CHILDHOOD FEARS AND ANXIETIES

THE HARVARD MEDICAL SCHOOL MENTAL HEALTH LETTER, AUGUST 1 988

A 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.

Judging 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 of 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.

One 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.

Separation 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.

SCHOOL REFUSAL

Many 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.”

Some 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.

The 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 children, 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.

Another 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.

ROOTS OF FEAR

Explanations 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.

Panic 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.

Despite 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.

According 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 conscious source.

John 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 sustenance.  Separation 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.

TREATMENT

Treatments 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.

Simple 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 favorite toy.

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.

Post-traumatic 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 and overbearing.

Persistent 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 optimistic.

FOR FURTHER READING

Lionel 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.

Washington, D.C.: American Psychiatric Press, 1984.

President and Fellows of Harvard College, 1988 Reprinted with permission.

Internet Mental Health (www.mentalhealth.com) copyright © 1995-1996 by Phillip W. Long, M.D.