This article will focus on the issue of anxiety in children. And, I will try to answer the questions: what is it? And what can you do about it? But first, let me share an observation from my own family.
My 15-month old daughter is working her way through her fear of “belue.” That’s baby-talk for a half-filled white balloon that has been floating around my house for a while. It’s apparently the squishy-ness that bothers her. So, she skirts around it exhibiting intense curiosity mixed in with fear. Last week, she poked it with her finger and ran away. A few days later she kicked it and watched it roll.
As a child psychiatrist, I’ve watched with fascination how her fear and her ability to overcome it is such an integral part of her normal development.
What is the difference between fear and anxiety?
So, how is anxiety different from fear? Fear is usually an immediate intense emotional reaction to a more imminent real or perceived danger (like “belue”). Anxiety, on the other hand, is more about anticipating a threat that might be lurking around sometime in the future.
Fear and anxiety overlap and may result in children having misguided cognitive/thinking patterns (“There are monsters under my bed”), leading to caution (“I need the lights on”) and potentially evolving to avoidant behaviors (“I do not want to sleep alone”).
Do fear and anxiety have any benefits?
Anxiety and fear are not always bad. At least not in the traditional way we think about it. Both serve an essential evolutionary purpose. For example, it probably saved the cave people from being eaten away.
Also, developmentally appropriate stranger anxiety protects infants and toddlers from venturing too far away from their primary caregivers, thus keeping them safe. Anxiety about disappointment or failure helps children practice their baseball skills to perfection and perform flawlessly as the turkey in the annual school play.
Functionally, anxiety serves to protect children day-to-day while they learn how to interact socially with others or master skills effectively.
How do you distinguish routine anxiety from an anxiety disorder?
Everyone falls on a spectrum of how much anxiety we create when presented with the same anxiety-provoking stimuli. Sometimes children develop a fear/anxiety response that is large enough to actually prevent them from doing these activities.
They may manifest physical or emotional symptoms, including the following:
- feeling overwhelmed
- throwing tantrums
- blanking out
- getting dizzy
These uncomfortable symptoms automatically generate a desire to get away from the anxiety-provoking stimuli by a variety of avoidance behaviors. You may hear your child complain: “My stomach hurts, so I can’t go to school today” or “I’m not reading my homework in front of the class, so I’ll just not do it.”
A diagnosis of an anxiety disorder should be considered (AmericanPsychiatricAssociation, 2013) when anxiety responses are beyond what is expected given a child’s developmental age and,
- interfere significantly with their ability to perform
- persist longer than what is reasonably expected, and
- is not attributable to the child’s cultural context[mfn]American Psychiatric Association. (2013). Anxiety Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA doi:10.1176/appi.books.9780890425596.dsm05 https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596[/mfn].
Why does my child have an anxiety disorder?
There is a fair degree of heritability in childhood anxiety disorders. Therefore, they tend to cluster together in families.
Other environmental factors that increase the risk of developing an anxiety disorder include,
- parental loss or separation,
- death in the family,
- change in school or friends,
- stress resulting from physical or sexual trauma,
- domestic violence, or
- parental over-protectiveness.
These events are also known as Adverse Childhood Events and are linked to a number of poor health outcomes both physical, as well as mental[mfn]Felitti, V. J. M. D., FACP, Anda, R. F. M. D., Ms, Nordenberg, D. M. D., et al (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258. doi:10.1016/S0749-3797(98)00017-8[/mfn].
Categories of anxiety
Anxiety disorders in children differ based on two factors: the nature of the anxiety-provoking situation and their emotional and cognitive reactions to it.
Separation anxiety disorder
The earliest of these anxiety disorders to appear in children is separation anxiety disorder. This disorder generally manifests in pre-school or school-age children. The child is typically extremely fearful of either being away from their primary caregiver, for example when going to daycare or school. Or they may be unduly afraid of something bad happening to their caregiver (eg. accident, death) ultimately resulting in separation. The fears manifest in the child having nightmares, becoming too clingy with parents, or throwing tantrums when the separation is anticipated.
Social anxiety disorder
Another prevalent anxiety disorder among children is a social anxiety disorder, also known as social phobia. This generally appears in children ages 8-15 years old. It manifests in fearful or avoidant behaviors in situations where they might be required to interact socially with others, such as in the cafeteria or at a party. It may also occur when the child is placed in a position to be scrutinized by their peers or others. Examples include acting, performance, and sports. These situations generally evoke negative feelings of being unfairly judged by others or being embarrassed or ridiculed in front of others.
Selective mutism is rare in comparison to other anxiety disorders. It involves the inability to speak in certain social situations where children are expected to speak (eg. in a classroom) even though they are able to speak normally in other situations.
Specific phobias involve an extreme fear response and/or avoidant behaviors in specific situations to an extent that is vastly greater than the actual risk involved. It can be in response to being in a specific situation, such as height, storms, or elevators. Or, it can occur as a reaction to specific objects (eg. spiders, clowns, needles, blood)
Sometimes teenagers experience a series of intense, unexpected panic attacks associated with one or more of the following symptoms:
- pounding heart
- breathing difficulty
- or a fear of dying
This experience can lead to a degree of worry about having similar future attacks. The teen may also exhibit avoidance behaviors, such as not going to the gym where they had their first attack, in an attempt to prevent these episodes.
Such panic attacks may constitute Panic Disorder or be associated with other diagnoses including depression or other anxiety disorders.
Generalized anxiety disorder
Finally, Generalized Anxiety Disorder in children is exhibited as excessive anxiety or worry in multiple areas of their functioning including at school and home. These could be related to any number of things, such as
- their performance (eg. getting homework or chores done)
- rarely health and financial concerns that children and adolescents find unable to control
There are other related anxiety-like disorders such as Obsessive-Compulsive Disorder and Post-Traumatic Stress Disorder that can also occur in children and adolescents.
What else is there?
Anxiety disorders significantly impact the child’s functioning and can reduce their quality of life by not allowing them to interact, explore, and grow in developmentally essential ways. Unless treated, they can continue to cause significant impairment throughout the life-span of an individual.
Anxiety disorders generally overlap with each other and are frequently associated with other mental health disorders like depression, behavioral problems, and the onset of substance use[mfn]Cummings, C. M., Caporino, N. E., & Kendall, P. C. (2014). Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull, 140(3), 816-845. doi:10.1037/a0034733[/mfn],[mfn]Fraire, M. G., & Ollendick, T. H. (2013). Anxiety and oppositional defiant disorder: a transdiagnostic conceptualization. Clin Psychol Rev, 33(2), 229-240. doi:10.1016/j.cpr.2012.11.004[/mfn],[mfn]McCauley Ohannessian, C. (2014). Anxiety and substance use during adolescence. Subst Abus, 35(4), 418-425. doi:10.1080/08897077.2014.953663[/mfn]. Children with anxiety disorders are also at a higher risk of suicidal thoughts and ideations[mfn]Hill, R. M., Castellanos, D., & Pettit, J. W. (2011). Suicide-related behaviors and anxiety in children and adolescents: a review. Clin Psychol Rev, 31(7), 1133-1144. doi:10.1016/j.cpr.2011.07.008[/mfn].
What can be done about it?
The good news is that effective treatments are available for childhood anxiety disorders [mfn]Wang, Z., Whiteside, S. P. H., Sim, L., et al. (2017). Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis. JAMA Pediatr, 171(11), 1049-1056. doi:10.1001/jamapediatrics.2017.3036[/mfn]. Most children benefit from a variety of psychotherapies or “talk-therapies.”
The underlying premise of most of these therapies for children involves identifying and correcting the cognitive or thinking errors that tend to be associated with anxiety. An example is a child who feels anxious about reading aloud in class. He may think “I’m going to stumble over my words and everyone is going to think I’m a loser.”
However, when combined with appropriate relaxation skills, the child can learn to change to a more effective way of thinking such as: “I may stumble over some words, but so does everyone else. It’s no big deal!”
Children can learn to cope with anxiety
Children can learn how to use coping skills to “calm” their anxiety down using strategies like deep breathing or chicken-fingers. Other skills-based trainings like social skills training or assertiveness training can complement the child’s progress and help build their confidence.
Most therapies for anxiety involve an appropriate and graduated dose of exposure to the anxiety-provoking stimuli, which allows for the practice of the skills and techniques learned.
Medications may also play a role, especially if the level of anxiety is moderate to severe. The largest evidence-base exists for the use of serotonergic medications like fluoxetine, escitalopram, or sertraline which helps normalize the low serotonin neurotransmitter levels that occur in brains of children with anxiety disorders.
It is important to discuss the benefits and risks of each of these options, or a combination, with your health-care provider before embarking on a particular course of therapy.
The bottom line for anxiety in children
The bottom line is that some degree of anxiety is an essential part of your child’s normal development. Recognize that and let them work through it while you hang around for safety and support. Maybe your child will have the ability to work through the fear on their own (e.g., the “belue” example). However, if it feels like their anxiety is excessive and is interfering with their quality of life, reach out for support and assistance from health professionals.
- American Psychiatric Association. (2013). Anxiety Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA doi:10.1176/appi.books.9780890425596.dsm05 https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596
- Felitti, V. J. M. D., FACP, Anda, R. F. M. D., Ms, Nordenberg, D. M. D., et al (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258. doi:10.1016/S0749-3797(98)00017-8 https://pubmed.ncbi.nlm.nih.gov/9635069/
- Cummings, C. M., Caporino, N. E., & Kendall, P. C. (2014). Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull, 140(3), 816-845. doi:10.1037/a0034733 https://pubmed.ncbi.nlm.nih.gov/24219155/
- Fraire, M. G., & Ollendick, T. H. (2013). Anxiety and oppositional defiant disorder: a transdiagnostic conceptualization. Clin Psychol Rev, 33(2), 229-240. doi:10.1016/j.cpr.2012.11.004 https://pubmed.ncbi.nlm.nih.gov/23313760/
- McCauley Ohannessian, C. (2014). Anxiety and substance use during adolescence. Subst Abus, 35(4), 418-425. doi:10.1080/08897077.2014.953663 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267890/
- Hill, R. M., Castellanos, D., & Pettit, J. W. (2011). Suicide-related behaviors and anxiety in children and adolescents: a review. Clin Psychol Rev, 31(7), 1133-1144. doi:10.1016/j.cpr.2011.07.008 https://europepmc.org/article/med/21851804
- Wang, Z., Whiteside, S. P. H., Sim, L., et al. (2017). Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis. JAMA Pediatr, 171(11), 1049-1056. doi:10.1001/jamapediatrics.2017.3036 https://pubmed.ncbi.nlm.nih.gov/28859190/
Nihit Kumar, M.D.
Nihit Kumar, M.D, completed his medical school in India before moving to Little Rock, Arkansas for his residency training in Psychiatry followed by a fellowship in Child & Adolescent Psychiatry as well as Addiction Psychiatry.
He is currently an Assistant Professor at the University of Arkansas for Medical Sciences (UAMS) and the Program Director for fellowship training in Child & Adolescent Psychiatry. He is passionate about teaching and mentoring students and residents.
He has authored multiple professional papers and regularly speaks with the media on topics related to mental health. He also volunteers his time as a board member of the National Alliance on Mental Illness (NAMI), Arkansas.