About anxiety and depression
What is anxiety and depression?
Anxiety is a normal emotion that is needed for survival, and is experienced by all people. Other words used to describe the emotion include fear, shyness, worry, nerves or stress. The extent or degree of anxiety felt in stressful situations differs from person to person, as do coping strategies used to deal with anxious feelings. When people experience anxiety to such an extent that it interferes with their daily functioning or life enjoyment, it may be a good idea to seek outside help.
Depression and sadness are also normal emotions at moderate levels and is experienced by most people when they lose something of importance to themselves. The extent of sadness and how long it lasts varies from situation to situation and from person to person. However, when depressed feelings last for a long time and interfere with your ability to do things, it is worth seeking help.
Around one in seven Australians suffer an emotional disorder like anxiety or depression at any point in time. Anxiety and depression are common emotional problems and affect people across their lifespan. Huge costs to the community come through increased use of medical services, disrupted social contacts, increased family disruption and reduced academic and career achievements. The work we do at the Centre for Emotional Health (CEH) is all about improving people’s quality of life.
Fortunately, there are several very effective treatments for anxiety and depressive disorders. These include psychological treatments, such as cognitive behavioural therapy (CBT) and medications, such as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). The psychological treatments we offer at the CEH are provided in groups or individually as appropriate, assisting people with life skills and coping tools for self-help.
Adult anxiety is the most common form of mental disorder. Work stress, relationship difficulties, having a child or thinking of future goals like retirement are everyday features that can be common causes of anxiety in adults. Common forms that anxiety can take include fears of social interactions and other people, fears of physical symptoms, fears of germs or sickness, repeated panic attacks, worry about everyday activities and problems, and worries about past events or future dangers.
Anxiety often includes physical symptoms such as sweating, a racing or pounding heart, blushing, trembling, nausea, chest pain or feeling dizzy. Anxiety generally occurs as a response to a feared situation and is made worse by negative or fearful thoughts. Common negative thoughts include “everyone thinks I’m stupid”, “I am incompetent”, “I am having a heart attack”, or “I will get sick or hurt”. Worries, fears, shyness and anxiety can affect all aspects of a person’s life including their social relationships, work, personal and family relationships, or their physical health.
Child and teen anxiety
Difficulties managing negative emotions like anxiety and depression are the most common mental health issues that affect children. Around 1 in 10 children have an emotional health disorder and this can cause children to perform below their best, have fewer friends, and miss out on activities that other children enjoy like sleepovers. Parents of children who struggle managing anxiety and depression often report that they must change the way the family works day to day so that their child does not get upset. In the long term, these children are more likely to have mental health problems throughout their life and they may difficulty making the transition to employment and independent living.
Child anxiety may takes several different forms including: worrying that something bad will happen and finding it difficult to be away from mum and dad (separation anxiety); being extremely shy, worrying about what others think of them and avoiding activities like parties, asking for help or speaking in front of the class (social anxiety); worrying a lot about everyday matters like
How do I know if my child’s anxiety is normal?
Most children have fears or worries of some form. To work out whether your child’s anxiety is normal, ask yourself the following question: Is my child’s anxiety stopping him/her from doing things he/she wants to be able to do or interfering with his/her friendships, schoolwork or family life? If the answer to this important question is “Yes a great deal!” then consider seeking professional help.
Other questions to ask are:
- Do most other children the same age also have the same fear or worry?
For example, it is normal for most children to experience separation fears when going to preschool or school for the first time. This fear is less normal at age 8 for example and may prompt you to seek help.
- How severe is my child’s reaction?
If a child is inconsolable or extremely distressed and hard to settle, this can start to interfere with the child’s and the family’s routine and is another reason to seek help.
Generalised Anxiety Disorder (GAD)
Generalised anxiety is a tendency to worry about many areas of life. Children with high levels of generalised anxiety are often described as “worriers” or “worrywarts”. They worry excessively about many areas such as schoolwork (getting things right, being on time), family relationships and family finances, friendships, health, safety (burglars) and new situations. These children are often overlooked because they can be very conscientious in the classroom and it is difficult to know that they are constantly worrying. Some of the signs of consistent worry are daydreaming, stomach aches, headaches, tiredness and inattention. They will often ask lots of question over and over in a new situation “What is going to happen?” or “What if….?” and they may spend a lot of time getting to sleep at night as they are worrying about the events of the next day. About 2-5% of children develop Generalised Anxiety Disorder (GAD) and this is usually considered when worries occur more days than not and the child finds it very difficult to stop worrying (Schniering, Hudson & Rapee, 2000). It is normal for children to have periods when they worry a lot but if the constant worrying persists for longer than 6 months then it is worth seeking help. Although some pre- school children may develop generalised anxiety, it does not typically emerge until a child reaches school age.
What can I do if my child has generalised anxiety?
Stepladders for generalised anxiety
Here is an example of a stepladder for an 8-year-old child who is fearful of being late. The child was least worried about being late to visit friends and most worried about being late to school. This child would also ask many repetitive questions to his parents about being late (like “What is the time? Are we going to be late? What will happen if I’m late?”) Thus the stepladder gradually reduces the number of reassurance seeking questions that the child is able to ask.
Each stepladder needs to be set up so that it matches the child’s level of worry/fear. The steps in the stepladder below may be too slow/easy or too fast/hard for some children. It will all depend on your child’s level of worry. It is often difficult to develop stepladders for general worries and it takes some good knowledge of your child’s worries and some creativity to help them to face the situation they are worried about (e.g., making a mistake)
Encourage and reward my child to
- Arrive only 5 minutes early to music class (Allowed to ask two questions about being late)
- Arrive on time to Andrew’s house (Allowed to ask two questions)
- Arrive 5 minutes late to visit Jo’s house (Allowed to ask two questions)
- Arrive at school five minutes before the bell goes (Allowed to ask one question)
- Be late to my music lesson by one minute. (Allowed to ask one question)
- Arrive at school one minute before the bell goes (Allowed to ask one question)
- Be 15 minutes late to visit Andrew’s house (Not allowed to ask any questions)
- Arrive at school as the bell goes (Not allowed to ask any questions)
- Arrive 5 minutes late to music (Not allowed to ask any questions).
- Arrive at school 10 minutes after the bell (Not allowed to ask any questions).
Coping skills for the stepladders
Toddlers (1-3 years): Repeat a phrase to the child “I can do it”
Younger children (3-6 years): Help the child to come up with a phrase he/she could say to themselves when they are in the situation such as “I can be brave” “I am safe” “I will be ok”
Older children (7+ years): You can help your child learn more quickly during the stepladders by helping them to think more realistically in the situation. Encourage your child to ask himself/herself: “Have I ever failed a test before?”, “How likely is that the bus will crash on the school excursion?”, or “What’s the worst thing that can happen if I forget my library books?”
Other helpful tips for worriers
Gradually reduce the number of reassurance seeking questions (e.g., “what is going to happen?”) your child is able to ask you. If you have already answered your child’s question, encourage the child to think about the situation, come up with the answers, and rely on their own judgment. It may help the child to write the answer down. Try to remain patient. You can reduce the number of reassurance seeking questions as part of a stepladder.
Some children use lucky charms, special clothes or a special object as a way of making a situation safe (e.g., “If I carry my phone in my pocket then I will be able to find out if something bad has happened to Mum” or “It will be okay as long as I can wear my blue pants”). This is okay in the initial steps of a stepladder but the child also needs to be able to face the situation without these comfort items to know that the situation is safe and that they can handle it on their own.
Sometimes if may be useful for the school to know about your child’s worries, particularly in advance of events such as school excursions, camps, or carnivals. This may help to prevent others in your child’s environment from either i) pushing your child too quickly to face situations or ii) encouraging the child’s avoidance (like giving them more time to get their schoolwork “just right”). On the other hand, it can sometimes be good practice not to tell the teachers. This way when the child faces the steps on his/her stepladder (like forgetting her
Providing constant reassurance to your worried child and allowing them to avoid the situations they worry about will exacerbate the problem. Gently encourage your child to face the situations he/she fears (using step ladders).
No matter how frustrated you feel, avoid criticising your child or making subtle negative remarks about his/her worry or reassurance seeking.
Separation Anxiety Disorder (SAD)
Separation anxiety reaches its peak between 14 and 18 months and typically decreases throughout early childhood. Stranger anxiety (
Problems with separation anxiety are more typical in younger children and less common in adolescents. Approximately 3-4% of children will develop separation anxiety disorder (SAD), (Schniering, Hudson & Rapee, 2000).
Separation anxiety disorder is diagnosed when:
- the anxiety interferes with the child’s life and subsequently the parent’s life
- the severity of the anxiety is inappropriate for the child’s developmental level and
- the symptoms have persisted for at least 4 weeks.
Children with separation anxiety fear that some harm or tragedy will occur to those they love leading to loss or long term separation. Separation fears are most commonly centred on the primary
What can I do if my child has separation anxiety?
A number of general steps to reduce your child’s anxiety are explained on the ‘Generalised Anxiety’ page. Here are some specific examples for dealing with separation anxiety.
Stepladders for separation anxiety
Here is an example of a stepladder for a 7-year-old girl who is fearful of leaving her mother, even for a short period. At the start of the stepladder, this child was unable to sleep alone and would sleep in the parent’s bed. Each stepladder needs to be set up so that it matches the child’s level of fear. The steps in the stepladder below may be too slow or too fast for some children. It will all depend on your child’s anxiety.
Encourage and reward my child to:
- Stay inside and play while Mum puts the washing on the line
- Stay in my bedroom and play for half an hour while Mum is in a different room
- Stay at home with Dad while Mum visits the next-door neighbour for 10 minutes
- Sleep on a mattress on the floor (next to Mum and Dad’s bed)
- Stay at home with Dad while Mum goes shopping for half an hour
- Stay at home with Dad while Mum goes out to lunch
- Sleep on the mattress on the floor but move it is closer to the door (away from Mum and Dad’s bed)
- Stay at home with my
auntywhile Mum and Dad go out for lunch.
- Stay at home with Dad while Mum goes out for the night.
- Stay at home with my
auntywhile Mum and Dad go out for the night.
- Sleep in my own bedroom.
- Stay at home with my
auntywhile Mum and Dad go out for the night and sleep in my own bedroom
Coping Skills for the stepladders
Toddlers (1-3 years): Repeat a phrase to the child “I will come back after lunch” “You will be ok”
Younger children (3-6 years): Help your child to come up with a phrase that they could say to themselves when they are in the situation such as “I can be brave” “Mummy will come back”
Older children (7+ years): You can help the child learn more quickly during the stepladders by helping them to think more realistically in the situation. Encourage your child to ask herself “What happened last time Mum went out for dinner?” “How likely is that Mum will be in a
Other helpful tips for separation:
- Tell your child when you are leaving and when you will be back. Some parents feel it will be easier to just sneak out the back when the child is settled. This will make it more difficult in the future when you are telling your child you might be leaving…
- Make the goodbye brief and don’t drag it out.
- When the child becomes distressed on separation briefly remind them of the plan you have developed (e.g., stepladder, coping skills, a reward for being brave) and when you will return.
- Settle your child in an enjoyable activity before leaving. For example, start playing blocks…
- If the setting is new (preschool, friend’s house, babysitter), spend time at the new place with your child before the separation occurs. The child needs to know this is a safe place/person. Your child will be less distressed if they are left in a familiar place with familiar people.
- Putting in the time initially to allow your child to feel safe, will save you time in the end.
- To increase your child’s feelings of safety, allow your child to take loved objects from home with them. These can be gradually phased out as the child becomes more confident.
- Keep a relaxed /happy expression on your face. If you show your child worried and distressed facial expressions, then they will think the place is not safe. It can be useful to tell your child’s crèche, preschool or kindergarten and inform them of your approach to your child’s separation fears. They can help you to achieve the steps on the stepladder.
- Avoiding separations from your child will exacerbate the problem. Gently encourage your child to separate and providing safe experiences of separations and reunions (using ‘stepladders’).
- No matter how frustrated you feel avoid criticising your child or making subtle negative remarks (like “he’s such a mummy’s boy”, “Don’t be such a baby”) about his/her difficulty separation.
Did you know?
90% of 10-month-old infants will become upset if a stranger approaches them in an unfamiliar room. Only 50% will become upset if the child is given time (10 minutes) to become familiar with the room (Sroufe et al., 1974).
Separation anxiety peaks in infants between 14 and 18 months and should slowly taper off.
Stranger anxiety is first common between 8 and 10 months of age continues through the first year but drops off in the second year.
Social Anxiety Disorder (SoAD)
Social anxiety is fear and worry in situations where the child has to interact with other people or be the focus of attention. Children who experience higher levels of social anxiety are more commonly described as shy, and the central problem is a fear that other people with think badly of them. They fear that they will do something or act in a way that will be embarrassing. The child may experience physical symptoms such as nausea, stomach aches, blushing, or trembling. Between 1 and 9% of children and adolescents will develop social anxiety disorder (SoAD) and this is diagnosed when the child’s social anxiety has persisted for more than 6 months and has a significant impact on the child’s life (Schniering, Hudson & Rapee, 2000). Children with social anxiety may avoid many situations that require interaction with other people, including meeting new people, talking on the telephone, joining teams or clubs, answering questions in class, or wearing the “wrong” clothes.
Social anxiety often goes unnoticed because the child is typically quiet and obedient in preschool/school and may not voice his or her fears. Of course, shyness in itself is not a problem (if everyone was an extrovert the world would be a much less interesting and enjoyable place), it is only problematic when it interferes with the child’s enjoyment in life. Many shy children develop satisfying and long-term friendships and have outstanding careers and achievements. However, if the shyness and social anxiety prevent the child from participating in everyday activities (such as classroom discussions), enjoyable events (such as parties) or from making lasting friendships then it is worth seeking help.
What can I do if my child has social anxiety?
A number of general steps to reduce your child’s anxiety are explained on the generalised anxiety in kids page. Here are some specific examples for dealing with social anxiety.
Stepladders for social anxiety
Here is an example of a stepladder for a
Encourage and reward my child to
- Say “hello” to one of your friends that she has met a few times.
- Say “hello” to a child she doesn’t know at the park
- Say “hello” to the person at the supermarket checkout.
- Say “hello” to an adult you have just met.
- Say “hello” to an unfamiliar child at preschool
- Say “Hello, Can I play with you?” to a child she doesn’t know at the park.
- Talk to a child she doesn’t know that well at preschool about what they did on the weekend.
- Visit a new group/class and say “Hello” and “Goodbye” to one of the children in the class
- Visit the new group/class and talk with one of the children in the class.
- Visit the new group/class and talk with two of the children in the class.
Coping skills for the stepladders:
Toddlers (1-3 years): Repeat a phrase to the child “I can do it”
Younger children (3-6 years): Help your child to come up with a phrase that they could say to themselves when they are in the situation such as “I can be brave”, “No-one will laugh”, “I will be ok.”
Older children (7+ years): You can help your child learn more quickly during the stepladders by helping them to think more realistically in the situation. Encourage your child to ask him/herself: “What happened last time when I asked a question in class?”, “How likely is that I will mess up my words?”, or “What did I think of my friend when he gave the wrong answer?”
Other helpful tips for social interactions:
- Prepare beforehand. Act out the steps at home before trying it in the real world.
- Do not force the child to talk or approach the situation in front of other people. For example, avoid saying in front of others “Come on. Say hello to Jane. Don’t be shy.” By doing the preparation beforehand, you can avoid having to increase the child’s embarrassment in the situation. A gentle, quiet reminder may be ok but don’t push it.
- If the child completes the step, acknowledge their achievement quietly if other people are close by and then make a big deal of it when you are with them alone.
- If the child is unable to complete the step, try again another day with more preparation (or perhaps try an easier step). Do not punish or scold your child for not completing the step.
- It can be useful to tell your child’s pre-school, kindergarten or school and inform them of your approach to your child’s social fears. They can help you to achieve the steps on the stepladder. This way other people in your child’s environment can give a consistent message. This will prevent others in your child’s environment from either i) pushing/forcing your child too quickly to face situations or ii) encouraging the child’s avoidance by not asking your child questions in class.
- Avoiding social situations will exacerbate the problem. Gently encourage your child to participate in social situations and start new activities.
- No matter how frustrated you feel, avoid criticising your child or making subtle negative remarks about his/her difficulty in social situations.
Did you know?
Embarrassment first develops at around 2-3 years of age!
Specific Phobias (SP)
Specific phobias (SP) are fears of particular things or situations. Some common specific phobias in childhood include the dark, storms, dogs, spiders, costumed characters, heights, blood and injections. When confronted with the situation, the child becomes extremely anxious and distressed. As with other anxiety problems, children with specific phobia will avoid the feared situation or be extremely distressed if they have to endure it. As with all the other anxiety problems, fears of specific objects or situations are very normal. It is only considered a disorder if it significantly interferes with the child’s daily activities, is not age-appropriate and persists for longer than 6 months.
About 2-9% of young people develop specific phobias (Schniering, Hudson & Rapee, 2000).
Post-Traumatic Stress Disorder (PTSD)
Post-traumatic Stress Disorder (PTSD) is a stress disorder which can develop in children and adolescents as a result of directly experiencing, witnessing or being confronted with a single-incident traumatic (stressful) life event, or a period of prolonged stress due to a traumatic experience.
‘Single-incident traumatic events’ may include experiencing or witnessing serious car or pedestrian accidents, serious falls, burns or other types of accidents, violent crimes (including assault), dog attacks, natural and man-made disasters (such as bushfires, house-fires, floods, chemical explosions, cyclones), undergoing emergency medical treatments, being diagnosed with a life-threatening medical condition (e.g., cancer), or being confronted with family members or close peers who have suffered from a life-threatening situation.
‘Potentially prolonged traumatic events’ include experiencing or witnessing repeatedly over weeks or months physical and/or sexual assault or abuse, or living or working in war affected regions.
Traumatic events which can cause PTSD involve a potential threat to one’s life, or a threat of injury to self or other people. Research has shown that up to 40% of children and adolescence have experienced at least one traumatic life event, whilst about 80% of individuals in their lifetime will have experienced at least one traumatic life event. However, not all children and adolescents who experience traumatic events will develop PTSD. However a proportion of young people may be at risk of developing PTSD.
PTSD symptoms in children and adolescents:
PTSD reactions in children and adolescents may include some of the following symptoms:
- Feelings of fear and anxiety. For example, a child involved in a bus accident may be scared travelling on transport, or being afraid of returning to the place the accident happened. Following a traumatic experience, fear and anxiety reactions in children may occur suddenly, (‘out of the blue’) and the child may not necessarily make the link between their fear and situations which give rise to their fear and anxiety symptoms, as trauma-related reminders (e.g., buses) may spread to include other distantly trauma-related experiences (e.g., travelling on other types of transportation including cars and trains).
- Upsetting images or thoughts about the experience. For example, having pictures of the event suddenly ‘pop’ into one’s mind which causes distress
- Feeling like the trauma is happening again; that is re-living the experience. Some images which pop into mind may be so vivid that they seem very real, as if the stressful event was happening all over again. This experience is called a ‘flashback’.
- Trying to avoid reminders of the event or may even ‘forget’ worst parts of the experience
- Avoidance reactions include avoidance of thinking, talking or being confronted with reminders of the experience
- Bad dreams (including nightmares) or trouble sleeping
- Bad dreams about the experience or in younger children they may be prone to having bad dreams in general (more regularly than usual since the traumatic event).
- Sleeping problems may also include trouble falling or staying asleep.
- Feeling irritable or easily angered
- Children may become more moody and even experience anger outbursts.
- May become jumpy at loud, sudden noises such as a car backfiring or skidding loudly, or a door slamming.
- Trouble concentrating
- Other physical symptoms
- Children may also report experiencing more physical symptoms such as head-aches and stomach-upsets following a traumatic event.
Other emotional responses following trauma
Children and adults may also experience other emotional reactions following a traumatic experience. The most common reactions include feeling low, sad or depressed; feelings of guilt (for e.g., surviving the experience whilst others may have been more seriously injured or even died), or self-blame (feeing somehow responsible or to blame for the trauma happening); feeling embarrassed or shame (at how they acted at the time of the trauma, and/or how they are coping with their trauma symptoms).
Persons recovering from a trauma may also experience grief reactions especially if they have experienced serious injury or witnessed other people dying. In addition, individuals recovering from trauma may also meet criteria for other anxiety and mood disorders including Major Depression.
Obsessive Compulsive Disorder (OCD)
Obsessions are thoughts that the child cannot get out of his/her head like “I am going to get very sick if I touch that dirty handle” or “Something terrible is going to happen if my books aren’t all in order”. Compulsions are behaviours or rituals that the child feels they HAVE to do over and over such as washing hands repeatedly in a particular pattern or organising toys in a very specific way. These obsessions and compulsions can also be a normal experience, but for some children it takes over their life.
Obsessive-compulsive disorder (OCD) is likely present when these obsessions and compulsions are repeated for long periods. Children with OCD will perform these rituals even if it gets them in trouble. Each compulsion is performed after an obsession to prevent a feared outcome from occurring (e.g., if I tap my fingers seven times then nothing bad will happen to Mum). After the compulsion, the child usually feels less anxious for a short time however, the anxiety peaks again the next time the obsessive thought comes into their mind. Other types of obsessions and compulsions include hoarding (not being able to throw anything away), thoughts about hurting someone (accidentally or intentionally), religious concerns or satanic images, horrific images, counting or tapping.
Between 0.2-1.2% of children and 3% of adolescents, develop OCD (Schniering, Hudson & Rapee, 2000). If obsessions or compulsions are interfering with daily activities then professional help is needed.
Panic Disorder (PD)
Children typically experience panic attacks as a sudden rush of fear that comes together with a number of physical feelings (like a racing heart, breathlessness, tightness in the throat or chest, sweating, light-headedness, and tingling). During a panic attack, the child may believe that he/she is dying or that something terrible is happening to them.
Panic disorder is a fear or worry about having panic attacks. Children with many types of anxiety may experience panic attacks or panic like symptoms in a feared situation (like before giving a speech for children or when going into a new situation, or when approaching a dog). This is different from panic disorder. For children with panic disorder, the fear is of the panic attack itself (“I might be dying”) rather than of the situation (e.g., people laughing, dog biting, getting lost).
Panic disorder is not common in young children and is more likely to be found in older adolescents/young adults. Rates of panic disorder in children and younger adolescents have been shown to be less than 1%. If a child begins to avoid many situations because of their panic attacks this is referred to as panic disorder with agoraphobia. If this occurs it is worthwhile seeking professional help.