Unfortunately, the presence of anxiety disorders is higher in children and adolescents who have clinical depression. Included in this group is separation anxiety disorder, panic disorder, phobias, obsessive-compulsive disorder, and generalized anxiety disorder. Although some of their symptoms may look alike, anxiety disorders have specific characteristics that are unique and different from depression.

How do you differentiate between normal anxiety and an anxiety disorder? Look for symptoms that are excessive or not appropriate for your child's age. For example, if your child is sucking her thumb at the age of nine, this is not something that a child her age would normally do.

Generally, look for the following symptoms: stuttering, clenched hands or jaws, nail biting, avoiding others, shaking, muscle tension, physical complaints such as headaches and tummy aches, and fears of loss. In addition to these symptoms, adolescents with depression run away more often than their peers. This act is seen as a way to avoid dealing with what is happening.

Seldom is there a teenager who has not felt misunderstood! An adolescent with anxiety is more emotionally reactive than usual. When any of these symptoms coexist with depression, the behaviors appear even more pronounced.

Separation Anxiety Disorder

In early childhood, anxiety disorders arise from stages of development that have normal anxiety issues, such as separation anxiety. Actually, this type of anxiety is normal to a point. During the toddler years, a child is learning about her world and beginning to navigate her journey independent of her caregiver. Anxiety and fear may be experienced as a child ventures out on her own. What makes her anxiety normal is that the feelings typically fade away as soon as she returns to her mother or another person with whom she has a very strong attachment.

The DSM-IV defines the separation anxiety disorder as:

Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

• Recurrent excessive distress when separation from home or major attachment figures or is anticipated

• Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures

• Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)

• Persistent reluctance or refusal to go to school or elsewhere because of fear of separation

• Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings

• Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

• Repeated nightmares involving the theme of separation

• Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

Additionally, the anxiety should be consistent for at least four weeks and be exhibited in a person under 18 years of age. However, separation anxiety is rarely diagnosed in children under the age of two. Anxiety is a necessary and critical part of this particular developmental stage when a child is forming his attachments. Distress during this time is both common and expected.

Panic Disorder

A racing heart, dizziness, sweating, feeling choked or smothered. If you have ever experienced these symptoms, you know what it feels like to have had a panic attack. Typically, a panic attack pops up without warning and can last from just a few minutes to several hours. When a child has more than one episode of panic, she is diagnosed with panic disorder. A child can have any of these symptoms, but she may also think she is dying.

A panic attack is traumatic to say the least, and the attack can lead to more problems, such as a huge fear of having more attacks or the avoidance of whatever the child thinks was the cause of her attack. For example, if a child has a panic attack at school, she may fear going back to school for fear she'll have another attack. She may avoid the classroom in which she had the attack because she thinks something about that particular room somehow caused the attack.

In the extreme, if she has depressive symptoms along with her anxiety, she might generalize from her school experience that other places may also cause a panic attack to occur. In extreme cases, some kids become fearful to leave home.

The symptoms of a panic attack, according to the DSM-IV, include:

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

• Palpitations, pounding heart, or accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath or smothering

• Feeling of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady, lightheaded, or faint

• Derealization (feelings of unreality) or depersonalization (being detached from oneself)

• Fear of losing control or going crazy

• Fear of dying

• Paresthesias (numbness or tingling sensations)

• Chills or hot flashes

Phobias

A phobia is an intense fear of things or places that provokes severe anxiety. A child doesn't even have to come in contact with something in order to develop a phobia. If a child has repeatedly heard her grandmother's stories of being afraid of heights, she can become extremely afraid of heights. She may avoid getting into elevators or anything else that will put her at risk of being high up and unable to get down.

Or perhaps a child had a chronic illness that necessitated many trips to the doctor along with shots or medicines. As a result, she may become extremely upset and scared at the mention of going to the doctor even for a routine appointment.

Social phobias result in a child avoiding circumstances where she might be judged or embarrassed. If she is forced to be involved with whatever is making her so anxious, she is likely to become even more anxious. At other times she might go ahead and persist, participating in an intensely stressful situation even though she is extremely uncomfortable.

Obsessive-Compulsive Disorder

This is a disorder involving either repetitive thoughts or behaviors, or both. The thoughts and acts are not just excessive worry. The DSM-IV defines obsessions as recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. The thoughts, impulses, or images are not simply excessive worries about real-life problems.

Compulsions are defined as:

These symptoms must be not only mentally stressful, but also are time consuming in that they take up more than one hour a day and cause significant impairment in day-to-day functioning.

Obsessive thoughts create extreme anxiety. Compulsive behaviors are often a way to address the obsessive thoughts and are believed to reduce the anxiety. Coupled with depressive symptoms, a child can be emotionally and physically paralyzed by the thoughts and acts associated with this disorder.

Generalized Anxiety Disorder

Has anyone ever described your child as a worrywart? Every child worries about something now and again. Generalized anxiety disorder means a child worries, excessively, about a wide range of things. Children do not necessarily understand that their concerns are irrational. Teenagers can differentiate reality from fantasy but cannot control the worrying.

Generalized anxiety disorder in children is called overanxious disorder of childhood and is defined by the DSM-IV as:

• Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities

• The person finds it difficult to control the worry

• The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past six months). Note: Only one item is required in children.

  1. Restlessness or feeling keyed up or on edge

  2. Being easily fatigued

  3. Difficulty concentrating or mind going blank

  4. Irritability

  5. Muscle tension

  6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

When anxiety and depression coexist, a child is on a never-ending cycle filled with discomfort, distress, and worry. The seeming lack of control makes children feel hopeless and scared. It doesn't matter which disorder is treated first, but getting at least some of the anxiety under control will help a child be able to more objectively address her depression.