AUTHOR: Dr Blanca E. Mancilla Gomez, MBPSs Nahory Hernandez Mancilla
CHILDREN, anxiety and the family system L
iving with anxiety is not an easy affair, the pressures of life, work, and economic commitments could have both physical and psychological effects when anxiety becomes unmanageable. Moreover, it could interfere with your everyday routine. Some may think that children ‘have it easy’, however children have their own worries and can also suffer from anxiety. Albano and colleagues (2003) mentioned that anxiety disorders are some of the most prevalent mental disorders in childhood and adolescence. Considering this, we want to support families to identify and prevent the development of what could become a detrimental cycle of anxiety. Here we have answered some of the most common questions we are asked in practice.
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What is anxiety and fear in children?
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lthough both terms are often used interchangeably, there are conceptual and physiological differences. Anxiety is an emotion characterised by an intense fear and discomfort with cognitive and somatic symptoms such as recurring intrusive concerns, tension, faster breathing, increased blood pressure and raising heartbeat. There is a disproportionate response and excessive worry with thoughts of danger, imminent catastrophe such as something terrible happening to their parents; and an urgent need to escape where they may try to avoid what makes them anxious for instance separation from parents, exams, social events, going to a specific place or performing a specific task. It is future-oriented, and entails a long-lasting response that focuses on a diffuse threat.Fear, on the other hand refers to a basic emotion that presents itself when a threat is detected, the somatic symptoms are very similar to those in anxiety. Nevertheless, this is considered an appropriate short-term response to a clearly identifiable threat, which is the most important difference.
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How can I detect that my child is anxious?
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bserve your child and look for indicating symptoms, such as your child avoiding specific situations, or perhaps your child seems impaired, exhibits bizarre thinking or confusion, does not listen or there seems to be ‘blanking out’ of thoughts. Identify a peculiarity such as constant stomachaches and headaches that have no medical cause. Recognise facial expressions or pathological motor-activity such as palpitations, uncontrollable shaking or hair pulling. Communicate, check if there are abdominal pains, excessive sweating, urge to urinate, blushing, starts feeling nauseous or dizzy (Have-de Labije, 2006). Probably some adults are familiar with these symptoms, sopay attentionand remember that anxiety is not an ‘adult thing’.
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How to explain reality to my child without underestimating my child’s thoughts?
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ry to avoid assumptions, what your child may be referring to may not be the same you are thinking. Always ask your child to describe and try to be precise with your reply by considering the external reality, which is what you and your child can clearly identify.
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How should I behave? What should they see in me so their anxiety does not increase?
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e congruent, modulate your behaviour by holding environment like Winnicott (1973) described, and most importantly listen to your child. For Bion (1967/1984) thoughts exist in a child but how to think those thoughts is developed through another mind, the parent or main carer. Therefore, the parent can help to alleviate anxieties by acting as a container. This means that the parent can soothe the child when is distressed by creating a safe context to put the child’s thoughts into it so the child can give the experience a meaning that should be understandable, thus enabling the child to gradually self-manage the thoughts that caused anxiety. For instance, try to see what the child is telling you through the child’s eyes and consider the vocabulary. Provide help to make the situation understandable based on what is happening in the external reality. Put the situation from a point of view where the child is safe and use a context that the child is familiar with. This way the child can give some meaning to the situation and process it to understand and feel more in control to avoid thoughts of imminent catastrophe which cause anxiety.
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How to ‘correct today’ to provide a better adulthood?
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romote positive interfamilial relationships without fights, quarrels, aggressions and violence. Avoid giving items that may be seen as rewards as a way to calm your child, remember that this could reinforce the unwanted behaviour if you are not cautious. Instead, provide a specific time to calm down, by containing your own anxiety you help your child. Expect a gradual change not an immediate one and provide help for transitions by being patient, positive and pertinent (PaPoPe). Although this article focuses on the main carer as a container,consider that there is a two-way interaction, a dyadic bidirectional regulation where the child also has an effect on the adult (Beebe, 2014). However, the adult is the one with more resources and skills to promote self-regulation.
Family systems – open vs closed
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irst of all, remember that we do not deal in absolutes, we are not ‘Sith Lords’ from Star Wars©, hence not everything is black or white and a family could be found in the middle trying to make sense of things. Therefore, our aim is to help families to identify features that are healthy and encourage positive relationships in the family. However, people also need to know which features are not helpful in order to identify them and avoid or prevent them. Consequently, here is a brief explanation of these family systems.
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The very first group one belongs to is the family, it is in this group where the human being can fulfil all the basic needs to survive and develop. This refers to basic needs such as protection, safety, affection, and recognition amongst others. Moreover, it also supports social competence so each individual can contribute to their society. The family group could nurture development or contribute to stagnation of the children. Importantly, children observe the relationship between parents, which is essential for the development of children’s mental health. A satisfactory and stablerelationship between parentswould often have an overall positive impact on the family; where as constant conflict and disputes in the parents’ relationship could exert a negative influence on how the family and its members function. Considering the latter, the function of the family system is not only to ensure the survival of the species but to generate an appropriate environment to enable the development of each member’s skills and strengths. It is in the family group where the members learn values, norms, and socially acceptable patterns of behaviour; which the family learned from the cultural society where it belongs to. The main objective of the family should be to help each member todevelop and grow. Therefore, it must meet certain requirements, Macias (1988) described them as follows: • Safeguard the young ones by providing all the basic needs such as warmth, food and protection. • Promote positive bonds and social unity so that the members can socialise harmoniously.
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• Encourage the development of individual, family and social identity in accordance to the social group the family belongs to. • Satisfy complementary needs and reciprocate those that have been given to foster prosperity and a flexible approach. This is to enable individualisation through respect and recognition. • The family should allow children pertinent social participation, so that they can identify their social role and gradually integrate into the social group they live in. • The family should maintain solidarity and unity, whilst encouraging autonomy, self-regulation and adaptability. Laing and Esterson (1964) highlighted that each individual has the family internalised, therefore when forming a new family both initial members have to ‘meet in the middle’. This means, to use those features where both coincide as strengths and the discrepancies as opportunities to form the new family. This could be translated as 1 + 1= 3, an addition where both parties contribute to shape the new family’s values, rules, and communication, whilst doing so they createtheir unique and particular family lifestyle. Each member learns in this system and this initial learning experience has an impact on their development and personality. Therefore, the prognosis of the family as a whole and the individual development of each member would depend on the parenting style; parents’ empathy; and the identification and understanding of their own feelings and those of their partner and children. This also means, the more empathetic parents are with their children, the less anxiety children would develop.
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Although research has found that some parenting styles and language of perfectionistic parents are strongly correlated with child anxiety (Affrunti et al., 2015), there is not enough evidence that can explain the significant relation between certain parenting styles such as overprotective parenting and the development of children’s anxiety (Vreeke et al., 2013).Chorpita and colleagues (1998) explained that a child’s autonomy could be limited when parents are controlling and do not demonstrate emotional warmth. Moreover, these features could make the child prone to feeling a lack of control over their environment, thus often leading to anxiety. In a study performed by Pereira et al. (2014) it was demonstrated that both parents had a great influence on the
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development of children’s anxiety. Specifically, maternal trait anxiety and paternal overprotection seemed to contribute to children’s anxiety as independent factors. Consequently, it is important to consider both parents or main carers when assessing the development of children’s anxiety and its treatment (Chorpita, 2007). According to Ackerman (1981) and Satir (1976/1991) there are three crucial factors found in the family group that will determine the development of an individual’s personality. a) SELF-ESTEEM that refers to one’s own worth. b) COMMUNICATION used to form relationships and socialise. c) NORMS that the family established and members have to abide by.
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Self-esteem
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elf-esteem is not determined by genes, it is learned and the first exposure happens in the family group. Through interactions and experiences the child will receive the messages that family members communicate to the child regarding his or her ‘value’ as a person. Therefore, a child attributes self-value in accordance to the worth he or she is given by the family members. When a child is exposed to other environments outside the core family such environments can reinforce feelings of self-worth or lack of it. A child withself-esteem is enabled to overcome failures in school and life. Where as a child with low self-esteem, irrespective of any success,would often doubt his or her self-worth. Self-esteem is transmitted to the child through messages that meaningful and important people in the child’s development send, either verbally, attitudinally, and through facial expressions and body language. However, sometimes parents do not perceive the impact that their actions could have on their child’s development. Furthermore, some parents may not be completely aware of the message they are conveying to their child.
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Clearly, family is vital for a child’s development, for instance children from conflictive families tend to feel undervalued, clumsy, with little or no assertiveness at all, undecided, and insecure. Often this is because they grew up in an environment with a distorted communication, with rigid norms, inflexible authority, with very critical parents who made constant derogatory comments and with punitive rules for any mistake; or the opposite, a family environment with no rules and extremely permissive. Parents with pertinent self-esteem tend to have more opportunities to provide their children with a nurturing family environment, with approachable figures of authority that provide guidance and congruent norms to develop appropriate communication. Therefore, children could develop a better understanding of their external surroundings and as a result, more adaptability, social competence and self-regulation to manage experiences that could cause them anxiety and distress.
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Communication
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his is an essential feature as it would determine the interaction with other family members and with other people outside the family group. As expressed in the previous section, communication has a great impact on the formation of self-concept, self-esteem and confidence. It is necessary to note that this factor ‘communication’ has different levels to consider such as verbal, attitudinal, body language, emotional tone, content, and facial expressions amongst others. Good communication needs to be congruent and consider the afore mentioned levels to avoid distortion of the messages. This way parents can be fully aware of the message they are conveying and the effect it has on their child.
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Confusion due to miscommunication in the family would interfere with a child’s positive learning of self-concept, there by hampering regulation and adaptability. For example, when communication is incongruent with family values children tend to feel confused and anxious. This is why communication between family members would determine the type of relationships the child will build up in either direction positive or negative within the family and in any other environment (Ackerman, 1981).
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Norms
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hese are a range of values that a group, in this case the family, abides by. These parameters are the guides for behaviours and tell every member what ‘should be done’. During childhood these norms are introjected and learned. There are norms to distribute duties and allocation of economic resources that should be congruent with the family’s values (Satir, 1976/1991). For instance if studying is important for the family, the group would invest in education for the individuals. All families have norms, irrespective of their background and family system. The norms are different and can contribute to development or stagnation. Furthermore, norms could determine degrees of approachability and consequently, the interaction amongst family members. It is crucial that every member of the family can identify, comment about and introject them; otherwise there could be no agreements and respect for a fruitful coexistence, which could have a deleterious effect on the family’s well-being. Norms should have a balance where the rules are neither overly lax nor unduly hard. When the rules are immoderately lax the family does not set clear limits, hence the child is free to decide how to behave regardless of his or her well-being. In the long-term a young child with no clear limits established from the beginning may not be equipped to be able to identify assertively what is pertinent and what is not, to adapt to different protocols, and to a lesser degree to share. This could cause severe conflicts for the child, especially at school where demands are made by different figures of authority and rules are specifically established. This also means
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that the child’s socialisation may be impaired as other pupils and figures of authority could reject the child in the first instance. Interactions and coexistence could become a great difficulty for a child that is excessively recalcitrant. Nevertheless, this does not mean that inordinate and rigid rules are appropriate. A family that is not flexible and expects perfect children that always behave and say what parents want to see and hear may contribute to situations where children cannot comment on real facts or lived experiences. Notice that such restrictions are precisely what could cause children to learn how to lie, create hatred and rancour against parents and authority figures. Moreover, this could lead to isolation, and they may develop a negative self-concept. Evidently, this contributes to an emotional cascade that could lead to dysregulated behaviours, anxiety, hostility, aggressiveness, self-harm and loneliness. These children could develop into adults that believe that they are either ‘extremely good’ or ‘extremely bad’, but without been either, they are just sentient beings. These three factors self-esteem, communication and norms interact, and together determine the family system.
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Closed family system
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elf-esteem: a child often feels diminished with low selfesteem and feels the need to constantly search for external approval. Communication: is indirect, incongruent, with recriminations, thus leading to confusion hindering the appropriate development of a child. Norms: are inflexible, unduly hard and there are excessive restrictions that impede spontaneity. Outcome: this usually results in a family that lives chaotically, fortuitously, with inappropriate processes and an excess of closure or openness. This has a negative impact on a child’s life and often develops into extreme anxiety,inapposite self-regulation and a destructive lifestyle.
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Open family system
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elf-esteem: a child can develop clarity with appropriate self-esteem that reinforces feelings of confidence, enabling autonomy and adaptability. Communication: is direct, clear, congruent, and figures of authority are approachable, this system stimulates and promotes growth for all family members. Norms: are open, flexible with clear boundaries based on the family’s values. There are opportunities to openly express individual perspectives without fear of reprisal from other family members. Outcome: the result is a family where each member lives in accordance to their external reality with pertinent adaptability. The latter leads to positive development with a constructive and fruitful lifestyle, where the child is enabled to self-regulate and provided with the necessary resources so that the child is able to manage anxiety and other feelings that could distress the child in the future. Although these are the extremes, the information provided is intended to support families to identify features that could help their family system to prevent and manage anxiety in children. The recommendation is to encourage the development of an environment that works more as an open system, where each individual supports
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the others. It is an evolving system that makes possible the interaction with other social systems. This leads to appropriate adaptability where exchanges and sharing are possible. Overall, it is a system where there is understanding as norms and limits are clear, well established, and guidance is provided without judgement. Self-regulation is promoted and the child is gradually enabled to manage novel and distressing situations that may arise in the future.
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Affiliations
Dr Blanca E. Mancilla Gomeza,b,c,d, MBPSsNahory Hernandez Mancillac,e,f,g a Mexican Association of Clinical and Health Psychology b Mexican Psychological Association c American Association of Science and Arts d National Autonomous University of Mexico (UNAM) e Oxford Health NHS Foundation Trust f British Psychological Society. g International Organisation of Psychology and Education
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Key Sources
• Ackerman, N. W. (1981). Diagnóstico y tratamiento de las relaciones familiares: Psicodinamismos de la vida familiar [The psychodynamics of family life: Diagnosis and treatment of family relationships] (H. Friedenthal and H. J. Pereyra Eds. and Trans.), 10th ed., 1994. Buenos Aires, Argentina: Hormé. • Bion, W. R. (1984). Second Thoughts. London, UK: Karnac Books. (Original work published 1967) • Chorpita, B. F., Brown, T. A., & Barlow, D. H. (1998). Perceived control as a mediator of family environment in etiological models of childhood anxiety. Behavior Therapy, 29, 457–476. • Macías, R. (1988). Formas de agresión al niño en la familia [Forms of aggression against a child in the family]. Asociación Psiquiátrica de América Latina,3, 33–42. • Pereira, A. I., Barros, L., Mendoça, D., &Muris, P. (2014). The relationships among parental anxiety, parenting, and children’s anxiety: The mediating effects of children’s cognitive vulnerabilities. Journal of Child and Family Studies, 23(2), 399–409. • Satir, V. (1991). Nuevas relaciones humanas en el núcleo familiar [The new people making] (J. I. Rodríguez y Martínez, Ed. and Trans.). México: Pax. (Original work published 1976) • Winnicott, D. (1973). The Child, the family, and the outside world. UK: Middlesex.
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References
• Ackerman, N. W. (1981). Diagnóstico y tratamiento de las relaciones familiares: Psicodinamismos de la vida familiar [The psychodynamics of family life: Diagnosis and treatment of family relationships], 10th ed., 1994. Buenos Aires, Argentina: Hormé. • Affrunti, W. Geronimi. E., M., C., & Woodruff-Borden, J. (2015). Language of perfectionistic parents predicting child anxiety diagnostic status. Journal of Anxiety Disorders, 20, 94–102. • Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety disorders. In E. J. Mash, & R. A. Barkley (Eds.), Child psychopathology, 2nd ed., (pp. 279–329). New York, USA: The Guilford Press. • Beebe, B. (2014). My journey in infant research and psychoanalysis: microanalysis, a social microscope. Psychoanalytic PsychologyAmerican Psychological Association, 31(1), 4–25. • Bion, W. R. (1984). Second Thoughts. London, UK: Karnac Books. (Original work published 1967) • Chorpita, B. F. (2007). Modular cognitive-behavioral therapy for childhood anxiety disorders: Guides to individualized evidence-based treatment, New York, USA: The Guilford Press. • Chorpita, B. F., Brown, T. A., & Barlow, D. H. (1998). Perceived control as a mediator of family environment in etiological models of childhood anxiety. Behavior Therapy, 29, 457–476.
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• Have-de Labije, J. ten (2006). When patients enter with anxiety on the forefront. Ad Hoc, Bulletin of the Dutch Society for short-term dynamic psychotherapy, 10(1),35–70. • Laing, R. D., &Esterson, A. (1964). Sanity, madness and the family. London: Penguin Books. • Macías, R. (1988). Formas de agresión al niño en la familia [Forms of aggression against a child in the family]. Asociación Psiquiátrica de América Latina,3, 33–42. • Pereira, A. I., Barros, L., Mendoça, D., &Muris, P. (2014). The relationships among parental anxiety, parenting, and children’s anxiety: The mediating effects of children’s cognitive vulnerabilities. Journal of Child and Family Studies, 23(2), 399–409. • Satir, V. (1991). Nuevas relaciones humanas en el núcleo familiar [The new people making] (J. I. Rodríguez y Martínez, Ed. and Trans.). México: Pax. (Original work published 1976) • Vreeke, L. J., Muris, P., Mayer, B., Huijding, J., Rapee, R. M. (2013). Skittish, shielded, and scared: Relations among behavioral inhibition, overprotective parenting, and anxiety in native and non-native Dutch preschool children. Journal of Anxiety Disorders, 27(7), 703–710. • Winnicott, D. (1973). The Child, the family, and the outside world. UK: Middlesex.
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