Children’s fears and anxieties
Children’s fears and anxieties
(This article was first printed in the December,
2004 issue of the Harvard Mental Health Letter. For
more information or to order, please go to http://health.harvard.edu/mental.)
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
This term describes children who refuse
to talk in certain situations where talking
is expected, such as a classroom or a doctor’s
office. Instead they may communicate by
gestures, nodding, or pulling and pushing.
Some children will talk only to their families
and close friends. Selective mutism is
classified as a distinct disorder in the
American Psychiatric Association’s
diagnostic manual, but many experts now
regard it as a rare symptom of social anxiety
disorder. It was formerly called elective
mutism, and the name change reflects a
recognition that these children are not
stubborn, but scared.
With some adjustments for age, children’s
anxiety disorders closely resemble their
adult counterparts. And, like anxiety-plagued
adults, children with one of the following
disorders often have others as well.
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
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 party.
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 without 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,
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.
treatment for anxious children
The role of drugs in the treatment of
children’s anxiety disorders is in
question. Because solid evidence of effectiveness
is lacking, the FDA has not approved any
drug for this purpose, with the exception
of selective serotonin re-uptake inhibitors
(SSRIs) for obsessive-compulsive disorder.
But some of these antidepressants have
been found effective and are approved for
the treatment of adult anxiety disorders.
Because these disorders seem so similar
in children and adults, many pediatricians
and psychiatrists also prescribe SSRIs
for anxious children.
Doctors will likely become more cautious
about these prescriptions in the future.
Several studies have found that SSRIs raise
the risk of suicidal thinking (although
not completed suicides) in depressed children
and adolescents, and an FDA advisory panel
has recommended prominent “black
box” warnings on the labels for the
drugs. (Only one drug, fluoxetine [Prozac],
is officially approved for the treatment
of childhood depression, but other SSRIs
have also been used.) Physicians will continue
to weigh carefully the risks and benefits
of prescribing antidepressants for anxious
children. When they do prescribe drugs,
they will be watching closely for signs
of suicidal thoughts or behavior, especially
in the first few weeks, when the risk is
Post-traumatic stress disorder. This
condition is the result of experiencing 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.
Causes of childhood anxiety
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 disorders. In a recent
study, adults who had been classified as behaviorally
inhibited at age two showed high activity in
the amygdala, a center of fear conditioning,
when they looked at the faces of strangers. Fearfulness
in monkeys and in humans is associated with irregularities
in the activity of the neurotransmitters dopamine
and serotonin, and with high levels of corticotropin
releasing hormone, a trigger of the stress response.
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.
According to behavioral learning theory, fears
arise through classical conditioning. An object,
person, or situation becomes frightening by association
with something that is inherently frightening
(such as a loud noise), and this conditioned
learning may then be transferred to other objects.
Operant conditioning, or learning by reward and
punishment, also helps to maintain anxiety disorders;
for example, parents might reward a child with
their attention mainly when she shows anxiety.
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.
Treating children’s anxiety
Diagnosing these disorders in children can be
difficult because fear and anxiety are also symptoms
of many other conditions, 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
The standard treatments resemble those for adult
anxiety disorders, although children’s
developmental needs must be accommodated and
the family should usually be involved.
Cognitive and behavioral treatment
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,
self-confidence, and trying out new kinds of
American Academy of Child and Adolescent
800-333-7636 (toll free)
Association of America
Federation of Families for Children’s
M ental Health
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.
Involving the family
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.
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