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Anxiety problems
Introduction
The purpose of this guide is to help families and clinicians work together to plan the evaluation
and treatment of children’s anxiety problems. Pediatricians and family doctors are very familiar
with the kinds of fears that children normally develop – fear of strangers, the dark, not wanting
to separate from their caretakers. This guide is designed to help families and clinicians decide
when a child’s anxieties go beyond the usual range and may warrant additional treatment.
Catching anxiety problems early may have long-term benefits. Most adults who have newlydiagnosed anxiety disorders report their symptoms began years or decades before in childhood.
Diagnostic features to explore
There are many different anxiety disorders – their treatment overlaps and some times it is hard
to distinguish one from another. A goal for primary care evaluation is to understand whether the
severity of problems of function or the possibility of a disorder with a specific treatment warrant
referral, or if treatment in primary care is reasonable. Nearly all anxiety treatment, however,
involves identifying the specific triggers for or symptoms of anxiety: The following list focuses on
what children do and on the triggers involved:
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Behavioral features
o Avoidance of feared activities, eg reluctance to go to school or to speak in front
of others, to take public transportation, or to go to the movies.
o Clinginess or reluctance to separate from trusted adults. This can include refusal
to sleep alone.
o Withdrawal. This can take the form of shyness in the presence of strangers or
large groups of people
o Tantrums/tearfulness/other outward displays of distress, when asked to engage
in a feared activity or to separate from a parent
Cognitive features
o Worry about harm coming to themselves, loved ones, or friends
o Fear of catastrophe (manmade or natural)
Somatic features occurring in particular situations.
o palpitations
o stomach aches, headaches, other aches and pains with no obvious cause
o breathlessness
o difficultly getting to sleep
o nausea
o feeling wobbly or 'jelly legs'
o 'butterflies'.
o Children who experience the sudden onset of palpitations, shortness of breath,
sweating, tremor, and often a feeling of dread may be having panic attacks.
Attacks can be in response to feared things or situations, but they can also be
spontaneous.
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Other possible explanations and complications
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Normal behavior - it is often difficult to diagnose anxiety disorder in young children,
because a moderate level of anxiety is normative at certain developmental stages.
o stranger anxiety peaks at 8-9 months;
o children are usually able to separate pretty easily by 3 years;
o 5-8 years: increases in worry about harm to parents or attachment figures;
o 9-12 years: recurrence of distress at separation
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Depression co-exists in half or more of anxious children and can be very difficult to
distinguish. Marked sleep disturbance, disturbed appetite, low mood, or tearfulness in
the absence of direct anxiety provocation could indicate that a child is depressed (this
may well be a single diagnosis – anxiety with depression – with a single treatment).
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Obsessive-compulsive disorder (OCD), indicated by the presence of rituals or
compulsive behaviors (excessive washing and fear of contamination are the most
common) . Most children have phases of ritualized behavior, which can usually be
distinguished from OCD by the degree of distress caused if a ritual is interrupted, and
the number of rituals present at any one stage.
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“PDD spectrum” disorders including Asperger’s Syndrome. Children who have these
difficulties also have greater or lesser problems with social relatedness (poor eye
contact, preference for solitary activities), language (often stilted), and range of interest
(persistent and intense interest in a particular activity or subject). They often will have
rigid expectations for routine or parent promises and become anxious or angry if if these
expectations are not met.
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Post-traumatic stress disorder if the onset of anxiety was preceded by an extremely
distressing experience. Parents are frequently unaware of exposures that children may
have had at school or in the community, as children don’t always reveal them. There
may be major traumas in the family (for example, serious illness in a parent) that are
similarly not discussed or disclosed.
o The three hallmark symptom clusters in PTSD are re-experiencing (often
repetitive play in children), avoidance of memories or situations that recall the
trauma, and hyper-vigilance (increased worry about safety, startles or
anxiousness at unexpected sounds or events).
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Maltreatment - children who have experienced physical, emotional or sexual abuse are
at high risk of developing emotional difficulties. Concern should be raised when anxiety
onset occurs over a short period subsequent to relatively normal development and when
no other explanation (eg change of school/family circumstances) is apparent.
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Physical illness - Medical issues that can mimic or provoke anxiety symptoms include
thyroid disease, hypoglycemia, side effects of medications (such as bronchodilators),
and endocrine tumors (pheochromocytoma). Drug or alcohol withdrawal is a
consideration for teens (the latter potentially a medical emergency).
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Psychosis – Though rare, the onset of bipolar disorder in schizophrenia in late
adolescence may be subtle and marked only by frightening hallucinations or delusions
that the teen does not disclose.
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o
Selective mutism: Children with normal language development who relatively suddenly
stop talking in certain situations (most often in school and to adults outside the home).
Can be confused with children making a language transition, for example, a child raised
speaking Spanish who is suddenly placed in an English-speaking class.
Decisions about referral
Reasons for referral to specialty mental health care may include:
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Multiple symptoms of anxiety in many domains of life (for example, is fearful of new
situations, doing things in public, has trouble separating, worries a lot)
When anxiety threatens to interfere with education
When symptoms are threatening the achievement of developmentally important goals;
for example, a shy child who is reluctant to mix with other children and this can’t be
overcome with parental or other support.
When the child or parent is very distressed by the symptom(s).
Where there are co-morbid behavior problems (the combination of shyness, anxiety, and
behavior problems is thought to be particularly risky for future behavior problems of a
more serious nature)
When the anxiety seems to be occurring in the context of serious trauma.
If the child seems to have panic disorder or OCD, both of which are potentially amenable
to combinations of medication and cognitive therapy.
General management and advice for children and parents
Clarifying environmental risks:
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Is an external problem causing the child to be anxious, for example bullying at school ,
academic difficulties, or disruption at home? Is the child’s worry about a parent’s welfare
legitimate because of a serious illness or domestic violence?
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Is the parent anxious? Anxious children very often have an anxious parent. It is thought
that children can learn to be anxious from their parents. Advise parents to minimize their
own displays of fear or worry when the child is present. A referral to adult mental health
services might also be appropriate.
Exposure to feared situations
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The eventual goal is to master rather than avoid feared things.
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The best-validated approach to fears is to gradually increase exposure to them in a
supported way (with much encouragement and in a safe setting). Exposures also often
start out brief and become longer.
o
Imagining or talking about the feared object or activity
o
Learning to tolerate a short exposure, or looking at pictures
o
Tolerating a longer exposure in a group or with a coach
o
Tolerating the feared activity alone but with a chance to get help if needed.
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During these trials parents need to stay as calm and confident as possible – if they
become distressed it will be a cue for the child to become distressed
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One exception to gradual exposure is likely to be when a children are avoiding school
o
Explore child’s reasons to rule out trauma, learning difficulties, medical conditions
o
Gently but firmly insist that child attend coupled with positive feedback, calm
support
o
Referral needed if absence becomes prolonged or parents reluctant to support
child’s return.
Rewarding brave behavior
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Give small rewards (including positive feedback) for displaying brave behavior.
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School-age children respond well to star charts. The rules for using star charts for brave
behavior are:
o
o
Only focus on one or two behaviors at a time
Have one star chart per behavior
o
Negotiate rules for the star chart, for example ‘sleeping in own bed for one night
= one star; four stars = trip to the pool’
o
Ignore mistakes and failures – do not ever mark them on the star chart. Simply
carry on awarding stars when they are earned.
Attention to overall parenting style
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Children can become anxious if parents are inconsistent about rules and expectations
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Are there “catastrophic” consequences for failure? (“I know dad will get angry if I bring
home a bad grade.”).
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Have children come to feel somehow responsible for the family’s stresses (“I know that
the only reason mom and dad work hard is so I can go to a better school, so I’m afraid
that if I don’t do well…”).
Resources
Bright Futures In Practice: Mental Health. Volume II. Tool Kit. “Tips for parenting the anxious
child” (pages 96-97).
Acknowledgments:
The concept, general outline, and some content adapted from the WHO Guide to Mental and
Neurological Health in Primary Care. More about the Guide can be found at
http://www.mentalneurologicalprimarycare.org
This is a draft version for teaching and demonstration purposes (4/11/09), made possible by
grant RO1 MH6269 from the National Institute of Mental Health. For information: Larry Wissow,
MD MPH, Johns Hopkins Bloomberg School of Public Health, 703 Hampton House, 624 N.
Broadway Baltimore, MD 21205. 410-614-1243; Lwissow@jhsph.edu.
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