Anxiety or fear is a basic emotion and a normal experience in life. While anxiety involves worrying about future events, fear is an immediate reaction towards current danger. One may feel anxious when giving a speech, taking an examination, or experiencing a sudden change. Anxiety is a normal reaction to stress and danger. However, when the anxiety or fear becomes excessive and unreasonable, causing subjective distress or objective impairments in daily functioning, it becomes a disorder.
Many children have transient worries during certain developmental stages. Infants show fear of loud noises and strangers. Toddlers and preschoolers are afraid of thunder, animals, insects, darkness, monsters, and separation. School-age children may worry about going to school and taking examinations, and their relationship with peers. Anxiety disorders are different from the developmentally normal fear or anxiety in that they are excessive, persistent, or extending beyond the developmentally appropriate periods. While normal anxiety alerts an individual to cope with the danger, pathological anxiety often occurs in the absence of an actual threat.
Anxiety disorders commonly seen in children:
Social Anxiety Disorder (Social Phobia):
Separation Anxiety Disorder:
Generalized Anxiety Disorder:
Anxiety disorders often cause significant interference in multiple domains of life. It affects children’s social relationships, daily routines, or academic functioning. Children suffering from anxiety disorders often have negative thinking styles and maladaptive behavioural patterns. They often overestimate the danger of objects or situations, and often react by avoidance coping. Some children may also present with temper problems. Physiological illnesses and psychosomatic complaints, such as headache, stomachache, sweating, and muscle pain are also frequently reported.
The irrational fears and avoidance behaviours often hinder children’s participation in social activities and friendship development, as well as affect their performance and involvement in school work, everyday contact with people, and daily functioning. Untreated anxiety disorders may persist into adulthood and lead to depression and substance abuse.
Adults with anxiety disorders may recognize that their fears or anxiety are excessive or unreasonable. However, such awareness may be absent in children. It may be difficult for children to explain their fears and worries verbally, particularly for younger ones. It is therefore important for parents to pay attention to signs and symptoms of anxiety. Changes in behaviour or increased tantrums are common red flags of stress and anxiety in children. Some children may also develop nervous habits, such as nail-biting, hair-pulling, or chewing on pencils. Other common signs include changes in sleep pattern or appetite, as well as somatic complaints.
Anxiety disorders are the most common form of psychiatric disorders in children, with a prevalence rate of approximately 7% overseas. In general, more girls are affected than boys. The local prevalence estimates and gender differences are largely compatible with those reported in Western countries.
The exact causes and mechanisms of anxiety disorders are not fully known. However, research suggests that biological, psychological, and environmental factors interact with each other in the development of anxiety disorders.
Anxiety disorders often run in families and genetic factors are believed to predispose some individuals to anxiety disorders. Imaging studies also indicate that people with anxiety disorders have atypical activities in specific areas of the brain, including the prefrontal cortex, limbic system, amygdala and thalamus.
Besides, abnormal levels of neurotransmitters (chemicals in the brain for transmitting information between nerve cells) also play a part in the cause of anxiety.
Psychological causes of fears and worries in children with anxiety disorders may include negative thinking, reluctance to making attempt, perfectionistic thinking, and fear of making mistakes. These thinking styles often result in apprehensive expectations when facing stress and difficulties.
External sources of anxiety and stress in children may include academic difficulties, conflicts with friends, family problems, etc. Parents’ attitudes and reactions may also affect the development and maintenance of anxiety problems in children. Parenting style, such as over-protectiveness, may exacerbate the problem. Sometimes parents may reinforce children’s anxious or avoidance behaviour unintentionally, such as giving excessive soothing. Children may also “learn” the anxious behaviour from parents through observation and modeling.
Comorbidities of multiple anxiety disorders or with other emotional and behavioural problems are commonly found among children with anxiety disorders. Compared to the normally developing peers, children with anxiety disorders are more likely to have comorbid depressive mood and attention and hyperactivity / impulsivity problems.
Choices of treatment depends on the type and severity of the anxiety problem. While psychological intervention is commonly used in the treatment of childhood anxiety, children who are older and with more severe symptoms may receive pharmacological treatment when psychotherapy cannot address symptoms adequately.
Individual or group cognitive behavioural therapy (CBT) is recommended as the first-line treatment. It addresses the interplay of thought, behaviour, and physiological responses that contributes to anxiety. Parents or carers are often involved to ensure the effective delivery of the treatment, especially in young children.
Children younger than seven typically do not yet have the cognitive ability to understand and apply the strategies on their own. CBT adapted for parents of children with anxiety disorder, family-based CBT with heavy parental involvement, and adapted Parent-Child Interaction Therapy (PCIT) have been found to be helpful. Parents play an important role in the treatment process,
Selective serotonin reuptake inhibitors (SSRI), selective noradrenaline reuptake inhibitors (SNRI) are commonly used to help relieve anxiety symptoms. On the other hand, benzodiazephine may be used to reduce the physiological symptoms (such as muscle tension). Some medications are fast-acting while others may take a few weeks to reach their full effects. The rationale for selecting a particular type of medication, the possible side effects, and the availability of other treatment options should be discussed with the parents. It is important to note that changes in dosage or type of medication, or discontinuation of medication should be done only under doctor’s supervision.
Current research evidence is still inconclusive. Yet, if children with excessive amount of anxiety are left without treatment, the condition is likely to persist or exacerbate. In contrast, the prognosis is generally good if timely and appropriate treatment is given.
Fighting the Anxiety Monster