Anxiety in Children and Teenagers: Ask the Psychologist

All children experience fear and worry, and learning to deal with these fears and worries is an important part of childhood development. Anxiety in children and teenagers can appear in many forms, affecting a child’s thoughts, physical state and behaviour. If a child or teenager’s fears become intense or pervasive and cause substantial impairment at home, school and/or in social settings, an anxiety disorder may be diagnosed. Like most things, prevention is of course best, but there are numerous effective treatment options, including strategies to help a child or teenager to manage their anxiety.
To learn more about anxiety in children and teenagers and its treatment, we spoke to clinical psychologist and Inner West Mum Amber De Lucia. Amber has been providing psychological services to children, adolescents and adults for more than ten years. Amber was one of our panellists at our Perinatal Depression and Anxiety Awareness Week Morning Tea, held in November 2017. She practises locally in Annandale.

First of all, what is anxiety?
Anxiety is a normal and healthy reaction we have all experienced. All children experience anxiety as part of their development. While no two anxious children will behave exactly the same, there are some broad similarities that we can describe.

What does anxiety in children look like?
When children experience anxiety, they’re likely to notice it affecting them in three ways. First, anxiety is experienced in the mental processes or thoughts that they have. Anxious children will have thoughts that centre around some type of danger or threat, e.g., they may worry that they or a loved one will be hurt or that they’ll be laughed at. Anxiety disorders are not always easy to recognise because young people often know that their fears are groundless and will try to conceal them.
Second, anxiety is experienced physically in the body. When a child becomes anxious, his or her body becomes pumped up or aroused. This is what is commonly known as the flight-or-fight response – its purpose is to help protect the person by preparing them to combat or escape potential danger. The flight-or-fight response includes changes such as a rapid heart rate, increased breathing, feeling sweaty, needing to go to the toilet, ‘butterflies’ in the stomach, dizziness or nausea. Therefore, when worried, anxious children may complain of stomach-aches, headaches, vomiting, diarrhoea or tiredness.
Third, anxiety affects children’s behaviour. When children are anxious, they may fidget, pace, cry, cling or shake. In addition, anxiety usually involves some type of avoidance. This may be obvious avoidance (e.g., refusing to take the garbage out in the dark) or it might involve more subtle avoidance (e.g., constantly being the teacher’s helper so that they do not have to interact in group class activities). Some children may even lash out at others or objects as a way of masking and managing their anxiety.
The amount of anxiety will vary from child to child. Some children are afraid of simply one or two things, e.g., going to sleep with the light out; others may be worried about many areas of life and may seem generally nervous and sensitive.

What anxiety disorders may present in children and teenagers?
There are a number of different presentations of anxiety in children, including Specific Phobias, Separation Anxiety, Generalised Anxiety Disorder, Social Phobia, Obsessive-Compulsive Disorder, Panic Disorder and Post-Traumatic Stress Disorder. Each of these presentations has common anxiety patterns. An anxiety disorder is likely if fears become intense or pervasive and cause substantial impairment in functioning across a number of domains, such as home, school and social settings.
The onset of anxiety disorders is often during childhood or adolescence, and they can follow a chronic fluctuating course. All anxiety disorders occur in both children and adults, and have similar although not identical symptoms, with the exception of separation anxiety which is particular to children and adolescents.

Are some children more at risk of developing anxiety than others?
Genetics, learning and a child’s temperament are the main causes for anxiety. There is probably not a specific anxiety gene. However, emotional sensitivity does seem to be genetically based. This can be both positive and negative. On the positive, the child is more sensitive, caring and responsible. On the negative, the child is more vulnerable to anxiety.
Anxious people have somehow learned to expect that the world is a dangerous place (either physically, emotionally or socially). Anxious children may have learned by observing parents, relatives, other adults or children. This learning may not have been obvious. Anxious children may pick up subtle cues about the way other people react to situations, even when that other person might be trying as hard as they can to hide how worried they feel about certain things. Children may model (copy) what they see. Anxiety may also be learned through bad experiences. There is also a range of parenting behaviours that can be related to childhood anxiety. This includes parenting that is critical, lacking in warmth, over-controlling, over-protective and that focuses on danger.
A child’s own temperament or personality may also make them vulnerable to anxiety. A child who presents with low self-esteem, a sense of things being out of their control or behavioural inhibition (withdrawn or shy) may be vulnerable to anxiety.
Whatever the cause, it’s important to get on and find the skills to deal with the anxiety.

What are some possible triggers of anxiety in children and teenagers?
The type of fears experienced at each stage of development is largely a reflection of the intellectual and emotional growth of the child at that point in time.

Infants are frightened by loud noises, intense sensory stimuli and falling.
Children aged one to two years are scared when separated from their parents and strangers.
Preschool-aged children dread the dark, animals, storms, strange imaginary beasts or monsters.
From ages five to seven, children can fear natural disasters, injury, animals and other things they may have heard of in the media.
From the age of 7 or 8 years, children begin to worry about their academic and athletic performance.
Adolescents are concerned about being disliked, rejected or criticised about their performance. They may have fear about the future and anxiety about existential and broader social issues.

What are some of the ways in which anxiety can present in young (preschool) children?

Not wanting to go to sleep
Not wanting to separate from parental figures
Startling easily
Requiring excessive reassurance
Becoming teary easily
Complaining of stomach pains or headaches – feeling physically ill and possibly vomiting

What are some of the ways in which anxiety can present in primary school-aged children?

Refusal to attend school, social events or activities
Not wanting to separate from parental figures
Becoming teary
Lashing out at others
Difficulty falling asleep or needing the company and comfort of a parent when they go to bed
Worrying that harm may come to their parents, themselves or friends and family (e.g., car accident, burglary, heart attack), and having vivid fantasies about it
Bed wetting
Complaining of stomach pains or headaches – feeling physically ill and possibly vomiting

What are some of the ways in which anxiety can present in teenagers?

Excessive worry, e.g., about fitting in, increased responsibility, sitting exams, performing in plays or speeches, going to the school camp or formal, harm that could come to themselves and others, existential issues
Thinking negatively about themselves
Isolation
Difficulty getting to sleep or staying asleep
Difficulty concentrating
Moodiness and/or angry outbursts
Physical symptoms, e.g., muscle tension, tightness in chest, feeling faint, sweating, pounding heart, dizziness, nausea, butterflies in stomach, possibly vomiting/diarrhoea

What are some signs to look for?
A child or adolescent with anxiety difficulties may:

Seek reassurance often
Avoid situations they feel worried or scared about
Try to get others to do the things they are worried about
Dislike taking risks or trying new things
Have lots of fears
Get upset easily
Have lots of worries
Tell you they have physical pains

You may notice your child or adolescent:

Clings to you
Asks for help with things they can do for themselves
Doesn’t want to get ready for school
Won’t go to sleep without a parent or other adult
Asks ‘will you do it for me?’ or ‘will you tell them for me?’ often
Worries a lot about doing things right
Prefers to watch others rather than have a go
Is scared of the dark, animals, injections, being alone, germs, tests, etc
Often cries over small things
May lash out over small things
Complains about being picked on a lot
Always sees the dangerous or negative side of things
Difficulty joining in with others at school
Is fearful of test situations

Does anxiety tend to look different between boys and girls?
Anxiety difficulties represent the most common form of psychological distress in childhood and youth. Gender differences exist for the reported levels of anxiety disorders. Specifically, girls tend to report more anxiety disorders compared with boys. More girls than boys have separation anxiety, phobias, generalised anxiety disorder and panic attacks, although the precise gender ratio is unclear.

If a parent is concerned about their child’s mental health, what should they do?
Visit your GP. Seek a referral for a mental health care plan so that they and their child can see a psychologist. It would also be valuable if the parent/s were able to speak to the child’s teacher about the child’s behaviour and see if that teacher has noted similar concerns or what they have observed.
Prevention is best. Early anxiety intervention programs or one-to-one and/or family counselling have been shown to reduce the number of children and youths developing anxiety disorders.
Depending on the severity of the anxiety, it may also be important for the child or adolescent to be assessed for medications by their GP, paediatrician or child psychiatrist in conjunction with seeing a clinical psychologist.

How do you work with a child or teenager experiencing anxiety?
For preschool and primary school-aged children, I incorporate the parents into the treatment. I may do so also for adolescents (depending on their wishes and the severity of the anxiety). I offer the parents education and strategies to manage the anxiety and ways to reduce the effect that the anxiety may have on the child. I then teach the child or adolescent some Cognitive Behavioural Therapy (CBT) strategies to help them identify, label, and challenge their anxious thinking and use gradual exposure to their anxiety-provoking situations in order to help them manage and mitigate their anxiety and show them that they can cope. In addition to CBT, I teach the child or adolescent and parents calm breathing techniques, relaxation, and mindfulness skills which is useful for those who tend to worry a lot or ruminate. It is like giving the children and adolescents a ‘tool kit’ full of different strategies that they can use to reduce the effects of their anxiety.
I like to work not just with the children or adolescents but also (if possible) with their parents, their GP, paediatrician or psychiatrist and hopefully their school too, so that the child feels supported and that everyone is on the same page.
Generally I hope to see dramatic improvements in the child’s or adolescent’s presentation within ten sessions, although this does depend on the type of anxiety and its severity.

How can families support their anxious child?
Parents can assist their child in the development of coping behaviours though specific parenting strategies that can be explained by a psychologist. Such strategies would include attending to positive behaviour and ignoring undesirable behaviour, modelling appropriate behaviour and learning to talk more about both positive and negative emotions we experience in everyday life.
Children like to feel supported and understood. It’s helpful for parents to provide specific feedback for what their child has done well or attempted that may have been anxiety provoking or scary. Do notice small achievements and praise your child.
Parents are also encouraged to foster independence so that their child will learn that they have the ability to do things on their own. This also offers the chance to build up a child’s self-esteem, resilience and confidence.
Parents should avoid providing excessive reassurance. By continually reassuring your child, you are giving them attention for their fears which can again serve to maintain the behaviour. Help your child take charge.
Lastly, it is important for parents to keep their own emotions in check!

What can families do to promote good mental health for the whole family?
It is imperative for parents who want to promote good mental health for the whole family to make sure that their children are getting enough good-quality sleep, that they are eating a varied and healthy diet, and that the children get plenty of outdoor exercise. Research states that exercise promotes wellbeing.
It is recommended that parents try to incorporate consistency in their parenting and offer routine as best they can. Children thrive when parenting is predictable and consistent.
Family time is vital too, even if it is just for half an hour every day or so. Children also benefit from one-on-one time with parents. This quality time may even give them an opportunity to talk about any thoughts or feelings that they may be struggling with.

Are there any resources on childhood anxiety that you can recommend?

Macquarie University runs Cool Kids programs for children of various ages from preschool and up.
Helping your Anxious Child: A Step-by-Step Guide for Parents by Rapee, Wignall, Spence, Cobham and Lyneham
The Centre for Clinical Interventions is a great site for parents and adolescents who wish to learn more about anxiety, self-esteem, anger or assertiveness. The site offers online or printable modules for the individual to work through at their pace to overcome their concerns.
AnxietyBC provides printable anxiety resources for parents, children and adolescents that experience anxiety.
The BRAVE Program is a free online program for the prevention and treatment of anxiety in Australian children and young people aged 8–17 and their parents.
Headspace
Kids Matter
Raising Children