Understanding Anxiety in Children and Adolescents
Defining Anxiety: Anxiety is the tense emotional state that occurs when one cannot predict the outcome of a situation. Anxiety becomes a disorder when a child exaggerates the risks and underestimates his/her ability to cope with a given situation. Anxiety is debilitating to children, causing physical complaints, decreased academic functioning and/or school attendance, and strained peer and family relations. Anxiety symptoms present in many ways. Below we outline the most common anxiety disorders.
Generalized Anxiety Disorder (GAD) is characterized by excessive and persistent worry about many areas of one’s life. Children with GAD often worry about their health, safety, and future, as well as the health, safety and future of their parents or other family members. This worry far exceeds normal worrying, in that it tends to occur frequently, is very difficult for the child to control or stop, and lasts for more than 6 months. Research suggests that children with GAD are at risk for increased problems in adolescence and adulthood.
Social Phobias are characterized by significant distress related to interacting with others. Children with social phobias have a normal desire to be with others, but are very fearful of social contacts. As a result, they frequently fear social situations and typically try to avoid situations in which they will have to interact with others. Anxiety about school has been found to be a common fear for more than half of children with social phobias. Fears related to school involve having to read or talk out loud, speak to others, and participate in some type of performance. Estimates suggest that about 1% of children and adolescents have social phobias. Children with social phobias often report many physical symptoms (nausea, shakiness, heart palpitations) when faced with socially distressing situations. This disorder can result in many long term problems including decreased social skills, social isolation and loneliness, and depression.
Obsessive Compulsive Disorder (OCD) has been estimated to occur in up to 1% of children and adolescents, but has been found to be frequently under diagnosed. OCD is characterized by: (a) Obsessions, which are frequently reoccurring thoughts, images or urges that the child experiences as distressing and intrusive; and (b) Compulsions, which are repetitive behaviors which are typically done in order to neutralize or lessen the anxiety and distress associated with an obsession. An example of this would be intense fears of germs (an Obsession), which is managed by frequently washing one’s hands (a Compulsion). Common childhood obsessions include fears of germs, fears of harming self or others, urges to order things, and sexual ideas. Obsessions and compulsions often change and vary over time.
Panic Disorders (PD) have been found to typically begin in adolescence, but there is some suggestion that the age of onset may be getting younger. PD is characterized by recurrent panic attacks. Panic attacks are intense anxiety reactions (occurring in the absence of real danger) which include both physical and psychological symptoms. Physical symptoms: dizziness, chest pains, nausea, trembling or shaking, chills or hot flushes, and sweating. Psychological symptoms: fears of losing control, going crazy or dying, as well as feelings of being detached from one’s self, e.g., feelings of unreality. In addition, PD is characterized by persistent concerns about having a panic attack. The vast majority of children and adolescents with PD also have other anxiety disorders and/or depressive disorders. There is also evidence that PD tends to be genetically linked, i.e., runs in families.
Specific Phobias (SD) are best thought of as extreme fears that persist over time, are not at all adaptive, and cause the child much distress. Phobias differ from normal fears in that normal fears are usually short-lived and adaptive where as phobias are intense and persistent fears which are excessive, unwarranted and unreasonable. Phobias, unlike other anxiety symptoms such as PD, are cued or prompted by the presence of the feared object or situation. Common phobias include excessive fears of animals, certain types of bad weather, and medical/dental procedures. Phobias appear to be more a result of learning and environment, than heredity, when compared to other anxiety disorders. Phobias also appear to have a younger age of onset than other anxiety disorders. Thus, parental involvement in the treatment process is very important.
Separation Anxiety Disorder (SAD) is the most common anxiety disorder, occurring in 3-5% of children and adolescents. SAD is characterized by an unrealistic and excessive fear of separating from a parent or parental figure, which is often accompanied by significant worries that harm will befall either the parent or child. School refusal is often associated with SAD, in both children and adolescents. School refusal or reluctance to attend school may be accompanied by physical complaints as well as by worry about parent or parent figures. There is some evidence to suggest that children and adolescents with SAD are likely to have a parent who is struggling with anxiety issues.
Posttraumatic Stress Disorder (PTSD) differs from other anxiety disorders in that the diagnosis of PTSD requires that the child or adolescent be exposed to a life-threatening event. Most experts agree that PTSD is likely under diagnosed. For PTSD to be diagnosed a child must be exposed to a life threatening event, must subsequently re-experience this event (through flashbacks, nightmares, or intrusive thoughts of the event), must seek to avoid and psychologically distance themselves from the event (avoid situations, places and events which remind them of the event), and must exhibit hyper-arousal (irritability, difficulties concentrating, hypervigilance, sleep disturbance and outbursts of aggression). Children and adolescents with PTSD have repeatedly been found to be at high risk for the development of other psychiatric problems.
1. Recognizing the Anxious Child: Fears and worries are a normal part of childhood. However, these fears and worries become problematic when the child cannot effectively manage them. A child who manages a frightening situation or concern in a healthy manner is responsive to suggestions, asks questions, and is reassured by the new information. In these instances anxiety and worry diminish. Conversely, the child with problematic anxiety exhibits unreasonable fear, often feels overwhelmed, frequently is preoccupied by specific fears, and may even regress when given suggestions for change. For this child, reassurance is never enough. Symptoms often increase in intensity and generalize to more situations, taking on a life of their own. The same holds true for adolescents.
Children suffering from anxiety present in many ways. Some children appear visibly stressed and frequently verbalize their worries and concerns. Some children keep their anxiety to themselves and worry silently. These children often appear tense and preoccupied. Some children may present as angry and irritable, as they are frustrated by the limitations resulting from their anxiety. Often, anxious children present with vague physical complains, stomachaches and headaches being the most common. These complaints typically occur prior to an anxiety causing situation, i.e., the child who often feels ill in the morning before school, but has no complaints at others times.
Distinguishing Anxiety from Attention Deficit Hyperactivity Disorder (ADHD)
Children with anxiety disorders often appear restless and inattentive. Thus, at times it may be assumed that they have ADHD. The table below differentiates the two disorders. It is particular important to distinguish between ADHD and anxiety as the two disorders require different treatment approaches.
follow through on
|Distracted by worries, rituals and fears. May
be afraid of hearing the question wrong,. May race through assignments due to nerves.
|Distracted by other kids and noises. Does not process instructions as difficulty sustaining focus. Tendency to rush through tasks in order to go onto something more fun.
|Unable to concentrate
||Afraid that work will be too hard; can’t tolerate the feeling of not being sure that something is right.
||Difficulty focusing due to feelings of boredom, a tendency to respond impulsively to other stimuli and difficulties sustaining focus.
|Impulsivity, blurts out answers, interrupts
||Fear that he will forget answer; needs reassurance that he is right; unable to leave as is, fears of making a mistake.
||Not enough processing available between idea and action - no mental brakes. Difficulties inhibiting impulses.
|Hyperactivity; fidgety, excessive talking
||Fidgety from anticipation, tension or worry. Wants to go home. Nervous energy; may be checking compulsions with questions
||Physical need to move, keep hands busy
In sum, the anxious child suffers from internal distractions while the child with ADHD suffers from deficits in the ability to inhibit and manage impulses.
Distinguishing Anxiety Disorders from normal childhood behaviors and worries: Anxiety is a normal part of life. Therefore, normal anxiety should not be confused with an anxiety disorder. For example, March and his colleagues argue that children normally exhibit some obsessive compulsive like behaviors, such as rituals or insisting on having things done in just a certain way. These behaviors are normal and most likely reflect a child’s strivings to develop a sense of mastery and control. In contrast, OCD symptoms are often bizarre in their content, hinder the child’s development and often are a significant source of distress. Similarly, separating from parents and anxiety about new situations is a common behavior, particularly in younger children and should not be confused with Separation Anxiety Disorder. Finally, specific fears and worry about the welfare of parents is a common concern of many children. These fears should not be considered a disorder unless they rise to the point where they cause the child significant distress, cannot be controlled by the child, are extreme in nature, occur frequently, and are enduring.
Distinguishing Anxiety Disorders from other disorders and problems: For those children who present with chronic complaints of headaches and stomachaches it is important to rule out that specific medical problems do not account for these symptoms. It is also important to carefully evaluate the child to make sure that other difficulties do not better explain the child’s symptoms. For example, a child who has been repeatedly threatened by peers at school does not have an anxiety disorder because they fear going to school. Similarly, a child who worries about the welfare of a parent, and has valid reasons for this worry, is more likely to benefit from having family problems addressed directly than learning to better manage his or her worries.
In sum, a careful assessment and diagnosis are the first step in treating anxiety disorders. It is important to determine if the child’s worries are to such a degree that they are indicative of an anxiety disorder. In addition, it is important to make sure that other problems do not better account for the child’s current difficulties.
2. Treating Anxiety in Children: Children with anxiety disorders have difficulty working through and processing their worries. When anxious their thinking is likely to be distorted, exaggerated, and unreliable. These children are also likely to have difficulties calming themselves when confronted with anxiety provoking thoughts and situations. Thus, anxious children need help learning how to: manage (modulate) their emotional reactions; develop strategies for more realistically appraising the sources of their anxieties; find ways to challenge and overcome their distorted thinking; and develop greater confidence in their abilities to manage stressful situations. Research has found that there are a number of strategies which are often helpful in reducing anxiety in children.
- Self-talk strategies: Children can be taught ways to talk to themselves to calm themselves and challenge irrational fears and/or excessive worrying. Children can learn how to not “let their fears boss them around any more.” For example, children can learn to better appraise situations, e.g., “This is a risk, but it’s a small risk. I can handle it. My brain shouldn’t be bothering me with the small risks, only the big ones.”
- Separate feelings from the facts: For example, ask your child, “How much of you feels scared something bad is going to happen? And, how much of you really believes it will happen?” Over time children can be helped to learn that when the facts are in charge, they are more in charge and less likely to feel scared and anxious.
Stay in the present: Anxious thinking is future thinking. All the “what-ifs” questions are future questions. “What if I don’t make the team? What if I fail the test? What if I can’t get into college?” What starts out as a question about the 4th grade math exam becomes super sized to the rest of life. Children can learn to stop projecting ahead and stay focused on the present, e.g., “learn to put up the stop sign and limit thinking to the situation at hand.”
Therapy and the treatment of anxiety: The strategies detailed above are often referred to as cognitive behavioral strategies. Cognitive Behavior Therapy (CBT) is a well researched treatment approach which emphasizes the identification and modification of irrational and unrealistic ways of thinking, and which focuses in a systematic way on helping individuals develop more effective ways to manage their anxieties, challenge and correct unrealistic ways of looking at the world, and develop more effective coping strategies.
While not all therapists describe their approach as Cognitive Behavioral most clinicians draw on and utilize these strategies to help children and adolescents overcome and more effectively manage their anxiety.
The role of the family: Children are greatly affected by their environment. Family stresses such as illness, unemployment, marital/family conflict, and divorce can trigger anxiety in children. Parents who are prone to anxiety and worry may inadvertently reinforce such behavior in their children. Parents who struggle with their own anxiety disorder may inadvertently model and reinforce less adaptive ways of coping. Conversely, parents can help children learn to be more realistic in their thinking and help protect them from life stresses. Anxious children need limits and structure, so that they do not give into their anxiety. Letting a school phobic child stay home from school is not a good solution. Parents can help their anxious child by putting limits on their child’s anxiety and not allowing the child to make choices that will only exacerbate their anxiety. Parents can also help anxious children by addressing and resolving family and marital stresses. Thus, an important part of treating anxiety in children is addressing stresses in the family and mobilizing parents as a resource to help their child.
Medication and the treatment of anxiety: There has not been extensive research on medication treatment of anxiety disorders in children and adolescents. Existing research has found that medication based treatment can be useful in the treatment of Anxiety Disorders. Specifically, there have been a number of studies that have found that OCD symptoms are reduced by medication. However, research has consistently suggested that therapy, utilizing cognitive behavioral strategies, is the treatment of choice in working with most anxiety disorders, and that medication can be a useful adjunct to therapy.
The Importance of a Comprehensive Approach to treating Anxiety Disorders. In sum, the treatment of Anxiety Disorders requires a comprehensive approach:
- Children and adolescents need to learn more effective strategies for managing their anxiety and for decreasing unrealistic and irrational thinking which may underlie their anxiety.
- Family stresses and problems that contribute to anxiety need to be addressed. This includes helping children and adolescents work through the impact of family problems.
- Biological vulnerabilities to anxiety can be addressed by learning how to manage physiological reactions (relaxation strategies) and with medication.
References and Recommended Reading
Chansky, T.E. Freeing Your Child From Anxiety. Broadway Books: NY, 2004.
Treadwell, K.R.H & Kendall, P.C. Self-talk in youth with anxiety disorders: States of mind, content specificity and treatment outcomes. Journal of Consulting and Clinical Psychology, 1996, Vol. 64(5), 941-950.
Kendall, P.C. Treating Anxiety Disorders in Children: Results of a randomized Clinical trial. Journal of Consulting and Clinical Psychology, 1994,
Vol. 62(1), 100-110.
Morris, T.L., & March, J.S. eds. Anxiety Disorders in Children and Adolescents. Guilford Press, New York, 2004.
A site developed by a Boston area psychologist. Offers general information on anxiety disorders in children, but tends to be a bit self-promotional.
A site developed by Philadelphia psychologists. Offers much information about Anxiety Disorders in children.
Additional sources of information for this fact sheet include:
The National Co-morbidity Survey Replication, reported in the June 2005 issue of the Archives of General Psychiatry, Vol. 62., No. 6, page 593-602.
Morris, T.L., & March, J.S. eds. Anxiety Disorders in Children and Adolescents. Guilford Press, New York, 2004.
Diagnostic and Statistic Manuel of Mental Disorders, IV. American Psychiatric Association, Washington, DC, 1994.