Anxiety Disorders in Children and Adolescents

Children and teens have anxiety in their lives, just as adults do, and they can suffer from anxiety disorders in much the same way. Stressful life events, such as starting school, moving, or the loss of a parent, can trigger the onset of an anxiety disorder, but a specific stressor need not be the precursor to the development of a disorder.

While children can develop any of the recognized anxiety disorders, some are more common in childhood than others. Some disorders tend to be specific to age development. Separation Anxiety Disorder and Specific Phobia are more common in younger children, about ages 6-9 years old. Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD) are more common in middle childhood and adolescence. Panic Disorder can occur in adolescence as well. As with adults, depression has a high rate of comorbidity in children, especially among teenagers.

Although children experience the symptoms of anxiety in much the same way as adults do, children display and react to those symptoms differently. This can lead to difficulties in diagnosis. It can also be difficult to determine whether a child's behavior is "just a phase," or whether it constitutes a disorder.

Social Anxiety Disorder (SAD)

SAD is usually diagnosed in the mid-teen years, but is found in children of preschool and grade school age. If not treated, SAD can persist into adulthood, and may place a child at risk for later depression and alcohol abuse.

Fear of at least one social situation (such as recess) or performance situation (such as taking a test).
Apparent fear when dealing with peers as well as when interacting with adults.
When faced with feared situation the child suffers anxiety symptoms:

sweating
racing heart
stomachache
dizziness
crying
tantrums
freezing
Avoidance or intense dread of feared situations.
Interference with school performance/attendance, the ability to socialize with peers or develop and maintain relationships.

School Refusal or Avoidance

A child experiencing more than just "school jitters" usually refuses to go to school on a regular basis, or has problems staying in school once there. This should not be confused with truant children who avoid school because of antisocial behavior or delinquency.

School refusal is often a symptom of a deeper problem and if not treated can have a negative impact on socialization skills, self-confidence, coping skills and, of course, education. Anxiety-based school refusal affects 2-5% of school-age children. It is common at times of transition, for example, graduating from elementary school to middle school and from middle school to high school. Anxieties tend to differ among age groups, but the most common stressors are:

separation anxiety
concerns about academic performance
anxieties about making friends
fear of a teacher or bully.

The most common ages for school refusal are between five and six, and between ten and eleven. Children who suffer from school refusal tend to be average, or above average in intelligence.

In addition to physical symptoms, there can be behavioral symptoms, which can manifest as:

Older children not only experience the stress that goes along with transition from one school to the next, but there is added academic pressure in the higher grades as students begin to see their futures unfolding before them. These stresses may manifest themselves in an extreme preoccupation with appearance, sleeplessness, or rebellion. As with younger children, it is important to keep the child in school, although they may fight it. Missing school reinforces anxiety, rather than alleviating it.

Common School Fears:

Being separated from caregivers;
Riding on the bus;
Eating in the cafeteria;
Using the school bathroom;
Being called on in class;
Changing for gym;
Interacting with other children or teachers;
Being picked on by peers or older children.

Separation Anxiety Disorder

Many children experience separation anxiety between 18 months and three years of age, when it is normal for a child to feel some anxiety when a parent leaves the room or goes out of sight. Usually he/she can be distracted from these feelings. Crying when first being left at daycare or pre-school is also common, and the crying subsides when the child becomes engaged in his/her surroundings.

Usually four year olds are able to leave their parents. If not, the problem could be Separation Anxiety Disorder, which affects approximately 4% of children. With Separation Anxiety Disorder, a child experiences extreme anxiety when away from home or separated from parents or caregivers. In this case, the desire to be in contact with missed persons is excessive, extreme homesickness and feelings of misery at not being with loved ones are common. While separated, it is not uncommon for these children to have fears regarding the health and safety of their parents.

Try to avoid going places by themselves;
Refuse to go to school or camp;
Be reluctant or refuse to participate in sleepovers;
Follow a parent around;
Demand that someone stay with them at bedtime, or "appear" in their parent's bedroom during the night;
Awake from nightmares about being separated from loved ones.

Onset of Separation Anxiety Disorder can occur any time before age 18, but it is most common in children between the ages of seven and nine.

Selective Mutism

Children who fail to speak in situations where speech is expected or necessary, to the extent that their reluctance or failure interferes with school and making friends, may be suffering from Selective Mutism, thought to be a severe form of Social Anxiety Disorder. Onset of Selective Mutism is usually before five years of age, but it often comes to a head when the child enters school. The average age of diagnosis is between 4-8 years old, but these children probably exhibited "extreme shyness" at a much earlier age. For Selective Mutism to be diagnosed the behavior must persist for at least one month. These children can be very talkative, even boisterous when at home, or in a place where they feel comfortable.

Stand motionless and expressionless, turn his/her head, chew or twirl hair, avoid eye contact or withdraw into a corner.
Become anxious before entering an uncomfortable situation, common symptoms of anxiety before social events include: stomach aches, headaches, and other physical ailments.
Children suffering from Selective Mutism will often display additional signs of severe anxiety: separation anxiety, frequent tantrums and crying, moodiness, inflexibility, sleep problems and extreme shyness. These can show up as early as infancy.

Specific Phobia

A specific phobia is defined as the intense, irrational fear of a specific object, such as a dog, or a situation, such as flying. Fears of animals, situations and natural occurrences are common in childhood, and often go away. A phobia is diagnosed if the fear persists for at least 6 months and interferes with a child's daily routine, an example of this is a child who refuses to play outdoors for fear of encountering a dog. Common childhood phobias include:

Unlike adults with specific phobias, children do not usually recognize that their fear is irrational or out of proportion to the situation, and they may not articulate their fears. Children will avoid situations or things that they fear, or endure them with anxious feelings, which can manifest as:

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder usually affects children between the ages of six and eleven. It is characterized by excessive worry and anxiety over a variety of things, including, but not limited to:

The affected child cannot control his/her worry and it interferes with normal activities. Physical symptoms of GAD include:

Children with GAD tend to be very hard on themselves, striving for perfection, sometimes redoing tasks repeatedly. They may also seek constant approval or reassurance from others.

Panic Disorder

Panic Disorder is diagnosed when a child suffers at least two unexpected Panic Attacks, followed by at least 1 month of concern over having another attack, losing control, or "going crazy." The most common age of onset for Panic Disorder is the early to mid twenties. It is not common in young children, but can begin in adolescence.

A Panic Attack is defined as the abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes, and includes at least four of the following symptoms:

a feeling of imminent danger or doom;
the need to escape;
palpitations;
sweating;
trembling;
shortness of breath or a smothering feeling;
a feeling of choking;
chest pain or discomfort;
nausea or abdominal discomfort;
dizziness or lightheadedness;
a sense of things being unreal, depersonalization;
a fear of ;losing control or "going crazy"
a fear of dying;
tingling sensations;
chills or hot flushes.

Children, like adults, often become apprehensive when in situations or places where they have previously had attacks, and may begin to avoid these situations and places. Agoraphobia can develop when the child begins to avoid situations in which he/she has had a panic attack previously, or situations and places from which the child feels that he/she would not be able to escape if experiencing a Panic Attack.