Many children and adolescents struggle with anxiety and worry. According to the National Institute of Mental Health (NIMH), based upon the National Comorbidity Survey-Adolescent Supplement, 31.9% of adolescents aged 13-18 were identified as having an anxiety disorder with 8.3% of those individuals having severe impairment (Merikangas, K.R., et al., 2010). According to this study, the median age of onset for all anxiety disorders was six years of age. These prevalence rates highlight the importance of addressing anxiety among our youth.
Additionally, recognizing the early age of onset, it becomes important to address childhood anxiety early in the child’s life to prevent years of struggling with anxiety and worry. Adults often believe anxiety in childhood will abate over time. Although this can be the case, it is apparent that these anxious kids, became anxious adolescents who may become anxious adults. In the National Comorbidity Study Replication, 19.1% of U.S. adults had an anxiety disorder over the past year and 31.1% of U.S. adults have experienced an anxiety disorder in their lifetime (Kessler, R.C., et al., 2005).
A common mistake made when discussing anxiety is thinking that all anxiety is alike. The type of anxiety disorder an individual is diagnosed with is very important in helping to determine the course of treatment. The first step toward helping a child struggling with anxiety is assessing the type of anxiety the child is experiencing. A child having difficulty going to school may have difficulty for a variety of reasons. School avoidance can be a presenting problem associated with symptoms of Separation Anxiety Disorder, Obsessive Compulsive Disorder, Panic Disorder with Agoraphobia, Social Anxiety Disorder or a Specific Phobia such as Emetophobia (fear of vomiting), to name just a few.
The treatment approach for each of the above disorders will be vastly different. Important components of the assessment process include asking questions about: triggers for anxiety, places the child / adolescent avoids, places the child / adolescent can go without anxiety, behaviors the child / adolescent exhibits in a variety of settings with and without their parents, ritualistic behaviors, social relationships, and the child’s / adolescent’s strengths and weaknesses.
Asking questions of parents as well as the child or adolescent is essential since parents may fail to recognize symptoms that may be due to anxiety. Also, the child or adolescent may be embarrassed to discuss their anxiety, although individuals who are anxious often are very willing to share their fears in a safe, supportive, nonjudgmental environment.
It is beyond the scope of this article to provide a comprehensive overview of the diagnostic criteria for the various anxiety disorders. However, it is important to understand the distinguishing features among these disorders (Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-V), 2013):
- The essential feature of Separation Anxiety Disorder is excessive fear or anxiety concerning separation from home or attachment figures.
- In Specific Phobia, the fear or anxiety is regarding a particular situation or object.
- Social Anxiety Disorder is marked by an intense fear or anxiety of social situations in which the individual may be exposed to possible scrutiny by others.
- Panic Disorder with Agoraphobia is marked by fear or anxiety of having a panic attack and fear of going places due to this fear.
- Generalized Anxiety Disorder occurs when an individual experiences excessive anxiety and worry about a number of events and has difficulty controlling the worry.
- Obsessive Compulsive Disorder requires the presence of obsessions/compulsions which are time consuming (more than an hour a day) or cause marked impairment or distress.
Helping individuals manage their anxiety and worry involves many components, the first involving educating families about anxiety. Most individuals would like their anxiety to “disappear”. Taking this approach sets the individual up for failure. Understanding the importance of anxiety and how anxiety is adaptive helps to decrease the level of fear over the symptoms. The body’s reaction of fight or flight is meant to protect us from danger. The problem becomes when innocuous events trigger that fight or flight reaction. Hearing thunder, going to a birthday party without a parent, having to talk in front of the class, sitting in an auditorium, and riding on the school bus are all common activities that may signify danger to someone with an anxiety disorder. The individual with the anxiety disorder may have a physiological reaction to the thought or object which then leads to an overestimation of danger.
Some very common errors in thinking among individuals struggling with anxiety are overestimation of risk and catastrophizing the outcome. For the above examples, a child/teen may believe thunder will lead to their house catching fire from a lightning strike. Riding on a school bus may lead to someone vomiting. If dropped off at a birthday party, the child may be afraid the parent will never come back. Sitting in an auditorium will cause a panic attack and the child will not be able to get out.
Cognitive behavior therapy teaches the child/teen and family strategies to better manage their anxiety. Possible strategies that are part of a treatment plan based upon the diagnosis include: education, relaxation, and breathing retraining to help reduce the physiological escalation of anxiety; cognitive restructuring (to evaluate the anxious thoughts); gradual exposure to feared situations; exposure to the physical symptoms; and exposure and response prevention.
Gaining the child’s/teen’s motivation to treatment is paramount. The individual must face their fears in order to overcome their fears. Without motivation, it becomes a war of wills invariably with the child winning. Parents must recognize that if they make their child’s life too safe by protecting them from each of their fears (e.g., sleeping in his/her room, letting him/her stay home from school, providing constant reassurance, engaging in compulsions by washing things for him/her, not allowing any guests in the home, etc.) the child/teen may decide that facing his/her fears is not worth the effort. If the child/teen has to feel anxiety, then there may be more willingness to participate in treatment. Additionally, parents and teachers need to recognize how they may be subtly reinforcing the individual’s anxiety. Giving extra attention for fear rather than for bravery is just one example of this. Therefore, the adults need to change the attention they provide so that they are reinforcing their child being brave while approaching feared situations.
The most important message to remember is that the goal in life is not to live anxiety free but instead to learn how to not give in to the anxiety. To be able to live your life doing the things you value rather than avoiding fear. There is hope for families struggling with anxiety and worry that with motivation, effort, the appropriate strategies, and learning new skills, the individual can learn to manage their anxiety and prevent it from interfering in their lives.
Debra G. Salzman, Ph.D. is a licensed psychologist in private practice at Behavior Therapy Associates in Somerset, New Jersey. She can be reached by phone at 732-873-1212 or by email at firstname.lastname@example.org and we invite you all to visit BTA’s website at www.behaviortherapyassociates.com.