Last partial update: July 2016 - Please read disclaimer before proceeding

Definition, incidence and causes

Anxiety is a normal response to a stressful life situation such as illness, imminent danger etc. At these times, it is normal for children to feel tense and irritable and sometimes even to panic. Such reactions are often beneficial, such as fear of strangers. These feelings are often accompanied by physical symptoms such as palpitations, sweating, chest tightness, tremors, difficulty in breathing, hot and cold flushes, nausea, difficulty swallowing, diarrhoea, headaches and muscle tension.

Anxiety disorders, on the other hand, are associated with persistent feelings of heightened anxiety that are inappropriate for the situation. These feelings lead to irrational responses that are significant enough to interfere with daily life activities, often involving the avoidance of situations associated with these concerns.

Anxiety symptoms usually develop during early childhood and anxiety conditions are at least as common in childhood as they are in adults, with the incidence of anxiety in children and adolescents being about 10 per cent. Like most mental illnesses, they are chronic in nature. There are numerous types of anxiety reactions that occur in children and adolescents and about 33 per cent of sufferers experience multiple anxiety reactions. About 33 per cent of children and adolescents suffering from anxiety reactions have coincident depression and commonly their education often suffers. If left untreated, they are much more likely to become anxious and depressed adults, develop substance/alcohol abuse, and endure unemployment and social isolation.

Causes of childhood anxiety

The exact cause of anxiety disorders is still unclear. However, in most cases there are both inherited and learned (environmental) components present. While the learned component has mostly occurred by the time young adulthood is reached, the good news is that there are many good programs for the management of anxiety that have strong evidence for their benefit; and it can be unlearned as well by using stress management programs and good parenting techniques.

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Types of anxiety disorders in adolescents and adults

There are various types of anxiety disorders with those occurring in children being significantly different to those occurring in adolescents and adults; although all adult anxiety disorders can also occur in children. (See below). Unfortunately, many people suffering from them do not seek help, with only about 30 per cent of suffers seeking professional mental health assistance. This is a pity as treatment with psychotherapy, usually cognitive behavioural therapy (CBT), commonly works well. The basics of CBT are discussed in the section on on Achieving change and in the section on depression.

Adult anxiety disorders

Generalised anxiety:
People with this disorder worry inappropriately about all manner of things, such as finances, health and relationships. Their worry is often associated with restlessness or feeling ‘on-edge’, irritability, insomnia, fatigue, muscle tension and impaired concentration. It occurs in about three per cent of Australians each year and is at least twice as common in women. It is often accompanied by agoraphobia (the fear of being in public spaces).

Agoraphobia:
These people have a fear of public places or situations from which escape is difficult. This is a very common disorder, especially in women, and is usually experienced in crowded situations, such as lifts or public transport. Hence sufferers often tend to stay at home. Sufferers may experience a panic attack.

Panic disorder:
These people experience recurrent extreme panic attacks which come on quickly and last usually for a short period. These attacks are associated with numerous symptoms including palpitations, shaking, numbness, sweating, chest pains, shortness of breath, nausea, choking, dizziness / faint feelings and feelings of being detached from oneself and losing control. Usually one symptom, such as shortness of breath, will become the focus of the disorder and the episodes are often misinterpreted as being due to or associated with a catastrophic medical condition such as a stroke or hear attack; sometimes sufferers fear that they will even die. The episodes are followed by a prolonged period of worry about another attack occurring and the person usually responds by taking steps to avoid situations where they fear another attack will occur. This often leads to an association with agoraphobia, as sufferers avoid places where panic attacks have previously occurred, and social phobia, as sufferers often associate attacks with specific social situations in which attacks have previously occurred. (Panic disorder can occur in association with any anxiety condition.) It occurs in about three per cent of Australians each year, is at least twice as common in women, and peaks in the mid 20s. About 30 to 50 per cent also have co-existing depression. This condition responds very well (90 per cent) to cognitive behavioural therapy. Antidepressants are also quite effective but there is a higher relapse rate than occurs with CBT.

Specific phobia:
Sufferers are inappropriately fearful of a specific situation or thing, such as spiders.

Social phobia (Social anxiety disorder):
Social phobia is very common, with as many as 10 per cent of the population suffering from the disorder at some time during their life and about two per cent suffering more severe impairment.

These people feel that their character is flawed in some way, for example that they are stupid, incompetent, uninteresting or unattractive, and that other people will think badly of them in some way. Thus, they fear public scrutiny and experience feelings of shame, fear and embarrassment when exposed to such scrutiny. This causes physical symptoms of blushing, rapid breathing, breathlessness, sweating, palpitations, nausea, dizziness or shaking and these symptoms may be bad enough to cause panic attacks. (The fear that symptoms such as blushing will expose their underlying anxiety about the social situation they are presently in only makes the situation worse.) Behavioural responses in sufferers range from excessive shyness to avoidance of the situation, flight from the situation or freezing during the situation. These symptoms and responses generally occur when mixing with people in public or in specific situations such as when the person speaks in public, takes tests or is examined, eats or drinks in public, or performs work duties under observation.

The disorder can significantly impair educational attainment and workplace advancement, and thus economic prospects.

Sufferers tend to be oversensitive to signals from others and can misinterpret these signals, often seeing every response as a negative one. There is also an inherited / ‘family learned’ component in many affected individuals, with parents and other family members often exhibiting similar social phobia traits.

Obsessive compulsive disorder:
These people inappropriately worry about recurrent, specific intrusive thoughts, ideas or impulses, such as cleanliness. They placate these obsessive thoughts etc by developing highly repetitive, stereotyped behaviours (compulsions), such as handwashing.

Post-traumatic stress disorder:
These people have unresolved anxiety associated with a particular traumatic event in their lives.

Anxiety disorders in children

Anxiety disorders have an incidence of about ten per cent in children and adolescents and while all adult anxiety disorders can also occur in children, there are several anxiety disorders that are specific to children. In children, separation anxiety disorder and generalized anxiety disorder are the two most commonly seen, both having an incidence of about three to four percent. Adolescents on the other hand mostly suffer adult type anxiety disorders, the most common being generalized anxiety disorder, social phobia, agoraphobia and panic disorder.

Separation anxiety Disorder (& School phobia)
This disorder mainly occurs in children around the age of six to eight years of age (most are under 12) and it is the most common anxiety disorder in this age group. The child fears being separated from primary care givers, their main concern being that some injury or illness will happen to the carer when they are away. The children often exhibit obsesssive traits.

It is usually associated with refusal to go to school (75 per cent ), school camps, friends’ homes etc. School refusal ocurs in about 5% of school-aged children, most commonly at the entry to primary (age 5 - 6) and secondary school (age 10 - 11). In older children bullying needs to be excluded as a cause.

Medical symptoms are commonly used to avoid leaving home, including headaches and stomach aches. Recurrent stomach aches are particularly common avoidance mechanism, being used at some time by up to 25% of school children; especially in girls. They are often over-investigated, leaving the true anxiety cause untreated. Nightmares also occur frequently.

Generalised anxiety disorder:
Generalised anxiety disorder is the next most common childhood anxiety disorder with an incidence of about 4 per cent. It is characterized by excessive worrying about future events, social acceptability and personal adequacy / competency. Affected children are often perfectionists and regularly seek reassurance for their worries.

Social phobia:
This disorder is characterized by avoidance of social or performance situations for fear of being embarrassed or being judged harshly. It usually involves a variety of tasks, including speaking or performing in public, being present at social gatherings. or meeting unfamiliar people. It usually appears in mid-adolescence; but initial tendencies often appear much earlier. If untreated, this disorder is often associated with substance abuse in late adolescence / early adulthood.

These adolescents are socially marginalised, often having few friends and having difficulty with initimate relationships. They are often anxious in school settings but relaxed at home.

Selective mutism:
Here children refuse to speak in specific situations, such as to strangers or when they are away from home e.g. at school. It can occur in a transient form when commencing school.

Post-traumatic stress disorder:
These children have unresolved anxiety associated with a particular traumatic event in their lives. In Australian children and adolescents this mostly occurs following exposure to chronic abuse (physical / sexual), domestic violence or a traumatic home event, such as the death of a family member or a motor vehicle accident. Children constantly relive these experiences and often have nightmares. They over-react to situations that remind them of these experiences with rage or complete shutdown.

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Preventing and addressing anxiety disorders in children - An important parenting issue

As anxiety disorders (and the depressive disorders that they are associated with) are often well established by late adolescence, the only realistic prevention strategy is to address factors causing the problem during childhood and adolescence.

While these disorders are more common in children with anxiety tcharacter traits, they are so commonand so debilitating that all parents need to adopt parenting strategies that can reduce their incidence. These mostly involve building resilience and self esteme in children. It is one of the most important topics on this web site and is covered in two separate sections. Both need to be read!

1. The first is 'Preventing anxierty and depression in children - Building resilience'.

2. The second in the section on parenting, which describes a variety of strategies aimed at reducing mental illness developing in children . To access this section click here 'Parenting'.

A even more worthwhile resource to access is the book I just want you to be happy Preventing and tackling teenage depression, written by three Australian doctors intimated involved in the challenge of preventing depression in children and adolescents; Professor Leanne Rowe, Professor David Bennett and Professor Bruce Tonge.(Published by Allen and Unwin 2009.) This book is aims to do just want it title suggests; help parents prevent and treat teenage depression.

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Identifying children showing early anxiety signs

Many children at increased risk of developing significant anxiety disorders can be identified early and treated effectively. Children at increased risk of developing anxiety disorders include those that:

are shy or withdrawn and have negative feelings, especially towards themselves
show symptoms of depression
have a family history of anxiety disorders
have overprotective and overly critical parents with unrealistic expectations for their children
have a predominantly ‘negative’ relationship with their parents
have suffered from neglect

Identifying anxious children is not always easy. They are often very well behaved at school and don’t bother anyone. Thus they can be easily missed. Typically, they will only show their fears by avoiding the situations that worry them, such as performing in public, participating in class discussions, or engaging in unfamiliar activities. This avoidance behaviour often occurs on Mondays or at the beginning of school terms and can include pretending to be sick, with headaches and stomach problems being common complaints. At school, anxious children usually require constant reassurance. They may ask many unnecessary questions and get upset when they make mistakes. Some are perfectionists with a pessimistic attitude to tasks, thinking they will never produce work that is good enough. They are often loners or have only a few friends. They may refrain from social activities, such as birthday parties, and have difficulty separating from parents. Problems with sleeping are not uncommon.

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Treating anxiety disorders in children and adolescents

General considerations

Childhood and adolescent anxiety is a serious problem and left untreated can affect lives for many years. It therefore needs to be treated seriously and help should be sought from a practitioner interested in and competent at treating this conditions. The approach taken depends on the type of anxiety disorder present. Treatment in most cases involves counselling using a form of cognitive behavioural therapy (CBT). CBT can be done with the child alone but there is evidence that it is better done with parents being involved and it is thought to be effective in at least 50 per cent of childhood anxiety cases. An outline of the principles of this therapy is given in the section on treating depression (Click here) and the chapter on Achieving change. (Click here).

Medication is rarely used for the treatment of anxiety in children. (Medication for anxiety is discussed in the section on adult anxiety and depression.)

Treatment of acute panic attacks is also covered in the section on adult anxiety and depression.

As stated above, many adults and adolescents with an anxiety disorder also have depression and it is important to recognise when these conditions occur together as these people are harder to treat. Generally speaking the condition which came first is the one that needs most attention, although anyone with significant depressive symptoms needs them treated as a priority.

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Avoid stimulant substances that increase anxiety

Some adolescents consume stimulant drugs that can make anxiety symptoms worse.

Caffeine
The most common of these are caffeine containing substances. Most adult consumption of caffeine occurs via tea and coffee but in adolescents, the main source is cola drinks and newer energy drinks, which can contain large amounts of caffeine and are becoming increasingly popular. More worrying is the fact that caffeine containing substances, mostly commonly guarana, are being added to alcoholic pre-mixed drinks that are targeted at adolescents and young adults. Caffeine increases excitement and the 'fight-and-flight' response, and its use is thus associated with an increase in unhelpful anxiety-like symptoms such as palpitations and tremors. The regular consumption of caffeine increases anxiety generally and can precipitate an acute anxiety (panic) attack.

Nicotine.
The nicotine contained in cigarettes increases excitement and the 'fight-and-flight' response, and its use is thus associated with an increase in unhelpful anxiety-like symptoms such as palpitations and tremors. Like caffeine, its regular consumption increases anxiety generally and can precipitate an acute anxiety (panic) attack. Cigarettes should be avoided altogether as they are such a general health hazard and are very addictive. About 33 per cent of young adults who commence smoking have great difficulty quitting later on.

Illicit drugs
Many commonly used illicit drugs are stimulants that can cause or exacerbate acute and chronic anxiety in their users. Such drugs include amphetamines and the related compounds ‘Ecstasy’ and ‘Ice’, and cocaine. These drugs should obviously be avoided in anyone with anxiety or depression or any other mental illness.

Alcohol use
Initially following consumption, alcohol acts as a depressant and is thus used by some people to reduce anxiety symptoms. (Drinking at social occasions to ease nerves is common practice for many young (and older) people.) However, a few hours after its use, alcohol acts as a stimulant and at this time anxiety sufferers are more likely to have acute anxiety / hyperventilation attacks. (Such attacks can also occur when experiencing a ‘hang-over’.) Dependence is also quite likely to develop in people with anxiety or depression. Alcohol is best to avoided in people with anxiety and depression.

Seeking help

Anxiety symptoms present in children (and adults) are always best addressed using the help of a health professional interested in and competent at treating the condition; a psychologist, child psychiatrist or a GP. (A GP is a good place to start the process of finding a suitable therapist.)

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Further information on childhood anxiety and parenting

Rapee, R., Spence, S., Cobham, V. and Wignall, A. Helping your anxious child. A step by step guide for parents. New Harbinger, 2000.
(There is also a book by Ron Rapee for therapists called Treating Anxious Children and Adolescents: An Evidenced-Based Approach. Published by New Harbinger)

Rowe L, Bennett D and Tong B. I just want you to be happy. Preventing and tackling teenage depression, Allen and Unwin 2009.

Macquarie University Child and Adolescent Anxiety Unit
www.psy.mq.edu.au/muaru.

The New Children’s Hospital, Westmead. (Click here for Children's Hospital at Westmead parent information resources.)

Further information on mental illness

Mental health resources

Mental Health Branch of the Department of Health and Aged Care www.mentalhealth.gov.au
This site provides information about crisis supports and contacts, general mental health information, mental health information brochures / publications about specific topics such as depression, anxiety, information about suicide prevention etc.
Ph 1800 066 247

Beyond Blue: The National Depression Initiative https://www.youthbeyondblue.com/?&gclid=CICs69Tvgc4CFQiVvQodF-0MFA

ybblue (Beyond Blue’s youth program) www.ybblue.com.au
Beyond Blue’s youth program (Self harm at ybblue (https://www.youthbeyondblue.com/understand-what's-going-on/self-harm-and-self-injury

Black dog institute www.blackdoginstitute.org.au
Provides information for clinicians and patient education.

Moodgym www.moodgym.anu.edu.au
An interactive program of CBT, more aimed at depression, developed by the Centre for Mental Health Research at the Australian National University.)

Reachout www.reachout.com.au
A resource for young people with depression.

Lifeline www.lifeline.org.au Ph 13 1114
Lifeline provides an immediate counseling service for all people)

Kids Help Line www.kidshelp.com.au
A national 24 hour counseling service for children and young people)
Ph 1800 551 800

CRUfAD, The Clinical Research Unit for Anxiety and Depression www.crufad.com
CRUfAD is a group of researchers and clinicians concerned with anxiety and depression. It is a joint facility of St Vincent's Hospital Ltd and the University of New South Wales in Sydney, Australia. The self-help section of the web site has useful information about both anxiety and depression for the general public.

Anxiety Panic Hub www.panicattacks.com.au
A consumer web site with a focus on meditation / mindfulness.

Mindmatters http://www.mindmatters.edu.au
A program that introduces mental health education to secondary schools.

A helpful Australian Government web site:
Children of Parents with a Mental Illness ('COPMI') (An Australian Government web site.)
http://www.copmi.net.au/

Further information on parenting

The Sydney Children's Hospitals Network (includes The Children’s Hospital at Westmead.)

This hospital network's web site (https://www.schn.health.nsw.gov.au) is a great source of information on children’s health topics. It provides fact sheets about many child health issues that are free and downloadable and lists books on most child health topics that have been assessed by members of the medical staff at the hospital. These books are available for purchase from the Kids Health Bookshop at The Children’s Hospital at Westmead (Phone 02 – 9845 3585) or they can be purchased via the ‘e-shop’ on the web site. Any profits go into supporting the work of the hospital.

Some suggested books on parenting children

Every parent. A positive approach to children’s behaviour by Matthew R Sanders, PhD.

More Secrets Of Happy Children by Steve Biddulph

Raising Kids- A parent’s survival guide by Charles Watson, Dr Susan Clarke and Linda Walton.

Bully Busting by Evelyn M. Field

Raising Boys by Steve Biddulph

Your Child's Self Esteem by Dorothy Corkhille Briggs

(All these books and many more appear in the ‘self esteem, behaviour and family life’ section of the books section in parents section of the Children’s Hospital at Westmead web site. https://kidshealth.schn.health.nsw.gov.au/bookshop-and-products) There is information about each book on the web site; just click over the title.) Better still, for parents able to visit the hospital, most of the books are available to view and there will be someone there to help with book selection.)

Some suggested books on parenting adolescents

What to do when your children turn into teenagers by Dr D. Bennett and Dr Leanne Rowe (This is a wonderful book that is unfortunately now out of print. Second hand copies may still be available.)

You can't make me by Dr D. Bennett and Dr Leanne Rowe

I just want you to be happy. Preventing and tackling teenage depression. by Professors Leanne Rowe, David Bennett and Bruce Tonge. Published by Allen and Uwin, 2009.

Puberty boy by Geoff Price

Puberty girl by Shushann Movsessian

The puberty book by Wendy Darvill and Kelsey Powell

Teen esteem by Dr P. Palmer and M. Froehner

Most children suffer anxieties at some time and another book (not on the above list) that is very useful for parents is - Helping your anxious child. A step by step guide for parents. by Rapee, R., Spence, S., Cobham, V. and Wignall, A.New Harbinger, 2000.

Live Well Live Long

Anxiety in children

Contents

Last partial update: July 2016 - Please read disclaimer before proceeding

Definition, incidence and causes

Causes of childhood anxiety

Types of anxiety disorders in adolescents and adults

Adult anxiety disorders

Anxiety disorders in children

Preventing and addressing anxiety disorders in children - An important parenting issue

Identifying children showing early anxiety signs

Treating anxiety disorders in children and adolescents

General considerations

Avoid stimulant substances that increase anxiety

Seeking help

Further information on childhood anxiety and parenting

Further information on mental illness

Mental health resources

Further reading on mental health topics

Further information on parenting

The Sydney Children's Hospitals Network (includes The Children’s Hospital at Westmead.)

Some suggested books on parenting children

Some suggested books on parenting adolescents

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