If we were living in an age of anxiety before the global Covid-19 pandemic, we’re surely emerging into an age of super anxiety now.
In an analysis of global data, researchers have estimated a 26 per cent higher incidence of anxiety disorders than would have been expected had the virus not hit. Young people and women are more likely to be affected than older people and men, according to the report in the UK medical journal, the Lancet.
"Youth have been impacted by the closures of schools and higher education facilities, and wider restrictions inhibiting young people from peer interactions," said the lead author, Dr Damian Santomauro of the University of Queensland, as reported by the Guardian.
Drawing on 48 studies published between January 1st, 2020, and January 29th, 2021, the international team estimated there were 374 million cases of anxiety disorders worldwide in 2020 – 72.6 million more than would have been expected. It also found a 28 per cent rise in depressive disorders.
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Ireland is no exception to this upward trend.
Pre-Covid-19, between one in four and one in five children/teenagers would have an anxiety disorder but not all of those to a severe degree, says consultant adolescent psychiatrist Dr Aileen Murtagh of St Patrick's Mental Health Services.
“Since the onset of the global pandemic, there’s no doubt about it, these referrals are exploding for a variety of factors,” she says. Young people are struggling to reintegrate after the cocooning, lockdowns and school closures.
A rise in “school phobia” has been reported and psychotherapist Stella O’Malley is one of many health professionals who is seeing more school refusal. Many families struggling with this have viewed it as “their own personal tragedy”, she suggests, not realising “it is a symptom of a really difficult societal event”.
Yet, anxiety is a perfectly normal human emotion. None of us lives without it, from our days of “separation anxiety” as an infant onwards, so when does it become an issue? Whether your child is at primary school, secondary school or a college student, you’ll want to know if their worrying is at a healthy level or verging on a “disorder”.
What is problematic anxiety in a child?
Anxiety becomes a problem when it affects a child's sense of who they are, their relationships and their engagement with school and other activities, summarises clinical psychologist Dr Malie Coyne in her book, Love in, Love Out: A Compassionate Approach to Parenting your Anxious Child. It's when "a child's worries – whether they're thoughts, feelings or physical sensations – are making them avoid situations, which in turn restricts their learning and enjoyment of life", she explains.
I struggle with anxiety myself and I can see it in my child, have I passed this on?
A genetic predisposition is believed to be one possible factor, along with learned behaviour within a family, as well as environmental triggers and experiences.
However, if you are inclined to anxiety yourself, it is possible you are overthinking your child’s anxiety. An anxious parent tends to presume a child’s small amount of anxiety is on a level with their own, says O’Malley, author of Fragile, a self-help book that looks at the rising tide of anxiety.
“They know how awful it can be; they presume their child’s anxiety is that level and sadly it can make it worse.” For this reason, she will always advise that the non-anxious parent takes over dealing with the child as much as possible, to see if that makes a difference.
As children’s anxiety is very sensitive to caregivers’ responses, an anxious parent may inadvertently play a role in maintaining a child’s anxiety, says Coyne.
What are the signs that it might be time to consult our GP?
If the feelings of anxiety are persistent and pervasive and impacting on the day-to-day life of a child, says GP Dr Brian Osborne, founding member of the Kingston Medical Centre in Galway and director of the Mental Health Programme with the Irish College of General Practitioners. Symptoms such as consistently poor sleep, poor concentration, headaches, irritability and avoiding certain situations would indicate they may need some extra support.
“Young children are sometimes unable to articulate their feelings so we are seeing children present with pains in their tummy, headaches or pains in their chest. They might have altered sleep, be tearful, acting out or have temper tantrums,” he explains.
They are missing out on social interactions and have become less physically active. “Older children and teenagers are presenting with lack of motivation, social withdrawal, poor sleep and we are seeing increased rates of anxiety and eating disorders,” he says.
It’s time to worry if standard tips and self-help strategies don’t seem to be working for your child, says O’Malley, who agrees that the GP is the best first port of call. Maybe you know as parents that you’re not really helping, either because you’re anxious yourself, as mentioned above, or you’re just finding it incredibly difficult to handle.
It takes “real bravery and courage” to seek help as a parent. While not advocating “rushing off” to professionals, many parents are inclined to cling on, trying to sort it themselves, she says, when six sessions of counselling would have nipped it in the bud.
Are there different kinds of anxiety disorders?
Yes, as outlined by the HSE in an online guide to young people’s mental health:
Generalised anxiety disorder – everyday situations at school or at home can cause uncontrollable worries.
Social anxiety – a fear of social situations.
Obsessive-compulsive disorder – unwanted impulses and/or the need to repeat things.
Post-traumatic stress disorder – this can develop after a major traumatic event.
Panic disorder – regular, sudden attacks of panic or fear.
Agoraphobia – the anxiety of being in certain places or situations.
Specific phobias – an overwhelming fear of an object, place, situation, feeling or animal, which can bring on a panic attack.
Hypochondria – fear that you have a serious but undiagnosed medical condition and, while this is more likely to develop in young adulthood, it can affect a child after they, or somebody close to them, has suffered an illness.
As a psychotherapist, O’Malley focuses “on the problems of living” and how to overcome those challenges, rather than fixating on a diagnosis. She believes a label can become a “shield to hide behind”.
What options would the GP have in managing the treatment of my child/teenager, or referring on?
More than 90 per cent of mental health care takes place in a general practice setting and remains accessible for patients and their families, says Dr Osborne. “GPs would engage with brief interventions on lifestyle and exercise. Alcohol and illicit drugs may be a factor in teenagers. They may benefit from talk therapy,” he says. However, not all parts of the health system, and in particular the mental health system, are as accessible as general practice, he says.
“Access to psychology in primary care is haphazard and has long waiting times. At present in Galway there is an 18-month wait for this service.
“Access for children and their families to CAMHS [Child and Adolescent Mental Health Services] can be problematic for children with moderate to severe mental health difficulties. A recent report showed that over 2,000 children are awaiting their first appointment.”
What about online supports?
There are more of these now, due to services having to adapt their operations under Covid-19 restrictions, and they can work well for adolescents and young adults. Jigsaw, one of the HSE-funded partners that delivers mental health services (see yourmentalhealth.ie), works with young people aged 12 to 25. It offers live group chats, facilitated by a clinician, and one-on-one chats with a clinician, as well as face-to-face sessions. There is a wide range of informative articles on the Jigsaw website for parents and guardians, as well as young people themselves.
The HSE also funds 50808, a free text service that provides support for people going through a mental health crisis. It would be no harm to make sure your teenager knows that they can text “HELLO” to 50808 to start a conversation, at any time of the day or night.
If anxiety is on a spectrum, what does it look like at the severe end?
Some of the young patients Dr Murtagh is seeing at the 14-bed Willow Grove Adolescent Unit of St Patrick's Mental Health Services in Dublin "have been in their bedroom for literally a year, or have been out of school for a couple of months. But that's the severe end of things and you don't want things to progress that far; you want people to get help before it escalates to that situation."
Anxiety and depression can co-occur in cases needing more intense support. “I would see quite a lot of young people who are suicidal but, what’s more common, is deliberate self-harm.
“They can’t cope with the emotions of anxiety so they engage in deliberate self-harm, not with suicidal intent,” she explains. “Sometimes feeling physical pain helps them manage their emotions, so work needs to be done to develop alternative, more adaptive coping strategies.”
Dabbling with substances to cope with anxiety may result in addiction problems. Or, what has definitely increased during the pandemic, she reports, is “eating disordered behaviour” among teenagers in response to anxiety. They couldn’t control when schools would reopen or when they’d see their friends, but they could keep a firm grip on exercise and food regimes.
“Sometimes they don’t have a full-blown eating disorder but they have eating disordered behaviour that affects physical health, weight and mood, as secondary to anxiety.” They could be restricting their diet, binge eating or comfort eating.
Dr Murtagh and her colleagues are seeing not only young people with pre-existing eating difficulties or anxiety that got worse during lockdown, but also those who have experienced the onset of eating disorders and anxiety disorders during the pandemic. “It probably was a trigger.”
How are more severe cases managed?
Even with severe anxiety, Dr Murtagh says that psychology and psychotherapy measures will be tried first before going down the route of medication. However, if a person is so overwhelmed by their anxiety that they can’t engage and benefit from psychotherapy, then medication is likely to be part of the treatment. It’s an impossible goal to be “free of anxiety”, she stresses, it’s a matter of being able to cope with it.
The rise in referral rates to Willow Grove for both anxiety and eating disorders is in line with a global pattern of increased service demand and longer waiting lists. Although one positive development out of Covid-19 is that it has created a homecare package, whereby adolescents are kept in for a minimum amount of time before being transferred home where they are under 24/7, multi-disciplinary care given remotely. Young people too anxious for inpatient admission can be managed entirely on a homecare package.
Family therapists support parents to model good coping behaviour. They also need to know it’s okay to expose children, in a graded, supported way, to face fearful situations.
Dr Murtagh recalls a boy she treated who talked about how his parents had been very understanding of his anxieties and he felt protected, as if encased in bubble wrap. “Then he said he got to secondary school and the bubble wrap burst,” she says. He couldn’t cope with the challenges as his parents had been so protective “out of, obviously, the best will in the world”, she acknowledges. “So it’s about teaching the parents how to support a child with anxiety.”
Can you suggest ways of doing that?
Be aware that you could unwittingly facilitate avoidance, which may provide short-term relief to anxiety but can entrench the problem. “If you have a child or teenager who is anxious about going to school and you say, ‘Okay, stay home today’, the problem is that could snowball,” Dr Murtagh warns. “And before you know it, you are in a complete school refusal scenario and the child hasn’t gone in say for two to three weeks.”
Rather, it’s about trying to problem solve and support the young person to reduce the anxiety but still face the situation. What steps could be taken to reduce their anxiety and enable them to cope?
Meeting a small child’s anxiety with compassion will build their resilience, advises Coyne, as it strengthens the pathways in their brains connecting help-seeking with soothing from loved ones. This will help them to self-soothe as they get older.
At what age is the onset of an anxiety disorder most likely?
A child with an anxious temperament is probably more predisposed to developing an anxiety disorder but, typically, the onset seems to be in adolescence or early adulthood. Some 75 per cent of all mental health difficulties develop before the age of 25.
Social Anxiety Ireland, a charity that specialises in supporting adults with a social anxiety disorder, is starting to work with under-18s. Research shows social anxiety, which affects approximately 13.7 per cent of Irish adults at any one time, tends to develop in adolescence, says Kevin O'Hanrahan. He and Kiera Cosgrove are two senior clinical psychologists leading a new programme of group therapy for those aged 16-19.
There are many reasons for the onset in teenage years, such as the transition to secondary school and stresses that come with being an adolescent. Yet research also shows people tend not to seek help for 10 to 12 years, so it makes sense to offer support earlier, to try to prevent entrenchment of the problem. Avoidance of social situations keeps the anxiety going and makes it worse over the years.
In adolescence there is, says Cosgrove, “a developmental drive to get out there and find their own tribe and when social anxiety gets in the way of that it can have a big impact on their development and sometimes their mood as well”.
This is why social anxiety and depression can become “terrible twins”.
What exactly is social anxiety?
“A key component is a fear of being evaluated by others in a social situation – often that is negative evaluation, like fear of embarrassment or humiliation, but positive evaluation can also be difficult for people,” says Cosgrove. “They just don’t want to be noticed or evaluated. That fear is persistent and it’s intense. It’s not a once-off thing and it’s excessive to what a situation might warrant.”
A second characteristic is avoiding social situations or enduring them with elevated anxiety. “It might not be all social situations – somebody, for example, might be able to do public speaking okay but find it difficult to meet in small groups.” It’s not a social skills deficit; people are able to negotiate the situation but “find it really anxiety evoking”.
Social anxiety should not be confused, either, with being an introvert, a person who wants to be on their own, says O’Hanrahan. “For those with social anxiety, they want to be with other people but it causes them intense anxiety.”
Does group therapy work for people with social anxiety?
“When you put people in a room and they find out that other people feel like this, it is really, really powerful,” says Hanrahan of the charity’s evidence-based approach. This free programme, aimed at neuro-typical youngsters, is to be run online initially over 14 weeks and will include a session for parents/guardians on how to support the young person. It is hoped to tailor a programme for adolescents with neuro diversity in due course.
