What is an Anxiety Disorder?
Anxiety at times is normal throughout a child’s development into adolescence and can help us to cope by getting us through a tense situation, cause us to study harder for an exam, or keep focused on an important speech.1 Young children usually grow out of normal short-lived fears such as being afraid of the dark, storms, animals, being separated from a parent, or strangers, but children and teens with an anxiety disorder experience fear, nervousness, and shyness and start to avoid places and activities.2,3 A child with an anxiety disorder cannot be comforted or reassured to get past his or her fear and anxiety.
Outlining Specific Anxiety Disorders 4,5,6
Understanding the types of anxiety disorders your child may have is key to getting them the proper treatment plan to help them overcome their fears and disorders. Below are some of the most common childhood anxiety disorders we see and treat:
- Generalized Anxiety Disorder: Children and teens with generalized anxiety experience chronic excessive anxiety about multiple areas of their lives, which may include school, family, social situations, health, and natural disasters. Children and teens with generalized anxiety disorder may be very hard on themselves and strive for perfection. They may also seek constant approval or reassurance from others. The 12-month prevalence of generalized anxiety disorder is 0.9% and is twice as common in females than males.
- Separation Anxiety: Children with separation anxiety feel excessive fear of being away from their home or caretakers. Children may complain of homesickness and refuse to go to school, camp, or sleepovers. These children commonly worry about something bad happening to their parents or caregivers or that they may become lost, kidnapped, or sick if they are apart. Children with separation anxiety cannot be distracted after a parent leaves and take longer than other children to calm down after a parent has left. The 12-month prevalence of separation anxiety disorder is 4% in children and 1.6% in adolescents.
- Specific Phobia: Characterized by anxiety and fear regarding a particular object (ex: spiders) or situations (ex: driving on the highway). The fear, anxiety, or avoidance is almost always immediately brought on by the phobic situation to a degree that is out of proportion to the actual risk posed. The etiology of specific phobia can be genetic or environmental. The 12-month prevalence rate of social anxiety is 7%, with a higher ratio of females exhibiting the disorder, especially in adolescence.
- Social Anxiety Disorder: Teens are more often diagnosed with social anxiety disorder than children. Children and teens with a social phobia feel anxiety in social settings or performance situations like being called on in class, starting a conversation with a peer, using a public restroom, speaking in public, or eating in a restaurant. Those with a social phobia suffer from an extreme fear of being humiliated or embarrassed in front of other people. It can cause uncontrollable and negative reactions to social situations and can result in isolation, depression, and substance abuse.
- Panic Disorder: When a child or teen displays intense physical symptoms like a rapid heartbeat or difficulty breathing that seem to occur out of no where, these are commonly associated with a panic disorder. The 12-month prevalence rate of panic disorder is less than .4% in children below the age of 14, and 2-4% in adolescents, with a higher ratio of females exhibiting this disorder.
- Obsessive Compulsive Disorder: If your child is having intrusive thoughts that are causing them anxiety and then move on to do ritualistic behavior, these are common traits of Obsessive Compulsive disorder.
- Selective Mutism: Characterized by a consistent failure to speak in social situations where there is an expectation to speak, even though the individual speaks in other situations. One example is a child who does not speak in school but speaks normally at home. The prevalence of selective mutism ranges from .03%-1%.
What type of anxiety is normal for children?
Below are some common anxieties children have at different age ranges.
- 2-4 years – anxiety about going on the potty, water (the bath/pools), dark, loud noises, “bad” people, strangers, costumed characters, being separated from parent, getting lost
- 5-7 years old – fear of the dark, monsters/ghosts, “bad” people, parent not returning, getting lost, bugs/animals/insects, doctors/dentists, thunder/lightning
- 8-11 years old – “bad” people/ghosts/supernatural, dying/sickness (themselves/loved ones/pets), social situations (peers liking them), taking tests
- 12 and beyond – social situations/what others think of them, appearance, school/athletic performance, things going on in the world (natural disasters/war/terrorism/crime)
An anxiety disorder differs from normal, developmentally appropriate fears in that it is more intense or lingers beyond what it is expected. Anxiety disorders interfere with functioning on a regular basis, leading to disruptions at home, in school or with friends. Children may do whatever they can to avoid situations that make them anxious. They may experience physical symptoms (e.g, headaches, stomach aches), seek excessive reassurance, engage in safety behaviors or rituals, or have frequent temper tantrums or explosive outbursts.
How Will Children Exhibit Anxiety?
Anxiety in children can take many forms, all of which I treat in my private practice:
- Specific fears or phobias – the dark, being alone, animals, monsters, etc…these are very common and actually the easiest symptoms to treat via exposure and other CBT techniques.
- Insomnia – avoidance of getting ready for bed, difficulty falling asleep, difficulty staying asleep, waking up too early. Children with sleep problems will often try to wake up their parents and sleep in their bed. It’s very important to quickly resolve sleep deprivation since it can increase the likelihood of other psychological disorders later in life, such as depression, anxiety, and alcoholism.
- Separation anxiety – difficulty separating from care givers, fear or worry something bad will happen to caregivers, nightmares about caregivers getting hurt, difficulty being alone. More common in young children and after a trauma.
- Generalized anxiety – uncontrollable worry, perfectionism, somatic complaints, vomiting, restlessness, asking too many questions, constant need for reassurance, worry about performance. these symptoms tend to be more diffuse which can make treatment more difficult.
- Post traumatic stress disorder (PTSD) – stems from a traumatic event such as abuse or death. symptoms include: dissociation, nightmares, flashbacks, hypervigilance, and avoidance of things that are similar to the trauma.
- Obsessive compulsive disorder (OCD) – obsessions (intrusive thoughts) and compulsions (ritualistic behaviors) that temporarily reduce anxiety about some type of fear. Examples include collecting objects, washing hands, touching objects, and checking behavior. Most effective treatment is response prevention and exposure.
- Selective mutism (SM) – children refuse to speak to certain people in certain situations for more than 1 month. Usually this starts after some type of upsetting event. School and home behavior plans with rewards work very well. SM can worsen overtime if not treated.
- School refusal – children avoid or refuse to got to school due to fear of something bad happening. It’s very important that children return to school immediately or the avoidance will worsen.
- Social anxiety – fear of being embarrassed in social situations by saying or doing something wrong. Very common in adolescents, especially those with underlying anxiety.
- Test anxiety – more common in older adolescents. symptoms include sweating, racing heartbeat, irrational thoughts, somatic complaints, vomiting, panic, freezing, and “brain fog.”
Anxiety is the most common reason parents seek treatment for their children. Without treatment, anxiety often persists and worsens over time.
Anxiety becomes a disorder when it:
- persists beyond what is developmentally appropriate
- interferes with a child’s ability to function or
- is ongoing or excessive
What causes an Anxiety Disorder?
Science has not identified one single cause of anxiety disorders, developing an anxiety disorder is usually the result of biological and environmental risk factors (such as parenting style). Genetics and your child’s temperament or innate personality style play an important role in predisposing children to anxiety disorders.
For example, a child who is innately cautious, quiet and shy is more likely to develop an anxiety disorder.4 Adverse childhood experiences can also contribute to risk for developing anxiety disorders.8
What can be done to treat an Anxiety Disorder?
Anxious children and teens can be quiet, compliant, and eager to please which may make it difficult to realize a child is struggling with anxiety or fear.2 Cognitive behavioral therapy (CBT) focuses on the relationships between negative or automatic thoughts, feelings, and behaviors and can help children and young people to deal with anxiety by using new ways of thinking.6,9
CBT has been shown to be significantly more effective than no therapy in reducing symptoms of anxiety. The National Institute of Mental Health has found that CBT, given with or without medication, can effectively treat anxiety disorders in children.1,9 Anxiety disorders are no one’s fault. However, they can complicate and add stress to your family life. Building a support network of friends and relatives helps.6
What are the treatment options for anxiety disorders?
- Psychoeducation: Psychoeducation involves learning about the causes of anxiety, how anxiety persists through both positive and negative reinforcement, and the different components of effective treatment for the anxiety. When the client is a child, this is done with both parents and children so that each person gains a better understanding of their role in the disorder and its treatment.
- Relaxation training: Relaxation training involves discussing how the body reacts to anxiety and then learning different skills to calm the body and turn on the relaxation response to decrease anxiety.
- Cognitive Reframing: In cognitive reframing, the therapist and client discuss the “worry thoughts” that the client has and then work to challenge those thoughts and come up with new, more rational thoughts instead.
- Exposure and Response Prevention (ERP): Exposure and Response Prevention is the act of facing one’s fear and not running away from it. A hierarchy of feared situations is created together with the therapist and, using the different cognitive and behavioral skills learned previously, clients begin to purposefully expose themselves to, and then remain in a feared situation, without engaging in behaviors, also called responses, that would eliminate the anxiety. The immediate goal is to remain in that situation until the level of anxiety has decreased and the long-term goal is to no longer feel the anxiety associated with the feared situation. To be effective, the exposures are first practiced in the office with the therapist and then are done at home throughout the week.
- Positive Reinforcement for exposures: Purposefully doing something that a person knows will make them highly anxious can be very difficult and, especially with children, a reward is needed to increase motivation to participate in exposures. Often, a reward chart is created whereby the child receives either points or a direct reward for each exposure that they engage in.
1 National Institute of Mental Health
2 AACAP – Anxiety Disorder in Children
3 ADAA- Living with Anxiety in Children
4 American Academy of Child & Adolescent Psychiatry
6NAMI – Anxiety Disorders in Children and Teens
7 Journal of Affective Disorders
8 Substance Abuse and Mental Health Services Administration
9 Cochrane – CBT For Anxiety in Children