National Institute for Health and Care Excellence. Generalized anxiety disorder. Scenario: management of a person with generalized anxiety. 2017. Available at:  https://cks.nice.org.uk/generalized-anxiety-disorder#!scenario (accessed May 2020)

[27] British National Formulary. 2020. Available at: https://bnf.nice.org.uk/ (accessed May 2020)

[28] Ferguson JM. SSRI Antidepressant medications: adverse effects and tolerability. Prim Care Companion J Clinl Psychiatry 2001;3(1):22–27. doi: 10.4088/pcc.v03n0105

[29] Yekehtaz H, Farokhnia M & Akhondzadeh S. Cardiovascular considerations in antidepressant therapy. J Tehran Heart Cent 2013;8(4):169–176. PMID: 260058484

[30] Warden D, Trivedi MH, Wisniewski SR et al. Early adverse events and attrition in selective serotonin reuptake inhibitor treatment: a suicide assessment methodology study report. J Clin Psychopharmacology 2010;30(3):259–266. doi: 10.1097/JCP.0b013e3181dbfd04

[31] NHS. Antidepressants. 2018. Available at: https://www.nhs.uk/conditions/antidepressants/ (accessed May 2020)

[32] National Institute for Health and Care Excellence. Antidepressant drugs. 2020. Available at: https://bnf.nice.org.uk/treatment-summary/antidepressant-drugs.html

[33] Funk KA & Bostwick JR. A comparison of the risk of QT prolongation among SSRIs. Ann Pharmacother 2013;47(10): 1330-1341. doi: 10.1177/1060028013501994

[34] Kannankeril PJ & Roden DM. Drug-induced long QT and torsade de pointes: recent advances. Curr Opin Cardio 2007;22(1):39–43. doi: 10.1097/HCO.0b013e32801129eb

[35] Yap YG & Camm AJ. Drug induced QT prolongation and torsades de pointes . Heart  2003;89(11):1363–1372. doi: 10.1136/heart.89.11.1363

[36] Haddad P. The SSRI discontinuation syndrome.  J Psychopharmacol 1998;12(3): 305–313. doi: 10.1177/026988119801200311

[37] Horowitz M & Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry .  2019;6:538–546.  doi: 10.1016/S2215-0366(19)30032-X

[38] Volpi-Abadie J, Kaye AM & Kaye AD. Serotonin Syndrome. Ochsner J 2013;13(4):533–540. PMID: 24358002

[39] Specialist Pharmacy Service. What is serotonin syndrome and which medicines cause it? 2020. Available at: https://www.sps.nhs.uk/articles/what-is-serotonin-syndrome-and-which-medicines-cause-it-2/ (accessed May 2020)

[40] Kirpekar VC & Joshi PP. Syndrome of inappropriate ADH secretion (SIADH) associated with citalopram use. Indian J Psychiatry 2005;47(2):119–120. doi: 10.4103/0019-5545.55960

[41] NHS. Get fit for free. 2019. Available at: https://www.nhs.uk/live-well/exercise/free-fitness-ideas/ (accessed May 2020)

[42] Anxiety UK. Physical Exercise & Anxiety. 2018. Available at: https://www.anxietyuk.org.uk/get-help/anxiety-information/physical-exercise-anxiety/ (accessed May 2020) 

[43] Chekroud SG, Gueorguieve R, Zheutlin AB et al . Association between physical exercise and mental health in 1.2 million individuals in the USA between 2011 and 2015: a cross-sectional study.  Lancet Psychiatry 2018;5(9):739–746. doi: 10.1016/S2215-0366(18)30227-X

[44] NHS. Types of talking therapies. 2018. Available at: https://www.nhs.uk/conditions/stress-anxiety-depression/types-of-therapy/ (accessed May 2020)

[45] Vieweg WV & Wood MA. Tricyclic Antidepressants, QT interval prolongation and torsade de pointes. Psychosomatics 2004;45(5):371–377. doi: 10.1176/appi.psy.45.5.371

[46] Kamochi H, Nii T, Eguchi K et al . Clarithromycin associated with torsades de pointes . Jpn Circ J 1999;63:421–422.  doi: 10.1253/jcj.63.421

[47] Snitker S, Doerfier RM, Soliman EZ et al . Association of QT-prolonging medication use in CKD with electrocardiographic manifestations. Clin J Am Soc Nephrol 2017;12(9):1409–1417. doi: 10.2215/CJN.12991216

[48] Montejo-Gonzalez AL, Llorca G, Izguierdo JA et al . SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline and fluvoxamine in a prospective, multicentre and descriptive clinical study of 344 patients. J Sex Marital Ther 1997;23(3):176–194. doi: 10.1080/00926239708403923

You might also be interested in…

Eating disorders: identification, treatment and support

Mental health considerations in older women

More than 1,000 patients stopped taking antidepressants after introduction of local deprescribing guidelines

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Ind Psychiatry J
• v.29(1); Jan-Jun 2020

Application of mindfulness on stress, anxiety, and well-being in an adolescent student: A case study

Anand kumar.

Department of Psychology, SNS College, Tekari, Gaya, Bihar, Tekari, India

Amool Ranjan Singh

1 Department of Clinical Psychology, RINPAS, Ranchi, Jharkhand, India

Masroor Jahan

Background:.

Stress and anxiety are the major problems students face in their lives and specifically in their academic life, which, in turn, has a significant negative impact on their academic performance. There are different approaches to deal with stress and anxiety, for example, cognitive behavioral therapy and relaxation techniques.

The present study was conducted to evaluate the applicability of mindfulness on stress, anxiety, and psychological well-being in an adolescent student.

In this study, single-case study design was used. The Pediatric Symptoms Checklist, Youth Self-Report, Institute of Personality and Ability Testing Anxiety Scale, and Checklist of Psychological Well-Being were administered on ten adolescent students. After the initial assessment, one participant was selected who was having significant level of stress, anxiety, and poor psychological well-being. Further detailed assessment was done using the Raven Standard Progressive Matrices, Parents' Observation Checklist, Teachers' Observation Checklist, and Students' Self-Observation Checklist. The student underwent 24 sessions of mindfulness training with a frequency of three sessions in a week. After completion of sessions, post assessment was done. He was re-assessed after 3 months.

After completion of mindfulness training, improvement was observed in stress, anxiety, well-being, and other variables, and the improvement was maintained till follow-up.

Conclusion:

Mindfulness training has the potential in effectively reducing stress and anxiety and increasing a sense of well-being, but the major barrier is getting fixated with an idea of what's the right way to do mindfulness and feel it.

Many studies have established a causal relationship between stress, anxiety, and psychological well-being on adolescent students. Adolescence has long been regarded as a group of people who are for themselves to find some form of identity and meaning in their lives.[ 1 ] Adolescence is the most vulnerable age for development; when a child once enters this stage requires intensive readjustment to school, social, and family life.[ 2 ] The World Health Organization[ 3 ] has reported about psychiatric morbidity in the range between 14.4% and 31.7% in Indian adolescents. The percentage of symptoms of depression, anxiety, and stress was 18.5%, 24.4%, and 20%, respectively.[ 4 ] The comorbidity of anxiety and depression was found 87% in the adolescents.[ 5 ] Suicidal behaviour[ 6 ] and poor psychosocial functioning such as poor academic performance were found.[ 7 ]

Hans Selye,[ 8 ] the father of stress theory, defined stress as “The nonspecific response of the body to any demand made upon it.” Stress is the reaction people have to excessive pressure or other types of demand placed upon them. It arises when they worry that they cannot cope. Stress is associated with emotional states, self-esteem, and subjective health complaints.[ 9 ]

Anxiety is one of the most common psychological disorders in school-aged children and adolescents worldwide.[ 10 ] Anxiety is feeling unrealistic fear, worry, and uneasiness, usually generalized and unfocused.[ 11 ] The adolescence can project what will happen in future and anticipate with considerable sophistication potential hazard, threat, and danger in many domains, particularly that of social relationship. They developed maladaptive fear that is usually referred to as anxiety.[ 12 ] Adolescence is often accompanied by restlessness, fatigue, problems in concentration, muscular tension, and other somatic complaints due to anxiety.

Shek[ 13 ] defines psychological well-being as that” state of a mentally healthy person who possesses a number of positive mental health qualities such as active adjustment to the environment, and unity of personality”. Adolescence can definitely be looked upon as a time of more struggle and turmoil than that during childhood. It has been established that factors such as school connectedness, good relationships with others, liking family and peers, closeness to others, physical activity, or healthy eating habits can protect young people and increase their psychological well-being.[ 14 ]

Mindfulness-based interventions is an old concept and well established. It is most firmly rooted in Buddhist Psychology of mindfulness. The term “mindfulness” is derived from the “Pali” language word “sati,” meaning to remember, but in terms of consciousness, it commonly signifies presence of mind.[ 15 ] It concerns a clear, nonconceptual, nondiscriminatory awareness of one's inner and outer worlds, including thoughts, emotions, actions or surroundings, and sensations and can be considered an enhanced attention to and awareness of the current experience or present reality, i.e., the awareness of being aware. Well-conducted mindfulness interventions have been known to improve adolescents' well-being; reduce worries, anxiety, distress, reactivity and bad behavior; improve sleep and self-esteem; and bring about greater calmness, relaxation, and self-regulation and awareness.[ 16 ]

The sample of the present study consisted of one adolescent student with average intelligent quotient level. He had no comorbid psychiatric, neurological, or medical illness.

CASE REPORT

Mr. R. K., a 15-year-old, single, Hindu, Hindi-speaking male, belonging to lower middle socioeconomic status, of nuclear family, hailing from an urban area of Jharkhand, was studying in the 9 th class. His father was a farmer and mother was a homemaker. There were five members in the family. Relationship among the family members was satisfactory. He frequently changed 5–6 different schools till the 7 th class and joined high school. The high school was too far from his residence. Hence, his father suggested him to stay at his sister's place (Mr. R K's aunty) where he had difficulty in adjustment. In the high school, his performance was poor. Still most of the time, he focused on studies and was trying to work hard, but did not get satisfactory outcome. He was not that much involved with friends. He aspired to become a teacher and wanted to be financially strong in future.

Presenting problem

In the middle childhood, he changed his school 5–6 times; as a result, his academic performance decreased. His family income was not sufficient to provide him quality and good education. His father was not confident in RK's abilities. Because of his father's attitude, he was disappointed and started worrying about his studies and his future. He was unable to enjoy the things he used to and would be afraid of new situations. He had problems in concentration. He wanted to be with his parents more than before. He was also having adjustment problems at his aunt's home. His motivation was low, and most of the time, he was apprehensive about studies and examination. His friends would also tease him for his highly disciplined behaviors. He would try hard, but his efforts were not paying off. His performance was poor in some subjects, whereas in others it was satisfactory.

For assessment, the following tools were used:

• Sociodemographic and clinical data sheet: A semi-structured pro forma was prepared by the researcher to collect information about the sociodemographical variables such as age, language, education, religion, and illness
• Raven's Standard Progressive Matrices (RSPM): It is a nonverbal, single and group administered intelligence test. It is used to measure intelligence of 5-year-olds to the elderly. This test consists of sixty multiple-choice questions (five sets [A to E] of 12 items each), listed in order of difficulty. Its reliability has found to be 0.88–0.93 with higher values[ 17 ]
• Pediatric Symptoms Checklist, Youth Self Report (Y-PSC): There are 35 items in Y-PSC. These items are designed to faceplate the recognition of physical, cognitive, emotional, and behavioral problems. The test–retest reliability of the PSC ranges from r = 0.84 to 0.91, with a cutoff score of 28, a specificity of 0.68, and a sensitivity of 0.95 for measuring psychosocial dysfunction of adolescence due to stressors[ 18 ]
• Institute of Personality and Ability Testing Anxiety Scale (IPAT): It includes 40 items and five factors (apprehension and tension are dominant factors in this scale, and others factors include emotional instability, suspiciousness, and lack of self-control). The average test–retest reliability coefficient across the test is 0.82. The Anxiety Scale has correlated moderately high with clinical ratings ( r = 0.49), and it also correlates strongly with other popular measures of general anxiety ( r = 0.70 with the Taylor Manifest Anxiety Scale and r = 0.76 with the Spielberger Trait Anxiety Inventory)[ 19 ]
• Checklist for Psychological Well-Being. This checklist is developed by Pundeer et al .[ 20 ] in 2013 at RINPAS to measure the psychological well-being of adolescents (13–16 years). This checklist consists of 18 items which measure six domains of psychological well-being. In this checklist, the students are expected to read carefully all statements which are related to their experience and feeling during the last 1 month
• Student's Self-Report Checklist: This checklist was prepared by the researcher for the secondary students. It has two other forms, i.e., Parents' Observation Checklist (POC) and Teachers' Observation Checklist (TOC). All the three forms are used in this case study. These checklists consist of 20 items. They measure the personal daily activity, academic activity and performance, physical health and sports, social and family health, and emotional stability. The scoring of this checklist involves three-point rating, i.e., often (score 2), sometimes (score 1), and never (score 0) for positive statements, whereas reverse scoring is used for negative statements. These checklists were made with the help of ten mental health professionals and research committee of RINPAS, Kanke, Ranchi.

Package and procedure

Package of mindfulness training.

In the present study, the content of the intervention was based on formal and informal exercise of mindfulness: body scan, breathing, and thought observation were included under mindfulness formal exercise.

• Introductions: As a cognitive conceptualization of stress, anxiety, and psychological well-being
• Formal exercise: Mindfulness body scan, mindfulness breathing exercise, and mindfulness meditation (thought observation)
• Informal exercise: Mindfulness in daily routine and domestic chores and others.

Approximately 24 sessions of mindfulness training with a frequency of three sessions in a week was given to the participant. Out of these 24 sessions, the initial two sessions were devoted to the introduction and psycho-education about stress, anxiety, and psychological well-being, i.e., how they affect our daily life functioning, how are they developed, and how they can be managed. Detailed information was given about the mindfulness formal and informal exercises. During the 3 rd and 4 th sessions, the participant was demonstrated the mindfulness formal exercises. After demonstration, one training session was given for formal exercise and after this, regular practice was started. He was trained and told to practice the same in the morning and evening at home as homework. Before beginning a new session, he was asked about the homework and if any problem was found, it was sorted out and any doubts were rectified. After each session, feedback was taken from the participant about any changes in his feelings and thoughts, and feedback was given to him about his success in performing the different mindfulness exercises. At the end of each session, he was assigned homework.

Method of formal exercise

The participant was asked to take a particular posture, a dignified posture that suggests that we are doing something important. He was made to sit in a comfortable posture on a mat on the floor. After attaining the comfortable posture of sitting, the participant was asked to close his eyes gently. Then, awareness is brought to the level of physical sensations by focusing own attention on the sensations of touch and pressure in the body where it makes contact with the floor. After this, he was instructed to explore these sensations for a minute or two and then body scanning was started. In the body scan, he was instructed first with demonstration and then without demonstration to visit each part of his own body, starting from the lower parts and progressing toward the upper part of the body such as the toe, foot, angle, shin, calf, knee, thigh of the right leg and then visit left leg followed by stomach, chest, both hands, shoulder, neck, mouth, cheek, eyes, and forehead (approximately 10 min). The aim of this exercise was to relax the body and after achieving relax state, he was moved in the breathing exercise. He was asked to simply observe breathing sensations as one was experiencing at the time of deep breathing by selecting some part of the breath cycle and paying attention to it as fully as possible. He was instructed to take breath slowly and to feel the touch of the breath as it passes in through the nostrils, trachea, and pharynx or the cool sensation of the breath above the roof of the mouth or, more usually, the expansion and contraction of the lungs and abdomen. After 10 min of breathing exercise, he was moved in the mindfulness meditation (thought observation). In this meditation, he was asked to observe his own thoughts and feelings from a distance, without judging them good or bad and where one had to notice the thoughts that were passing through one's mind. Apart from this, he had to notice the feelings that were passing through his own body. He was instructed to observe those thoughts and feelings without judging them as good or bad, and without trying to change them, avoid them, or hold onto them (approximately 10 min).

Informal exercise

He was asked to pick an activity and do it mindfully of the routine works such as brushing the teeth, bathing, clothing, eating, and bicycling. He was instructed to totally focus on what he is doing: the body movements, the taste, the touch, the smell, the sight, the sound etc., to feel every touch of sensation of every movement.

Initially, ten students from St. Joseph's High School Ranchi, Jharkhand, were selected for assessment by using Y-PSC, IPAT, and Checklist of Psychological Well-Being (CPWB). After the initial assessment, one participant was selected who was having significant level of stress, anxiety, and poor well-being. He had not undergone any psychotherapeutic intervention for stress and anxiety. Further detailed assessment was done using the RSPM, Student's Self-Observation Checklist (SOC), POC, and TOC. Duration of intervention was kept for 24 sessions (three sessions in a week with duration of 45 min of each session). After completion of sessions, post assessment was done after a gap of 5 days with the help of the same tools which had been used earlier. The student was re-assessed after 3 months. This present research program was approved and reviewed by the Protocol Review Committee and Ethics Committee of Ranchi Institute of Neuro-Psychiatry and Allied Sciences, and the mindfulness training was taken by an expert professor in yoga and philosophy. Before the intervention, formal permission was taken from the administration of school and consent was taken from parents.

Analysis of data

In the present study, scores were obtained by simple mathematical tools including addition and subtraction as well as comparing method. On Y-PSC, a score of 21 indicates mild-level psychosocial impairment. High score was obtained on emotional area. The main features include afraid of new situations, irritability, worries, want to be with parents more than before, feeling hopelessness, feel that he is bad, doesn't show feelings, has little energy, and gets distracted easily. On the IPAT, his score was 42 that indicates high level of anxiety. The main features include apprehension, insecurity, self-reproaching, worrying, troubled, uncontrolled, frustrated, and tensed. On CPWB, the score was 7, which indicates mild level of impairment with the features of unhappiness and low satisfaction. On the POC, the score was 14, which indicates mild level of impairment with the features of feeling anxious in study work, not interested in curricular activities, and irritability. On the TOC, the score was 23, which indicates moderate level of impairment with the features including poor personal responsibility, work is not done in a positive way, feeling anxious in study work, carelessness, not interested in curricular activities, and irritability. On the SOC, the score was 12, which indicates mild level of impairment with the features of feeling anxious in study work, not interested in curricular activities, and irritability.

After completing 24 sessions, post test was administered, measuring many parameters, and the findings are presented in Table 1 . The analysis indicates that significant level of improvement occurred in all variables. The participant's score on the YPSC was 21 and after therapy, the score lowered down to 8, indicating improvement in emotional, behavioral, and physical symptoms of psycho-social functioning and follow-up score revealed that the therapeutic outcome was maintained in the areas of emotional and psychosocial functioning, whereas in behavioral domain, there was a slight decline. On IPAT, the score was 42 as found in preassessment, and his score improved to 23 on postassessment; the follow-up score showed that the therapeutic outcome was maintained. He also showed improvement in overall psychological well-being after therapy sessions and the therapeutic outcome was maintained till follow-up. His psychological well-being score in preassessment was 7, whereas the score in posttherapy assessment was 2 and on follow-up was 1. Similarly, on observation checklists, his score improved in all the three Forms, that is, parent, teacher, and self-observation forms. Major improvement was found in the self-observation form and psychological well-being and the therapeutic outcome was maintained in all the three areas.

Comparison of the scores of preassessment, postassessment, and follow-up

IPAT – Institute of Personality and Ability Testing Anxiety Scale; Y-PSC – Pediatric Symptoms Checklist, Youth Self Report; CPWB – Checklist of Psychological Well- Being; POC – Parents’ Observation Checklist; TOC – Teachers’ Observation Checklist; SOC – Students’ Self-Observation Checklist

By the end of the 3 rd week session, some improvement was seen in concentration. He told, now I am able to much concentrate in the classroom than earlier as well as during home work and other activities. Gradually, his worrying attitude was changing. Over a period of 7 weeks, he started enjoying his daily activities. He could relate to every area of his personal life without becoming anxious. After the 15 th session, his frequency of afraid of new situations decreased. He feels more energized and motivated. Overall, improvement was shown in terms of stress, anxiety, and well-being. Further, it resulted in positive self-observation in different domains of life, and he received positive evaluation from teachers and parents. The scores on follow-up showed that the therapeutic outcome was maintained on anxiety and psychological well-being in the POC and SOC, whereas a slight decline was noticed on the Stress and TOC.

Stress, depression, and anxiety all the negative indicators of mental health are significantly positively correlated.[ 21 ] Inadequate family environment of adolescents in terms of parental hostility, rejection, and inconsistencies can all contribute to psychological problems, namely, anxiety, stress, and depression.[ 22 ] Life without stress cannot be imagined and up to a certain limit may be adequate for personality development, but if noncongeniality prevails for a longer period, these stresses become too severe which may affect the psychic equilibrium, producing maladaptive patterns of behavior. Stress and anxiety are the offshoots of inadequate interaction with the environment, and family environment is the chief cause.[ 23 ]

In practicing mindfulness, one becomes aware of the current internal and external experiences, observes them carefully, accepts them, and allows them to be let go of to attend to another present moment's experience.[ 24 ] The individual acquires control over his or her life by choosing to learn the mindfulness technique, to consistently practice it, and to apply it to daily life.[ 25 ] Mindfulness-based stress reduction is helpful in significant reduction of dissociative experiences and significant improvement in mindfulness in adolescents.[ 26 ]

The findings of the present study are consistent with the findings of a study that involved mindfulness-based cognitive behavioral therapy for the treatment of emotional problems (depression, anxiety, hopelessness, and perceived stress) in a sample of adolescents affected by HIV/AIDS. The analysis found preliminary support for mindfulness -based cognitive therapy as useful in reducing the symptoms of emotional disturbances on self and teacher reports to the levels of clinical significance and reliable change.[ 27 ] Another study studied the effects of a modified 8 week mindfulness-based program (MBP) course for 4–18 year olds peoples. When compared with a control group, the young people who received MBP reported significantly reduced symptoms of anxiety, depression, and somatic distress and increased self-esteem and sleep quality.[ 28 ]

The present study findings are also in concordance with the findings of a study that investigated an MBP, delivered by teachers, involving ten lessons and three times' daily practice of mindfulness meditation. Overall, there was a significant increase in scores on self-report measures of optimism and positive emotions. Teachers' reports showed an improvement in social and emotional competence for children in the intervention group and a decrease in stress, aggression, and oppositional behavior.[ 29 ] Mindfulness-based therapy has the potential of providing effective treatment for emotional disturbances (stress, anxiety, and depression) in adolescents; further research is needed to test the efficacy of the intervention with a larger sample of such adolescents.[ 27 ]

Mindfulness is a type of meditation and exercise of awareness of self. The participant may control and improve his or her daily activities after learning the mindfulness skill. Mindfulness-based intervention is effective in reducing the level of stress and anxiety and developing life skills. It is difficult to understand the mindfulness practice, especially for secondary school students. However, mindfulness training is helpful in enhancing psychological well-being and reducing the emotional disturbance.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

• How we help
• Individuals with ADHD
• Care Teams & Providers
• Our Coaches
• Join Our Team
• Blogs & Guides

Perfectionism in Students: A Case Study in Coping With Academic Anxiety

By Brittany Peterson

What is Perfectionism?

Perfectionism is not simply when a student strives for excellence. In a New York Times magazine article, Melissa Dahl quotes psychologist Thomas S. Greenspoon, explaining that “perfectionistic people typically believe that they can never be good enough, that mistakes are signs of personal flaws, and that the only route to acceptability as a person is to be perfect.” That’s a lot of pressure for a student to handle.

How Does Perfectionism in Students Manifest?

Parents want to see their children achieve good results for their efforts — but when a child is mired in perfectionism, it can lead to hours wasted in ineffective pursuit of the perfect essay, report, or problem set — with very little on paper to show for all that effort. And frequently, there are plenty of tears and meltdowns in the process, as well.  It’s easy to imagine the frustration involved in attempting to produce error-free assignments. After all, mistakes are a natural and expected part of the learning process!

The Research and the Risks

Paul Hewitt, PhD and Gordon Flett, PhD have spent nearly three decades researching perfectionism. According to Etienne Benson, of the American Psychological Association , Hewitt and Flett’s work has “found that perfectionism correlates with depression, anxiety, eating disorders and other mental health problems.” It’s no wonder that parents worry when their children spend endless hours perfecting their homework.

The Solution

While it can be a challenging and sometimes slow process, students can surmount the pitfalls of perfectionism with their schoolwork. Helping a child develop self-management skills, as well as gain a more realistic understanding of perceived expectations, can go a long way in easing the stress associated with perfectionism. Below is a glimpse into some of the challenges that our perfectionistic students face and how we, as adults, can help these students become more confident and productive.

A Case Study in Coping with Perfectionism

Jameson was a middle schooler full of energy, eager to please, polite, attentive, diligent … and wracked with academic anxiety. During a coaching session, Jameson described a take-home project he was assigned the week before. As he detailed the elements of the project, the strain spread across his face. When I asked how much he’d done already, he burst into tears. Despite having completed about 75% of the tasks, he was simultaneously stressed about his belief that what he’d done wasn’t good enough, and that there wasn’t enough time to finish the remaining 25%.  

One of Jameson’s work patterns was that he would begin an assignment, panic part way through about not having enough time, and end up wasting even more time in that panic zone.  Thus, his fear of not having time was self-fulfilled as he squandered a lot of his afternoons stressing out. Knowing this pattern, I gave Jameson 10 minutes of “Worry Time”, during which he focused entirely on listing the specific aspects of this assignment he was stressed about. When the timer went off, “Worry Time” would be over and work would begin.

Once we had the list of fears, I told Jameson it was time to investigate each one. By shifting our attention towards an investigation, Jameson’s tears halted and he became intensely curious about what evidence we might uncover. We started with his biggest fear: that what he had wasn’t good enough.  “Well, there’s only one way to find out,” I announced as I handed him the project instructions sheet, “so start reading me the directions.” Thinking like the teacher, I created a scoring rubric based on the criteria Jameson read aloud. Then, we evaluated his work based on the rubric. As it turned out, he was actually about 90% finished, and the pieces he had done scored quite well. “Well, let’s cross that fear off the list, buddy, because it clearly doesn’t exist!” I exclaimed. Jameson faltered at first, but soon realized there wasn’t really any use fighting the point: He’d self-assessed his work using the guidelines of the project and it was looking great.

We moved on to the second fear: that there wasn’t enough time to complete the rest. Now that he knew there was actually only 10% remaining, we made a list of the things he still needed to do, we over estimated how much time each one would take, and then we made a plan for the rest of the evening. Jameson used the 30/30 app to list his tasks and the time each would take. We also included a bonus 10-minutes of “Worry Time” so that Jameson had a chance - and the time for that opportunity - to acknowledge his stress. When we were done inputting our list into the app, it showed us Jameson’s end time if he got started right away: 7:46pm. Not too late at all.

Through our work together, Jameson gradually learned to evaluate his work based on the actual standards of the assignment - those given by the teacher - and not his own standards of what “perfect” meant. In addition, he often began to effectively use his “Worry Time” as a chance to acknowledge his concerns and evaluate their validity. Sometimes, “Worry Time” was followed by this guided meditation app or breathing exercises when Jameson needed an extra boost of emotional regulation. And finally, Jameson began to work with his tendencies by allowing for the actual amount of time different tasks take him (compared to the amount of time he thought it should take him), when planning his work .  

These new management habits didn’t completely stop Jameson from ever doubting the quality of his work, or himself. Rather, these tools and strategies armed Jameson with options for coping with perfectionism whenever he struggled to produce an assignment for school.  

When a student has perfectionist tendencies that hinder productivity and confidence, it’s important to have the right support on board. Oftentimes, a counselor or therapist working in tandem with an Executive Function coach can form an effective team to keep harmful effects of perfectionism in check.

Do you know a child who could benefit from support to manage academic anxiety? Contact us below to find out how coaching can be part of the solution.

About the Author

Brittany peterson.

Brittany Peterson is a college writing instructor, certified writing tutor, and senior executive function coach at Beyond BookSmart. She began her career in education at Quinnipiac University earning a Bachelor of Arts in English and Masters degree in Secondary Education. Feeling motivated to expand her pedagogical skill set, Brittany pursued a second Masters degree in Composition and Rhetoric at the University of Massachusetts Boston. After graduating, she became a full-time lecturer at UMass Boston where she currently serves as the Assistant Director of Composition and teaches first-year composition to a diverse classroom culture including English Language Learners and nontraditional students from a variety of academic backgrounds. Brittany's experience with adult learners, diverse cultures, and a range of learning abilities has enabled her to become a flexible educator who is sensitive to individual learning needs and intrinsically invested in their educational success.

Previous Post

The Secret to Success in College: An Educational Consultant's View

Why College Students Struggle (Even if High School Was a Breeze)

Latest Post

How much screen time is too much 4 expert screen use tips for parents, how to improve working memory for kids: 5 expert tips, 22 adhd coping skills that you need to learn, related post, talking to teachers: building self-advocacy in college students.

Visiting a professor during office hours in college can be a daunting task, especially for freshmen ...

Awkward Adolescence: 4 Tips to Help Your Student Master Self-Care

For most of us, simply thinking about our early teen years can quickly produce cringe-worthy...

3 Tips for Parents of Struggling Students with Overachieving Siblings

“Please stop graduating.” I remember reading this line quite vividly in an otherwise comical card...

• Open access
• Published: 19 April 2024

Causes and outcomes of at-risk underperforming pharmacy students: implications for policy and practice

• Alice Campbell 1 ,
• Tina Hinton 1 , 2 ,
• Narelle C. da Costa 1 ,
• Sian E. O’Brian 1 ,
• Danielle R. Liang 1 &
• Nial J. Wheate 1  

BMC Medical Education volume  24 , Article number:  421 ( 2024 ) Cite this article

Metrics details

This study aimed to understand the key determinants for poor academic performance of students completing a Bachelor of Pharmacy (BPharm), Bachelor of Pharmacy and Management (BPharmMgmt), or Master of Pharmacy (MPharm) degree.

Data were collected on pharmacy students who had not met academic progression requirements between 2008 and 2018 at The University of Sydney, Australia. This included: age at the start of pharmacy degree; gender; whether they transferred from another university; whether they were a domestic or international student; Australian Tertiary Admissions Rank upon entry, previous studies in biology, chemistry, or mathematics; show cause triggers (units of study failed); number of show causes; students’ written show cause responses; weighted average mark at last show cause or graduation; whether they graduated and were a registered pharmacist; and, the number of years they spent studying the degree. Descriptive studies were used to analyse student characteristics using SPSS software, and student self-reported reasons for poor performance were analysed reflexively using thematic analysis procedures using NVivo.

This study included 164 pharmacy students enrolled in a BPharm (79.3%, n  = 130), BPharmMgmt (1.2%, n  = 2), or MPharm (19.5%, n  = 32). Of the students, 54% ( n  = 88) were men, 81% ( n  = 133) were domestic students, 15% ( n  = 24) transferred from another degree program, and 38% ( n  = 62) graduated from the course. Show cause students were less likely to graduate if they transferred from another degree program ( P  = 0.0002) or failed more than three units of study (UoS; P  < 0.0001). The most commonly failed UoS were related to organic or pharmaceutical chemistry, and the top student self-reported reasons for poor performance was stress/anxiety, physical health, and depression.

Pharmacy schools should aim to address student foundational knowledge in chemistry, identify at-risk students early using pre-subject testing, and provide better services to address student mental health.

Peer Review reports

Introduction

A student’s academic performance in higher education is typically defined by their achievement of learning outcomes and demonstration of their ability to apply the concepts taught. Measurement of these attributes can include assessments, quizzes, role plays, field work, practical placements, workshops, tutorials, laboratories, and examinations. In most higher education programs, a minimum standard of academic achievement is required in order to progress through the course, to ensure the student has gained adequate knowledge and skills, and that they have achieved the specified learning outcomes. In this regard, poor academic performance can be defined by instances where a student fails to meet the expected minimum academic standard. Usually this comprises a minimum overall score in a subject and/or passing a specific barrier assessment, which is ultimately linked to their retention or attrition.

Understanding the key determinants of student success, failure, retention, and attrition has become increasingly important for higher education institutions, and has been the subject of extensive research over the past few decades. Early studies on student attrition focused primarily on student characteristics [ 1 ], before attention shifted to interactions between the student and their institutions. Prominent researchers, including Spady [ 2 , 3 ], Tinto [ 4 , 5 ], and Bean [ 6 ] proposed models to explain the interplay between academic and social integration leading to underperformance, and eventually, attrition. More recently, interest has increased in examining student engagement [ 7 , 8 , 9 ], where the student and institutions have a joint responsibility for academic success. To be successful, a student needs to participate, and higher education institutions need to provide an appropriate learning environment, opportunities, and support [ 10 ].

Studies on the key determinants of student underperformance reveal an array of contributing factors. Recent systematic reviews on underperformance and dropout rates show that key determinants fall into categories relating to the institution, personal life, demographics, and social integration [ 11 , 12 ]. Within higher education institutions, studies have found that an academic’s professional knowledge and pedagogical skills, along with the institution’s learning resources, course structure, and environment, are key factors that influence academic performance and non-completion [ 13 , 14 , 15 , 16 , 17 ]. Teaching methods that higher institutions adopt have also been evaluated, with student-centered approaches that encourage active learning resulting in better performance when compared with a traditional teacher-centered approach [ 15 , 16 ].

In terms of individual factors, studies have found a lack of effort, distraction, poor time management, and no longer being interested in the course as having a negative impact on academic performance [ 14 , 15 , 18 , 19 ]. Active learning (e.g. self-quizzes, completing problem sets, and explaining concepts) has been found to yield better academic outcomes when compared with passive learning (e.g. reading lecture slides or class notes, watching lecture videos, and reading textbooks) [ 20 , 21 ]. In the same study, how early a student studied in relation to their exam did not affect their outcome, whereas students who were more distracted during the time they allocated for study, performed worst [ 20 , 22 ]. Education-related stress, poor mental health, exam anxiety, and sleep quality are also factors found to cause poor performance [ 23 , 24 , 25 , 26 , 27 ]. Other studies have shown that part-time students and those who have previously failed subjects are at risk of further poor performance and attrition [ 17 , 28 , 29 ]. Social factors including cyberbullying [ 30 ], homesickness for international students [ 31 ], and excessive socialising [ 16 ] also have a negative effect on academic performance.

Working status was found to negatively impact academic performance [ 27 ], where poor academic outcomes were correlated with a longer time spent at work [ 16 , 28 , 32 ]. Many studies have associated the lower socioeconomic status of students and their family, or financial strain with poor academic performance [ 27 , 28 , 29 ]; whereas, other studies have shown that students in families where one parent has attended higher education tend to achieve higher grades [ 31 ]. Some studies have found men and minority students are more at risk of poor performance [ 31 , 33 ]. Part-time students are much more likely cite work and family responsibilities as reasons for stopping their studies [ 17 ]. Research on students whose first language is not that of the higher education institution is mixed, with some confirming it to be a key attributor to underperformance [ 34 , 35 , 36 ], along with students with a migrant background or who are first-generation university attendees (commonly referred to as first-in-family) [ 31 , 37 , 38 ]. In contrast, other studies have found that academic performance of international students was similar, or better, than domestic students [ 39 , 40 ].

A government panel in Australia reported that the leading drivers for non-completion in higher education are both institution-related (learning environment, an academic’s ability to teach, student to staff ratios, student engagement, and support services) and student-related (health, finance, and personal responsibilities) [ 41 ]. A survey conducted by the Australian Bureau of Statistics (ABS) identified the top three reasons for attrition for students studying a bachelors degree to be: loss of interest, employment/financial reasons, and personal reasons (health, family, or other personal reasons). For postgraduate courses, reasons for attrition were highest in the order of personal reasons, employment/financial, followed by loss of interest [ 42 ].

Where a student has underperformed, they may be offered remediation assessments; to re-enroll and attempt the entire subject again, which may result in a delay in degree completion; or in some cases, be excluded from reenrolling into the same course for a period of time [ 43 , 44 ].

Consequences of poor performance vary across higher education institutions and may depend on the reasoning provided, extent of underperformance, and number of failed subjects. Key stake holders impacted by poor performance and attrition from higher education can include the students and their families, the higher education institution they are enrolled in, their community workforce, and government. Non-completion directly impacts the funding and reputation of an institution [ 17 , 45 , 46 ]. In Australia, where the cost of higher education for domestic students is subsidised by the federal government, non-completion incurs a direct cost to both the student and the tax-payer. The cost to the student includes lost time, psychological health, student debt, and forgone income [ 9 ]. From the perspective of workforce planning, a delay or non-completion of study reduces the number of employees entering into the workforce, and can lead to workforce shortages and place a burden on those currently in the field.

There are many studies that have examined the key determinants for student success or underperformance and attrition in health; however, most have focused on nursing or medical education [ 13 , 15 , 47 , 48 , 49 , 50 ]. Consequently there are limited studies that have examined the rate and reasons for attrition within pharmacy degrees. Being a degree known to be difficult in technical content, and which requires students to achieve a high level of competence, it is important to investigate reasons for attrition and potential opportunities for improvement in student teaching and engagement.

In this study we analysed 10 years of demographic data and responses to why academic progression requirements had not been met in a cohort of students enrolled in a Bachelor of Pharmacy (BPharm), Bachelor of Pharmacy and Management (BPharmMgmt), or Master of Pharmacy (MPharm) degree at The University of Sydney. Our aim was to understand the key determinants for poor performance within this group of students and identify opportunities for policy and practice to reduce underperformance in the future.

Approval for this study was granted by the Human Research Ethics Committee of The University of Sydney (2022/815).

Data collection

The inclusion criteria for this study were students enrolled in a BPharm, BPharmMgmt, or MPharm degree between the period of 2008 and 2018 (inclusive), who were required to provide a minimum of one show cause at any stage of their study. Data collected on each student included: age at the start of pharmacy degree; gender; whether they transferred from another university; whether they were a domestic or international student; Australian Tertiary Admissions Rank (ATAR) upon entry, which is a percentile score that ranks Australian students finishing secondary school in relation to their academic achievement [ 51 ]; previous studies in biology, chemistry, or mathematics; show cause triggers (units of study failed); number of show causes; students’ written show cause responses; weighted average mark (WAM) at last show cause or graduation (WAM is an average grade score indicating a student’s overall academic performance over the course of their degree and is similar to a grade point average) [ 52 ]; whether they graduated; and, the number of years they spent studying the degree. Whether those students who had graduated were currently registered as a pharmacist in Australia was retrieved using the Australian Health Practitioner Regulation Agency online registry list [accessed in 2023].

Data analysis

Researchers Da Costa, O’Brien, and Liang collected, screened, and de-identified the data, and researchers Campbell, Hinton, and Wheate analysed the data. Descriptive statistics, including mean ± SD, median, and frequencies (count and percentage) were calculated using Microsoft Excel. Mann-Whitney U tests were undertaken in GraphPad Prism 9.0 (GraphPad Software, Boston, MA, USA) to ascertain any differences between ATAR scores. Chi Square analyses were undertaken in GraphPad Prism 9.0 to compare categorical data including differences between men and women, domestic and international students, transferring and non-transferring students, and graduating and non-graduating students.

Written show cause responses were transcribed by Campbell and uploaded into NVivo (1.5.1) software (QSR International, Massachussets USA). The show cause responses were analysed reflexively using inductive thematic analysis procedures [ 53 ].This involved manually reviewing each show cause response to identify emerging themes relating to the reasons stated by the student for their poor performance. From the themes identified, a total of 43 codes were generated based on the ideas, trends, and content. Coding was conducted in a theory-driven manner, seeking to code information referencing the specific themes arising from the show cause response [ 53 ]. Themes were guided by the frequency of mention, and reported in the results if there was more than a single mention. The frequency of the subthemes was analysed to demonstrate the prevalence of stated factors that the student believed led to their poor performance.

Show cause process

Pharmacy students who do not meet the progression requirements of their degree enter one of three stages of academic intervention (Fig.  1 ). Triggers for a student not meeting the requirements for progression include: awarded a fail grade in over 50% of total units of study (subjects; UoS) taken in a semester or teaching period; an average grade (WAM) less than 50 across all UoS in a semester or teaching period; failing one, or more, barrier or compulsory UoS which includes CHEM1611, CHEM1612, PHAR2822, and any 3000 or 4000 level UoS for BPharm/BPharmMgmt; and any single UoS for MPharm; any practical component (e.g. field work or clinical work), failing the same UoS twice, having unsatisfactory attendance, or exceeding the maximum time limit allowed for the degree to be completed.

Students who fail to meet progression requirements for the first time are placed on Stage 1 of the at-risk register at which point they receive a letter from the Faculty of Medicine and Health, and are advised to complete a ‘Stay on Track’ survey and information session. At the discretion of the Associate Dean of Education, some students at Stage 1 may be required to consult an academic adviser. If a student is enrolled in a degree with a duration of less than two years full-time (e.g. MPharm), they are advised that should they fail to meet progression requirements in the following semester, they would be asked to ‘show good cause’ in order to be allowed to re-enrol in the same program; that is, they would be excluded from the degree for two years unless they could give reasons for why they should be allowed to remain studying. They are also recommended to speak to an academic advisor.

Stage 2 is triggered for a student in a 4 or 5 year undergraduate degree program (e.g. BPharm and BPharmMgmt) if they fail to meet progression requirements after being placed on Stage 1 in the previous semester, at which point the faculty sends a letter, advising the student to complete the ‘Staying on Track’ survey if they had not yet done so, and to consult an academic adviser. Stage 3 is triggered if a student fails to meet progression requirements a third time, or fails the same compulsory or barrier UoS, or any practical component twice. Students on Stage 3 are required to ‘show good cause’ and provide reasonable evidence to be allowed to re-enrol into the degree program.

The three at-risk stages of academic intervention for students who fail to meet course progression requirements. Show cause is required at Stage 2 (MPharm) or Stage 3 (BPharm/BPharmMgmt) in order to re-enrol

Demographics

In total, 164 pharmacy students received at least one show cause notification between the period of 2008 to 2018 (inclusive) and were enrolled in a BPharm (79.3%, n  = 130), BPharmMgmt (1.2%, n  = 2), or MPharm (19.5%, n  = 32) degree (Table  1 ). Of the students, 54% ( n  = 88) were men, and 81% ( n  = 133) were domestic students.

Students who transferred from another degree program made up 15% ( n  = 24) of the sample, and were a median two years older than those who did not transfer (median age 21, range 19–43 years). All students who transferred from another degree, were enrolled in the BPharm. Ninety-two percent of transfer students ( n  = 22) were domestic and 71% ( n  = 17) were women.

The age of students at the start of their degree was positively skewed, with a median age of 19 years for BPharm and BPharmMgmt (range 17–43 years). For MPharm, the median age at commencement was 24 (range 20–24) years. The median age of domestic students at the start of their BPharm or BPharmMgmt degree was 19 (range 17–43) years compared with international students at 22 (range 18–33) years. For MPharm, the median age for domestic students at commencement was 24 (range 20–54) years while for international students it was 24.5 (range 22–38) years.

Performance on entry and exit of the degree

The ATAR scores of the students in either the BPharm or BPharmMgmt were not normally distributed ( n  = 78, mean ATAR 88.8 ± 4.8) (Supplementary Figure S1 ). The average ATAR required for entry into BPharm and BPharm/Mgmt at the University of Sydney is around 90. Of the 24 students who transferred from another degree program, the ATAR score was available for four students, with an average of 78.8 ± 9.8, including two outliers who had ATAR scores of 67.80 and 74.15. The average ATAR on entry to the degree of the students who graduated was 89.4 ± 3.4, which was similar to those who did not graduate, 88.5 ± 5.4. A Mann-Whitney U test showed this difference was not statistically significant (W = 702.5, p  = 0.937).

The proportion of students who graduated after receiving at least one show cause was 37.8% ( n  = 62), of which 77.4% ( n  = 48) were registered as pharmacists at the time of data collection (Fig.  2 ). One student did not graduate their BPharm; however, they did return and complete the MPharm degree and was registered as a pharmacist at the time of data collection. The median time taken to graduation was 7 (range 1–9) years for students enrolled in the BPharm and 3 (range 2.5-8) years for those enrolled in the MPharm. During the study period, 188 students were enrolled in the BPharmMgmt degree but only two (1.1%) were required to show cause due to poor performance. Neither of those two students graduated.

A WAM score was available for all but three of the 164 students. The overall average WAM either at last show cause, if the student had not graduated, or at degree completion was 52.1 ± 12.0. For students who graduated (38.5%, n  = 62), the average WAM was 62.2 ± 5.1, while for those who did not graduate (61.5%, n  = 99), the average WAM was 45.7 ± 10.5.

When the proportion of students who graduated was compared across the ATAR bands (Table S1 ), it was evident that show cause students who entered their degree with an ATAR between 85 and 89.99 were more likely to graduate (44%) when compared with those who entered their degree with lower (27%) and higher (25–35%) ATAR scores.

Units failed

Across the cohort, show cause students received between 1 and 8 show cause notifications (Fig.  1 ). When the proportion of students who graduated was compared across the number of show causes received for those who received 1–5 show causes, the rate of graduation ranged from 36 to 50%, while none of the students who received six or more show causes graduated.

Percentage of students who graduated (black) and did not graduate (grey) by number of show causes received

Number of failed UoS

The median number of UoS failed across the three degree programs was 8 (BPharm, range 2–33), 9 (BPharmMgmt, range 5–13), and 5 (MPharm, range 2–12), respectively. In total, 8.5% ( n  = 14) students were required to show cause because they failed 2 or 3 UoS, 19.5% ( n  = 32) students failed 4 or 5 UoS and 72% ( n  = 118) students failed more than 6 UoS. Of the 14 students who failed 2 or 3 UoS, 86% were studying the MPharm degree and the remaining were BPharm students. Students who failed 4 or 5 UoS, were studying a BPharm (66%), BPharmMgmt (3%), or MPharm (31%) degree. The majority of students who failed more than 6 units were studying BPharm (91%), followed by MPharm (8%), and BPharmMgmt (1%). Students who failed 2 or 3 UoS were significantly more likely to graduate when compared with those who failed 4 or 5 UoS, or more than 6 UoS \( (X_2^2=21.86, \text{P}<0.0001)\) (Supplementary Figure S2 ).

Type of failed UoS

The most failed UoS that triggered a show cause across students in the BPharm and BPharmMgmt degrees were a mix of pharmaceutical sciences, chemistry and biology, across the first and second years of the degree programs (Table  2 ). The top five UoS failed were Basic Pharmaceutical Sciences (8.8%, 116/1314 fails; unit code: PHAR1812), Chemistry 1B (Pharmacy) (6.9%, 91/1314 fails; unit code: CHEM1612), Drug Discovery and Design 1 (6.7%, 88/1465 fails; unit code: PHAR2811), Molecular Biology and Genetics (6.5%, 86/1314 fails; unit Code: MBLG1001), and Chemistry 1A (6.2%, 81/1314 fails; unit code: CHEM1611).

For students studying the MPharm, the majority of UoS failed were for pharmaceutical sciences in first year and one specific pharmacy practice unit (PHAR5717) in the second year. The top three UoS failed for MPharm were Pharmaceutical Chemistry 1A (12.6% 19/151 fails; unit code: PHAR5513), Pharmaceutical Science (7.9%, 12/151 fails; unit code: PHAR5515), and Pharmaceutical Chemistry 1B (7.9%, 12/151 fails; unit code: PHAR5516) (Table  3 ).

Gender, transfer and international students

There was no significant difference between the number of men and women who graduated after receiving at least one show cause \( (X_1^2=0.056, \text{P}=0.813)\) . There was also no significant difference in the number of UoS failed \( (X_2^2=2.249, \text{P}\hspace{0.17em}=\hspace{0.17em}0.325)\) or number of show causes received \( (X_6^2=2.829, \text{P}=0.830)\) between men and women.

Students who transferred from another degree program were significantly less likely to graduate \( (X_1^2=13.53, \text{P}\hspace{0.17em}=\hspace{0.17em}0.0002)\) . The likelihood of graduating was not statistically significant different between domestic and international students who received a show cause \( (X_1^2=0.88, \text{P}<0.348)\) (Supplementary Figure S3 ).

Student responses to show causes

There were 293 show causes in total, of which only 141 show cause response letters were available. Reasons given by students for their poor performance could be classified under four major themes: personal life matters, institutional aspects, social integration, and interest in the course (Fig.  3 ). Personal life matters could be further sub-divided into health, study familiarity, responsibilities, and other personal life matters.

The majority of show cause responses attributed poor performance to personal life reasons (87%, 396 responses), followed by institution-related (8.8%, 40 responses), lack of interest in the degree (2.2%, 10 responses), and social integration (2%, 9 responses). The five most mentioned personal life reasons that led to poor performance were stress and anxiety ( n  = 63, 45%), physical health ( n  = 51, 36%), and depression ( n  = 39 28%). This was followed by family health, mentioned 37 times (26%), and reasons relating to employment or financial health, mentioned 33 times (23%). Reasons that related to the institution totalled 40, interest of the course totalled 10, and social reasons totalled 9. Personal life health-related reasons accounted for 41% of show cause responses. These included a combination of physical, mental, and unspecified health issues.

All show cause responses provided by students could be categorised into four major themes. Personal life was subcategorised into health, study skills, responsibilities, and other personal life

Some students identified a lack of study-related skills and study familiarity as a source of underperformance. Reasons included: carelessness in exams, poor study habits, language barrier, being an international student or mature age student, misjudging the course difficulty, overloading, burning out after high school, and being unaware of opportunities to apply for special consideration. Another set of reasons provided for underperformance included: needing to meet responsibilities and commitments for family, friendships, and romantic relationships. A variety of other personal life reasons were provided, which included: employment, finance, transition to independent living or a new country, living environment, distance to travel to the university, needing to relocate, and being physically unable to attend classes.

Student show cause responses that attributed poor performance to inefficiencies within the institution included UoS changes, error or poor timing of exams, dissatisfaction with the course and staff, and unhelpful support. Some students found the UoS content too difficult. Social reasons that lead to poor performance included: bullying, stigma from peers once failing, and homesickness (for those studying abroad). Another reason provided was no longer being interested or committed to the course.

This study investigated the key determinants of underperformance by pharmacy students at an Australian higher education institution. Our findings indicate that across the students enrolled in BPharm, BPharmMgmt, and MPharm degrees, those who had failed more UoS overall, were less likely to graduate. The types of UoS failed were weighted towards chemistry-based subjects, and the most frequent student-reported reasons for poor performance were related to personal health.

Our study also found that students who transferred from another higher education institution were less likely to graduate compared with students who had not transferred. Some studies in the US have found that students who transfer to bachelors programs from similar institutions or community colleges, which are US institutions that only offer two year undergraduate associate degrees that lead to a specific skilled job or can be used to transfer into a bachelor course [ 54 ], experience ‘transfer shock’ where grade point average (GPA) declines at the post transfer institution, which can eventually result in attrition [ 55 , 56 ]. In contrast, other studies have found no significant effects from transfers, and an overall lack of consensus on this as a universal experience [ 57 , 58 ]. A study that examined transferring engineering students found that students who transferred from similar degrees were more likely to graduate when compared with students who transferred from less comprehensive degrees [ 56 ]. A literature review that examined transferring student performance found factors that negatively influenced persistence and course completion included: a lack of social integration, limited transferrable credits, lower GPAs, lack of funding, distance from institution, academic rigour, and personal work/life balance [ 57 ].

Our analysis also found that students failing more than three UoS were more likely to not graduate when compared with those who failed fewer UoS. This finding parallels many studies that show students with poor academic outcomes are more likely to not complete their degree [ 59 , 60 ]. A recent study on student attrition, found that students who failed one subject were more likely to fail more subjects, and also had a four-fold higher likelihood of not graduating [ 27 ]. The Grattan Institute presents similar statistics, where students who consistently fail to meet academic progression requirements eventually decide to leave or are excluded from re-enrolling by the university [ 61 ].

The high occurrence of underperformance in relation to chemistry is consistent with other studies [ 62 , 63 ]. Pancyk et al. found that chemistry marks were correlated with attrition while biology marks predicted likelihood of delayed graduation for Master of Science (in Pharmacy) students. Another study found that the prior attainment of a Bachelor of Science degree to be a predictor of performance in a Doctor of Pharmacy program [ 64 ]. In countries, such as the US, where a specialised pre-admissions pharmacy test (Pharmacy College Admissions Test; PCAT) is used for entrance into a pharmacy program, the PCAT score correlated with student academic performance in the pharmacy course [ 65 ]. There are five areas examined by the PCAT, including: writing, biological processes, chemical processes, critical reading, and quantitative reasoning [ 66 ]. There is also evidence that better outcomes attained in pre-pharmacy biology and mathematics GPA [ 67 , 68 ], or having completed a four-year bachelor course, contributes to student performance in American pharmacy colleges [ 64 , 69 , 70 ]. Another study found prior academic achievement in secondary school, or pre-university study, can predict performance in an UK MPharm course; however, not the likelihood of graduation [ 71 ]. Other studies have found that pre-tests, for certain UoS, like biochemistry and pharmaceutical calculations conducted before starting a subject are correlated with overall subject performance, which makes these tests a good predictor for at-risk students [ 67 , 68 ].

The most common reasons reported by students for their underperformance in the present study were stress and anxiety, personal health, and depression. This is consistent with current literature [ 17 , 23 , 24 , 25 , 26 , 27 ], and the 2022 Australian Student Experience Survey [ 72 ], which reported that health or stress, followed by work/life balance were the leading causes for students attrition. A specific study in pharmacy students found that exam anxiety had a negative impact on student performance in pharmacy practical exams [ 26 ]. Psychological distress among students completing a higher education degree in Norway showed negative impacts on their self-perceived academic ability, and course progression [ 73 ]. Another study investigating students’ self-reported explanations for their poor academic performance found mental health as a contributing factor, and vice versa, where poor performance intensified mental distress [ 27 ]. Although the Australian Bureau of Statistics also reported personal health reasons as a major contributor for non-completion in bachelor programs between 2018 and 2019, the leading reason was that students were no longer interested in their chosen degree. In the same report, non-completion of masters degrees was driven by family, health, or other personal reasons [ 42 ]. Student mental health is a significant driver of attrition and is common across both private and public higher institutions in Australia [ 41 ]. The mental health burden on students is recognised at The University of Sydney and so significant mental health support is offered. All students are able to access free counselling and psychological support sessions, there is a 24/7 mental health support telephone line, and additional self-help resources (like mindfulness and relaxation) are provided through the university’s website. Mental health first health training is also included in the curricula for all pharmacy degree programs at the university.

Successful completion of a pharmacy degree requires not only academic ability, but a certain level of pre-knowledge, in particular, biology and chemistry, to decrease failure rates in these subjects, avoid delays in degree completion, and possible attrition. Institutions should aim to address these barriers by introducing pre-requisite subjects or mandate compulsory bridging courses if a prior level of knowledge attainment in these subject areas is not provided. Alternatively, pre-tests for certain UoS can be conducted prior to the course commencement to identify at-risk students, and additional academic support services can be offered.

With student poor mental health found as the most common self-reported reason for poor performance in this study, often exacerbated by academic performance pressures, institutions should implement policies for early detection and support for students going through challenging times. Such policies could include more frequent reminders for students to self-assess their mental health, and information on where to seek support services. This could take form in programs being introduced prior to lectures, access to support portals made more prominent on online learning platforms, or self-check surveys to be taken at a frequency deemed appropriate.

Limitations

The present study had a number of limitation. Not all student’s ATAR scores (or equivalent) were available. The method of collecting whether a student was registered as a pharmacist was based on them not having changed their last name which may be the case for some students who changed their name after graduation (e.g. upon marriage). Students who may be registered as a pharmacist in countries other than Australia could not be determined. Not all student show cause reasons were available because of the change from physical to electronic filing over the period studied. The limited number of students who received five or more show causes also meant the study was not powered to establish a cut-off whereby after receiving a certain number of show causes, the chance of graduating is highly unlikely.

Conclusions

This study investigated the key determinants for poor academic performance in a cohort of pharmacy students enrolled in a BPharm, BPharmMgmt, and MPharm degree. The key factors that influenced whether a show cause student completed their studies included whether they transferred from another institution, and failed more than three UoS. The UoS with the highest fail rates were chemistry based, and the most frequent student self-reported reason for poor performance was personal stress and anxiety. The results indicate that pharmacy schools should aim to address student foundation knowledge in chemistry, identify at-risk students early using pre-subject testing, and provide better access and knowledge of available services to address student mental burden. Future studies should investigate whether students who have completed chemistry and biology pre-requisites perform better in their pharmacy degree.

Data availability

The data that support the findings of this study are available on request from the corresponding author, N.J.W.

Aljohani O. A comprehensive review of the major studies and theoretical models of student retention in higher education. High Educ Stud. 2016;6:1–18.

Article   Google Scholar  

Spady WG. Dropouts from higher education: an interdisciplinary review and synthesis. Interchange 1984. 1970;1(1):64–85.

Spady WG. Dropouts from higher education: toward an empirical model. Interchange. 1971;2(3):38–62.

Tinto V. Dropout from higher education: a theoretical synthesis of recent research. Rev Educ Res. 1975;45(1):89–125.

Tinto V. Leaving college: rethinking the causes and cures of student attrition. 2nd ed. Chicago: University of Chicago Press; 1993.

Google Scholar  

Bean JP. Dropouts and turnover: the synthesis and test of a causal model of student attrition. Res High Educ. 1980;12(2):155–87.

Tight M. Student retention and engagement in higher education. J Furth High Educ. 2020;44(5):689–704.

Carini RM, Kuh GD, Klein SP. Student engagement and student learning: testing the linkages. Res High Educ. 2006;47(1):1–32.

Thomas L, Kift S, Shah M. Student retention and success in higher education. Cham: Springer International Publishing; 2021. pp. 1–16.

Book   Google Scholar  

Coates H. The value of student engagement for higher education quality assurance. Qual High Educ. 2005;11(1):25–36.

Al-Tameemi RAN, Johnson C, Gitay R, Abdel-Salam A-SG, Hazaa KA, BenSaid A, et al. Determinants of poor academic performance among undergraduate students—A systematic literature review. Int J Educ Res. 2023;4:100232.

Lorenzo-Quiles O, Galdón-López S, Lendínez-Turón A. Factors contributing to university dropout: a review. Front Educ Res. 2023;8.

Wilkinson TJ, McKenzie JM, Ali AN, Rudland J, Carter FA, Bell CJ. Identifying medical students at risk of underperformance from significant stressors. BMC Med Educ. 2016;16:43.

Le HTTN, La HTT, Le TP, Nguyen TTT, Nguyen NT, Tran TP. Factors affecting academic performance of first-year university students: a case of a Vietnamese university. Int J Educ Prac. 2020;8(2):221–32.

Sharma P, Singh P, Kalhan S, Garg S. Analysis of factors affecting academic performance of MBBS students in pathology. Ann Int Med Dent Res. 2017;2.

Mascolo M, Castillo J. The origins of underperformance in higher education in America: proximal systems of influence. Pedgog Hum Sci. 2015;5(1):1–40.

Norton AC, I. and, Mackey W. Dropping out: the benefits and costs of trying university. The Grattan Institute, 2018. p. 1–65.

van Rooij E, Jansen EPWA, Van de Grift W. First-year university students’ academic success: the importance of academic adjustment. Eu J Psychol Educ. 2017;33:1–19.

Arshad M, Zaidi SM, Mahmood D. Self-esteem and academic performance among university students. J Educ Pract. 2015;6:2015.

Walck-Shannon EM, Rowell SF, Frey RF. To what extent do study habits relate to performance? CBE - Life Sci Educ. 2021;20(1):ar6.

Roick J, Ringeisen T. Students’ math performance in higher education: examining the role of self-regulated learning and self-efficacy. Learn Individ Differ. 2018;65:148–58.

Nonis SA, Hudson GI. Performance of college students: impact of study time and study habits. J Educ Bus. 2010;85(4):229–38.

Jevons C, Lindsay S. The middle years slump: addressing student-reported barriers to academic progress. High Educ Res Dev. 2018;37(6):1156–70.

Pascoe MC, Hetrick SE, Parker AG. The impact of stress on students in secondary school and higher education. Int J Adolesc Youth. 2020;25(1):104–12.

May RW, Bauer KN, Seibert GS, Jaurequi ME, Fincham FD. School burnout is related to sleep quality and perseverative cognition regulation at bedtime in young adults. Learn Individ Differ. 2020;78:101821.

Hadi MA, Ali M, Haseeb A, Mohamed MMA, Elrggal ME, Cheema E. Impact of test anxiety on pharmacy students’ performance in Objective Structured Clinical examination: a cross-sectional survey. Int J Pharm Pract. 2018;26(2):191–4.

Ajjawi R, Dracup M, Zacharias N, Bennett S, Boud D. Persisting students’ explanations of and emotional responses to academic failure. High Educ Res Dev. 2020;39(2):185–99.

Rodríguez-Hernández CF, Cascallar E, Kyndt E. Socio-economic status and academic performance in higher education: a systematic review. Educ Res Rev. 2019;29:100305.

Tomul E, Polat G. The effects of socioeconomic characteristics of ctudents on their academic achievement in higher education. Am J Educ Res. 2013;1:449–55.

Peled Y. Cyberbullying and its influence on academic, social, and emotional development of undergraduate students. Heliyon. 2019;5(3):e01393.

Sun J, Hagedorn L, Zhang Y. Homesickness at college: its impact on academic performance and retention. J Coll Stud Dev. 2016;57:943–57.

Triventi M. Does working during higher education affect students’ academic progression? Econ Educ Rev. 2014;41:1–13.

Voyer D, Voyer SD. Gender differences in scholastic achievement: a meta-analysis. Psychol Bull. 2014;140(4):1174–204.

Dafouz E, Camacho-Miñano MM. Exploring the impact of English-medium instruction on university student academic achievement: the case of accounting. Engl Specif Purp. 2016;44:57–67.

Civan A, Coskun A. The effect of the medium of instruction language on the academic success of university students. Educ Sci: Theory Prac. 2016;16:1981–2004.

Sawir E. Language difficulties of international students in Australia: the effects of prior learning experience. Int Educ J. 2005;6:567–80.

Mishra S. Social networks, social capital, social support and academic success in higher education: a systematic review with a special focus on ‘underrepresented’ students. Educ Res Rev. 2020;29:100307.

López MJ, Santelices MV, Carmen Maura T. Academic performance and adjustment of first-generation students to higher education: a systematic review. Cogent Educ. 2023;10(1).

Zheng RX, Everett B, Glew P, Salamonson Y. Unravelling the differences in attrition and academic performance of international and domestic nursing students with English as an additional language. Nurse Educ Today. 2014;34(12):1455–9.

Rienties B, Beausaert S, Grohnert T, Niemantsverdriet S, Kommers P. Understanding academic performance of international students: the role of ethnicity, academic and social integration. High Educ. 2012;63(6):685–700.

Final Report -. Improving retention, completion and success in higher education. Higher Education Standards Panel; Australian Government Department of Education; 2017.

Qualifications. and Work, 2018-19. Australian Bureau of Statistics; 2020.

Academic Progression. The University of Sydney [updated 31 March 2023; cited 2023 September ]. Available from: https://www.sydney.edu.au/students/academic-progression.html .

Failed. withheld and invalid units: Monash University; [updated 2023; cited 2023 September]. Available from: https://www.monash.edu/students/admin/enrolments/change/failed-withheld-invalid-units .

OCED. Education at a Glance 2023. Organisation for Economic Co-operation and Development Publishing 2023 [Available from: https://www.oecd-ilibrary.org/content/publication/e13bef63-en .

Yorke M, Longden B. Retention and student success in higher education. McGraw-Hill Education (UK); 2004.

Faisal R, Shinwari L, Hussain S. Academic performance of male in comparison with female undergraduate medical students in pharmacology examinations. J Pak Med Assoc. 2017;67:204–8.

van Moppes NM, Willems S, Nasori M, Bont J, Akkermans R, van Dijk N et al. Ethnic minority GP trainees at risk for underperformance assessments: a quantitative cohort study. Br J Gen Pract Open. 2023;7(1).

Liu XL, Wang T, Bressington D, Nic Giolla Easpaig B, Wikander L, Tan JB. Factors influencing retention among regional, rural and remote undergraduate nursing students in Australia: a systematic review of current research evidence. Int J Environ Res Public Health. 2023;20(5).

Caponnetto V, Dante A, Masotta V, La Cerra C, Petrucci C, Alfes CM, et al. Examining nursing student academic outcomes: a forty-year systematic review and meta-analysis. Nurse Educ Today. 2021;100:104823.

Australian Tertiary Admission Rank. Universities Admission Centre; [cited 2023 November ]. Available from: https://www.uac.edu.au/future-applicants/atar .

Weighted Average Mark (WAM). The University of Sydney; 2023 [cited 2023 November]. Available from: https://www.sydney.edu.au/students/weighted-average-mark.html .

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.

Community College. Education USA; [cited 2023 November ]. Available from: https://educationusa.state.gov/ .

Ivins T, Copenhaver K, Koclanes A. Adult transitional theory and transfer shock in higher education: practices from the literature. Ref Serv Rev. 2017;45(2):244–57.

Smith NL, Grohs JR, Van Aken EM. Comparison of transfer shock and graduation rates across engineering transfer student populations. J Eng Educ. 2022;111(1):65–81.

Aulck L, West J. Attrition and performance of community college transfers. PLoS ONE. 2017;12:e0174683.

Diaz PE. Effects of transfer on academic performance of community college students at the four-year institution community. Coll J Res Prac. 1992;16(3):279–91.

Li I, Carroll D. Factors influencing university student satisfaction, dropout and academic performance: an Australian higher education equity perspective. Perth: National Centre for Student Equity in Higher Education, Curtin University;; 2017. p. 56.

Sosu EM, Pheunpha P. Trajectory of university dropout: investigating the cumulative effect of academic vulnerability and proximity to family support. Front Educ. 2019;4.

Cherastidtham I, Norton A, Mackey W. University attrition: what helps and what hinders university completion? Grattan Institute; 2018.

Panczyk M, Rebandel H, Belowska J, Zarzeka A, Gotlib J. Risk of attrition from master of science in pharmacy degree program: 15-year predictive evaluation. Ind J Pharm Educ Res. 2016;50(1):70–9.

Houglum JE, Aparasu RR, Delfinis TM. Predictors of academic success and failure in a pharmacy professional program. Am J Pharm Educ. 2005;69(1–5):283–9.

McCall KL, Allen DD, Fike DS. Predictors of academic success in a doctor of pharmacy program. Am J Pharm Educ. 2006;70(5):106.

Meagher DG, Pan T, Perez CD. Predicting performance in the first-year of pharmacy school. Am J Pharm Educ. 2011;75(5):81.

Pharmacy College Admission Test American Association of Colleges of Pharmacy. [updated 2023; cited 2023 October]. Available from: https://www.aacp.org/resource/pharmacy-college-admission-test .

Vinall R, Khansari P, McDowell J, Ried LD, Kreys E. Impact of completion of a pre-pharmacy biochemistry course and competency levels in pre-pharmacy courses on pharmacy student performance. Pharm 2019;7(3).

Aronson BD, Eddy E, Long B, Welch OK, Grundey J, Hinson JL. Identifying low pharmaceutical calculation performers using an algebra-based pretest. Am J Pharm Educ. 2022;86(1):8473.

Chisholm MA, Cobb HH, DiPiro JT, Lauthenschlager GJ. Development and validation of a model that predicts the academic ranking of first-year pharmacy students. Am J Pharm Educ. 1999;63(4):388–93.

Chisholm MA, Cobb HH, Kotzan JA. Significant factors for predicting academic success of first-year pharmacy students. Am J Pharm Educ. 1995;59(4):364–70.

Bush J. Entry characteristics and academic performance of students in a master of pharmacy degree program in the United Kingdom. Am J Pharm Educ. 2012;76(7).

2022 Student Experience Survery. National Report. 2023.

Grøtan K, Sund ER, Bjerkeset O. Mental health, academic self-efficacy and study progress among college students - the SHoT Study, Norway. Front Psychol. 2019;10:45.

Download references

No funding was received for this research.

Author information

Authors and affiliations.

Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, 2006, Sydney, NSW, Australia

Alice Campbell, Tina Hinton, Narelle C. da Costa, Sian E. O’Brian, Danielle R. Liang & Nial J. Wheate

Charles Perkin Centre, Faculty of Medicine and Health, The University of Sydney NSW, 2006, Sydney, NSW, Australia

Tina Hinton

You can also search for this author in PubMed   Google Scholar

Contributions

ND, SO, and DL collated and de-identified the data. AC, TH, and NW analysed the data and wrote the manuscript.

Corresponding author

Correspondence to Nial J. Wheate .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Ethics approval and consent to participate

The University of Sydney Human Research Ethics Committee (HREC) reviewed and approved this study (Approval number 2022/815). All methods were carried out in accordance with relevant guidelines and regulations. As this study utilised de-identified data collected retrospectively, The University of Sydney Human Research Ethics Committee (HREC) gave ethics approval for an informed consent waiver so consent did not need to be obtained from the students whose data was used in the analysis.

Consent for publication

Not applicable.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Campbell, A., Hinton, T., da Costa, N.C. et al. Causes and outcomes of at-risk underperforming pharmacy students: implications for policy and practice. BMC Med Educ 24 , 421 (2024). https://doi.org/10.1186/s12909-024-05327-z

Download citation

Received : 16 January 2024

Accepted : 18 March 2024

Published : 19 April 2024

DOI : https://doi.org/10.1186/s12909-024-05327-z

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Higher education
• Underperformance

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Teaching & Learning

• Education Excellence
• Professional development
• Case studies
• Teaching toolkits
• MicroCPD-UCL
• Assessment resources
• Student partnership
• Generative AI Hub
• Community Engaged Learning
• UCL Student Success

Using reverse mentoring to support inclusivity

Antonia Aluko, a student in Greek and Latin, worked with Dr Mazal Oaknin to reverse mentor a group of educators working in Gender Studies on how to make their teaching more inclusive.

15 April 2024

Only got a minute? Jump straight to Antonia's and Mazal's top tips

I worked with Dr Mazal Oaknin, Associate Professor (Teaching) in Spanish Language and Literature and Gender Studies, to formulate this project in response to our growing understanding of the non-inclusive teaching models in the Faculty of Arts and Humanities.

Our project “Decolonising Gender Studies Through Reverse Mentoring in the Faculty of Arts and Humanities” took place within the 2023-4 academic year. 

The aim this reverse mentoring project was to inform and equip teaching staff in our faculty on how to be more considerate of the multi-faceted experiences and interests of their students. 

Facilitated by students

We facilitated three sessions on inclusive teaching:

• Session 1: we explored some of the legislation regarding inclusivity and engagement in the classroom, as well as introducing participants to key scholars that have not always been included in traditional Gender Studies reading lists.
• Session 2: we focused on the benefits of inclusive teaching for students and how this increased student satisfaction and attainment
• Session 3: we shared techniques and methods of inclusive teaching so that participants could have inclusive teaching resources to use in their everyday teaching experiences

Together, the group discussed their own personal experiences in classrooms as educators and students. They used these conversations to form opinions and strategies on how to approach the modules that they are teaching with intersectionality, diversity, and inclusion in mind . 

Each session included a lunch or coffee break where participants had time to interact and socialise. 

Our approach and preparation

Intersectionality was at the forefront of our approach. We ensured that our project answered questions in regard to disability, race, gender, class as well as other protected characteristics.

Over a month, Dr Mazal Oaknin offered training and support to equip me with the tools to facilitate the sessions with confidence and ease .  

I collated a questionnaire for prospective mentees and shortlisted candidates who were selected out of UCL’s teaching staff. I also prepared handouts and presentations for the sessions, to give mentees a sense of an agenda and structure.  

We were delighted with the feedback from staff after the sessions. 100% of the attendees found the sessions very helpful. All attendees all said they would recommend the project to their colleagues and felt they left with practical ideas for making their classes more inclusive.  

Antonia's top tips:

• Always adapt sessions so participants are shown examples relevant to them. 
• Use a range of materials, including videos, Mentimeters and interactive activities. 
• Plan in tasks that get people talking, allowing there to be a space for open communication and discussion. 

Mazal's top tips and how staff can benefit from reverse mentoring:

• Staff mentees are exposed to new ideas to make modules more diverse and inclusive . Be ready to apply the lessons learnt to the modules you are teaching.
• Through participative discussions, professional friendships are developed between participants with different levels of seniority. Encourage a social atmosphere in the sessions and if possible offer food and drinks. Time for mingling is a must!
• Staff mentees gain new perspectives, skills, and insights from the student mentor: Make sure you listen to your mentor. Offer your help, but make sure not to take the lead .
• Staff mentees become more aware of different biases and more committed to escalating complaints.  Show cultural humility, become an ally, acknowledge power imbalances and practice self-reflection .
• Participants can promote and share good practices with the rest of participants, and also with other colleagues in and beyond UCL. Share the lessons learnt in your departmental meetings, committees, conferences, townhalls. 

Antonia Aluko: 

“ I think it makes the case for the benefit of reverse mentoring and how it can benefit the experiences of teaching staff at UCL by being educated on the student experience by their students. Additionally, I think it combats issues of un-inclusive experiences as a student within UCL by considering the nuanced experiences and various backgrounds of students and their educators.  I think it makes the case for the benefit of reverse mentoring and how it can benefit the experiences of teaching staff at UCL by being educated on the student experience by their students. Additionally, I think it combats issues of un-inclusive experiences as a student within UCL by considering the nuanced experiences and various backgrounds of students and their educators. 

Anonymous attendee: 

It was very useful to hear practical suggestions from Antonia and colleagues, and to exchange experiences in different scenarios in a safe, friendly environment.” I think it makes the case for the benefit of reverse mentoring and how it can benefit the experiences of teaching staff at UCL by being educated on the student experience by their students. Additionally, I think it combats issues of un-inclusive experiences as a student within UCL by considering the nuanced experiences and various backgrounds of students and their educators. 

Case studies 

Funnelback feed: https://cms-feed.ucl.ac.uk/s/search.json?collection=drupal-teaching-lear... Double click the feed URL above to edit

ABM Students Participate at NGA Show

Gained valuable experience at grocery industry event.

Best Bagger

Students assisted with the "Best Bagger" competition.

Student Standout Awards

Students evaluated products and services for the Student Standout Awards.

Case Study Competition

Students developed a business strategy for a grocery chain.

April 16, 2024

Seven agribusiness and food industry management students recently brought home valuable experience and recognition from the National Grocers Association (NGA) Show.

Held at Caesar's Palace Forum in Las Vegas, the NGA Show is a premier event for the grocery industry, bringing together retailers, wholesalers, and a passionate student community that included students from Cornell, University of Findlay, St. Joseph’s University, Arizona State, Kansas State, Auburn, Cal Poly San Luis Obispo and Fresno State.

Students Justin Kipper, Carmen Diaz, Elizabeth Vargas, Ariadna Castro, Megan Ebner, Avalon Anderson, and Irvin Ayon were not just attendees; they were active participants at the show in several activities.

One of the activities was the Student Standout Awards, which tasked them with forming cross-university teams and evaluating hundreds of products and services showcased on the expansive NGA Show Expo Floor.

The floor included 350 companies eager to connect with industry stakeholders. From Center Store and Fresh Food innovations to cutting-edge technology solutions, the students had a front-row seat to the future of grocery retailing.

The cross-university teams each tackled a specific award category: Center Store, Fresh, Health & Wellness, Pharmacy, Operational Services, Sustainability in Store Design & Equipment, and Technology.

Armed with a set of insightful questions, they approached each booth, engaging with company representatives and learning how these products and services could empower independent grocers.

Through these insightful dialogues, the expo transformed into a real-world learning lab for the students, exposing them to the grocery landscapes and giving them invaluable industry knowledge while honing their critical thinking and communication skills.

Best Bagger Competition

Cal Poly Pomona students Castro, Vargas, and Diaz also assisted with the Best Bagger Competition, which puts the spotlight on a fundamental skill in the grocery industry – bagging – and on customer service and company pride.

Grocery store baggers from across the country battled it out for the coveted championship title and a grand prize of $10,000.

The students’ support ensured a smooth-running event and exemplified the collaborative spirit fostered by the agribusiness program.

Student Case Study

In the ever-evolving landscape of the grocery industry, maintaining a competitive edge requires not just adaptation but forward-thinking strategies that anticipate future trends.

This was the challenge the agribusiness management students embraced in the Student Case Study.

Their mission was clear: to revitalize Niemann Foods Inc. by transitioning its County Market stores into B-level stores, rebranded as "Niemann's Market."

Niemann Foods faced the dual challenge of executing a successful rebranding strategy to build customer loyalty while adapting to the changing dynamics of the grocery industry.

The team was comprised of Kipper, serving as the senior program manager, Anderson as head of marketing strategy, Ayon as senior community activities director, Diaz as visual design manager, with valuable contributions from Vargas, Castro, and Ebner.

Under the expert guidance of Lecturer Katie Horvath, a seasoned professional with 15 years of experience in the grocery and consumer packaged goods) retail sector, the student consultant team embarked on a journey to redefine the shopping experience at Niemann's Market

The key questions posed to the student team revolved around creating an integrated shopping experience, aligning the rebranding with future customer preferences—especially in the fresh category—and differentiating Niemann's Market in the coming decade.

The students' proposal focused on leveraging technology and community engagement to revolutionize the shopping experience at Niemann's Market. Their strategic plan included the implementation of Custom Shelf Talkers and new cost-saving Electronic Shelf Labels (ESL) Digital Shelf Tags.

These innovations aimed not only to enhance the in-store experience but also to achieve significant cost savings through labor reduction and efficiency in promotional activities.

Furthermore, the team devised a compelling marketing strategy titled "Look closer, find more at Niemann's," emphasizing the unique value proposition of the rebranded stores. By integrating these elements, the students projected a rate of investment of 73 percent or more, with substantial savings in labor and material costs, while also saving valuable time spent on price changes each week.

Gerry Kettler, Niemann’s director of consumer affairs, lauded the students' presentation, highlighting the impactful ideas they brought to the table.

"Your students rocked the presentation with their ideas! I cannot wait to work with these students," he remarked.

Although the team did not clinch the top prize, their innovative cost-saving initiative caught the attention of independent grocers across the United States, with seven grocers keen on implementing their strategies.

As these bright minds continue to make their mark on the industry, the experience gained from the Student Case Study serves as a foundation for their future endeavors. Their work with Niemann's Market is a testament to the transformative power of innovative thinking in maintaining a competitive edge in the dynamic grocery industry.

The collaboration between Cal Poly Pomona students and Niemann Foods, Inc. exemplifies the potential for academic institutions and industry leaders to work together in addressing real-world challenges.

The students' ability to apply their knowledge, creativity, and strategic thinking to a complex business scenario underscores the quality of education and training provided by agribusiness and food industry management program at the Huntley College of Agriculture.

• India Today
• Business Today
• Reader’s Digest
• Harper's Bazaar
• Brides Today
• Cosmopolitan
• Aaj Tak Campus
• India Today Hindi

Case study: Balancing JEE preparations with sports and extra-curriculars

For students aiming to excel in competitive exams such as jee and neet, striking a balance between academic rigour and extracurricular activities can be quite challenging..

Listen to Story

Many say that a lack of balance between education, game & extracurricular activities can lead to a dullness in a student’s personality. This timeless saying highlights an essential truth: finding balance is crucial for a satisfying and prosperous life. For students aiming to excel in competitive exams such as JEE and NEET, striking a balance between academic rigour and extracurricular activities can be quite challenging.

As we talk of sports and extracurricular activity it is critical to distinguish between mindless and conscious leisure activities. While mindless pursuits such as binge-watching TV or incessantly browsing through social media may bring short respite, they yield little in the way of personal development. Mindful leisure activities, on the other hand, such as playing sports, reading, or listening to music, not only refresh the mind but also improve general well-being.

TAKING EXAMPLES OF VARIOUS STUDENTS

Take, for instance, Sriyashas Mohan Kalluri, a remarkable student who embodies the FIITJEE ethos. Starting from the FIITJEE’s Four Year Classroom Programme (IX - XII), upgraded to PINNACLE - Two Year Integrated Program (XI – XII), excelled not only academically but also in the field of sports. As a national-level archer and Khelo India athlete, Sriyashas showcased his prowess beyond the academic sphere, culminating in a remarkable achievement of 100 NTA score in JEE Main 2024 Session 1.

Consider Harshit Singh, a student from FIITJEE’s Four Year Classroom Programme (IX-XII), secured an impressive All India Rank (AIR) 112 in JEE Advanced 2022. Despite his rigorous academic schedule, Harshit remained deeply involved in basketball, even representing his institute in the inter-IIT Sports meet where he clinched the third position in basketball. Harshit thanks his success to FIITJEE which not only honed his academic skills but also facilitated his growth as a sportsman.

A West Bengal state topper, Harshit points to the importance of concept building skills imparted by FIITJEE, which alongside the invaluable study materials provided, proved to be instrumental in his JEE Main & JEE Advanced preparation.

" I want to thank FIITJEE for my achievements and the study material, specifically the rankers study material given after finishing the syllabus, proved to be really important resources containing JEE Advanced focused questions to me," said Harshit.

Similarly, Madhav Bansal's journey exemplifies the holistic approach fostered by the institute. Beginning his educational journey from the FIITJEE’s UDAYA : Two-Year Classroom Programme (VII - VIII), which extended to the Four-Year Classroom Programme (IX-XII), Madhav's pursuit of excellence raged beyond academics. A Hindustani Classical Music Distinction Holder, Madhav's multifaceted talents were nurtured alongside his academic endeavours, resulting in another remarkable feat—a perfect 100 NTA score in JEE Main 2024 Session 1.

It's not merely about excelling in academics; it's about nurturing talents, fostering a well-rounded personality, and instilling a sense of balance that transcends the confines of textbooks. FIITJEE's Integrated School Programmes offer a structured yet flexible approach, allowing students ample time for both academic pursuits and extracurricular activities. With a stress-free environment and effective time management strategies, the institute empowers students to thrive intellectually while actively participating in a variety of activities.

Nisarg Chadha's journey exemplifies the multifaceted development encouraged by the institute, which works in offering stress reduction and better academic strategies. Nisarg achieved remarkable success in JEE Main 2020, securing All India Rank (AIR) 2, while also excelling in table tennis and pursuing his passion for music. Nisarg who also plays the tabla, credits FIITJEE’s stress-free environment and supportive ecosystem for enabling him to manage his academic pursuits alongside extracurricular interests and competitive examinations such as NSEP, NSEC, NSEA, INPhO, and INChO. He attributes his ability to navigate these exams to FIITJEE's computer-based All India Test Series, which familiarised him with test patterns and enhanced his preparedness.

Ankit Mondal , an All India Rank (AIR) 172 in JEE Advanced 2021, shares his experience of striking a balance between academics and personal interests during his Two-Year Classroom Programme (XI-XII) at FIITJEE. Despite his rigorous study schedule, Ankit dedicated his evenings to his passion for painting and actively participated in school activities, maintaining an active social life.

“Following the schedule devised by teachers along with their advice is what helped me effectively tackle stress and focus on everything in life while aiming big and scoring high”, shares Ankit .

Another student, Jasraj Singh’s journey from FIITJEE, highlights that supportive environment and personalised guidance are essential to get success in academics and extra-curricular activities. Alongside his commitment to basketball, Jasraj also excelled academically under the guidance of FIITJEE’s faculty, who provided additional support during periods of absence due to sports commitments. Jasraj underscores the role of the institute in not only facilitating his academic preparation but also in raising awareness about various competitive exams and providing guidance to navigate them successfully.

Countless success stories demonstrate the efficacy of balanced preparation. Students like Sriyashas, Madhav, Jasraj, Ankit, Nisarg, and Harshit, along with numerous other peers, have demonstrated the potential to achieve a harmonious balance between excelling in competitive tests and actively engaging in sports and extracurricular activities. These achievers demonstrate that academic brilliance and comprehensive growth are not mutually exclusive.

“Sports should be an integral part of our everyday life. Some people think that sports is important only for physical well-being, I feel sports is important for overall development of an individual. We are a large and diverse nation, and sports can be a great means of national integration. From sports, we learn the sportsman spirit and that acts as a lubricant in our social life. More than winning, sports help you learn to deal with defeats. It helps you become a fighter, and teaches you not to lose heart after defeats,” PM Modi has said earlier while calling for the promotion of sport in India.

• Skip to main content
• Keyboard shortcuts for audio player

Ex-assistant principal charged with child neglect in case of boy who shot teacher

The Associated Press

Signs stand outside Richneck Elementary School in Newport News, Va., Jan. 25, 2023. Denise Lavoie/AP hide caption

Signs stand outside Richneck Elementary School in Newport News, Va., Jan. 25, 2023.

NEWPORT NEWS, Va. — A former assistant principal at a Virginia elementary school has been charged with felony child neglect more than a year after a 6-year-old boy brought a gun to class and shot his first-grade teacher .

A special grand jury in Newport News found that Ebony Parker showed a reckless disregard for the lives of Richneck Elementary School students on Jan. 6, 2023, according to indictments unsealed Tuesday.

Parker and other school officials already face a $40 million negligence lawsuit from the teacher who was shot, Abby Zwerner. She accuses Parker and others of ignoring multiple warnings the boy had a gun and was in a "violent mood" the day of the shooting.

Criminal charges against school officials following a school shootings are quite rare, experts say. Parker, 39, faces eight felony counts, each of which is punishable by up to five years in prison.

The Associated Press left a message seeking comment Tuesday with Parker's attorney, Curtis Rogers.

Shots - Health News

'say something' tip line in schools flags gun violence threats, study finds.

Court documents filed Tuesday reveal little about the criminal case against Parker, listing only the counts and a description of the felony charge. It alleges that Parker "did commit a willful act or omission in the care of such students, in a manner so gross, wanton and culpable as to show a reckless disregard for human life."

Newport News police have said the student who shot Zwerner retrieved his mother's handgun from atop a dresser at home and brought the weapon to school concealed in a backpack.

Zwerner's lawsuit describes a series of warnings that school employees gave administrators before the shooting. The lawsuit said those warnings began with Zwerner telling Parker that the boy "was in a violent mood," had threatened to beat up a kindergartener and stared down a security officer in the lunchroom.

The lawsuit alleges that Parker "had no response, refusing even to look up" when Zwerner expressed her concerns.

When concerns were raised that the child may have transferred the gun from his backpack to his pocket, Parker said his "pockets were too small to hold a handgun and did nothing," the lawsuit states.

Architecture

With gun control far from sight, schools redesign for student safety.

A guidance counselor also asked Parker for permission to search the boy, but Parker forbade him, "and stated that John Doe's mother would be arriving soon to pick him up," the lawsuit stated.

Zwerner was sitting at a reading table in front of the class when the boy fired the gun, police said. The bullet struck Zwerner's hand and then her chest, collapsing one of her lungs. She spent nearly two weeks in the hospital and has endured multiple surgeries as well as ongoing emotional trauma, according to her lawsuit.

Parker and the lawsuit's other defendants, which include a former superintendent and the Newport News school board, have tried to block Zwerner's lawsuit.

They've argued that Zwerner's injuries fall under Virginia's workers' compensation law. Their arguments have been unsuccessful so far in blocking the litigation. A trial date for Zwerner's lawsuit is slated for January.

Prosecutors had said a year ago that they were investigating whether the "actions or omissions" of any school employees could lead to criminal charges.

What schools can (and can't) do to prevent school shootings

Howard Gwynn, the commonwealth's attorney in Newport News, said in April 2023 that he had petitioned a special grand jury to probe if any "security failures" contributed to the shooting. Gwynn wrote that an investigation could also lead to recommendations "in the hopes that such a situation never occurs again."

It is not the first school shooting to spark a criminal investigation into school officials. For instance, a former school resource officer was acquitted of all charges last year after he was accused of hiding during the Parkland school massacre in 2018.

Chuck Vergon, a professor of educational law and policy at the University of Michigan-Flint, told The AP last year that it is rare for a teacher or school official to be charged in a school shooting because allegations of criminal negligence can be difficult to prove.

More often, he said, those impacted by school shootings seek to hold school officials liable in civil court.

• elementary school