CHILDHOOD FEARS AND ANXIETIES
HA RVARD MEDICAL SCHOOL MENTAL HEALTH LETTER,
RVARD MEDICAL SCHOOL MENTAL HEALTH LETTER,AUGUST 1 988
child’s world is magical and menacing—full of mysteries and dangers,
real and imaginary, that most of us forget as adults. In one survey of a
thousand children, 90 percent had some specific phobia between the ages
of 2 and 14. In another study, 43 percent of children between the ages
of 6 and 12 had “many fears and worries.” Most of these anxieties
are not associated with psychiatric disorders or psychopathology. It can
be difficult to decide when a child’s fears are so serious that they
need treatment. The categories used for adult anxiety disorders, like
most adult psychiatric diagnoses, are inadequate when applied to the
constantly growing and changing bodies and minds of children.
Fears that are normal at one age become incapacitating a few
years later; and chronological age is not decisive, since different
children have different rates of development.
which fears are abnormal demands a knowledge of which ones are normal.
Newborns fear loss of support and loud noises. Fear of strangers begins
at six months to a year and normally persists until the age of two or
three. Fear of separation from parents begins about the age of one and
may last until seven or eight. Preschool
children often fear animals, large objects, dark places, changes in the
environment, masks, ‘bad’ people, supernatural creatures, and
sleeping alone. Older children may worry about death, examinations, and
events in the news such as kidnappings and wars. Teenagers have many
social and sexual anxieties. Most of these fears are mild and transient.
Fear becomes a problem only if it interferes with activities normal at a
given age, and in most cases it presents a mental health problem only if
this situation lasts at least a month. By one estimate, 8 percent of
boys and 11 percent of girls have clinically significant anxiety of some
kind before the age of 18. A survey in the province of Ontario, Canada
found that 6 percent
children aged 4 to 6 and 2.5 percent of children aged 12 to 15 might be
in need of treatment for fears and anxieties. Perhaps 2 to 3 percent of
children at some time have enough fear of school to worry their parents
and teachers. Researchers
have never agreed on how to classify children’s fears.
General anxiety or specific phobias can be symptoms of many
severe childhood psychiatric disorders, including autism, major
depression, schizophrenia, and conditions involving brain damage.
Anxiety disorders in a narrower sense fall into several distinct
patterns. Most of these are exaggerated, prolonged, or disabling
versions of normal childhood fears, and some are similar to adult
anxiety disorders. The boundaries of the disorders are disputed; any
child who has some of the anxiety symptoms discussed here is likely to
have others as well.
type of symptom is a simple phobia. Any of the common childhood fears,
and many others, can become clinically significant phobias if they are
severe enough, persist long enough, or occur at an inappropriate age.
Phobias in children come and go rapidly up to the age of 10, and they do
not usually require treatment unless there are other symptoms, such as
excessive general anxiety or refusal to go to school.
anxiety is a more serious matter. It is a disabling fear of being apart
from one’s parents or away from home that lasts for several weeks or
more. It may develop either spontaneously or under stress (a move, a
death in the family) and sometimes lasts for several years, waxing and
waning. Children with separation anxiety fear going to school or camp or
even sleeping in a friend’s home. They demand excessive attention from
their parents, cling to them, follow them around, even try to climb into
their beds at night. When separation threatens, they may develop
headaches and stomachaches. They often fear that if they are apart from
their parents, either they or the parents will come to harm. This fear
may take the form of vague anxiety (in young children) or specific
fantasies of accidents, illness, disappearance, torture, or murder
(especially in older children). Children
with separation anxiety may become withdrawn, apathetic, depressed, and
unable to concentrate.
children are reluctant to go to school; a few become so anxious that
they will not go at all. The refusal may be brought on by an illness, an
accident, a move, or a change of classrooms or teachers. Unlike truants,
who are relatively fearless and avoid school to pursue other interests
elsewhere, these children usually stay home or run home if they are
forced to go. When the time for school approaches, they plead and weep,
develop physical symptoms, and may even have a panic
reaction—sweating, trembling, racing heart, and dizziness. These
symptoms are often a predecessor of adult panic attacks and agoraphobia
(fear of public places and crowds). Sometimes the problem is a true
school phobia. At school, children must submit for the first time to
impersonal authority and rules made outside the home. They are compared
with strangers and threatened with failure. They may have to recite in
class before an audience and undress in front of people who are not
members of their families. They can be frightened by bullying, teasing,
and harsh or critical teachers. In other cases, the source of the
symptoms is fear of leaving home—separation anxiety—rather than fear
of going to school. Therefore “school refusal” may be a better
general descriptive term than “school phobia.”
children have a more pervasive problem; they are painfully shy or
develop incapacitating shyness for a period of months or more. The
current diagnostic manual of the American Psychiatric Association,
DSM-III-R, calls this condition “avoidant disorder of childhood.” It
is most common at ages five to seven, and more common in girls than in
boys. These children shrink from strangers, even after long exposure to
them, and even when they have reached an age when fear of strangers is
no longer normal. They
blush, fall silent, and cling to their parents in the presence of other
children or adults. They avoid children’s games and social situations.
They commonly suffer from phobias and various forms of anxiety.
childhood condition analogous to adult generalized anxiety disorder is
sometimes called overanxious disorder. It is equally common in both
sexes. Children with this problem are self-doubting, self-conscious, and
worried about meeting other people’s expectations. They constantly
seek approval and reassurance from adults, and fear adults who seem
‘mean’ or critical. The problem is thought to be more common in
small families and higher social classes. These
too, often have separation anxiety and phobias. Their pervasive anxiety
must be distinguished from an adjustment disorder, that is, anxiety
caused by the need to adapt to a serious change or loss.
childhood problem rooted partly in anxiety is obsessive-compulsive
disorder (see HMS Mental Health Letter, October 1985).
The symptoms are intrusive, unwanted thoughts which create
mounting tension that can be relieved only by repetitive, compulsive
actions. The acts are designed to relieve some fear which the victim
knows to be irrational; for example, a fear of catching or transmitting
disease. According to one estimate, the earliest symptoms of adult
obsessive-compulsive disorder begin at an average age of 10. In a 1984
survey, it was found that one-third of adults with obsessive-compulsive
disorder had had the disorder as children. Post-traumatic stress
disorder has complicated, dramatic symptoms and an unusual cause: an
overwhelming event beyond the range of ordinary experience, such as a
major accident, a natural disaster, kidnapping, or brutal physical
assault. Post-traumatic stress is best known in adults, especially
combat soldiers, but a few studies of children who have undergone
traumatic experiences suggest that the symptoms are similar. They may be
jumpy and have nightmares, phobias, and panic attacks for years
afterward. They sometimes regress emotionally to an earlier age at which
they feared strangers. They avoid situations reminiscent of the
traumatic event or re-enact it in compulsive play. Pessimism, a sense of
vulnerability, school difficulties, sleep problems, and emotional
numbness are common.
for children’s fears and anxieties are disputed.
Clearly, innate temperament is important. Some fears are nearly
universal and appear to be survival mechanisms: fear of darkness,
strangers, snakes, heights, loud noises, being stared at. The question
is, why do most children succeed in outgrowing or coping with fears and
some do not? A few seem to be temperamentally shy.
Studies have shown that the 15 percent of children who have the
highest resting heart rates at age 2 are also more likely to develop
unusual fears at age 5 to 7 -- fears of television violence, kidnappers,
or going to the bathroom alone at night. Temperamentally susceptible children are apparently more
likely to become fearful when they have older brothers and sisters.
attacks are another source of children’s fears. Probably they are not
just a heightened form of ordinary anxiety but have a distinct
biological source, possibly a chemical imbalance in the nervous or
endocrine system (see HMS Mental Health Letter, December 1984). A sudden
assault of heart palpitations, chest pain, breathlessness, nausea, and
sweating, with an accompanying sense of impending doom, provides a
powerful motive for avoiding the place or situation in which it occurs.
This anticipatory anxiety—fear of fear itself—may cause multiple
anxieties and phobias. Twenty-five to 50 percent of adult patients with
panic attacks say they began before the age of 20, and about 20 percent
of adult patients with panic attacks had school phobia or separation
anxiety as children.
a recent tendency to emphasize biology more and upbringing less, most
explanations of childhood fears still implicate the emotional climate of
the family as well. A combination of anger and dependence on an
overprotective or depriving mother may contribute to separation anxiety.
Anxious parents may make their children anxious by contagion or
imitation. A child’s anxiety is sometimes reinforced by a parent who
does not want the child to leave home; for example, the marriage may be
bad and the mother or father dependent on the child for companionship.
Parents can also create anxiety by identifying themselves too strongly
with a child and regarding the child’s triumphs and defeats as their
own. One study of 58 children referred to a clinic for separation
anxiety or over anxiousness found that 83 percent of their mothers had
had an anxiety disorder at some time in their lives.
to classical psychoanalytic theory, anxieties and phobias are defenses
against unconscious conflict rooted in early upbringing. Certain
memories, drives, and feelings are so painful that they must be
repressed and displaced onto an object peripherally or symbolically
associated with the real source of anxiety. The conscious anxiety or
phobia is a protection against unconscious wishes and drives. Freud’s
most famous example was the case of little Hans, a boy who feared
horses. According to Freud, Hans unconsciously felt himself to be in
competition with his father for his mother’s love (the Oedipus
complex) and anticipated his father’s revenge. That fear was repressed
and displaced onto horses, a symbol of the father. Having something
specific to fear was easier than suffering from anxiety without a
Bowlby’s theory of attachment and loss is a contrasting explanation
for at least one type of childhood fear: separation anxiety. According
to Bowlby, children’s fearfulness is not a derivative of unconscious
anxiety involving unacknowledged feelings toward their parents. Its
basis is the emotional attachment needed for survival. An infant must be
close to its mother (or some equivalent) for physical and emotional
gradually becomes more bearable as the child grows older. A child
prematurely removed from its mother becomes agitated and shows a typical
response with symptoms resembling those of separation anxiety.
Behavioral learning theorists have a different conception of fears and
phobias that emphasizes neither biology nor the family as such, but a
universal process of conditioning—learning by stimulus and response.
Classical conditioning occurs when an initially neutral stimulus becomes
frightening because it is repeatedly associated with an inherently
frightening (unconditioned) stimulus. J.B. Watson, the founder of
behaviorism, repeatedly showed a white rat to a young child and made a
loud noise (the unconditioned stimulus). The child came to fear rats and
mice, then all furry animals, and eventually even a Santa Claus with a
beard. When he was then repeatedly allowed to see the rat without
hearing the noise, the boy recovered, but one more presentation of the
rat together with the sound was enough to reactivate the phobia. Another
type of behavioral learning, operant conditioning, is said to help
explain why fears are maintained once they have been established. The
principle is that behavior will continue if it is reinforced or
rewarded. For example, if parents pay attention to a child mainly when
he refuses to go to school, he is likely to develop a serious problem.
In general, once something has become frightening, there is an automatic
reward (peace of mind) for avoiding it, and avoidance becomes
a learned response.
for childhood fears and anxieties include school counseling,
psychodynamic, cognitive, and behavioral therapies, family therapy, and
drugs. Many children need these treatments in combination simultaneously
or successively. Some of the drugs used in treating adult anxiety
disorders are also helpful to children. One study has found that the antidepressant imipramine (used
to treat panic attacks and agoraphobia in adults) is more effective than
a placebo in children who refuse to go to school. Forty-five children
participated in the experiment; after six weeks, 70 percent of those
taking imipramine and 44 percent of those taking a placebo were able to
return to school. Antianxiety drugs such as buspirone and the
benzodiazepines have occasionally been successful with overanxious
children, but research is limited. The beta-blockers (propranolol and
others) have been used safely in children; they relieve physical
symptoms of anxiety by suppressing activity in the sympathetic nervous
system. All these drugs, of course, have side effects and dangers.
Prescribing them for children requires even more caution than
prescribing them for adults. Drugs are usually not the first choice in
treating children and should never be the only treatment.
phobias, in children or adults, can usually be eliminated by exposure to
the feared object in imagination or (preferably) in reality, backed by
reassurance, persuasion, and instruction from a therapist or parent.
This technique is most closely identified with behavioral learning
theory, but even therapists who doubt the behavioral explanation of
phobias—it is usually hard to find evidence of classical
conditioning—admit that the best way to defeat fears is to face them.
More than 50 different terms are used for various types of exposure
treatment. It is unclear whether these differ fundamentally or which
ones work best for which patients. Perhaps the best known is systematic
desensitization, or reciprocal inhibition. Patients are induced to relax
and then encouraged to approach the feared object. Older children can be
trained in deep breathing or muscle relaxation, or they can learn to
talk themselves out of fear-provoking thoughts.
Younger children can be placed near the feared object and allowed
to do something reassuring and enjoyable like eating or playing with a
common procedure is to present the patient with a graded hierarchy of
situations from least to most frightening. For example, a young child
who fears water is given a favorite toy to play with in the bathroom;
the toy is gradually moved closer and closer to the tub and finally put
inside. The child can be rewarded (reinforced) by praise, encouragement,
or more tangible benefits for each small step. Another behavioral
technique is modeling, which means asking the phobia victim to emulate
another person, in this case usually another child, who is fearless in
the face of the stimulus; for example, a child who fears dogs is shown
another child the same age who plays with a dog boldly. Any exposure
therapy takes time; often exposure must last for hours.
stress disorder may require individual, group, and family therapy, in
addition to antidepressant drugs for the treatment of panic reactions.
Hypnosis has also been used. The therapy must be designed to help
clarify and interpret children’s feelings about the traumatic event so
that they can assimilate it and go on with their lives. Less specific
types of fear and anxiety are also treated mainly with psychotherapy and
family counseling. Overanxious children can be helped by brief
individual psychotherapy, sometimes combined with group therapy, family
therapy, or school counseling. Shy or avoidant children may need
encouragement through supportive psychotherapy (sympathetic listening,
advice, and reassurance) to become more self-confident and independent.
Assertiveness training is a type of behavior therapy often helpful for
shy children. It makes use of modeling and rehearsal: the therapist or
another adult shows the child how to act more assertively in specific
ways (for example, talk more loudly) and asks the child to imitate and
practice the behavior. The
parents of a shy child may have to correct a tendency to be belittling
refusal to go to school is a complicated problem that may require a
different combination of treatments in each individual case. Although
most cases are handled by families with no great difficulty, school
refusal quickly becomes an emergency.
It is out of the question to wait for weeks while the problem
works itself out; professional help is usually needed if a child refuses
to go to school for three consecutive days. Mental health professionals
must cooperate with social workers, school administrators, and teachers
as well as parents. Relaxation and desensitization are sometimes used to
prepare the child. Antidepressant
drugs may also help. A therapist may accompany the child to school, and
a parent may have to sit in class the first day. The child must be
monitored after returning to school, because relapse is common after a
weekend, vacation, illness, or move. It is important to find out whether
the main source of the problem is the child, the home, or the school.
The child might be suffering from depression or some other unrecognized
psychiatric disorder. Perhaps the child’s mother is overprotective and
the child is responding to her anxiety. The parents may be in serious
conflict over discipline and other matters, or they may be rewarding the
child with attention for staying at home. Sometimes the family
entanglement is quite complicated; for example, the mother keeps her
child at home because she is depressed and needs companionship, and the
child stays, despite underlying anger, because of fantasies about saving
her. When the parents or the family as a whole need help, conjoint
family therapy (therapeutic sessions attended by all family members) may
be useful, usually along with individual therapy for the child. When the
source of fear is the school itself—genuine complaints about teachers,
bullies, and so on—the therapist must work closely with the school’s
staff to change the conditions that are making life difficult for the
child. Fortunately, most childhood fears are treatable or fade by
themselves, and most children with troubling anxieties are reasonably
healthy as adults (although boys and girls over 11 are harder to treat,
and their fears are more likely to be symptoms of deeper problems). Shy,
avoidant children sometimes become adults with personality disorders,
but usually they do not. Children with problems of school refusal
ordinarily do not have agoraphobia as adults, although they may be
somewhat sensitive and cautious. Even the effects of traumatic stress
can be attenuated over the years. This is an area in which mental health
professionals and their patients and clients can afford to be
Hersov. School refusal. In Michael Rutter and Lionel Hersov, eds. Child
and Adolescent Psychiatry: Modern Approaches, Second Edition. Oxford.
Blackwell, 1985. Rachel Gittelman. Anxiety disorders in children. In
Lester Grinspoon ed., Psychiatry Update.
The American Psychiatric Association Annual Review, Volume III.
D.C.: American Psychiatric Press, 1984.
and Fellows of Harvard College, 1988 Reprinted with permission.
Mental Health (www.mentalhealth.com) copyright © 1995-1996 by Phillip
W. Long, M.D.