Dr Amina Al-Yassin There are many different types  of anxiety disorders which can affect children and   young people, and it can sometimes be a little bit  difficult to tell the difference between them. But   as a parent, a Teacher, a Youth Worker, or anyone  working with children, the most important thing   is that you can identify when a child may be  suffering from an anxiety disorder, and that you   can help them get the support they need. That is  much more important than working out exactly what   type of anxiety it is, which the Doctor or mental  health professional will be able to diagnose. Amongst children, the most common types of  anxiety disorder are separation anxiety,   social anxiety, and generalised anxiety  disorder, and in older young people,   such as teenagers and adolescents, panic  disorder is also quite common. The average   age for developing an anxiety disorder in  children and young people is 11 years old. The most common type of anxiety disorder in  younger children, children below the age of 12,   is separation anxiety. This is when a child is  very worried when they are separated from their   parents or their carer. It’s very common  in young children. It usually develops at   around six or seven months of age, and it  can make settling into school or into any   activity where the parent or carer will not  be available much more difficult. Some young   people have a more general school-based anxiety,  where the concern is more about school itself,   rather than the separation from the parent  or carer. They may be anxious as a result   of homework and schoolwork, or friendships  or bullying, or they may be anxious because   they’ve moved from one class to the  other, or one school to the other. Children do not always talk about  their feelings and their worries,   and sometimes school-based anxiety can  show itself up in physical symptoms,   like headaches or tummy aches, especially in  the mornings, and especially on school days.  Some children and young people have social  anxiety, and this is when going out in public,   seeing friends, taking part in activities and  social activities with many other people can   cause lots of fear or worry. This is not  the same as shyness. Shyness is common,   many people are very shy, but this is when  the shyness is so severe that it can really   affect their ability to go out and to  engage and to do the normal things that   people would usually like to do, like seeing  friends, speaking on the phone, or mixing   with others. Social anxiety is more common in  young people who have been through puberty. Another type of anxiety disorder  are the phobias. A phobia is a   specific worry about a very specific  thing. Many children are afraid of   dogs or monsters or spiders, and this is a  normal part of growing up. However, again,   if this fear is becoming so severe that  it’s affecting their ability to get on   with their normal day-to-day life, that’s  when it would be considered to be a phobia. Anxiety is not always specific to a particular  thing. Generalised anxiety disorder is when   someone can feel quite worried and they  can’t quite pin down what the reason is.   They may be worried about lots of different  things, rather than one specific event,   and they may, sort of, feel anxious or worried  all the time, they may not even remember the   last time they felt relaxed. This is when we  would call this generalised anxiety disorder. There are many other types of anxiety disorders  too, such as post-traumatic stress disorder,   which happens when a child or young person has  experienced a life threatening, or an event   that was perceived to be life threatening, and  obsessive compulsive disorder. However, these   anxiety disorders are more common in adults rather  than children, so they won’t be our focus today. We all worry from time-to-time. All of us  experience anxiety and anxiety is a very normal   part of being a human, and in many cases, it can  be very helpful. It can help us to – it can help   warn us about danger and it can help us to avoid  situations that may be unsafe for us. However,   how do we know when a worry or a fear  that a child has is more than just normal   anxiety and is becoming an anxiety disorder,  something that may need more help and support? I like to remember this by the words  TRAM, T-R-A-M. T is for transient,   is this something – is this anxiety, this worry  or this fear, is it something that has come and   that is getting better? In which case, it’s  less of a worry than if it’s been there for a   long time and it’s persisted. The R stands for  reactive, is this anxiety or worry happening   as a result of a very specific event? So, for  example, moving from one school to the other,   or moving home, or parental breakup. All of this  would be expected to cause anxiety in a child   for a period of time. This is a reactive  phenomenon and that’s also less worrying. Is this appropriate? That A stands for  appropriate, is this anxiety appropriate   for their age and their development? So, a  two-year-old who is very worried about leaving   their mother, or going into nursery, that’s,  you know, that’s a normal developmental stage,   and something that wouldn’t be very worrying.  However, if we found the same behaviour in someone   who was 12 or 13, then it would definitely  be worth looking into it a bit further. And, finally, the M is for manageable. Is this  anxiety – you know, they feel it, they experience   it, but they’re able to carry on with their  normal life. They’re able to go to school,   they’re able to see their friends, or  is it really getting in the way and   becoming not very manageable? That’s  when we would worry about it more. So, TRAM, T for transient, R for reactive,  A for appropriate, and M for manageable. So,   for example, if you were to go into a  high school just before the exam period,   most of the children, if not all of them,  would be feeling pretty anxious. However,   most of them would still be able to come into  school, they would be able to complete their exam,   and they would probably perform at the  level that was expected, or predicted,   by their Teachers. So, in that case, that’s  normal anxiety and nothing to worry about. However, if there was a young person who was so  anxious that they were unable to come to school,   or they were unable to sit their exams, or  they were sitting their exams and they were so   anxious that their performance was so much less  than what would be expected by their Teachers,   that’s when we would start to wonder  whether this was more than normal anxiety. So, when should you get professional help for a  child if you’re concerned about their anxiety? Number one If you feel that it’s not  getting better, it’s getting worse,   you have tried a few tactics, you’ve tried a few  things to help them yourself, and it’s not helped. Number two If you think it’s really  starting to affect their schooling,   their relationships, their performance  at school or their attendance at school,   or you think it’s really  slowing down their development. Number three If the anxiety is happening  very frequently and lasting for quite a while. Number four If you feel that it’s really  starting to affect the activities and the   friendships that they usually enjoy. So, for  example, they’re becoming really withdrawn,   they’re going to great lengths to avoid any  situation that make – may make them feel anxious,   and that means that they’re maybe not doing the  normal activities, clubs, or seeing the friends   that they usually see. And, finally, if it’s  starting to affect their sleep or their eating. So, we all worry from time-to-time.  Anxiety can be very normal,   but we definitely need to be on the  lookout for what we call the “red   flags,” the signs that mean that a child  or young person may need some more help. Anxiety at different ages Does  the age of a child affect whether   or not they experience an anxiety  disorder? The simple answer is yes. So, in the UK, anxiety disorders are  estimated to affect approximately five   to 19% of all children and adolescents, but  only two to 5% of children younger than 12,   so, in general, anxiety disorders are more  common in older children. And there are some   important differences when it comes to age and,  in fact, when thinking about anxiety disorders,   it’s very important to understand a  child’s age and their developmental stage. So, for example, in separation anxiety, from the  age of about six months to three years, it’s very,   very common for a young child to have separation  anxiety. In fact, a child who does not show any,   sort of, reaction to being separated from their  carer would be a cause for concern. And so,   in this age group, it’s very normal for children  to become quite clingy, to cry, to be distressed,   if separated from their parent or carer, and it’s  a normal developmental stage and something that   should probably get better by the age of two to  three. If this was to persist for much longer,   or if it was to really start to affect their  ability to attend or engage with nursery or   school, then that’s when we would start wondering  whether it was separation anxiety disorder,   and separation anxiety is the most common  anxiety disorder in children younger than 12. If we now look at a slightly older  age group, the preschool children,   so children aged about three to five. In  this age group, it’s very common to have   specific fears or phobias, and common fears  in this age group are things like monsters,   spiders, strangers, and the dark, and  usually these fears slowly start to get   better on their own. And usually the child may  need comforting or reassurance, but it will   not really get in the way of their day-to-day  functioning and their day-to-day activities. However, if these phobias are persisting,  they’ve been there for a long time,   if it means that the child’s becoming  withdrawn or anxious, and if it means   that the child is going to great lengths to avoid  any situation which may make them feel anxious,   that’s when we start to wonder if this is a phobia  and something that may need professional help. And, finally, and again, in the older age  group, if we are now looking at adolescents,   teenagers, children who are post-puberty, in  this age group, panic disorder is more common,   as is social anxiety disorder. And  perhaps this is as a result of all   the body changes that they go through at  this time, increasing self-consciousness   and the increasing importance and pressure of peer  relationships. So, anxiety can be affected by age,   both the type of anxiety that different  age groups experience is different,   as well as the prevalence, or how common  anxiety is, in every age group is different. There has been some research into the differences  between anxiety and mental health disorders in   males and females. A large Danish study  looked at the prevalence of all mental   health disorders and neurodevelopmental  disorders, including autism and ADHD,   between males and females. And they  found that if we count them all up,   then, overall, males have more mental health  and neurodevelopmental disorders than females. However, interestingly, if we look just  at anxiety, and especially if we look   at that adolescent age group, then anxiety is  more common in females than males, and that this   difference emerges really early, so that even  if you were to look at six-year-old children,   anxiety is almost twice as likely in girls  than in boys. Scientists have been asking   what the reason is for this difference, and it  may well be that there are different genetic   and biological factors that  play a part in this difference. However, it’s also worth considering whether the  expectations that society has on boys and girls,   on males and females, on men and women, may be  playing a part too. And some people think that   it may be that society is much more accepting  of externalising, or outwardly expressions of   emotions, such as anger and aggression in  males, whereas, for females, where that’s   less acceptable, the, sort of, reactions we have  to difficult emotions are more internalising. So,   for example, feelings that we keep inside  with anxiety and depression being an example. So, it may be that there are biological  differences, or genetic differences,   or it may be that this is due to social norms  and expectations. What’s important is that we   are aware of anxiety disorders, and that we’re  able to identify any young person who may be   struggling, regardless of their gender, and we’re  able to offer them the support and help they need. There is one other group that’s incredibly  important when it comes to anxiety and to   mental health disorders, and these are children  and young people who have diverse gender roles,   or who may not conform to traditional gender  roles. In this group, mental health disorders,   including anxiety, are unfortunately much more  common, and it’s also more common to have suicidal   thoughts and self-harm. And so, this is a group  that we need to be particularly sensitive to,   ensuring that we offer support and help as early  as possible to avoid those outcomes. No matter   what a child’s gender role or biological sex  is, we should always be on the lookout for any   signs of anxiety, or any other mental health  disorders, because early identification means   that we’re able to support the child or young  person early, signpost them to the right places,   and get them the help they need, so  that they’re able to make a recovery. Can anxiety get better? Without treatment, so this  is if we do not recognise that a child is very   anxious, we do not get them the help and support  that they need, anxiety is likely to persist,   and it can go on to affect a child’s social and  family functioning, and their overall quality of   life. Anxiety disorders in childhood can increase  the risk of anxiety disorders in adulthood as   well, and they can, also, if untreated and  unmanaged, they can increase the risk of the   person going on to develop depression and low  mood, substance use disorders, or self-harm.   Anxiety is often seen as a problem that can  lead to other problems if it’s not treated,   and so that’s why it’s very important to detect  it and to get help for it as soon as possible. If we look at mild anxiety, okay, this is –  most children do grow out of mild anxiety.   However, a few can continue being  anxious and can sometimes become   anxious or depressed as adults. Even if they  do not become anxious or depressed as adults,   anxiety can limit a young person’s activities,  their attendance at school, their friendships,   or their attendance at other activities,  which can mean missing out on education,   or missing out on making friends, and  so the emotional effects of this can be   long-lasting. And so, even in mild anxiety, it’s  important to detect this early and get help early. With more moderate and more severe anxiety,  again, the earlier you can get help,   the more likely it is to have a positive  outcome. And studies have shown that up   to about 68% of children who receive treatment for  their anxiety, and the treatment can be therapies,   or medications in some cases, so 68% of these  children showed a significant improvement in   their anxiety, and in at least half of them,  this improvement remained for six years. So,   when they were looked – when those children were  investigated and asked questions six years later,   half of them were still in remission, so they  were not experiencing their anxiety anymore. So, I think the important message here is that  anxiety can persist and it can last, and so it   is important for early help to be offered, and  early support to be offered, especially when   anxiety is more moderate or more severe, and that  when this treatment and support is given, there is   a good chance of recovery. Anxiety is not black  and white, on or off, though, and with any child   who is predisposed to anxiety, it’s important to  always be aware that certain transition points   or certain stressful points throughout life  may make the anxiety come back or get worse. So, these are things like starting a new  school, moving from primary to secondary school,   or a family break up, or big exams that year. So,  if we know that a child we look after is known to   have anxiety, or has experienced anxiety in the  past, then we need to be very sensitive around   those points, to ensure that we put extra support  in place, and that we are especially aware and on   the lookout for any signs of anxiety, so that  we’re able to support them through that time. You know, there’s a lot to say for being  proactive and for taking a preventative approach,   trying to prepare and plan ahead for anything that  may be stressful, rather than managing the crisis   after it happens. So, with anxiety, again,   the most important thing is to be able  to identify it, to get help early,   and to manage and anticipate any future anxiety  provoking events and preparing for them.