How parents can help with children's fears

A girl whirls at lofty heights, sometimes upside down in the splits, sometimes climbing up a loose cloth like a spider. Anna* is 15 years old. What keeps her safe? The sling wrapped around her foot? Or is it the fear that makes Anna perform every movement with the utmost caution? The teenager has been doing circus acrobatics for five years, favouring the vertical cloth and aerial ring. She is afraid of heights, she says. But she feels safe on these apparatus. Why? Anna: «Because I can hold myself up.»

Then, in the evening, at home. Anna helps her father cook. The cheese is missing. «Can you get it from the cellar, please?» her father asks. Anna hesitates. It's dark in the cellar. What if someone is there? What if the door closes and she is locked in alone? In no time at all, her thoughts pile up to form a fearful structure. «Please come with me,» Anna says quietly to her younger sister. Her sister moans: «You're always scared!» - and then goes with her.

During puberty, girls are affected by anxiety twice as often as boys.

One in ten children experience anxiety requiring treatment in the course of their development. Boys and girls are affected about equally often in childhood - in adolescence, girls are affected about twice as often as boys.

But what is anxiety, where does it come from and how can parents recognise it in their child? What are the typical anxiety disorders? And how are they treated? We want to get to the bottom of these and other questions.

What does anxiety mean for children and young people?

Anxiety is the most common disorder in children and adolescents, says Susanne Walitza, Director of the Department of Child and Adolescent Psychiatry and Psychotherapy at the Psychiatric University Hospital Zurich. «Early treatment is important because anxiety spreads, can become chronic and lead to other disorders such as depression.»

Before a pathological anxiety can be treated, it must be recognised. It is not always easy for parents to decide when an anxiety is normal, when it is clinically relevant and when it is an anxiety at all. «Children don't talk much about anxiety,» says Susanne Walitza. «Anxiety generally manifests itself more through physical symptoms.» Children then complain of stomach ache, nausea or headaches, for example.

Fear has many faces

In psychology, anxiety is understood as an emotion that relates to a situation that is perceived as threatening. The nature of the threat remains rather vague and is accompanied by ideas about what could happen. Fear is to be distinguished from this: it relates to a specific threat and can be justified. However, if the fear is exaggerated, it triggers an immediate reaction and can lead to physical symptoms and avoidance behaviour. In such a case, we speak of a phobia. If there is no externally recognisable danger for a sudden and intense fear reaction, it is called panic.

Anxiety is one of the fundamental emotional states, and it plays a central role in childhood and adolescence in particular. With every transition from one developmental phase to another, new challenges arise, the child learns unknown things, increases its autonomy and is made aware of and protected from dangers through the experience of fear. This goes hand in hand with typical, generally weak developmental fears such as fear of strangers, monsters, illness or rejection.

An anxiety disorder is when the anxiety is unfounded, severe and persists for a long time, causing suffering and affecting the child. «In the long term, an anxiety disorder prevents the child from developing,» says Simone Munsch. She is a professor of clinical psychology and psychotherapy and head of the psychotherapy practice at the University of Fribourg.

Fear has a tendency to spread: «First it relates to the aeroplane. Then to the bus, the train, the car. And in the end, the child doesn't want to leave the house at all.» A child expands its range of movement over the course of its development. Clinically relevant anxiety does the opposite: «It severely restricts the range of movement. Not just for the child, but for the whole family.»

One of the first anxiety disorders in the course of development is separation anxiety disorder. «It first appears at the age of three or four. From the age of 12 or 13, this type of anxiety subsides again,» says Silvia Schneider. The professor teaches clinical child and adolescent psychology at Ruhr University Bochum. She has conducted various studies on separation anxiety in Basel.

Break off your holiday because of fears?

The Imhof family experienced how anxiety can restrict their freedom of movement. Daughter Elena developed a severe anxiety disorder at the age of six. Her mother Simone kept a diary - the «Elena book» - at regular intervals, recording the most important developmental steps and experiences of her daughter. The following lines were written down at different times:

«Ureter irritation [...] made you so insecure that you no longer wanted to go to nursery school. Someone could be sitting on the toilet if you needed to go urgently!» | «Mum and I put your shoes on together and I carried you to kindergarten, shouting at the top of my voice.» | «We had to cancel the holiday.»

Our family experienced a total breakdown.

Simone about her daughter Elena's fear

These few sentences give an idea of how strongly fear must have affected the Imhofs' everyday life. Mum Simone says: «Our family experienced a total breakdown.» Elena hid behind the sofa and clung to the living room pillar, screaming. It took two adults to get her dressed. The parents were always on call in case they had to pick Elena up somewhere. Elena's little sister Lilly spent school breaks with her big sister and the grandparents accompanied their granddaughter to psychotherapy on Wednesdays.

Elena can only vaguely remember today. «I think it was from vomiting,» she says. Emetophobia is the technical term for this specific anxiety disorder. Fears are categorised differently depending on the diagnosis system and the age of the person affected.

Three common anxiety disorders in childhood and adolescence are the emotional disorder with separation anxiety, the phobic disorder and the disorder with social anxiety - for the sake of simplicity referred to below as separation anxiety disorder, phobia and social anxiety disorder. Generalised anxiety disorder and agoraphobia (claustrophobia) occur much less frequently in children.

From one fear to the next?

«Most children have a developmentally typical fear of separation and strangers from eight months to the end of their second year. The child learns to differentiate between attachment figures and strangers. If the child retains this anxiety after the age of two, we speak of a disorder that requires treatment.» Around 3 in 100 children are affected. They avoid separation situations, cling to the caregiver, cry, defy and sometimes react aggressively.

«You fought back - with your hands and feet. In the truest sense of the word.» This is how Simone Badertscher Imhof recorded a separation situation in the «Elena book» on 15 January 2011. Did the girl have separation anxiety? «Separation was always an issue for Elena,» says the mother. «But we couldn't do enough with it.» So they diagnosed what Elena was so obviously expressing: a fear of vomiting.

Another common anxiety disorder in childhood is phobia. Susanne Walitza says: «All sorts of things can be the subject of a phobia: animals, syringes, blood or darkness, for example. Sometimes it's also bizarre things.»

Inconspicuous does not mean without problems

Avoidance behaviour can make you lonely, especially in the case of social anxiety disorder. «This anxiety mainly affects adolescents and young adults,» says Simone Munsch. «The anxiety relates to various situations: Performance, meeting someone, flirting, speaking in front of others at school or giving presentations.» It often takes a long time for outsiders to notice the anxiety. «Anxious people don't stand out much at school,» says Simone Munsch. «Quiet boys are often a relief for teachers. The focus is more on the children who demand attention.»

I wondered if I had been too strict and if I was to blame.

Anna's father about his daughter's fear

Like other parents, however, he also looked for the fault in himself: «When Anna fell ill, I was faced with the question of guilt. I asked myself whether I had been too strict. When the children were noisy, I sometimes said: 'Just shut up now! Then there was the separation and divorce situation. That leaves its mark on the children, there's no doubt about it.» In hindsight, however, he was able to let go of the question of guilt: «I gave the children back some of the responsibility, let them live more and also put my foot down to spend quality time with them.»

Is it the parents' fault?

Mike's mum suffers from a physical illness. She often feels that she is not there enough for her son. She lives separately from Mike's father in the same household. Towards the end of the month, money sometimes gets tight. «I'm also anxious myself,» she says. Elena's mother also looked for the reasons in herself. «You automatically ask yourself this question,» says Simone Badertscher Imhof. «But we have wanted children, a supportive relationship and we reflect a lot - actually a good starting point.»

Anna also has a supportive environment. Her parents live apart, but there is regular contact with her father and mother. And although her sisters sometimes grumble about Anna's anxiety, they are completely supportive of their sister. «I do things with her that make her happy,» says Clea*, the youngest of the three girls.

Research shows that parents influence their children's anxiety. Anxiety is contagious, explains Simone Munsch: «If anxiety-avoiding behaviour prevails in a family with regard to threatening situations, the child learns this.» But the psychologist emphasises: «Anxiety never has just one cause. In most cases, there are various factors that ultimately cause it to overflow: critical life events such as a separation, the loss of a loved one or a pet, or a move.» These events can trigger anxiety, but they don't have to.

Therapies encourage children and parents

Anxiety disorders are easily treatable. Many experts cite cognitive behavioural therapy as the treatment method of choice. Put simply, this therapy method exposes the child to the anxiety-inducing situation in stages until the child becomes accustomed to it and the anxiety gradually disappears.

It is important to make sure that the siblings are not neglected.

Susanne Walitza, Director at the University Hospital Zurich

Depending on the complexity of the anxiety disorder and depending on the therapy, this may be shorter or longer. For Elena's sister Lilly, it could have gone on longer. She was allowed to have a hot chocolate with her grandparents in a tea room while Elena saw the psychologist. «It's important to make sure that the siblings don't miss out,» warns Susanne Walitza. That's why she often invites them to the initial consultation. «But if the affected child goes into therapy, the siblings benefit anyway. Once the anxiety subsides, there is more room for normal everyday life at home again.»

Anna and her two sisters are currently making efficient use of this everyday space. They have transformed the parlour into a circus ring. The three of them practise figures, the splits and make a tower: one balances on the other. «I'm going to fall,» Clea can be heard hissing. «No,» says Anna. «I'll hold you.»

Therapies against anxiety

• Cognitive behavioural therapy is considered to be the most effective therapy method for anxiety disorders. Two important elements are exposure and habituation: if a child is afraid of dogs, this means that the child is gradually brought into contact with a dog - mentally, with images, sounds or in real life. Exposure sometimes requires ingenuity on the part of the therapist, for example with the fear of vomiting, as with Elena, or the fear of a guillotine, as with Mike. In the end, the child remains in this situation until it gets used to it and the fear subsides. «The habituation is the actual therapy,» says Simone Munsch, Professor of Clinical Psychology and Psychotherapy at the University of Fribourg and head of the psychotherapeutic practice centre. «The fear diminishes with each session.» The child is rewarded with positive reinforcers, such as a sticker, when it displays the desired behaviour. As a rule, therapy lasts between 2 and 16 sessions. «But it's worth waiting until someone is ready. The biggest mistake is to go into exposure before everything has been really well discussed and everyone agrees on the procedure,» warns Simone Munsch.
• In play therapy, like the one Elena attended, anxiety - and often the defence against anxiety - is revealed through play, as child and adolescent psychiatrist Thomas Koch explains. His play therapy room is a paradise for children: a sofa to hide under, a lamp with a mushroom hat, Barbies, cars, Playmobil, a doll's house, soft toys - even toy guns. «They occasionally lead to discussions with the parents,» says the therapist. But sometimes they are important. He thinks of a 5-year-old boy who could neither talk nor separate from his mother when he started kindergarten. «In therapy, he wasn't afraid at first,» says Thomas Koch. «He fended them off by trying to impress me, by organising fights and by banging me. He first showed the defence - how he dealt with this fear. It took a year before the boy was sure that the relationship would last. Then he showed me his fear and helplessness for the first time. From then on, things slowly started to improve.» The game began to change. What had previously been fragmented elements became a story with a common thread. Thomas Koch often observes this change. He adapts to the game, interprets, comments and creates connections to what is being said. «I put into language what is happening. And the child sees how I react to their play. This gives them a theory of themselves and of others.»