Children are often fearful of dogs, spiders, injections and the dark, but phobias can be dismissed by adults as unimportant.
For children with serious fears, that can be risky. The story of Sophie Waller is an extreme case in point. The eight-year-old from Cornwall died in December 2005 after an operation to remove eight milk teeth which left her so upset that she refused to eat, drink or speak.
Sophie’s experience alone is tragic, but the lack of service provision makes it worse. Sophie’s parents tried to alert doctors at the local hospital but were instead referred to a child psychologist. Although the parents spoke to the community psychologist on the phone a couple of days before Sophie died, an appointment could only be arranged for the following week. For her part, the psychologist says she wasn’t given a full picture of Sophie’s condition on the phone.
Sophie Waller’s case was exceptional, bringing together a very severe phobia with poor communication about the extent of her problem. But conservative estimates suggest that anxiety and phobias of some form affect one in 30 children.
Isobel Summers, now 19, suffered from severe school phobia and emetophobia – the fear of vomit – from the age of nine. “I used to get a lot of panic attacks in certain situations at school – I was frightened of going into school assembly and of boarding coaches,” she says. “I was longing for someone to ask me what was going on, but I found everyone to be quite distant.”
A supportive GP eventually referred her to a therapist, but that didn’t happen until her phobias became so bad that she couldn’t attend school when studying for her GCSEs.
Even after finally being referred to the local child and adolescent mental health service (Camhs) it took a further nine months before she started a course of cognitive behavioural therapy (CBT), despite being fast-tracked for provision.Under-resourcing
The under-resourcing of Camhs is a long-standing problem, plus there is virtually no guidance relating to children with anxiety. The Department of Health says that most cases of anxiety are mild enough to be dealt with in schools and only severe cases would need to be dealt with by mental health services. How those are handled varies on a case-by-case basis.
In the absence of an existing treatment, Dr Sam Cartwright-Hatton of Manchester University has been developing a way to help anxious under-10s by training their parents to support their children. She says that CBT isn’t suitable for such young minds because it involves complex thinking and communication. Instead, she says: “We’re trying to get parents to give kids a calm and consistent parenting style. For even good parents life can be hectic, but anxious children need structure and clear ways to manage behaviour.
“We can then teach them how to develop confidence. Say a child is afraid of using the toilet by themselves – once the child has built up to doing it, we get the parents to give them a treat to encourage them.”
She describes the work as getting parents to become “mini-therapists”. A trial of 74 families shows impressive results. Over a period of 10 weeks, 37 families were given the extra parental training, while the other 37 used whatever local services were available to them. Two thirds of the children in families with extra training were free of their main anxiety by the end of the trial, whereas only 15% were when they used existing provision alone.
For older age groups CBT can be helpful but the approach needs adapting. Anxiety UK ran workshops on childhood anxieties for CBT practitioners in July last year. Nichola McSorley, a CBT therapist who was on the course, says: “I already had the tools to do this from working with adults, but this helped me to channel them to work with children. If we can address anxiety at an early age then they don’t come in later in life.”
The one-day training sessions help to support young people in a way that is “not exactly comic book, but more accessible,” says McSorley. “It’s hard for an adult to show their feelings, particularly for men, but it’s even harder for children who can’t differentiate between thoughts and feelings. You have to be so careful in general, but especially with children.”
Cartwright-Hatton is pushing for her form of therapy for under-10s to be made available on the NHS, but acknowledges that this will take time because waiting lists for services are long, and diagnoses of phobias are far from straightforward.
When such support isn’t available, Dr Cartwright-Hatton says it is important to consider whether there is something influencing a child’s difficult behaviour. “Misbehaviour is often caused because they are terrified of something. Sit and talk to kids and don’t assume you know what the problem is.”
When such anxiety or phobia is recognised, it can be treated, as shown by the progress that Summers has made. Despite her old fear she now has to encounter vomit on a daily basis in her job as an auxiliary nurse. But she says that adult support has to be provided for children now to deal with the fears.
“Some adults think that you will just get over it but it needs to be respected and for it to be to be taken seriously,” she says. “You need an adult who can offer a listening ear.”
Autism and anxiety
Autism can make it difficult for a person to understand and communicate with the world, which can exacerbate other phobias and anxiety. Jenny Ravenhill, the principal educational psychologist for the National Autistic Society, says that anxiety could be considered the “natural state” for those with autism.
Because it is so fundamental to the condition, there is far greater recognition of how to deal with it. Ravenhill says that normal CBT can’t be used because of the limited verbal skills of those with autism, but that it can be modified. “You can translate it into something that isn’t verbal,” she says. “If you’re asking them how scary something is on a scale of one to 10, instead of asking them with words, you can instead lay a tape out on the floor and get them to walk to where it’s most scary.”
Ravenhill says that children with autism benefit from structure and routine, at which point the object of their fear can be introduced slowly into what will be considered a safe environment. Where necessary, calming methods can be used to reduce a child’s fear to an acceptable level.
While there is more awareness about how anxiety and autism are linked, Ravenhill says that because the child’s fear can make them appear disruptive, adults need to be patient. “It’s about knowledge and awareness and not assuming that the child is being genuinely difficult. You need to understand that so that they can calm down.”
• Panic disorder/attacks: 19% of the UK’s total population suffer from panic
• Generalised anxiety disorder (GAD): 19%
• Acrophobia: 13%
• Social phobia: 13%
• Obsessive compulsive disorder (OCD): 12%
• Arachnophobia: 12%
Source: Anxiety UK