What are effective strategies for managing test anxiety?

Managing Test Anxiety: Evidence-Based Strategies

The most effective approach to managing test anxiety is cognitive-behavioral therapy (CBT) combined with skill-focused interventions, which produce the largest treatment effects and should be the first-line intervention. 1

First-Line Treatment: Cognitive-Behavioral Therapy

CBT with cognitive restructuring and combined behavioral/skill-focused approaches produces effect sizes greater than 0.90, making them the most powerful interventions for test anxiety. 1

Core CBT Components That Must Be Included:

• Cognitive restructuring to address negative self-talk (e.g., "I am doing poorly on this") and off-task thoughts (e.g., "I wish this were over"), which are significantly elevated in high-test-anxious individuals 1
• Systematic desensitization through graduated exposure to test-taking situations, which produces large effect sizes (>0.90) 1
• Anxiety management training combined with behavioral techniques 1
• Study skills and test-taking skills training, as these skill-focused approaches enhance treatment effectiveness when combined with CBT 1, 2

Treatment Duration and Format:

• Deliver 6-8 weekly sessions for adolescents, which has shown significant reductions in test anxiety with high acceptance rates 3, 2
• Treatment effects appear rapidly—significant improvement can occur within 8 weeks of cognitive-behavioral intervention 2
• For secondary school students (ages 14-16), a 6-session CBT protocol specifically designed for test anxiety produces large reductions compared to wait-list controls 3

Second-Line Interventions with Moderate Effect Sizes

If CBT is not immediately available or as adjunctive treatment:

• Relaxation training (medium effect size) can be used, though less effective than CBT 1
• Stress inoculation training produces medium effect sizes 1
• Biofeedback respiratory practice devices show promise in recent research, with significant reductions in test anxiety symptoms when used during exam periods 4

Addressing Underlying Cognitive Patterns

High-test-anxious individuals engage in more negative self-evaluation and off-task thinking during tests, which must be directly targeted in treatment. 1

• Focus cognitive restructuring on reducing negative self-statements about performance 1
• Address the paradox that high-test-anxious students use more coping self-statements (e.g., "try to relax") but still experience high anxiety—this suggests their coping strategies are ineffective and need replacement with evidence-based techniques 1

Study Skills and Academic Support

Integrate study skills training with anxiety management, as the combination produces larger effect sizes than either alone 1

• Teach specific test-taking strategies alongside anxiety reduction techniques 2
• Implement early prevention programs at the university level, as students benefit from learning organizational and study strategies before test anxiety becomes entrenched 5
• Progressive muscle relaxation, guided imagery, and self-instruction training combined with study skills show significant improvement in academic self-esteem and test performance 2

Important Clinical Considerations

Screen for Comorbid Conditions:

• 54% of test-anxious children meet criteria for another anxiety disorder, most commonly social phobia (which co-occurs in 75% of cases) 1
• High-test-anxious individuals report elevated depression and hopelessness, requiring assessment and potential treatment 1
• Test anxiety often reflects global emotional distress including fearfulness, general anxiety, and depression 1

Common Pitfalls to Avoid:

• Do not rely solely on relaxation techniques—they produce only medium effect sizes compared to CBT's large effects 1
• Do not assume coping self-statements alone are sufficient—high-test-anxious students already use these but remain anxious, indicating need for more comprehensive cognitive restructuring 1
• Do not ignore the skill deficit component—previous experience of failure in assessment situations is a major determinant of test anxiety and requires direct remediation 1

For Adolescents with Severe, Functionally Impairing Anxiety:

If test anxiety is part of a broader anxiety or panic disorder pattern:

• Consider combination treatment with CBT plus sertraline (SSRI), which shows superior outcomes for functionally impairing anxiety in adolescents aged 6-18 years 6, 7
• Start sertraline at 25 mg daily for 3-7 days, then increase to 50 mg daily, with target therapeutic dose of 50-175 mg daily 6
• Monitor weekly for suicidal ideation in the first weeks after starting SSRIs, as adolescents have increased risk (0.7% vs placebo) 6

Practical Implementation Algorithm

1. Assess severity: Determine if test anxiety is isolated or part of broader anxiety disorder with functional impairment 1
2. For isolated test anxiety: Initiate 6-8 session CBT protocol with cognitive restructuring, systematic desensitization, and study skills training 3, 2
3. For test anxiety with broader anxiety/panic: Refer for combination CBT plus SSRI 6, 7
4. Add adjunctive interventions: Consider biofeedback respiratory devices or relaxation training as supplements 4
5. Monitor response: Expect improvement within 6-8 weeks; if no response, reassess for comorbid conditions 3, 2