Childhood and adolescence are key risk phases for the development of anxiety symptoms that can range from transient and mild to a lasting anxiety disorder.

Anxiety is a basic emotion present from infancy in response to a threat. Usually it is not considered pathological as it is a healthy brain response that facilitates the avoidance of danger. But anxiety becomes maladaptive when its frequency and intensity cause problems such as avoidance behavior or significant distress.

So when anxiety becomes overly frequent, severe, and persistent, this can be called pathological anxiety. Recognising the difference between normal and pathological anxiety can be hard in children, who naturally show fears and anxieties as part of normal development.

If concerns are raised about a child or young person, the American Academy of Child and Adolescent Psychiatry (AACAP) recommends screening by a healthcare provider - either the child’s primary care provider or a mental health specialist. Diagnosis may then be made by a child psychiatrist or other mental health expert who carries out a mental health assessment which usually include a complete emotional and social history, interviews with the child and their caregivers, and possibly standardized testing.

Childhood anxiety is a public health concern due to its prevalence - which seems to be rising - and the impact it has on children, families, and communities. Anxiety can delay healthy development by interfering with children's ability to reach social, emotional, cognitive, and academic milestones.

However, mental health support is not always adequately provided to children, and a significant portion of children receive no mental health treatment even when diagnosed.

National surveys suggest that 13% to 20% of children in the US are diagnosed with a mental, emotional, or behavioral disorder each year, although most of these surveys have focused on adolescents aged 12 to 17 years.

Trends across time indicate that although the rate of some childhood mental disorders has remained relatively stable, depression among adolescents has increased. Among the population including younger children, aged three to 17 years, 7% have anxiety or behavioral/conduct problems, and 3% have depression. For each disorder, the rate becomes higher with older age.

Inevitably, the Covid-19 pandemic is impacting the mental health of young people, who have a raised susceptibility to long term consequences. Researchers from the Federal University of Minas Gerais in Brazil examined the impact, and found that children are responding to the stress of the pandemic differently depending on their development stage.

Dr Ana Simoes-e-Silvac and colleagues performed a meta-analysis of 51 research articles and found "high rates of anxiety, depression, and post-traumatic symptoms among children". They add that new supportive strategies have appeared during the pandemic, but so far there are no measures of their effectiveness.

"Some groups seem to be more vulnerable to the mental health burden of the Covid-19 pandemic," they write in The International Journal of Disaster Risk Reduction, "and the mitigation actions should prioritize them" in order to "spare children not only from the severe cases of Covid-19 but also to help them to deal with the mental health burden of the pandemic."

Researchers at the National University of Singapore have also looked at the impact of Covid-19 on young people. In Frontiers in Psychiatry, they write, "Children are a vulnerable group of the population who can experience anxiety which potentially can lead to long-lasting implications on their health for years to come.

"The current pandemic may lead to many children having heightened levels of anxiety. Fortunately, children are resilient. They can adjust and adapt to new situations quickly; this is especially so if they have secure attachments and a responsive relationship with a caregiver.

"It is prudent for healthcare professionals to have heightened vigilance for anxiety in children, especially in those with a known medical history of developmental disabilities and chronic medical illnesses. Parents should also be encouraged to seek professional help for themselves if they feel overwhelmed."

Regarding very young children, diagnosing anxiety and depression can be particularly complex. Diagnoses of mental health conditions in very young children are relatively rare but research has shown that medication is often given to preschool-aged children without accompanying psychosocial intervention.

The time a child starts school coincides with the average age for an anxiety diagnosis in children - between four and eight years old. But this is not the only time a child might develop anxiety symptoms.

Adolescence, a time of dramatic changes in body and behavior, is also a time of increasing incidence of anxiety and depression, as well as eating disorders, personality disorders and substance abuse.

Children and adolescents experience anxiety in their own individual ways but if anxiety symptoms last for a while and are not addressed, they might become an ongoing challenge.
Older children might feel they will not be understood, even if they tried to explain their feelings.

There are many types of anxiety disorder with their own symptoms, although each may overlap with another. They include generalized anxiety disorder, post-traumatic stress disorder, social anxiety disorder, specific phobias, obsessive-compulsive disorder, panic disorder, and separation anxiety.

A strong sense of connectedness to family and school have been found to reduce the chance of developing anxiety in adolescence. In a 2021 study, Dr Danielle Eugene at the University of Texas at Arlington, TX, and colleagues looked at the impact of connectedness to family, school, and neighborhood on depression and anxiety among 2,590 adolescents from disadvantaged backgrounds.

They found that adolescents who reported strong connections to their family and school were significantly less likely to show anxiety, however neighborhood connectedness did not reach statistical significance in this study.

The researchers believe their results have "important implications". They report, "In the US there is a strong national interest in social connectedness as a key determinant in promoting positive well-being in adolescents through building strong bonds and creating protective relationships that support adolescent mental health."

A later life event also coincides with the peak period for the onset of mental illnesses. This is the transition to university or to leaving home. "Emergent adulthood", (age 16 to 25 years) is a time of increased autonomy as well as accelerated brain development that can bring increased susceptibility to stressors.

University students are faced with several risk factors for anxiety and depression, such as financial responsibility, moving away from family and friends, and adapting to new academic expectations.

A recent study by Dr Anne Duffy of Queens University, Kingston, Ontario, Canada, examined this stage of life. The researchers surveyed 1,686 first-year students at the beginning and end of the academic year. This showed that "increased university connectedness" lowered the risk of depressive and anxiety symptoms, and increased the odds of recovery for students who showed depressive and anxiety symptoms at the start.

"University connectedness may mitigate the risk of persistent or emergent symptoms, whereas drug use appears to increase these risks," the authors write in the journal BMJ Open. They suggest offering flexible timetables, on-campus professional support, and opportunity for students to create new social networks.

"Although the transition to university may be a high-risk period for the emergence of internalising symptoms and disorders, it also provides opportunities for resiliency and prevention," they conclude.

Overall, the prevalence of anxiety in children and young people has increased in recent years. Alongside limited access to mental health treatments, this translates into a growing number of young people with untreated problems. Many experts are calling for renewed efforts to expand service capacity to best meet the mental healthcare needs of this age group.

References and Resources

1. Beesdo, K. et al. Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V. Psychiatric Clinics of North America, Volume 32, Issue 3, September 2009, doi: 10.1016/j.psc.2009.06.002
   https://doi.org/10.1016/j.psc.2009.06.002
2. Ghandour, R. M. et al. Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children. The Journal of Pediatrics, 12 October 2018 doi: 10.1016/j.jpeds.2018.09.021
   https://doi.org/10.1016/j.jpeds.2018.09.021
3. Marques de Miranda, D. et al. How is COVID-19 pandemic impacting mental health of children and adolescents? International Journal of Disaster and Risk Reduction, December 2020 doi: 10.1016/j.ijdrr.2020.101845
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481176/
4. Kang, Y. Q. et al. Managing Children's Anxiety During COVID-19 Pandemic: Strategies for Providers and Caregivers. Frontiers in Psychiatry, 12 November 2020 doi: 10.3389/fpsyt.2020.552823
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7688908/
5. Paus, T. et al. Why do many psychiatric disorders emerge during adolescence? Nature Reviews Neuroscience, 12 November 2008 doi: 10.1038/nrn2513 https://www.nature.com/articles/nrn2513
6. Adams, K. L. et al. Mental health trajectories in undergraduate students over the first year of university: a longitudinal cohort study. BMJ Open, 1 December 2021 doi: 10.1136/bmjopen-2020-047393
   https://bmjopen.bmj.com/content/11/12/e047393
7. Eugene, D. R. et al. Connectedness to Family, School, and Neighborhood and Adolescents’ Internalizing Symptoms. International Journal of Environmental Research and Public Health, 29 November 2021 doi: 10.3390/ijerph182312602
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8656744/

About the Author:

Jane Collingwood is a medical journalist with 17 years experience reporting on all areas of medical research for online and print publications. Jane has also worked on a range of medical studies funded by the UK National Health Service within the University of Bristol in the South West of England. Jane has an academic background in psychology and has authored books on stress management and respiratory infections. Currently she is combining journalism with a national coordinating role on the UK's largest surgical research trial.