Anxiety is a condition of persistent and uncontrollable nervousness, stress, and worry that is triggered by anticipation of future events, memories of past events, or ruminations over day-to-day events, both trivial and major, with disproportionate fears of catastrophic consequences.
Stimulated by real or imagined dangers, anxiety affects people of all ages and social backgrounds. When it occurs in unrealistic situations or with unusual intensity, it can disrupt everyday life. Some researchers believe anxiety is synonymous with fear , occurring in varying degrees and in situations in which people feel threatened by some danger. Others describe anxiety as an unpleasant emotion caused by unidentifiable dangers or dangers that, in reality, pose no threat. Unlike fear, which is caused by realistic, known dangers, anxiety can be more difficult to identify and alleviate.
A small amount of anxiety is normal in the developing child, especially among adolescents and teens. Anxiety is often a realistic response to new roles and responsibilities, as well as to sexual and identity development. When symptoms become extreme, disabling, and/or when children or adolescents experience several symptoms over a period of a month or more, these symptoms may be a sign of an anxiety disorder, and professional intervention may be necessary. Two common forms of childhood anxiety are general anxiety disorder (GAD) and separation anxiety disorder (SAD), although many physicians and psychologists also include panic disorder and obsessive-compulsive disorder , which tend to occur more frequently in adults. Anxiety that is the result of experiencing a violent event, disaster, or physical abuse is identified as post-traumatic stress disorder (PTSD). Most adult anxiety disorders begin in adolescence or young adulthood and are more common among women than men.
According to the U.S. surgeon general, 13 percent, or over 6 million children, suffer from anxiety, making it the most common emotional problem in children. Among adolescents, more girls than boys are affected. About half of the children and adolescents with anxiety disorders also have a second anxiety disorder or other mental or behavioral disorder, such as depression.
Causes and symptoms
A child's genetics, biochemistry, environment, history, and psychological profile all seem to contribute to the development of anxiety disorders. Most children with these disorders seem to have a biological vulnerability to stress, making them more susceptible to environmental stimuli than the rest of the population.
Emotional and behavioral symptoms of anxiety disorders include tension; self-consciousness; new or recurring fears (such as fear of the dark, fear of being alone, or fear of strangers); self-doubt and questioning; crying and whining; worries; constant need for reassurance (clinging to parent and unwilling to let the parent out of sight); distractibility; decreased appetite or other changes in eating habits; inability to control emotions; feeling as if one is about to have a heart attack, die, or go insane; nightmares ; irritability, stubbornness, and anger; regression to behaviors that are typical of an earlier developmental stage; and unwillingness to participate in family and school activities. Physical symptoms include rapid heartbeat; sweating; trembling; muscle aches (from tension); dry mouth; headache ; stomach distress; diarrhea; constipation ; frequent urination; new or recurrent bedwetting; stuttering ; hot flashes or chills; throat constriction (lump in the throat); sleep disturbances; and fatigue. Many of these anxiety symptoms are very similar to those of depression, and as many as 50 percent of children with anxiety also suffer from depression. Generally, physiological hyperarousal (excitedness, shortness of breath, the fight or flight response) characterizes anxiety disorders, whereas underarousal (lack of pleasure and feelings of guilt) characterizes depression. Other signs of anxiety problems are poor school performance, loss of interest in previously enjoyed activities, obsession about appearance or weight, social phobias (e.g., fear of walking into a room full of people), and the persistence of imaginary fears after ages six to eight. Children with anxiety disorders are often perfectionists and are concerned about "getting everything right," but rarely feel that their work is satisfactory.
Shyness does not necessarily indicate a disorder, unless it interferes with normal activities and occurs with other symptoms. A small proportion of children do experience social anxiety, incapacitating shyness that persists for months or more, which should be treated. Similarly, performance anxiety experienced before athletic, academic, or theatrical events does not indicate a disorder, unless it significantly interferes with the activity.
Separation anxiety disorder (SAD) is the most common anxiety disorder among children, affecting 2 to 3 percent of school-aged children. SAD involves extreme and disproportionate distress over day-to-day separation from parents or home and unrealistic fears of harm to self or loved ones. Approximately 75 to 85 percent of children who refuse to go to school have separation anxiety. Normal separation fears are outgrown by children by the ages of five or six, but SAD usually starts between the ages of seven and 11.
When to call the doctor
A qualified mental health professional should be consulted if a child's anxiety begins to affect his or her ability to perform the three main responsibilities of childhood: to learn, to make friends, and to have fun. Often fears and anxieties come and go with time and age. However, in some children, anxiety becomes severe, excessive, unreasonable, and long-lasting (usually considered as long-lasting if the child experiences the elevated level of anxiety for a month or more), interferes with the child's ability to function normally, and causes the child to be distraught and easily upset, thus necessitating professional intervention.
Diagnosing children with an anxiety disorder can be very difficult, since anxiety often results in disruptive behaviors that overlap with other disorders such as attention-deficit hyperactivity. Children showing signs of an anxiety disorder should first get a physical exam to rule out any possible illness or physical problem. Diagnosis of normal versus abnormal anxiety depends largely upon the degree of distress and its effect on a child's functioning. The degree of abnormality must be gauged within the context of the child's age and developmental level. The specific anxiety disorder is diagnosed by the pattern and intensity of symptoms using various psychological diagnostic tools.
Depending on the severity of the problem, treatments for anxiety include school counseling, family therapy , and cognitive-behavioral or dynamic psychotherapy, sometimes combined with antianxiety drugs. Therapies generally aim for support by providing a positive, entirely accepting, pressure-free environment in which to explore problems; by providing insight through discovering and working with the child or adolescent's underlying thoughts and beliefs; and by exposure through gradually reintroducing the anxiety-producing thoughts, people, situations, or events in a manner so as to confront them calmly. Relaxation techniques, including meditation, may be employed in order to control the symptoms of physiological arousal and provide a tool the child can use to control his or her response.
Creative visualization, sometimes called rehearsal imagery by actors and athletes, may also be used. In this technique, the child writes down (or draws pictures of) each detail of the anxiety-producing event or situation and imagines his or her movements in performing the activity. The child also learns to perform these techniques in new, unanticipated situations.
In severe cases of diagnosed anxiety disorders, anti-anxiety and/or antidepressant drugs may be prescribed in order to enable therapy and normal daily activities to continue. Previously, narcotics and other sedatives, drugs that are highly addictive and interfere with cognitive capacity, were prescribed. With pharmacological advances and the development of synthetic drugs, which act in specific ways on brain chemicals, a more refined set of antianxiety drugs became available. Studies have found that generalized anxiety responds well to these drugs (benxodiazepines are the most common), which serve to quell the physiological symptoms of anxiety. Other forms of anxiety such as panic attacks, in which the symptoms occur in isolated episodes and are predominantly physical (and the object of fear is vague, fantastic, or unknown), respond best to the antidepressant drugs. Childhood separation anxiety is thought to be included in this category. Psychoactive drugs should only be considered as a last treatment alternative, and extra caution should be used when they are prescribed for children.
Studies consistently report that anxiety disorders can be debilitating and impinge seriously on a person's quality of life. Despite their common occurrence, little is underbstood about the natural course of anxiety disorder. Adults experiencing anxiety disorders often report that they have felt anxious all of their lives, with one half of adults with general anxiety disorder reporting that the onset of the condition occurred during childhood or adolescence. Anxiety disorders can be chronic, and the severity of symptoms can fluctuate significantly, with symptoms being more severe when stressors are present. Without treatment, extended periods of remission are not likely.
Parents can help their child respond to stress by taking the following steps:
- providing a safe, secure, familiar, and consistent home life
- being selective in the types of television programs that children watch (including news shows), which can produce fears and anxieties
- spending calm and relaxed time with their child
- encouraging questions and expressions of fears, worries, or concerns
- listening to the child with encouragement and affection and without being critical
- rewarding (and not punishing) the child for effort rather than success
- providing the child with opportunities to make choices; with more control over situations, the child has a better response to stress
- involving the child in activities in which he or she can succeed and limiting events and situations that are stressful for the child
- developing an awareness of the situations and activities that are stressful for the child and recognizing signs of stress in the child
- keeping the child informed of necessary and anticipated changes (e.g., moving, change of school) that may cause the child to be stressed
- seeking professional help or advice when the symptoms of stress do not decrease or disappear
The child should also be encouraged to use various techniques to reduce stress, including the following strategies:
- talking about problems to parents or others whom the child trusts
- relaxing by listening to music, taking a warm bath, meditating, practicing breathing exercises, or participating in a favorite hobby or activity
- respecting themselves and others
- avoiding the use of drugs and alcohol
- feeling free to ask for help if he or she is having difficulties with stress management
Psychological —Pertaining to the mind, its mental processes, and its emotional makeup.
Psychotherapy —Psychological counseling that seeks to determine the underlying causes of a patient's depression. The form of this counseling may be cognitive/behavioral, interpersonal, or psychodynamic.
Shyness —The feeling of insecurity when among people, talking with people, or asking somebody a favor.
Stress —A physical and psychological response that results from being exposed to a demand or pressure.
Parenting an anxious child is difficult and can create stress within the entire family. Parents need to help the child learn and apply techniques to manage his or her anxiety. The use of support groups and professional assistance is recommended.
Parents of children with anxiety disorders may exhibit anxiety symptoms themselves and should also seek professional assistance.
Chansky, Tamar E. Freeing Your Child from Anxiety: Powerful, Practical Solutions to Overcome Your Child's Fears, Worries, and Phobias. New York: Broadway Books, 2004.
Dacey, John S., and Lisa B. Fiore. Your Anxious Child: How Parents and Teachers Can Relieve Anxiety in Children. New York: John Wiley & Sons, 2001.
Fox, Paul. The Worried Child: Recognizing Anxiety in Children and Helping Them Heal. Alameda, CA: Hunter House Publishers, 2004.
Rapee, Ron, Sue Spence, and Ann Wignall. Helping Your Anxious Child. Oakland, CA: New Harbinger Publications, 2000.
Spencer, Elizabeth, Robert L. Dupont, and Caroline M. Dupont. The Anxiety Cure for Kids: A Guide for Parents. New York: John Wiley & Sons Inc., 2003.
Wagner, Aureen Pinto Worried No More: Help and Hope for Anxious Children. Rochester, NY: Lighthouse Press Inc., 2002.
Anxiety Disorders Association of America. 8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910. Web site: http://www.adaa.org.
National Institute of Mental Health (NIMH), Office of Communications. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Web site: http://www.nimh.nih.gov/.
The Child Anxiety Network. http://www.childanxiety.net/ (accessed October 11, 2004).