The Worried Child: Recognizing Anxiety in Children and Helping Them Heal

Introduction

This book was written for everyone who has contact with children. Parents, teachers, child-care workers, doctors, nurses, school guidance counselors, psychotherapists, child-protection workers, and even police officers can all benefit from learning about anxiety in children.

Addressing children throughout the world in May 2002, Kofi Annan, Secretary General of the United Nations, declared, We, the grown-ups, have failed you deplorably. The message was delivered to a General Assembly chamber in New York City packed with three thousand heads of state from more than 180 countries. In addition, the audience included another three thousand doctors, social workers, and representatives from nongovernment organizations. In bluntly criticizing the world’s leaders for failing to protect children—the future of humanity—Secretary Annan focused on violence, poverty, and disease. While he did not specifically mention anxiety, the very failures to which he referred contribute to this soaring epidemic.

The message has been echoed in the United States. The Surgeon General’s Office, the Department of Health and Human Services, and the Substance Abuse and Mental Health Services Administration (SAMSA) have all reported a crisis in the mental-health needs of our children and adolescents. SAMSA indicates that one in five American children and adolescents has a mental-health problem. If one in five children had pneumonia, we would consider it an epidemic, and federal funds would probably be allocated to help manage the crisis.

Some experts call today’s children the shell-shocked generation. The increasing rate of traumas to children, such as divorce and family breakdown, crime and violence, drug abuse, a failing school system, and recent terrorism, is affecting our children and producing anxiety in many cases. The number of adolescent suicides has doubled since the 1970s, and whereas previously there were no known suicides under the age of fourteen, today there are cases as young as five years of age.

Violence surrounds us in the news, on television, in movies, and even in video games, and children are directly affected by it. It is estimated that up to 19 percent of children carry weapons to school, and each week one student is killed by a firearm. Gunshots are the second leading cause of death by injury in the United States: In 1997 there were 32,436 gun-related deaths, 12.3 percent of which were children under age twenty. In addition, thousands of children are hospitalized each year due to physical abuse by their parents, and each year another two thousand to three thousand children are actually killed by their own parents. The number of children suffering from anxiety is likely to increase due to this trend toward greater stress and violence in the world, and the resulting threats to children’s security.

Anxiety is the most common emotional disorder in the nation—and perhaps the world. It is estimated that thirty-seven million Americans suffer from a diagnosable anxiety disorder, and that at some point in their lifetime 25 percent of the population will develop anxiety symptoms that would benefit from professional help. Anxiety outranks other emotional problems, including depression and substance abuse. Furthermore, anxiety is one of the most common reasons for medical visits. Anxiety is often responsible for sleep disorders, digestive disorders (nausea, constipation, irritable bowel syndrome, diarrhea), high blood pressure, and other ailments.

The true prevalence of anxiety in children is difficult to estimate because anxiety is invisible and is often overlooked and misdiagnosed, even by health-care professionals. Large surveys indicate that 10 to 15 percent of American children meet the diagnostic criteria for an anxiety disorder, making it the most common class of pediatric emotional disorder. The most common childhood anxiety disorders are generalized anxiety disorder, separation anxiety disorder, and specific phobias, each affecting between 3 and 6 percent of all children. Social anxiety disorder, obsessive-compulsive disorder, and selective mutism (inability to speak in certain situations) affect roughly 1 to 2 percent of children. Agoraphobia (avoidance of anxiety-arousing situations) and panic disorder are considered rare in children, although some children do avoid school or social situations to protect themselves from anxious feelings. In many cases, children are afflicted with more than one anxiety disorder, and it is also common for anxious children to experience depression. The various types of anxiety disorders that afflict children are described in more detail in Chapter 2 of this book.

Childhood anxiety disorders often go unrecognized and untreated because of a widespread belief that they are innocuous and that children will grow out of them. Yet anxiety disorders in children and teenagers can affect their school attendance, academic motivation, learning ability, memory, social life, concentration and attention, and sleep.

Anxiety sufferers overutilize health-care resources in an effort to obtain a correct diagnosis and effective treatment. The total annual cost in the United States for treatment of anxiety disorders (doctor and emergency-room visits, drugs, and medical tests) is estimated at over $42 billion, about one-third of the total mental-health bill and several billion more than the costs for treating depression. As an example of the high costs for anxiety, an estimated $33 million per year is spent on heart tests for people with panic attacks but no actual physical problems. Furthermore, the indirect costs to society in terms of missed work and lower productivity due to anxiety is in the range of $66 thousand annually per patient.

Severe anxiety in children is a far-reaching problem because it diminishes physical health, as well as intellectual, emotional, and social development. Many learning-impaired children suffer from anxiety, and many children and adolescents with behavior problems are suffering from the effects of stress and anxiety. Without appropriate help, most of these children and adolescents will grow up to be anxious adults with a multitude of medical problems, such as muscle tension and pain, digestive disorders, sleep disturbance, and weakened immune systems. In addition to those afflicted with severe anxiety, countless children suffer from anxiety that is beyond normal but less than severe. These include children who are shy, withdrawn, or inhibited, as well as those whose anxiety may be mistaken for depression, hyperactivity, or physical illness.

The longer children with anxiety go unrecognized and untreated, the larger the risk grows that they will suffer physically, emotionally, socially, and academically. If we can understand, identify, and intervene early enough, anxiety can be prevented from interfering with children’s normal development and overall quality of life. Unfortunately, many physicians—including pediatricians—are not attuned to anxiety underlying physical symptoms, and even when they can identify an anxiety disorder they may lack knowledge about local treatment resources. As a result, proper diagnosis and treatment for anxiety disorders are generally only provided to one-quarter of those who need such help.

How This Book Can Help

The seeds of adult anxiety are sown in childhood. Most anxious adults had early warning signals—some form of anxiety in childhood that may have gone unrecognized or untreated. My purpose in writing The Worried Child is to help you identify the symptoms and causes of anxiety in children, and learn the steps that can be taken to prevent years of suffering. Throughout the book I provide suggestions and guidance for parents, professionals, and children themselves to reduce anxiety and to encourage self-confidence, optimism, and skills for success.

The Worried Child is divided into three parts. Part I (Chapters 1-3) discusses the difference between normal anxiety and anxiety disorders, the types of anxiety disorders that typically occur in children, and the personality profile of anxious children. In addition, Part I introduces a key concept for understanding how anxiety develops in children.

Part II (Chapters 4-9) addresses the key sources of child anxiety. These chapters reveal the influences of family (performance pressure, divorce, discipline styles, family stress, anxiety in parents, and other issues) and society (dangers in the environment, sexual abuse, health-care policies, advertising, and other concerns). Separate chapters devoted to terrorism and war, media impact (television, video games, music, and Internet surfing), and schools can also be found in Part II, as these are powerful sources of anxiety in kids. As a special feature, I have included in this part of the book many concrete suggestions for counteracting such sources of anxiety. In addition, I have included an Appendix at the end of the book containing suggestions for how teachers and school administrators can reduce anxiety in children.

In Part III (Chapters 10-13), The Worried Child describes how anxiety can be treated through a variety of professional interventions that include psychotherapy, modern medication, and alternative systems of medicine. You will find that with appropriate help the success rate for treatment of anxiety disorders in children is approximately 80 percent. You will also find guidelines as to when and how to seek professional help. A unique feature of this part of the book is Chapter 12, which is written specifically for young people. It provides advice and guidance they can use to help themselves. The book’s final chapter discusses a variety of successful anxiety therapy cases from my practice. These cases illustrate the anxiety disorders discussed in Part I, as well as the therapy techniques described in Part III.

My Experience with Anxiety

My personal experience with anxiety has sensitized me to the nuances and special considerations involved in treating children with anxiety disorders. I developed several anxiety conditions early in life, including posttraumatic stress and generalized anxiety. As an adult, I also experienced panic anxiety with agoraphobia. A number of childhood experiences set the stage for these anxiety reactions: my parents’ divorce, sexual abuse, a near-death experience requiring an emergency tracheotomy, and growing up in a violent and racially tense community in New York City known at the time as Hell’s Kitchen.

For many years I was unable to relax, and I often distracted myself through studying and socializing. I was anxious most of the time, and my stress level was high due to my perfectionism, need for control, high achievement drive, and other personality traits. Throughout my childhood and adolescence, I concealed my anxiety and presented myself as outgoing and self-confident. And yet the more successful I was in the outer world—high school track-team captain, high school yearbook editor, dean’s list at Yale University, and professional leadership positions—the greater the pressure to hide my anxiety.

Many of the strategies that were helpful in my coping with and eventually overcoming my own anxiety are discussed in this book. They included learning how to relax, exercise and outdoor recreation, healthy diet, expressing feelings more directly, addressing anxiety-producing personality traits, and changing cognitive patterns such as worry and negative thinking. These strategies are appropriate for children, and they will be found throughout the book.

In addition to my personal anxiety background, I have been a psychologist for almost thirty years, with a practice devoted primarily to anxiety. I have found that many of my anxious adult patients had early warning signals of anxiety in childhood, including such symptoms as school phobia, shyness, excessive social anxiety, and anxiety associated with public speaking. I have also worked professionally with hundreds of children, and have found that early intervention can counteract anxiety and make a significant difference in overall happiness and success.

My personal and professional experience convince me that although anxiety usually begins in childhood, it can be overcome at any point in life, including adulthood. But why should children suffer for years when early recognition and intervention can reduce their anxiety and increase their self-confidence, optimism, and chances for reaching their highest potential? My hope is that The Worried Child will help your children reach these goals and experience the joy of living without anxiety.

PART I

Anxiety in Children: When Is It Normal, When Is It a Disorder?

CHAPTER 1

What Is Anxiety?

Anxiety is a normal part of life for everyone, especially children. Separation from parents in early childhood, taking an exam in school, giving a presentation in front of a class, and interviewing for college are all examples of normal anxiety. Anxiety can even be helpful by motivating children to cope with some of these challenges. However, persistent or intense anxiety is abnormal, and when it interferes with daily life it can become a disorder requiring professional help.

So how do we know when we’re seeing normal anxiety in children, and how do we know when it’s problematic?

This chapter introduces the key concepts necessary for understanding anxiety. In it, we will make a distinction between the normal anxiety experienced by most children and anxiety disorders (which are discussed in detail in Chapter 2). This introductory chapter also provides an overview of the biology of anxiety by describing the fight-or-flight reaction and how it relates to fear and anxiety. In addition, the three ingredients model of anxiety is introduced as a foundation for understanding how anxiety develops in children.

We will also take a preliminary look at the environmental stresses and threats that lead to anxiety in children, as well as the personality traits usually found in children who develop anxiety disorders. Those personality traits are the subject of Chapter 3.

The environmental causes of anxiety are addressed in Part II of the book, where the influences of family and society are explored. These include the impact of performance pressure, child abuse, terrorism and war, the media, schools, religion, sexuality, divorce, drugs and alcohol, parental anxiety, and health-related issues. Throughout Part II, you will find suggestions on how to minimize the effects of many of these sources of anxiety and thereby reduce anxiety in your child.

In spite of our best efforts as parents, there are many stresses and threats beyond our control that can lead to anxiety disorders in children. Therefore, two of the aims of this book are 1) to help you determine if your child could benefit from professional help and 2) to provide insight into psychotherapy, medication, and other approaches. In Part III, you will find information about available treatments for anxiety, including when and how to find a suitable professional to work with your child.

What Is Anxiety and Why Is It So Prevalent Today?

To begin our understanding of anxiety, let us clarify some related terms that will be used throughout the book. These key terms are often used interchangeably, but there are some important distinctions among them. Here is a quick preview:

FEAR—an instinctive reaction to a clear and present danger or threat

ANXIETY—a state of apprehension or worry about a danger or threat that might occur

FRIGHT—a state of fear when danger or threat catches us by surprise

STRESS—any situation (positive or negative) that requires adjustment or change

Fear is part of our survival instinct. When we are confronted with a dangerous or life-threatening situation, we automatically react with the fight-or-flight response. A survival center in the brain—the locus ceruleus—triggers this defensive reaction for the purpose of self-preservation. Chemical messengers (adrenaline, norepinephrine, adrenocorticotropic hormone, serotonin, and others) are released into the bloodstream to activate the entire system. For example, muscles tense to prepare for fight or flight, heart rate increases to supply extra oxygen to the body, vision and hearing become acute and focused, breathing intensifies to assist in oxygen supply, and posture assumes a self-protective mode. By this reaction, we become energized and we prepare to protect ourselves when threatened. All this takes place without our thinking about it, and once the fight-or-flight reaction begins it cannot readily be stopped.

The fear and survival reactions in children involve the same bodymind mechanisms as they do in adults. And when these reactions are chronic (due to frequent threats or stresses), they can lead to the next stage of symptoms, which includes difficulty concentrating, memory impairment, fatigue, physical complaints, anxiety and phobias, and difficulty relaxing. In children, these symptoms may manifest as low motivation, deterioration in school grades, or social problems.

Anxiety is related to fear. But while fear is an appropriate reaction to clear danger or actual threat, anxiety is the same reaction to a perception of danger or threat. In other words, anxiety is the fear reaction triggered by the possibility of danger or threat. In children, dangers and threats consist of anything that jeopardizes emotional security or physical dependency. They can include sexual or physical abuse, witnessing violence, divorce of parents, being bullied, losing a parent, injury or serious illness, and other stresses. The high rate of such stresses and threats facing today’s children is the main reason why anxiety disorders have become so prevalent.

Anxiety tends to develop after a child experiences a frightening or traumatic situation. For example, a child who has a traumatic social experience (which can range from social embarrassment to blatant physical or sexual abuse) may initially have a fear reaction, but the lingering aftermath may include persistent worry, concern, and dread—in a word, anxiety.

The survival reaction takes no chances, occurs quickly, and gives little time for thought. Furthermore, for self-preservation the brain’s survival center makes no distinction between possible and actual threat: Taking time to think or evaluate may be costly when faced with actual threat or danger. But the concept of threat today is often ambiguous or uncertain. Another reason why anxiety is so prevalent right now is that global stress and perceived threats are increasing, and they are magnified by vivid media coverage. As a result, we learn to see many situations as life-threatening. Indeed, many people recognize that their anxiety is irrational, but they are still unable to control it.

Anxiety can be explained to children by asking them to imagine being a small animal, such as a rabbit, living in nature where there is a clearly established system of predators and prey. When a vulnerable animal is threatened, it senses danger and hides until it is safe again. When it is safe, the rabbit relaxes and resumes normal activities.

Threats That Lead to Anxiety in Children

Let us consider some of the stresses and threats that lead to anxiety in children, keeping in mind that a perception of danger has the same effect as an actual danger or threat. Any situation that threatens children’s basic security can lead to an anxiety disorder. Divorce, for example, often involves a reduction in a child’s contact with one parent and generates anxiety about whether the parents will be there to provide care and protection. During divorce children often believe that if one parent can leave, then the other parent might also leave. For young children, security is based on the depth and consistency of emotional bonding with primary caregivers, typically the parents. Therefore, by minimizing loss of contact and maximizing involvement in a child’s daily life, an anxiety reaction to divorce can be reduced.

Any childhood experience involving a fear reaction or threat to security can develop into an anxiety disorder. Such experiences can include the following:

• Seeing a gun or weapon

• Seeing violence on television or in movies

• Divorce of parents

• Violence in the home (often associated with alcoholism)

• Theft of personal property

• Becoming sick and vomiting

• A serious or painful injury

• Illness in a parent

• Sexual or physical abuse

• Being bullied in school

• Natural disaster (hurricane, flood, fire)

• Terrorism or war

What is common to most anxiety disorders is an intense emotional response to an experience, such as one of the events listed above, followed by worrying about a reoccurrence. However, it can sometimes be difficult to pinpoint the initial anxiety reaction, especially since anxious children are generally more aware of their reactions and emotions than of their cause. The causes of anxiety in children are discussed in more depth in Part II of this book.

The Role of Stress in Children’s Anxiety

As a source of anxiety in children, stress can be any situation that involves unusual demands, strenuous effort, adjustments, or change, and it can be both positive and negative. One measure of stress is the Life Change Scale, which lists life events that are considered stressful, ranked by their severity and the likelihood of their producing bodily reactions. For adults, the highest stresses include death of a loved one, serious illness in the family, divorce, and marital separation. Less devastating but still stressful are increased responsibilities at work, financial problems, and family relocation. The lower end of the stress scale includes minor traffic violations, holiday stress, and planning a vacation. The impact of stress is considered cumulative. That is, a combination of several stresses during a period of approximately one year can cause a person to develop symptoms such as anxiety. By taking appropriate action, however, a person can reduce the impact of stress. Exercise, getting enough sleep, psychotherapy, reducing commitments and responsibilities, and other steps can offset the effects of stress.

The concepts used in the Life Change Scale can be applied to children. Table 1.1 lists many stresses that affect children, as well as a scoring system for estimating the likelihood of stress-related symptoms. Note that the stresses with highest impact include loss of a parent, divorce/separation, school stress, and family issues, all of which are addressed at various points in this book. Keep in mind that managing stress in children will lower the risks for physical or emotional problems. Suggestions for how to do this are included throughout the book.

TABLE 1.1: SOURCES OF STRESS IN CHILDREN

Another source of stress is the recurring demands of daily life that we assume are normal and that fill our schedules with increasing speed and intensity. For adults, such demands include working for a living, raising children, maintaining a home, doing the laundry, shopping for food, cooking and kitchen cleanup, recreation, and even socializing. Recognizing these demands as sources of stress, biologist Hans Selye wrote a now classic book on stress, titled The Stress of Life. He asserted that stress is an inherent and inevitable part of life.

Furthermore, in modern life our efforts to manage stress can become another source of stress. Our recreational activities, exercise, and even vacations are often approached with the same time pressure as the rest of our daily lives.

Children today can be as rushed and stressed as their parents, and this is often because of their parents’ stress. In an effort to provide opportunities and to jump-start their children’s success in life, many parents are overloading kids with extracurricular activities such as sports, music, art, and various other social, religious, educational, and recreational activities. The net result is stress in children who have too little personal time for relaxation and stress recovery. Chances are high that if the parents are feeling stressed and overwhelmed, their children are also feeling the same way.

On the other hand, stress itself does not necessarily lead to anxiety. We can handle stress without negative impact if we recover regularly. If we do this, our stress-recovery pattern becomes balanced, our energy reserves are replenished, and we can deal effectively with more stress. Some steps people can take toward stress recovery include regular exercise, adequate sleep and rest, proper nutrition, effective time management, positive social activities, and meditation. We will discuss these and other steps in later chapters.

However, when our recovery practices fail to keep pace with the demands of stress, we gradually deplete our energy reserves and wear down our resistance. We then go out of balance and develop early warning signals of stress overload in the form of mild symptoms. Headaches, backaches, difficulty relaxing, muscle twitches, and low energy can all be early warning signals of stress overload. When these signals are ignored, they may intensify until we are forced to notice and respond. This often occurs as anxiety, such as panic attacks, nightmares, or phobias. Why some children develop an anxiety disorder instead of a different set of symptoms is determined by personality type and family circumstances, as we will discuss later.

Emotions and Anxiety

In the preceding sections we have taken a preliminary look at some of the traumatic or threatening events that can cause anxiety in children. Those events can be thought of as external triggers of anxiety—that is, circumstances occurring in a child’s environment. But internal experiences, such as strong emotions, can also trigger anxiety. Actually, it would be more accurate to say that emotional arousal involves the same bodily reactions as the fight-or-flight response. Anger, for example, involves arousal in the form of muscle tension, increased heart rate, increased blood pressure, and intensification of breathing—effects associated with the fight-or-flight response. Excitement is another easily recognizable example. But other emotions, such as guilt, grief, and shame, can also involve bodily reactions similar to those triggered by the fight-or-flight response.

The distinction between external danger and strong internal emotions can be confusing, especially for the sensitive, anxiety-prone child, who tends to fear strong bodily reactions. As we will see in Chapter 5, many anxiety sufferers are raised in families where emotions are not discussed, or where they are expressed inappropriately, or even actively discouraged. In some families, strong feelings, such as anger, may be associated with out-of-control behavior. For these reasons, many people who develop anxiety disorders tend to be fearful of strong emotions. The onset of emotional states can therefore signal danger and trigger anxiety. To counteract this pattern, and to help children become more comfortable with emotions and how to express them, psychotherapy for anxious children usually includes education about emotions and communication skills.

Some of the techniques