Supporting parents of 4-8-year-old children with mild to moderate anxiety

What is this resource about?

This practice guide provides information about anxiety in childhood years that span from home/childcare to the first years of primary school. It aims to help generalist services support parents to address mild to moderate anxiety for children in this age group (approximately 4-8 years). Anxiety in children aged 9-12 years is addressed in a separate guide: Supporting parents when pre-teen children are experiencing mild-moderate anxiety

The resource covers:

• What is anxiety?
• What is happening for children aged 4-8 years?
• What are the signs of anxiety?
• What does anxiety involve?
• What keeps anxiety going?
• How can practitioners support a parent caring for a child with anxiety?
• When and how can practitioners make effective referrals to a mental health service?
• How can parents support their child experiencing anxiety?

There are also three accompanying parent guides:

• Parent Guide 1: What is anxiety?
• Parent Guide 2: Gathering information about your child’s experience of anxiety
• Parent Guide 3: Supporting your child

Who is this resource for?

This resource is for practitioners working with the parents of children aged 4-8 years who may be experiencing mild to moderate levels of anxiety. Practitioners may work in adult-focused agencies such as family support, health, drug and alcohol services, or other relevant services such as general practice and paediatrics. These services can play an important role in promoting children’s wellbeing and health by supporting parents in their parenting.

While the guide is focused on ages of 4-8 years, this information may also be relevant to children who are experiencing changes earlier or later than their peers.

There are three parent guides which accompany this resource. These guides are specifically related to strategies that can be implemented by parents to identify and support mild to moderate anxiety.

When to refer to specialist services?

Anxiety occurs across a long continuum, from occasional ‘butterflies’, to feelings of panic which can be recurring and disabling. Even though most children who experience mild or occasional anxiety will not need to see a mental health professional, there may be circumstances that mean a referral to a specialist service is important. Learning more about the child’s experience of anxiety helps practitioners and parents to decide when support from a mental health professional may be required.

If the parent shares with you any of the below, refer the family to their GP, their paediatrician or a mental health professional for specialised support:

• The child’s level of anxiety is significantly impacting on learning, wellbeing, relationships, and family life
• The child experiences ongoing physical discomfort or pain, and medical/physical explanations have been ruled out.
• The child is delayed in other areas of their development, such as social, motor or language skills.
• The child will not talk to anyone outside their family home.
• The child has been diagnosed with a chronic health condition, disability or mental health condition e.g. attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), down syndrome, intellectual disability, autism spectrum disorder.
• The parent’s mental health and wellbeing is deteriorating based on the child’s feelings or behaviour.

Anxiety is our body’s normal response to a perceived threat. There are times when feeling anxious can be useful and helpful. For example, someone worried about being late for a job interview may set their alarm to get out of bed earlier than usual, choose the clothes they are going to wear to the interview the day before and allow extra time to travel to the interview. This is a time when feeling a bit anxious gives us the focus and energy to plan ahead.

Feeling anxious can also protect us from danger. For example, when someone sees a snake, feeling anxious may mean that they move far away from the snake to protect themselves or stay very still until the snake moves on. This is called the flight, fight and freeze response, and our bodies activate this response when we are in danger. While this response is important for our survival when we are in danger, for some people this response is activated when they are not in immediate threat, impacting on their wellbeing.

Experiencing anxiety every now and again is a normal part of the human experience. Most of the time these feelings come and go, and do not last long. Anxiety becomes a problem when the feelings persist, impacting on our wellbeing and preventing us from doing things that are important to us.

Children also experience anxiety. Occasionally feeling anxious is a normal part of growing up and learning about the world. As children develop, it’s common for them to feel anxious about a variety of situations, objects and people. Pre-school aged children may be anxious about changes in their routine, separating from their parents and spending time with unfamiliar people. In the early school years, children may feel anxious about the dark, monsters and ghosts.

When children have worries that don’t go away, get worse or interfere with their daily life, it could be a sign they are having problems with anxiety. If these problems persist and are not addressed, these children are more likely to experience anxiety issues during adolescence and later in life (Wehry et al., 2015).

The good news is there are techniques that professionals, parents and children can use that improve anxiety in young children. Some of these strategies are shared later in this resource.

Development

A significant amount of development occurs between the ages of 4-8 years, across many domains. Children of this age improve their skills and confidence gradually over time. This section describes developmental milestones that are typically seen for this age group, although it is worth noting that milestones may occur at different times for different children.

Younger children (4-5 years) will usually engage in fewer temper tantrums than in the toddler years, but may still be demanding at times. Their ability to express and control emotions increases, and in the later years of this age group (6-8 years) children will become better at games that involve winning, losing and playing fair.

Children in this age group can be keen to please the important adults in their lives, including teachers and parents. Younger children tend to enjoy imaginary play (which can include imaginary friends), as well as singing, dancing and role playing. Older children may be more aware of world events via the news or social media, which can lead to anxiety or fear. They are also sensitive to scary stories that older siblings or peers might share with them, such as ghost stories.

Cognitive skills also gradually increase across these ages. Younger children can typically understand opposites and count to 10, and they start to tell stories and use rhyming words. Older children have improved memories and ask lots of questions as they work to make sense of the world around them. They can more effectively explore their feelings and thoughts and can engage in longer conversations and voice their opinions, as well as increasingly wanting more say in what they can or can’t do. They can be easily distracted and forget requests, including doing chores, so patience is needed.

During this period of development, children are increasingly independent in completing daily tasks, such as using cutlery or scissors, toileting, and brushing teeth, although younger children may still need some help or supervision. Gross motor skills are increasing – younger children are learning to skip and jump while running, whereas older children can manage more complex movements such as doing cartwheels or jumping down steps.

Home/childcare to primary school transition

One of the most significant events in these childhood years is the transition from home or early childhood education to primary school. School readiness depends not just on the child, but on the environments that surround them. As children move from home to structured learning environments, their connections to families and social networks are particularly important in terms of learning and development (Sayers, West, Lorains, Laidlaw & Robinson, 2012). Data from the Australian Early Development Index (Department of Education, 2019) indicates, however, that in 2018 just over one in five children in their first full year of school have developmental vulnerabilities in one or more domains.¹

The school transition can bring many opportunities for learning and friendship that build during school years. These friendships will gradually involve practicing skills such as sharing and negotiating, but this may be challenging and overwhelming for children at times. Bullying behaviours, both as perpetrator and/or victim, may begin in the school years, so it is important for parents to be aware of any signs. These may include physical or emotional signs, such as cuts or scratches, missing property or being teary or withdrawn, or problems with school such as school refusal, staying close to teachers or sitting alone. See https://raisingchildren.net.au/school-age/behaviour/bullying/bullying-signs for more information.

How common are anxiety disorders in children aged 4-8 years?

It is difficult to know the prevalence of anxiety disorders in childhood, especially for this age group (4-8-year-olds). The best quality national data comes from the 2015 Young Minds Matter survey on the national prevalence of mental health difficulties in children (Lawrence, Johnson, Hafekost, Boterhoven De Haan, Sawyer, Ainley & Zubrick, 2015). The results showed that in children aged 4-11 years old, 7.6% of boys and 6.1% of girls had experienced an anxiety disorder in the previous 12 months. For 4-17-year-olds, anxiety was more prevalent for children in families with lower incomes and where family functioning was rated as ‘poor’. Over half (58%) of 4-11-year-olds with an anxiety disorder missed at least one day of school in the previous 12 months due to anxiety symptoms.

Anxiety diagnoses have increased in recent times, with one study indicating that diagnoses in children and adolescents (mean age of 10-11 years old) made by paediatricians nearly doubled between 2008-2013. Possible reasons are a rise in anxiety, but also greater awareness and willingness to seek help (Danchin, Gulenc, Efron, Sciberras, Symeonides & Hiscock, 2019).

^{1 The five domains measured are: physical health and wellbeing; social competence; emotional maturity; language and cognitive skills; communications skills and general knowledge.}

Reasons for anxiety in children aged 4-8 years

There are many reasons why children experience anxiety. Common ones include:

• Past experiences. For example, a child who has been bitten by a dog becomes anxious around dogs as a result.
• Genetics. Anxiety runs in families, and some children are born with an anxious temperament. It is worth noting that even if genetics is a contribution to anxiety, there are strategies that can help.
• Learning. Some children learn to be worried or afraid due to the comments or behaviours of their parents, siblings or others close to them. This can happen in two ways:
  • From the way others, particularly parents, act on an everyday basis (e.g. they get anxious when a dog approaches).
  • From what others say to the child (e.g. “Be careful of the dog, it might bite you. Don’t’ go near the dog. Stay near me.”)
  • Children of this age may also be worried about issues/topics they hear on the television and radio.

Common anxieties for children aged 4–8 years

It’s not unusual for children to occasionally worry throughout their development. When these worries are persistent or at a high level, children might be experiencing anxiety. The next section, ‘What are signs of anxiety?’ outlines some of these signs.

Young children may experience the following different types of anxiety. It can be helpful to know the type of anxiety children experience when making decisions about the kind of support they might need. The common types of anxiety include:

Separation anxiety

It’s common for young children to want to be close to their family. Some children though, become anxious when separated from their home, parents and immediate family. They worry that they will be permanently separated from their family due to something negative happening to them or their family, such as a car accident or sudden illness.

Social anxiety

Children who are outgoing and chatty around immediate family but who become shy or withdrawn, avoid attention and fear being judged by others, might struggle with social anxiety. Some children with social anxiety may be worried that others will not like them or will judge them negatively. They might compare themselves to others. Parents may describe these children as ‘slow to warm up’. This can impact on the child’s ability to make friends, participate in school activities, and ask adults (e.g. teachers) for help when they need it. With support these children can learn the skills needed to interact with others.

Specific fears

Some children might be worry-free most of the time but have a high level of fear about specific situations or objects. This fear may be a result of their own negative experience or of hearing about others having a bad experience. For example, a child seeing a dog jump on another child at the park might be worried that a dog is going to jump up on them. To avoid this, the child may ask to be picked up when dogs get close or hide behind their parents.

Common fears include:

• the dark
• dogs
• the dentist
• thunderstorms
• spiders.

General anxiety

Rather than a specific worry, some children have persistent worries about lots of different situations, events, places, objects and people. If these worries are having an impact, it could be a sign that they have general anxiety. These children may seek lots of support in trying new things, during uncertainty and changes to normal routine, such as having a relief teacher or transitioning to school.

For more information on the different types of anxiety children experience see https://healthyfamilies.beyondblue.org.au/age-6-12/mental-health-conditions-in-children/anxiety

When we experience anxiety, our body, feelings, actions and thoughts are affected. Children experience anxiety in a range of ways and at first it can be hard for adults to recognise. Sometimes children’s experience of anxiety will be interpreted as ‘naughty’ or ‘defiant’ behaviour. When adults are curious about their child’s emotional world, they seek to understand the purpose of their child’s behaviour. Behaviour that appears to be ‘defiant’ might be a child’s attempt to escape/avoid an anxiety provoking situation. Learning about how a child experiences anxiety will give parents clues on how they can support their child as well as when additional help may be needed. The boxes below provide some examples of how young children may experience and show anxiety.

How we think about an event, situation, person or object, significantly influences our emotional experience and how we act. The image below illustrates how our thoughts, physical sensations and actions are linked to the experience of anxiety.

Example 1: Components of anxiety

Example 2: Attending kindergarten

Example 3:  Time away from parents

The way adults respond to children experiencing anxiety makes a difference. There are two core reasons anxiety in children is maintained:

1. Reassurance by others

When young children are anxious, they will usually go to trusted adults or older siblings for reassurance that everything will be OK, to help calm their emotions, and to avoid the anxious situation. During these times, parents often give the child lots of hugs and special attention. While validating the child’s worry is important (e.g. “You’re scared about going to the party, because there might be dogs there”), too much reassurance can be unhelpful. You can read more about reassurance in ‘Parent Guide 3: Supporting your child’.

2. Avoidance of anxious situations

It is important that children are gently encouraged to gradually face their worries, so they learn they can cope with these feelings and that their worries might not be as bad as they expected. If children do not get the opportunity to practice this skill of facing their worries, they are more likely to continue to experience anxiety later in childhood and adolescence.

Parents and other adults play a very important role in supporting children to gradually face their worries.

It is important to gather information about the child’s experience of anxiety before making any decisions about the type of support they need. This information will help the practitioner and the parent work through the decision tree in the next section. It’s important to ask questions about the:

• frequency
• intensity
• duration
• level of avoidance
• impact of anxiety on the child

Example questions practitioners can ask parents include:

• “Can you describe for me what happens when your child is feeling anxious? What sorts of things do they say or do?”
• “How often does your child get anxious?”
• “How long has your child experienced anxiety?”
• “If you were to rate the intensity of your child’s experience of anxiety on a scale of 0-10, with 0 being calm and relaxed with no anxiety, and 10 being terrified. How would you rate your child’s usual experience of anxiety?”
• “How long does it take for your child to feel calm again after they have felt anxious?”
• “Do you think your child’s worries or fears are stopping them from pursuing activities or interests that they enjoy, spending time with their friends, going to school, or doing things as a family?”

It is important for children to share their experience of anxiety. Some parents may benefit from guidance about how to have these conversations with their child. You could say something like:

“Sounds like we need to get a better understanding of what’s happening for Ellen when she’s feeling anxious. I’ve got a handout here which outlines some tips about how you, or you and I together could get a better understanding from Ellen. Would you be interested in us working through this together?”

Download a copy of the guide

What do you do now?

Once you and the parent have an understanding of the child’s experience of anxiety, use the decision tree as a guide for what to do next.

This decision tree covers:

• when this resource is helpful for practitioners to gain an understanding of what is happening for children and anxiety, but no action is required at that moment
• when this resource is helpful for practitioners in supporting a child with mild to moderate anxiety
• when parents should seek a GP referral to a mental health professional.

It should be worked through in collaboration with the parent.

You do not need to be an expert in parenting or anxiety to help a parent whose young child is experiencing mild-moderate anxiety. By building a trusting, collaborative relationship and familiarising yourself with the information in this guide, you can make a positive impact. This section covers some ways that practitioners can:

• invite a parent to explore their child’s anxiety
• explore the impact of anxiety on the child and the family (see Parent Guide 2 for more information)
• support the parent to set a goal for what they would like for their child
• understand how parents have been supporting their child
• offer strategies for how a parent may be able to help their child (see Parent Guide 3 for more information)
• provide support to the parent when they are trying the strategies with their child.

What to do if parents are contributing to the child’s anxiety?

Anxiety tends to run in families. There is a strong genetic component to anxiety, and we can learn to be anxious from our own and other people’s experiences. Important family members (siblings, parents, close family and friends) are role models for children and can unintentionally teach children to be fearful of situations, people or objects.

Sometimes family members seek to protect and keep children safe by limiting the child’s exposure to age-appropriate experiences and risks (Creswell et. al., 2017). When children do not get the opportunity to learn the skills and build the confidence to handle age-appropriate risks and situations, they can learn that these situations are scary and should be avoided. Over time, this can contribute to children experiencing anxiety.

By working with parents to understand how anxiety works, they may gain greater insight into their own experience, as well as that of their child. Parents reducing their own anxiety response and demonstrating positive coping strategies are important factors in reducing their child’s own experience of anxiety.

There might be occasions to raise parental anxiety with the parent. Raising this topic with families can be challenging. When thinking of broaching this topic, consider the timing – is there enough time in the session? Is the parent in the right frame of mind for you to raise this topic, or are they feeling overwhelmed today? To maintain a collaborative relationship, choose your time carefully. The following is an example of how you might raise this issue:

“Parents are children’s most important teachers. Children learn so much by watching their parents. They learn important life skills, as well as how to approach life, other people and how to engage in the world around them. If children learn that the world is a safe place and bad things only happen sometimes, they are less likely to feel anxious than a child who learns that the world is dangerous”.

“Without even knowing it parents are giving their children these messages. I’m wondering what types of messages Henry is picking up about the world from you? Do any ideas pop to mind?”

“You mentioned that you feel really stressed at the park, often being really strict with Henry and telling him not to go on the slides in case he falls off. What are you worried might happen if he fell off? What impact might this message have on Henry?”

If parental anxiety is impacting on the child’s progress, you could practice how the parent will respond to their child during times of anxiety. For example, together you could practice what the parent could say that demonstrates the confidence they have in their child’s skills, rather than their worries of a potential threat. Instead of saying, “I don’t think you can do this by yourself, let me help so you don’t get hurt”, the parent could say, “You can give this a go by yourself. If you need my help, I’ll be right here”.

If the parent is experiencing a consistently high level of anxiety, a referral to a mental health professional is advised.

What to do if child anxiety is contributing to parent anxiety?

Children who experience anxiety can develop very convincing reasons why they should not do the things that they are anxious about. This can lead parents and other family members to also feel anxious about those situations and how their child might respond – creating a challenging parenting scenario for any parent. To avoid this challenging situation, the family may decide not to pursue these anxiety provoking situations. Over time, this increases parent and child anxiety as they do not learn how to cope in those situations.

It is important parents keep encouraging and supporting their child’s gradual efforts to do the activities they feel anxious about. See Parent guide 3 for more information on strategies.

If the parent is experiencing a consistently high level of anxiety themselves, a referral to a mental health professional is advised.

Some children and parents may need support from a mental health professional due to their unique circumstances and the nature and level of anxiety. In these situations, your role is to support the family to engage with another service. The decision tree you saw earlier steps through some scenarios of when it’s important to refer to a specialist mental health provider. Here are some additional tips:

1. Inform the family early that you can provide some information and suggestions about anxiety, but that if their child is experiencing high or distressing levels of anxiety, it’s recommended they seek advice from a mental health professional.
2. If you feel that the family’s needs are outside of your professional expertise or it’s not possible to have regular supervision, refer the family to another service.
3. Provide options to the family so they can decide the course of action that best suits them. Research services available in the family’s local area. Some options include:
   • Refer to a counsellor or psychologist via the school or early childhood services if the issue is impacting on learning or making friends. If there is no service available through the school, see referral option (b).
   • Refer to a psychologist via a GP or community health provider if the issue is impacting life outside the education setting.
   • Refer to a paediatrician via a GP if a thorough assessment of a child’s development, learning and emotional health is required.
4. When sharing information or options with parents, ensure it is evidenced based. Helpful and reliable websites include the Brave program from Beyondblue and the Raising Children Network. You can find a full list of suggested resources at the end of this guide.
5. Family circumstances can change quickly. As you build a trusting relationship with a parent or child, they may share more information with you. If you have a reasonable belief that the parent or child are at risk of harm, seek guidance from a supervisor and follow your agency’s policies regarding mandatory notification to child protection, the police, child mental health services or adult mental health services.

References

Cohen, L. (2013). The opposite of worry: the playful parenting approach to childhood anxieties and fears.

Creswell, C., Parkinson, M., Thirlwall, K. & Willetts, L. (2017). Parent-led CBT for child anxiety: Helping parents help their kids. New York, NY: Guildford Publications.

Creswell, C. & Willetts, L. (2019). Helping your child with fears and worries: A self-help guide for parents. London, England: Robinson.

Danchin, M., Gulenc, A., Efron, D., Sciberras, E., Symeonides, C. & Hiscock, H. (2019). Trends in prevalence and management of childhood anxiety by Australian paediatricians. Academic Pediatrics, 19(1), 35-43.

Department of Education. (2019). Australian Early Development Census National Report 2018. Retrieved from: https://www.aedc.gov.au/resources/detail/2018-aedc-national-report

Lawrence, D., Johnson, S., Hafekost, J., Boterhoven De Haan, K., Sawyer, M., Ainley, J., & Zubrick, S. (2015). The Mental Health of Children and Adolescents: Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Canberra, ACT: Department of Health.

Rapee, R., Wignall, A., Spence, S., Cobham, V., & Lyneham, H. (2008). Helping your anxious child: A step-by-step guide for parents (2^nd edition). Oakland, CA: New Harbinger Publications, Inc.

Sayers, M., West, S., Lorains, J., Laidlaw, B., & Robinson, R. (2012). Starting school. Family Matters, 90, 45-56.

Wilson, R. & Lyon, L. (2013). Anxious kids, anxious parents: 7 ways to stop the worry cycle and raise courageous and independent children. Deerfield Beach. FL: Health Communications, Inc.

Wehry, A., Beesdo-Baum, K., Hennelly, M., Connolly, S. & Strawn, J. (2015). Assessment and treatment of anxiety disorders in children and adolescents. Current Psychiatry Reports 17 (7). Retrieved from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480225/