Anxiety issues are common for primary school children. While it is normal for children to have some worries and fears, and these can be instructive and protective, we might become concerned when:
- children feel anxious more than other children of their age and level
- anxiety stops them participating in activities at school or socially
- anxiety interferes with their ability to do things that other children their age do easily
- the fears and worries seem out of proportion to the issues in their life.
When children become anxious more easily, often and intensely than other children, they may be diagnosed with an anxiety disorder. Anxiety disorders affect 6.9% of children aged 4-11 years and can include social phobia and other phobias, separation anxiety, generalised anxiety disorder, panic disorder, obsessive compulsive disorder and post-traumatic stress disorder (Lawrence et al., 2015). Anxiety disorders in children can have an ongoing, pervasive and negative impact on development, relationships, family life and school adjustment and, if not effectively identified and responded to, can persist into adulthood.
How does anxiety develop and how does it present?
Anxiety can develop from a number of sources. Physical symptoms of anxiety are more easily triggered in children with ‘anxious temperaments’. Learning can also play a part as children can see the world as a dangerous and unpredictable place. Exposure to media (e.g. disasters or tragic events) and family conversations and responses to the world can contribute to the child’s ideas about what is dangerous or not. Sometimes families may unknowingly contribute to children’s natural cautiousness by being over-protective, which can unintentionally encourage children to avoid situations they feel anxious about. Parents and carers may also unintentionally contribute to a child’s anxiety by modelling anxious behaviour themselves; being overly controlling or intrusive (which can affect a child’s sense of autonomy and the development of coping skills); or by tolerating or encouraging escape and avoidance behaviours in the child. Stressful situations or events can also trigger problems with anxiety.
Families and school staff may notice signs of anxiety in children that can include:
- worries, fear and avoidance of a range of issues and situations, and/or a strong need for reassurance
- sleep difﬁculties, including difﬁculty falling asleep, nightmares and trouble sleeping alone
- wanting things to be perfect, a child may be so dissatisﬁed with his/her own work that he/she will tear it up and redo it several times
- reluctance to ask for help
- difficulty joining in social activities with peers
- stomach pains, headaches, skin disorders (particularly when the child has to do something that is unfamiliar or that they feel uneasy about)
- being fearful of test situations or performing in front of others
- becoming upset when leaving parents.
Assessment of children with anxiety concerns
Early assessment and intervention are important to help build children’s capacity to cope well and build resilience in confronting the anxiety-provoking situations. It is essential that psychological assessment is comprehensive and gathers information from multiple sources, such as the child, parents and carers, and school staff. Self-report measures or scales (e.g. Child Behaviour Checklist) can assist this process, as well as semi-structured diagnostic tools such as the Anxiety Disorders Interview Schedule for DSM: Child and Parent Versions. Other anxiety symptom scales such as the Spence Anxiety Scale, Preschool Anxiety Scale, Children’s Moods, Fears, and Worries Questionnaire and resilience assessments for protective factors, such as the Devereux Student Strengths Assessment can help provide a comprehensive evaluation.
Like any mental health difficulty assessment, it is important to utilise a biopsychosocial approach that helps develop an understanding of the child’s context in relation to anxiety concerns. This approach helps understand the type, intensity, frequency and duration of anxious behaviours as well as predisposing (e.g. family history), precipitating (e.g. school stressors), perpetuating (e.g. avoidance) and protective (e.g. optimistic/hard working child) factors.
Psychological support and interventions
Psychological support typically involves teaching children to reduce avoidance and use more effective coping skills. This is typically achieved through cognitive behavioural therapy which can focus on techniques such as relaxation, learning to replace unhelpful thoughts with helpful self-talk, identifying and regulating emotions, increasing positive coping role models, and building step plans, exposure exercises and problem-solving skills. Interventions need to have the coordinated support of parents and carers and school staff.
Supporting families is crucial, as families can provide support to the child as they learn new coping skills and practise them in situations they may have previously avoided. It is particularly important, when children present with anxiety concerns, that families are supported and involved because, if the child has anxious parents, they are likely to have anxiety themselves. Important strategies include incorporating brave role models (where it is ok to make mistakes); limiting excessive reassurance and avoidance behaviours; breaking larger goals into small steps; helping reinforce helpful thinking and self-talk; and supporting children to be brave and face their fears. Medication may be helpful in severe cases, used in conjunction with psychological support. However, it is important for health and community professionals to remind families of the pros and cons of medication and support parents in making decisions about using medication; along with working in partnership with GPs and psychiatrists.
Resources and references
Lawrence. D., Johnson, S., Hafekost, J., Boterhoven D.H.K., Sawyer, M., Ainley, J., Zubrick, S.R. (2015). The mental health of children and adolescents. Report on the second Australian child and adolescent survey of mental health and wellbeing. Canberra: Department of Health.