By Professor Kevin Gournay
Used Dec. 94 and Oct 99 and March 2011
Like adults, children have a whole range of fears and, for the most part, these fears are normal. Fears often start for no apparent reason and subside again just as quickly. As any parent knows, some childhood fears can be intense and illogical and while most children go through phases of fear of the dark, small animals, strangers and other normal reactions, many children often become fixated on particular objects such as vacuum cleaners or other household appliances. Fear behaviour is seen in toddlers right through to school aged children and again, most parents will be able to tell you of fears which have come and gone during various stages of development – sometimes the same fear raises its head on several occasions, but often there is a shift in focus. Even severe fears and phobic behaviour in children can disappear and it would be true to say that there are certainly many people who have had severe phobias in childhood who have grown up to become virtually fearless.
Toddlers between about 18 months to 5 years are often afraid of animals and, after the age of 4 or 5, children often become preoccupied by darkness and imaginary monsters. Similarly, the imagination begins to go into overdrive from early school age – by about the age of 8 or 9 there is often a concern about bodily injury and sometimes children become quite preoccupied about death. Separation fears are, of course, common in most children, either at the beginning of their nursery school education or later when they attend ordinary school. Sometimes these fears re-emerge when changing schools at a later age. Social fears often begin after the age of 8 but these fears are often accentuated in children entering puberty. As with other fears, most of these will decline. In childhood there are few “fear” differences between girls and boys however, in some cultures girls have more apparent fears than boys.
What should one do about fears and phobias in children? The short answer is that for most children not much is the right answer. As I have said above, most fears will tend to disappear. However, it is probably wise to say that giving fear behaviour a lot of attention may well make it worse rather than better and meaningless reassurance is certainly unhelpful. It is much better to try to encourage a child to face its fear and protecting the child from, say, the noise of the vacuum cleaner by not using it in the child’s presence is certainly unhelpful. As with adult fears, the time to act is when the problem consistently begins to upset and/or interfere with normal activity and/or if there is a persistence of the fear beyond a reasonable period of time.
At this point it is worth noting that obsessive/compulsive disorder is relatively rare in childhood – although most children will go through some superstitious phases, like the fears and phobias described above, most of these childhood habits will disappear.
Unfortunately, professional treatment for childrens’ fears and phobias is not widely available and, in my view, much of what is offered is inappropriate. There is an undue emphasis on psychoanalytically based treatments which often put a child through considerable distress: sometimes families are dragged along in the process and the outcomes are debatable. There are some cases where behavioural treatments of children are not the treatments of choice – for example children who have experienced sexual abuse or other traumas. Such children often need patient approaches. It should be empathised that these need not necessarily be linked to a psychoanalytical approach.
Most children who have intense fears or phobias will respond to simple strategies based on the principles of education and relaxation. Relatively small children can understand the mechanisms of anxiety, providing that these are put in the right way, and one should never underestimate children’’ ability to see things which you may consider as an adult complex. The fight or flight reaction can be explained easily. The behaviour of a cat when under threat is very often a good example. Children can be taught the principles of muscle relaxation and there are a whole range of relaxation audiocassettes available for use with children.
The role of modelling behaviour is very important and there is some evidence that children brought up with fearful adults, copy the fear and avoidance behaviour. However, even if the parents are themselves phobic, they can encourage their children not to avoid and there is no reason why phobic parents cannot train their children in a very positive fashion. The old principle of reward for appropriate behaviour is worth bearing in mind. Very often, children will be greatly encouraged by the use of the ‘star’ chart, the ‘stars’ possibly being exchanged for some treat, or even an increase in pocket money!
It is worth mentioning the most severe phobias and most common is school phobia. School phobia and truancy are sometimes difficult to distinguish but parents should first of all rule out obvious causes such as difficult relationships with a teacher or, bullying. Once the causes have been ruled out, it is worth attempting to devise a programme whereby the teacher and parents are involved and the child gradually faces classroom situations. The parent needs to ensure that while they are encouraging and reinforcing, they themselves do not get over anxious and transfer this to the child. When school phobia persists for more than a few weeks, the child’s GP should be involved and referral to an appropriate specialist should be sought.
Unfortunately, children can often suffer Post Traumatic Stress Disorder and this can be related to a range of traumatic events including, child sex abuse and road traffic accidents; a large number of children in Northern Ireland have witnessed the dreadful acts of violence and terrorism of the past 25 years. Post traumatic stress in children is often difficult to treat and referral to a specialist service such as that based at the Maudsley Hospital in London should be considered. Often local services do not have the necessary expertise in this area.
In conclusion, the overall message is that most childrens’ fears and phobias are transient and there is little indication that for these children any specialist treatment is needed. However, when fears and phobias do become a problem, the same principles as apply to adults should be implemented. In the case of phobias there is always a need for gradual exposure, education and anxiety management training incorporating relaxation procedures are the mainstay of these approaches. Having said that, if, as a parent, you are worried about your child, it is always worth seeking advice and I am pleased to say that GPs are now increasingly becoming aware of this area.
**Recommended reading: Anxiety in Childhood and Adolescence, by Frank Carter and Peter Cheeseman.
Available from most good bookshops or libraries.
Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.