CHAPTER 53

Fears, Phobias, and Anxiety

Carol D. Berkowitz, MD, FAAP

Fears are normal feelings that cause emotional, behavioral, and physiological changes that are essential for survival. Fears are associated with psychological discomforts, such as a negative, unpleasant feeling. Children may develop fears in response to actual events (eg, earthquakes) or as a result of the temporal association of 2 events (eg, seeing a scary movie on a rainy day and then becoming afraid of rain). Some fears seem to be innate, and others seem to be developmental. Children fear different things at different ages. For example, school phobia is sometimes particularly problematic in young, school-age children. Worry is the cognitive manifestation of fear and anxiety.

Phobias are overwhelming, intense, highly specific, and often irrational fears. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, defines a phobia as excessive anxiety accompanied by worry occurring more often than not, for at least 6 months and associated with 1 or more of the following: restlessness, easy fatigability, difficulty concentrating, irritability, tense muscles, and disturbed sleep. Childhood phobias can be divided into 5 categories: animals (eg, spiders, snakes, dogs), natural environment (eg, heights), medical related (eg, doctors, dentists, injections), situations (eg, flying), and other (eg, loud noises, rain, thunder). Specific phobias are often managed by avoidance and may not present to the physician for treatment. Social phobias (also called social anxiety disorders) are specific to social situations that arouse intense concerns about humiliation or embarrassment. Fear of speaking in public may represent a social phobia. Selective mutism involves children who are able to speak but are unable to do so in certain settings, such as school. This probably represents 1 form of a social phobia. When these fears are combined with avoidance behavior, they may be incapacitating. Anxiety refers to fear without a definable source. It is characterized by a physiological response and may be perceived as a vague feeling of uneasiness, apprehension, and foreboding of impending doom. A child may experience an anxiety problem where there is significant but not severe distress and an anxiety disorder when the distress is excessive or functioning is impaired. Fifteen percent to 20% of youths have anxiety disorders, the most prevalent psychiatric condition in children and adolescents. Girls are twice as likely to develop anxiety disorders as boys. There is often a positive family history of anxiety disorders, which is felt to be related to a genetic predisposition and environmental factors. Children with autism spectrum disorder have an increased incidence of anxiety and anxiety-related disorders (see Chapter 132).

Different strategies are useful for dealing with different fears. It is important for parents not to trivialize these fears or reinforce them but to empower children to deal with them.

It is also important to realize that parents sometimes foster fears by using threats with children, such as, “The doctor will give you a shot unless you eat your spinach,” or “The boogeyman will get you.” By fostering fears, the parents are also fostering dependency. Parents lack the imagination that children have and find it difficult to understand the degree of fear that children experience.

The opportunities for primary care physicians to counsel families about childhood fears has increased over the past decades related to a number of catastrophic events, such as the terrorist attacks of September 11, 2001 (9/11), hurricanes Katrina and Sandy, the earthquake in Haiti, the tsunami in Sri Lanka, and tornados in the midwestern United States. Acts of violence, such as multiple mass shootings, often at schools (eg, Columbine, Sandy Hook, Virginia Tech, Marjory Stoneman Douglas High School), also create fear and anxiety in children and adolescents who witness these events on television and through messages posted on social media. It is important to recognize the pervasiveness of mental health sequelae following disasters and the factors that influence the prevalence of these disturbances. One percent of children in New York, NY, lost a relative on 9/11. There is a greater risk of mental health sequelae if there are poor social supports or a prior history of psychopathology or if the child is fearful or shy by nature. Natural disasters have a lesser effect than intentional ones. While many of the recent disasters have been acute and unexpected, there are children who are continuously exposed to what has been called “process trauma” in the form of war, detention of children and families seeking political asylum in the United States, and child abuse.

Epidemiology

Fears follow a developmental pattern (Box 53.1). Neonates are believed to have no fear, although young infants whose faces are covered with a blanket struggle to toss off the blanket. Infants who are 6 months of age exhibit what is known as stranger anxiety in response to unfamiliar persons, places, or objects. To combat this anxiety, infants seek refuge with a parent. Stranger anxiety becomes equated with separation anxiety and reaches a peak at 2 years of age. Children between 6 months and 2 years of age are also frightened by loud noises and falling or quickly moving objects.

Children between the ages of 2 and 5 years are in what is termed the age of anxiety. They fear many things, including animals, abandonment, loud noises, and darkness. Children in this age group are particularly fearful of physicians, hospitals, and getting hurt. Young children are afraid of those who are physically disabled, who represent bodily injury, and monsters and scary movies. They sometimes displace their anger onto monsters and witches and attribute to these imaginary characters the bad feelings they are experiencing. Children in this age group have strong imaginations, which makes it difficult for them to differentiate fantasy from reality.

Children between 6 years of age and adolescence tend to have more abstract thoughts, and their fears are less relevant to physical immediacy. These children are afraid of the death of their parents or the burning of their home. They also fear war, growing up (expressed as “How will I know what to do?”), going into the next grade, being alone or kidnapped, and the divorce of their parents. Children in this age group are often reluctant to bother their parents with their fears, and they can easily misinterpret parental concerns when they over-hear parental conversations. Separation anxiety, which may manifest as school phobia and may be referred to as separation anxiety disorder, may occur in school-age children. The prevalence is estimated at 3.2% to 4.1%, although up to 50% of third graders report separation anxiety symptoms. Separation anxiety disorder is defined as developmentally inappropriate, excessive anxiety precipitated by actual or anticipated separation from home or family. Affected children develop physical complaints (eg, stomachaches) on school days. The parent-child relationship may be disturbed or made insecure (eg, marital discord, maternal illness), and the child is fearful of leaving the parent alone. Childhood school phobia and parental history of panic attacks and agoraphobia may be associated.

Fears during adolescence relate to social functioning, such as public speaking or talking to members of the opposite sex. Older children are also concerned about school failure and physical injury. They have many of the same fears expressed by school-age children, although phobias are uncommon. Social phobia is a distinct entity and is different from shyness, as reported in a recent study of adolescents. Social phobia is a potentially impairing psychiatric disorder. Overall, phobias occur in less than 1.7% of the general population but are reported in 13% of children with other emotional or behavioral problems.

Anxiety disorders are rare in childhood but more common during adolescence. They may include panic attacks, which involve the sudden onset of intense fear or discomfort associated with physiological symptoms such as palpitations and shortness of breath. Fear about a panic attack may lead to agoraphobia (ie, the avoidance of going away from home). Posttraumatic stress disorder (PTSD) involves a set of symptoms that recurs after a person has experienced a traumatic event. Symptoms include intense fear, helplessness, or a sense of horror. The person reexperiences the trauma, avoids circumstances that are reminiscent of the trauma, and is in a state of hyperarousal. It is estimated that 5% of men and 10% of women have a lifetime prevalence of PTSD.

Pathophysiology

Fear has its basis in a series of psychophysiological reactions, which are mediated through a series of neurotransmitters. The reaction is often referred to as the fright/flight response and is critical for survival. The response is regulated through the limbic system. Elevated levels of certain transmitters, such as γ-aminobutyric acid and norepinephrine, are associated with feelings of anxiety. Excess serotonin has also been related to anxiety disorders.

Studies on the neurobiology of pediatric anxiety disorders demonstrate dysfunction in the amygdala prefrontal-based circuits. The amygdala is responsible for the initiation of the central fear response and is noted to be “overactivated” in magnetic resonance imaging of individuals with anxiety disorders. The prefrontal area helps regulate amygdala activity. Other areas of the brain have also been implicated in anxiety disorders in youth.

Differential Diagnosis

The challenge for physicians is to assess the etiology of the fear and to differentiate normal fears from those that may be signs of unusual stresses or signs of psychopathology. Appropriate fears represent a real reaction to a real danger. As a rule, children are more resilient than adults and recover more rapidly from traumatic events. However, children are prone to inappropriate fears, which may develop for a number of reasons.

Inappropriate fears may occur because of operant conditioning, in which a conditioned stimulus becomes associated with another object. Fear of the other object becomes reinforced through this association. Inappropriate fears may also develop in a child whose parent has the fear (modeling) or through witnessing a fearful event in the media (informational). True phobias represent neuroses and may occur in more than 1 family member.

School phobia, also called school refusal, may occur under 3 distinct conditions. Not uncommonly, young children who are entering school for the first time are frightened. This fear is a normal component of separation anxiety, which usually resolves within a few days of starting school. This is also referred to as adaptive anxiety. In contrast, older children may experience school phobia because they are truly afraid of a school situation. They may fear a teacher, violence, or a bully. To avoid the problem, children may actually request to change classrooms or schools. It is important to talk with children to find out what is behind their fear of school.

Some children who seem fearful of school, however, are actually concerned about parental separation (ie, separation anxiety). Frequently, these children enjoy school and miss it when they are absent. Absences occur when children’s feelings of separation from parents are so intense that they do not allow them to function well in school settings. Children are worried that something bad will happen to them or to their parents when they are apart. This separation anxiety disorder may result from parental illness or parents’ fostering dependency in children. Children then see parents as vulnerable and are uncomfortable about leaving them alone. To qualify as an anxiety disorder, the symptoms must last at least 4 weeks.

School phobia is the third leading cause of school absenteeism after transient illness and truancy. Fifty percent of children with school phobia have other problems, including depression (28%), tantrums (18%), sleep disturbances (17%), obsessive-compulsive behavior (11%), other fears (10%), enuresis (3%), and learning disabilities (3%). Overall, school phobia has a good prognosis, although adolescents do not do as well as younger children, and individuals with a higher IQ have a poorer outcome. Twenty percent of parents of children with school phobia have a diagnosable psychiatric disorder. Issues of parent-child dependency are often a concern.

Another type of childhood fear concerns physicians and hospitals. Children have many concerns about what happens to them at the doctor’s office. They are particularly fearful of needles. To children, needles represent possible mutilation. When asked to represent needles in drawings, children often portray needles as larger than themselves and very pointed. They comment that needles are sharp (eg, “Needles can make you pop, just like a balloon”; “Needles can also take out all your blood until you die”). In addition, children are preoccupied with what happens to their blood. One youngster commented, “They check out your blood to see if it’s good or bad, and if your blood is bad, then it means that you need to have more tests.” Another youngster thought that physicians were doing a “blood taste” rather than a blood test.

Hospitalization raises other issues concerning parental separation as well as painful procedures. As children adjust to hospitalization, they progress through 3 stages: protest, during which they complain about the hospital and cry; despair, during which they have given up hope that their parents will return; and detachment, during which they seem to be adjusting but actually have distanced themselves from their parents. Unrestricted visitation by family members and involvement of child life specialists mitigates much of the distress.

Evaluation

Physicians should explore the area of childhood fears and phobias at routine health supervision visits, even if parents do not have specific concerns. Sometimes parents are embarrassed by children’s fears (eg, the fear of an older child to sleep without a night-light; the fear of dogs, which may preclude the child from visiting certain friends). Parents may not report children’s fears unless these fears seem to be unusually intense. Practitioners may ask children, “What is the scariest thing you can think of?” If children are having difficulty providing details, physicians may ask them to name things that other children fear or to complete the sentence, “I feel afraid when….” Alternatively, practitioners may suggest things that other children may fear: “Do the kids you know seem to be worried about kidnapping?”

Several instruments have been used to assess the level of anxiety in children. These include the Multidimensional Anxiety Scale for Children, 2nd Edition; Spence Children’s Anxiety Scale ; and Screen for Child Anxiety Related Disorders. The latter instrument is in the public domain and readily available. It includes statements for children (eg, “I get scared if I sleep away from the house”) that are then scored “Not True or Hardly Ever True” (0), “Somewhat True or Sometimes True” (1), and “Very True or Often True” (2). There is a separate page for parents that includes similar statements framed as, “My child gets…”, rephrasing the statement that their child rated. Scores are added up and the total score, plus the items that scored high, help distinguish the nature of the anxiety; a score of greater than 25 indicates an anxiety disorder, with subcategories including panic disorder or significant symptoms, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and significant school avoidance. Another instrument is a book called, What to Do When You Worry Too Much: A Kid’s Guide to Overcoming Anxiety. This book suggests a number of strategies (eg, setting up a worrying time, not worrying if it’s not the designated time) in addition to discussing the origin of different worries (eg, “How do worries get started?”).

History

The evaluation of children with specific fears demands a careful history that provides information about situations in which children are fearful (Box 53.2). Physicians should consider fears within a developmental context because many childhood fears are normal and experienced by all children. It is also important to look at changes in the family situation. Children sometimes develop what seem to be fears but in fact are behaviors designed to manipulate other family members. For instance, young children who sense marital discord may insist on sleeping with their parents as a way of ensuring that the parents are together rather than separate.

Physical Examination

A routine examination is warranted, but findings are usually normal. Such an evaluation, however, is particularly important if presenting complaints include symptoms such as abdominal pain, headache, or palpitations.

Laboratory Tests

As a rule, laboratory tests are not required unless the symptoms suggest an organic etiology, such as hyperthyroidism, as the cause of palpitations.

Management

Management of the fear or phobia is determined by the degree to which children are incapacitated. As a general rule, children should be empowered to conquer their fears. Children’s books that address the issues of certain fears can help achieve this empowerment; for example, The Berenstain Bears in the Dark discusses specific worries such as fear of lightning and thunder. These books often explain the basis of such natural phenomena in easy-to-understand terms. Books also normalize particular fears and show how 1 character is fearful. Parents can recreate some of the sounds that children fear. For example, children who are afraid of the noise the wind makes are shown a teakettle from which hot steam blows through the whistle, creating the same noise as the wind. For fears about nuclear war, empowering children to become active, such as joining a nuclear protest group, may be useful.

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