Recognising Anxiety Disorders in Children

Anxiety disorders are one of the most common mental health problems identified in children. Estimates of the rates of prevalence vary greatly from 8% to 27% lifetime prevalence by age 18.

Chronic anxiety disorders are associated with increased risk of other serious mental health problems in later life. Therefore, early identification and treatment is key.

Normal fears vs Anxiety Disorder

Fears and worries are a normal part of child development and the content of fears change according to the individual’s developmental stage.

Anxiety disorders occur when the intensity of the fear or worry is so high that it starts to impact on the child’s functioning and well-being and/or when the anxiety is out of context with their developmental stage.

‘Normal’ fears in development

Main Key Symptoms

Physiological symptoms of anxiety:

• This is the innate fight or flight reaction that occurs in the body in situations of fear or danger.
• In children with anxiety disorders this response is activated in feared situations, for example being away from parent (separation anxiety), having to speak to a teacher (selective mutism).
• Symptoms include heart beating faster, sweating, shortness of breath, tension in muscles, shakiness, nausea, headaches.
• Negative thoughts or worries:
• These will often be ‘what if’ thoughts about what will happen in the future and their ability to cope with this. These can often be extreme and unrealistic (for example, the worst thing that could possibly happen).
• Thoughts can take the form of rumination about past events (such as, a child with social anxiety replaying a difficult interaction with peers).
• Thoughts may often be associated with vivid and detailed images of the worst thing happening, which can increase physiological arousal.
• The young person may spend a significant amount of time focusing on these worries and may develop worries about worrying itself.

Avoidance:

• Marked avoidance of feared situations for example, particular places, people, animals or objects.
• They may start to avoid situations that they previously used to enjoy such as birthday parties.
• This avoidance may begin in a few situations but can easily become more generalised and have a significant impact on functioning, such as school avoidance.

Safety behaviours:

• Young people with anxiety disorders may develop certain ways or routines for doing things or need to have certain items with them as they feel this will help to keep them ‘safe’. These are known as safety behaviours. For example, always having to carry water or mints with you if you are fearful of being sick and being unable to leave the house without these items.
• Reassurance seeking from caregivers can be crucial safety behaviour in children with anxiety disorders.
• Safety behaviours may give some initial relief from anxiety. However, this is often short-lived and in the long-term safety behaviours actually maintain anxiety.
• Children may show increased distress if they are unable to carry out a safety behaviour.

Prolonged anxiety can often lead to feelings of low mood and there is a high comorbidity between anxiety and depression.

Special characteristics in pre-school and school aged children

Tantrums/behavioural outbursts:

• These may be frequent, severe, and appear out of context with the situation. The child may find it difficult to name what is making them angry or distressed and may direct aggression towards primary caregivers.
• Behavioural outbursts can include crying, shouting, screaming, banging or throwing objects and in extreme cases may result in lashing out or physical aggression.
• Care should be taken to understand difficulties leading to a behavioural outburst. However, relevant age appropriate consequences/boundaries should still be enforced for problematic behaviour, as would be the case with any child.

Problems with sleep, including nightmares about feared situations:

• Worrying at bedtime can be very common for children and young people. This is often a time when there are fewer distractions for their worries. They may have fears about being left alone at night. This can impact on their ability to fall asleep and may lead to waking up in the night.

• Children may also experience nightmares or bad dreams linked to situations in the past or their worries about the future.

• Younger children may struggle to sleep on their own and may request to sleep in parent’s room or sleep with the light on.

Friendships:

• Anxiety disorders can lead to difficulties in peer relationships, with young people finding it hard to make and sustain friendships.

Separation from adults:

• Children may feel safer with adults who are perceived as being able to cope if fears come true. They may become clingy and not wanting to separate from caregivers. This, in turn, can further impact on friendships due to missing out on social situations as they do not want to be away from caregivers
• At school, children may want to spend time with teachers or lunchtime staff during break times.

Illness:

• Children and young people may often confuse the physiological symptoms of anxiety as signs of illness. This often serves to heighten anxiety, making the physical symptoms worse and reinforcing the belief that there is something wrong. For example, tummy aches and developing a fear of being sick.
• Children may also cite physical symptoms as reasons not to attend school or social situations in order to avoid or escape feared situations.

Other common symptoms associated with anxiety disorders, but also with depression, are:

• not being able to concentrate
• irritability
• lacking enjoyment
• tearfulness
• moodiness

Risk factors for developing anxiety disorders

General risk factors are:

• Genetics/temperament – Children may be naturally predisposed to have a more anxious temperament. There may be a history of anxiety disorders or mental health difficulties in the family, leading to an increased risk of the young person developing a disorder.
• Bullying and problems with peers – young people that have experienced bullying or that are isolated and have difficulties with friendships at school may be more likely to develop an anxiety disorder.
• Being exposed to adversity including parental separation, ill health or bereavement, or more traumatic experiences such as accidents or child abuse.
• School problems – falling behind or struggling with schoolwork may lead to increased anxiety.
• Direct experience with feared stimuli (traumas, embarrassing events, negative experiences with specific phobias, such as dogs or needles)
• Parents’ or caregivers’ own anxiety can impact on children by modelling anxious behaviour. For example:
  • Receiving rewards or reinforcement for fearing/avoiding certain situations or stimuli
  • Being repeatedly told that certain situations/people/stimuli are highly dangerous
  • Witnessing others talk/behave in fearful ways

*The more risk factors the more likely it is that a child could develop an anxiety disorder

Watchful waiting

A parent or teacher may not need to refer immediately to a healthcare professional if the anxiety is mild. Instead they may keep an eye on the child and offer support. If the symptoms persist or worsen then they may consider consulting with the GP and discussing whether a referral to a health care professional would be beneficial.

How to help

• talk to the child about cause of anxiety
• make links between physical sensations and anxiety – normalise these sensations
• if possible, encourage child to face feared situation in a way that feels manageable for them

When to refer

When anxiety persists, or gets worse and when it impacts on functioning for example, refusing to go to school.

Whom to refer to

The GP or the Special Educational Needs Coordinator (SENCO) or school nurse.

What are the treatments offered?

Cognitive Behavioural Therapy (CBT) is the main recommended treatment for children and young people with anxiety disorders (looking at how the child’s problems, feelings, thoughts and behaviour all fit together and influence each other)

Research suggests that the crucial component in any anxiety disorder treatment is exposure to the feared stimulus (either imaginal or in vivo)

With younger children, treatment should routinely involve the parents/caregivers in order for them to be able to support with exposure outside of sessions.

Treatment in serious cases

When the anxiety symptoms are severe and persist despite psychological forms of treatment, pharmacological treatment may be considered. It should always be administered in conjunction with continued psychological support and treatment. Medication can only be prescribed by a psychiatrist specialising in the mental health of children and young people.

Dr Tessa Crombie and Dr Jessica Richardson
South London and Maudsley NHS Foundation Trust

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