Stress and anxiety in our children are the top mental health issues worrying callers to ChildLine and teachers alike (see Headteacher Update, 2023). The general consensus is that anxiety is common and rising in our young, and even in the very young (Thornton, 2024).
Estimating the significance and scale of the problem
Often assumed to be a teenage issue, anxiety in young children is under-researched, under-recognised, and under-treated (Creswell et al, 2020).
Anxiety is noxious in itself, disruptive of social, emotional, and academic development – and anxiety in early childhood is also strongly predictive of later mental health problems (Bittner et al 2007; Finlay-Jones et al, 2024). Expert opinion increasingly suggests that addressing anxiety effectively in the primary school range is not only important for the anxious child, but that early intervention can mitigate mental health problems in adolescence and beyond (Creswell et al, 2020; Luby et al, 2020).
We have no direct data on the scale of anxiety in primary schools, but we can estimate it. We know that innate temperament affects a child’s resilience, and that between 25% and 35% of children have an innate temperament that makes them vulnerable to anxiety (Lionetti et al 2018; Rothbart, 2012).
We know that childhood anxiety can be triggered by family adversity, whether economic or interpersonal (Draisey et al, 2020; Reiss et al, 2019), that it can be associated with social disadvantage (Williams, 2018), and that anxious or depressed parents foster anxiety and depression even in infants (Morales-Munoz et al, 2022; O’Connor et al, 2003).
Given the anxious times we live in, and the high incidence of anxiety in adults, it would be surprising if anxiety were not a significant and rising issue in our primary schools.
We know that, whereas most mental health issues begin in late childhood or early adolescence, anxiety issues tend to begin earlier than this, in early childhood or even infancy (Solmi et al, 2022; Sullivan & Opendak, 2021).
Anxious teenagers are more likely than their peers to have been anxious children (Bittner et al, 2007; Finlay-Jones et al, 2024). Around 1 in 4 of our teens report anxiety in surveys. The inference is that anxiety may well be common in our primary schools.
Addressing anxiety in the primary range
Addressing anxiety in primary school children presents a variety of different problems.
Sometimes anxiety is signalling something very wrong in a child’s life – bullying in school, for example, family issues or even abuse, occasionally a diagnosable mental disorder - and those things need investigating and addressing with the appropriate expert help.
But often anxiety in the young is more generalised, more amorphous, more a “way of being” than a reflection of a specific problem or mental disorder.
A predisposition to anxiety reflects a temperament that is highly reactive to negative events and poor at regulating the resulting emotion.
For such children, learning to better regulate emotional responses would be a major blessing, providing a foundation for a more resilient way of being.
We are never going to eradicate the capacity for anxiety in the young – and indeed that would be a bad idea: anxiety is (or should be) a functional emotion, energising and motivating us to avoid or deal with threats.
It is a part of our evolutionary “toolbox” for self-preservation and survival. With the way the world is going, helping the young to learn to manage this emotion in constructive ways would offer a powerful tool for life.
School-based interventions
How best then to help the young learn to manage anxiety constructively? In other words, what are the effective interventions for the primary school range and how cost-effective are these options? Below, I consider three common approaches.
Mindfulness
Many schools have invested resources in mindfulness in recent years. Even very young children can practise simple forms of mindfulness, such as the “3-3-3” approach, which asks the child to name three things they can see, then identify three sounds they can hear, then move three different parts of their bodies.
The exercise can be fun, may distract from worries, and can refocus the child in the present moment.
Mindfulness was at one time vaunted as the panacea for the mental health crisis in our young. However, research suggests a more cautious view.
There is little or no evidence on the efficacy of mindfulness at the primary school age range. In adolescents, evidence is equivocal (Felver et al, 2016; Kallapiran et al, 2015). The reported benefit is often small, and since there is generally no control group for comparison, it is unclear whether these benefits actually reflect the practice of mindfulness or would have occurred without it.
A meta-review of research (Farias & Wiholm, 2016) concludes that when mindfulness is compared to other activities and treatments, there is insufficient or only inconclusive evidence that it is effective. More worryingly, the data suggest that while some individuals may benefit from mindfulness techniques and others will not be affected in any substantial way, a number of individuals may suffer mild or even severe adverse effects (Lustyk et al, 2009).
Cognitive behavioural therapy (CBT)
The gold standard intervention for children with anxiety disorders is CBT, cognitive behavioural therapy, delivered by a trained professional.
This can be effective in helping a child or adolescent to manage anxiety better (Sigurvinsdóttir et al, 2020). But offering professional CBT in schools requires serious resources.
Creswell et al (2024) report some evidence for the effectiveness of a digital tool, with professional supervision, in supporting parents to use a version of CBT to moderate anxiety in children aged 5 to 12.
However, digital tools for CBT are only really effective if supported by trained professionals (Thornton, 2023) and this can soak up resources.
Digital tools may offer promise, but without professional and preferably face-to face support with professionals, such tools can also pose serious problems (Thornton 2023).
And then, a meta-analysis of the impact of CBT programmes in schools suggests the benefits may be short lived: fading after six months (Hugh-Jones et al, 2021).
Parent-child interaction therapy (PCIT)
PCIT is a less familiar approach, which has shown some promise. As the name implies, this approach recruits and trains parents to help their child recognise, understand, and regulate emotions (Luby et al, 2020).
Rather than removing or denying all sources of anxiety, this approach suggests exposing children to mild anxieties, and supporting them as they learn to recognise and label their emotional response and helping them to learn how to react to the situation in constructive ways.
This approach has been shown to be successful even with the very young (Luby et al 2020). Like CBT, PCIT directly addresses the psychological processes that underly a propensity for anxiety – the tendency to be highly reactive to negative events and poor at regulating emotions.
The advantage of PCIT is that it is an enhancement of natural parenting processes which can support the child all through childhood and adolescence.
In training parents in better ways to foster the emotional development and resilience of their child, PCIT may also incidentally offer parents new insight into managing their own mental health – thus providing a resource for the whole family. The resources committed to that training may offer a long-lasting and cost-effective intervention.
- Dr Stephanie Thornton is a chartered psychologist, author and lecturer in psychology and child development. She is the co-author of Understanding Developmental Psychology (Macmillan International/Red Globe, 2021). Read her previous articles for Headteacher Update via www.headteacher-update.com/authors/dr-stephanie-thornton
Further information & references
- Bittner et al: What do childhood anxiety disorders predict? Journal of Child Psychology and Psychiatry (48), 2007.
- Creswell, Waite & Hudson: Practitioner review: Anxiety disorders in children and young people – assessment and treatment, Journal of Child Psychology and Psychiatry (61), 2020.
- Creswell et al: Digitally augmented, parent-led CBT versus treatment as usual for child anxiety problems in child mental health services in England and Northern Ireland, The Lancet Psychiatry (11), 2024.
- Draisey et al: Associations between family factors, childhood adversity, negative life events and child anxiety disorders: An exploratory study of diagnostic specificity, Behavioural and Cognitive Psychotherapy (48), 2020.
- Farias & Wiholm: Has the science of mindfulness lost its mind? BJPsych Bulletin, 40, 2016.
- Felver et al: A systematic review of mindfulness-based interventions for youth in school settings, Mindfulness (7), 2016.
- Finlay-Jones et al: Systematic review and meta-analysis: Early irritability as a transdiagnostic neurodevelopmental vulnerability to later mental health problems, Journal of the American Academy of Child and Adolescent Psychiatry (63), 2024.
- Headteacher Update: Mental health: Anxiety, stress and low mood top list of Childline calls, 2023: www.headteacher-update.com/content/news/mental-health-anxiety-stress-and-low-mood-top-list-of-childline-calls
- Hugh-Jones et al: Indicated prevention interventions for anxiety in children and adolescents: A review and meta-analysis of school-based programs, European Child and Adolescent Psychiatry (30), 2021.
- Kallapiran et al: Review: Effectiveness of mindfulness in improving mental health symptoms of children and adolescents: A meta-analysis, Child and Adolescent Mental Health (20), 2015.
- Lionetti et al: Dandelions, tulips and orchids: Evidence for the existence of low-sensitive, medium-sensitive and high-sensitive individuals, Translation Psychiatry (22), 2018.
- Luby et al: The differential contribution of the components of parent-child interaction therapy emotion development for treatment of preschool depression, Journal of the American Academy of Child and Adolescent Psychiatry (59), 2020.
- Lustyk et al: Mindfulness meditation research: Issues of participant screening, safety procedures, and researcher training, Advances in Mind-Body Medicine (24), 2009.
- Morales-Munoz et al: Maternal postnatal depression and anxiety and the risk for mental health disorders in adolescent offspring: Findings from the Avon Longitudinal Study of Parents and Children cohort, Australian and New Zealand Journal of Psychiatry (57), 2022.
- O’Connor et al: Maternal antenatal anxiety and behavioural/emotional problems in children: A test of a programming hypothesis, The Journal of Child Psychology and Psychiatry and Allied Disciplines (44), 2003.
- Reiss et al: Socioeconomic status, stressful life situations and mental health problems in children and adolescents: Results of the German BELLA cohort-study, PLoS One (14), 2019.
- Rothbart: Becoming Who We Are: Temperament and personality in development, Guildford Press, 2012.
- Sigurvinsdóttir: Effectiveness of cognitive behavioral therapy (CBT) for child and adolescent anxiety disorders across different CBT modalities and comparisons, Nordic Journal of Psychiatry (74), 2020.
- Solmi et al: Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies, Molecular Psychiatry (27), 2022.
- Sullivan & Opendak: Neurobiology of infant fear and anxiety: Impacts of delayed amygdala development and attachment figure quality, Biological Psychiatry (89), 2021.
- Thornton: Digital technologies: Are they the solution for young people’s mental health? British Journal of Child Health (4), 2023: www.magonlinelibrary.com/doi/abs/10.12968/chhe.2023.4.3.151?af=R
- Thornton: Depression in the very young: Implications for the teenage years, British Journal of Child Health (5), 2024: www.magonlinelibrary.com/doi/abs/10.12968/chhe.2024.5.2.90
- Williams: Stress and the mental health of populations of color: Advancing our understanding of race-related stressors, Journal of Health and Social Behavior (59), 2018.