Middle Childhood

Middle childhood, the stage of development from age 6 years to 12 years is typically characterised by issues of self-esteem or emotional well-being, and bullying (Magro et al., 2019). Self-esteem or emotional well-being is a dynamic construct that grows and diminishes across the ages and is of particular importance at this stage of development. Self-esteem is characterised by instability and formation particularly during middle childhood (Magro et al., 2019). It is important at this stage to understand how self-esteem impacts a child given the correlation between healthy self-esteem in the middle years, and positive psychological development in adulthood. A correlation between positive peer support, a sense of belonging and positive family environment influences a child’s self-esteem trajectory.

Bullying impacts a child’s self-esteem significantly. Bullying is an intentional act of causing fear, distress or harm to someone with unequal power and is widespread across this stage of development with prevalence rates ranging from 9% to 54% (Craig et al., 2009; Nansel et al., 2004, as cited in Wicks-Nelson & Israel, 2019). Victims of bullying are typically anxious, insecure, cautious, sensitive, quiet, nonaggressive and experience low self-esteem more than other children. Typically, victims of bullying do not have one single protective friend in their class resulting in a greater risk of depression, loneliness and suicide. Additional affects of bullying relate to fear, insecurity and anxiety.

Anxiety 

Anxiety generally is a future-focussed emotion and is not unusual for children in the middle years in stressful situations such as school. Anxiety disorders on the other hand, is characterised by excessive and persistent fear or worry affecting day-to-day functioning. Anxiety disorders in middle childhood are pervasive, manifesting learning and social difficulties resulting in significant impairment to a child’s academic, social and family functioning. As cited in Gouze et al. (2021), prevalence rates of children experiencing some form of anxiety including General Anxiety Disorder, Social Anxiety (SA), Agoraphobia, Separation Anxiety Disorder (SAD) and specific phobias vary considerably with rates estimated at 2.5 % to 5% (Rapee et al., 2009); 12% to 25% (Franz et al., 2013; Lavigne et al., 2009), and as high as 41.2% (Cartwright-Hatton et al., 2006; Costello et al., 1996, as cited in Affrunti & Woodruff-Borden, 2015). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013b) does not refer to one specific anxiety syndrome rather various anxiety disorders classified within a broad category of internalising disorders. Severity varies from mild to severe, often with high rates of comorbidity.

Children with persistent anxiety, commonly display internalised behaviours such as withdrawal, sadness, fear, and a lack of self-confidence. Additionally, sleep problems, reduced ability to concentrate, poor school performance, diminished emotional awareness and augmented emotional inhibitions are characteristic of anxiety disorder, thus impacting social interactions with peers, teachers and family members. In the case of SAD, due to fear of leaving a significant attachment the following morning, children can experience difficulties with getting to sleep or disturbed sleep throughout the night thus affecting school attendance and the natural development of peer relationships. Due to avoidant behaviours experienced by children with SAD, the establishment and longevity of meaningful friendships and the attendance of family events can be problematic. Excessive worry and intrusive thoughts along with sleep deprivation experienced by children with anxiety, affects focus and concentration thus impacting academic performance, peer relationships and family relationships. Despite little understanding of the cause of anxiety disorders, genetic, environmental, psychological and developmental factors are believed to be key factors that play a role in the development of anxiety in the middle childhood years (APA, 2020a).

Research indicates a small gender difference with girls presenting with higher rates of anxiety than boys (Kadam, 2014). Anxiety typically co-exists with other problems leading to comorbidity resulting in later drug use, peer conflict and poor social relationships, poorer academic grades, and suicidal ideation. It is not uncommon for a child who experiences anxiety disorder to go unnoticed in a school setting due to the limited understanding by teachers and parents. Additionally, children often lack the emotional intelligence and language to express extreme feelings of apprehension and worry (Kadam, 2014). SAD is found to be of most pervasive for this age group and debilitating for a child who is required to attend school on a daily basis

Evidence of Symptoms

Anxiety is a multifaceted experience for children and can be difficult to recognise because anxiety typically affects a child’s thoughts and feelings. Anxiety is easy to overlook due to a level of anxiety being somewhat normal in middle childhood, and due to high rates of comorbidity (Aschenbrand et al., 2005). In addition, children can present as happy at the same time as feeling anxious. Children with anxiety present with somatic, cognitive and emotional symptoms. When a child experiences anxiety three types of reactions occur: (1) overt physical behavioural responses such as running away, shaking, crying, trembling voice and eyes closing, (2) cognitive responses such as thoughts of being scared, disapproving thoughts of the self and images of bodily harm, and intrusive and repetitive worrying thoughts about what might happen which can incur cognitions resulting in avoidant behaviours; which in turn results in more fear, and so a cycle continues (3) physiological responses including rapid heart rate and decreased respiration, muscle tension and stomach pains, nausea and increased perspiration. It is also noted in the DSM-5 that children may express anxiety by crying, exhibiting tantrums, freezing or clinging behaviours.

Symptoms often begin around six years of age, although this can vary. Anxiety can be seen in terms of inhibited emotional expression, shyness, and withdrawal in social situations. Some children come across as perfectionists; based on their own opinion of what perfect is and therefore things need to be ‘just right’. In such cases it is often the pressure the individual places on themselves that causes anxiety thus affecting school performance or resulting in performance anxiety even in extra-curricular activities. Anxiety typically impacts a child’s self-esteem and social skills; impacting friendship development and feelings of being alone or isolated.

In the school setting, a comprehensive, culturally sensitive, age appropriate assessment must be carried out (Wicks-Nelson & Israel, 2015). While diagnosis is not the role of a Guidance Officer (GO), gathering information can help decision making processes, academic planning and intervention. Observations, structured Diagnostic Interviews, self-reported questionnaires including the Revised Child Anxiety and Depression Scale, and Functional Behaviour Analysis can be carried out by multiple key stakeholders including the teacher, specialist teachers, and parent/s to help gather relevant information; acting as a foundation to direct intervention and possible referral options. Assessing the interplay between the individual child and their environment is key to comprehensive assessment. Diagnosis at some stage by the appropriate professional is an important part of supporting a child with any type of anxiety disorder as research suggests that untreated anxiety disorders in childhood can lead to chronic mental health conditions in early adulthood (Pauschardt et al., 2010, as cited in Van Meter et al., 2014).

Impact on the Individual and Interactions

Anxiety is pervasive and debilitating, and without treatment can lead to chronic mental health. It can affect a child’s self-esteem, social development and academic progress. School refusal, and avoidance of situations or events deem as a threat by the individual can result. Avoidant behaviours typically occur for those children with specific phobias. In such a case the individual may have thoughts of catastrophic events occurring should they be exposed to a particular feared situation or event. In the case of social anxiety disorder, cognitively, children experience fear of embarrassment or are excessively worried about what others think of them. Often thoughts relate to how they perceive themselves typically focusing on their negative attributes which is related to the level of social-cognitive maturity at this stage of development (Wicks-Nelson & Israel, 2015). Children with anxiety are typically unaware that their reaction or behaviours as a result of anxiety are disproportionate to the event or situation. Peer and family relationships can be jeopardised due to avoidant and extreme behavioural challenges expressed by the individual child. Maladaptive avoidant strategies to counteract anxiety can restrict both the child’s activities such as school, parties and local community events. Family members can also be impacted as avoidance of family events with unfamiliar people or an uncertainty of what to expect is also common.

Suggested Interventions

Assessment and early intervention are key to supporting a child with anxiety (Nabors, 2020). When considering the development of an Individual Support Plan, the role of collaborative practice ensuring key stakeholders are considered particularly during the assessment phase is of utmost importance. Establishing and maintaining an open, trusting professional relationship with key stakeholders and sharing relevant information adds to a holistic assessment and treatment plan (Bryce, 2017).

In addition, the attributes of the Guidance Officer (GO) such as congruence, unconditional positive regard, and empathy, self-reflection, building a trusting therapeutic relationship and understanding of child development are key components essential to providing emotional support to children with anxiety. Children have difficulty with verbal communication skills particularly when it comes to articulating and expressing thoughts and emotions. Therefore, appropriate use of media activities such as imaginative play or miniature animals, dolls or Lego are best used to engage a child; thus, providing them with a safe space to share their story. Cognitive behavioural therapy (CBT; Geldard et al., 2017) is an effective evidence-based approach to treating child anxiety and offers successful outcomes for many children as it directly addresses thoughts and behaviours. CBT helps the child to change unhelpful beliefs, attitudes, thoughts and ideas bringing relief of cognitive dissonance brought on by emotional distress (Geldard et al., 2019). Components of psychoeducation, relaxation and stress managements skills, affective expression and modulation along with cognitive coping and processing skills are ways in which a GO can provide intervention for a student. Working from an ecological perspective utilising a strength-based approach, a GO could focus on building capacity with the child, parents and school community.