Childhood Anxiety Disorders

Anxiety disorders differ from normal anxiety. Anxiety is a healthy and important emotion that everyone has, to alert them to danger so that they can take effective steps to avoid or escape from the danger. Anxiety disorders, on the other hand, occur when people have excessive and persistent fears and worries about things or situations that do not pose real danger. While every day stress-induced anxiety is usually brief and easily managed, persistent anxiety can last for months and impact on daily functioning. For young children, this includes school refusal, absenteeism and reduced class participation, which impacts on learning, academic achievement, ability to make friends and maintain relationships, and developing independence in a variety of domains. Many anxiety disorders develop during childhood and if left untreated tend to continue into adolescence and adulthood. Anxiety disorders include separation anxiety disorder, selective mutism, phobias, social anxiety disorder, agoraphobia, and generalised anxiety disorder.

Anxiety symptoms will vary across the different anxiety disorders in terms of the types of situations or things that are feared. The symptoms typically last for at least 6 months but this duration may be shorter for very young children (e.g., approximately one month for separation anxiety and two months for selective mutism). In very young children, associated features may include tantrums where a child shows anger and aggression in response to the anxiety (i.e., the ‘fight’ aspect of ‘fight or flight’). Other associated features include withdrawal, sadness, difficulties concentrating on work or play, and frequent reassurance-seeking.

Separation anxiety disorder:

• Distress when separation occurs or is anticipated
• Fear or reluctance to be alone, clings to parent, or follows parent around the house
• Reluctance or refusal to go to school or elsewhere
• Complaints of physical symptoms when separation occurs or is anticipated
• Reluctance or refusal to go to sleep alone or sleep when away from home
• Nightmares with a separation theme
• Worries about harm happening to self or caregivers, including fear of dying

Selective Mutism:

• Consistent failure to speak in social situations where there is an expectation to speak (e.g., school) even though the individual speaks in other situations (e.g., home)

Phobias:

• Animals
• Natural environments (e.g., height, thunderstorm)
• Blood/Injection/Injury
• Situational (e.g., being in an aeroplane or a lift)

Social anxiety disorder:

• Has fear of and/or avoids participating in group activities
• Has fear of and/or avoids going to a party or social event
• Has fear of and/or avoids talking with a stranger, on the phone, or in front of a group
• Reluctant or refuses to write in front of other people, eat in public, or use a public bathroom

Agoraphobia:

• Fear and worries about using public transportation, being in open spaces or in enclosed places, standing in line or being in a crowd, or being alone outside of the home
• Fear and worries about inability to escape or get help in the event that they panic, or experience other incapacity or embarrassing symptoms

Generalised anxiety disorder:

• Excessive worry about every day or real-life problems
• Restlessness or feeling keyed-up or on edge
• Irritability
• Muscle tension or non-specific tension
• Easily fatigued
• Difficulty concentrating or mind going blank
• Sleep disturbance, especially difficulty falling asleep
• Dread or fearful anticipation (non-specific)

There are multiple factors that contribute to the development of an anxiety disorder. This makes it difficult to prevent them from happening or predicting who may develop one. It is natural for children to avoid things or situations that make them feel anxious. However, by doing so they “learn” that the way to get rid of their anxiety is to avoid, which then results in more avoidance. It is also normal for children with problematic anxiety to often rely on their parents for help to avoid the things and situations that they fear or worry about. Parents may accommodate their child’s anxiety by deliberately doing or not doing something to reduce their child’s anxiety. For example, a parent may speak on behalf of their child with selective mutism or social anxiety, or not send their child with separation anxiety to school. This pattern of behaviour of feeling scared, turning to a parent, and then feeling the relief of avoidance can turn into a vicious cycle that strengthens the anxiety and leads to an anxiety disorder. It is usually challenging to control a child’s anxious behaviours, thus it may be easier and more effective for parents to change and control their own behaviour first.

These are some strategies that parents can use to help their children manage anxiety before it turns into a disorder:

• Accept and acknowledge your child’s anxiety. Often times, parents may say “Don’t be scared” or “There’s nothing to be afraid of” because the things or situations that their children fear are indeed not scary to them. However, it is scary for a child with anxiety. One way to acknowledge the anxiety is by identifying the feeling, usually fear or worry, and describing it to the child. For example, “This is hard for you and you’re scared you can’t do it”, “You feel scared when I’m not around”, or “It doesn’t feel good when others look at you or talk to you”.
• At the same time, it is important to believe that your child has the ability to tolerate slightly more anxiety over time. Combine the above acceptance with statements such as “You will be okay” or “You can learn to manage it” to let your child know that you have faith in their ability to be alright and to function in spite of their anxious feelings. For example, when separating at childcare, say, “I know you’re scared when I’m not around, but I know you’ll be okay after a while.”
• Do not accommodate by “helping” your child avoid things or situations they are scared of. It is perfectly okay to help your child avoid real danger but do not help them avoid non-dangerous events (e.g., school, performance, talking to others). Continue to send them to school instead of staying at home because of their anxiety. If your child is scared to greet or talk to others, tell them to wave instead as a start. This is a supportive compromise because it does not allow ‘escape’ from greeting others and it provides a start for the child to be comfortable greeting others nonverbally first before making verbal attempts at a later time.
• Reduce reassurance-seeking. All children need reassurance at times but children with anxiety usually engage in excessive reassurance-seeking, sometimes even more than a parent can provide. Asking reassurance for the same thing over and over again is an unhelpful way of coping. By frequently reassuring your child, you are preventing them from realising that their anxiety will reduce after a while. They “learn” that they have to go to you to relieve some of their anxiety. Some examples of reassurance seeking are asking parents to check something repeatedly or calling the parents at work multiple times to check on them. It may be difficult to deny your child reassurance but think of it as a long-term solution so that your child learns that he or she has the ability to manage anxiety. You can say, “I’ve already told you the answer to that question, I am not going to answer that.” It is often easier to control your own behaviour by not answering your child’s question than to ‘force’ your child to stop asking questions. It’s okay for your child to continue to ask questions and seek reassurance, but what you can do is stop answering them after you’ve already provided some assurance.
• Praise your child! Be observant of times that they are brave and are able to manage some anxiety. For example, when you fetch your child from school, say “I’m so proud of you! You were a little bit scared this morning but you were okay in the end. Well done!” Remember to use a pleasant and enthusiastic tone. Try not to nag them for crying or being scared. Focus instead on your child’s ability to be okay in spite of the anxiety.

There are multiple causes and risk factors for developing an anxiety disorder. Genetics, environmental factors (e.g., life stressors), and temperament (e.g., negative affect, behavioural inhibition) can account for the development of anxiety disorders.

The diagnosis of an anxiety disorder is usually made by a clinician such as a psychologist or medical doctor. Tools such as structured interviews, questionnaires, behavioural observations and interactions are often used to aid in the diagnosis of an anxiety disorder.

Research has identified interventions that are effective in reducing anxiety and managing anxiety disorders. These interventions usually focus on addressing the thoughts and behaviours behind the anxiety. Strategies typically focus on helping individuals face the feared object or situation instead of avoiding or escaping them. Parent-based intervention is also available for very young children with an anxiety disorder who are not able to participate effectively in direct intervention due to their reduced language and cognitive abilities.