Anxiety in children and adolescents

Anxiety only becomes a mental illness when it has ‘spun out of control’ and makes daily life difficult. This may, for example, be if anxiety prevents you from going to school, or if you do not dare leave home alone. 

Sometimes, your anxiety also affects your family life. This may occur if so much attention is paid to your anxiety that your family can no longer function in an ordinary way. This may, for example, be if you experience so much anxiety about going to school that your mother or father have to stay at home from work. Or if you are so nervous about sleeping in your own bed that you have to sleep with your parents.

There is no research to indicate that there is a special gene that causes anxiety. So you do not inherit anxiety from your parents.

However, researchers have found that a certain sensitivity may well be inherited. In some families, one parent may have a more nervous disposition than the other. In other families, one parent or other close relatives may suffer from more severe anxiety. This increases the risk of a child also developing anxiety.

Being born with this sensitivity is not only a negative thing. Greater sensitivity can mean that you develop into a very caring and empathetic person. However, such sensitivity also increases the risk of developing worries, anxiety and sadness.

If one or both your parents suffer from anxiety, they may end up overprotecting you, which can make you anxious because you come to see the world as a dangerous place. And you may (without thinking about it) end up mimicking your parents’ behaviour.

If your mother is afraid of answering the phone because it causes her anxiety not knowing who is at the other end of the line, you may also become afraid of answering the phone. You may therefore start to avoid answering the phone – even though you were not initially afraid to do so.

When you feel anxiety, your body gets ready for fight or flight. Therefore, your muscles tense up and your heart beats fast. Mentally, you will also be ‘vigilant’ and be highly aware of everything around you.

You may also feel physical discomfort. This may be abdominal pain and headache, diarrhoea, vomiting or fatigue. 

When you have anxiety, your thoughts will often revolve around an imminent danger or threat. You may have thoughts that your or your family will have an accident or that you will do something wrong and be laughed at. You are often not able to see the situation from a less dangerous perspective.

Your behaviour, that is what you say and do, is automatically affected by your negative thoughts and physical reactions. For example, you may react by becoming angry, tense or upset.

At the same time, you will probably try to avoid what is causing you anxiety. This is called ‘avoidance behaviour’. This may be ‘clear avoidance’. For example refusing to sleep in a dark room if you are afraid of darkness. It may also be more ‘veiled avoidance’. For example using a headache as an excuse if you are afraid to attend a social event.

There are different degrees of anxiety. If you find yourself at one end of the scale, you have such severe anxiety that you cannot go to school or be with your friends.

If you are at the other end of the scale, you only feel anxiety in individual situations. The rest of the time you do just as well as your peers. How much you suffer from anxiety may also vary from day to day.

Sometimes, symptoms of anxiety may resemble symptoms of physical illness. This may, for example, be heart palpitations and dizziness. Therefore, it must always be excluded that this concerns a physical illness. Your own doctor will examine this.

Once it has been assessed that the symptoms are not due to physical illness, you will be examined by the psychiatric services for children and adolescents. Here, a therapist will talk to you and your parents. The therapist will ask about:

• What symptoms of anxiety you experience
• In what situations your anxiety occurs
• How your anxiety has developed.

The therapist will also ask your parents about how you have developed from when you were an infant and about whether you have other difficulties. You will also talk about whether there are other members of your family who suffer from anxiety or other mental illness. A diagnosis is made on the basis of the overall examination.

Specific phobias are anxiety about very specific things. You may, for example, be afraid of snakes, heights or needles. If you have a specific phobia, you will do everything you can to avoid what you are afraid of.

Separation anxiety is anxiety about being separated from a parent or other primary caregiver. Most often your mother.

In a small child, the anxiety may manifest in the child following their parents around the house.

In a school-aged child, separation anxiety may surface in connection with school or sports camps. Being away from home for an extended period of time may cause severe homesickness. At the same time, a child may feel excessively worried that something will happen to their parents while they are away.

Experiencing anxiety in many different situations is called generalised anxiety. If you suffer from generalised anxiety, you worry about lots of different things. Examples could be:

• Your performance at school or in sports
• Whether you are goodenough as a friend, brother or sister.
• Your health
• What to say and do
• News on TV.

You will often need your parents to repeatedly reassure you that everything will be alright.

Social anxiety is about being anxious and worried in social situations.  If you suffer from social anxiety, you worry that others will think badly of you. You may come across as shy and inhibited and not feel like meeting new people. You will probably also not feel like talking to shop assistants.

You may also feel anxious about showing visible signs of anxiety. You may be afraid that others will see you blush, notice that your hands are shaking or see you vomit.

Panic disorder is a pronounced fear of suddenly having a panic attack and becoming totally paralysed. More adolescents than children have panic attacks. An attack often comes out of the blue, causing severe heart palpitations, sweating, dizziness and shortness of breath.

If you have experienced panic attacks several times, you may become so afraid of having another attack that you no longer want to leave your home and choose instead to isolate yourself.

Many children and adolescents suffer from more than one type of anxiety. Some also have other mental disorders or developmental disorders. This may, for example, be learning difficulties, ADHD or autism.

Psychoeducation is a form of teaching about anxiety that is offered to both you and your parents. Here you will learn about:

• What anxiety Is
• How the disorder occurs
• What the symptoms are
• How anxiety typically develops. 

You will also receive information about treatment with medication and psychotherapy.

You may be offered a series of individual sessions with a therapist. Often, you will also be offered a number of joint sessions with your parents.

Or you and your parents may be offered group therapy, which means sessions together with a number of other families with children or adolescents who suffer from anxiety. Together with your therapist, you and your parents decide what would be the best form of therapy for you.

Cognitive behavioural therapy often produces good results. In brief, cognitive behavioural entails that you gradually, systematically and by agreement do precisely what you are afraid of. When you slowly challenge what you are afraid of, you will learn over time that it is less dangerous than you thought.

Example

For example, if you are afraid of drowning when swimming in deep water, you will start by going out into shallow waters where you can touch the bottom and where you dare to be. You will subsequently need slowly to venture out into slightly deeper waters and work on feeling secure there as well. You continue like this – step by step – until you reach deep waters.

Along the way, you work with both your thoughts and feelings. An example of thoughts that may help you could be: 

I feel that I am getting scared of drowning. But I know that these are just emotions and harmless bodily sensations.  When I can no longer touch the bottom, I will start swimming. I have to remind myself that I know how to swim in shallow waters. I need to do the same thing when I reach deep waters.

By reducing demands you can get relief from some of the things in your daily life that cause you distress. For example, you may be allowed to skip some classes at school for a period if this makes it easier for you to get through the day.

It may sometimes be necessary to supplement therapy with medication. You will typically be offered medication if you have severe or long-term anxiety where therapy has not helped enough. The medication reduces the degree of anxiety. It subsequently becomes easier to work therapeutically with your anxiety.

When you need to start on medication, this is done in consultation with a doctor. The doctor will prepare a plan for how you are to take the medication. To avoid side effects, it is important that you start on a small dose of the medication, which can then slowly be increased to the full dose.

As a general rule, antidepressants of the type SSRIs are used for treatment of anxiety. SSRI stands for selective serotonin reuptake inhibitors. Serotonin is a neurotransmitter which acts on some of the chemical processes in the brain that take place in connection with an anxiety disorder. Drugs of the SSRI type are used to treat depression and anxiety.

A psychiatrist will always assess what treatment is suited for you. During your treatment, you may encounter doctors, psychologists, nurses and other professional groups.

Side effects

When you receive medication, you must attend control visits with your doctor. Your doctor will assess whether the treatment is working as it should and whether you are receiving the right dose. Your doctor will talk to you about side effects and consider whether you may benefit from switching to another drug.

Like all other drugs, antianxiety medication may cause side effects. Not all persons experience side effects. If you do experience side effects, this will generally only be at the beginning of the treatment.

Some of the most frequent side effects are nausea, difficulty sleeping and restlessness in the body. In very rare cases, adolescents (with depression) have had new or worse suicidal thoughts during the first period on the medication.

Misconceptions about the condition are common if you do not know very much about anxiety. You may think that you are physically ill because you have heart palpitations, restless stomach, etc. 

You may also think that other people find that you are doing something strange or that you look strange, and that they will generally be highly critical of you.

It is therefore important that both you and your parents receive psychoeducation and instruction about what type of anxiety you have. Simply learning that your symptoms are caused by a well-described (and treatable) mental disorder can help calm you down.

The purpose of both psychotherapy and medication is to prevent recurrence. In therapy, you gradually learn to counter what causes your anxiety. The strategies that you have developed through the consultations can also be used in new contexts that cause you anxiety. Your therapist will discuss this with you when the course of your therapy is coming to an end.

In addition, together with your therapist, you will also work to determine any stressful factors in your daily life and what you can do to reduce them.

If you receive medication, it will help you to counter your anxiety better in your daily life – and to overcome your anxiety in the long term.

In addition, it is important in any case that you focus on your general well-being. Therefore, you should follow a healthy and varied diet, make sure you get a good night’s sleep, get fresh air and exercise and remember, not least, to spend time with the people you care about.

There are several things you can do if you suffer from anxiety:

• Think about what you would like to be able to do that your anxiety is preventing you from doing. You may think about what your peers can do and which you cannot due because of your anxiety. 
• The best thing you can do to help yourself is to defy your fears and gradually start doing what you are afraid of. Over time, you will then find that your thoughts about different horror scenarios are far worse than what you experience in real life. And you need to experience and feel on your body that reality is far more peaceful and positive than what you fear.
• Accept help, both from a professional therapist and from your parents. Together with you, the therapist can prepare a plan for how you can defy your fears in small steps.
• The therapist can also help remember all the positive steps you are making in the process and assist you further if you have a recurrence. Your parents can support, encourage and help you stick with the goals you set for yourself.
• Neither your parents nor your therapist can eliminate your anxiety for you. You are the one who need to make the decision to fight your anxiety. It is known that the more frequent you practise opposing your anxiety, the greater the effect you will have from your therapy.
• When you are undergoing therapy for anxiety, there may be a need for some considerations to be taken in other areas. Fighting anxiety is demanding. Therefore, you may need to reduce the demands made on you in other areas. It may, for example, be that less demands are made on you in school for a period of time.

If your child has anxiety, there are several things you can do to help:

• Participate in psychoeducation where you can gain more knowledge about anxiety.
  
  
• It may also be a good idea to read books on anxiety, to acquire a greater understanding of what anxiety is and how it is treated.
  
  
• You can request consultations with your child’s therapist to gain more in-depth knowledge about anxiety and how you can support your child.
  
  
• Be open with your child when you experience something that makes you nervous. Tell your child how you overcome your nervousness. That way you can be a good role model.
  
  
• If you have a tendency towards anxiety yourself, it is important that you delimit this and work with your own worries. Otherwise, it can be transferred to your child. 
  
  
• Avoid overprotecting your child. This will only aggravate the anxiety. Do not help maintain your child’s avoidance behaviour. Instead, support your child with encouragement, specific strategies and agreements on participation in familiar activities and contexts. 
  
  
• Avoid showing irritation or disappointment to your child. Instead, try to help your child see his or her own situation and the consequences that the anxiety has had, and then attempt to encourage your child to counter the anxiety.
  
  
• Talk to your child about anxiety only being thoughts and not reality, and that the anxiety has caused him or her to see everything in a negative light.
  
  
• Talk to your child about what he or she would like to be able to do if his or her anxiety did not prevent this. Encourage your child to accept treatment and give your full support.
  
  
• If your son or daughter’s anxiety is triggered at school or in connection with leisure activities, you can agree with him or her that you will tell the teachers and educators about the anxiety. Talk to them about how they best support your child in countering his or her anxiety. It is a great help to your child that there is the same understanding of his or her difficulties at home, at school and at leisure activities.