Anxiety and mental health in children
Fearful and anxious behaviour is common in children. Most children learn to cope with a range of normal fears and worries. However, extra help may be needed 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, more often and more intensely than other children, they may be diagnosed with an anxiety disorder. The most common anxiety disorders in children of primary school age are phobias, generalised anxiety disorder and separation anxiety. Research estimates that between approximately two and nine per cent of children and adolescents in Australia have anxiety disorders.
How anxiety affects children
In addition to feeling highly anxious, children’s thinking is usually affected. The threat or danger they are concerned about appears to them to be much greater than it actually is. Thinking about the situation that causes them to be anxious makes them more worried and tense.
Children with anxiety may develop their own strategies to try to manage situations that cause them distress. Often this involves trying to avoid the situation or having a parent or other adult deal with it for them. Avoiding a situation makes it more likely that the child will feel anxious and be unable to manage it the next time. This behaviour makes it more difﬁcult for the child to cope with everyday stresses at home, at school and in social settings.
Anxiety can also result in physical difﬁculties such as sleeplessness, diarrhoea, stomach aches and headaches (sometimes referred to as somatic complaints). It can also involve irritability, difﬁculty concentrating and tiredness.
How do you notice anxiety in children?
- Fear and avoidance of a range of issues and situations.
- Headaches and stomach aches that seem to occur when the child has to do something that is unfamiliar or that they feel uneasy about.
- Sleep difﬁculties, including difﬁculty falling asleep, nightmares and trouble sleeping alone.
- Lots of worries and a strong need for reassurance
- Wanting things to be perfect. For example, 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. Sometimes anxiety creates an obstacle that prevents children asking for help from the teacher about a problem with learning.
- Children who ask too much for reassurance may also be overly anxious.
- Difﬁculty joining in. Children with high levels of anxiety may be afraid to join in class discussion, take part in sport or games or go to school camp.
- Requests to go to sick bay. Anxious children often complain of stomach aches and headaches.
- Fearful of test situations. Some children do not do as well as they can in test conditions because they are struggling with anxiety. They may also be too self-conscious to perform in front of the class.
Common anxiety disorders in primary school-aged children
Type of anxiety
What that means
Separation Anxiety relates to fear and distress at being away from the family. There is commonly a fear that something bad will happen to a loved one while they are separated. Fear of separation is considered developmentally appropriate up to two years of age, but it should lessen as children get older. Children with Separation Anxiety may complain about feeling sick. They may make frequent trips to the sick bay at school or sometimes refuse to go to school altogether. School camps and sleepovers are commonly major problems for children with Separation Anxiety.
Phobia is diagnosed when particular objects, situations or events such as injections, spiders or heights bring about intense fear and avoidance even though realistically the threat of harm is small. See fears and worries for more information.
Social Phobia refers to extreme levels of shyness and fears of being seen in a negative light. Children with Social Phobia avoid a range of social interactions such as talking to new people, speaking up in class or performing in public. They are frequently self-conscious and will often have a limited number of friends.
Generalised Anxiety Disorder
Generalised Anxiety Disorder is diagnosed when children have excessive and unrealistic worries about a broad range of possibilities. They may worry about things that might happen, about their own past behaviour, or about how good they are at their schoolwork or how popular they are. They often lack conﬁdence and need a lot of reassurance.
Post-Traumatic Stress Disorder
Post-Traumatic Stress Disorder may develop following a traumatic event such as being in a serious accident, experiencing a life-threatening event or witnessing extreme violence. Symptoms include changes in sleep pattern, irritability and problems with concentration. There may also be mental ﬂashbacks and re-experiencing of the event. Themes relating to the trauma may be seen in children’s drawings or in play.
Obsessive Compulsive Disorder
With Obsessive Compulsive Disorder, the child is affected by persistent unwanted thoughts, often about dirt or germs, or sometimes a need for symmetry. To try to stop the thoughts the child feels compelled to repeat a particular action, such as washing his or her hands or repeated counting. Older children usually recognise that the thoughts and behaviours do not make sense even though they are driven by them.
Anxiety can lead to school refusal. When children refuse to go to school as a result of anxiety it is usually accompanied by physical complaints, such as stomach aches or headaches.
How do anxiety disorders develop?
Humans are primed for survival to respond to situations where there are dangers or threats. Some people, including children, react more quickly or more intensely to such situations where there is danger or threat. The physical symptoms of anxiety (eg increased heart rate, faster breathing) are more easily triggered in children with anxious temperaments.
Having an anxious ‘internalising’ temperament often means that children react more to threats in the environment. This appears to be partly an inherited characteristic. Children with anxious temperaments are often cautious in their outlook and shy in relating to other people. Sometimes stressful events trigger problems with anxiety. Children who experience more stressful events over their lifetime than others or who have gone through particularly traumatic events may experience increased anxiety.
Learning may also play a part in the development of an anxiety disorder. Some anxious children may learn that the world is a dangerous place. They may learn that it is easy to get hurt either physically or socially. They may fail to learn positive ways to cope and depend more and more on unhelpful ways of dealing with situations that cause them anxiety.
Sometimes families may contribute to children’s natural cautiousness by being over-protective. This can unintentionally encourage children to avoid situations they feel anxious about.
How are anxiety disorders diagnosed?
Feeling anxious or fearful at times does not mean that a child has an anxiety disorder. Whether or not a diagnosis is made depends on how often, how easily and how intensely a child experiences the emotional symptoms of anxiety and how much it interferes with everyday living. To make a diagnosis, mental health professionals usually talk to the child and to family members. They may also ask teaching staff, parents, carers and children themselves to fill out questionnaires. The child’s age is an important factor in deciding whether the anxiety is a serious difﬁculty. This is because having certain fears is normal for children.
For example, if an infant cries when an unfamiliar person wants to hold him, his fear is judged as perfectly normal for his age. However, if a 12-year-old girl refuses to go to school because she fears something terrible will happen to her healthy mother, this may be evidence of an anxiety disorder.
Anxiety and other mental health difficulties
Children with anxiety can experience more than one type of anxiety difﬁculty or disorder. Anxiety can be more common in children with other developmental difﬁculties. For instance, it is common in children with Autism Spectrum Disorders and also can tend to occur in children with Attention Deﬁcit Hyperactivity Disorder (ADHD) and Oppositional Deﬁant Disorder. Anxiety and depression also often appear together. Children with anxiety symptoms can be more likely to grow to experience depression as teenagers, although this can depend on a lot of factors.
What professional supports are available?
Early assessment and professional support for children’s anxiety difﬁculties is most beneﬁcial. Psychological supports are very helpful for anxiety. Medication may be helpful in some cases, particularly when anxiety symptoms are very severe. Psychological support for anxiety disorders not only reduces the current difﬁculties but also helps to prevent anxiety and depression at later ages.
- Psychological support for anxiety typically involves teaching children to reduce avoidance and use more effective coping skills, such as relaxation and learning how to replace unhelpful thoughts with helpful self-talk.
- For phobias, professional support may involve gradually being exposed to the feared object or situation and the teaching of coping skills.
- Professional support works equally well whether it is run in groups or individually.
- Families are often involved in professional support. Education about emotions and the role of anxiety is helpful for some families. Family members can provide important support as the child learns new coping skills and practises using them in situations they may have previously avoided. The involvement of parents and carers has been shown to be especially important for younger children. For children whose anxiety is less severe, school-based social and emotional learning programs that build resilience and coping strategies can be very helpful.
How to assist children with anxiety problems
Children with anxiety difﬁculties are often quiet and obedient. This can lead to their difﬁculties being overlooked. It is important to take note of children’s worries so that their difﬁculties can be addressed sooner rather than later.
General principles for assisting children with anxiety disorders
Increase children’s helpful coping skills
Anxious feelings are fed by anxious thinking. It is important not to dismiss children’s anxious feelings, but to help children see that the situations they are worried about may not be as bad as they think.
Teach by example
Showing children how you cope positively with feeling anxious or stressed and remaining calm and positive when they are feeling anxious can help them to feel more conﬁdent.
Avoid taking over
Children with anxiety are usually very happy for someone else to do things for them. However, if adults take over, it stops children from learning how to cope themselves.
Encourage children to ‘have a go’
Having a go helps to show children that they can cope. Praise or reward them for every step they manage to take.
Steps for learning how to cope with anxiety about speaking in front of others
The child helps to construct the steps from easiest to hardest then practises using coping skills to try the ﬁrst step. When the child is able to cope without anxiety he/she moves up a step to the next level. Efforts should be acknowledged at each step using praise, rewards and positive self-talk.
1. Discussing a school project with a small group of other children
2. Starting off the group discussion
3. Presenting your part of the project to your group
4. Presenting your project to the class as part of your group
5. Presenting by yourself a project you have prepared with your group
6. Giving a two minute talk to class that you have prepared yourself
7. Presenting with your group at school assembly
8. Giving a report on your own at school assembly