Anxiety is common in children and teenagers but what is normal and what is not is often hard for parents to gauge.
Dr Cristina Cacciotti Saija gives a detailed explanation to help parents understand their children’s anxiety better.
It is normal for children and adolescence to display signs of anxiety. These are often developmentally appropriate and not in need of targeted attention.
For example, it is typical for babies and toddlers to fear loud noises, strangers and separation from a key attachment figure.
Similarly, it is quite normal for an adolescent to worry about social exclusion or the impact of ‘making a fool of themselves’. However, for some children,
age appropriate fears do not always dissipate instead these may worsen in nature and severity as they move through key developmental milestones.
It is now widely acknowledged that anxiety disorders comprise the most common disorder of childhood and adolescence and can largely impact their development.
The largest impact of child anxiety is on family processes although anxiety disorders also affects a child’s social, academic and vocational function.
Development and Risk for Anxiety Disorders in Childhood and Adolescence
Accumulating evidence has supported the familial aggregation of anxiety disorders. Several studies suggest that children with anxiety disorders are significantly
more likely than other children to have a parent with an anxiety disorder. It is currently believed that the genetic component to child anxiety is
probably common across anxiety disorders meaning there is little difference in heritability across specific anxiety disorders.
In terms of other risk factors, temperament style characterised by shyness, behavioural inhibition and withdrawal have been repeatedly associated with
childhood and adolescent anxiety. Key indicators of a child high on this temperament style include; a long time to communicate with strangers, remaining
within close proximity of safety figures, signs of discomfort or withdrawal when faced with novelty, as well as restricted and inhibited social behaviours.
Parenting styles have also been associated with increased risk for childhood anxiety specifically overprotective/overcontrolling parenting and negative/critical
parenting practices. Of the two parenting styles, overprotective parenting is more consistently associated with anxiety whereas critical parenting
tends to be more strongly correlated with depression. In sum, it is well established that a combination of both biological and environmental factors
largely contribute to the onset and maintenance of anxiety disorders in childhood and adolescence.
Common Signs of Anxiety in Childhood and Adolescence
At Home:
Fear and avoidance of certain topics or situations (e.g, unfamiliar people, changes to routines, discussion about study or exams, social withdrawal)
Physical complaints (e.g., stomach aches and headaches) and increased emotionality/reactivity
Sleep difficulties including problems falling to sleep, nightmares or over sleeping
Increased worries and a constant need for reassurance and/or planning
Strong ritualistic behaviours (e.g., checking, washing, superstitious thoughts and actions)
Think their mind is controlled or out of control
Self-harms (e.g., cutting, scratching, burning or hitting)
Experiences thoughts of suicide in more extreme cases
At School:
Difficulty joining in class discussions, sport games, excursions or camps
Reluctance to ask for help due to fear of increased attention or needing to speak out loud
A strong desire for perfection in academic performance and/or physical appearance
Increased sick days or visits to the sick bay
Strong attachment to particular teachers or peers as a way to increase feelings of safety
Over working or procrastinating due to fear of failure
Is unable to enjoy pleasurable activities anymore
Social isolation and avoidance of social interaction
Common Anxiety Disorders in Childhood and Adolescence
When children become anxious more frequently and more intensely than their same aged peers, they may meet clinical diagnostic criteria for an anxiety disorder
according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Anxiety disorders in children and adolescents commonly include: phobias,
generalised anxiety disorder, separation anxiety, post-traumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD).
Specific Phobia
Phobia is diagnosed when particular objects, situations or events (e.g., needles/blood, dogs or heights) create intense fear and avoidance even though
threat of imminent harm is minimal.
Generalised Anxiety Disorder
Generalised Anxiety Disorder is diagnosed when children have excessive and unrealistic worries about a range of topics (e.g., harm to self/others, health
and wellbeing of self/others, physical appearance, academic performance, social acceptance). They often lack confidence and require frequent reassurance.
Social Anxiety Disorder
Social Anxiety Disorder is diagnosed when children experience a strong fear of negative social evaluation and consequently avoid social interaction or
being the centre of attention (e.g., talking on the phone, participating in show and tell or class presentations). They typically believe that people
will think badly of or laugh at them, they are shy and withdrawn and have difficulty meeting new people or joining in groups.
Separation Anxiety
Separation Anxiety relates to fear and distress triggered by being away from the family or strong attachment figures. There is commonly a fear that something
bad will happen to a loved one in their absence or that they may not re-unite.
Post- Traumatic Stress Disorder (PTSD)
Post-Traumatic Stress Disorder may develop following a traumatic event such as experiencing or witnessing a life-threatening event. Symptoms typically
include disrupted sleep patterns, irritability and poor cognitive function (e.g., decreased concentration). There may also be re-experiencing of the
event or avoidance of triggers that remind them of the traumatic experience.
Obsessive Compulsive Disorder (OCD)
OCD is an anxiety disorder where a child experiences unwanted and repeated thoughts, feelings or images (obsessions) that create distress and propels them
to perform a ritualistic behaviour (compulsion) to alleviate the associated discomfort. Common obsessions in children and adolescence include; germs/hygiene,
symmetry, sexual/aggressive thoughts and superstitions (e.g., lucky or unlucky numbers and colours etc). Common compulsive rituals include; washing,
checking, repeating certain phrases or touching/tapping a certain number of times in a set way.
How to Help Your Child or Adolescent Manage Anxiety
It is important to acknowledge early warning signs indicating that your child or teen may be anxious so that strategies can be established to enhance effective
coping skills. Below are some general principles that may be useful when assisting children with anxiety difficulties.
Highlight Why Worry Is Useful
Many children worry about worry so it is important to explain that worry does have a purpose and in the right situations and in the right doses, worry
can in-fact be useful. For example, explain to your child that when our ancestors were hunting and gathering food, worry helped them avoid attacks
from wild animals. In modern times, we don’t need to run from predators, but we are left with an evolutionary imprint that protects us, namely, worry.
Teach your children that worry is normal. It can help to protect and motivate us and everyone experiences it at some point in their life. However,
sometimes our body sets off “false alarms” but this type of anxiety (worry) can be managed with some basic strategies.
Model How To Be A “Thought Detective”
Rather than teaching your child or teen to ‘think positive’, the best remedy for unhelpful thinking is evidence-based thinking. This can be achieved in
three basic steps:
Catch you thoughts: Imagine all your thoughts floating above your head in a bubble. Try to catch one of your worry thoughts like “What if no-one wants
to sit with me at lunch”?
Gather evidence: Collect evidence to confirm or disconfirm your worry thought. Teach your child that it is important to focus on observable, factual evidence
rather than feelings. Feeling are subjective and constantly changing.
Supporting evidence: “I’ve had trouble finding friends to sit with at lunch before”
Disconfirming evidence: “This has only happened a couple of times”; “Most of the time, I have friends to sit with at lunch time”; “I am friends with most
children in my class. I should be able to find atleast one friend to sit with”.
Weigh up the evidence and challenge your thought: Weigh up the evidence for and against the worry thought and help your child create a more rational response.
This is often best described as having a debate with yourself.
Avoid Avoiding Triggers of Anxiety
The benefit of facing your fears is supported by evidence demonstrating that avoidance plays a key role in maintaining fear primarily due to missing opportunities
to learn that feared outcome may not be as bad as expected, or in most cases, may not even occur. Accordingly, gradual exposure to feared situations
in small, achievable steps is a simple way to assist your child to face their fears. For example, a child who feels anxious when public speaking, may
benefit from a simple exposure hierarchy such as this:
Discussing a school project with a group of peers
Starting off the group discussion
Presenting a part of the project to your group
Presenting your project to the class as part of your group
Presenting by yourself a project you have prepared with your group
Giving a two minute talk to your class that you have prepared by yourself
Presenting with your group at school assembly
Presenting by yourself at school assembly
It is important after each step to discuss with you child whether a) their feared outcomes came true? b) their distress decreased the longer they remained
in the situation (i.e. the process of habituation)? and c) whether there is a more helpful way to look at their initial worry thought?
Allow Them To Worry
Sometimes telling someone not to do something will increase the likelihood and their urge to engage in the behaviour. It can be helpful to allow your child
daily ‘worry time’ in limited doses. This may involve encouraging your child to allocate 15mins each day to write, draw or journal some of their worries
from the day. If you encourage your child to engage in worry time, it is also important that they agree not to engage in worry thoughts that may creep
into their mind during the day. Instead encourage your child to “try and catch it” and to “put it in their pocket” ready to take out for worry time
later in the day. The theoretical rationale underpinning this technique is that often, delaying worry, can decrease the intensity of the initial emotional
reaction created by the thought. Consequently, the thought may no longer bear that same significance and importance as originally believed and may
become more amenable to challenging and re-interpretation in a rational manner.
Accessing Professional Support and Treatment for Anxiety
Professional information and advice can be obtained from various sources:
Your family GP or health specialist
The School counsellor or welfare teacher
Your local community health centre
A specialist in the assessment and treatment of anxiety disorders such as a Clinical Psychologist or Psychiatrist
Treatment
For young people with severe anxiety, it is likely that the first form of treatment will include psychological therapy where the focus is on modifying
unhelpful thoughts and behaviours that occur in situations that make them anxious. Cognitive Behaviour Therapy (CBT) is an evidence-based treatment
focused on developing skills to improve mood, physical symptoms of anxiety and behaviour by examining irrational thinking patterns. In more severe
cases, medications can be prescribed, typically, serotonin reuptake inhibitors (SSRI’s). These medications target a neurotransmitter called serotonin
and work particularly well when used as an adjunct to CBT.
Dr Cristina Cacciotti Saija (PhD, USYD) is an experienced Clinical Psychologist and researcher with expertise in the assessment and treatment of youth and adult mental health difficulties. She is also a busy Mum of two.
Dr Cristina Cacciotti Saija offers private consultations at Uspace, St Vincent’s Private Hospital Darlinghurst, Ph (02) 8382 9760.
Key References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Creswell, Cathy, Polly Waite, and Peter J. Cooper. “Assessment and management of anxiety disorders in children and adolescents.” Archives of disease in
childhood 99.7 (2014): 674-678.
Kendall, Philip C., et al. “Clinical characteristics of anxiety disordered youth.” Journal of anxiety disorders 24.3 (2010): 360-365.
Rapee, Ronald M., Carolyn A. Schniering, and Jennifer L. Hudson. “Anxiety disorders during childhood and adolescence: Origins and treatment.” Annual review
of clinical psychology 5 (2009): 311-341.
Zhang, Yuqing, et al. “Comparative efficacy and acceptability of psychotherapies for acute anxiety disorders in children and adolescents: study protocol
for a network meta-analysis.” BMJ open 5.10 (2015): e008572.
