By: Michael G. Conner, Psy.D,

Children who experience fear and anxiety will tell you how they feel, but only when they are not afraid of being embarrassed, humiliated or punished. Parents face special challenges because children with anxiety tend to be nervous, avoidant, annoying or exhausting. If you become frustrated and make these children feel bad, they stop being honest and start telling you that they are tired, sick, "fine" or just don't care.

Without real help, anxious and nervous children will try to avoid feeling bad. Many start to avoid situations where there is only a small chance they will end up feeling bad. Eventually they end up making choices based on feared situations and not realities. If this continues, many of these kids will try to make new friends who will help them feel better. But in most cases they just end up learning to avoid and escape the challenges of life through isolation, skipping school, joining "fringe" groups, thrill seeking, rejecting socially responsible behavior or using alcohol and other drugs.

In time, children begin to express anger instead of their fear. Anger feels better than fear and it is easier for children to blame others if they can’t escape feeling bad. On the other hand, blaming their self instead of others leads to depression. Children reinforce and give power to their fears when they act to avoid or escape unrealistic fears. In this way the anxiety grows. The child's confidence will suffer and they will fail to thrive at home and in school.

Approximately 1 out of 10 children suffer from an anxiety disorder. Most children experience anxiety purely on the basis of psychological, social and environmental influences. Twin studies of identical twins have shown that anxiety can occur with one twin but not the other. Anxiety disorders are not necessarily inherited although some people appear to inherit a risk or vulnerability for an anxiety disorder from their family. Brain imaging studies have produced minimal data to suggest there is a single defect or problem in the brain that causes or contributes to anxiety.

Once a fear or anxiety reaction has been created, the reaction tendency can be maintained number of ways. The most common are:

• Self-talk or "automatic" thoughts. What a person believes can cause an emotional reaction. Errors in thinking or catastrophic conclusions contribute a great deal to anxiety reactions (e.g. I can't handle new situations alone. All dogs want to bite me.)
• Escape and avoidance behavior. Taking actions to escape or avoid a fearful situation reinforces and give power to a fear (e.g. A child steps on a dogs tail and is bitten by the certain type of dog. The child is then afraid of dogs and avoids them. The fear grows as the child begins to avoid all dogs.)
• Inappropriate responses to a fearful child. The response of parents and significant others can create secondary trauma. Feelings of shame, guilt and inadequacy increase the risk of self-defeating thought as well as escape and avoidance behavior (e.g. A parent ridicules a child for feeling afraid instead of rewarding the child’s effort and courage.)

Parents should be concerned if their child requires medication for anxiety. The idea of a child using medications before a child’s brain is fully developed is a concern to many professionals. Benzodiazapenes are the largest class of these drugs and are referred to as sedative-hypnotics. These drugs are effective in reducing or eliminating symptoms, but they can be highly addictive. Very few physicians will prescribe these drugs to children because of the addiction risks. There are a number of non-addictive medications but children are generally unwilling to tolerate the side effects. Medication is usually the second choice after a comprehensive and competent trial of psychotherapy.

The challenge for parents is to find a competent mental health professional and to create a structured life experience for their child that supports treatment and recovery over an extended period of time. A structured and therapeutic life experience is more powerful than individual counseling and psychotherapy. A well run group therapy can be equally effective. Programs and activities that build confidence are generally superior to "talk therapy" and intellectual approaches. The time required to treat these disorders can range for months to years. Most should be resolved within 3 months. There are essentially four treatment approaches that underlie all therapy.

• Modeling. Children observe another person interacting effectively with the feared situation or object. Adaptive responding is demonstrated with guided instruction, encouragement, a perception of improvement and constructive feedback.

• Contingency Management. External events that follow the patient's fear/anxiety reactions are manipulated using rewards for successful interaction and bolder steps. Rewards are withheld for refusing to interact. Children are made to feel better while facing their fears.

• Self-Management. Subjective and physiological reactions are altered or changed by teaching the child adaptive ways to appraise an upcoming situation, adaptive ways of thinking and deep muscle relaxation techniques.

Psychotherapy requires significant commitment of time while treatment of anxiety with medication requires less effort. Psychotherapy is almost always the first treatment of choice except in cases where anxiety is so severe that immediate relief is necessary to restore functioning and to prevent immediate and severe consequences.

Psychotherapy, or the psychotherapist, can generally be considered ineffective if a trial of 3 months has not produced a measurable and noticeable improvement. A decision to change therapists or to start a medication may be necessary at this point. Several trials of psychotherapy or medications may be necessary to successfully treat anxiety disorders.