CHAPTER
20

Helping Anxious Children Recover

In This Chapter

• Learning which childhood fears are normal
• Discovering how you can help your kids overcome typical fears and worries
• Finding out how much childhood anxiety is too much
• Checking to see how much anxiety is impacting your child’s daily life
• Identifying when and how to get professional help for your child

Are youngsters more anxious these days? Well, consider some of the stressors many parents face: divorce, less access to extended family and friends, and a lack of social connectedness. On top of this is our increased awareness of security threats such as violent crime, terrorism, child abduction, and catastrophic diseases. This increased awareness fosters both a lack of trust and an increased sense that we must always be vigilant and on-guard. The same issues that cause adults to feel anxious can unsettle youngsters, too.

If children are more anxious these days, then how much anxiety is too much? When is a fear “normal,” and when is additional help warranted? In this chapter, we take a look at what amount of anxiety is typical of childhood and what is not. We also talk about how you can help your children with normal fears and what you can do when the problem is too big for you. No matter how large or small your child’s problem is, though, keep this in mind: help is available.

MYTH BUSTER

Shy kids always become shy adults. Reality: only 25 percent of children classified as inhibited at 2 years of age were still rated such at age 7. And 99 percent of the “shy” children were inhibited in some situations, but not in all of them.

Childhood Anxiety

Jessica, 6, cried and refused to get out of her mother’s car with her older brother on her first day of school. She has always tended to stick close to her mother and worries whenever her mother is away from home without her. She has nightmares that her parents will die in a car accident or plane crash, and she’ll go on play dates only if her mother stays with her or nearby. Once she temporarily got separated from her parents in a department store and was almost inconsolable.

Ryan, 13, is so nervous around other kids that he won’t participate in any school activities. He has only one friend, a child he’s known since preschool. He sits in the back of the room and refuses to speak out loud in class, even though his grades suffer because of it. On days when the teacher goes around the room and makes students take turns answering questions, he breaks into a sweat and can’t concentrate.

Samantha, 9, is teasingly called “worrywart” by her friends and family. However, lately her symptoms have been getting worse, and she is tense, irritable, and sleeping more poorly than usual. Her mother is concerned and frustrated by Samantha’s constant worrying and need for reassurance. Samantha frets about every school assignment and whether girls in her class like her. She gets very upset when she overhears her parents arguing, and she asks her mother if they will divorce.

Jessica, Ryan, and Samantha are all struggling with an anxiety disorder. Even though their diagnoses are different and their symptoms vary, they have one thing in common: life is hard. Apparently, more and more children are anxious today; two meta-studies reported in the Journal of Personality and Social Psychology compared thousands of children and college students from the 1950s through the 1990s and discovered that “normal” schoolchildren by 1981 were more anxious than child psychiatric patients in the 1950s. Subsequent research has shown anxiety levels appearing to plateau around the early 1990s. They haven’t worsened since then, but they’re still higher than they were a few decades ago.

Importantly, childhood fears are very common. Most children have several fears at any given age; some studies, in fact, show that 90 percent of children between the ages of 2 and 14 are afraid of at least one thing—thunder, the dark, being sucked down the bathtub drain, etc. To some extent, this is a normal part of growing up.

ANXIETY ATTACK

Sleep problems can be a cause of anxiety in children. Abnormal sleep patterns (not getting enough sleep, falling asleep at school or during other activities) may result in excessive fears, preoccupations, and anxiety.

Children’s fears often grow out of experiences that they can’t understand or perceive as threatening. Because so much of the world is new, fears can serve a protective purpose; they encourage a child to be cautious until she or he either understands a situation better or is able to cope with it more effectively. For example, a 1-year-old may not understand why a vacuum cleaner makes such a loud noise and, as a result, is frightened by it. Common “triggers” for normal childhood fears include the following:

• Witnessing other people’s reactions: If you’re afraid of spiders, it’s possible your child will pick up on this and exhibit the same response.
• A frightening event: A 4-year-old who gets briefly separated from his dad at the park may develop separation fears. Even witnessing someone get bitten by an aggressive dog, or observing a serious car accident, can result in lasting fearfulness.
• Family disruption: All families have disagreements from time to time, but if there is a constant air of hostility in your home, your child can absorb that tension. The loss of a parent or the parents’ divorce can precipitate the development of fears of separation or other unpredictable events.

ON THE CUTTING EDGE

Twenty-five percent of children involved in motor vehicle accidents may show signs of acute stress disorder, even if they weren’t seriously injured; symptoms include intrusive thoughts or images and sleep difficulties.

Stage Fright

As you’ve seen, childhood fears are common and can serve a useful purpose; they encourage a child to be cautious and provide a manageable opportunity to overcome irrational fears. Because fear is a response to real or perceived danger, it makes sense that what is perceived as dangerous will depend on the child’s developmental level and natural temperament. How children think affects what they fear; preschoolers, for instance, are often afraid of monsters under the bed, whereas an older child is likely to be afraid of real “bad guys,” such as robbers or kidnappers.

Here’s a look at some of the common fears kids have at different stages in their childhood—and how they typically express them.

Infants

Fears: falling, being dropped, and loud noises. From 7 to 9 months until about 18 months, they’re also often afraid of strangers.

Clues: crying, stiffening, and sometimes shaking.

Toddlers

Fears: strangers, separation from parents, animals, bugs, storms, sirens, large objects, dark colors, darkness, people with masks (including clowns), Santa Claus, monsters, and “bad” people such as burglars. Youngsters at this stage are often afraid of being separated from their parents.

Clues: crying, trying to avoid the person or thing they’re afraid of (which can often look like a temper tantrum but which immediately ceases when the child gets away from what is feared).

Preschoolers

Fears: separation from parents, being left alone or sleeping alone, and imaginary figures, such as ghosts, monsters, and supernatural beings.

Clues: crying, physical symptoms such as stomachaches or headaches.

School-Age Children

Fears: being home alone (younger school-age children may still fear separation from parents), poor school achievement or peer acceptance, violence, kidnapping, illness or physical injury, disasters such as floods, earthquakes, and tornados.

Clues: sleep disturbances, stomachaches or headaches, excuses about not wanting to go somewhere or do something, “jumpiness,” and tearfulness.

Adolescents

Fears: social rejection, poor achievement in school, unpopularity, and sexuality, including dating and sexually transmitted diseases.

Clues: withdrawal from parents, irritability, forgetfulness/distractibility, overreaction to minor changes in family routine.

Just like adults, children of all ages can become anxious about changes, such as moving to a new house or school, divorce, and so on. And, as you’ve seen, some children are naturally more fearful than others. However, if your child’s fear isn’t keeping him or her from eating and sleeping, going to school, or playing with friends, parents and children can often deal with the fears on their own.

ANXIETY ATTACK

Children often love to hear stories about kids who have experienced similar fears. Check out ces.purdue.edu/providerparent/Child%20Growth-Development/Books_onfears_Children.htm for a list of children’s books about coping with fears.

Overcoming Childhood Fears

Perhaps the biggest challenge for parents in dealing with childhood fears is understanding how differently the world can look from a child’s viewpoint. It can be confusing to have a child who is enthralled with fire or fearless in the face of oncoming traffic (things you’d like them to be afraid of) become petrified by her older sister’s Halloween costume or insist on a nightly search for monsters in the closet. How tempting it can be to dismiss these fears as foolish or unimportant or to try to explain to a 4-year-old that ghosts aren’t real.

You can also forget that you, too, had fears that came and went and, as a result, assign too much importance to a child’s age-appropriate concern. Overreacting may teach a child that when he acts afraid, he’ll be sure to get attention. Alternatively, if you become anxious or worried in response to a child’s fear, this may increase his anxiety level. Parents can unwittingly play a key role in reinforcing and encouraging normal childhood fears so that they continue long after their age-appropriateness has diminished. Of course, a child who is predisposed toward anxiety may tend to develop more long-lasting fears.

Finding the Middle Ground

As with many aspects of parenting, the trick in helping a child work through his or her fear is to find the middle ground between “I’ll protect you from it” and “get over it.” For example, helping children learn about what scares them (why fire trucks have sirens, what vacuum cleaners do) is a better strategy than arguing about whether the fear is legitimate or the situation objectively dangerous.

Talk about your own childhood fears, especially what it felt like to be afraid and how you learned to cope with your fears. Remember how much children thrive on rituals and routine and create a sense of structure and predictability in your home. Children are also less scared when they feel they have some control over a situation. Activities like field trips or fire drills can be stressful; ask your child what she or he expects and tell them what will happen. Take a child who’s going into the hospital for a tour ahead of time; slowly introduce your dog-terrified child to some stuffed animals or a litter of puppies. Prepare your child for the next thunderstorm with information about lightning and thunder.

Don’t forget to use your child’s wisdom. Ask your child what would help him or her feel less afraid and encourage them to come up with ways to manage their feelings. Express pride when you notice their moments of personal courage, such as climbing the jungle gym or reaching out to a new classmate. As children grow older, you can use their intellectual maturity as well; for example, an older child can understand the difference between “probability” and “possibility,” which can help them more realistically evaluate situations that provoke their anxiety.

ON THE CUTTING EDGE

Here’s another reason for parents to conquer their own anxiety. Research on children undergoing surgery found that the presence of a calm parent during the administration of anesthesia helped an anxious child; if the parent was anxious, however, calm children became more anxious, and an anxious child derived no benefit at all from the parent’s presence.

Additional Strategies for Coping with Fears

Here are some additional strategies that can come in handy:

• Teach your child how to rate fear (just as you did with anger in the last chapter). If your child can visualize the intensity of the fear on a scale of 1 to 10, with 10 being the strongest, he or she may be able to “see” the fear as less intense than first imagined. Younger children can think about how “full of fear” they are, with being full “up to my knees” as not so scared, “up to my stomach” as more frightened, and “up to my head” as truly petrified.

• Don’t cater to fears. Avoiding vaccinations because a child is afraid of shots, or crossing the street to avoid a dog, reinforces that these are things to be feared and avoided. Instead, provide support and gentle care as you approach the feared object or situation.
• Find practical solutions. A nightlight in the hallway, for example, can ease a fear of the dark.
• Practice skills with your child. If your youngster is afraid of giving a speech in front of the class, encourage her to practice with you. If he’s worried about his sports performance, spend time playing catch with him at home.
• Remind your child of other things that he was afraid of in the past but no longer fears.
• Praise small “brave” steps in the right direction.
• Give your child coping options, such as using you as “home base” to which he can return for safety. Teaching positive affirmations, such as “I can do this,” and “I will be okay,” can help a child feel less anxious in fearful situations. So can relaxation techniques such as deep breathing (imagining that the lungs are balloons that are inflating with each deep breath) and visualization (imagining himself floating on a cloud or lying on a beach).
• Encourage your child to exercise. This not only helps relieve stress by distracting him from what he’s anxious about, but also triggers a physiological “relaxation response.” Children who are anxious often feel tired (stress can be fatiguing, and it can also cause rapid, shallow breathing, which can result in feeling tired because of lack of oxygen), and so they don’t feel like exercising. Exercise will improve their energy and ease their worries. If you can, join in with your kids so it will be a fun family affair, not one more chore they “have” to do.

Childhood Anxiety Disorders

Although all children are afraid some of the time, no child should be afraid all of the time. Some children don’t outgrow their fears; instead, the fears may get worse and interfere with their daily lives. Unfortunately, childhood anxiety disorders are often overlooked or misjudged, and it’s important to note that many adult diagnoses have their first manifestations in childhood.

Given that the lifetime prevalence for anxiety disorders in adults is about 25 percent, we can make an educated guess that there are a lot of children with treatable mental conditions who are suffering needlessly. In fact, a recent review of many studies showed that about 10 percent of children experience some kind of anxiety disorder.

For example, separation anxiety disorder, intense fear and worry about being apart from family members or others to whom the individual is most attached, affects approximately 4 to 5 percent of U.S. children between ages 7 and 11. Social anxiety disorder typically surfaces during adolescence, although it can be preceded by a period of shyness in childhood. In addition, children can—and do—develop specific phobias (many of which have their onset in early childhood), generalized anxiety disorder, panic disorder (more rarely), and related conditions like obsessive-compulsive disorder (OCD), post-traumatic stress disorder, and depression.

Symptoms of Separation Anxiety

Although separation anxiety is normal during a period of infancy, growing kids may develop a more intense version that can interfere with everyday life. Here are some signs that a child might be experiencing serious separation anxiety:

• Constant thoughts and intense fears about the safety of parents and caretakers
• Refusing to go to school
• Frequent stomachaches and other physical complaints
• Extreme worries about sleeping away from home
• Being overly clingy
• Panic or tantrums at times of separation from parents
• Trouble sleeping or nightmares

Symptoms of Phobia

As you saw in Chapter 15, people can develop phobias about many common objects or situations. If you think your child might have phobic anxiety, here are two hallmarks to watch for:

• Extreme fear about a specific thing or situation (for example, dogs, insects, or needles)
• The fears cause significant distress and interfere with usual activities

Symptoms of Social Anxiety

Although many kids feel a little shy in new situations, there may be more to it if you see the following in your child over time and across a range of situations:

• Fears of meeting or talking to people
• Avoidance of social situations
• Few friends outside the family

Other Symptoms of Anxious Children

Kids have many ways of expressing their fears, but here are some of the more common behaviors to watch for:

• Many worries about things before they happen
• Sleep deprivation due to worry, fear, or attempts to control these concerns
• Constant worries or concerns about family, school, friends, or activities
• Repetitive, unwanted thoughts (worries or obsessions) or actions (compulsions or avoidance of certain situations)
• Fears of embarrassment or making mistakes
• Low self-esteem and lack of self-confidence
• Family conflict over seemingly mundane issues (such as going to school or a minor change in routine)

In evaluating whether or not a child has an anxiety disorder, professionals often consider four factors:

• How intensely does the child experience the anxiety symptoms? Do they make her physically ill? Do her worries take up much of the day?
• How long have the symptoms lasted? Anxiety that lasts longer than a month may indicate a need for professional treatment.
• How age-appropriate are the child’s fears? Separation anxiety at 1 year is not a matter of concern; it might be if the child is 9.
• How much do the anxiety symptoms prevent the child from engaging in, and enjoying, regular activities? Is the child missing sleepovers or not getting ready for school in the morning?

For you as a parent, though, your primary questions are often how much emotional pain your child is experiencing and how you can help lessen it.

Red Flags

Because anxious children may be quiet, compliant, and eager to please, their difficulties may be overlooked. Parents may be the first, or the best, ones to recognize when a child’s problems are too much for him or her to manage. In looking at this checklist, the focus is on the perspective of the child—not on clinical diagnosis; what matters is the amount of distress and pain your child is experiencing.

Has your child’s anxiety lasted more than one month?

Does your child worry a lot about the future?

Does your child often ask unnecessary questions and repeatedly ask for reassurance?

Does your child worry excessively about a number of events and activities?

Does your child get frequent stomachaches and headaches at school?

Does your child have nightmares about being separated from you or excessive fears about something bad happening to you?

Does your child seem exceedingly anxious or uncomfortable with peers, to the point that she or he avoids them?

Does your child feel extremely nervous when she has to do something (play a sport, speak up in class) while others watch her?

Have you noticed your child’s school work or social activities declining?

Does your child seem to make a lot of excuses to avoid school whenever possible? (An example would be “illnesses” that magically improve as soon as he or she is allowed to stay home.)

Does your child throw temper tantrums to avoid certain activities or objects?

Does your child constantly worry about things that have already happened?

Does your child have certain rituals or routines that are extremely distressing when disrupted?

Does your child worry to the point that she feels physical symptoms (like throwing up, dizziness, shakiness, or sweatiness)?

Does your child redo tasks because he’s never satisfied with his performance?

Does your child constantly worry about how well she is doing at school or in competitive activities?

Is your child consistently afraid to meet or talk to new people?

The more items you recognize in your child, the better the odds you can benefit from the advice of a professional.

Differences in Expression of Anxiety Symptoms in Children

When it comes to anxiety in children, an educated parent is the best advocate for his or her child. Having a clear understanding of what anxiety disorders look and feel like can be a great aid in understanding when a fear is just a “stage” and when it’s a warning signal. Parents who have struggled with anxiety themselves can be quick to pick up on the current of fear running through a child; used wisely, your sensitivity can enable you to help your child work quickly through normal fears and get early treatment when the child’s fears are excessive or limiting.

However, although anxiety symptoms are often similar in adults and children, they are sometimes expressed differently. Unlike adults, child anxiety sufferers often can’t manipulate their environment to avoid a frightening situation. For example, socially anxious children must attend school and will be asked to read out loud, take part in a class project, or go on a field trip. As a result, in an attempt to better manipulate their environment, children with anxiety disorders may be angrier and more defiant in comparison to their grownup counterparts. Anxiety or fear can result in temper tantrums.

ANXIETY ATTACK

Pay attention to what turns a temper tantrum on and off. If your child’s “fit” immediately and consistently stops when you allow him or her to avoid a certain situation or event (go to school, attend a birthday party), that’s a clue that the temper tantrum was about that activity.

Similarly, anxiety symptoms in children often reflect their level of intellectual development. For instance, all children engage in magical thinking, an immature thought process that confuses correlation with causation. I was mad at my dad and then he died; therefore, I caused his death. In this worldview, effects and their causes are not objectively determined, but mediated by the child’s own desires; it is raining because I am sad.

STRESS RELIEF

It can be challenging to balance promoting self-confidence in new situations and teaching your child to be cautious in potentially dangerous ones. The best defenses against the real dangers of the world are age-appropriate supervision, knowledge (safety rules, emergency procedures), and preparation (code words, how to say “no”).

Helping Your Children Recover

Not only are we recognizing that many adult anxiety disorders begin in childhood, we are more and more aware that the sooner an anxiety sufferer gets help, the better off she or he will be. In recognizing that a fear has gone on too long or is taking its toll on your child’s social or academic life, you can get your child the help she or he needs and prevent additional problems such as lack of friends, school difficulties, and low self-esteem. You can also prevent your child’s anxiety disorder from causing family problems or robbing you of the joy of parenting a happy and well-adjusted child.

So what can you expect when you take that leap of faith and schedule that first appointment? You can expect your child to get better; the vast majority of children treated for an anxiety disorder show significant improvement in three to four months. You can expect your child to gradually face his or her fears. The most common (and research-validated) psychotherapy approach is gradual exposure to scary situations and objects, similar to that discussed in Chapter 17. Depending upon the severity of your child’s symptoms and your personal values/beliefs, you should be prepared to discuss medication.

ANXIETY ATTACK

When seeking a mental-health professional for your child, consider talking over your concerns with your child’s pediatrician, teacher, or guidance counselor. Not only do they know you and your child well, but they should also be involved in any assessment of the problem.

You can also expect to take an active role in your child’s recovery. You can do your homework and make sure the therapist you choose has specific experience working with children who have anxiety disorders. You can work with the therapist to make sure the messages you give your child at home are in sync with your child’s treatment. You can discuss ways you can encourage your child to practice their newfound skills. You can explore ways you can simultaneously support your child, set limits on inappropriate behavior, and keep your family on an even keel. In the process, you can remind yourself of the big picture; no matter what genetic cards your child is dealt or what comes up, you as a parent are a powerful coach in helping your children develop the coping skills to succeed.

MYTH BUSTER

If my child needs help, I must be a bad parent. No one would think less of you if your child had diabetes or cancer. A mental illness is no different. The greatest harm comes from leaving a mental illness untreated. But just like with physical problems, the prognosis is better when a mental health problem is treated early.

The Least You Need to Know

• Worries and fears are a normal part of growing up.
• Parents can help their children overcome age-related fears by finding a balance between “get over it” and “I’ll protect you.”
• When childhood fears last too long and disrupt a child’s daily activities, she or he may have an anxiety disorder.
• Children can be diagnosed with the same anxiety disorders adults have. However, the expression of their symptoms can be different.
• Parents can play an active role in their child’s recovery by getting the right professional help and working with the therapist to reinforce new skills at home.