Childhood anxiety disorders involve excessive fear or anxiety that differs from normal developmental fears through its intensity or persistence beyond the appropriate developmental period. The fears or anxiety can be manifest by physical symptoms of distress (headaches, stomach aches, skin disorders), perfectionism, excessive reassurance seeking, great difficulty dealing with change, nightmares and difficulty going to sleep at the beginning of the night. Anxiety disorders in children can include separation anxiety disorder, specific phobias, social anxiety disorder and generalised anxiety disorder, and can also lead to school refusal.
Anxiety disorders in children have an ongoing, pervasive and negative impact on relationships, family life and school adjustment. Anxious children develop a pattern of avoidance of many family and school activities, which prevents them from enjoying developmentally appropriate activities. Many of the anxiety disorders that develop in childhood will persist into adulthood if not treated.
Various published studies have reported that one in five children and adolescents are identified with a range of elevated symptoms of anxiety throughout development.
General principles of psychological assessment
As anxious symptomology is commonly pervasive, it is important that psychological assessment is conducted with multiple sources including the child, his or her caregivers and teachers, where possible. A comprehensive assessment should include a thorough interview and self-report measures to understand the presenting difficulty, support diagnosis and track intervention outcomes. A biopsychosocial approach is recommended including evaluation of: the type, intensity, frequency and duration of anxious behaviours; any precipitating or maintaining factors; client/medical/family history; protective factors; and any comorbidity/suicidality, as is frequently seen with anxiety disorders.
Assessment measures may include either semi-structured diagnostic interviews, such as the Anxiety Disorders Interview Schedule for DSM: Child and Parent Versions, or self-report, parent-report or teacher-report measures. The Spence Anxiety scales are a well-supported Australian set of assessments for children, and are freely available with local norms. Alternatively, the Beck Youth Inventories are a comprehensive evaluation of emotional and social indicators of depression, anxiety, anger, disruptive behavior and self-concept. Lastly, resilience assessments such as the Devereux Student Strengths Assessment provide an overall view of not only symptomology in children but also protective factors including socio-emotional competencies.
Evidence-based psychological treatment guidance
Cognitive behavioural therapy (CBT) aimed at teaching children to identify and regulate their emotions is the gold standard for treating anxiety. However, when working with children it is essential that these skills are delivered in a developmentally appropriate way. Play therapy techniques and parenting skills training are highly valuable in ensuring children are engaged and understanding skills, and parents have the knowledge to reinforce coping at home. There are specific treatment components to give skills to families and teachers in order to maximise positive treatment gains. Both individual and group formats have proven to be effective, with the key target of normalisation, rather than stigmatisation, being emphasised in both formats.
Key targets for CBT treatments should include: increasing self-awareness; promoting empathy skills; relaxation skills and self-management training; mindfulness and attention training; challenging and replacing unhelpful thinking; increasing positive coping role models and support networks; building step plans and exposure exercises; problem-solving skills training; friendship skills; and maintenance and generalisation of skills.
The first randomised control trial for childhood anxiety was conducted using Kendall’s Coping Cat and today it remains a leader in childhood interventions. For groups programs, the FRIENDS protocols (for ages 4 to adult) have a strong evidence base in Australia and worldwide, with both randomised control trials and meta-analysis supporting these protocols for anxiety prevention and treatment. For helpful suggestions on adjusting evidence-based programs to incorporate more play, see Drewes (2009).
Emerging treatment directions for the future
Intervention delivery via computer-based technologies is being evaluated for treating anxiety disorders in children. To enable a comprehensive approach to the prevention and treatment of childhood anxiety disorders, future directions and evaluations should include:
- Building resilience in children of all ages within the school curriculum
- Family involvement in group interventions
- Developmentally-targeted interventions across age groups: pre-school, primary school, high school and school leavers
- Modalities of group intervention – holiday intensives versus once a week, school term interventions
- Evaluating the benefit of providing parents and teachers with an adult resilience program in parallel to children’s interventions.
Key reading and information sources
- The prevention of child and adolescent anxiety: A meta-analytic review (Fisak Jr, Richard & Mann, 2011)
- Rationale and principles for early intervention with young children
- at risk for anxiety disorders (Hirschfield-Becker & Biederman, 2002)
- Cognitive behavioural therapy for anxiety disorders in children and adolescents (James et al., 2012)
- Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review (Reynolds et al., 2012)
- Blending play therapy with cognitive behavioral therapy: Evidence-based and other effective treatments and techniques (Drewes, 2009)