When normal fears become phobias

Healthy child - June 2005


Dr. Alyna Chien


Most of us have seen children get profoundly upset and even throw fits over what seem to be harmless objects and images or commonplace events. Sometimes these reactions border upon the severe.

There have even been cases of children showing up in the hospital emergency room with severe anxiety.

How can parents tell when their child has crossed the line between a normal level of anxiety and a true anxiety disorder?

It is normal for children to have concerns about the world around them. What children worry about and how much they worry depends on their age, temperament and personal experience. It also depends on what their parents worry about, their family’s experiences, their cultural heritage and the surrounding culture as a whole. The sources and severity of normal childhood anxiety fluctuate over time. In general, the sources of fear expand while the severity of those fears diminishes as the child grows into adulthood. 

One of the earliest manifestations of normal anxiety is the clinging and crying that occurs during infancy. This behavior usually begins between 6 and 10 months of age, peaks between 12 and 18 months of age and resolves by the time kids are 3 years old—as long as the family continues to provide stable and secure relationships for the child. The timing of this anxiety is thought to coincide with the infant’s ability to distinguish herself from her caregiver.

Separation anxiety disorder occurs when children demonstrate consistent reluctance to be without a particular caregiver for more than four weeks’ duration.

Preschoolers are better able to identify or state the source of their fears. They tend to worry about dark places and imaginary situations. It is important to provide them with simple explanations and a gentle exploration of scary ideas and places. These fears can become entrenched if parents help the child avoid the fearful stimulus entirely. Although very young children have a difficult time understanding that their fears are unrealistic, repeated reassurances are usually sufficient to help preschoolers cope.

Preschool is the earliest age at which children develop true phobias, where the same object or situation causes immediate crying, sweating or tantrums for at least six months.

School-age children often express or manifest a wider array of concerns and worries. These can center around school attendance, participation and work.

School refusal can be associated with an underlying separation anxiety disorder, where children avoid school because they do not wish to be separated from their caregivers—in part because they are worried about the caregiver’s well-being.

School refusal also can be associated with a social phobia, where kids try to avoid potentially humiliating situations such as participating in class or completing assignments. Increased stress at home, such as a divorce or major illness, can also contribute.

In both situations, children usually respond well to firm, calm insistence that they attend school and a small reward for each school day completed.

Adolescents can express anxiety about a greater variety of topics, including uncontrollable events such as natural disasters, war and ill relatives, in addition to concerns about school and friends.

Some fears are based in reality where real consequences are at stake—not doing well on an exam or having a car accident, for example—and their gravity should not be minimized. Instead, adolescents should be encouraged to think and act on ways of alleviating those fears—studying more or driving primarily during daylight hours in good conditions.

Teens who have unrealistic worries, worries that intrude upon other thoughts or sudden feelings of fear or foreboding unrelated to any particular trigger, may have an underlying anxiety disorder.

Worrying behaviors are evaluated based on a child’s development stage, their content and how much they interfere with a child’s life.

Once a true anxiety disorder has been identified, successful treatment almost always relies on a combination of parent training, school/daycare involvement and therapy.

Depending on the nature and severity of the anxiety disorder, using medication may be warranted—but always in conjunction with other therapies and with the effort to maintain routines at home.

Alyna Chien is the mother of two, a pediatrician and a Robert Wood Johnson Clinical Scholar at the University of Chicago’s Department of Pediatrics.

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