Anxiety Disorders




Anxiety is a common experience to all, including children and youth. Although many people may consider anxiety to be a negative experience associated with stress or problems, it can serve a positive function by alerting one to imminent threats or danger. Anxiety is also a marker for typical developmental patterns and can serve as an indicator that social and emotional development is progressing as expected. The first major developmental signs of anxiety occur at about 6 to 7 months of age, when the infant becomes distressed about the presence of unfamiliar people. This pattern is known as stranger anxiety and indicates that the child is now beginning to differentiate people in the environment, which is a cognitive skill. These  reactions  usually  subside  by  about  12 months of age. At about 12 to 15 months of age, toddlers may demonstrate signs of separation anxiety and become upset when a familiar caretaker, most often the parent, leaves them with someone else. They may cry, cling, and plead for the parent not to leave. This pattern also indicates that the child is progressing cognitively and is beginning to understand that parents can leave and express fear that they might not return. These behaviors usually resolve by about 2 years of age, and although the child may prefer the presence of parents, he or she is able to separate from them and enjoy being with others. These patterns are normal and should not cause undue concern, unless they are severe, protracted, or occur at ages not expected of the child. For example, it is common for children to have some separation anxiety when starting school, but it usually resolves quickly and does not remain a problem.

Anxiety Disorders t1 Table 1    Major Signs of Anxiety

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Signs Of Anxiety

Anxiety may be shown in several behaviors, which can be cognitive, behavioral, or physiological in nature. Cognitive signs include difficulties with memory and concentration, whereas behavioral manifestations include rapid speech and sleeping problems. Physiological responses include excessive perspiration and rapid heart rate. Table 1 summarizes the major signs of anxiety.

The central cognitive characteristic of anxiety is worry, which is apprehension about an anticipated real or imagined event or threat over which the person feels to have inadequate control. Worry has a predictable developmental pattern that corresponds with levels of cognitive development. Being able to worry requires that the child be able to anticipate a future event or outcome. At preschool and young childhood levels, children have difficulty thinking about more than one future event at a time and anticipating outcomes. At elementary ages, children increase their ability to consider multiple possibilities and outcomes, increasing their proneness to anxiety. Adolescents and adults develop abstraction skills and hypothetical deductive reasoning ability and can think about their own thinking. Although these skills may be helpful, they may also provide a basis for being able to anticipate several outcomes over which little control is perceived, which may contribute to the development of anxiety that interferes with functioning. The specific conditions that create anxiety are not well understood, but the ability to anticipate even one negative event may cause anxious reactions. In particular, high levels of anxiety can interfere with problem solving by causing impairments in perceiving all possible solutions, selecting a solution, or applying a selected option.

Excessive worry does not have to have a basis in reality, but if a child perceives a situation to be threatening, anxiety can result. I once worked with a young boy whose parents were flying out of state for a short time while he stayed with grandparents. He was extremely fearful that the plane was going to crash and that they would be killed. Although acknowledging that the likelihood of such a catastrophe occurring was very small, he could not resolve the fear that it might happen. To him, the fear, however irrational and unlikely,  was  extremely  worrisome  and  interfered with his daily behavior.

Trait And State Anxiety

Anxiety that is chronic and is seen as a typical personality or behavioral characteristic is termed trait anxiety. This type of anxiety is most commonly associated with anxiety disorders and is manifested across a range of situations. State anxiety is experienced in specific situations, such as when taking tests or public speaking. Although there is not necessarily a high correspondence between trait and state anxiety, people with high trait anxiety are more prone to state anxiety and to experience performance problems.

Anxiety Disorders

When anxiety is extremely high in frequency, duration, or intensity, an anxiety disorder may occur. Anxiety problems that warrant intervention occur in up to 15% of the population. The estimated prevalence rate of anxiety disorders in children and adolescents is about 2.5% to 5.0%. These disorders often are not detected because children with anxiety disorders often are not disruptive or do not call attention to themselves. As a way to cope with anxiety, children often withdraw from anxiety-producing situations, and they may appear to be uninterested or unmotivated. Some anxious types of behavior often are seen in children with attention deficit hyperactivity disorder, which may make it difficult to differentiate the two conditions. Anxiety disorders also co-occur with depression in about 50% of cases, although anxiety is associated with positive affect, whereas depression is associated with negative affect. When anxiety and depression disorders coexist, the anxiety disorder most likely preceded the depressive disorder. Girls tend to report anxiety symptoms more often than boys, although the difference may be due, in part, to boys’ reluctance to report them. Up to about 10 or 11 years of age, there are few meaningful differences between the genders, although boys’ anxiety seems to dissipate faster. Consequently, girls and women are more likely to be given diagnoses of an anxiety disorder.

The only anxiety disorder specifically associated with children, separation anxiety disorder (SAD) is characterized by developmentally inappropriate difficulties with separation from adults, usually parents. The reasons for SAD can be complicated and cannot be covered here. Otherwise, children may have the same types of anxiety disorders as adults, including generalized anxiety disorder, posttraumatic stress disorder, and obsessive-compulsive disorder.

Causes Of Anxiety Disorders

The causes for anxiety disorders can be based in either biological or environmental factors. Although environmental factors may contribute to the development and maintenance of anxiety symptoms, there is ample evidence to suggest that children with anxiety disorders may be biologically predisposed to anxiety. These children often are described as fearful, cautious, perfectionistic, apprehensive, “high strung,” or having social difficulties. Evidence also suggests that some children may have a pattern termed behavioral inhibition, which appears to be a biologically based pattern associated with being fearful, less sociable, and easily distressed and having low attention shifting and high levels of negative affect (distress, fear, inhibition). These children appear more likely to develop anxiety disorders.

Children and adolescents who are exposed to chronic  stressful  and  unpredictable  circumstances that are not resolved easily may be at greater risk for developing  anxiety  disorders.  Parenting  practices also may contribute to anxiety disorders. For example, some research suggests that parents who are overprotective may encourage and reinforce avoidant and inhibited behavior in their children. New situations remain new to the child, leading to impaired ability to cope and perceptions that the environment is negative.

Interventions For Anxiety Disorders

Interventions  for  anxiety  disorders  in  children and youth often are complex and require multifaceted approaches, including working with the family. It is beyond the scope of this entry to give details about interventions, but there are some methods that have shown evidence of effectiveness in treating anxiety disorders. With proper intervention methods, most anxiety disorders can be successfully treated. It is not usually realistic to expect that all anxiety will be removed; rather, the goal should be to reduce it to a manageable level.

Cognitive-Behavioral Interventions

These methods emphasize changing distorted or deficient beliefs that contribute to the development and maintenance of anxiety. The most effective methods include multiple sessions of instruction, practice in learning and applying new skills, and homework assignments.

Behavioral Interventions

These methods include systematic desensitization, muscle relaxation training, self-reinforcement, self-management, and positive reinforcement techniques.

Counseling Interventions

Although  these  types  of  interventions  may  not be as effective in treating specific anxiety symptoms, they may be helpful in learning needed adaptive and social skills.

Family Interventions

Because anxiety often is associated with family and parenting issues for children and youth, family-based counseling and parent training may be indicated to alter dysfunctional parent–child–family interactions.

References:

  1. Anxiety Disorders Association of America, http://www.adaa.org/
  2. Morris, T. , & March, J. S. (Eds.). (2004). Anxiety disorders in children and adolescents (2nd ed.). New York: Guilford.
  3. Vasey, W., & Dadds, M. R. (Eds.). (2001). The developmental psychopathology  of  anxiety.  New York:  Oxford University Press.