Anxiety in Children

Anxiety in Children

Summary

Anxiety is a natural physiological and psychological response to certain stressful situations. Normally, anxiety is part of the body’s alarm system, alerting a person to danger or providing extra energy to help accomplish a task. However, some children experience excessive anxiety that may indicate the presence of an anxiety disorder or another mental health condition.

Anxiety causes symptoms such as racing pulse, sweating, dry mouth, tremors and stomach upset. Children who are anxious may worry about situations before they even occur and may feel a general fear about the well-being of family and friends. They may worry about potential problems at school or when engaged in activities. Severe anxiety can interfere with a child’s ability to live a productive life.

A single stressful event can trigger temporary anxiety in a child. The cause of long-term anxiety is often more difficult to trace. Family difficulties – such as marital strain, financial problems, parental alcoholism or illness of a family member – may create an atmosphere of tension that breeds long-term anxiety. Genetic factors may also play a role.

Anxiety disorders are among the most common psychological conditions to affect children. Up to 10 percent of children may have at least one anxiety disorder, according to the National Mental Health Association. Examples of anxiety disorders that commonly affect children include generalized anxiety disorder (GAD), separation anxiety disorder, social anxiety disorderand phobias.

Early diagnosis and treatment of anxiety in children is crucial. Failure to adequately treat anxiety can result in loss of friendships, social and academic difficulties, and feelings of low self-worth. Physicians and mental health professionals can work together to rule out other physical or emotional disorders before diagnosing a child with an anxiety disorder. Sometimes, anxiety may be a symptom of another psychological disorder such as depression. Children diagnosed with anxiety disorders have a number of effective treatment options. In many cases, a combination of psychotherapy and medications may be the best treatment.

About child anxiety

Anxiety is a natural response to certain stresses or worrisome situations that triggers both physiological and psychological changes in a person. Like adults, children often experience feelings of anxiety, although the way a child reacts to these feelings may differ from how an adult processes them.

Most infants first begin to exhibit signs of wariness or anxiety between the ages of 7 months and 9 months. Normally, anxiety is part of the body’s alarm system, alerting a person to danger or providing the extra energy to help accomplish a task. However, some children experience anxiety for no particular reason, or anxiety that is out of proportion with the actual threat that may be present.

It is natural for children to exhibit anxiety in many types of situations and at various stages of development. For example, preschoolers may fear the dark or certain animals. As children grow older, they may continue to experience anxieties related to certain events (e.g., thunderstorms, a big test at school). In most cases, these fears are temporary and quickly pass when the anxiety-producing situation is resolved. Parental support and reassurance often helps to reduce these temporary bouts of anxiety.

However, some children may experience anxiety that is present much of the time. These children may feel anxious even when such emotions cannot be traced to any kind of precipitating event. Such anxiety may interfere with a child’s ability to perform normal tasks, ranging from school work to getting a good night’s sleep. Anxiety can also impair a child’s social development. As children grow to adolescence, they may feel anxiety surrounding social situations or may have a general sense of anxiousness that is present much of the time.

If children’s anxiety meets certain criteria, a physician will diagnose them with an anxiety disorder. These disorders are among the most common psychological conditions to affect children. Up to 10 percent of children may have at least one anxiety disorder, according to the National Mental Health Association. In other cases, a child’s anxiety may be a symptom of another mental health disorder such as depression.

Types and differences of child anxiety

There are several major types of anxiety that children may experience. All share the quality of excessive and irrational fear. The fear may be of a specific object or situation, or it may be generalized fear for which the child cannot identify a specific source. Types of anxiety commonly associated with children include:

  • Generalized anxiety disorder (GAD). Diagnosed when children worry excessively about all types of life issues, including their health, family, school work, and the potential for destructive events such as accidents and natural disasters. Children may be unable to relax, even when there are no signs of trouble. Children with GAD may worry intensely, often about future events. The sense of worry may be irrational or disproportionate to the actual situation. GAD tends to be more common in middle childhood and adolescence.

  • Separation anxiety disorder. Children with this disorder experience intense anxiety when separated from caregivers or homes. They worry excessively about the well-being of their parents or caregivers. Separation anxiety itself is a normal reaction for very young children between the ages of 18 months and 3 years. However, by the time a child is about 4 years old, they should be more comfortable temporarily leaving their parents. If this is not the case, separation anxiety disorder may be present. The disorder is most common in children between 6 and 9 years of age. Children with separation anxiety have a tendency to cling to parents or caretakers and may throw tantrums when they are separated from these guardians. They also tend to fear sleeping away from home.

  • Social anxiety disorder. Involves a strong fear (phobia) of social situations and situations in which the child is expected to perform. Also known as social phobia, social anxiety disorder tends to be more common in middle childhood and adolescence. Children with this condition may fear speaking up in class and tend to have few friends. Social anxiety disorder is often present before age 5, but may not be diagnosed until the child enters school.

  • Selective mutism. A severe form of social anxiety disorder that involves a refusal to speak in situations where such communication is expected. Children with this condition tend to talk only or mostly at home and may remain largely silent in other situations, such as daycare, school or visits to the homes of friends or relatives.

  • Anxiety-based school refusal. Also known as school avoidance, it involves problems with school attendance that are related to the child’s fear of leaving home (most often in younger children), fear of the unfamiliar or of being embarrassed at school (most often in older children). Anxiety-based school refusal tends to heighten between the ages of 5 and 6 years, and again between the ages of 10 and 11 years. It is often associated with children who have separation anxiety disorder or social anxiety disorder.

  • Obsessive-compulsive disorder (OCD). Diagnosed when a child is helpless to control intrusive and unwanted thoughts (obsessions) and/or to stop performing ritualistic actions (compulsions), such as repetitive hand washing. This condition usually begins in early childhood or adolescence.

  • Panic disorder. Diagnosed when a person regularly experiences panic attacks – sudden episodes of fear and anxiety that usually last between 10 and 30 minutes. The attacks can cause symptoms such as racing heartbeat, heavy perspiration and shortness of breath. In some cases, panic disorder may be accompanied by agoraphobia, a type of phobia in which patients fear being caught in a place or situation in which escape might be difficult, or being trapped in circumstances in which medical help might not be available during an emergency. In other cases, panic disorder actually causes agoraphobia. Panic disorder is uncommon before adolescence and tends to begin between the ages of 15 and 19 years.

  • Phobias. Diagnosed when a person has extreme and irrational fears of something that in actuality poses little or no threat. For example, social phobia involves a fear of being judged by others. Children often have phobias when they are young – onset is generally between the ages of 6 and 9 years – but usually outgrow them. However, patients with specific phobias continue to suffer from intense fear of certain objects (e.g., spiders) or situations (e.g., heights). People with phobias avoid objects or situations that they view as threatening. Children with phobias are less likely than adults to realize that the fears are irrational or out of proportion to the situation.

  • Post-traumatic stress disorder (PTSD). Diagnosed when a child who has experienced a traumatic event such as war, rape, child abuse or a natural disaster begins to have nightmares, flashbacks, depression or other symptoms for more than a month. Symptoms may include constant thoughts about a traumatic event, recurrent nightmares or insomnia, re-enactment of traumatic events through play, difficulty eating and a tendency to be easily startled. Stress disorders that occur within a month of the event are known as acute stress disorders.

In addition, there are several less common anxiety disorders. Some children may have intense anxiety that does not fit the criteria for any of the recognized anxiety disorders. In such cases, they may be diagnosed with “anxiety disorder not otherwise specified.”

Potential causes of child anxiety

Research continues as to how the brain creates feelings of anxiety and fear. Scientists believe that an almond-shaped structure called the amygdala serves as a central location that coordinates messages between the parts of the brain that process incoming sensory signals and the parts that interpret those signals. The amygdala warns the body when a threat is present, triggering anxiety or fear.

Another brain structure called the hippocampus also helps process threatening signals and changes information into memories. Research shows that people who have experienced severe stress (such as child abuse or combat) appear to have a smaller hippocampus than people who have not experienced such stresses.

A single stressful event – such as an impending athletic competition or the approach of a major storm – can trigger temporary anxiety in a child. This is a normal reaction that usually turns into relief once the event is over.

However, some children experience a level of ongoing anxiety that has the potential to interfere with their daily lives. The source of this anxiety is not always apparent. In some cases, family difficulties – such as marital strain, financial difficulties, parental alcoholism or illness of a family member – may create an atmosphere of tension that breeds anxiety. 

The exact cause of most anxiety disorders is unknown, but a combination of psychological, biological and environmental factors may be responsible. Heredity is also believed to play a role in many anxiety disorders. The combination of heredity and the anxiety experienced may vary.

For example, many people may experience the same trauma during combat, but not all develop post-traumatic stress disorder(PTSD). Most anxiety disorders begin in childhood, adolescence or early adulthood.

Signs and symptoms of child anxiety

Anxiety itself often creates symptoms such as racing pulse, shortness of breath, sweating, dry mouth, tremors, headaches, nightmares and upset stomach. Children who are anxious on a regular basis often appear to be uptight or extremely tense, and may cry or have tantrums on a frequent basis. Their anxieties may overwhelm their ability to perform certain activities, and they may cling to parents and seek reassurance from parents and others in authority. In some cases, it may be hard to detect the anxiety because some children tend to withdraw and become quiet and compliant. Children who are anxious may also worry about situations before they occur and may have a general fear about the well-being of family and friends. They may worry about potential problems at school or when engaged in social activities. They often have low self-esteem and lack self-confidence, and fear being embarrassed or making mistakes.

Diagnosis methods for child anxiety

In many cases, parents and children are unaware that the child is suffering from general anxiety or an anxiety disorder and may visit a physician because of the child’s physical symptoms. For example, parents of children who have recurrent stomachaches may not realize their child’s anxiety is causing the symptoms.

In other cases, children may not experience acute physical symptoms, but may instead describe feelings of unease. Anxiety may interfere with the ability of these children to live normal lives, and parents may seek medical care to correct the problem.

When a child visits a physician, the physician will compile a thorough medical history and perform a physical examination. The physician will have to rule out the possibility of an underlying medical illness that may be causing the physical or emotional symptoms. Blood and urine tests, imaging tests and other forms of assessment may be employed to narrow the list of potential causes of symptoms.  

Once other conditions have been ruled out, the physician may diagnose an anxiety disorder if certain criteria are present. All anxiety disorders have their own, specific criteria as defined by the American Psychiatric Association(APA).A child who appears to have an anxiety disorder may be referred to a child and adolescent psychiatrist or other mental health professional specializing in the treatment of this age group. Experts in mental healthcare can establish a diagnosis for one or more anxiety disorders or another condition such as depression.

Treatment and prevention of child anxiety

Early treatment of anxiety is crucial to prevent unnecessary obstacles during a child’s formative years. Failure to adequately treat anxiety can result in loss of friendships, social and academic difficulties, feelings of low self-worth and anxiety in adulthood. Studies have shown that children with untreated anxiety disorders are also more likely to develop substance abuse problems.

Children diagnosed with anxiety disorders have a number of effective treatment options. In many cases, a combination of psychotherapy and medications may be the best treatment. In other cases, one form of therapy may be more beneficial than another. For example, certain phobias respond only to psychotherapy.

Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of anxiety in children. These drugs are usually effective in treating anxiety disorders, even in patients who are not depressed. Antidepressants sometimes take several weeks to become effective, so patients and their families should not become discouraged if they do not see immediate improvement. Many children who are prescribed antidepressants will continue treatment for about one year, and will require regular consultation with a physician to monitor their response.

Parents should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the FDA has advised that antidepressants may increase the risk of suicidal thinking in some patients and all individuals being treated with these drugs should be monitored closely for unusual changes in behavior.

Anti-anxiety medications may also be prescribed, although they are less commonly used in children. Certain anti-anxiety medications, most notably the benzodiazepines, are generally prescribed only for short periods of time, because patients may become physically and psychologically dependent upon them. Patients with panic disorder may take the drug for as long as six months to a year.

Patients should not stop using antidepressant or anti-anxiety medications without physician supervision, because it may cause withdrawal symptoms or relapse of the condition.

Psychotherapy is particularly effective for anxiety disorders, such as social phobia and panic disorder. It is likely to take the form of behavioral therapy or cognitive therapy, or a combination of the two (cognitive behavioral therapy). In behavioral therapy, the patient learns to change specific actions and to use different techniques to stop certain behaviors. The patient may learn relaxation techniques, such as deep breathing, and may be gradually exposed to situations that are frightening and in which they can test new coping skills.

Cognitive therapy involves learning new skills to react differently to situations that typically trigger anxiety. Patients also learn about negative thought patterns that increase anxiety and ways to redirect such thinking.

Psychotherapy for children with anxiety disorders is likely to last around 12 weeks. It may be conducted one-on-one or in a group setting. Patients may also be treated for other psychological or physical conditions while they receive treatment for an anxiety disorder.

Researchers also believe that specialized training for parents of anxious children may help reduce anxiety in children. However, further research is necessary.

Questions for your doctor about child anxiety

Preparing questions in advance can help a parent have more meaningful discussions with their child’s physicians regarding their conditions. Parents may wish to ask their child’s doctor the following questions related to anxiety in children:

  1. What symptoms might indicate that my child has significant anxiety?
  2. How can I differentiate between normal anxiety and problem anxiety in my child?
  3. How will you diagnose my child’s condition?
  4. Should I alert the school or daycare staff about my child’s condition?
  5. What are my child’s treatment options?
  6. What are the potential risks and side effects of these treatments?
  7. Is there anything I can do to ease my child’s anxiety?
  8. What steps can I take to increase the odds that my child’s treatment will be effective?
  9. How long will it take for my child’s condition to improve?
  10. What signs might indicate that my child’s anxiety is becoming worse or improving?
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