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Anxiety and Anxiety Disorders in Children: Information for Parents

By Thomas J. Huberty, PhD, NCSP
Indiana University

Anxiety is a common experience to all of us on an almost daily basis. Often, we use terms like jittery, high strung, and uptight to describe anxious feelings. Feeling anxious is normal and can range from very low levels to such high levels that social, personal, and academic performance is affected. At moderate levels, anxiety can be helpful because it raises our alertness to danger or signals that we need to take some action. Anxiety can arise from real or imagined circumstances. For example, a student may become anxious about taking a test (real) or be overly concerned that he or she will say the wrong thing and be ridiculed (imagined). Because anxiety results from thinking about real or imagined events, almost any situation can set the stage for it to occur.

Defining Anxiety

There are many definitions of anxiety, but a useful one is apprehension or excessive fear about real or imagined circumstances. The central characteristic of anxiety is worry, which is excessive concern about situations with uncertain outcomes. Excessive worry is unproductive, because it may interfere with the ability to take action to solve a problem. Symptoms of anxiety may be reflected in thinking, behavior, or physical reactions.

Anxiety and Development

Anxiety is a normal developmental pattern that is exhibited differently as children grow older. All of us experience anxiety at some time and cope with it well, for the most part. Some people are anxious about specific things, such as speaking in public, but are able do well in other activities, such as social interactions. Other people may have such high levels of anxiety that their overall ability to function is impaired. In these situations, counseling or other services may be needed.

Infancy and preschool. Typically, anxiety is first shown at about 7�9 months, when infants demonstrate stranger anxiety and become upset in the presence of unfamiliar people. Prior to that time, most babies do not show undue distress about being around strangers. When stranger anxiety emerges, it signals the beginning of a period of cognitive development when children begin to discriminate among people. A second developmental milestone occurs at about 12�18 months, when toddlers demonstrate separation anxiety. They become upset when parents leave for a short time, such as going out to dinner. The child may cry, plead for them not to leave, and try to prevent their departure. Although distressing, this normal behavior is a cue that the child is able to distinguish parents from other adults and is aware of the possibility they may not return. Ordinarily, this separation anxiety is resolved by age 2, and the child shows increasing ability to separate from parents. Both of these developmental periods are important and are indicators that cognitive development is progressing as expected.

School age. At preschool and early childhood levels, children tend to be limited in their ability to anticipate future events, but by middle childhood and adolescence these reasoning skills are usually well developed. There tends to be a gradual change from global, undifferentiated, and externalized fears to more abstract and internalized worry. Up to about age 8 children tend to become anxious about specific, identifiable events, such as animals, the dark, imaginary figures (monsters under their beds), and of larger children and adults. Young children may be afraid of people that older children find entertaining, such as clowns and Santa Claus. After about age 8, anxiety-producing events become more abstract and less specific, such as concern about grades, peer reactions, coping with a new school, and having friends. Adolescents also may worry more about sexual, religious, and moral issues, as well how they compare to others and if they fit in with their peers. Sometimes, these concerns can raise anxiety to high levels.

Anxiety Disorders

When anxiety becomes excessive beyond what is expected for the circumstances and the child�s developmental level, problems in social, personal, and academic functioning may occur, resulting in an anxiety disorder. The signs of anxiety disorders are similar in children and adults, although children may show more signs of irritability and inattention. The frequency of anxiety disorders ranges from about 2 to 15% of children and occurs somewhat more often in females. There are many types of anxiety disorders, but the most common ones are listed below.

Separation anxiety disorder. This pattern is characterized by excessive clinging to adult caretakers and reluctance to separate from them. Although this pattern is typical in 12�18-month-old toddlers, it is not expected of school-age children. This disorder may indicate some difficulties in parent-child relationships or a genuine problem, such as being bullied at school. In those cases, the child may be described as having school refusal, sometimes called school phobia. Occasionally, the child can talk about the reasons for feeling anxious, depending on age and language skills.

Generalized anxiety disorder. This pattern is characterized by excessive worry and anxiety across a variety of situations that does not seem to be the result of identified causes.

Post-Traumatic Stress Disorder. This pattern often is discussed in the popular media and historically has been associated with soldiers who have experienced combat. It is also seen in people who have experienced traumatic personal events, such as loss of a loved one, physical or sexual assault, or a disaster. Symptoms may include anxiety, flashbacks of the events, and reports of seeming to relive the experience.

Social phobia disorder. This pattern is seen in children who have excessive fear and anxiety about being in social situations, such as in groups and crowds.

Obsessive-compulsive disorder. Characteristics include repetitive thoughts that are difficult to control (obsessions) or the uncontrollable need to repeat specific acts, such as hand washing or placing objects in the same arrangement (compulsions).

Characteristics of Anxiety

Although the signs of anxiety vary in type and intensity across people and situations, there are some symptoms that tend to be rather consistent across anxiety disorders and are shown in cognitive, behavioral, and physical responses. Not all symptoms are exhibited in all children or to the same degree. All people show some of these signs at times, and it may not mean that anxiety is present and causing problems. Most of us are able to deal with day-to-day anxiety quite well, and significant problems are not common. The chart at the end of the handout demonstrates behaviors that, if present to a significant degree, can indicate anxiety that needs attention. As a parent, you may be the first person to suspect that your child has significant anxiety.

Relationship to Other Problems

Although less is known about how anxiety is related to other problems as compared to adults, there are some well-established patterns.

Depression. Anxiety and depression occur together about 50�60% of the time. When they do occur together, anxiety most often precedes depression, rather than the opposite. When both anxiety and depression are present, there is a higher likelihood of suicidal thoughts, although suicidal attempts are far less frequent.

Attention Deficit Hyperactivity Disorder. At times, anxiety may appear similar to behaviors seen with Attention Deficit Hyperactivity Disorder (ADHD). For example, inattention and concentration difficulties are often seen in children with ADHD and with children who have anxiety. Therefore, the child may have anxiety rather than ADHD. Failing to identify anxiety accurately may explain why some children do not respond as expected to medications prescribed for ADHD. The age of the child when the behaviors were first observed can be a useful index for determining if anxiety or ADHD is present. The signs of ADHD usually are apparent by age 4 or 5, whereas anxiety may not be seen at a high level until school entry, when children may respond to demands with worry and needs for perfectionism. A thorough psychological and educational evaluation by qualified professionals will help to determine if the problem is ADHD or anxiety. If evaluation or consultation is needed, developmental information about the problem will be useful to the professional.

School performance. Children with anxiety may have difficulties with school work, especially tasks requiring sustained concentration and organization. They may seem forgetful, inattentive, and have difficulty organizing their work. They may be too much of a perfectionist and not be satisfied with their work if it does not meet high personal standards.

Substance use. What appears to be anxiety may be manifestations of substance use, which may begin as early as the pre-teen years. Children who are abusing drugs or alcohol may show sleep problems, inattention, withdrawal, and reduced school performance. Although substance abuse is less likely with younger children, the possibility increases with age.

Interventions

Anxiety is a common experience for children, and, most often, professional intervention is not needed. If anxiety is so severe that your child cannot do expected tasks, however, then intervention may be indicated.

Does My Child Need Professional Help?

Answering the following questions may be helpful in deciding if your child needs professional help:

  • Is the anxiety typical for a child this age?
  • Is the anxiety shown in specific situations or is it more pervasive?
  • Is the problem long term or is it recent?
  • What events may be contributing to the problems?
  • How are personal, social, and academic development affected?

If the anxiety is atypical for the child�s age, is long standing, does not seem to be improving, and is causing significant problems, then it is advisable to talk with a professional, such as the school psychologist or counselor, who might recommend a referral to a community mental health professional. Individual counseling, or even group or family counseling, may be used to help the child deal with school, family, or personal issues that are related to the anxiety. In some cases, a physician may recommend medication. Although medication for childhood disorders is not well researched and side effects must be monitored, this treatment may be helpful when combined with counseling approaches.

How Can I Help My Child?

Although professional intervention may be necessary, the following list may be helpful to parents in working with the child at home:

  • Be consistent in how you handle problems and administer discipline.
  • Remember that anxiety is not willful misbehavior, but reflects an inability to control it. Therefore, be patient and be prepared to listen. Being overly critical, disparaging, impatient, or cynical likely will only make the problem worse.
  • Maintain realistic, attainable goals and expectations for your child. Do not communicate that perfection is expected or acceptable. Often, anxious children try to please adults, and will try to be perfect if they believe it is expected of them.
  • Maintain a consistent, but flexible, routine for homework, chores, and activities.
  • Accept mistakes as a normal part of growing up, and that no one is expected to do everything equally well. Praise and reinforce effort, even if success is less than expected. There is nothing wrong with reinforcing and recognizing success, as long as it does not create unrealistic expectations and result in unreasonable standards.
  • If your child is worried about an upcoming event, such as giving a speech in class, practice it often so that confidence increases and discomfort decreases. It is not realistic to expect that all anxiety will be removed; rather, the goal should be to get the anxiety to a level that is manageable.
  • Teach your child simple strategies to help with anxiety, such as organizing materials and time, developing small scripts of what to do and say, either externally or internally, when anxiety increases, and learning how to relax under stressful conditions. Practicing things such as making speeches until a comfort level is achieved can be a useful anxiety-reducing activity.
  • Listen to and talk with your child on a regular basis and avoid being critical. Being critical may increase pressure to be perfect, which may be contributing to the problem in the first place. Do not treat emotions, questions, and statements about feeling anxious as silly or unimportant. They may not seem important to you but are real to your child. Take all discussion seriously, and avoid giving too much advice and instead be there to help and offer assistance as requested. You may find that reasoning about the problem does not work. At times, children may realize that their anxiety does not make sense, but are unable to do anything about it without help.
  • Do not assume that your child is being difficult or that the problem will go away. Seek help if the problem persists and continues to interfere with daily activities.

Conclusion

Untreated anxiety can lead to depression and other problems that can persist into adulthood. However, anxiety problems can be treated effectively, especially if detected early. Although it is neither realistic nor advisable to try to completely eliminate all anxiety, the overall goal of intervention should be to return your child to a typical level of functioning.

Resources

Bourne, E. J. (1995). The anxiety and phobia workbook (2nd ed.). Oakland, CA: New Harbinger. ISBN: 1- 56224-003-2.

Dacey, J. S., & Fiore, B. (2001). Your anxious child: How parents and teachers can relieve anxiety in children. San Francisco: Jossey-Bass. ISBN: 0-78796-040-3.

Manassis, K. (1996). Keys to parenting your anxious child. New York: Barrons. ISBN: 0-81209-605-3.

Website

Anxiety Disorders Association of America�www.aada.org

National Mental Health Association�www.nmha.org

Thomas J. Huberty, PhD, NCSP, is Professor and Director of the School Psychology Program at Indiana University, Bloomington, IN.

� 2004 National Association of School Psychologists, 4340 East West Highway, Suite 402, Bethesda, MD 20814�(301) 657-0270.