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Subject PSYCHOLOGY

Paper No and Title PAPER No.15: Clinical Psychology

Module No and Title MODULE No.4: Childhood Anxiety Disorders

Module Tag PSY_P15_M4

TABLE OF CONTENTS
1. Learning Outcomes
2. Introduction
3. Types of Anxiety Disorders in Children
3.1 Generalized Anxiety Disorder
3.2 Separation Anxiety Disorder of Childhood
3.3 Phobic Anxiety Disorder of Childhood
3.4 Social Anxiety Disorder of Childhood
4. Treatment
4.1 Relaxation Techniques
4.2 Cognitive Behavioral Therapy
4.3 Medication
5. Summary

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1. Learning Outcomes
After studying this module, you shall be able to

 Know about the anxiety disorders in children

 Learn about their causes
 Identify about the symptoms
 Analyze how they are treated

2. Introduction
In our everyday lives we may experience some type of uneasiness or discomfort in certain
situations or in certain places etc. These feelings can range up to mild discomfort to highly
unbearable feelings like panic attacks. This feeling of uneasiness can be experienced by all age
groups and it may vary in intensity. For example, in adults it may be common to experience
anxiety in situations where they need to meet with a deadline at work.

Anxiety can commonly be experienced by children also, such as when they have an exam to
write, or in situations with high adjustments like divorce of parents or change of school.
Sometimes anxiety can be useful and motivating in our everyday lives. For example, when we are
worried about writing a test, that worry or anxiety motivates us to work hard and prepare better
for the upcoming challenge. But when this anxiety becomes overly strong and takes over the
senses of an individual which forces him to stop using his mental abilities, problem solving skills,
doing his daily tasks, avoiding social settings and disturbing the daily functioning of the
individual overall, it becomes pathological.

Anxiety is like an alarm system to the human body which is activated when our body experiences
danger or an emergency situation. When the person finds himself in such a situation, he feels
certain sensations such as, sweating, palpitation, increased heartbeat, dizziness, high blood
pressure etc; these sensations are called fight or flight sensations.

Anxiety is a complex mix of unpleasant emotions and thought processes that are both more
directed to the future and much lesser than fear (Barlow 2002). Anxiety is not only consisting of
cognitive/subjective factors but also consists of physiological and behavioral changes or factors.
The three components can be seen clearly in an individual suffering from intense feeling of
anxiety.

 Cognitive/ Subjective level the individual experiences negative mood, worry, a sense of
inability to predict the future threats and self preoccupation.
 Physiological level consists of bodily changes from within and outside as well such as,
palpitation, high BP, sweating, dizziness etc.

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 Behavioral level consists of behavioral changes such as

the urge to take flight or fight from the situation
(Barlow, 1988, 2002).

Anxiety is an emotion identified by thoughts filled with tension and worry as well as feelings of
restlessness and several bodily or physical changes like increased levels of blood pressure. People
diagnosed with anxiety disorders generally have repeatedly occurring intrusive thoughts or
concerns. They try to avoid to going in certain places or be present in certain situations out of
worry. They may also have physical changes or symptoms in the body such as palpitation,
sweating, shaking or trembling, dizziness. (Encyclopedia of Psychology).

Anxiety disorder is considered to be a pathological condition comprising of an excessive sense of

apprehension, with physical symptoms such as sweating, palpitations, and feelings of stress.

There are several disorders caused due to excessive anxiety experienced by an individual. It can
occur in adults as well as children and adolescents. Thus, anxiety is not something that comes or
develops with age; there are several environmental as well as internal factors on which the
occurrence of these disorders depends on.

Figure 2: Physical effects of anxiety disorders

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3. Types of Anxiety Disorders in Children

Anxiety in children is not easily identifiable, because children have a lot of energy which keeps
them moving around and energetic. To the parents this high level of activity of sometimes
irritability might seem very normal and therefore they might ignore the symptoms that might be
leading the child to an anxiety disorder. Thus, it is very important for the parents or the care taker
to identify the type of anxiety that is being experienced by the child. Doing so, will help the
therapist to treat the child accordingly and also because the treatment that is chosen depends upon
the symptoms or the type of anxiety the child shows.

3.1 Generalized Anxiety Disorder (GAD)

Anxiety is an emotion which has an adaptive property, this property helps the individual to plan
and prepare for future threats or sometimes even events. But, for some people this anxiety and
worry becomes a matter of great concern because it takes a chronic, excessive and unreasonable
twist for them. These individual suffer from what may be diagnosed as the Generalized Anxiety
Disorder or the free-floating anxiety.

Diagnostic Guidelines given by ICD-10

The person or patient must show primary symptoms of anxiety most days for atleast many weeks
at each time, and generally for many months. These symptoms should comprise elements of:

(a) Motor tension (headaches due to tension, restlessness, shaking in complete body, lack of
relaxation);
(b) Autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric
discomfort, dizziness, dry mouth, etc.)and
(c) Apprehension (tension about future mishaps, feeling “on the edge”, lack and inability in
concentrating etc.).

There are certain ways in which the therapist or the psychologist may diagnose the generalized
anxiety disorder in the child. They use very specific observations and some tests that are
completely suitable in assessing the level of anxiety in the child or adolescent. In cases where the
child is too anxious or too small to talk, the parents are investigated in order to gain completely
reliable information. In case of adolescents, it is better to ask him or her because at that age he or
she is more aware of his or her bodily changes than anyone else.

Some causes of generalized anxiety disorder have been mentioned below:

 Psychosocial perspective believes that this disorder is a result of the unconscious

conflicts between the ego and the id impulses due the lack of development of the defense
mechanisms in the patient or because they have been broken down. It is believed by
Freud, that the sexual impulses or the aggressive feelings that were suppressed in the past

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with punishment or negative reinforcement come out

as free floating anxiety in the present.
 Another explanation given by the psychoanalytic psychologists is the repeated occurrence
of unpredictable and uncontrollable events. In cases where this happens, the individual is
never ready for the defending behavior and is caught by surprise all the time. This leads
to an unsettling and unexpected worry all the time about the unpredictable events that
might take place.
 Cognitive biases for threatening information are another causal factor which
psychoanalysts came up with. It is believed and has also been proven with the help of
studies and researches that an anxious person will perceive any information as negative
and threatening as compared to a person who is not at all anxious. Thus, these individuals
who are suffering with anxiety preferentially allocate their attention to situations that are
threatening, worsening their condition and never coming out of this problem.
 There are some biological causes as well which may lead to the generalized anxiety
disorder. Genetic evidence of GAD is mixed, it does seem likely that there is a modest
heritability, although smaller than for most other anxiety disorders (Hettema, Prescott, &
Kendler, 2001). Another biological cause may also be the functional deficiency of
GABA.

3.2 Separation Anxiety Disorder of Childhood

It is commonly seen that preschool children and toddlers show some signs of anxiety at some
level. This type of anxiety can be seen at times of mother child separation or the care-taker and
child separation. Separation anxiety disorder should only be confirmed when the fear of
separation comprises a high degree of anxiety and especially during the early age of childhood.
The word Separation in this disorder is one that is different from the regular separation; such as
the divorce of parents, death of a parent or the care taker or associated to serious disturbances in
the social functioning of the environment in which the child lives.

Children with separation anxiety disorder have higher tendency to worry about separation than
children who do not suffer from this disorder. Even the slightest of separation can overwhelm the
child in such cases, such as going away to attend school, sleeping, when the parent has to leave
the child at home when he or she has some outside work to do. The child may experience extreme
fear related to the death or major illness of a parent due the fear of losing one of them. If the child
wants to let the feeling of anxiety go away, then he tries to cling onto the parent the whole time,
not go out and play with other children and sometimes also making excuses of stomachaches or
headaches to stay with the parent. It is commonly seen that the child can stay away from one
parent much easily than the other one.

This disorder is difficult to diagnose because children who have this type of anxiety may have
other types of anxiety disorders other than this one alone. Such children have many bodily
complaints like mentioned above including stomach aches or headaches which leads to the parent
getting more worried about them, and subsequently spending more time with the child. It is
important that a specialist in this field such as a psychologist for children handles such cases by
collecting appropriate information about the child and then leading to a conclusion.

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Some of the symptoms identified by ICD-10 are:

 An imaginary and constantly occurring thought of tension about something wrong or

harmful happening to the closest person of the child;
 An imaginary, constantly occurring worry that unexpected and scary event might take
place that might separate the child from his loved ones;
 Persistent repeatedly occurring or a constant fuss about not sleeping unless the loved one
or the attachment figure is around the child;
 Constant and inappropriate worry of being left out alone at home or outside at any time of
the day;
 Recurrent disturbing dreams about separation;
 Constant occurrence of bodily symptoms (nausea, stomachache, headache, vomiting, etc.)
in situations that involve separation from a major attachment figure such as leaving home
to go to school;
 Overly and repeatedly occurring stress in anticipation of, during, or immediately
following separation from a much loved one.

Some causes of Separation Anxiety Disorder are:

 This type of anxiety often occurs after there has been a very sad and disturbing event in
the life of the child. These events may include the loss of a loved one, loss of a pet,
migration from one place to another, joining of school etc.
 Another cause may be that some children have over-protective parents due to which they
develop such a disorder. Also, there is a possibility that there may not be a true cause of
the child’s anxiety but just a pass on from the parent itself. The fact that the anxiety of the
parent can move on to the child, shows that this disorder can be inherited.

3.3 Phobic Anxiety Disorder of Childhood

Phobias in adults, is defined as an individual who suffers from a strong and persistent fear that is
unreasonable and excessive and is enhanced or triggered when the individual is in the presence of
a specific stimulus or situation.

Phobias may become so intense sometimes that they may resemble panic attacks, but the only
difference between the two is that phobias have a specific stimulus or are triggered in specific
situations whereas, on the other hand, panic attacks are experienced without any specific
stimulus.

In children, phobias may not be the correct term, but phobic anxiety can be used in their case.
Children, like adults can also develop a fear for specific objects or situations and are also
identified as phobias. But some fear of specific objects (agoraphobia) may only be during a
developmental phase and they might subside over the years thus, called phobic anxiety. During
childhood the most common fear is of animals, especially during the pre-school years. When the
child comes across a situation which he fears, he tends to start crying, becomes clingy, freezes
there (figure 5) or may also throw tantrums. This disorder has a very short life span if treated and
taken care of in time. But if this disorder is not taken care of, and is enhanced due to certain

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environmental difficulties, then it may develop into a social or

specific phobia in the growing years of the child till adulthood.
Some commonly seen childhood phobias include the fear of planes, injections or sharp objects,
dogs, bugs, spiders, lizards etc.

Symptoms of Phobic Anxiety Disorder in childhood as mentioned by ICD- 10 are mentioned

below:

 The beginning of phobias happens during the developmental years of the child;
 Level of anxiety needs to be at such a level that it is clinically abnormal; and
 The anxiety does not form part of a more generalized disorder.

3.4 Social Anxiety Disorder of Childhood

Other than specific type of phobic anxiety the child may also experience social phobic anxiety,
which may occur in situations which are overcrowded, and the child might feel distressed on
seeing so many new faces and also, situations where the child is required to make a public
appearance or public performance. This phenomenon is normally seen in second six months of
the child’s life, as he moves out of his or her home environment into the outer world and
experiences new and strange situations.

Thus, this classification must be applicable for disorders that are diagnosed for children below the
age of 6 years. During these years the child starts going to school and makes new friends,
performs on stage, confronts teachers, meets new people in school, etc. For some children this
may be a wonderfully new and amazing experience, but children who afraid of such situations
may experience social anxiety. Some symptoms of Social Anxiety Disorder given by ICD-10 are
stated below:

Children suffering from this disorder are seen with a repeatedly occurring fear of completely
strange people. The fear is associated with a normal degree of selective attachment to parents or
to other familiar person. The avoidance or fear of social is of a degree that is outside the normal
limits for the child’s age and is associated with clinically significant problems in social
functioning.

Social Anxiety Disorder may be caused due to some of these factors:

 Genes play an important role in explaining the biological cause of this disorder. That is, if
the child’s parents or any relative, close or far has a similar condition, then there is a
possibility of the child acquiring that condition too.
 It is also believed that certain individuals develop this disorder because they have seen
anxious behavior around them all their life and learn from them. There is also a possibility
that this disorder is a result of over protective parenting style.
 The life experiences of the child may also cause the child to acquire this disorder. For
example, if the child has been humiliated at some point of time by his friends or teachers,
he may have been bullied, sexually abused by an elder person, family conflicts, divorce or
separation of the child’s parents etc.

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 Children who are withdrawn, restrained, shy or timid

when confronted with a new situation are thought to be
more prone to developing social anxiety disorder.

4. Treatment

4.1 Relaxation Techniques

When an individual is suffering from anxiety, a lot of bodily changes take place including dry
mouth, increased breathing palpitation, sweating, fastening of heart beat and sometimes high
blood pressure. Whereas, in relaxation mode the individual is in a completely opposite state
where he or she, breathe slowly, body temperature is cool, heart beat is normal and stable, body
muscles are relaxed etc. Thus, if anxiety needs to be decreased it is very important for the person
to be relaxed thus; relaxation is an anxiety- relieving tactic. Relaxation techniques have been
found to be most effective in the betterment of Generalized Anxiety Disorder. Some commonly
used relaxation techniques have been mentioned below.

 Progressive muscle relaxation- this type of relaxation is specifically for the muscle
relaxation, wherein, the individual suffering from any anxiety disorder systematically
tenses and then relaxes each and every part in the body. This exercise should be done in
one direction, that is, from head to toe or from toe to head. And as your body relaxes
muscle by muscle, the mind will follow automatically.
 Deep breathing- breathing in an anxious person becomes intense and faster when he
faces a difficult situation or object which causes bodily changes such as dizziness,
breathlessness, lightheadedness, dry mouth and much more. Therefore, the aim of this
technique is to stabilize the individual’s breathing pattern in anxiety provoking situations.
 Meditation- is a type of relaxation technique which has been found to be extremely
effective not only for anxiety disorders but also for other disorders. The most effective
type of meditation has been proved to be effective is the mindfulness meditation. If
meditation is performed on a regular basis then it is believed to boost energy levels and
activity on the left side of the prefrontal cortex, which is considered to be the area of the
brain responsible for feelings of serenity and joy.

4.2 Cognitive Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a type of therapy which has been found to be very helpful
in treating anxiety based disorders. Task of Cognitive-behavioral therapy is to help us find out the
distortions in the way we look at the world around us and ourselves and correct them into healthy
ways.

In this type of therapy the child is taught to identify the negative feelings and thoughts and then
taught to replace these negative thoughts with positive ones. The child here is also taught how to
distinguish between the unreal and the real thoughts. The child will receive “homework” to
practice what is learned in therapy.

These are some techniques that the child can use immediately and for years to come. The
psychologist or the therapist and the parents of the child take care whether the child is improving
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or not in the home as well as the school setting. CBT is

generally short-term and sessions last about 12 weeks but the
benefits are long-term.

Cognitive Behavioral Therapy consists of four steps:

 Education- The child who comes to the therapist might not even know what he is there
for, thus the child’s parents need to understand very clearly the meaning of anxiety and
what type of anxiety it is. Only when they have complete information about their child
will they will be able to corporate with the therapist.
 Monitoring- involves the tracking of specific situations in which the child experiences
maximum anxiety, how long the anxiety lasts and what are the physiological and
behavioral changes that take place at that time.
 Cognitive Control Strategies- with the help of CBT, one learns to thinks realistically
and then change the complete mind process and patterns simultaneously. As the child is
made aware of these negative and disturbing thoughts and made to confront them, they
will slowly subside and that child will get used to such situations and also the feeling of
anxiety will subside overtime.
 Behavioral Strategies- Some effective behavioral techniques are problem-solving skills
and Time management.

4.3 Medication

There are three types of medication prescribed for generalized anxiety disorder specifically:

 Buspirone – This anti-anxiety drug, known by the brand name Buspar, is generally
considered to be the safest drug for generalized anxiety disorder. Unlike the
benzodiazepines, buspirone isn’t sedating or addictive. Although buspirone will take the
edge off, it will not entirely eliminate anxiety.

 Benzodiazepines – These anti-anxiety drugs act very quickly (usually within 30 minutes
to an hour). The rapid relief the benzodiazepines provide is a major benefit, but there are
serious drawbacks as well. Physical and psychological dependence are common after
more than a few weeks of use. They are generally recommended only for severe,
paralyzing episodes of anxiety.

 Antidepressants – A number of antidepressants are used in the treatment of generalized

anxiety disorder. However, the relief antidepressants provide for anxiety is not
immediate, and the full effect isn’t felt for up to six weeks. Some antidepressants can also
exacerbate sleep problems and cause nausea.

5.Summary
 Anxiety is a complex blend of unpleasant emotions and cognitions that is both more
oriented to the future and much more diffuse than fear (Barlow 2002).
 Anxiety causes a number of physiological, cognitive as well as behavioral changes in an
individual.

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 There are 4 types of anxiety disorders in children

including; generalized anxiety disorder, Separation
anxiety disorder, Phobic anxiety disorder of childhood and Social anxiety disorder of
childhood.
 The symptoms have been mentioned after each disorder directly taken down from the
ICD-10.
 Treatment of these disorders in children is quite common including Relaxation
techniques, Cognitive Behavioral therapy and Medication.

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MODULE No.4; Childhood Anxiety Disorders