Anxiety is, to a degree, a normal part of childhood. Since children have had fewer experiences than adults, their world is often new and scary. They may be frightened by common events, such as the beginning of school, or by special upsets, such as moving to a new house or becoming seriously ill. In addition, each generation of children is confronted by new sources of anxiety. Today’s children, for example, are repeatedly warned, both at home and at school, about the dangers of Internet browsing and networking, child abduction, drugs, and terrorism. They are bombarded by violent images on the Web, on television, or in movies. Even fairy tales and nursery rhymes contain frightening images that upset many children.

Children may also be strongly affected by parental problems or inadequacies. If, for example, parents typically react to events with high levels of anxiety or if they overprotect their children, the children may be more likely to respond to the world with anxiety (Becker et al., 2010; Levavi et al., 2010). Similarly, if parents repeatedly reject, disappoint, or avoid their children, the world may seem an unpleasant and anxious place for them. And if parents are divorced, become seriously ill, or must be separated from their children for a long period, childhood anxiety may result. Beyond such environmental problems, there is genetic evidence that some children are prone to an anxious temperament (Rogers et al., 2013).

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For some children, such anxieties become long-lasting and debilitating, interfering with their daily lives and their ability to function appropriately. These children may be suffering from an anxiety disorder. Surveys indicate that between 14 and 25 percent of all children and adolescents experience an anxiety disorder (Mian, 2014). Some of the childhood anxiety disorders are similar to their adult counterparts. Childhood specific phobias, for example, usually look and operate just like the phobias of adulthood (Pilecki & McKay, 2011), and a number of untreated childhood phobias grow into adult ones.

More often, however, the anxiety disorders of childhood take on a somewhat different character from that of adult anxiety disorders. Consider generalized anxiety disorder, marked by constant worrying, and social anxiety disorder, marked by fears of embarrassing oneself in front of others (APA, 2013). In order to have such disorders, people must be able to anticipate future negative events (losing one’s job, having a car accident, fainting in front of others), to take on the perspective of other people, and/or to recognize that the thoughts and beliefs of others differ from their own. These cognitive skills are simply beyond the capacity of very young children, and so the symptoms of generalized anxiety disorder and social anxiety disorder do not usually appear in earnest until children are 7 years old or older. In short, odd as it may sound, some patterns of anxiety cannot fully unfold until children are afforded the “benefits” of cognitive, physical, and emotional growth (Davis & Ollendick, 2011; Weems & Varela, 2011).

What, then, do the anxiety disorders of young children look like? Typically they are dominated by behavioral and somatic symptoms rather than cognitive ones—symptoms such as clinging, sleep difficulties, and stomach pains (Morris & Ale, 2011; Schulte & Petermann, 2011). They tend to center on specific, sometimes imaginary, objects and events, such as monsters, ghosts, or thunderstorms, rather than broad concerns about the future or one’s place in the world (APA, 2013; Davis & Ollendick, 2011). And they are more often than not triggered by current events and situations (Felix et al., 2011).

Separation anxiety disorder, one of the most common anxiety disorders among children, follows this profile (APA, 2013). The disorder is common (but not unique) to childhood, begins as early as the preschool years, and at least 4 percent of all children experience it (APA, 2013; Mash & Wolfe, 2012). Sufferers feel extreme anxiety, often panic, whenever they are separated from home or a parent. Jonah’s symptoms began when he was a preschooler and continued into kindergarten.

Children like Jonah have enormous trouble traveling away from their family, and they often refuse to visit friends’ houses, go on errands, or attend camp or school (see Table 17-1). Many cannot even stay alone in a room and cling to their parent around the house. Some also have temper tantrums, cry, or plead to keep their parents from leaving them. The children may fear that they will get lost when separated from their parents or that the parents will meet with an accident or illness. As long as the children are near their parents and not threatened by separation, they may function quite normally. At the first hint of separation, however, the dramatic pattern of symptoms may be set in motion.

Separation anxiety disorder may further take the form of a school phobia, or school refusal, a common problem in which children fear going to school and often stay home for a long period (APA, 2013). Many cases of school phobia, however, have causes other than separation fears, such as social or academic fears, depression, and fears of specific objects or persons at school.

Despite the high prevalence of childhood and adolescent anxiety disorders, around two-thirds of anxious children go untreated (Winter & Bienvenu, 2011; Chavira et al., 2004). Among the children who do receive treatment, psychodynamic, cognitive-behavioral, family, and group therapies, separately or in combination, have been used most often. Each approach has had some degree of success; however, cognitive-behavioral therapy has fared the best across a number of studies (Mohatt, Bennett, & Walkup, 2014; Edmunds, O’Neil, & Kendall, 2011). Such treatments parallel the adult anxiety approaches that you read about in Chapter 5, but they are tailored to the child’s cognitive abilities, unique life situation, and limited control over his or her life. In addition, clinicians may offer psychoeducation, provide parent training, and arrange school interventions to treat anxious children (Lewin, 2011).

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Clinicians have also used drug therapy in a number of cases of childhood anxiety disorders, often in combination with psychotherapy (Mohat et al., 2014; Bloch & McGuire, 2011). Not only do they prescribe antianxiety drugs, but antidepressant and antipsychotic drugs as well (Comer et al., 2011, 2010). Drug therapy for childhood anxiety appears to be helpful, but it has begun only recently to receive much research attention.

Because children typically have difficulty recognizing and understanding their feelings and motives, many therapists, particularly psychodynamic therapists, use play therapy as part of treatment (Landreth, 2012). In this approach, the children play with toys, draw, and make up stories; in doing so they reveal the conflicts in their lives and their related feelings. The therapists then introduce more play and fantasy to help the children work through their conflicts and change their emotions and behavior. In addition, because children are often excellent hypnotic subjects, some therapists use hypnotherapy to help them overcome intense fears.