Most children experience various fears throughout their childhood, and some of these fears are specific to developmental stage. In contrast to fear, anxiety is defined as an anticipatory response to perceived threat, either internal or external. Both fear and anxiety are characterized by distressing “fight or flight” reactions and a plethora of other physiological responses that may affect multiple systems, such as cardiac, pulmonary, gastrointestinal, and neurological. Anxiety is further characterized by cognitive symptoms, such as feelings of losing control or losing one’s mind, unwelcome or intrusive thoughts, inattention, insomnia, and even perceptual disturbances, such as depersonalization or vague visual images. Children who are anxious tend to be frequent doctor
visitors, presenting with a variety of vague aches, pains, and physical symptoms that may frustrate health care providers. Separation anxiety disorder and selective mutism, two anxiety disorders that begin in childhood, have been discussed in Chapters 8 and 9. The present chapter will discuss the anxiety disorders of generalized anxiety, phobias, and obsessive-compulsive disorder.

Children with generalized anxiety disorder (GAD) worry excessively about upcoming events and occurrences. This worry has continued mostly unabated for at least 6 months. They worry unduly about their academic performance or sporting activities, about being on time, or even about natural disasters such as earthquakes. The worry persists even when the child is not being judged and has always performed well in the past. Because of their anxiety, children may be overly conforming, perfectionistic, and unsure of themselves. They tend to seek approval and need constant reassurance about their performance and social acceptability. The child may appear restless, tense, irritable, or fatigued. Somatic complaints are common.

Phobic disorders are heterogeneous, consisting of specific phobias, which involve a single feared object or situation, or social phobia, a more serious and impairing condition. Phobic disorders need to be differentiated from the normal episodes of fear often seen in childhood. The difference between having a phobic disorder or an age-appropriate episode of fearfulness is based on developmental considerations, the length and intensity of fearful affect, and the severity of accompanying impairment of everyday functioning.

Fear and avoidance occur in response to a specific object or situation in specific phobias. The anxiety is intense and immediate. Animals, natural disasters, blood or injury or enclosed places are common examples of fears that are common in specific phobias. However, when the feared object or situation is not present, the child functions normally.

Social phobia is more common in adults than in children, but it can be quite debilitating.

Children suffering from social phobia have a persistent fear of being embarrassed in social situations, during a performance, or if they have to speak in class or in public, get into a conversation with others, or eat, drink, or write in public. Feelings of anxiety in these situations produce physical reactions such as palpitations, tremors, sweating, diarrhea, blushing, and muscle tension. Social phobia can lead to school refusal with subsequent school failure and even truancy charges. Socially phobic youth frequently avoid all meaningful social relationships. These children do not have a primary social disability (as one might see with an autism spectrum disorder). However, severe avoidance of social situations may seriously impede normal social development.