Children's Fears and Anxieties
A child's world is full of dangers, real and imaginary, that many
adults forget they ever experienced. Most childhood fears are normal,
temporary, and eventually outgrown, but studies still show that anxiety
disorders are among the most common childhood psychiatric conditions.
In a high proportion of cases, it turns out that the symptoms of an
adult anxiety disorder first appeared in childhood, so treatment of
abnormal childhood anxiety is not only important for its own sake but
may help prevent adult disorders.
Children's minds and emotions are constantly changing and developing,
and they do not all develop at the same rate, so it is not always easy
to distinguish normal fears from those that require special attention.
Newborns typically fear falling and loud noises. Fear of strangers begins
as early as six months and persists until the age of two or three. Preschool
children usually fear being separated from their parents; they may also
be afraid of large animals, dark places, masks, and supernatural creatures.
Older children may worry about death in the family, failure in school,
and events in the news such as wars, terrorist attacks, and kidnappings.
Adolescents have sexual and social anxieties and concerns about their
own and the world's future. These anxieties become a problem only if
they persist and cause serious distress, destroy family harmony, or interfere
with a child's development or education.
Generalized anxiety disorder. Formerly called
overanxious disorder of childhood, these days generalized anxiety in
children is recognized as the same disorder of uncontrolled worry that
occurs in adults. 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, storms, burglary, hurting themselves while playing,
or the amount of gas in the tank. They often feel restless and tense
and complain of headaches, stomachaches, and other physical symptoms.
Social anxiety disorder (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 it is no longer normal. They may be
afraid of reading aloud, starting a conversation, or attending a birthday
Obsessive-compulsive disorder. This disorder
consists of intrusive unwanted thoughts (obsessions) which cause mounting
tension that is sometimes relieved by repetitive actions (compulsions).
It is usually classified as an anxiety disorder because the obsessions
often involve a fear, such as contracting a disease or the death of a
parent. Adults with this disorder know that obsessions are irrational,
but young children may not, so the symptoms overlap with generalized
Panic disorder. In a panic attack, a sudden
feeling of overwhelming dread or impending doom is accompanied by intense
physical sensations - sweating, heart palpitations, chest pain, trembling,
breathlessness, dizziness and nausea. Repeated panic attacks and fear
of them can lead to constant worry about future attacks and their implications,
including thoughts of losing control, "going crazy," or dying. A common
result of this anticipatory anxiety is agoraphobia - avoiding an increasing
number of places and situations in which a panic attack might occur.
Separation anxiety. Fear of being away from home or
one's parents, normal in the very young, is called separation anxiety
disorder when it persists in older children. It may develop spontaneously
or under stress, such as a death in the family, and can also result from
social phobia or panic attacks. Children with separation anxiety may
be afraid to go to a camp, sleep at a friend's house, or even attend
a birthday party with out their parents. They may follow their parents
around the house and even try to climb into bed with them at night. When
threatened with separation, they develop physical symptoms. Often they
fear that during a separation either they or their parents will come
to harm; in older children, this fear may involve specific fantasies
of accidents, illness, and crime.
Simple phobias. Fear of certain specific objects
or situations is common, normal, and usually temporary in young children.
These fears come and go rapidly up to the age of 10 and require treatment
only if they are excessive and unreasonable, persist for a long time,
or occur at an inappropriate age. Some common objects of phobias are
thunderstorms, water, elevators, choking, blood, large animals, and insects.
Post-traumatic stress disorder. This condition
is the result of experi encing or witnessing a frightening or horrifying
event outside the range of everyday experience, such as a major accident,
natural disaster, or physical or sexual assault. Severe child abuse is
a common cause. There are three kinds of symptoms. One is re-experiencing
- intrusive memories, nightmares, a tendency to reenact the traumatic
event in compulsive play, and anxiety when exposed to anything that recalls
some aspect of the experience. The second group of symptoms results from
a desperate need to avoid thoughts and feelings, people, and places associated
with the trauma. This avoidance may come to include more and more of
life, eventually producing numb detachment from one's own feelings and
estrangement from others. The third set of symptoms is heightened arousal
- irritability, angry outbursts, jumpiness, insomnia, and poor concentration.
Children's anxiety disorders have both genetic and environmental roots.
Anxiety disorders run in families, and twin and adoption studies show
that heredity is a factor. Some children are "behaviorally inhibited" -
as early as the age of four months, they tend to cry and shrink back
in the presence of strangers, while their hearts begin to beat faster.
This temperamental shyness is associated with later development of anxiety
The early environment can also contribute to anxiety disorders. Child
abuse as a source of post-traumatic stress disorder is the clearest example,
but less severe stress is also significant. Children must be close to
their mothers or other caregivers for physical and emotional sustenance;
their fear of separation is rooted in the emotional attachment needed
for survival. Children who are insecurely attached are more likely to
develop anxiety disorders, and anxious or depressed parents may make
their children feel insecure.
Diagnosing these disorders in children can be difficult because fear
and anxiety are also symptoms of many other condi tions, including depression,
bipolar disorder, and attention deficit disorder. Parents are not always
sensitive to children's signs of anxiety, and teachers often give helpful
perspective because they have experience with many children for comparison.
Before diagnosing an anxiety disorder, it is important to find out first
whether the child has good reasons to be afraid, such as abuse by a parent
or a classroom bully.
Cognitive behavioral therapy is the best confirmed treatment for anxiety
disorders in children and adolescents. Its effectiveness has been shown
in studies lasting as long as four years. A common method is graduated
exposure to frightening objects or situations, with rewards for success
in facing fears. Young children with phobias, for example, can be placed
near the feared object and allowed to do something reassuring and enjoyable
like eating or playing with a favorite toy. Older children can be shown
how to use deep breathing or muscle relaxation, or be taught to talk
themselves out of self-defeating and fear-provoking thoughts. Another
technique is modeling - asking the anxious child to emulate the therapist
or another child who shows no fear.
Cognitive and behavioral methods often work best in groups, which provide
shy and fearful children with opportunities for making friends, increasing
self-confidence, and trying out new kinds of behavior.
Play therapy using toys, puppets, and drawings may help young children
recognize and express their fears. Psychodynamic therapy may help older
children understand some of the sources of their anxiety. Supportive
counseling - sympathetic listening and reassurance - should accompany
any form of treatment for anxiety in children.
Parents and other family members can help in many ways. They can be
educated about how to manage a child's anxiety. They can facilitate cognitive
behavioral therapy by providing models of self-confidence and problem-solving
and rewards for overcoming fears. Sometimes a family problem is the source
of the child's anxiety, or an anxious child thinks he or she is the cause
of any trouble in the family. In that case, joint family therapy in which
all members participate may be a good idea.
Long-term research on the treatment of these disorders is rare, and we
know little about what works specifically for children, as opposed to adults.
The influence of family and marital problems is substantial but difficult
to quantify. There is little good evidence about the risks and benefits
of drugs. Fortunately, children usually grow out of the fears or can be
successfully treated. Shy children do not necessarily become adults with
anxiety disorders. Even the effects of traumatic stress may fade over the
years. This is one field in which optimism is a plausible attitude for
mental health professionals.
January 2005 Update
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