Anxiety

Overview

Anxiety disorders are the most common mental health disorders of childhood and adolescence, with almost one in three adolescents (31.9%) meeting criteria for an anxiety disorder by age 18. It is a normal, adaptive reaction, as it creates a level of arousal and alertness to danger. The primary characteristic of anxiety is worry, which is fear that future events will have negative outcomes. Anxious children are much more likely than their peers to see minor events as potentially threatening. For example, giving a brief oral report might be slightly anxiety-producing for most children, but the anxious child is much more likely to believe that his or her performance will be a complete disaster.

Defining Anxiety

Infancy and Preschool

Anxiety first appears at about 7–8 months of age as stranger anxiety, when an infant becomes distressed in the presence of strangers. At about 12–15 months of age, toddlers show separation anxiety when parents are not nearby. Both of these reactions are typical and indicate that development is progressing as expected. In general, severe stranger and separation anxiety dissipate by the end of the second year of life. Anxiety at this age is primarily associated with fears of strangers, new situations, animals, the dark, loud noises, falling, and injury.

School Age

Up to about age 8, many causes of anxiety continue from preschool levels with a focus on specific, identifiable events. With age, sources of anxiety become more social and abstract, such as worrying about friends, social acceptance, the future, and coping with a move to a new school. Adolescents tend to become more worried about sexual, religious, and moral issues as they continue to develop. In the vast majority of cases, children and adolescents cope well with these situations and severe or chronic anxiety is not common.

Signs of Anxiety

Not all children will show all signs or show the same signs to the same degree, but a stable pattern that interferes with performance may be cause for concern.

Thinking & Learning

concentration problems
memory problems
attention problems
problem-solving difficulties
worry

Behavioral

restlessness
fidgeting
task avoidance
rapid speech
irritability
withdrawal
perfectionism
lack of participation
failing to complete tasks
seeking easy tasks

Physical

stomach discomfort
rapid heart rate
flushing of the skin
perspiration
headaches
muscle tension
sleeping problems
nausea

Types of Anxiety Disorders

A child or adolescent may have an anxiety disorder if anxiety is a pattern causing persistent problems. Several types of anxiety disorders exist, impairing social, personal, or academic functioning. The frequency of anxiety disorders ranges from about 3% up to 20% of children and adolescents. In infancy and preschool children, anxiety disorders are infrequent. They most often start to emerge in early childhood and may persist into adulthood. The frequency of anxiety disorders in boys and girls is about the same during elementary school years, but differences between them emerge in adolescence, with girls being two to three times more likely to develop anxiety disorders. With a 10% frequency rate, a middle school class of 30 students could have as many as three students with an anxiety disorder and perhaps two of them would be girls.

Separation Anxiety Disorder (SAD)

SAD is the only anxiety disorder specific to children and is associated with fears about leaving familiar people, usually parents. In extreme situations, children might refuse to leave their home or not want to stay overnight with a friend. Sometimes, they may refuse to attend school, a pattern often termed "school phobia," although "school refusal" is more accurate. It is not unusual for preschool children to express separation anxiety, but persistent or extreme separation anxiety is atypical for school-aged children and may reflect concerns about family matters, safety, or fears of social rejection.

Post-Traumatic Stress Disorder (PTSD)

PTSD is most often associated with distress as a result of a traumatic situation. The most common types of trauma in children are exposure to violent crime, auto accidents, home fires and injuries, natural disasters, domestic violence, physical and sexual abuse, and serious physical illnesses. Symptoms of PTSD include emotional numbing, avoidance, detachment from others, sleep difficulties, angry outbursts, reliving the experience through stressful memories, flashbacks, and concentration problems. Incidence rates for PTSD symptoms in traumatized children are as high as 20%, and the overall rate in children is about 3%, depending on the circumstances. Girls appear to have higher rates of PTSD than do boys.

Generalized Anxiety Disorder (GAD)

GAD is associated with pervasive and high levels of anxiety across a variety of situations with no apparent events that trigger it. It is the most common childhood anxiety disorder and tends to persist to some degree into adulthood. These children often are described as "highstrung" and are often very concerned about doing things well; they may show perfectionist tendencies. The tendency to worry frequently about relatively minor things is a primary defining characteristic of GAD. Children with GAD tend to stay in a relatively high state of physical arousal and often appear stressed much of the time. GAD also tends to be chronic and does not dissipate over time without help, perhaps requiring professional intervention.

Social Phobia

Children who have excessive fear and anxiety about being in social situations and being evaluated by others are experiencing social phobia. The fear of social situations is out of proportion to the actual situation, although some children may not be able to identify specific stressors. The typical age of onset is in adolescence or early adulthood, although shyness and social discomfort can be seen as early as 2 or 3 years of age. Typically, onset is gradual without obvious triggering events.

Diagnosis Criteria

Based on DSM-5: Generalized Anxiety Disorder (300.02) (F41.1)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Note: Only one item required in children.

1. Restlessness, feeling keyed up or on edge.

2. Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. Irritability.

5. Muscle tension.

6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia],contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Causes of Anxiety Disorders

Considerable research has focused on genetic and environmental causes of anxiety. In general, there is a genetic contribution of about 30% in childhood anxiety disorders. It appears, however, that a general tendency toward anxiety is transmitted, rather than a predisposition for specific disorders. Biological influences include temperament, which is a fairly stable personality trait. Anxious children tend to have an inhibited, cautious, and tentative temperament that predisposes them to anxiety disorders. Some anxious children may have differences in certain parts of the brain that affect attention, concentration, and memory. Family factors appear to play an important role, especially from some mothers who overprotect their children, model anxious behavior, and prevent exposure to stressful situations.

Effects on School Performance

Highly anxious children tend to struggle with various demands of school and to be inattentive, perfectionistic, forgetful, or unwilling to participate due to concerns about failure or embarrassment. They may avoid difficult tasks, seek easy tasks, and not volunteer or readily participate in classroom activities. Because withdrawal is a typical response to avoid feeling anxious, anxious children may be perceived by teachers as unmotivated, lazy, or uninterested in school. In fact, the majority of these children want to do well and be involved, but the motivation to avoid feeling anxious is high.

Effects on Social Performance

Anxious children tend to withdraw socially to avoid experiencing anxiety, which leads to further problems of fitting in and making and sustaining friendships. Over time, more social problems and deficits may occur, making the situation worse. Avoidance and worry may offer short-term solutions but have cumulative negative effects and provide little long-term relief.

Interventions

If severe, anxiety problems may require professional help outside the school. Teachers and parents can ask some initial questions when determining what to do:

How typical is the anxiety for the child's age?
Does it tend to be situation-specific or pervasive across situations?
Are there any current events, changes, or circumstances that may help to explain the problem?
What effects on personal, social, and academic performance are evident?
What has been tried to help the situation?
What has helped and what has not helped?

What to Consider When Selecting Interventions and Supports

Interventions will be different depending on a child's age and developmental level, the severity of anxiety symptoms, and the presence of other psychological conditions. Young children are more likely to express anxiety through behavior. They typically have limited understanding about why they are experiencing anxiety and may be unable to talk about the source of their worries. As such, strategies that focus directly on behavior will be more useful than those that target thinking (Barrett, 2000). In contrast, older children and adolescents are better able to talk about the situations in which they feel anxious and are more capable of describing their own thinking. With older children, strategies that address both thinking and behavior (that is, cognitive–behavioral therapy) can be used. For those with more severe anxiety symptoms or other co-occurring psychological conditions (e.g., depression, oppositional defiant disorder, or attention deficit hyperactivity disorder), multiple intervention strategies should be used simultaneously, and families should consider treatment by a mental health provider. Although the strategies listed below can help to prevent and reduce anxiety symptoms, a therapist should be consulted when the anxiety symptoms are so severe that they interfere with normal functioning and typical activities such as attending school and socializing with peers. Cognitive–behavioral therapy (CBT) and exposure therapy (ET) are the most commonly used evidence-based therapeutic modalities to address anxiety symptoms. In CBT, children are taught to identify the thoughts, behaviors, and somatic symptoms associated with their anxiety. In ET, children create a fear hierarchy of anxiety-inducing situations and are gradually exposed to the stressors. High parental involvement is necessary to optimize the effectiveness of CBT and ET. Children are expected to practice exposures and relaxation exercises between therapy sessions. Parents should prompt and assist children in completing these homework exercises and reward children for compliance with therapeutic activities. In consultation with a pediatrician or child psychiatrist, families may consider supplementing psychotherapy with medication treatment if the anxiety symptoms are very severe and if the child displays a limited response to psychotherapy.

School-Based Interventions

establish predictable routines
set clear and reasonable expectations
break tasks into manageable units
have specific evaluation criteria
provide opportunities for practice and rehearsal
pair anxious students with peers who are confident and supportive

give special responsibilities
give time to relax when anxiety becomes high
reduce or avoid unexpected situations
avoid punitive and negative attitudes
reduce time constraints, if possible
move student to a quiet area with fewer distractions

Home-Based Interventions

be consistent in how you handle problems and administer discipline
be patient and prepared to listen
avoid being overly critical, disparaging, impatient, or cynical
maintain realistic, attainable goals and expectations for your child
do no communicate that perfection is expected or acceptable
maintain consistent but flexible routines for homework, chores, activities, etc.
do not treat feelings, questions, and statements about feeling anxious as silly or unimportant
often, reasoning is not effective in reducing anxiety - do not criticize your child for not being able to respond to rational approaches

accept that mistakes are 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
practice and rehearse upcoming events, such as giving speech or other performance
teach your child simple strategies to help with anxiety, such as organizing materials and time, developing small scripts of what to do/say to himself/herself when anxiety increases, and learning how to relax under stressful conditions
seek outside help if the problem persists and continues to interfere with daily activities