There are different types of responses to increased anxiety:

1. Emotional response
   This includes feeling anxious.
2. Cognitive response
   This includes negative cognitions.
3. Behavioural reaction
   This includes avoidance.
4. Physiological reaction
   This includes trembling, sweating and more.

Anxiety disorder includes an overactivation of the amygdala and other bodily, cognitive and behavioural reactions in the absence of danger.

The older children get, the higher the probability that they develop an anxiety disorder. The prevalence of anxiety disorders in the general population is 0.5% - 5%. The prevalence of anxiety symptoms (i.e. above-average anxiety symptoms) is 5% to 10% in children and young people. Girls typically have increased levels of anxiety disorders in adolescence compared to boys.

There are three types of children who do not go to school:

1. School refusal
   This refers to a refusal or a reluctance to go to school. These children mostly stay at home and have severe emotional disturbance (i.e. anxiety). There is no anti-social behaviour and the parents make efforts to get the children to school.
2. School withdrawal
   This refers to parent-motivated school absenteeism (e.g. children have to stay home from school to help in the household).
3. School truancy
   This refers to school absenteeism to do something other than school (e.g. hang out in the mall)

There are several signs to recognize anxiety in children and adolescents in clinical practice and school:

1. There will be unrealistic and excessive concern about past or future event and about their own performance.
2. There will be a constant need for confirmation.
3. There will be a lot of somatic complaints (e.g. stomach ache).
4. There will be restlessness and alertness.
5. There will be concentration problems.
6. There will be avoidance behaviour.
7. There will be a low(er) self-esteem.
8. There will be a lot of fatigue.
9. There will be problems after holiday, weekends and going away.
10. There will be problems in saying farewell to parents.
11. There will be a lot of blushing.
12. There will be anxiety regarding negative opinions of others.

There is a lot of comorbidity in anxiety disorders with other anxiety disorders (1), depression (2), aggression (3) and school refusal (4).

There are several risk and protective factors for anxiety disorders:

1. Genetics
   The hereditary factor is between 45% of 68%. This could be both a risk and protective factor but the research is scarce and there is no consensus.
2. Temperament
   The emotionality (1), neuroticism (2), behavioural inhibition (3) and score on the trait fear (4) influence the development and maintenance of anxiety disorders. However, these dimensions are very similar to each other.
3. Cognitive factors
   This includes specific cognitive and attention characteristics (e.g. tendency to overestimate the risk of danger; believing I cannot do it). This is typically determined using self-report and response time measurements.
4. Effortful control
   This refers to focusing and shifting attention towards relevant stimuli and the ability to inhibit behaviour (i.e. inhibition). It is a temperamental characteristic which allows the child to focus upon a goal while inhibiting reactions to immediately present stimuli. It allows for active planning and for future action. The disinhibition in effortful control is positive inhibition (e.g. regulate interference by terrifying stimuli).
5. Parents and family
   Parents with anxiety more often have children with anxiety-related problems. Children with anxiety disorders are not more likely to have mothers with lifetime anxiety disorders but they are more likely to have mothers with current anxiety disorders. Children with anxiety disorders are more likely to have fathers with lifetime anxiety disorders but not more likely to have siblings with anxiety disorder. There is diagnostic specificity as the child often had the same type of anxiety disorder as the parent.
6. School
   The school climate is experienced as unsafe when the school is large. Bullying (1), change of school (2) and strict teachers (3) are additional school-related risk factors for anxiety disorders.

Whether something is a risk or protective factor depends on the way the factor is present in a child’s life (e.g. low effortful control is a risk factor while high effortful control is a protective factor).

Behavioural inhibition refers to shyness and emotional reservation among unknown people and places and withdrawal from social events (i.e. observing rather than participating). Extreme social seclusion is associated with internalizing problems and a negative self-image if it persists in the long-term. It is possible that effortful control moderates the effect of neuroticism on the development of child psychopathology.

There are two methods of processing information:

1. Explicit information processing (e.g. CATS – N/P)
   This is slow and conscious processing of information.
2. Implicit information processing (e.g. Stroop task)
   This is fast and unconscious processing of information.

The overactivity of vulnerability and danger schemas could lead to a distorted interpretation bias (1), attention bias (2), memory bias (3), which could, in turn, lead to anxiety.

The parents of anxious children have several characteristics:

1. The parents encourages and strengthen avoidance.
2. The parents facilitate negative, threatening interpretations of ambiguous situations.
3. The parents model anxious behaviour.
4. The parents monitor and protect children to a high degree from emotionful situations.
5. The parents discourage discussions about negative experiences.

The parenting style overprotection is associated with anxiety but the causal direction is unclear. The anxiety of the child appears to trigger the overprotective parenting style. Parental overinvolvement could lead to reduced opportunities for exposure to novelty or potentially difficult situations which reduces a child’s opportunities to determine accurate information about threat and coping. Parent’s anxious behaviour could also promote and maintain child anxiety through modelling.

The role of mothers appears to be providing protection and care whereas the role of fathers appears to be encouraging children to take on challenges. This means that the role of fathers might lead to less fear whereas the role of mothers leads to more fear. However, this has not been fully studied.

Cognitive behavioural therapy (CBT) is the most evidence-based prevention and treatment method for anxiety disorders. The main techniques include cognitive therapy (1), behavioural technique exposure (2), understanding emotions (3), relaxation (4) and social skills training (5). The behavioural technique exposure refers to approaching the fearful stimuli gradually. Treatment for child anxiety appears to be less effective when a parent has an anxiety disorder.

Diagnostic specificity states that children of anxious parents are at a greater risk to develop the same anxiety disorder as their parent because parents model or communicate the specific anxieties to the child. Children with anxiety disorders are more likely to have a mother with a current anxiety disorder. Children with social anxiety disorder were more likely to have fathers with lifetime anxiety disorders.

There appears to be specificity for social anxiety disorder and general anxiety disorder. The specificity of social anxiety disorder could be explained by the lack of social skills of the parent which are then modelled to the children. It could also be explained by fathers showing less challenging behaviour. It is possible that the mother transmits cognitive styles (e.g. coping styles) associated with general anxiety disorder to their children.

The child susceptibility hypothesis states that some children who are genetically susceptible to the development of an anxiety disorder because of an anxious temperament are more likely to be affected by the consequences of living in a family with parental anxiety disorders than siblings who are not genetically susceptible.

Behaviourally inhibited temperament (1), maternal anxiety (2), parental overinvolvement (3) and absence of a secure attachment (4) are predictive factors of child anxiety. The absence of a secure attachment could lead the child to develop a worldview which is unsafe and untrustworthy. Parenting appears to play a moderating role in the development of anxiety.