An anxious generation

Anxiety disorders are common in children and adolescents and can manifest in different ways

 

 

 

With new teachers, new classmates and new routines, the back-to-school season can be a source of anxiety for many children. According to a renowned, award-winning child and adolescent psychiatrist, that’s normal – to a certain extent.

“We all experience a little bit of anxiety,” Dr. Suneeta Monga told parents at a recent online workshop titled Conversations About Anxiety.

“Feeling anxious at times is very normal and happens to all of us,” says Monga. “In children, fear and worry are common. Even young children can be scared about different things.”

If anyone would know, it’s Monga. A professor of psychiatry at the University of Toronto and the associate psychiatrist-in-chief at The Hospital for Sick Children, Monga’s clinical work and research focuses on helping children and youth with anxiety and mood disorders.

“Some anxiety is normative and transitory and experiencing a little bit of anxiety can actually be a bit beneficial,” says Monga. “A person who can be a bit anxious and looks both ways before they cross the street… it’s not a bad thing,” she says. Nor is a child who worries about an upcoming test and decides to study in preparation. “But anxiety that is present all the time, that causes you or your child not to be able to function, that’s when we start to call the anxiety an anxiety disorder.”

Pediatric anxiety disorders are a serious mental health condition, says Monga. Anxiety disorders are also one of the most common mental health conditions seen in children and adolescents, affecting between 10 and 20 percent.

Ottawa resident Élise (last name withheld to protect privacy) was officially diagnosed with generalized anxiety disorder at age 14.

In the decade since, the Ottawa resident has learned to recognize her own anxiety symptoms: tightness in the chest, shortness of breath and feelings of frustration.

“I also tend to experience overstimulation – everything being too loud, too bright, or textures being ‘off’” says Élise. “If not addressed, I can have a ‘classic’ panic attack [with] crying and hyperventilating. It has also manifested in various forms or self harm as an attempt to deal with or distract from the physical and emotional impacts.”

Monga emphasizes that it’s a grey line between normative anxiety and anxiety disorder. “It really depends on how much the anxiety is impacting or interfering in your child’s life,” she says.

 

 

As a toddler, Lisa M.’s son (names withheld at request to protect the family’s privacy) experienced anxiety symptoms when his parents dropped him off at daycare.

They were more severe than the normal toddler hesitance to go somewhere new and continued long after he became comfortable at the daycare, says the Ottawa resident.

“Reassuring words or validation of his fears don’t get through and he will do impulsive things like throwing things or hitting people,” says Lisa. “It’s a very noticeable difference because when he’s well-regulated, he’s a happy, polite, caring kid.”

Diagnosed with ADHD at age six, Lisa’s son was formally diagnosed with anxiety last year, at age 10.

Even with his current anxiety medication and strategies learned from his occupational therapist, Lisa’s son still experiences occasional anxiety attacks and panic attacks, but is now equipped to recognize what is happening.

“Anxiety still impacts his daily life,” says Lisa – “it makes it hard for him to do things that he enjoys and it makes his relationships with family and friends unpredictable.”

Élise has developed her own coping mechanisms but like Lisa’s son, is still affected by anxiety.

“Sometimes I can very easily manage my own anxiety with various skills and tools I’ve learned over the years,” says Élise. “Other times I still struggle quite a bit.”

Monga says the important thing to know is that an anxiety disorder is not going to improve without some form of treatment.

Anxiety disorders are caused by a combination of biological and environmental factors, similar to any other physical health condition like allergies or diabetes, says Monga.

“There’s a component of genetics, and there’s a component of temperament. And there’s some modelling (the way you react to a scary event or a difficult situation is observed by your child).  All of this coming together can cause an anxiety disorder.”

There are six types of anxiety disorders: phobias (specific fears, such as fears of dogs or heights); separation anxiety (a concern outside the normal sphere that something bad will happen when they are not with a parent or caregiver); generalized anxiety disorder (these “worrywarts,” as Monga refers to them, “worry about everything and anything”); selective mutism (inability to speak in certain situations out of worry that their voice sounds loud or weird); panic attacks and panic disorders (overwhelming sense of anxiety hallmarked by physical symptoms including heart pounding and inability to breathe); and social anxiety disorder (fear of doing something embarrassing in front of others). With social anxiety, everyday events like gym class, show-and-tell, oral presentations and even picture day become challenging, says Monga.

We need to talk about self-harm

Sometimes, children and adolescents can engage in self-harm or the use of substances to cope, says Monga, or expressing not wanting to be alive or disappearing. In this case, urgent professional support through a family doctor, pediatrician or through a hospital emergency department must be sought.

What happens after a  mental health services referral?

A physician, psychiatrist or psychologist is required for a diagnosis of anxiety disorder. Core elements of an assessment (for the purpose of evaluating whether the anxiety meets the criteria for an anxiety disorder) will typically include questionnaires and speaking with the family together, with the child or youth alone and then with the parents alone, says Monga.

As medical conditions are often co-occurring, an assessment can also determine whether other psychiatric conditions or anxiety disorders exist.

Treatment and management plans

A clinician working with the family should provide treatment and help develop a management plan, says Monga.

While medications, typically antidepressants, are required for more severe cases of anxiety, milder symptoms of anxiety can be highly responsive to basic things like healthy eating, and regular sleep/wake times as well as eliminating caffeine and monitoring screen time. Exercise is also a great strategy for decreasing anxiety, says Monga. Helping children recognize feelings and empathizing with the worry – but not reinforcing it – helps.

Monga also suggests modelling effective coping strategies and teaching relaxation strategies such as calm breathing, imagery or mindfulness, as well as helping the child face fears slowly and gradually. “The more a child avoids an anxious situation, the bigger that fear or worry becomes,” Monga says.

She encourages parents to communicate results of a child’s assessment with appropriate staff at the child’s school. Sometimes, clinicians may ask for permission to speak with the school as well. “It’s really critical to have a good collaborative team between the school team and mental health team,” Monga says.

As a mom who’s been through it, Lisa has advice for other parents.

“Our situation has been complex and it has been very challenging navigating the different professionals and interventions,” Lisa says. “It is hard work and you’re going to have to be a squeaky wheel to get on the right waiting lists and into the right therapy groups. The other thing I would say is that medication can be your friend, but it isn’t always a magic bullet and it also takes work to find a combination that works for your little one. Finally, while dealing with mental health struggles, kids are still developing and growing – what works for a seven-year-old might not work for an 11-year-old, so this is a long process and not a fix-it-once kind of situation.”

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What normative fears may look like based on developmental age

Infants “Infants are afraid of loud noises,” says Monga. “They’re easily startled.” There’s a normative stranger anxiety as well. “At some point in time, they start to recognize, ‘this is mom or dad or my caregiver’ and everyone else is a stranger.”

Toddlers Normative fears include fear of the dark, imaginary creatures and separation anxiety, the latter of which typically develops at six to eight months and may last until ages three or four years.

School-aged children When kids start to go to school, they have a wider awareness of the world around them. “They may start to have normative worries about getting hurt, or a storm or something bad happening to them,” says Monga.

Older children and adolescents “We see their worries become more about ‘am I doing OK at school? or Am I doing OK with my friends?’ ‘Am I healthy?’ These fears are kind of normal if they are transitory and don’t last for a long time and kind of come and go,” says Monga. Adolescence is a time of emotional ups and downs, but parents should observe whether their teen is more sensitive or more irritable than their peers and whether they have frequent emotional outbursts or are withdrawing from family and friends and previously enjoyed social events and extracurricular activities.

 

Signs and symptoms of anxiety

Anxiety manifests in a child’s thoughts, physical symptoms and in their behaviour and may include:

• headaches
• stomach aches
• rapid heart rate
• difficulty breathing
• avoidance
• meltdowns and tantrums
• perfectionistic tendencies
• need for reassurance
• difficulty in trying new things
• appearing restless and intense
• difficulty sleeping
• picky, fussy eaters
• moodiness or irritability
• school refusal

 

 

“An anxiety disorder is more than just a little anxiety. The anxiety is impacting your child’s ability to get to school or to make friends or to speak at school, or to demonstrate how smart they are.”

• Suneeta Monga