The rise in anxiety seen in children is a complex issue. The debate around the issue is well served by using terms accurately. This blog defines some of them.
Anxiety is the word we use to describe an emotional state. It is a feeling of worry or apprehension about something in the future with an uncertain outcome. All three criteria are important:
- The worry
- The uncertain outcome
- In the future
Similar but not synonymous words are:
- distress – anguish, suffering, torment
- fear – distress in response to real or perceived threat
- worry – to fret, brood or dwell on a potential or actual problem
- psychological stress – a feeling of strain or pressure
The commonest mislabeling seen in clinical practice is the use of the word anxiety to describe what is in fact distress or fear or worry.
An Anxiety Disorder is a medical condition. It is not simply a lot of anxiety (the emotion). In Anxiety Disorders, the emotion of anxiety must be sufficiently severe to impair day-to-day function, with distress that is either prolonged and/or intense. Further, the intensity or length of distress must be out of proportion to the threat. The level of distress must be corrected for developmental level (eg developmentally appropriate irrational fears are normal eg fear of the dark, separation anxiety). The classification is described in the Diagnostic and Statistical Manual of the American Psychiatry Association Edition V (DSM V).
Unfortunately, we use the word anxiety in two senses, and it causes confusion.
Anxiety is to Depression, as anxiety is to sadness.
Part of the confusion over terminology can be traced back to the American psychologist Raymond Cattell. In the 1960’s, Cattell proposed classifying anxiety as:
- State Anxiety – the experience of the state of anxiety in the present moment, in the here and now
- Trait Anxiety – the predisposition in personality and temperament to suffer from a heightened sense of anxiety the emotion, wherein
- the degree of distress is disproportionate to the trigger
- the threshold for its onset is lowered
In this, he was not describing pathological entities (ie Anxiety Disorders as per DSM V). However, Cattell’s classification can be traced through to our 21st C modes of speech. When we say someone has ‘Anxiety’, we usually mean Cattell’s concept of Trait Anxiety, and not the formal diagnosis of an Anxiety Disorder.
Bullying is harassment or intimidation (both physical or non-physical), which is:
- Maliciously intended to cause distress
- From a position of strength or superiority
- Successfully exploiting that position of strength or superiority, and
- Severe enough to be out of the ordinary and/or prolonged
Teasing is of two types:
- Intended to be good-natured taunting; humorous and performed with good will
- Notwithstanding it may be mis-interpreted by the sufferer
- Intended to be malicious; not humorous, and certainly not good-willed
- To ridicule, attempt to provoke, or to taunt
- Not exploiting, or not successfully exploiting a position of strength or superiority (ie the victim has successfully denied the bully any advantage of strength or superiority).
- Not out of the ordinary or prolonged
Teasing is often wrongly called bullying these days. That is not to diminish the seriousness of malicious teasing.
In coping with everyday difficulties, we demonstrate initiative, resilience, and perseverance (see Smooth Road Analogy). When we are overwhelmed by these difficulties, we surrender to the distress; we relinquish control over ourselves and/or the situation.
Individuals, both adults and children, have a ‘threshold’ of surrending. In children, the threshold is built with growth and development. This is one aspect of resilience (eg a refusal to submit to the bully’s assertion of strength or superiority).
In assessing anxiety in a child, the child’s threshold of surrendering is important. In anxiety, the level of distress must be corrected for developmental age. If the child’s coping mechanisms are immature, a lack of resilience may contaminate the presentation.
Getting the diagnosis (or more correctly the synthesis) right is crucial for effective therapy. Getting it wrong compounds the problems.