When Lea* clung to the doorframe screaming and refused to go to school, Martina Hissmann* realised that they really had a problem. «Until then, I had thought that we could handle it ourselves, just as we had managed everything else,» says the mother of the now twelve-year-old from Basel. But now the initial «I don't want to» and «I don't want to go to school» had suddenly turned into «I can't».
Lea couldn't because she was afraid. More and more children and young people are in the same situation as her – not only in Switzerland, but all over the world. Even before the outbreak of the coronavirus pandemic, 7.5 to 10 per cent of them suffered from anxiety disorders, with girls more frequently affected than boys.
Now, it's 15 to 20 per cent of young people, which is twice as many. This was the finding of a meta-analysis published in the journal Jama Pediatrics in 2021. Since then, experts say, the situation hasn't changed much.
Anxiety disorder versus anxiety disorder
What exactly is an anxiety disorder? How does it develop and which children are particularly affected by it? What can parents do and how can children overcome their fears? This dossier aims to answer these and other questions below.
The terms «anxiety disorder» and «anxiety illness» can be used interchangeably. Marina Zulauf Logoz prefers the term «anxiety disorder». «It is neutral and descriptive, indicating that something is disturbed and not functioning properly. The term «anxiety disorder», on the other hand, sounds very negative to me, at least when the anxiety disorder is not so severe and has not been present for very long,» says the child and adolescent psychotherapist at the Psychiatric University Hospital Zurich (PUK).
If, on the other hand, the impairment is very severe, the term «anxiety disorder» can be a relief for patients.
Different forms of anxiety
Fear has many faces. Phobias are one form of anxiety disorder. They involve a fear of certain objects or situations: spiders or dogs, needles or buttons. Or a fear of being trapped in a lift or aeroplane.
Social phobia is quite common in middle childhood. «In its mildest form, it manifests as stage fright. However, if it is more pronounced, fear of strangers can prevent a child from making friends,» says Zulauf Logoz. At its core, this is about the fear of being judged negatively by other people.
Children with generalised anxiety disorder are often very exhausted; they are in a state of physiological alarm.
Children with selective mutism experience a similar but much more debilitating fear . They only speak at home and with close family members and friends, while remaining silent towards others at school and nursery.
Emotional disorders involving separation anxiety are also among the anxiety disorders that affect young children. Children with this disorder are afraid of any situation in which they are separated from their parents. Some of them do not even want to stay alone in a room and cannot be separated from their mum and dad when it is time to go to bed.
Panic disorder rather rare
Generalised anxiety disorder is more unspecific. Young people affected by it constantly have exaggerated worries spinning around in their heads, with virtually every topic triggering free-floating fears. «These boys and girls appear very exhausted, are often pale and agitated, because anxiety is always associated with a physiological state of alarm,» says Zulauf Logoz.
Another form of anxiety disorder is panic disorder. Young people who are just starting out in life or going through puberty experience sudden, intense anxiety attacks. They sweat, tremble, have a racing heart and circulatory problems, and often feel as though they are in a life-threatening situation – even fearing for their lives.
«Another typical symptom of panic disorder is the fear of another panic attack. Those affected withdraw, stop going to school and generally stop leaving the house,» says Zulauf Logoz.
The vast majority of children and adolescents affected by an anxiety disorder suffer from a phobia, social anxiety or separation anxiety. More severe forms such as generalised anxiety disorder and panic disorder are relatively rare, with studies citing figures of 0.5 to 2 per cent of those affected.
The cause of fear
Anxiety disorders occur at different ages. While separation anxiety is particularly common in young children, cases of social anxiety increase sharply when children are between eight, nine and ten years old. «This is when they start to be judged by those around them,» says Zulauf Logoz.
«Parents are no longer constantly there, and suddenly the child hears things like «You're stupid» or «Look, she's wearing funny trousers».» The expert advises taking a very close look at any form of fear. This is because many seemingly general, vague fears often have a very specific cause.
Lea's trigger
For Lea, it was mainly Tuesdays that caused her great anxiety. Lea's parents – she a doctor, he an engineer – needed to ask a few questions and have several discussions before they understood why. Lea's class teacher was known for her conservative methods.
Those who didn't listen had to stand facing the wall in the classroom. The next level of escalation was being sent out of the classroom and a phone call to the parents. The fact that the teacher often seemed to start shouting out of the blue was an additional stress factor for Lea, who was sensitive to noise .
It was particularly bad when there was a school trip: in order to get the class safely from A to B, the teacher demanded discipline by shouting and imposing collective punishments. Swimming lessons were on the timetable on Tuesdays – which was equivalent to a school trip. At some point, Lea no longer wanted to go to school on Tuesdays.
«It started very gradually,» says Martina Hissmann. «At first she tried it and then came back, then came the shame of what the other children might think if she skipped school. And it ended with the whole family already stressed on Sunday evening because of the looming Tuesday.»
Is there a predisposition?
Who actually develops an anxiety disorder? «There is certainly a biological predisposition in people who tend to be more anxious by nature,» says Christian Fleischhaker. «But this does not automatically result in an anxiety disorder; other factors also play a role.» The acting medical director of the Clinic for Psychiatry, Psychotherapy and Psychosomatics at the University Medical Centre Freiburg has seen a massive increase in cases in his wards since the coronavirus pandemic began.
«We really left children and young people out in the cold back then when, from one day to the next, they were no longer allowed to meet their peer groups or go to school,» says Fleischhaker. But he also sees the rapidly changing world, with its still unresolved crises and wars, as a driver of anxiety disorders: «This is already highly frightening for many adults, so you can imagine how it must seem from the perspective of children and young people.»
Children who are overly protected or who experience too little emotional closeness are more likely to develop anxiety disorders.
Social media as a catalyst
Added to this is social media, which, «from a professional point of view, is a major accelerant when it comes to damaging mental health.»
Experts estimate that anxiety disorders can be 30 to 50 per cent hereditary. In these children, the body's own alarm system is more sensitive than in others. But parenting style can also have an impact. Children who are overly protected or who experience too little emotional closeness are more likely to develop anxiety disorders. And those who have other mental or physical illnesses are also more prone to anxiety disorders than healthy children.
Seek help early
Anxiety disorders fluctuate, says Marina Zulauf Logoz. They occur with varying intensity, change their appearance and are also influenced by how those around the anxious person treat them. Whether they are ridiculed, their anxiety dismissed as exaggerated, or whether the child's suffering is recognised and taken seriously.
One thing is clear, however: untreated anxiety disorders usually take an unfavourable course and have a negative impact on the development of those affected.
With an anxiety disorder, a lot can be achieved in just a few therapy sessions.
Marina Zulauf Logoz, psychotherapist
«We know from a large New Zealand study that young people without anxiety disorders are one and a half times more likely to graduate from university and two and a half times more likely to complete an apprenticeship than those with anxiety disorders,» says Zulauf Logoz. She therefore strongly advocates seeking professional help as early as possible.
The younger the children, the more integrated they are into the family and school systems. Parents and teachers can work together to ensure that, for example, the fear of going to school is gradually overcome.
Risk of depression
«With anxiety disorders, you can achieve a lot in just a few sessions, thereby reducing the amount of time children suffer and lose quality of life,» says Zulauf Logoz. Because the waiting time for therapy places is often long, some clinics and institutions offer prevention and information evenings. There, parents can easily find out how to deal with their anxious child.
Untreated anxiety disorders can all too quickly lead to depression. «We see this combination in around three quarters of the cases we treat on a day-care basis here,» says Christian Fleischhaker. Anxiety and the feeling of being at its mercy not only cause social withdrawal, but also destroy self-esteem. There are almost no positive experiences left, which ultimately leads to episodes of depression.
Recognising fear
But how can parents tell the difference between normal shyness and anxiety, which will disappear on its own as the child grows older, and behaviour that requires treatment? The two decisive criteria are personal distress and impaired development. If normal developmental tasks such as making friends or learning a certain degree of autonomy and independence are blocked, parents should take a closer look.
A typical example is school camp. Being excited and homesick is completely normal. However, if a child starts worrying weeks in advance about whether they will be able to cope, and even the thought of it stresses them out, then parents should keep an eye on the situation.
«Parents worry that they are harming their child by «forcing» them to go along, but this can actually be a useful way of confronting their own fears. They realise that it's not so bad once they've overcome their fear,» says Zulauf Logoz. It is important that parents sensitively motivate their child to take part in this experiment.
Not a case of «don't be so silly»
One refusal alone does not necessarily indicate an anxiety disorder. However, a series of refusals forms a pattern that is worth paying attention to. If your teenage daughter repeatedly asks to be picked up from sleepovers at her friends' houses because she would rather sleep at home, parents should consider whether there might be more to it than meets the eye.
This also applies when everything appears to be functioning well externally. The child has good grades, can take exams, studies voluntarily – but studies late into the night, makes a «drama» out of it every time, and cries a lot. «Subjective suffering is sufficient grounds for therapy,» says Zulauf Logoz. She often finds that it is precisely those who do not cry out their fears and act them out who are overlooked and receive help far too late.
Anxiety becomes harmful when it is too strong, too frequent or occurs in situations that are not objectively threatening.
Lea's parents understood that this was not a case of «stop being so dramatic». They tried gentle persuasion, logic, creativity and strictness, and spoke to the school psychologist, but nothing helped. «When I had to drag my child away from the doorframe, I knew we needed professional help,» says Martina Hissmann.
Lea agreed to take this step. She was often annoyed with herself, really angry: «It's so stupid that I'm acting like this, I'll just do it now!» – and then the fear got the better of her again.
Faced with fear
Confrontation therapy with a behavioural therapist, also known as «habituation therapy», has proven effective in treating anxiety disorders. However, the waiting time for a therapy place in Switzerland is currently between three and five months.
During the sessions, the trigger for the fear is addressed. Zufluss Logoz likes to use the image of a large mountain or a ladder that the children climb step by step. Those who are afraid of monsters first look at pictures of them, spiders are initially placed on the hand in rubber form, and it is sufficient to manage just a small part of the way to school at the beginning.
Anxiety disorders are usually treated by encouraging those affected to face their fears head-on.
Binia Roth, psychotherapist
«Parents need to be brought on board. It is their job to practise exposure with their children at home and reward them,» explains Zulauf Logoz. «For touching a spider three times, they get a sticker, and for five stickers, they get a small gift – something like that.»
Getting used to it also involves explaining the background in detail to parents and children in advance. Why are we actually afraid? What happens in the body at that moment? And why are certain fears important, while others are only hindrances?
Taking committed action
Confrontation therapy originates from cognitive behavioural therapy. A further development of this is acceptance and commitment therapy, or ACT for short. «With anxiety disorders, you should generally face your fears head-on first; we call this exposure. ACT does this in its own way,» says Binia Roth, child and adolescent psychotherapist at the Schlüsselberg group practice in Basel. Young people who have been suffering from an anxiety disorder for a long time and have become withdrawn can particularly benefit from ACT.
What is an anxiety disorder?
Fear becomes harmful when it is too strong, too frequent or occurs in situations that are not objectively threatening. Experts refer to this as an anxiety disorder. Those affected are afraid of things that others consider normal. They experience the same physical and psychological symptoms as with «normal» fear. The intensity can vary greatly from person to person, but usually increases if the excessive fear is not treated.
The aim of therapy is to encourage proactive behaviour. To achieve this, the fear must first be recognised and accepted. «And not just the fear itself,» says Binia Roth, «but also all the processes surrounding it. What do I do or not do to avoid feeling fear? For example, do I avoid going out with friends in the evening because I'm afraid they won't like me? Or am I afraid of coming across as uncool? What things do I avoid so that I don't have to feel lonely?"
What values are important to me?
In a second step, Binia Roth shifts the focus to young people's personal values. We share and adopt our parents' values for a long time, and it can be challenging to look at what makes us independent and what is important to us.
«We spend a lot of time identifying important values such as honesty and loyalty,» says Binia Roth. As an example, she cites a person with social anxiety who is also very loyal and willing to stand up for others.
If their best friend then organises a small birthday dinner, the anxious person would actually prefer to cancel. In such a case, the value of «standing up for others» could mean participating anyway and helping their friend organise the party. In this way, activated values can help overcome fears and blockages and enable people to do what is important to them.
Practising mindfulness
Another important pillar of ACT is mindfulness: Why am I feeling tense right now? What am I worried about? Once the values have been identified, they are built upon: What could be done tomorrow to get a little closer to this value?
«For example, if you have defined the value of connectedness for yourself, you must overcome your fear and write a message to someone and arrange to meet in three or five days,» says Binia Roth. «This brings us back to the element of confrontation, which is also used in behavioural therapy."
Talking to children about feelings
Even though anxiety disorders can usually be treated effectively, it would be even better not to develop them in the first place. Christian Fleischhaker is convinced that many cases could be prevented if children were educated about them at an early age: «Nowhere in our school systems do we have a subject that teaches basic knowledge about fundamental emotions. What are they, how can I recognise them, and what purpose do they serve?»
Such a course in lower school, preferably taught by teachers who already have a trusting relationship with the children, is the best form of prevention. In such a course, children could also learn that fear is not such a silly thing after all, but that the body actually has a reason for feeling it. «If you understand and can put this into context, it automatically makes you less afraid and makes it easier to ride out the wave of fear when it comes,» says Fleischhaker.
A happy ending for Lea
For a good year, Lea's parents accompanied her to therapy every week. With a classic deconditioning programme, the girl learned to face her fear step by step. On Tuesday, she first went to school but did not go swimming. Then she walked with her class to the tram but did not get on. Later, she rode a few stops but got off before the swimming pool.
«For me, the most important insight from this whole story was that we had waited far too long. My goal was to find a solution to the problem. I just couldn't let it go and say, «This needs to be handled by professionals,»» says Martina Hissmann. She is very relieved that the family finally took this decisive step. Now all she hears from Lea is, «Swimming? Yes, of course I'll go.»
*Names changed by the editors
