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Childhood Anxiety Disorders

Research suggest approximately 5% to 18% of children suffer from an anxiety disorder. In general, anxiety disorders can begin at any age. However, different types of anxiety disorders appear to affect children of differing age groups. For example, Separation Anxiety Disorder appears to be more common in younger children while Generalized Anxiety Disorder is more frequently diagnosed in adolescents. Most common of all the anxiety disorders is Specific Phobia; it’s important to keep in mind, however, that certain fears are normal for children as they develop. Girls appear to be affected by problems with anxiety more frequently than boys, but any child is capable of developing an anxiety disorder.

“I don’t want to go to school.”
“I have a tummy ache.”

For many parents, these are familiar complaints. But for children who express physical complaints on a regular basis, or who miss too many days of school, or who persistently avoid being alone or with other children, the problem may be more serious than being sick.

Many people believe that children do not have anxiety problems. All the signs of a problem may be there but the child is expressing distress in a way that is hard for an adult to recognize. Often, a child’s fearful behavior is regarded as a passing stage. A painfully shy child may be seen as cute or endearing. Sometimes temper tantrums are not the product of a willful or disobedient youngster, but the only means a child has of expressing how afraid he or she is of certain situations.

Lisa, who is 14 years old, had always been reluctant to be separated from her mother. Far more often than the average child, she reported stomach aches or headaches and would insist she needed to stay home from school to recuperate. When her parents planned evenings out alone or weekend trips with the kids Lisa often threw tantrums or sulked.

Lisa is a bright student who managed to get passing grades despite her many absences. However, when she graduated from a small grade school and was enrolled in the much larger junior high school Lisa refused to go. She insisted her mother quit her part-time job to provide home schooling. Lisa and her parents sometimes came close to physical battle in the mornings arguing about the need for her to attend school. As time went on, it became clear that Lisa had an anxiety problem.

What is Anxiety?
Anxiety is the body’s natural alarm system. It warns of danger. There are situations when it is perfectly normal to feel a little anxious, such as before an important test. Anxiety has physical, mental, and behavioral aspects. Children who are anxious usually experience some physical symptoms (e.g., rapid heartbeat, feeling dizzy, shortness of breath, muscle tension, or difficulty sleeping). They also experience scary thoughts (e.g., “I can't sleep with the light off. There may be a monster under my bed and it could get me.”) And they often express their anxiety behaviorally by avoiding situations, which make them uncomfortable.

What is an Anxiety Disorder?
Anxiety becomes a “disorder” when the discomfort or disability it creates significantly interferes with day-to-day living. Certain problems, such as avoiding school, are readily apparent. However, a child may express fear in less obvious ways. For example, physical illness, such as frequent stomach aches for which there is not a medical diagnosis, may be a sign of anxiety. Other signs include behaviors, which are uncharacteristic of a child, such as temper tantrums, oppositional behaviors, or refusing to be separated from family members.

It is important to keep in mind that certain fears are developmentally appropriate for children. For example, fear of the dark or monsters is normal for a 2 or 3 year old, but not expected in a teenager. Especially with young children, it is important that parents check with a pediatrician or family doctor in order to find out whether a child’s fears are typical, or if they are uncommon for his or her age. Children’s teachers can help determine if anxious behavior seen at home is also happening at school and whether the behaviors are age-appropriate.

What are the Kinds of Childhood Anxiety Disorders?
In this section, we describe the different anxiety disorders that can occur in children. Some anxiety disorders affect both adults and children. Other disorders are diagnosable only in children.

• Separation Anxiety Disorder:
  Developmentally inappropriate and excessive anxiety concerning being separated from home or from those to whom a child is attached (usually parents).
  

• Panic disorder:
  Repeated panic attacks consisting of periods of intense fear or discomfort in which several physical symptoms (e.g., racing heart, sweating, trembling, shortness of breath, choking sensation, dizziness, nausea or stomach ache, etc.) develop abruptly and reach a peak in a short period of time. Children are not always able to express the fear well and may describe their attacks with terms like “a yucky feeling”.
  

• Panic Disorder with Agoraphobia:
  Panic attacks accompanied by anxiety about being in places or situations from which escape may be difficult or embarrassing or in which help may not be available in the event a panic attack occurs. This condition is more common in adults.
  

• Specific Phobia:
  Marked and persistent fear that is excessive or unreasonable and is triggered by the presence of a specific object or situation (e.g., animals, heights, blood or injury, tunnels, driving, flying, etc.). Temporary specific phobias (e.g., fears of the dark or strangers) are common in childhood, but phobias, which persist, can be problematic.
  

• Social Phobia:
  Persistent fear of social situations (e.g., parties), performing in front of others or other situations in which the person is the center of attention and fears he or she may do something embarrassing or humiliating or may experience the disapproval of others. Children may express social anxiety by crying, tantrums, freezing, or shrinking from social situations or unfamiliar people. Severe shyness may be a sign of social phobia.
  

• Obsessive-Compulsive Disorder:
  Persistent thoughts, impulses, or images which are intrusive, unwanted and cause marked anxiety or distress and which the person attempts to neutralize by engaging in repetitive behaviors (such as hand washing, ordering, checking) or mental acts (such as praying, counting, or repeating “good” thoughts or words silently).
  

• Posttraumatic Stress Disorder:
  Children that have experienced, witnessed, or been confronted with an event that involved actual or threatened death, serious injury, or threat to the physical integrity of themselves or others may experience depression, anxiety, and other disturbing symptoms long after the traumatic event. Also, they may persistently re-experience the traumatic event in the form of repetitive play, nightmares, flashbacks, or re-enacting a theme relating to the trauma.
  

• Generalized Anxiety Disorder:
  A general tendency to worry excessively about a variety of concerns. Common symptoms are restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and disturbed sleep.
  
  Other Problems Related to Anxiety Disorders:
  While not specifically an anxiety disorder, trichotillomania can involve anxiety. It is characterized by repeatedly pulling out ones hair (including scalp hair, eyebrows, lashes, and other body hair) and is frequently seen in children and adolescents. Tourette’s Disorder is a neurological disorder that in some cases has an anxiety component. Individuals with tourette’s have motor and sometime vocal tics. Tics are sudden, rapid, recurrent non-rhythmic, stereotyped motor movements or vocalizations. This disorder sometimes occurs along with obsessive-compulsive disorder.

What should I do if I think a child has an anxiety disorder?

If you suspect a child has a problem with anxiety, a thorough evaluation by a mental health professional knowledgeable in the diagnosis and treatment of anxiety disorders may be helpful. A comprehensive evaluation will incorporate information from a variety of sources including family and, with permission sometimes others who interact with a child, such as teachers and physicians. The evaluation should consider anything that might be contributing to a child’s problem. When the evaluation has been completed, the professional should provide specific recommendations regarding treatment.

What kinds of Treatment are Available?
Anxiety disorders are very treatable. A treatment plan should be developed that is tailored to the particular needs of each child. Often, treatment includes a well-balanced combination of several approaches.

Cognitive Behavior Therapy:
The primary goal of cognitive behavior therapy is to help people modify the way they think, feel, and behave. Although every child’s therapy is somewhat unique, there are several common components. Both the child and family members are educated about the nature of the particular anxiety disorder present. Misperceptions are corrected. Treatment may also include behavioral experiments, or “exposures”, designed to help children confront feared situations in a gradual, step-by-step manner. Anxiety management skills are taught to help a child learn to manage the symptoms of anxiety effectively. In addition, other behavioral skills or interventions (e.g., assertion, habit control, contingency management, response prevention) may be a necessary part of treatment, depending on the particular problem.

Medication:
In some cases, medication can be helpful. There are a number of different medications available to treat anxiety disorders. Whether medication is needed and what kind of medication to use depends upon the type of problem and other factors specific to the child This, of course, should be discussed with the child’s physician. However, specific medications are commonly prescribed for some anxiety problems. For example there are drugs known as SRI’s (serotonin reuptake inhibitors), such as fluvoxamine (Luvox), fluoxetine (Prozac), and clomipramine (Anafranil). They are used to treat obsessive-compulsive disorder. Benzodiazepines, such as alprazolam (Xanax) and clonazepam (Klonopin), and tricyclic antidepressants such as imipramine, are often prescribed to treat panic disorder. These are only examples, however. Other drugs are available, depending on the type of problem. Selection of each child’s medication depends on many factors that need to be considered by the child’s physician.

Family Therapy:
With most children, family involvement is critically important. This may involve the parents or even the entire family participating in therapy. Typically the child’s therapist educates the family about the problem and provides guidelines for how to be helpful. In some instances, the therapist may help the family set-up a reward program to help motivate the child to comply with treatment. More extensive family counseling is sometimes needed.

Other Treatments:
In some cases, other types of psychotherapy may be beneficial. A child’s therapist may also recommend that certain other family members seek individual therapy so they are better equipped to support the child’s progress. Support groups are sometimes available which provide children with moral support and a chance to learn they are not alone.

Where can I find help for my child?
While it would be reassuring to say that the average psychologist, psychiatrist, therapist, social worker, or counselor is skilled in the type of treatment approaches described above, this is not the case. Even mental health professionals who specialize in the treatment of children are not all experienced in the treatment of childhood anxiety disorders. There may be only a handful of professionals in your area skilled in the cognitive-behavioral treatment of anxiety disorders and specifically, in the treatment of anxiety disorders in children.

Contact resources in your community such as a university medical center of an anxiety disorders treatment center and ask about the kinds of treatment available. If you live in a community in which this kind of facility is not available contact the Anxiety Disorders Association of America (301) 231-9350 or your local Mental Health Association. They may be able to provide you with the names of practitioners in your area. Finally, do not hesitate to ask questions of the professionals you contact for help. They should not be offended by questions about their credentials and experience in the treatment of children with anxiety disorders.