Anxiety and Spiritual Development

Our Key Ministry blog series on Anxiety and Spiritual Development was presented on Church4EveryChild from June 5-30, 2011.

Signs That a Child Might Struggle With Anxiety

Some common signs and symptoms often associated with clinically significant anxiety in children are listed below.

“What if” questions refer to hypothetical situations unlikely to come true that are a cause of ongoing distress to the child.  Some examples would include:

“What if my Mom and Dad get into a bad accident on the way home?”

“What if there’s a burglar in our house while I’m sleeping?”

“What if Jesus isn’t who He claimed to be?”

“What if the stuff in the Bible isn’t true?”

Avoidance represents a conscious or unconscious reluctance to engage in age-appropriate tasks and activities associated with feelings of anxiety.  Common situations in which avoidance is demonstrated may include:

▪               Riding the school bus

▪               Calling a friend to invite them to play

▪               Going to dances or sporting events in middle school or high school

▪               Large group activities where a child may have been publicly embarrassed  

The child in need of constant reassurance may persist in their fears of a serious medical illness despite appropriate examination and testing from a physician, or reassurances from a teacher or principal that an anxiety-provoking situation has been resolved.

Children with excessive physical complaints without an identified cause may be experiencing significant worries that they are unable to communicate or embarrassed to communicate with a parent or caring adult.

Sleep disturbance is a very common symptom of anxiety in children and teenagers. Kids prone to anxiety may cope relatively well during the day when the busyness of school, friends, extracurricular activities, homework and entertainment help take their mind off specific worries or fears.  Without the distractions of the day, children may be most aware of their fears at night and often have more difficulty falling asleep as a result. Those with separation anxiety may need to fall asleep in the presence of a parent, insist upon sleeping in their parents’ room if they awaken during the night or have difficulty sleeping alone in their room.

Difficulties with concentration and attention can arise from persistent fears or obsessive thoughts. It is important to distinguish difficulties with focus and concentration occurring acutely in association with specific thoughts, fears or situation from longstanding difficulties with attention that occur across two or more different situations and predate the onset of anxious symptoms as would be in the case among kids with ADHD.

Excessive perfectionism is often a sign of Obsessive-Compulsive Disorder (OCD).  The type of perfectionism that helps a child to do their best studying for a test or mastering a skill wouldn’t be cause for concern unless it became counterproductive to accomplishing a specific task or began to interfere with the child’s ability to complete other age-appropriate developmental tasks.  Examples of excessive perfectionism would include:

Rewriting an entire assignment because of a mild flaw in penmanship

The inability to turn in a less than perfect school project

Chronic school tardiness from excessive time spent grooming in the morning

Excessive absence from school may occur in conjunction with a variety of anxiety disorders.  Kids with separation anxiety are more likely to want to stay home for relatively mild physical complaints, or present to the nurse’s office at school requesting to be sent home. Those with social anxiety may be uncomfortable with peer interactions associated with school. Children predisposed to panic disorder may be more prone to episodes in a confined classroom setting where they experience difficulty leaving without being noticed by peers.

Children who are acutely embarrassed or uncomfortable may lie when directly questioned by a parent or a teacher. In these circumstances, the child may be less concerned with avoiding a specific consequence as opposed to deflecting the conversation away from a topic that evokes feelings of anxiety. Kids will answer such questions by responding “I don’t know.”

The Many Faces of Anxiety in Kids

Within our overarching category of anxiety disorders, a number of specific conditions have been described that are characterized by the context in which the child’s anxiety symptoms occur. These conditions are listed below:

Kids with Separation Anxiety Disorder experience excessive fear or distress when away from home or a significant attachment figure, usually a parent. Challenges for such kids may include leaving for school, sleeping alone, spending the night away from home, managing concerns about the health or well-being of parents or caregivers, staying with a babysitter when parents go out or playing alone upstairs or in the basement when a parent or sibling is not present in the room. They may voice a variety of physical complaints on Sunday night or following an extended vacation in anticipation of returning to school and are often frequent visitors of the school nurse.

Kids with a Specific Phobia experience fear of specific objects or situations that leads to avoidance of the object or situation, or great distress if the situation is endured. Common phobias for children might include insects, animals, car or air travel, amusement park rides, or a fear of doing something embarrassing after observing a similar incident with another child. An example of this would be the child who becomes fearful of eating lunch in the school cafeteria after witnessing another child vomit.

Kids with Generalized Anxiety Disorder experience chronic, excessive worry, much of the time, most every day in multiple areas of functioning. Such concerns often involve schoolwork, health, safety, natural disasters, storms, social interactions or world events. They experience at least one chronic physical symptom in association with their fears. Kids with generalized anxiety often exhibit excessive perfectionism and experience more distress than may be evident to parents or teachers.

Kids with Social Anxiety Disorder experience significant fear and distress around unfamiliar peers and in performance situations. They experience great discomfort with social scrutiny and are very fearful of embarrassing themselves in front of peers. Kids with social anxiety may have difficulty ordering food in a restaurant, using the telephone to call a friend or attending a party when they don’t know most of the kids who were invited. Teachers may complain that kids with social anxiety don’t participate enough in class, don’t ask questions or don’t seek out help when they need it.

Kids with Selective Mutism persistently fail to speak, read aloud or sing in specific situations (e.g., school, church) despite speaking normally in other situations. They may whisper or communicate selectively with certain peers or teachers. Selective Mutism is thought to represent a manifestation or subtype of social anxiety.

Kids with Panic Disorder experience brief, recurrent, unanticipated episodes of intense fear, and may subsequently avoid places or situations associated with the episodes (agoraphobia). Panic disorder is different from panic attacks that occur in response to a specific situation associated with another anxiety disorder, such as separation or social scrutiny. Kids with panic disorder may experience symptoms in classrooms or other places where they might experience difficulty leaving without drawing unwanted attention from others.

Kids with Obsessive-Compulsive Disorder (OCD) will experience recurrent, intrusive thoughts or compulsive, recurrent, repetitive behavior associated with significant mental distress. They may display excessive perfectionism, have difficulty making decisions when asked to choose from several alternatives, fear that they may be drawn to certain actions or behavior against their will, hoard useless items or materials or exhibit time-consuming rituals such as counting, checking, arranging or ordering items, grooming or washing. In school, kids with OCD may read assignments repetitively because of fears of overlooking important information, experience difficulty completing assignments or tests within the required time because of perfectionism or rewrite assignments because of minor errors in penmanship.

Conditions That Can Mimic Anxiety in Children and Teens

Common conditions that often result in anxiety symptoms or occur in conjunction with anxiety symptoms are listed below.

Attention-Deficit/Hyperactivity Disorder (ADHD) may mimic symptoms of anxiety, or occur concomitantly with one or more anxiety disorders. Up to 30% of children and 50% of adults with ADHD will also be diagnosed with one or more anxiety disorders.  Kids with ADHD may experience anxiety because of difficulties meeting academic expectations in home or in school. They may experience anxiety in social situations because impatience, impulsivity and poor listening skills lead to rejection by peers, avoidance of such situations by the child and delayed development of age-appropriate social skills.

Children and teens with Asperger’s Disorder or non-verbal learning disorders often present with rigidity, inflexibility and obsessive, perseverative anxiety symptoms. The intense preoccupation seen with specific topics or objects in children with Asperger’s disorder is often mistaken for specific obsessions associated with Obsessive-Compulsive Disorder. They may also exhibit avoidance and withdrawal in social situations, repetitive behaviors and significant social skill deficits.

A child with a specific learning disorder such as dyslexia may become very anxious in school or at church when confronted with the expectation of reading aloud. Kids with unrecognized and untreated learning disorders may exhibit significant anxiety when asked to take tests, begin to evidence school refusal and experience signs of separation anxiety or physical symptoms of anxiety, especially on Sunday evenings or following extended breaks from school.

Some children experience anxiety symptoms that occur only during episodes of another mood disorder, such as Major Depression or Bipolar Disorder.  Kids with depression may experience difficulty sleeping, panic and physical symptoms similar to those seen in anxiety disorders. Some researchers have reported increases in obsessive thinking among youth with Bipolar Disorder experiencing manic episodes, along with restlessness, irritability and insomnia. In such cases, it is important to determine whether symptoms of anxiety were present at times when the child wasn’t experiencing an acute mood disturbance in order to arrive at an accurate diagnosis and prognosis.

Youth experiencing symptoms of a psychotic illness (Schizophrenia, Brief Reactive Psychosis) may evidence severe anxiety associated with paranoid thoughts and altered perceptual experiences along with marked social isolation and withdrawal.  In addition, children who have experienced Post-Traumatic Stress Disorder (PTSD) following significant trauma or abuse may experience marked symptoms of anxiety associated with nightmares, flashbacks and vivid recollections associated with the traumatic event(s).

Anxiety symptoms may also be caused by a variety of medical conditions. Parents should consider having their child seen by their pediatrician or family physician to rule out such potential causes of anxiety, even in situations when mental health intervention is being pursued.  Such conditions include, but are not limited to hyperthyroidism, asthma, seizure disorders, migraine headaches and lead intoxication.

Other prescription medications associated with anxiety-like symptoms include medications prescribed for asthma, guanfacine and atomoxetine. Anxiety is a potential side effect associated with many prescription and over-the-counter medications, including cold medications, antihistamines and diet pills. Energy drinks with high caffeine content are an increasingly popular precipitant to anxiety symptoms among teenagers.

Alternatively, anxiety is a common cause of a variety of physical complaints that result in frequent physician visits and school absence.  When symptoms such as a pounding heartbeat, sweating, shaking, difficulty breathing, chest pain or pressure, fear of choking, nausea, chills or dizziness interfere with a child’s ability to function on a day to day basis and can’t be attributed to a specific medical condition or cause, referral to a mental health professional with appropriate training and experience in assessment and treatment of children with anxiety is appropriate.

What Causes Anxiety Disorders in Children and Teens?

Multiple risk and protective factors contribute to the experience of anxiety in any given child.

Genetics clearly play an important role in the development of anxiety. Children of parents with anxiety disorders are more likely to develop anxiety disorders. These effects occur independently of parenting style or family environment.

Temperament, also described as a child’s natural predisposition plays an important role in the development of anxiety. Children who are more shy and inhibited are at greater risk of experiencing anxiety. Such effects may be further mediated by activation or inhibition of other circuits in the brain.  Persons with social anxiety experience activation of the amygdala, one of the structures in the brain that makes up the limbic system, a brain circuit involved in the regulation of emotion. As a result, they are often prone to overreact to relatively innocuous social cues.  Anxious children also experience a failure of the brain’s prefrontal cortex to accurately assess the level of risk in a given situation. The end result is a child who interprets risk differently than their peers and experiences fear in situations that most of their peers tolerate.

The neurochemistry of anxiety is extraordinary complex. At least six different neurotransmitter systems in the brain demonstrably contribute to anxiety symptoms. Neurotransmitters are chemicals responsible for transmitting electrical impulses from one cell to another in the nervous system. An increase or decrease in the activity of one neurotransmitter system impacts the activity of all of the other systems.  Medications used to treat anxiety typically increase the activity of one primary neurotransmitter system.  Neurotransmitter systems involved in learning modulate the activity of systems associated with anxiety and vice versa.  To further complicate matters, another set of proteins collectively referred to as neuropeptides affect both memory and anxiety while functioning as hormones in other parts of the body.

Parents can model inappropriate responses to anxiety-provoking situations for their children and unintentionally reinforce maladaptive coping strategies and patterns of avoidant behavior. Children who on the basis of temperament are vulnerable to anxiety are more prone to the effects of overprotective, excessively critical and controlling parenting styles.

Children with insecure attachment relationships with caregivers (especially at risk are adopted children and children who have experienced significant trauma, neglect or abuse during critical stages of development) are at greater risk of developing anxiety disorders in childhood.

Anxiety symptoms may also be caused by a variety of medical conditions. Parents should consider having their child seen by their pediatrician or family physician to rule out such potential causes of anxiety, even in situations when mental health intervention is being pursued.  Such conditions include, but are not limited to hyperthyroidism, asthma, seizure disorders, migraine headaches and lead intoxication.

In my practice, one of the most common precipitants to anxiety symptoms is stimulant medication prescribed for the treatment of ADHD.

ADHD symptoms may play a protective role in mitigating anxiety in kids with both conditions. One common therapy strategy used in working with kids with anxiety is to train them to distract themselves or to substitute other more pleasant thoughts when struggling with fears or obsessions. Kids with ADHD are naturally distracted by their inner thoughts and external circumstances. As a result, they are less likely to perseverate on a specific thought or fear. When they are started on medication for ADHD and become less distracted in response to the medication, they often become intensely more aware of bothersome or intrusive thoughts and experience far more difficulty ignoring or letting go of those thoughts.

Whenever I’m asked to see a child who has become more moody, irritable or emotional while being treated with ADHD medication, I ALWAYS ask detailed questions about anxiety symptoms.

Other prescription medications associated with anxiety-like symptoms include medications prescribed for asthma, guanfacine and atomoxetine. Anxiety is a potential side effect associated with many prescription and over-the-counter medications, including cold medications, antihistamines and diet pills. Energy drinks with high caffeine content are an increasingly popular precipitant to anxiety symptoms among teenagers.

Challenges Kids With Anxiety Face in “Doing Church”

On Sundays, Joshua would complain of having to use the bathroom just as the family was ready to walk out the door for church, usually emerging twenty minutes after the last service was scheduled to start. When he would attend church, he generally refused to participate in Middle School ministry activities with his sixth grade peers, opting instead to attend the adult worship service with his parents.

A child with significant anxiety will likely face multiple impediments to full participation in the children’s or youth ministry of their local church. The specific thoughts, experiences and situations that create obstacles to participation and growth will be unique to each child, but the list below describes common challenges parents and church staff can anticipate when ministering to children and youth with anxiety. We’ll look at these challenges in more detail over the next week:

Children who may cope reasonably well with fears during the week in a school environment with familiar friends and teachers will often experience physical symptoms of anxiety in anticipation of a less structured environment at church with more unfamiliar people and situations. The child prone to obsessions or perseveration may manifest their anxiety associated with church through severe anger outbursts, irritability, and difficulty transitioning from whatever activity they were engaged in when it’s time to get ready to leave for church. Ministry leaders can help by creating welcoming environments that are pleasant without being too stimulating and chaotic. Kids with anxiety are more likely to become uncomfortable during transition times before and after ministry activities when peers are unsupervised and engaged in impulsive or aggressive play.

Several years ago, Mike (a boy receiving treatment for ADHD and anxiety) was visiting a church with his parents for the third or fourth time. While his parents were speaking with some other adults in the worship center after the service, the children’s ministry staff and volunteers had left their area enabling some older boys to engage in aggressive play. One of the boys considerably older and larger than Mike started wrestling with him and shoved his face into the carpet. By the time his parents came to pick him up, Mike had significant abrasions on both sides of his face. Surprisingly enough, his family began to worship regularly at the church, but Mike always insisted on going with his parents to the adult worship service and never again was involved in children’s ministry activities.

Few situations will be more overwhelming for kids (and many adults) than the prospect of visiting a church for the first time. For a child who experiences great anxiety in new situations, the opportunity to visit at a time the church is relatively quiet when they can become familiar with a few people, visit the room or area where their activities will occur, and understand the process when the family comes to worship is often very helpful in enhancing the likelihood their family’s first experience at the church will be a positive one.  Churches with greater electronic sophistication might consider posting virtual tours of their facility on video, permitting children (and their parents) to visualize every aspect of their weekend worship experience.

“Doing Church” With Separation Anxiety or Panic Disorder

Kids with separation anxiety will have often have difficulty when they and their parents go in different directions for church activities appropriate for their age group. The combination of the child’s internal distress and the anxiety both the child and parent feel when their emotions are on display in a very public place often result in a very unpleasant experience that influences their attitudes about church attendance. Having a quiet area available close to the entrance to the children’s ministry area allows for parents to process the separation through the use of problem-solving strategies with less emotional distress for the child and their family. Training greeters and staff to recognize families in need of extra support and to quickly locate support personnel before and after church services is also critical to avoiding a very negative experience for the child and parents.

Some children with separation anxiety may benefit from the opportunity for a parent to accompany them through their worship service or Sunday school experience. If the child is able to separate to go to school, connecting them with familiar peers at church upon arrival may help ease the transition. Allowing the child to see where their parent will be at church and offering (with permission of the parent) to take the child to their parent can help to ease distress associated with separation.

One way to identify kids at risk of separation anxiety disorder is to look for kids from families who regularly attend church sitting with their parents in the worship center or sanctuary while children’s programming is taking place.

Large group worship experiences may be distressing to children and youth prone to panic attacks with agoraphobia. Panic episodes are often triggered in warm, noisy, crowded environments and exacerbated by the person’s distress at not being able to leave the environment without drawing untoward attention. Reserving a few open seats near an exit for families to access after the beginning of the service or the availability of folding chairs in the back of the sanctuary or near video monitors in the lobby allows families of children prone to panic attacks to attend worship without having to explain their situation to an usher.

Children and adults with anxiety often prefer to blend into the background and experience great distress when recognized in front of others.  Sensitivity to this type of attention is often heightened during the middle school years when kids in general are exquisitely sensitive to how they’re perceived by their peer group. The spontaneous, enthusiastic, well-intentioned youth pastor may make a seemingly innocuous comment about a child with anxiety in front of the larger group at church that results in such a sense of embarrassment for the child that they never return to the group.

The middle school pastor at one of our local churches is very enthusiastic and does a terrific job of connecting with kids. The pastor has a policy of “No kid sits alone at church,” which is obviously well intentioned. I know a fabulous kid (Hannah) who volunteers at this church, is very responsible, has a great heart for God and a number of good friends. Hannah is a little on the shy side but doesn’t have issues of such significance to warrant a diagnosis of Social Anxiety Disorder. One morning when Hannah was sitting by herself at the middle school worship service, the pastor asked several girls to sit with Hannah in front of the entire group. After that morning, Hannah would only go to her large group service when she was assured that one or more of her friends would promise to walk in with her from the beginning of the service.

Small Groups, Retreats and Mission Trips

Small group participation will frequently trigger distress among children and teens with anxiety. They will have more difficulty perceiving the small group as a safe place for sharing and disclosure. The child’s expectation of being pressured to participate in groups can result in overwhelming anxiety. Group leaders need to be careful to avoid pressuring kids to participate or call attention to their lack of participation. Kids who are reluctant to contribute to a group can still benefit significantly from the comments and contributions of leaders and peers. Parents who observe their child becoming angry, irritable, argumentative or avoidant when encouraging them to participate in small groups should share their concerns with the child’s group leader or pastor so steps may be taken to make their child’s experience a positive one.

Ministry leaders need to reinforce the value of confidentiality if kids with anxiety are to effectively participate in small groups. Trust may be a significant concern…kids with anxiety may be more concerned than others that their comments and behaviors will be reported back to parents.

Retreats and mission trips are an additional challenge for kids with anxiety disorders. The combination of an unfamiliar location, new experiences and separation from caregivers can be a recipe for disaster for an anxious child. Their willingness to participate in such activities may be contingent upon knowing in advance who their roommate will be. Kids prone to panic attacks may experience great distress during long bus or plane trips. Children with insect or animal phobias will be reluctant to participate in trips to campsites.  Those with social anxiety may be uncomfortable with mission or service trips involving unfamiliar kids from other churches. A surprising number of kids continue to experience separation anxiety into their teen years. A red flag that a child or teen might struggle on a mission trip is their inability to do sleepovers at friends’ homes or reluctance to do overnight camps during the summer.

Ministry leaders may help by showing sensitivity to parental requests to pair their child with a preferred roommate, putting a good friend in the child’s discussion groups, providing as much information as possible in advance about the site of the retreat and anticipated activities. Pictures and video may be very helpful…when kids can see where they will be staying and visualize the types of activities they’ll be engaged with, unrealistic fears are diminished.

One last comment…I’m aware of churches that place a very high value on the importance of kids doing mission trips in which parents of kids who stay home feel like second-class citizens. It’s important not to criticize parents reluctant to push their kids to participate in the trips. Just this week, I spoke with a parent who felt extremely uncomfortable as a result of the pressure their child was experiencing from church leaders to do a trip. This pressure can be especially acute for kids when their parent has a staff position at the church or serves on the church Board and children/youth ministry leaders have expectations that parents will “support the program.” The role of parents in guiding the spiritual development of kids may be of even greater importance for children with anxiety…church leaders need to be careful in respecting the judgment of parents as to whether participation in specific ministry activities will be helpful.

What Can Parents Do to Promote Spiritual Growth?

A child or teen maintaining an active involvement in the children’s or youth programming at their local church may spend 50-100 hours per year engaged in ministry activities. A parent may have 3,000 hours per year or more in which to influence their child while together at home, in the car, on vacation or over meals. Even if anxiety poses an obstacle to their child’s full participation in church-based activities parents retain the greatest opportunity (and responsibility) for instructing their child in the Christian life.

First and foremost, parents can model for their children the fruits of the spirit: love, joy, peace, patience, kindness, goodness, faithfulness, gentleness and self-control. Actions and attitudes are powerful influences with our kids. The child with ongoing anxiety may be more sensitive to angry or insensitive comments, unintentional slights or approval withheld. Parents who demonstrate Christ-like attributes are most likely to have the quality of relationship with their child to allow them to exert influence once their child reaches the age when their behavior can no longer be easily controlled.

Next, parents can demonstrate to their children how their faith in Christ and use of spiritual disciplines helps them to cope with the day-to-day fears and anxieties that are part of living in a fallen world. Consider the following verse:

Be anxious for nothing, but in everything by prayer and supplication with thanksgiving let your requests be made known to God. And the peace of God, which surpasses all comprehension, will guard your hearts and your minds in Christ Jesus.

                                                                        Phil 4:6-7 (NKJV)

The child with anxiety might respond to those verses by thinking “I’m anxious because I don’t pray enough and I’m not thankful enough.”

The parent who wishes to model positive coping strategies for their child can be a blessing to their child by allowing them to witness their parent using prayer offered in a spirit of thanksgiving as a tool from God for addressing their own fears and anxieties.

Finally, the parent of a child who struggles with anxiety can seek to partner with the children’s/youth ministry team at their local church. Some churches offer training and curriculum for parents interested in home-based models of religious education. Parents who want to take responsibility for teaching their child about faith may be reluctant to ask for help from church staff or struggle to identify appropriate strategies for taking the next steps without some guidance and direction from staff. Children’s and youth ministry leaders can’t be expected to read the mind of a child with anxiety. Parents need to communicate with church staff when specific activities or situations produce fear or avoidance sufficient to interfere with their child’s church participation. Church staff and volunteers need to keep such information in confidence, ask parents for suggestions for interacting with their child when they exhibit signs of anxiety at church and communicate the love of Christ to the child and their family.

The Lord is my light and my salvation; Whom shall I fear? The Lord is the defense of my life; Whom shall I dread?

                                                                        Psalms 27:1 (NKJV)

Understanding Treatment of Anxiety Disorders in Kids

The treatment of anxiety disorders in children and youth may not seem terribly relevant to serving kids in church environments, until one recognizes that pastors and church leaders are looked to as resources by families when their children are in need of help.

In general, the most effective approach to treating kids with significant anxiety is a combination of medication and a very specific counseling approach referred to as cognitive-behavioral therapy (CBT).  While combination therapy may work best, not every child needs medication at the outset of treatment. The severity of the child’s anxiety and the degree to which anxiety interferes with the child’s day-to-day functioning usually determines the approach to treatment.  Kids with milder forms of anxiety will typically try counseling before medication. Those most likely to require a trial of medication are those with moderate to severe anxiety, those with other psychiatric or emotional disorders in conjunction with anxiety and those who have not responded or responded incompletely to an appropriate trial of cognitive-behavioral therapy.

The most comprehensive study to date examining treatment of anxiety in children and teens was the Child and Adolescent Multimodal Treatment (CAMS) study. In this study, 488 children between the ages of 7-17 diagnosed with separation anxiety disorder, social anxiety disorder or generalized anxiety disorder were randomly assigned to groups treated with sertraline (brand name: Zoloft) for twelve weeks, 14 sessions of CBT, medication plus CBT, or placebo pills.  Response rates were as follows:

From a statistical standpoint, the combination of CBT and medication was significantly more effective than therapy alone or medication alone. CBT and medication were equally effective, and both treatments were more effective than placebo pills.

What’s so unique about cognitive-behavioral therapy (CBT)?

CBT is the counseling approach with the most research support for effectiveness in the treatment of kids with anxiety disorders.

In CBT, children learn coping skills to develop a sense of mastery over anxiety symptoms or situations associated with significant distress. CBT approaches used to treat children with anxiety include educating the child and their parents about the anxiety disorder and the purpose of therapy, equipping them with relaxation techniques to help moderate physical symptoms associated with anxiety, addressing misperceptions that lead to negative expectations and negative self-image, exposing the child to situations, real or imagined, associated with anxiety symptoms, and development of strategies to help prevent the relapse of symptoms.  Behavioral interventions are designed to help positively reinforce the child’s willingness to expose themselves to anxiety-provoking situations.  Parents are taught the various interventions and strategies so they can serve as coaches, helping their children to practice the strategies at home.

The component of the counseling found to be most impactful in the CAMS study was exposure.  Exposure usually occurs later in the course of treatment and occurs when the child is deliberately placed in a situation that would usually provoke great anxiety, after having been equipped with coping strategies for managing their response to the situation.  For example, a child unwilling to go outside because of a fear of being stung by bees might go to a park in the middle of summer with their therapist for a picnic lunch.

Specific CBT interventions are tailored to the nature of the child’s anxiety symptoms.  Children with phobias may benefit from graded exposure to the object or situation that triggers fear. They may benefit from observing their therapist or parents as they approach the object or situation they fear.  Social skill training may be incorporated into treatment of children with social anxiety.

Two studies demonstrated that educating kids about the nature, causes and course of anxiety disorders without teaching other CBT techniques was of benefit in reducing anxiety symptoms.  Presumably, educational interventions along with supportive counseling result in kids becoming more comfortable with exposing themselves to anxiety-provoking situations.

Are other approaches to counseling or therapy helpful to kids with anxiety disorders?

While a great deal of case experience is reported using traditional psychodynamic psychotherapy to treat anxiety disorders in children, there is very little research support for such treatment approaches.

Several studies have examined family-based treatment approaches to the child with anxiety. The CAMS study included two visits specifically to train parents in the use of CBT techniques. Other studies have shown benefit from addition of a parental component to treatment in situations when one or both parents are anxious.

What are the limitations of talk therapy for kids with anxiety?

Not every child is going to respond to cognitive-behavioral therapy. In the CAMS study, 40% of kids who received CBT alone hadn’t experienced a significantly positive response after twelve weeks of treatment with the best therapy protocols conducted by expert clinicians at prestigious academic medical centers. Twelve weeks may feel like a lifetime to the child experiencing acute anxiety as well as to the parent who has to cope with feelings of helplessness watching their child suffer.  The benefits of talk therapy in the CAMS study only became significant by the ninth week of the study. Kids don’t immediately become proficient in the anxiety management skills learned in therapy sessions.

A very significant limitation of talk therapy is the degree to which success of the treatment is dependent upon the level of skill of the child’s therapist. Most clinicians will have had some lecture and class discussion of the principles of cognitive-behavioral therapy. Fewer will have had specific training or supervision in CBT. Fewer still will have had training or supervision in implementing CBT with children as opposed to adults. In many parts of the U.S. families may not have access to adequately trained clinicians. The most competent clinicians often choose not to accept the highly discounted rates of payment offered by insurance companies.

When should medication be considered for kids with anxiety? Medication is appropriate for children who experience moderate to severe functional impairment from anxiety symptoms, fail to respond or respond incompletely to psychotherapy or experience one or more comorbid conditions that require concurrent treatment. Medication is also appropriate when anxiety symptoms interfere with the child’s ability to participate in or benefit from talk therapy, or situations when the family is unable to access therapy for geographic or financial reasons.

What medications have been shown helpful in children and teens with anxiety? The serotonin-specific reuptake inhibitors (SSRIs) have been recognized as the medication of choice for treating anxiety, according to practice parameters developed by the American Academy of Child and Adolescent Psychiatry. This class of medications, including fluoxetine (Prozac™), sertraline (Zoloft™) and fluvoxamine (Luvox™) has been shown to be effective in treating children and teens with selective mutism, social anxiety disorder, separation anxiety disorder, generalized anxiety disorder and obsessive-compulsive disorder. The SSRIs as a class have been more extensively researched than any other category of medications for pediatric anxiety disorders and don’t typically require blood work or EKG testing upon initiation of medication or during the course of ongoing follow-up. Imipramine (Tofranil™) and clomipramine (Anafranil™) are members of an older class of medications known as tricyclic antidepressants that have been shown to be effective in treating specific types of anxiety in kids. These medications have fallen out of favor with many clinicians because they are associated with a small, but not insignificant risk of cardiac effects, resulting in the need for ongoing monitoring of EKG tests. Tricyclics are also far more likely than the SSRIs to result in death in the event of a purposeful or accidental overdose. Nevertheless, clomipramine was shown in one analysis of the research literature to be the most effective medication for the treatment of pediatric obsessive-compulsive disorder. No other medications have been shown in well-designed research studies to be effective in the treatment of pediatric anxiety disorders. Benzodiazepines (Ativan™, Valium™, Klonopin™ and Xanax™) may be used on a very short term basis to rapidly reduce acute anxiety that interferes with a child’s ability to attend school or participate in talk therapy as an adjunct to a SSRI, since several weeks or more of continuous treatment with an SSRI is often required for clinical response. Benzodiazepines must be used very carefully because sedation, disinhibition and cognitive impairment have been reported as side effects and children can become dependent upon the medication.

What do we hope medication will do for a child with anxiety? The goal when using medication is to reduce the frequency and severity of the child’s anxiety symptoms and allow them to function in an age-appropriate manner in school, at home, with friends and in extracurricular activities. For some types of anxiety, such as panic disorder and school phobia complete remission of anxiety symptoms may be possible. With obsessive-compulsive disorder, a 50% improvement in the frequency and severity of obsessive thoughts and compulsive behavior may represent a very positive response to medication. While some children may respond very quickly to the effects of medication, a rapid response (within a week or less) is generally the exception as opposed to the norm. For most anxiety disorders, two to four weeks or longer may be required to fully assess the clinical response on a given dose of a SSRI. Children with OCD may not fully respond to a given medication for eight weeks or longer. In the CAMS study, kids experienced the greatest improvement from medication in the first four weeks of treatment, but further improvement was seen between week 4 and week 8 in a study that permitted optimization of the child’s medication dose. If a child hasn’t responded to an optimal dose of medication for most types of anxiety within eight weeks or for OCD within twelve weeks, it is unlikely the child will respond to ongoing treatment with that medication.

When I’m discussing the use of medication for anxiety with a child and their parent(s), I usually tell them medication may make it easier for them to make use of the tools and skills they will learn in their therapy to help manage their anxiety symptoms. I don’t want to create unrealistic expectations for medication or subject kids to multiple medication trials because parents or kids are disappointed by a less than expected response.

If medication can result in episodes of anxiety, obsessive thinking or compulsive behavior that are 50% less frequent, last for 50% less time and are 50% less severe, the child will usually feel significantly better. They are then in a better position to effectively manage the remainder of their symptoms through the skills they learn in CBT.

Is Medication Safe for Kids With Anxiety?

One of the greatest ongoing controversies in the fields of child psychiatry and pediatrics is the question of how safe SSRIs are in children, teens and young adults. The safety issue of greatest concern involves reported risks of SSRIs increasing suicidal thoughts during the first 30-60 days of treatment in persons under the age of 25.

In 2004, The FDA issued a “black box” warning, requiring manufacturers of all medications reported to have antidepressant effects, to include a warning in the package labeling for each drug stating an increased risk of suicidal thoughts in pediatric patients. The warning was subsequently extended to adults ages 18-25.

Some important points to consider:

In the 30 or so well-designed research studies involving approximately 5,500 children and teens evaluating the safety and effectiveness of SSRIs, there have been zero completed suicide attempts.

Rates of suicide among children and teens in the U.S. began declining around 1990, shortly after fluoxetine and sertraline were approved for use in the U.S., and continued to decline until 2003. In 2004, following a 20% decrease in the pediatric use of SSRIs resulting from the black box warning, the suicide rate went up for the first time in 15 years.

Rates of suicidal ideation among participants in pediatric trials of SSRIs for anxiety are lower than rates in studies of depression.

Kids being treated with SSRIs should be monitored closely for the development of any new-onset suicidal thoughts during the first two months of treatment and following increases in the dose of medication being used.  When the warning was first issued, physicians were encouraged to see youth treated with SSRIs on a weekly basis for the first month of treatment, and every other week for the next two months. While this recommendation was dropped, one additional benefit of combining CBT with medication is the availability of the therapist to closely monitor for the emergence of suicidal thinking in children and teens taking SSRIs.

What other side effects might my child experience from medication?

In general, the SSRIs as a group are well tolerated. Most side effects are mild and resolve over time. Gastrointestinal symptoms such as nausea, pain or diarrhea, headaches, increased motor activity and insomnia are common side effects.  Children with a predisposition to bipolar disorder need to be screened carefully prior to initiation of an SSRI and closely monitored for the possibility the medication may worsen symptoms of a mood disorder.

With the exception of fluoxetine, children shouldn’t stop taking an SSRI suddenly because of the risk of withdrawal symptoms. Such symptoms include dysphoric mood, irritability, agitation, dizziness, headaches, anxiety, and insomnia. When discontinuing medication, a gradual dose reduction supervised by the child’s physician is generally the best approach.

How long will children have to take medication for anxiety?

Unfortunately, there are very few studies examining the long-term safety and effectiveness of medication for anxiety in children and teens.

2013 Accessibility Summit Presentation:

Here’s the Slide Share presentation Dr. Grcevich gave at the 2013 Accessibility Summit on the topic: Supporting Kids and Teens Who Struggle With Anxiety

Additional Resources:

American Academy of Child and Adolescent Psychiatry Anxiety Disorders Resource Center...contains lots of useful resources, including recommended books, resources for clinicians, Facts for Families (parent downloads), frequently asked questions, video clips, information on research and training, links to other useful websites, and information for families looking for help.

OCD in Kids…This is a website developed by Key Ministry Board member Rhonda Martin for children with Obsessive-Compulsive Disorder (OCD), their parents and and treating professionals. The website was designed as a companion to Rhonda’s best-selling children’s book, Stuck, describing the life of Cinnamon, a young girl with OCD.

Updated January 17, 2016