Anxiety disorders in children

Introduction

Anxiety is part of our survival instinct. When we are faced with a threatening situation our brains and bodies respond by kicking into safety mode. All of us have been born with the natural fight or flight response that helps us to deal with a threatening situation. That part of our brain causes the nervous, fearful feeling we call anxiety. During periods of anxiety, there is a rapid dump of chemicals and mental transition executed in your body for survival. One by product is that the more logical part of your brain gets put on hold while the brain stays at “Fight Flight “stage. In other words, it is really hard for your child to use logic and think clearly.

Childhood itself is quite an anxious process, with new learning skills, meeting new challenges, overcoming fears and navigating a world that does not always make sense to them. It can sometimes be very overwhelming for the child and the normal comforts and inputs provided by an adult does not seem quite enough and they experience anxiety.

Anxiety disorders are the most commonly experienced mental illnesses. Not diagnosing and treating a child with anxiety leaves a child at a risk of under performing in school, poor social skills and a low self-esteem.

While everyone experiences anxiety at some point, but when children feel worry that is difficult to control and interferes with their daily functioning it could be anxiety. The difference normal worry and an anxiety disorder is the severity.  There are 3 important factors which influence our approach to dealing with distress.

Biological factors: The brain has special chemicals called neurotransmitters that send messages back and forth to control the way a person feels. Serotonin and Dopamine are two important neurotransmitters that when out of balance cause feelings of anxiety.

Family: Anxiety has a genetic pre-disposition. It also may be learned by observing an anxious parent or caregiver.

Environmental: A traumatic experience (example, divorce or serious illness or death of a parent, abuse etc.) could trigger anxiety.

Symptoms of anxiety:

Physical

• Rapid heart / Quick breathing or difficulty breathing
• Muscle aches / Dizziness / Tingling
• Excessive sweating
• Fatigue / Burnout
• Headaches
• Lack of appetite
• Sleep issues

Emotional

• Ongoing worries about peers/ school /activities/ events
• Anticipatory fears
• Need for perfection
• Constant thoughts about safety of self and family members
• Reluctance to go to school
• Clingy behavior
• Inability to concentrate and stay focused on a task
• Inability to relax
• Avoidance to certain situations

Types of anxieties

1) Generalized Anxiety Disorder

If your child has generalized anxiety disorder, he will worry excessively about a variety of things such as grades, peers, leaving parents and going to school, safety of parents, death etc. The worry will occupy a large portion of his thoughts, will need constant validation and need way more pushing and encouragement a start a new task.

Case Study :  5-year-old girl studying in U.Kg.  Very bright and performed well academically. Her reason for referral was , her mother reported that she would keep worrying about her performance, she would not sleep well as she would lie awake thinking if she has completely all her homework, before leaving home she would keep asking her mother to come early and pick her up, she keeps calling up her father every few hours when she is at home to reassure herself that he is safe, she worries about the world coming to an end. She spent a large chunk of her day worrying about something.

2) Panic disorder

Panic disorder is diagnosed if your child suffers at least two unexpected panic or anxiety attacks, followed by at least one month of concern over having it again.  This is characterized by the occurrence of panic attacks and deep distress about their possible return. These events are extremely stressful and frightening. Should your child experience these events, she may describe it as sudden over whelming fear and palpitations and an intense desire to flee. Panic attacks can occur in any anxiety disorder, usually in response to the focus of that disorder. For example, a child who has separation anxiety may have a panic attack when a parent leaves. Children who fear being trapped in places with no places with no way to escape easily, may have a panic attack.

Case Study : 6-year-old boy had developed his first panic attack when their car had broken down in the tunnel while travelling on a family holiday. His second attack took place a month later when they were at a crowded theatre watching a movie, they had got seats in the middle row. The line of treatment for this normally includes pharmacology and behavior therapy.

3) Separation Anxiety Disorder

 A disorder in which children become excessively anxious when separated from parents. Crying, tantrums or clinginess are healthy reactions to separation and a normal stage of development. Separation anxiety could start at around 1 year and continue till 4 years of age. A little worry over leaving parents is normal. Some children however, experience separation anxiety that does not go away, even with a parent’s best efforts. The level of anxiety exceeds their developmental level. They experience an intense anxiety at being separated from parents and it interferes with normal day to day activities. A child must experience these symptoms for at least 4 weeks for the diagnosis to be made.  Children are especially prone to separation anxiety during times of stress.  

Case Study : 5-year-old boy was referred for treatment as he was manifesting severe anxiety at being separated from his mother. He would have severe distress coming to school, interacting with peers or concentrating on play and school activities. At home he had become very clingy with his mother and would constantly want to be with her. He did not want to sleep without her. He had apparently overheard a fight between his parents a couple of weeks ago in which his mother had spoken of leaving the house and going away. This was the trigger of his separation anxiety. Counselling and family therapy along with pharmacology was his line of treatment.

4) Selective Mutism

Selective mutism is an anxiety disorder in which a person normally capable of speech cannot speak in specific situations or to specific people if triggered. Children with selective mutism have an actual fear of speaking and of social interactions where there is an expectation to speak and interact. Some children might be completely mute and unable to speak to anyone in a particular social setting. While some might be mute with select people. They may freeze, be expressionless and severely affected in that specific setting or with that person. Children with selective mutism normally speak in certain situations normally. Traumatic mutism on the other hand is when the children due to a trauma goes mute in all situations.

Case study :  4-year-old girl in L. Kg was referred by her class teacher as this child never spoke in class. It was almost 6 months since school had begun and she never interacted with her teacher. She had no academic concerns.  Her mother was very surprised to hear that as at home she was talkative. She interacted with only one child in the class. The parents in the clinical history shared that 3 months into her nursery class last year her teacher had yelled at her and punished her, (at age 3.6 years) this triggered her fright and since then she was developed selective mutism in school. She was absolutely vivacious at home. Intensive counselling was her line of treatment.

5) Social Anxiety disorder

Social anxiety disorder involves an intense fear or phobia of social and performance situations.

Pre school children manifest it through fear of new things, excessive crying or whining, freezing or clinging and refusing to speak. School aged children with Social anxiety disorder have fear of reading aloud in class, fear of talking to other children, ordering at a restaurant, fear of attending a birthday party, of having friends visit their home, worry about being judged by others and refusal to participate in school activities. As a result, they avoid situations and when a situation cannot be avoided, they experience significant anxiety and distress. They feel helpless.

They struggle with excessive self -consciousness that goes beyond shyness.

Case Study :  7-year-old boy who was coined as being extremely shy since the time he joined school in Nursery. He would freeze if asked to read or perform, never volunteered for any activities in school, had just one friend and would eat his tiffin alone.  His mother referred him as attendance in school was irregular and avoidance had started setting in, as every time there was an activity where he thought he might be singled out he would avoid going to school. This would result in overthinking about it, lack of proper sleep and an unhappy state of mind.

Counselling and classroom intervention strategies were used to help him deal with this concern.

6) Specific Phobia

Specific phobia is characterized by an excessive and irrational fear of an object or situation not normally considered dangerous. Children with specific phobia are not anxious in general, they only become so when confronted with the particular thing that causes them terror, whether its darkness, clowns, balloons, loud sound, blood, insects, animals, enclosed spaces etc. They go far beyond the ordinary fears of childhood and do not subside even with reassurance from parents or caregivers.  The fear can be triggered directly by encountering the thing itself or by indirectly, by it being used as a threat in disciplining, hearing stories about it etc.

Children with specific phobias will anticipate and avoid the thing that triggers their fear and this avoidance can interfere with normal activities. Children do not realize this fear is unwarranted.

Some children and adults experience panic disorder combined with agoraphobia (an intense fear of the outside world). Children are so terrified of encountering or experiencing the object of their fear that they feel unsafe anywhere but at home and will resist venturing out

Case Study :  6-year-old girl was referred for severe distress in enclosed spaces especially if dark. She had stopped sleeping on her own, wanted her mother to be with her. She would not go to the washroom alone, she would get up in the night abruptly and cling to her mother, this was seen for over 2 months. Clinical history revealed that the father had used the negative reinforcement of time out in an enclosed corner of the house on 2 occasions.  This had triggered the onset of this specific phobia of dark enclosed spaces.

Parenting and child counselling along with pharmacology was her line of treatment.

7) Obsessive Compulsive Disorder

This is an anxiety disorder, characterized by unwanted and intrusive thoughts (obsessions) and feeling compelled to perform rituals and routines to try and ease the anxiety (compulsions). It has a neurobiological basis. They are linked to fears such as touching a dirty object and thus compulsive rituals to control the fear, example excessive washing of hands. Pre school children often have rituals around meals, bathing and bath time.  The compulsive acts can be excessive, disruptive and time consuming. They may interfere with daily routine and relationships. Example of compulsive acts could be washing hands excessively, checking and rechecking many times, hoarding objects. Counting and recounting, grouping objects, asking the same question again and again. The child may not understand why they do these rituals. They may feel embarrassed that the behaviors occur and cannot be controlled.

OCD is not a phase your child is going through and they are not deliberately misbehaving or trying to get your attention.  It normally is a chronic condition and managing it with proper treatment is important.

Pharmacology and psychotherapy are essential to manage this condition.

Case Study : An eight-year-old child referred by his school for rituals being performed in class consistently. He would sit only on a particular chair, he would wipe it with a red cloth 3 times, then use it. He would count up to 3 then answer a question. He would keep his bag facing in a particular manner. His pencil box would have pencils of exactly the same length and he would sharpen them regularly to get them at the same height. His bag and pencil box had to be arranged in a particular manner and it would bother him if the arrangement was disturbed. He was pre occupied doing these rituals the whole day and it was impacting his social skills and academic performance in spite of being very bright.

8) Post Traumatic Stress Disorder (PTSD)

Children with PTSD may have intense fear or anxiety, become emotionally numb or easily irritable or avoid places and people after experiencing or witnessing a traumatic event or life-threatening experience. Someone who is a victim of violence, injury or harm can re-experience their trauma in the form of flashbacks, memories, nightmares or scary thoughts, especially when they are exposed to events or objects that remind them of the trauma.  Intrusive thoughts and memories of the traumatic event cause stress, anxiety and depression. PTSD in children is different than in adults as younger children can show more fearful and regressive behaviors.  People with PTSD very often may not get the required professional help as its understandable to feel frightened after going through a traumatic event.

Not every child who has been through a traumatic experience develops PTSD.

Case Study : 5-year-old girl who was involved in a car accident with her parents and grandparents in the same car. She lost her grandmother in this accident and was injured herself. She was in shock for a few weeks and manifested the symptoms of PTSD after a month.

Intensive counselling, play therapy, cathartic activities, family grief therapy and pharmacology is her line of treatment.

Conclusion points

All children experience anxiety. Certain fears and anxieties are typical for specific age groups. But seeking help for your child if you observe its severe and consistent and not age specific is important.  Parents can often feel helpless when they see their child experience intense fear or worry. Having a professional talk and assess your child will help with a specific diagnosis and timely intervention.

Certain tips that can be useful in helping your child who has anxiety

• Stay calm as they model your behavior
• Avoiding a lot of reassurance and instead teaching your child how to problem solve and reassure himself
• Discouraging avoidance of feared situation/ object as this may only give temporary relief
• Physical calming skills for parents and child to practice together to reduce physical reaction and improve relaxation
• Thinking skills for the child that teach him to identify anxious thought patterns and errors in thinking as well as strategies to change these anxious thoughts
• Confronting fears by taking small baby steps towards doing the opposite of avoidance or flight reactions
• Avoid saying Do not worry/ there is nothing to worry about/ you will be fine/ stop thinking about it/ sleep it over.

Most important is to seek timely professional help and be compassionate and patient with your child.