‘Life is ten per cent what you experience and ninety per cent how you respond to it’ (Dorothy M Neddermeyer). This is very true when it comes to anxiety in children with neurodevelopmental disorders, as effective interventions can prevent unintended consequences. Every one of us has experienced anxiety and worry. After all, fright, flight and freeze are evolutionary survival responses.
All children, like adults, experience fears and worries. But most of these fears are temporary, and most children outgrow them. However, in a proportion of these children, worries and fears are persistent and distressing. When these fears and worries start affecting a child’s life or functioning at home or school, then that is not normal. Such anxiety or fear needs addressing. This is when a parent or teacher should seek help.
Anxiety disorders are the most common childhood-onset mental health disorder. The Royal College of Psychiatrists in the U.K. estimates that nearly 300,000 young people in the U.K. have an anxiety disorder. The prevalence estimates for anxiety in children vary from 6-9%. But anxiety is even more common in children with neurodevelopmental disorders.
There are a different kind of anxiety disorders such as separation anxiety, social anxiety, general anxiety, specific phobias and fears. As a general rule, the more severe the anxiety disorder – the greater the impairment in functioning – the more likely it is to persist.
What are the signs and symptoms of an anxiety disorder?
Parents or the child’s teachers could notice some of the following features:
- Difficulty in concentration
- Restless and fidgety
- Being fearful or panicky
- Feeling breathless
- Breathing fast but shallow
- Nausea or feeling sick
- Lack of appetite
- Somatic complaints, e.g. headache, pain in chest or stomach
- Bladder or bowel issues, e.g. increased frequency to toilet
- Sleeping difficulties, e.g. difficulty falling asleep or staying asleep
- Educational difficulties, e.g. poor school attendance or performance
- Behavioural difficulties, e.g. oppositionality, aggression, withdrawn
- Lack of interest or avoidance of play, leisure, and outdoor activities
- Irritable, difficulty in relaxing
- Frequent need for reassurance
In children with neurodevelopmental disorders, in addition to some of the above features, you also see a worsening or exaggeration of their underlying condition. Hence anxiety can:
- Increase in socialisation difficulties
- Exacerbate a child’s communication difficulties
- Exaggerate his or her attention difficulties
- Worsen a child’s coordination abilities
All this will result in impacting the child’s social and or academic functioning at home and school.
What neurodevelopmental disorders does Anxiety frequently accompany with?
Anxiety can commonly present with any of the following conditions in children:
- Autism Spectrum Disorder (ASD)
- Attention Deficit Hyperactivity Disorder (ADD or ADHD)
- Developmental Coordination Disorder (DCD or Dyspraxia)
- Sensory Processing Difficulties with sound, sight, smell, texture or taste
- Specific learning difficulties such as Dyslexia, Dyscalculia
- Talented and Gifted
- Obsessive-Compulsive Disorder (OCD)
- Oppositional Defiant Disorder (ODD)
- Tics/Tourette syndrome
- Low mood/Depression
Why is it essential to address anxiety early on?
Many children miss out on being identified. Even in children with a neurodevelopmental disorder, anxiety as comorbidity is frequently overlooked or not assessed. Hence many suffer in silence according to the Royal College of Psychiatrists. It is crucial to identify anxiety as an issue and seek help, especially when it starts having an impact on the child’s well-being and functioning either at home or at school.
Anxiety can have many unintended consequences, such as:
- Low self-esteem
- Low confidence
- Underachievement in learning and education
- Underachievement in sports and leisure
- Poor peer relationships/friendships
- Destabilise family’s functioning
- Increase the risk of depression
- Substance abuse in later life, etc.
What is the role of a neurodevelopmental paediatrician?
If you have no concerns regarding your child’s development apart from anxiety, then you should read the steps outlined in the next section titled ‘What to do about anxiety?’.
However, if you have concerns regarding your child’s development, or if you suspect that your child may have a neurodevelopmental disorder such as ASD or ADHD, then a neurodevelopmental paediatrician will be able to help you with the following:
- Decide whether your child has a rational fear, a phobia, an anxiety disorder or a medical disorder
- Check your child’s development. The developmental status needs to be taken into consideration when evaluating a child for an anxiety disorder.
- Carry out a full physical examination including neurological assessment
- Rule out medical conditions that can mimic anxiety such as hyperthyroidism, hypoglycaemia or a pheochromocytoma. These medical conditions present with physiologic symptoms overlapping those seen in children with anxiety.
- Most importantly, assess your child for a neurodevelopmental disorder such as ADHD, ASD, Learning disabilities (L.D.) etc.
In many children with anxiety, diagnosing the underlying neurodevelopmental disorder and addressing it with a comprehensive management plan, maybe all that is required to address the anxiety.
What to do, if you are worried about anxiety in your child?
The first thing to do is to speak to your child. Listen to what they are worried about. Don’t dismiss or belittle their concerns. Instead, reassure them. Try to see the positive side of worry – worry can help you get prepared, be ready, keep one safe, helps cope with bad stuff, helps solve problems or allow you to show your child that you care.
Explain to your child using metaphors such as ‘worries are like waves, they come, and they go’ or ‘worry is a like an overhanging cloud, that eventually disperses or moves away’. Let them know that most people experience anxiety or fear at times. Using these explanations and having honest discussions can help them cope better and be open to you.
Next, get the basics right, i.e. diet, exercise and sleep. Focus on eating regularly and having a balanced diet consisting of fruits and vegetables. Exercise and physical activity help release endorphins that improve mood and mental well-being. Having good sleep hygiene and sleep routine will help to get adequate sleep. Having sufficient sleep is an integral part of self-care. Good sleep has been shown to have a positive effect on mood, attention, behaviour and learning.
Having a routine helps. Routines provide reassurance. Creating a visual calendar and or a visual timetable helps process information, give a child a sense of predictability and control. Practising mindfulness and relaxation techniques are effective. You could also use distraction techniques or have a ‘worry-box’. There are various other strategies you could try, such as helping your child reclaim a lost interest, doing something new, going outdoors, watching a film together or making new friends.
If the above measures are not successful in addressing your child’s anxiety, then the next course of action would be to speak to your GP (General Practitioner). Your GP could refer your child to ‘talking therapies’ or CBT (Cognitive Behaviour Therapy). These therapies/CBT help your child manage their anxiety by changing the way they think and behave.
Some of the CBT techniques that are used to address children’s anxiety are as follows:
- Accepting that anxiety is a normal emotion
- Avoiding ‘avoidance’ and take part in activity or school despite Anxiety
- Checking that you have a cause to be anxious
- Helping you turn pointless worry into a plan
- Life is living with some uncertainty and risk
- Giving yourself a break from unreasonable rules
- Refusing to let anxiety hold you back
- Enlisting help with change
- Getting help from a professional CBT therapist if needed
In most children, all the above measures are effective in addressing anxiety satisfactorily. However, in a small proportion of cases a referral to CAMHS (Child and Adolescent Mental Health Services) or a Child Psychiatrist may be required, if the above environmental, behavioural and cognitive measures do not adequately address a child’s anxiety.
Anxiety disorders, when identified and addressed adequately, have a good prognosis.
Sources of further information
- Anxiety U.K., a charity, providing information and support. https://www.anxietyuk.org.uk/
- The Child Anxiety Network, an information resource about child anxiety http://www.childanxiety.net/Resources_for_Parents.htm
- Young Minds runs a parent information service. https://youngminds.org.uk/find-help/for-parents/
- Childline runs a confidential helpline for children. https://www.childline.org.uk/
- No Panic, a charity that helps people with panic attacks and OCD. https://nopanic.org.uk/
- Living life to the full. https://llttf.com/
- Mind, for better mental health. https://www.mind.org.uk
- Royal College of Psychiatrists, https://www.rcpsych.ac.uk/mental-health
- A downloadable booklet for parents to know more about Anxiety, from The Mental Health Foundation of U.K., https://www.mentalhealth.org.uk/publications/anxious-child-Download
- American Psychiatry Association-Information for Patients and Families, https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders
- Woodward LJ, Fergusson DM. Life-course outcomes of young people with anxiety disorders in adolescence. J Am AcadChild Adolesc Psychiatry 2001; 40:1086
- Bittner A et al. What do childhood anxiety disorders predict? J Child PsycholPsychiatry 2007; 48:1174
- Kessler RC et al. Prevalence, persistence and socio-demographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2012; 69:372
- MerikangasKR et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Co-morbidity Survey Replication. J Am Acad Child Adolesc Psychiatry 2010; 49:980