All youth at some time in their lives become anxious or fearful, particularly during typical childhood transitions, such as starting a new school, attending overnight camps or sleepovers, taking tests, dating, or participating in other social activities. Although the majority of youth move through such anxious episodes with little or no disruption to their lives, 10-20% of youth experience anxiety symptoms that are so extreme that they significantly affect their academic, social, and emotional development. When this happens, the child may have an anxiety disorder.
Children develop certain anxiety disorders at specific developmental stages. For example, Separation Anxiety Disorder, Selective Mutism, and Specific Phobias usually occur in children under the age of nine, whereas Generalized Anxiety Disorder, Social Phobia, Obsessive-Compulsive Disorder, and Panic Disorder often emerge in middle-late childhood through adolescence. Acute Stress Disorder and Post-Traumatic Stress Disorder can occur at any age. Youth may exhibit symptoms of anxiety differently than adults, and the presence of anxiety does not always indicate that the child has an anxiety disorder.
Anxiety Disorders in Youth
Separation Anxiety Disorder
Children aged 18 months to 5 years are often anxious, and will cry, plead, and occasionally tantrum when separated from their parents and caretakers. Separation anxiety is a natural and normal developmental stage that typically does not persist beyond the preschool years. However, for approximately 3-5% of children, separation remains a terrifying ordeal even when they are older. When separated from their primary caretakers, these children fear that they or a parent will be harmed or that they will be abandoned. These children may refuse to attend school, go to parties, sleepovers, or participate in other developmentally appropriate activities. Separation Anxiety Disorder can be diagnosed any time before age 18 years, but is most common in children between the ages of seven and nine. The typical signs of Separation Anxiety Disorder include:
- Episodes of crying, clinging, or tantrums when separating from a parent or caretaker, and/or difficulty remaining apart (e.g., frequent telephoning when the caretaker is away or pleading with the caretaker to come home early); Refusal to attend school, after-school care, camps, or sleepovers;
- Complaints of stomachaches or other health problems when there are no clear signs of illness (e.g., fever or vomiting) and that result in time at home with the parent;
- Difficulty being alone or apart from a parent even within the same location (e.g., cannot be in a different part of the house from the parent);
- Demands that a parent be present until the child falls asleep, or frequent Ånighttime visits to the parent's bedroom;
- Nightmares about being parted from parents, family, or loved ones.
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Children are often more quiet than usual in new situations or when meeting people for the first time, but once the child warms to the situation and person, he or she usually begins to speak. However, children with Selective Mutism refuse to speak in many or all situations; typically they refuse to speak outside of the home or when away from their family. Some researchers consider Selective Mutism to be a childhood variant of social anxiety (see below). The impact upon the silent child is enormous, as he or she misses opportunities to make friends, achieve academic milestones, and participate in academic or after school activities, all of which depend on his or her willingness to speak and interact with others. Selective Mutism typically occurs between the ages of two to four years, although the problem may not be diagnosed until the child enters school and the mutism becomes more evident. Selective Mutism affects about 0.5% of children, although evidence suggests that it may be under-diagnosed. The typical signs of Selective Mutism include:
- Child is outgoing and talks openly and freely at home, exhibiting no difficulties with language and does not have a developmental disorder;
- Child does not speak in school, and may use friends to talk for him or her;
- Child will talk to best friend at home but no where else;
- In public the child does not speak at all or communicates only to a designated person;
- Child has a definitive list of people with who he or she will and will not talk; Child may whisper in lieu of talking at a normal volume.
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Fears of spiders in the bathtub or monsters under the bed are a natural part of a child's development, as are fears of strangers, the dark, loud noises, weather, animals, injury and more. Such fears are considered adaptive and the child typically outgrows them over the course of months and they do not interfere with the child's daily life. Yet some children experience persistent and extreme fears; they may cry, freeze, or cling when they are in the feared situation or near the feared object. Common phobias include: dogs, spiders, snakes; environmental situations such as heights, small spaces, thunderstorms, water, and darkness; blood and injury; travel by car, plane, or boat; and loud noises, doctors/dentists, vomiting, choking, and illness. Children with phobias often miss important life experiences like school trips, family vacations, or recreational activities because they are afraid of contact with the feared item. The typical signs of a Specific Phobia include:
- The child had a prior upsetting encounter with the feared object or situation (e.g., child was bitten by a dog);
- Individuals in the child's life have identical fears (e.g., teacher is afraid of spiders, aunt Jane won't ride in elevators.);
- When the child encounters, or anticipates encountering, the objector situation, he or she becomes highly distressed or angry, crying, freezing, clinging to an adult, and even refusing to approach to the object or situation;
- The child's fear persists in spite of support and encouragement from others and does not diminish in intensity.
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Generalized Anxiety Disorder
All children experience intermittent anxiety, but some children experience constant and unrelenting worry, and a diagnosis of Generalized Anxiety Disorder (GAD) should be considered. Youth with GAD seem to worry about everything, including grades, homework, performance in sports and other activities, relationships, health, family, and world events. These youth are often perfectionists who spend countless hours and energy on school projects for fear that they will make a mistake or perform poorly, or who struggle to fall asleep as they lie awake worrying. The typical signs of GAD include:
- Daily uncontrollable worry about a range of things;
- Extreme responses to minor setbacks such as major tantrums if homework is incomplete, or crying uncontrollably because she or he is catching a small cold;
- Physiological signs of anxiety such as trouble relaxing, being easily fatigued, difficulty falling or staying asleep, sore muscles, and irritability.
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Throughout childhood and adolescence, youth are expected to interact with peers and adults and, thereby learn essential social skills and cultural values. For most youth, social interactions are enjoyable, and the skills and pleasure gained from these experiences outweigh any fears of "saying the wrong thing." However, a small percent of youth develop Social Phobia, which is characterized by an intense fear of negative evaluation by others that results in anxiety in social situations, social inhibition, and withdrawal from and avoidance of social situations. Youth with Social Phobia are interested in developing friendships and interacting with others, but their intense anxiety prevents them from doing so. Unfortunately, these youth are frequently overlooked by peers and adults alike. Their social avoidance is typically minimized (Åshe's just shyâ), or stigmatized ("he's a bit nerdy"). The typical signs of Social Phobia include:
- Strong fears of doing something embarrassing, saying the wrong thing or being laughed at by others;
- Behavioral avoidance, including poor eye contact, answering in brief sentences or mumbling, and turning away from the person;
- Limited participation in school, such as refusing to answer questions or read aloud in class, skipping lunch, and avoiding performance situations and group interactions;
- Limited participation in social activities, such as finding excuses not to attend sleepovers, parties, camps, etc., and refusing to make phone calls or initiate social contact with others;
- Fear of interaction with adults and strangers, as evidenced by inability to order in a restaurant, approach a teacher, or ask an adult for assistance.
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Some children require a bit more structure and routine than other children. They are more comfortable when they have a specific bedtime routine or when their stuffed animals are positioned "just-so" on the bed. However, during late childhood and early adolescence 0.5 - 1% of youth exhibit these and similar behaviors to an extreme degree and may be suffering from Obsessive-Compulsive Disorder (OCD). OCD is characterized by persistent intrusive thoughts, images, or urges that are highly distressing to the child (obsessions), resulting in rituals intended to reduce this distress (compulsions). OCD can produce significant interference in the youth's academic, family, and social functioning including poor concentration in class due to obsessions that interfere with concentration, or difficulty completing assignments due to compulsive erasing or re-writing, and avoidance of contact with other children due to fears of contamination. The typical signs of OCD include:
- Recurrent and persistent thoughts, images, or impulses that are unwanted;
- Repetitive behaviors or mental rituals to alleviate the discomfort or anxiety experienced by the thoughts, images or impulses;
- The youth may exhibit an awareness that these obsessions and compulsions are senseless or "silly" even though he or she feels compelled to engage in the rituals.
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Panic Disorder with or without Agoraphobia
Panic attacks are characterized by an extreme and sudden onset of fear, and a range of physiological and cognitive symptoms such as racing heart, difficulty breathing, and the belief that one is dying. Agoraphobia is anxiety about being in particular situations where the youth might have a panic attack and be unable to easily escape, escape without embarrassment, or in which help may be unavailable. Panic attacks and agoraphobia are not common in childhood, but can emerge in adolescence, and are similar to Panic Disorder with or without Agoraphobia in adults. For a full description of Panic Disorder with or without Agoraphobia see: Panic Attack and Agoraphobia
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Post-Traumatic Stress Disorder
Teaching the youth alternative and more adaptive ways of thinking to increase control and decrease arousal and anxiety.
Providing a concrete approach to solving every day problems so that the youth can become skilled at managing unexpected events and thus decrease arousal and anxiety.
Teaching the youth verbal and non-verbal skills designed to get his or her needs met in adaptive ways, including skills for handling teasing or bullying.
Increasing the youth's ability to approach feared objects or situations without using rituals to cope.
Teaching the youth skills so he or she can maintain gains after treatment has ended.
Traumatic events can occur at any point across the life span, including childhood and adolescence, and include experiences such as witnessing the death of a loved one, experiencing a natural disaster, or being physically or sexually abused. Although most youth are resilient and recover from such trauma, some youth experience a range of psychological, behavioral, and cognitive symptoms that persist over time and indicate the presence of Acute Stress Disorder or Post-Traumatic Stress Disorder. For a full description of Post-Traumatic Stress Disorder see:
Treatment components are selected based on the youth's symptoms and problems and are delivered in sequence, with new skills presented when previous skills have been mastered. Careful consideration of the youth's developmental age ensures that the youth can effectively learn and apply a variety of skills. Parents are an integral part of treatment and are taught many of the same skills that the youth learns so they can help the youth learn to manage his or her anxiety.
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