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Coping with Anxiety and Phobi... Health Article

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Anxiety in children and teenagers

Childhood is, by its very nature, marked by certain fears — of monsters, of the dark, of being left with a new babysitter, of starting school, and so on. As children get older they outgrow these fears and may develop new ones, like the fear of failing a test or of being embarrassed when called on in class. But apart from these normal developmental fears, many children also suffer from anxiety disorders — up to 13%, according to the Surgeon General's report on mental health.

The prevalence of anxiety disorders in children is greater than was previously thought. Until the 1994 publication of the Diagnostic and Statistical Manual–IV (DSM-IV), the standard diagnostic manual of psychiatric conditions, children with persistent and significant fear of social situations were said to have either avoidant disorder of childhood or adolescence, which is a kind of personality disorder, or overanxious disorder of childhood. But the DSM-IV eliminated these two categories when it became clear that the symptoms of avoidant disorder of childhood or adolescence were actually those of social phobia, and the symptoms of overanxious disorder were the same as those of generalized anxiety disorder.

Children affected by anxiety disorder

According to the Surgeon General's report on mental health, 13% of children suffer from an anxiety disorder.

Full range of anxiety disorders

Some anxiety disorders start in childhood or affect only children. The prime example is separation anxiety, an extreme difficulty being away from home or loved ones. It's the most common anxiety disorder in preadolescent and younger children, affecting 4%–5% of them.

In addition, all the anxiety disorders that affect adults can also affect children. Some disorders begin in childhood. For example, obsessive-compulsive disorder usually starts around ages 6–15 in boys, although for females, it usually begins in early adulthood. Social phobia also tends to start early.

Children often differ from adults in the particular focus of their anxieties. Adults with generalized anxiety disorder, for example, usually worry about a variety of ordinary things, such as household finances, family members' health, and responsibilities at home or at work. Children with the disorder worry mainly about their performance in school or sports, even when their competence isn't being evaluated.

Anxiety disorders that most commonly appear in children include these:

Separation anxiety disorder. Many infants and toddlers cry when their parents leave for work or go out for the evening, but children with separation anxiety disorder fear that their parents will be harmed if they go out. They also have nightmares about separation and become extremely agitated at the thought of being away from home (see "Symptoms of separation anxiety disorder"). Although children may eventually "outgrow" separation anxiety disorder, they have a greater risk of developing a significant anxiety disorder as teenagers and adults.

Symptoms of separation anxiety disorder

Many children become anxious when they must be away from home or from their parents, but those with separation anxiety do so regularly and excessively. The worry lasts for at least four weeks and causes significant distress or even impairs the child's ability to function normally. Separation anxiety starts before age 18. It consists of at least three of the following symptoms:

excessive distress when the child is away from home, separated from his or her parents or other significant loved ones, or anticipating such a separation
extreme worry about losing loved ones or having them come to harm
persistent, excessive worry that a terrible event will lead to a separation from loved ones, for example, getting lost or being kidnapped
reluctance or refusal to go to school or elsewhere because of fear of separation
excessive fear or reluctance to be alone, without loved ones at home, or without important adults in public places
reluctance or refusal to go to sleep without being near a loved one or to sleep away from home (such as at summer camp or a friend's house)
recurring nightmares about separation
complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation occurs or is anticipated

Generalized anxiety disorder. Children with this disorder are self-conscious, self-doubting, and excessively concerned about meeting other people's expectations. They need constant reassurance and approval from adults. They may worry about school grades or refuse to go to school at all (see "School refusal"). Other sources of anxiety may revolve around storms, burglary, hurting themselves while playing, or the amount of gasoline in the car's gas tank. They often feel restless and tense and complain of headaches, stomachaches, and other physical symptoms.

School refusal

Reluctance to go to school is one of the most troubling symptoms of generalized anxiety, social anxiety, or separation anxiety in children. They may plead to be excused from school, complain of illness, and run home if forced to go. The problem may be a fear of leaving home or a fear of school itself — a place where they must submit to impersonal authority and rules made outside the family, often for the first time. They are compared with strangers and sometimes shamed by critical teachers or frightened by bullies. The problem may develop after a brief illness, an accident, or the death of a relative; sometimes a new school year with new teachers is the trigger.

School refusal is an urgent problem that must be confronted not only with treatment of the underlying anxiety disorder, but also with more immediate action. Depending on where the problem seems to originate, a therapist may want to meet with school staff, parents, or both. Sometimes a therapist or parent has to go to school with the child on the first day. Some children must be monitored for relapses that occur after a weekend or vacation.

Social phobia. Children with this disorder are painfully shy and fear exposure to anything unfamiliar. They cling to their parents and may be afraid of other children as well as adult strangers at an age when such fear is no longer normal. They may be afraid of reading aloud, starting a conversation, or attending a birthday party. Some children with social phobia may refuse to talk in situations where talking is expected, a symptom known as "selective mutism." Examples include a classroom or a doctor's office.

Obsessive-compulsive disorder. As with adults, childhood obsessive-compulsive disorder consists of intrusive unwanted thoughts (obsessions) that cause mounting tension that is sometimes relieved by repetitive actions (compulsions). The obsessions often involve a fear, such as contracting a disease or the death of a parent. While adults with the disorder are usually aware that their symptoms are irrational and strange, even though they can't stop them, children lack this perspective and don't question the validity of their fears or the compulsive rituals they follow to cope with these thoughts.

Panic disorder/panic attacks. As with adults, children may experience a sudden feeling of overwhelming dread or impending doom accompanied by intense physical sensations, such as sweating, heart palpitations, chest pain, trembling, breathlessness, dizziness, and nausea.

Simple phobia. Fear of certain specific objects or situations is common, normal, and usually temporary in young children. Treatment is warranted only if fears are excessive and unreasonable, persist for a long time, or occur at an inappropriate age. Some common objects of childhood phobias are thunderstorms, water, elevators, choking, blood, large animals, and insects.

Post-traumatic stress disorder. In children, post-traumatic stress disorder commonly stems from severe child abuse; it may also be triggered by a major accident or a natural disaster. Symptoms may include intrusive memories, nightmares, a tendency to reenact the traumatic event in compulsive play, irritability, angry outbursts, jumpiness, insomnia, and poor concentration.