About Anxiety Disorders

Real Life Stories

Charlie, now 11 years old , is entering 6th grade in a middle school. Each September since kindergarten the start of school has always been a struggle for him. This year his distress escalated with the added demand of starting in a new school, and by November he missed twenty-six days of school. His academic work has suffered, and his teachers have sent his assignments home. Charlie insists that he can't complete them without his mother's presence. He worries that something bad may happen to his mom while he is in school.

Corinne's mother tried everything she could think of to get her 14-year-old daughter to join an after-school club or accept invitations to parties at classmates' homes. Corinne insisted that she would rather stay home and read; she didn't think she fit in with her friends any more and didn't know what to say to them. When she did venture out with a cousin, it took her hours to do her makeup because she didn't think she looked quite right.

Charlie has been diagnosed as having Separation Anxiety and Corinne has Social Phobia; both are types of Anxiety Disorders.

What are the symptoms?

Everyone worries sometimes, but there are some people, even children, who just can't stop or ignore their worries. It has been estimated that five to twenty percent of all children have been diagnosed with an Anxiety Disorder, making it the most common internalizing mental health problem children face. Studies also suggest that teens with an Anxiety Disorder are at risk for developing Major Depression. Although school refusal is not a specific diagnostic category of anxiety, it is important to assess the specific type of anxiety that prevents a child from attending school. The most common types of Anxiety Disorders in youth are:

Separation Anxiety Disorder (SAD) is characterized by a child's extreme fear of being away from home or from their primary caretakers. The main fears of SAD children center around being lost or of something terrible happening to them or their parents. These children often refuse to sleep alone and often crawl into their parents' beds during the night. They may complain of nightmares, stomachaches or other physical symptoms, and often refuse to attend school due to their fears of separation. About four percent of all children have SAD, which should not be confused with normally occurring separation anxiety seen between eighteen months and three years of age, or the stranger anxiety which is typically seen at seven to eleven months of age. To meet the criteria for a diagnosis of Separation Anxiety Disorder the child must have particular symptoms of excessive anxiety for at least four weeks.

Generalized Anxiety Disorder (GAD) takes the form of excessive and uncontrollable worry. Children with GAD worry about many things, such as the future, being on time for appointments, health, school performance, crime, change in routines, and family matters. Typically, the child worries when there is really no problem or any realistic circumstance to cause the worry. GAD is often accompanied by muscle aches or tension, concentration difficulties, sleep disturbance, irritability, or other physical symptoms. To meet diagnostic criteria, the child must exhibit at least one physical sign of anxiety, such as restlessness or sleep difficulties, for more days than not in the past six months.

Social phobia (SOC) is an excessive fear of being negatively evaluated, rejected, humiliated or embarrassed in front of others. Therefore children and adolescents with social phobia fear a wide range of situations such as giving oral reports, gym class, speaking to adults or peers, starting or joining in conversations, eating in public, and taking tests. They may fear unfamiliar persons, and therefore have difficulty making friends or meeting new people. The term "painfully shy" is an apt description. Some studies have shown that youth with social phobia may have a heightened risk for other problems in adolescence and adulthood, such as problem drinking and depression resulting in part from social isolation and limited social contacts.

Panic Disorder with or without Agoraphobia (PD) is recognizable by the classic symptoms of a panic attack such as shortness of breath, pounding heart, tingling and numbing sensations, hot or cold flushes, and terror when in certain situations or places. During a panic attack the child feels intense fear or discomfort, a sense of impending doom or sensations of unreality. Panic attacks may or may not accompany agoraphobia, the fear of being stuck in a situation where help or escape is unavailable. Panic attacks occur less frequently in children, but are not unusual in adolescents.

Who is likely to have it?

Children of any age have worries, but when the worries and fears don't go away, are inappropriate for their age, and stop children from engaging in their usual activities in the usual way an Anxiety Disorder may be present. For example, a child may be so worried about getting a perfect score on a test that he studies without respite; a child may be so afraid of not having the right answer that she never raises her hand. Youngsters who have an Anxiety Disorder behave in ways to control or avoid a situation that makes them anxious, or to get attention. An Anxiety Disorder can occur seemingly without warning or be present for a long time without anyone realizing what it is. The earlier the onset, the more likely that a child will suffer with multiple anxiety disorders and other complex comorbid disorders such as depression, before reaching adolescence.

Why does it happen?

Anxiety Disorders result from a combination of family and biological influences. Studies suggest that young children who are temperamentally (at birth) shown to be shy or tentative in unfamiliar situations may be more prone to anxiety. Some research suggests that anxiety may be caused by a chemical imbalance involving norepinephrine and serotonin. Yet more research is necessary to examine the relationship between anxiety and serotonin. Other research implicates specific brain mechanisms, involving hormones and respiratory functions, as potential pathways to anxiety. Anxiety Disorders tend to run in families, but the complex relationship between genes, biological systems, and anxiety is not well understood. Moreover, evidence suggests that anxiety and phobic reactions can be learned, either through direct experience or observations of others.

How is it treated?

Being sure of the diagnosis. In order to decide if a child or adolescent has an Anxiety Disorder, professionals will need information as to how the child has been anxious, and if it has continued despite steps taken to alleviate it. They will decide if the fears are normal for the child's age, and they will evaluate the degree to which the anxiety interferes with the child's life. A professional will also take a close look at people or situations that may be unwittingly reinforcing the child's anxious behaviors.

Medication which works directly on the central nervous system and brain may be prescribed to help a youngster feel calmer as he works toward healthier everyday functioning.

Cognitive Behavior Therapy (CBT) is effective in assisting a child or adolescent with controlling anxiety and regaining a normal life. CBT involves education about the nature of anxiety, along with teaching specific skills for managing the physical sensations, negative thoughts, and problematic behaviors that accompany the anxiety. Through CBT an individual learns, in a step-by-step fashion, to master the situations that cause anxiety.

Combination Therapy involves a combination of medication and CBT. This is good news because behaviors and reactions that are learned can be modified, and through CBT coping strategies can be taught.

Questions & answers

How did my child become so anxious? Is it my fault?

Looking for blame is not productive for parents or children. Anxiety disorders are most likely the result of the interaction between a child's biological sensitivity and experience. Children react in a physically anxious way to various situations, especially when they feel they are not in control. In addition, they may distort or exaggerate events in their minds; for example, thinking that if something can happen to someone else it can happen to them in an even worse way. This thought process is called catastrophizing.

Isn't this just a phase my child is going through? It's normal to be scared sometimes.

Anxiety disorders can start in childhood and can be a chronic problem. Certainly all kids go through phases when they are more worried about things than at other times. This kind of worry is different from the anxiety that interferes with home life, academic performance, peer relationships, and the ability to distract oneself and move on from the problem.

What should I look for when I think my child may have a real problem with anxiety?

With the help of a professional, it is important to identify how intense the symptoms are, whether the reaction and the behaviors are extreme, and how long the problem has persisted.

Will my child always be like this?

Everyone must learn to live with a certain amount of anxiety. Fortunately, anxiety disorders are highly treatable. Appropriate treatment can reduce or completely prevent the recurrence of problems in 70 to 90% of patients. Cognitive behavioral treatments teach children skills to cope with both the physical symptoms and the behavioral reactions. For example, children are taught coping and mastery skills such as relaxation techniques and coping phrases to tell themselves when anxiety is at its height.

How do I parent a child with an anxiety disorder?

With good intentions, parents are apt to rescue their children -- to try to comfort and soothe them when they are feeling upset and anxious. However, this approach can teach the child to give up quickly and rely on others to make him feel better. Although it is difficult, parents should let their child feel some distress, question the child about what is happening, and think about what he or she should do. In this way, parents let the child experience some struggle rather than be rescued; they help the child choose ways to manage the situation, and praise them for their attempts as well as for their successes.

About the Author

Robin F. Goodman, Ph.D., is a clinical psychologist specializing in bereavement issues.

References and Related Books

For Adults:

Anxiety Disorders in Children and Adolescents
J. S. March
Guilford 1995

Clinical Handbook of Anxiety Disorders in Children and Adolescents
A. Eisen et al (Eds.)
Jason Aronson 1995

For Children:

Into the Great Forest: A Story for Children Away From Parents for the First Time
I.W. Marcus & P. Marcus
Magination Press 1992

Night Light: A Story for Children Afraid of the Dark
J. Dutro
Magination Press 1991

About the NYU Child Study Center

The New York University Child Study Center is dedicated to increasing the awareness of child and adolescent psychiatric disorders and improving the research necessary to advance the prevention, identification, and treatment of these disorders on a national scale. The Center offers expert psychiatric services for children, adolescents, young adults, and families with emphasis on early diagnosis and intervention. The Center's mission is to bridge the gap between science and practice, integrating the finest research with patient care and state-of-the-art training utilizing the resources of the New York University School of Medicine. The Child Study Center was founded in 1997 and established as the Department of Child and Adolescent Psychiatry within the NYU School of Medicine in 2006. For more information, please call us at (212) 263-6622 or visit us at http://www.aboutourkids.org/.