Mental Health

Anxiety is a normal human emotion that often begins in childhood. It is a feeling of uneasiness in day to day situations.  It becomes a disorder when the anxiety interferes with normal activities and happiness. With supportive treatment there is evidence this will be of lifelong benefit. Anxiety is often known as an ‘internalising’ condition. This means the child is ‘bottling up’ emotions and they will find it difficult to communicate how they feel. This ‘pressure cooker’ affect will boil over at times resulting in tantrums, meltdowns, and ‘internal distress’. This article is designed to help parents understand anxiety and how to manage it.

What is normal Anxiety ?shutterstock_166376249

Anxiety has its place to keeps us safe.  For example when crossing a busy road a small amount of anxiety will help us focus and enhances our senses. Infants develop  ‘stranger anxiety’ around 7 – 9 months of age.  Doctors will see lots of anxious toddlers who become upset during routine examinations. This is a defence mechanism to ‘keep safe’ and not stray far from the parents. As the toddler explores the environment in the immediate vicinity of the parent he or she will repeatedly return for reassurance and then head out again. This is labelled the circle of security. Many toddlers will feel anxiety when they start daycare, or kindergarten, and over time this will lessen as they are ‘exposed’ to this  positive experience. Moving through the ages, first day of school, talking in front of the class, can all cause anxiety and this is relatively normal as these challenges are successfully negotiated. Anxiety becomes a problem through either its persistence or intensity.

What Causes Anxiety Disorder ?

Childhood experiences coupled with  genetic susceptibility may increase the propensity to feeling anxious. However these childhood experiences do not necessarily have to be serious or significant. It is the child’s perception – the genetic component – that will be at fault.  Experiences lay down thought ‘pathways’ that head in an anxious and negative direction.  These pathways become well worn ways of thinking. For example when told about an upcoming holiday the non anxious child will think of the fun things that will be happening, and will be appropriately excited. The anxious child may worry about things going potentially wrong such as the travel, (what if we crash?), the food (what if I don’t like it or get sick?) and will feel uncomfortable with the upcoming change. Psychologists try and show children how to change this ‘thinking pathway’. This is called cognitive behaviour therapy and has been shown to be effective.

This is not due to ‘parenting’.  

Many parents, particularly Mothers carry a lot of guilt, thinking that somehow they have ’caused’ this anxiety.  In most cases this is not the case.  Many children  come from particularly stressful family situations, yet these children are functioning well with no symptoms of anxiety. On the other hand some children have parents who have excellent parenting skills, are supportive and attentive yet the child suffers from  anxiety. This genetic susceptibility is best described as the way the genetic cards have fallen.  However parenting can contribute to the anxiety if the child is constantly shielded or protected from the situation that causes anxiety. For example the parent is unable to leave the child at day-care during separation anxiety, or writes a note excusing a child from a potential anxiety causing situation such as speaking in class. 


The types of Anxiety Disorders and their symptoms

These include separation anxiety, generalised anxiety, social anxiety, phobias and obsessive compulsive disorder. This breakdown is useful for psychologists and psychiatrists and for analysing treatments but in reality children tend to have an over-riding type, but borrow symptoms from the others.

This is the most common form of anxiety. The young child will be overly clingy and will take a long time to settle when away from parents. Most children by the age of three can accept the temporary absence of a parent. But with separation anxiety disorder this persists in intensity and frequency. At home the child will follow the parent(s) around the house and require repeated reassurance. During the night independent sleep is difficult or impossible. The older child will similarly be ‘attached’ to a parent, usually the Mother and will worry that something bad will happen to their parents or siblings. School refusal is not uncommon. Stomach aches, headaches are a common complaint and older children may develop panic attacks in certain situations.


Is basically as it sounds. Overwhelming unrealistic worries about health, school, their parents, and peers will dominate the child who has generalised anxiety. They will have problems focusing on schoolwork and require extraordinary reassurance. These children can sometimes be overly ‘adult’ and they are ‘perfect’ school students sometimes. At home the parents are exasperated as these children have bottled all their emotions up to ‘soldier on’ during school and at will unleash at home. Teachers are quite surprised to hear the problems the parents are experiencing. These children will often complain of headaches and abdominal pains and ‘feel sick’.


Represents avoidance of situations that may result in ridicule or embarrassment. The child is overly shy, thinking ‘what if’ thoughts. This can result in them avoiding exams, or oral presentations and hence detrimentally affect school. This anxiety is also seen in generalised anxiety. However the child with social anxiety only, will have no symptoms when they are with familiar family and peers.  In some cases school refusal occurs.  The older child with school refusal will most likely have Social anxiety, whereas the younger child will have separation anxiety.


This anxiety can occur with generalised anxiety. The obsessions involve unwelcome thoughts or intrusions that can be distressing and may often involve bodily wastes or secretions. The compulsions are the need to perform a particular behaviour to alleviate a self defined anxiety. For example repeated hand washing, checking or repeated touching  behaviour. At times of stress (bedtime, preparing for school), some children touch certain objects, say certain words, or wash their hands repeatedly. OCD is diagnosed when the thoughts or rituals cause distress, consume time, or interfere with occupational or social functioning.


How do you Diagnose Anxiety ? 

When a child has a mental health problem, they are struggling to function. They find life extremely difficult and challenging.  School, home, relationships are difficult and the symptoms mentioned above are prominent. There are some screening tools available for childhood anxiety online. One example is called the SCARED screening tool. There are two questionnaires  one for the child to fill out and one for the parent.

Click on the following link:

A formal diagnosis can only be made by a health professional such as a child psychologist,  GP who is trained in child health, a paediatrician or a child psychiatrist. These screening tools simply show that further assessment is needed.

How to Manage Anxiety Disorder ?

When anxiety is managed correctly this lessens the risk of anxiety and depression during adolescence and adulthood. 

So what has research shown to be the most affective treatment for anxiety disorder ? I have divided this into four groups. Firstly a stable environment, followed by parenting, talking therapy, and finally a discussion on child psychiatry and  medication

Having a stable adult, who provides a positive attachment is essential if any treatment is going to be successful. Paediatricians and child mental health experts agree that there is little point in embarking on treatment if those who are responsible have their own mental health issues that impact on the child. Someone who provides safety, a role model, and security needs to be involved to ensure therapy works. Setting this up can sometimes be all that is required to ensure a child’s anxiety lessens to the point where life and self esteem improves. This may require some difficult decisions. For example a susceptible child may develop severe separation anxiety due to bullying by either peers or a teacher and unless this situation is dealt with there is little point in spending time and money on counselling or other therapies. If there is no agreeable solution then moving the child to another environment maybe all that is needed. Treatment for residual anxiety will be far more effective when the environment is supportive. Finally ensure sleep is adequate and diet is healthy.  Caffeine has been found to  increase anxiety in some children and eliminating such drinks will help with both sleep and the anxiety.


This flows on from environment. Firstly ensuring boundaries, and appropriate warmth is essential. But parenting the anxious child will present it’s own challenges. Luckily there are a great deal of resources and tips available both online and in print. Teaching how to parent these children is difficult and each child will present with unique challenges. Many parents will feel such empathy for their children’s feelings that they try and help them avoid these stressful situations, which can at times reinforce the anxiety and lessens the ability of the child to learn independence and resilience.  For example if a child has significant anxiety at school drop off the parent needs to set small goals which are achievable and rewardable. In this instance there is reward for dropping off at the door of the classroom rather than being delivered to the teacher. The next week the child is left a short distance from the classroom door, and so forth until the child proudly exits the car and walks into the school independently. These small goals help the child show that they can be independent which helps with their self esteem. This stepladder approach can be applied to many anxiety causing situations.  Some more examples are found on at raisingchildren.net.au

Dealing with  negative explosive behaviour can be more challenging. This  is due to the child being unable to manage their own emotions, which bubble over and present as crying, meltdowns, door slamming and violence to parents or siblings. This is a kind of flight or fight response  can invoke a similar emotion in parents who may react in ways they later regret. In short the reaction of the parent should be similar to that of a soccer referee. Firm time out to allow the controlling of emotions is essential. For the older child and adolescent here are a few dos and don’t

    • Do provide a consequence that is easy to manage and will make the child think about their actions
    • Do point to the bedroom without engaging in arguments or discussion
    • Do ensure a fresh start a short time later (not the end of the week)
    • Don’t Yell, smack or threaten
    • Don’t lecture, nag or repeatedly engage the child.Front cover_jpeg

This is easier said than done and sometimes it is worth getting professional advice. Consequences and time out are important and should be immediate and also redeemable and refundable.  One method which is outlined by child psychiatrist Dr Brenda Heyworth in her book [ilink url=”http://www.itsajungle.com”]’Its a Jungle'[/ilink]  is a simple rule involving the concept of ‘5 or 24’. This means that the child needs to go their room, for a few minutes (5) or a consequence of significance will be invoked for 24 hours.  After the 5 minutes there is a ‘fresh start’.  The child may want to stay in his or her room (fine) or might come out cranky (this is fine too) or may come out apologetic. If the behaviour is repeated then the 5mins is repeated. However if the child refuses then the ’24’ rule is invoked.  Nowadays this could mean losing internet use, or mobile phone for 24 hours.  For the younger child it may mean removing a favorite gadget or toy.  This is well explained in her book and is highly recommended to parents of children who are providing extraordinary parenting challenges.

In addition rewarding appropriate emotional responses with positive consequences is also extremely important. Catching them ‘being good’ encourages a child to take a more responsible emotional path.


Helping children with anxiety is the bread and butter of child psychologists as it is the most common mental health disorder. The psychologist will assess the anxiety, establish some goals then work with the child and parent towards lessening this anxiety. Cognitive Behaviourial Therapy and managing worries, anxieties, phobias and improving resilience should be the goals of such therapy. This may requires a number of sessions and in Australia there is funding through medicare which will offset the cost of seeing a psychologist. This treatment works when the following occurs.

  • The child enjoys the sessions and is able to utilise the strategies
  • The parent backs up therapy with appropriate environment and parenting

These sessions are particularly useful if the child is keen for help, the parent and caregivers have a positive outlook and there is persistence and consistency.  On the other hand if the child is incapable of engaging, or the parent is hoping that the psychologist is there to ‘fix it’ then this is unlikely to result in a positive outcome.


A paediatrician is sometimes useful where the situation is complex or where simple techniques and psychology has not improved the situation. A paediatrician will re-assess and escalate management and occasionally consider a trial of medication. 


Further information

Having coordinated the care of such children here are a few tips that might help.

  • Ensure your (parent or primary caregiver) mental health is adequate to support the child.  Strategies are less successful if the parent is suffering
  • Ensure diet and sleep and screen time are addressed
  • These children need a lot more scaffolding at home and school in order to function properly
  • The child psychologist needs to have a ‘connection’ with the child so he or she is keen to return.
  • 30% of children will have more than one anxiety disorder or another mental health disorder such as ADHD or Autistic Spectrum Disorder
  • 30% of children with chronic medical conditions will have some anxiety. 

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ADDstands for attention deficit disorder. Children, adolescents and adults with this diagnosis have trouble with focus (attention), impulsivity, and sometimes hyperactivity.  The latter results in the acronym ADHD.  To be diagnosed the core symptoms detrimentally affect all aspects of life, have been present since early childhood, and are not explained by another condition. This is a brief summary. See the resources for further information. 

 

Assessment

ADD is usually suspected during early school years where parents, teachers and others involved in the child’s care feel the symptoms are significant, problematic and are age inappropriate. The symptoms include

Attention Deficit

Attentional problems are manifest as appearing not to listen, inability to complete tasks, easily distracted, and avoiding tasks requiring sustained mental effort. This leads to a chaotic and disorganised life which requires significant support  to get through day to day tasks and challenges.

Impulsivity

Impulsivity is to act prior to considering the result of such actions. Examples include calling out, inablity to wait turns, interrupting, lashing out, reactive behaviour.

Hyperactivity
 

Hyperactivity is the most understood core symptom. The child will be in constant motion as if ‘driver by a motor’, has trouble sitting still, will talk out of turn, will run, jump and climb when this is not permitted and cannot play quietly

Disorder

This is the most important letter of the acronym. For a true diagnosis the child is not functioning as they should for their age.  As parents, peers and other adults become increasling frustrated at the inability of the child to ‘listen and learn’ the child’s self esteem starts to plummet as they feel constantly ‘picked on’. This leads to anxiety, sadness and even depression. 

 

Diagnosis

Where the above core symptoms cause significant problems in all areas of the child’s life, impact their learning and relationships, and those around them need to provide extraordinary support a diagnosis of ADD should be considered. A formal diagnosis in Australia is generally performed by paediatricians and child psychiatrists.  They will take a history and review information gathered from home and school and questionnaires.

Management

Providing an understanding, positive, safe environment which focuses on the strengths and abilities of the child is the cornerstone of supporting children with ADHD.  This involves the carers around the child learning about how to manage the day to day challenges and supporting the child’s self esteem.  The core symptoms cannot be ‘fixed’ but setting up such an environment lessens the negativity that often surrounds these children.

Resources

 

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