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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 or education.

Selective mutism

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 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 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 anxiety disorder.

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, 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.

Drug 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 a nd 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 greatest.

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.

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.

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 classroom bully.

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, increasing
self-confidence, and trying out new kinds of behavior.

Resources

American Academy of Child and Adolescent Psychiatry
800-333-7636 (toll free)
www.aacap.org

Anxiety Disorders
Association of America
240-485-1001
www.adaa.org

Federation of Families for Children’s Mental Health
703-684-7710
www.ffcmh.org

Other therapies

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.

References

Goldsmith HH, et al. “Linking Temperamental Fearfulness and Anxiety Symptoms: A Behavior-Genetic Perspective,” Biological Psychiatry (Dec. 15, 2000): Vol. 48, No. 12, pp. 1199–1209.

Northey WF, Jr, et al. “Childhood Behavioral and Emotional Disorders,” Journal of Marital and Family Therapy (Oct. 2003): Vol. 29, No. 4, pp. 523–45.

Vasey MW, et al., eds. The Developmental Psychopathology of Anxiety. Oxford University Press, 2000.

Velting ON, et al. “Update on and Advances in Assessment and Cognitive-Behavioral Treatment of Anxiety Disorders in Children and Adolescents,” Professional Psychology: Research and Practice (Feb. 2004): Vol. 35, No. 1, pp. 42–54.

Williams TP, et al. “Pharmacologic Management of Anxiety Disorders in Children and Adolescents,” Current Opinion in Pediatrics (Oct. 2003): Vol. 15, No. 5, pp. 483–90.