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Seven Steps to Help Your Child Worry Less
A Family Guide for Relieving Worries and Fears
By Sam Goldstein, Hagar Kristy, Robert Brooks, Richard A. DiMatteo
Specialty Press, Inc.Copyright © 2002 Sam Goldstein, Ph.D., Kristy S. Hagar, Ph.D. and Robert Brooks, Ph. D.
All rights reserved.
Why Do Children Worry?
What is Worry?
As noted in the previous chapter, children can worry about many things. Although the kids on Bonneville Street each had different worries, varying in intensity and evoking different reactions, they all had one thing in common — they experienced a sense of uneasiness or discomfort about something that could happen in the future. They worried because they were uncertain about what would happen, or they worried because they made a prediction about what was going to happen that had an adverse or less than favorable outcome. For example, Lisa worried about the family trip (uncertainty), Marty worried about the next time he went to the dentist (the visit might be deadly), and Kathy worried about failing tests (bad outcome).
Why is worry important?
Worry can be considered a normal response to many situations. If children didn't worry (even slightly) about doing well — say, on a math test — then it is likely that they would not learn or perform as effectively. Mild worry can be a motivator to take action such as preparing for a speech, studying for a test, or training for a sports competition. A certain degree of worry also serves as protection and self-preservation. Children's worries about their own safety and the safety of their loved ones are common and can hopefully assist them in making choices that will keep them out of harm's way.
What is Fear?
Worry associated with harm as the result of a specific animate (e.g., animal) or inanimate (e.g., airplane) object, leads to fear. Fear is often accompanied by physical symptoms, including changes in heartbeat, blood pressure, and hormones. In the extreme situation, this is referred to as a phobia. A phobia results in a specific, isolated, and persistent fear of a particular object, animal, or person. Fears become phobias when efforts to avoid the perceived fear significantly interfere with daily life.
Temporary fears are common in children — many being age- or time-specific. Some begin with a startle reaction to a certain event during infancy or toddler years, and, in some cases, progress to simple phobias. Many years ago, a psychology researcher, John Watson, attempted to develop a phobia in little Albert, a young child. He exposed the child to a white rat and simultaneously banged a pot with a metal spoon behind the child's head. The child was startled and cried. After only seven of these exposures, whenever the child saw the rat, he began to cry. Fortunately, Watson was also able to demonstrate that this process could be reversed by slowly exposing the child to the rat and bringing the rat closer and closer to the child. Eventually the child did not cry in the presence of the rat.
Mild fears are quite common in children of all ages. Girls, however, report more fears than boys. Children's fears appear to change as they mature. Preschoolers are usually fearful of menacing animals and the dark. Some even become fearful of harmless, fantasy characters. As children mature, these types of fears decrease and are replaced with more realistic fears involving social and school issues. In the adolescent years, teens may fear failure or criticism.
Researchers have identified five distinct groups of fears in children and teens. These are:
1. fear of failure and criticism from adults
2. fear of the unknown
3. fear of injury and small animals
4. fear of danger and death
5. medical fears
The ten most common fears reported in children include:
1. being struck by a car
2. not being able to breathe
3. a bombing attack
4. being burned in a fire
5. falling from a high place
6. a burglar breaking into the home
7. an earthquake
9. poor grades
Although mild fears are common in children, fears developing into phobias are less common. Severe phobias occur in less than 1% of children, while mild phobias have been reported to occur in between 5% and 7% of children. Animal phobias often start before age five, while social phobias tend to arise after puberty. Fears and phobias related to heights, darkness, or storms, for example, will have a variable age of onset.
When Does Worry Become Anxiety?
Anxiety develops out of worry when, despite the efforts of parents (and even children themselves) to provide reassurance, the worry persists and grows. The anxiety then begins to cause significant problems. Children's behaviors change to avoid or minimize the triggers of anxiety (e.g., not studying for a test due to worry about failing, complaining of a stomachache every morning in an attempt to avoid school). While minor changes in routines are common and can be relatively uneventful (e.g., walking home from school "the long way" to avoid a scary dog), excessive changes in routines or behaviors to avoid anxiety-provoking stimuli are more troublesome and distressing (e.g., refusing to walk home from school at all due to unrealistic worry about being attacked by dogs). Changes in behavior can also be accompanied by physical symptoms of anxiety (e.g., queasiness, muscle tension, heart pounding). Worry and fear become anxiety when children cannot be reassured and their behavior significantly changes in order to reduce or avoid the feared object or situation.
How common is anxiety?
Worry and fear are common human experiences. Anxiety, too, is considered to be a natural and expected (though hopefully temporary) reaction to daily stressors, special occasions, deadlines, etc. Unfortunately, normal worry, fear, and anxiety have not been studied separately from clinical anxiety — anxiety that causes extreme distress and usually leads to seeking treatment. Therefore, it is unclear how many children experience moderate anxiety that falls between normal reactions and severely distressing and potentially incapacitating clinical anxiety. It is not uncommon for children to suffer in silence, and sometimes, only when parents notice a change in behavior does a child's worry, fear, or anxiety come to light.
How does anxiety affect people?
Anxiety can have a significant affect on people of all ages in various ways. Anxiety can affect the way we think about a situation, our behavior, and our physical reactions.
Thoughts: As we have discussed, the experience of anxiety involves certain thoughts, feelings, behaviors, and bodily responses. Thus far, this step has focused on the thoughts and feelings that fearful, worried, or anxious children develop. It is clear that they begin to think differently about their experiences, filtering what they see, hear, and feel in a negative manner.
For example, while exiting a roller coaster, most children have interpreted the sensations of the coaster as pleasurable and enjoyable. However, others leave the ride and form an entirely different interpretation of it. They leave with negative thoughts and feelings — scared, concerned about their health and safety. Thinking about the ride as pleasurable is the furthest thing from their minds.
Behavior: Children develop a tendency to want to avoid situations that produce anxiety. In a previous example, a child starts to think about a frightening dog that he may encounter on the way home from school. He starts to worry because he can't predict for sure whether he will meet up with the dog that day. In order to stop the worrying, the boy decides to take another route home. His behavior changes in order to reduce his worry. While this can be a very adaptive problem-solving skill, it can sometimes lead to excessive avoidance (e.g., if the boy has to go four to five blocks out of his way) or an inflexible pattern of problem solving (e.g., if he believes he can never walk home that way again because he might see the dog). His initial avoidance of the situation, reinforced by the fact that he did not see the dog on the alternate route home, makes him more likely to repeat the same solution again in the future. This is called negative reinforcement. Negative reinforcement occurs when there is a change in behavior to stop or avoid an unpleasant, aversive, or unpredictable (the negative) feeling, thought, or action. The reinforcement part occurs because it feels good to avoid unpleasant things.
This behavior can be observed in everyone in certain situations. Avoiding unpleasant, uneasy, or unpredictable situations reduces anxiety. Unfortunately, sometimes children may also start to avoid situations that are similar to the original situation. In the previous example, a child starts to avoid walking home from school a certain route due to worry or anxiety about being attacked by dogs. Eventually, that worry may generalize to other situations (e.g., walking home from school altogether, to a friend's house, to the store, to the park).
Physical: Anxiety makes the body react — breathing becomes more shallow and/or more rapid, muscles tense, and the heart starts beating faster. While intense fear or anxiety causes the body to demonstrate noticeable levels of these physical signs (e.g., barely escaping danger in a car accident, giving a speech in front of 250 people), less intense anxiety-provoking situations can cause less noticeable and sometimes undetectable physical reactions. In any case, the body may react by clenching the teeth, slightly tensing the neck or shoulder muscles (a common cause of tension headaches), or developing a chronic shallow pattern of breathing.
Types of Anxiety
In this section, we will discuss the different types of anxiety that can affect children. Phobias, separation anxiety, social anxiety, panic, stress-related anxiety, and generalized anxiety can each significantly impact a child's ability to function normally. Each type of anxiety will be described below.
A phobia is an intense fear of a specific object or situation that causes avoidance or extreme discomfort. Common childhood phobias include school, animals, heights, water, doctors, and loud noises. Children's phobic responses can be quite different from those of adults. While adults will often avoid or easily verbalize situations or things that they fear, children may have less opportunity to avoid phobic situations and may also have limited awareness and/or vocabulary to adequately express the things they fear. Common phobic reactions in children can include crying, tantrums, and/or clinginess to adults.
Separation anxiety is fear or excessive distress when separated (or separation is anticipated) from an important adult (usually parents) or place (e.g., home). Other symptoms of separation anxiety include persistent or excessive worry that harm will befall parents or other loved ones, fears of extended separation through malicious intent of others (e.g. being kidnapped), and not wanting to go to sleep without parents close by (also manifested by refusing to sleep away from home). Separation anxiety is an expected developmental phenomenon for children and is typically strongest during 14 to 18 months of age. As children get older, separation anxiety should significantly decrease. It is important to note that nearly all children, at some point, worry about their first sleepover away from home, their family's safety, or if they will be safe and not have bad dreams when they fall asleep. Again, it is when the anxiety becomes severe and persistent and negatively impacts the child's emotions and behavior that it is considered excessive.
Concern about performing, interacting, or being embarrassed in social situations is probably one of the most common and normal worries that all humans experience at one time or another. How many times have parents worried about giving a presentation at work, hitting that perfect shot in front of golf buddies, or going to a party where they hardly know anyone? Common childhood social concerns include many of the same situations: giving a talk in front of the class, going to a birthday party, not wanting to strike out while playing stickball in gym class, etc. Performance anxiety becomes social anxiety when the fear or worry is persistent and leads to certain behaviors (e.g., crying, avoidance, isolation) when a child anticipates having to be in the situation.
Panic or panic attacks can best be described as physical and/or emotional reactions to an anxiety-provoking situation or object. All of the types of situations described above can include panic attacks as a manifestation of the specific anxiety. Sometimes children and adults experience a sense of panic without a specific anxiety -provoking stimulus. This reflects a strong biological component to panic. Children who experience panic attacks often provoke the most worrisome and concerned reactions from their parents, because their behavior can be so much more severe and demonstrable compared to other coping strategies such as avoidance or clinginess. The emergence of panic attacks often spearheads parents' motivation to seek treatment for their child's anxiety. Common physical symptoms of panic include tachycardia (heart racing), sweating, trembling, nausea, dizziness, hyperventilation, feeling cold or hot, numbness or tingling, and/or experiencing a smothering sensation. Emotional/cognitive symptoms can often include fear of dying, fear of losing control, derealization (feeling like things aren't real), depersonalization (feeling apart from one's self), having a desire to flee or escape from a particular event or setting, and/or feeling immobilized.
Stress-related anxiety typically occurs when someone (child or adult) has experienced or observed an event or series of events which are highly stressful or even traumatic. Consider the common example of test anxiety. It has been suggested that at least one -third of all students experience some degree of bothersome test anxiety. Suppose 12-year-old David had a particularly hard time on the last three math tests he had taken. As the semester progresses, like Kathy, David finds it more and more stressful to take and even prepare for a math test. While he may not necessarily avoid studying and may not be fearful of going to math class, his motivation, enjoyment, and perseverance in math is weighed down by the extreme distress he experiences just thinking about it. Stress-related anxiety can be paired with everyday, common occurrences that become aversive based on an individual's personal experience. In other words, while math class may be particularly stressful for David, many of his peers may enjoy the opportunity to learn math. There are, however, highly emotionally charged or traumatic situations in which most people would experience a stress-related anxiety reaction. Events in which serious injury or threat of injury occurs (either observed or experienced), combined with intense fear, horror, or helplessness is referred to as Posttraumatic Stress Disorder. Car accidents, violent crime, natural disasters, and abuse or other bodily harm are all examples of potentially serious, traumatizing situations. Children who experience severe traumatic events will be discussed in greater depth in step two.
Generalized Anxiety ("Worry Warts")
Through experience, temperament, or a combination of both, some children are just prone to worry. These children tend to worry about all kinds of stuff, including many of the things listed above. When children's worrisome ways get out of control and excessive, either in intensity or scope, it is referred to as generalized anxiety. In other words, the anxiety they may experience in one or two situations generalizes to many other aspects of their lives. Like Lisa, these children often experience a "runaway train" of thoughts, feelings, and behaviors. They worry about the unpredictability of numerous events, situations, or activities. They experience a never-ending barrage of "what ifs" such as: "What if I fail?", "What if I don't wake up tomorrow?", "What if something happens to mom or dad?", "What if she calls on me to answer the question?", "What if that dog bites me?", and on and on.
Causes of Worry, Fear, and Anxiety
Believe it or not, a tendency to worry is much more common in some families than in others. However, this occurrence does not prove either an experiential, genetic, or environmental basis in the transmission of the problem from parent to child. As we have discussed, common sense tells us that many life events may lead to the experience of worry, fear, or anxiety. This pathway likely represents a number of factors, including the occurrence of the event, the individual's past experiences through which they filter the present anxiety provoking event, and possible genetic or biological risks that cause people to experience certain events more intensely.
As of this date, no specific gene or set of genes has been identified as responsible for worry, fear, or anxiety. At this writing, no adoption studies of anxiety disorders have been performed, either in children or adults. A number of twin studies have compared anxiety in identical and non-identical twins in an effort to separate genetic from environmental causes. Studies have focused on the amount of anxiety or fearfulness in the general population of twins compared to twins with significant anxiety. General fearfulness, particularly of the unknown, danger, or injury may be the result of a significant genetic effect. Panic disorder demonstrates the strongest genetic effect, while phobias demonstrate the weakest genetic effect. Additionally, of all the anxiety conditions, separation anxiety disorder may be more significant in females than males. What we do know is that when adults with anxiety problems are asked about their childhood, they often report multiple anxiety problems beginning at young ages. Perhaps by appropriately identifying those at risk for excessive worry and anxiety at young ages and providing them with the support, education, and coping strategies described in this manual, we may improve their lives.
Excerpted from Seven Steps to Help Your Child Worry Less by Sam Goldstein, Hagar Kristy, Robert Brooks, Richard A. DiMatteo. Copyright © 2002 Sam Goldstein, Ph.D., Kristy S. Hagar, Ph.D. and Robert Brooks, Ph. D.. Excerpted by permission of Specialty Press, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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