Anxiety Disorders in Children

The symptoms of anxiety in children are very similar to those found in adults. The following common diagnoses can be made in children. According to the DSM-IV the various subtypes of anxiety share many similar features and differ primarily in the specific focus of the fear. Children experience anxiety in response to a perceived threat in their environment, and while the types of stimuli perceived as threatening vary from one anxiety disorder to the next the anxiety response tends to be similar. When they are anxious, these children focus excessively on the negative outcome that may occur, experience many somatic changes, and go to a great length to avoid threatening situations.

Common Anxiety Diagnoses:

• Separation Anxiety Disorder
• Generalized Anxiety Disorder
• Social Phobia
• Specific Phobia
• Obsessive-Compulsive Disorder
• Post Traumatic stress Disorder and related conditions

Separation Anxiety Disorder

Children with separation anxiety disorder have excessive anxiety about separation from caregivers to whom they are emotionally attached. They worry that some hard or tragedy will occur to those they love, leading to loss or long-term separation. For example, one young boy with separation anxiety disorder believed that if his mother went out to see a movie with his father, she would be killed, either in the car while travelling there or while watching the movie. Separation fears are most commonly centred on the primary caregiver – usually the moth – but fathers, grandparents, and other family members can sometimes be included.

Children with separation anxiety experience a great deal of distress on separation or even the threat of separation. They cry, plead desperately with the caregiver, and may throw tantrums. They are often clingy, and like to stay in close proximity to the caregiver. Somatic complaints such as headaches, nausea, and vomiting are common. They may experience nightmares involving themes of separation, death and loss, and may have associate sleep difficulties. They do whatever is within their power to avoid separating from important attachment figures: they avoid situations such as attending school, sleeping alone, playing at others friends’ homes, and staying away overnight. The disorder is most typical of younger children and is less common in adolescents. When making the diagnosis of separation anxiety, it is important to ensure that the anxiety is inappropriate to the child’s developmental level and is not within the normal range of behaviours for their age.

Generalized Anxiety Disorder

Children and adolescents with generalized anxiety disorder are commonly described as ‘worriers’ by their parents. They worry excessively about many areas of life functioning, such as schoolwork, family, friends, health and any new or unusual situation. As a general guideline for making this diagnosis, the worry needs to be more days than not for a minimum of six months. These children show a persistent tendency to make negative predictions and to presume that the worst possible outcome will occur. For example, one 12 year old girl was certain that she would perform poorly in a school examination and that this would mean she would never be able to pursue a successful career. These beliefs lead to chronic worry and high anxiety about schoolwork, poor concentration and attention and, in turn, to reduced academic performance.

Children with GAD report difficulties controlling the worry and often seek reassurance or comfort from others. Over time, constant reassurance can further reinforce negative beliefs. Despite a common belief that GAD is manifested only as worry, these children will show considerable avoidance behaviour – for example refusing to try anything new or unusual. Other associated problems include poor concentration, irritability, restlessness, fatigue, sleep disturbance and somatic symptoms such as muscle tension, headaches or stomach aches.

Social Phobia

Children with social phobia are highly fearful of social or performance situations in which they are exposed to unfamiliar people or possible evaluation. They fear that they will do something or act in a way that will result in humiliation or embarrassment. In brief, they fear that others will negatively evaluate them. For example, one sixteen year old boy was very anxious about asking a girl out on a date. He worried that he would make mistakes and stutter while asking her out. He thought that she would reject him and think he was a fool, resulting in total humiliation. Older children and adolescents are typically able to recognise that their fears are excessive or unrealistic. This is not always the case with younger children, who may lack insight into the extreme nature of their fears.

When faced with social or performance situations, socially phobic children experience intense anxiety and distress. Younger children will cry, freeze, withdraw, or hide behind people to whom they are emotionally attached. The anxiety in social situations is associated with physiological changes such as nausea, stomach aches, blushing, sweating, trembling, heart palpitations, and dizziness. Young people with social phobia are so fearful of negative evaluation that they avoid social or performance situations in any way they can. Commonly avoided situations include public speaking, meeting new people, eating in public, playing sports, attending parties, speaking in class, and speaking to authority figures. When avoidance is not possible, the situations are endured with intense daily functioning, and in some children may hinder social-emotional development. Children and adolescents with severe social phobia tend to have few friends, be involved in few recreational or extracurricular activities and may have poor social skills.

Specific Phobia

Children with specific phobias have excessive fears of particular objects or situations such as the dark, animals, heights or blood. When confronted with the specific stimulus, the children become anxious and distressed. As with the other anxiety disorders, children with specific phobias will avoid the feared object or situation whenever they can, or endure it with anxiety. These patterns of fear and avoidance can interfere with the young person’s normal routine. In making a diagnosis, however, it is important to remember that mild fears during childhood are fairly common and should not be confused with phobias. Fears are considered to be specific phobias only if the degree of anxiety and avoidance is clearly excessive compared to other children their age, and interferes markedly with areas of life functioning.

Obsessive-Compulsive Disorder

Children with OCD experience persistent obsessions and compulsions. Obsessions are recurrent thoughts, images, or urges that are intrusive and distressing. Compulsions are repetitive behaviours that are performed in response to obsessions, and are aimed at preventing negative events. Common types of intrusive thoughts reported by young people include concerns about harming others or themselves, contamination, superstitious ideas about bad luck or karma and religious concerns. Common compulsions include washing or cleaning, checking, repeating rituals, ordering and hoarding or saving. Compulsions sometimes involve other people, such as family members. For example, a child may require a specific verbal response in order to complete a ritual.

Children with OCD perform compulsions following an obsession in order to prevent a feared outcome from occurring. After the compulsion has been carried out, they usually experience an immediate decrease in their level of distress. However, this decrease is typically short lived because doubt or other triggers in the environment can result in further intrusive thoughts. It is not uncommon for children or adolescents to feel the need to perform a ritual five times or more. As a general guideline for making this diagnosis, the compulsions must last more than an hour per day. Typically the obsessions and constant compulsions become highly frustrating and time-consuming for the individual. Avoidance of cues in the environment that trigger intrusive thoughts is common. This often leads to marked life interference and feelings of depression.

For example, one 15 year old girl experienced intrusive thoughts every time she used the toilet. Her intrusive thought was “If I don’t wash my hands thoroughly with soap, I will infect the rest of my family with germs and they will get very sick.” In response to this thought, she would meticulously wash her hands with soap for around five minutes after she used the toilet. As she walked away from the bathroom, she would experience further intrusive thoughts, such as, “I haven’t gotten rid of all the germs yet and could still infect people”. She would then perform more hand washing. This cycle would typically continue for long periods until she felt satisfied that there were no longer any germs on her hands, and her anxiety level would then drop. Over time, her hands became chaffed and sore from the constant washing, further increasing her distress.

While adolescents can generally recognize the unrealistic nature of their thoughts and behaviours, younger children can lack insight. Younger children may be reluctant, or unable, to verbalize the nature of their obsessions due to a limited understanding of their difficulties, language limitations, or embarrassment. In such cases parent reports and behavioural observation of compulsions are a necessary source of information.

Post-Traumatic Stress Disorder and Related Conditions

Children with PTSD display a set of characteristic symptoms that develop following exposure to a traumatic, physically threatening event. Children show many of the same features of PTSD that adults do, although in children the specific expression of each symptom may be slightly different. They re-experience the trauma in various ways, such as via distressing recollections, dreams of the event, or distress at exposure to cues that remind them of the event. Children with PTSD avoid such cues, and generally show increased arousal when exposed to or reminded of the trauma-related cues. Younger children may report more generalized dreams of monsters, of rescuing others, or of threats to self or others. Themes related to the trauma often emerge during play. For example, younger children may repeatedly enact crashes with vehicles. Younger children with PTSD may be unable to verbalise the nature of their fears or the extent of their distress. In such cases, behavioural observation and parental report provide important assessment information.

A related disorder, acute stress disorder, has only been introduced with the publication of the DSM-IV. The features are very similar to those of PTSD but the diagnosis can be made within the first month following trauma (PTSD requires at least one month of persistent disturbance.) Where a child appears to be distressed by a stressful life event but does not meet the full criteria for acute stress disorder or PTSD, he or she may be more likely to meet criteria for an adjustment disorder, which refers to a clearly defined stressor in a child’s life.