Children's Anxiety

A Contextual Approach

Peter Appleton

• Publisher: Routledge
• Year: 2008
• Print ISBN: 9780415459440
• eBook ISBN: 9781134126248
• Topic: Psicologia
• Subtopic: Psicologia dello sviluppo

Children's Anxiety: A Contextual Approach provides an introduction to anxiety in children and teenagers, emphasising the importance of understanding the life circumstances of young people. The book provides an up-to-date account of research on the developmental, familial and social context of child anxiety, along with nine vibrant and detailed case studies illustrating the ways in which young people can be helped to deal with serious and complex anxiety problems.

In order to begin to understand complex anxiety within children's life circumstances Part One of the book provides the reader with a developmental framework for thinking about children's anxiety. Part Two then presents nine in depth case studies, organised not by the type or nature of anxiety but by the context within which problematic anxiety can occur. Part Three acts as a summary of the key points emerging from the clinical case studies.

This book will be essential reading for those working and training in the specialist field of child mental health, as well as community and hospital professionals working with children and young people, including teachers, doctors, social workers and nurses.

Part I

Chapter 1
A developmental framework for understanding children’s anxiety

Peter Appleton

In point of fact, evidence suggests that in an overwhelming proportion of cases the eventualities a child fears can be understood wholly, or at least in part, in terms of his actual experiences.

(Bowlby, 1973, p. 272)

We start with four brief examples of complex anxiety, in particular life-contexts:

1

In October 1998, 400 young people were enjoying a discotheque in an old warehouse in Göteborg, Sweden. At midnight a fire erupted and swept through the building, leaving 63 dead. Two hundred and thirteen teenagers were physically injured. The majority of survivors had witnessed terrifying scenes. At 18-month follow-up, 25 per cent of the survivors were experiencing diagnosable levels of post-traumatic stress disorder (PTSD)—flashbacks, nightmares, intense distress at memories or reminders of the event, efforts to avoid thoughts and activities that might remind one of the event, hypervigilance, and difficulties in concentration. Schoolwork had been badly affected, with a high rate of school drop-out, and for those attending, difficulties in concentration, and lower grades (Broberg et al., 2005).

The majority of the young people attending the disco were from immigrant families. Many of the families had war-related experiences from their countries of origin. For those adolescents born outside Sweden, the rate of PTSD was 31 per cent, compared with 17 per cent for those born in Sweden. Immediately after the fire there were strong feelings that the public services had not done everything they could to provide help, and find out what had happened. The authorities responded by providing a special support organisation, which continued its work for three years. Many adolescents found it immensely difficult to request help.

2

Children who have seen their parents repeatedly being violent to each other will usually experience severe anxiety. Very young children can show clear signs of post-traumatic stress, following the witnessing of domestic violence (Scheeringa et al., 1995; Scheeringa et al., 2005). Flashbacks occur as repetitive and trauma-re-enacting play. If children themselves are hit repeatedly, or sexually abused, or exposed to significant emotional maltreatment or neglect, anxiety, depression, and behavioural difficulties may occur (Cicchetti, 2004; Maughan and Cicchetti, 2002).

Some children who have been repeatedly abused may go into foster care. Sadly, many children then find themselves unable to form secure attachments to a foster carer. A succession of foster homes may then ensue. The original anxiety associated with abuse (and with close relationships) is compounded by anxiety about when the next move might be. Agencies may not have the resources to provide therapeutic help for the child, or indeed to support the foster parents. This may increase the chance of additional moves for the child.

3

Social anxiety disorder (or social phobia) is a condition in which the young person fears negative evaluation or rejection by others, or humiliation in front of others (Albano and Hayward, 2004). The perception that negative evaluation by others is likely, and may have serious consequences, is amplified by intense self-consciousness. Exposure to the feared social situation provokes anxiety and may provoke panic. Worry about these specific situations interferes with day-to-day life, and active avoidance of particular social situations is usual. In severe cases the young person may not be able to acknowledge the difficulties, may have lost contact with friends, and may have withdrawn from school. Depression is frequently associated with social anxiety disorder.

Although shyness is a risk factor for social anxiety, it is only ‘minimally or quite important’ in explaining the development of the problem (Albano and Hayward, 2004, p. 204). In one prospective study, other risk factors include parental divorce, early puberty in girls, and ethnic minority status. Retrospective studies have thrown up a very wide range of family and social risk factors, many suggesting that parents may ‘overprotect’ the child, not supporting him or her in learning to approach new and difficult situations. Some parents, in these circumstances, may themselves have experienced trauma as a child, and may feel that they are protecting their child from undue distress. Some socially anxious children are bullied and rejected by classmates, confirming the child’s expectation that he or she will be humiliated. Schools vary in their capacity to address the complex issues that arise for children with anxiety disorders, and for children who are bullied.

4

Children with intellectual (or learning) disabilities are more likely to develop emotional and behavioural difficulties (including problematic anxiety) than those without intellectual disabilities. Part of the multifold explanation for this association is the greater number and range of adverse life events experienced by children with intellectual disabilities. In particular, children with intellectual disabilities are more likely than children without intellectual disabilities to experience parental separation, parents being in trouble with the police, serious illness requiring hospitalisation, and death of a close friend (Hatton and Emerson, 2004). The specific life events of parental separation, parents having problems with the police, death of a close friend, parental financial crisis, serious childhood illness, and break-up of an adolescent’s steady relationship, are all associated with higher prevalence of emotional disorders in children with intellectual disabilities (Hatton and Emerson, 2004). In addition, the cumulative effects of a series of adverse life events on children’s psychological difficulties seem to be more pronounced in children with intellectual disabilities.

In each of the four examples above, anxiety, fear, and other psychological difficulties exist as part of a complex background and time-line of previous, current, and possible future contextual factors. These factors clearly need to be borne in mind when trying to understand the nature of the child’s anxiety. In Sweden the young peoples’ PTSD symptoms had to be understood in the context of their family’s previous war-related experience, and the immensely complex current concerns of the immigrant communities about the fire and its aftermath. For children who have witnessed domestic violence, or have been abused within the family, there is likely to have been a history of traumatic relationship difficulties before the abuse, and there are likely to be further separations and losses for the child, some of which will be difficult to comprehend, and will therefore raise further anxiety. For specific anxiety disorders, such as social anxiety disorder, there may be additional psychological difficulties (such as depression), and there may be family and/or school contextual issues, all of which need careful account in understanding the anxiety. And for children with developmental disorders, we need to understand both the nature of the specific developmental disorder, and the child’s family and social circumstances.

Anxiety and child development

In this first chapter I will lay out a framework of thinking about children’s anxiety, in its developmental and life-context.

When a developmental approach is applied to our thinking about children’s anxiety, 10 key themes emerge (see Box 1.1). Each of these themes will be explored in turn.

Box 1.1 A developmental framework for children’s anxiety

1 No single causative factor: children’s problematic anxiety is the outcome of a number of factors coming together, over time.

2 Development-in-context: the individual child developing in his or her family, a network of shared relationships, neighbourhood, school, and culture.

3 Risk and resilience.

4 Anxiety and fear as ‘early warning systems’ or ‘defence systems’ during the long period of children’s development.

5 The central part attachment relationships play in the child’s sense of security and safety, and their experience of anxiety.

6 Parents, carers, and families: protecting children, and providing encouragement to explore and problem-solve.

7 The key role of peers and friends in understanding children’s anxiety and confidence.

8 The developing self and anxiety.

9 The concept of pathways—the individual child’s ‘trajectory’ through his or her development.

10 Pathways to change, and turning points.

No single cause

A key message from the developmental anxiety literature is that no single factor in a child’s background, or genetic history, causes him or her to experience problematic levels of anxiety (Sameroff, 2006; Vasey and Dadds, 2001). It is always useful to assume that there are several factors, and that these factors have interacted during the child’s development.

Patrick Bateson and Paul Martin offer a cooking analogy:

The processes involved in behavioural and psychological development have certain metaphorical similarities to cooking. Both the raw ingredients and the manner in which they are combined are important. Timing also matters. In the cooking analogy, the raw ingredients represent the many genetic and environmental influences, while cooking represents the biological and psychological processes of development. Nobody expects to find all the separate ingredients represented as discrete, identifia...

Table of contents

• Contents
• List of boxes, figures and table
• Notes on contributors
• Preface
• Acknowledgements
• Part I
• Part 2
• Part 3
• Index