How does anxiety affect children and what can schools do to help?
There is a growing concern about the mental health and wellbeing of children and young people, with recent statistics suggesting that one in ten children need support for mental health difficulties. Whilst schools are an ideal setting to identify and respond to concerns about the mental health of children, teachers often report that they feel inadequately prepared to recognise and support children with mental health difficulties. This article will focus on the topic of anxiety, one of the most common mental health difficulties in school-aged children and adolescents. It will present some findings from a recent research project, provide some information about how to recognise the signs and symptoms of anxiety and consider the benefits of a school-based anxiety prevention programme.
What is anxiety?
Anxiety is something that all children will experience from time to time. It is a normal response to situations that we find threatening. Similar to a smoke alarm, anxiety can be incredibly useful when it works properly. This is because anxiety helps to prepare the body to respond appropriately to danger – to either “fight or flight”. When faced with a perceived threat, the brain communicates with the rest of the body that danger is imminent and the body responds with a number of physiological changes. The heart beats faster so that blood can be carried to where it’s most needed. The liver releases extra sugar for energy and the body starts to sweat to prevent overheating. This response is helpful and adaptive if faced with a real danger such as an attacker, fire or wild animal. For some children, however, their smoke alarm is much more sensitive and goes off when danger is much less imminent – for example, a friend’s birthday party, attending school or speaking aloud in class. This can be extremely scary and exhausting for children and their families.
What causes anxiety?
The cause of anxiety is likely to differ from individual to individual. There is some evidence, however, that anxiety can be caused by both genetic and environmental factors. Some children are more likely to develop an anxiety disorder because it runs in their family (that is, they have a genetic predisposition). For other children, stressful life events such as the death of a loved one, parental separation or moving house can be the cause. Some children grow up in an environment where others are fearful and anxious which “teaches” the child that the world is a dangerous and threatening place. Sadly, some children grow up in an environment where danger is actually imminent (for example, in a home where there is domestic violence) which can result in them being in a constant state of fear and anxiety as well. It is important to work individually with each child, and their family, to try to understand the cause of their anxiety.
How common is it?
Research suggests that approximately two to four per cent of children will meet the criteria for an anxiety disorder (Costello et al., 2003). However, the number of children identified as having anxiety seems to be on the increase. At University College London (UCL), we recently ran a research project in which 182 children from Year 5 (aged nine to ten years) completed a questionnaire called the Spence Children’s Anxiety Scale (SCAS). The SCAS has statements such as “When I have a problem, my heart beats really fast” and “I can’t seem to get bad or silly thoughts out of my head”. Children are asked to rate these statements on a three-point scale ranging from 0 (“Never”) to 3 (“Always”). We found that 38 per cent of children had scores that were clinically concerning and would require further investigation from professionals to see whether they met the criteria for an anxiety disorder. Interestingly, only 18 per cent of children were identified as concerning by teachers. This indicates that teachers may not identify all children who self-report with clinically concerning levels of anxiety. Why is this? The “internal” nature of anxiety can make it difficult to detect. Many anxious children will also fit the profile of an ideal pupil: docile, quiet, and compliant. Whilst they may not challenge the teacher’s authority or be disruptive, anxious children are likely to be very distressed, which means that spotting them is very important.
When should we worry about the worriers?
Children are often exposed to situations that make them feel nervous or afraid. For example, a first day at school, a maths test or a dentist appointment. The majority of children will be able to manage these situations with gentle reassurance from adults. For a smaller number of children, these situations will activate their internal smoke alarm and cause the following changes in thoughts, feelings and behaviours:
- thoughts – anxious children may view particular situations as more threatening and dangerous than other children. They may have persistent negative thoughts such as “I’m going to get sick and die” (health anxiety) or “People are thinking bad things about me” (social anxiety). It can be helpful for ask children to keep a thought diary and rate how frequently particular thoughts occur and how much they believe their thoughts on a scale of one to ten
- feelings – some children may be able to report that they feel worried, scared, frightened or nervous. It can be helpful to ask children to rate the intensity of this feeling on a scale of one to ten
- behaviour – given that the experience of anxiety can be incredibly uncomfortable, anxious children will often engage in desperate attempts to avoid the situations that cause them distress. They may refuse to participate in activities that other children enjoy, pretend to be ill so that they do not have to attend school or avoid social interactions with others. This can reduce anxiety in the short-term but reinforces the fear in the longer-term.
If these changes occur when there is no apparent danger, persist over time and interfere with the child’s daily life then it may be useful to seek professional support from the child and adolescent mental health service (CAMHS) or educational psychology service (EPS). It may also be worth considering a school-based intervention.
How can schools support children with anxiety?
Over the last decade, there has been an increasing interest in school-based anxiety prevention programmes. There are a number of reasons for this. First, children spend a considerable amount of their time in school and often have excellent relationships with school staff – an important pre-requisite for being able to talk about thoughts, feelings and behaviours. Second, mental health programmes that are delivered in schools (for example, to a whole class of children) can reduce stigmatisation, enhance peer support and increase the opportunity for social learning, prompting and rewarding by the peer group. Third, and perhaps most importantly, there is growing evidence that appropriately trained teachers can deliver mental health programmes effectively and prevent anxiety disorders from arising in school-aged children (Barrett and Turner, 2001).
Many of the anxiety prevention programmes used in schools draw on a cognitive-behavioural therapy (CBT) approach. This approach is based on the idea that our thoughts about a particular situation can affect how we feel and behave. For example, if a child is asked to read aloud in class and has a thought such as “everyone is going to laugh at me”, they might feel very anxious and behave in a disruptive way so that they can avoid the task completely. Many anxiety prevention programmes aim to challenge children’s negative thoughts as well as encouraging them to face their fears. This can be achieved, for example, by using a graded exposure approach. This involves educating children that overcoming fear is best achieved by gradually confronting it, then working with them to identify a fear hierarchy where exposure to feared situations, activities or objects is ranked according to difficulty, starting with the ones the child considers most achievable (Graham, 2004). For example, a child who has a fear of reading in class may rank reading alone as an achievable first step. The child could then work towards reading with a family member, being asked a question about a book in class, reading in a small group and then reading aloud in the classroom. Importantly however, this technique is not likely to be effective when used in isolation. Many anxiety prevention programmes last between eight to 12 weeks so that children can learn all of the necessary skills to recognise, understand and take control of their anxiety.
Top tips for supporting anxiety:
- support the child, and their family, to understand their anxiety. The smoke alarm analogy is a useful one
- help the child to notice their anxiety-related thoughts (such as, “People are thinking bad things about me”). It can be helpful to ask children to write their thoughts down on paper and rate how much they believe their thoughts on a scale of one to ten.
- encourage the child to verbalise how they are feeling. For younger children, use drawing or play to support this
- consider implementing a school-based anxiety prevention programme. These programmes can be delivered by appropriately qualified mental health professionals as well as teachers who have received specific training in the approach
- if you have serious concerns about the mental health of a child or young person, seek professional support from the child and adolescent mental health service (CAMHS) or educational psychology service (EPS).
Dr Amy Phipps is an Educational and Child Psychologist working in the Royal Borough of Greenwich. She recently completed the Doctorate of Child and Educational Psychology (DECPsy) at University College London (UCL).
Dr Sandra Dunsmuir is the Director of the Educational Psychology Group at UCL:
Barrett, P., and Turner, C. (2001). Prevention of anxiety symptoms in primary school children: Preliminary results from a universal school-based trial. British Journal of Clinical Psychology, 40(4), 399-410.
Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., and Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of general psychiatry, 60(8), 837-844.
Graham, P.J. (2004). Cognitive Behaviour Therapy for Children and Families (2nd Edition). Cambridge, UK: Cambridge University Press.