Middle Childhood

Middle childhood occurs between approximately ages 6 and 12, primary school age, and is a time when children face new cognition and experiences. Significant cognitive skills in, for instance, logical thinking, complex reasoning, self-regulation, executive functioning and problem solving develop (Carr, 2015; Collins, 1984; DelGuidice, 2018; Feldman, 2005). During middle childhood, children gain access to new settings where they learn to master these new skills. Exposure to wider social environments, such as school, increase children’s interpersonal relationships. Children are expected to gain independence and autonomy to self-regulate their emotions and interact successfully with a range of adults and peers (Carr, 2015).

The process of socialisation, integration into society and forming a personal identity are all important aspects of middle childhood. Children become more independent from the family and friendships increase in importance – more complex friendships form, with pressure from peers increasing. Alongside these challenges is an individual’s growing awareness of their body as puberty approaches. Children can become very conscious of body image and often become self-critical (Centres for Disease Control and Prevention, 2021c & d).

In middle childhood, the ability to self-evaluate and compare oneself to others increases. Aspects of appearance, academic ability, athleticism and social performance all become attributes to self-evaluate and compare. Some children will gain a sense of competence and self-efficacy while others may develop a sense of inferiority, influencing self-esteem and anxiety levels (Carr, 2015). A major challenge for children during this phase is the need to find their place in society and to fit in. This proves more challenging for some than others. During this journey of self-discovery and development of autonomy, some children become more difficult to manage, less respectful and preoccupied with their own interests – they can be egocentric (Geldard et al., 2019; Wicks-Nelson & Israel, 2015). Some children, during middle childhood, experience intense emotional responses which can impact daily functioning, leading to both internalising and externalising disorders (Carr, 2015; Wicks-Nelson & Israel, 2015).

General Anxiety Disorder

Anxiety is a future-oriented emotion, characterised by an elevated level of apprehension and lack of control, and involves a range of complex behaviour, cognitive and physiological responses when something is perceived as risky, frightening or worrying (Barlow, 2002; Carr, 2015; Wicks-Nelson & Israel, 2015). It is a basic human emotion and is part of the normal developmental process (Carr, 2015; Headspace, 2022b; Wicks-Nelson & Israel, 2015).  As Be You state, “feeling anxious is a survival response to situations where there are dangers or threats, however, some people react more intensely to such situations” (2022c, p. 1).  Anxious feelings can become problematic when very intense, when they are persistent, impact everyday functioning or are developmentally inappropriate. Such feelings may lead to mental illness, a longer-lasting mental health problem, such as an anxiety disorder and require clinical attention (Carr, 2015; Wicks-Nelson & Israel, 2015).

Anxiety disorders are the most common mental health condition in Australia (Barrett & May, 2007; Be You, 2022a), and are among the most common disorders experienced by children (Wicks-Nelson & Israel, 2015). According to the Australian Institute of Health and Welfare (AIHW; 2020a, p. 85), “[i]n 2013-14, an estimated 314,000 children aged 4-11 (almost 14%) experienced a mental disorder.” AIHW goes on to state that, “[a]nxiety disorders were the second most common disorders among all children (6.9%), and the most common among girls (6.1%)”.

Anxiety is a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (5th ed; DSM -5; American Psychiatric Association [APA], 2013b), The DSM-5 (2013b) defines a number of anxiety related disorders, such as Separation Anxiety Disorder, Specific Phobia, Social Anxiety disorder (Social Phobia), Selective Mutism, Panic Disorder, Agoraphobia, and Generalised Anxiety Disorder (GAD) (APA, 2013b; Wicks-Nelson & Israel, 2015). GAD can impact an individual’s interpersonal relationships, social competence, and ability to adjust in school (Barrett, 1998; Barrett & May, 2007).

Evidence of Symptoms 

Generalised Anxiety Disorder (GAD) is the experience of excessive, disproportionate anxiety and worry occurring the majority of days for at least 6 months (APA, 2013a). These feelings of apprehension can be about a number of events or activities. The child finds it difficult to control the worry. The anxiety or worry is not restricted to a particular situation or resulting from recent stress (APA, 2013a; Carr, 2015; Wicks-Nelson & Israel, 2015).

In the case of children, the anxiety and worry are associated with at least one of the following symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension and/or sleep disturbance. These symptoms result in clinically significant impairment in various areas of functioning and are not explained by another mental disorder (APA, 2013b; Wicks-Nelson & Israel, 2015). As Wicks-Nelson and Israel (2015, p. 120) state, children with GAD “seem excessively concerned with their competence and performance in a number of areas” – academics, peer relations, sports – setting high expectations for themselves, seeking approval and constant reassurance. Children within middle childhood may also worry about wider aspects of life such as natural disasters and fears of climate change (Carr, 2015; Wicks-Nelson & Israel, 2015). Average age of onset is approximately age 10, with the number and intensity of symptoms increasing with age (Wicks-Nelson & Israel, 2015). Children who meet the diagnostic criteria for GAD are likely to meet the diagnostic criteria for additional disorders. For example, younger children, those in the earlier stage of middle childhood, are likely to receive a concurrent diagnosis of separation anxiety disorder, whereas those in the later stage, moving into adolescence, may receive a concurrent diagnosis of depression or social anxiety disorder (Wicks-Nelson & Israel, 2015).

Impact on the Individual and Interactions

Generalised Anxiety Disorder (GAD) can impact individuals in the middle childhood phase in a number of ways. In general, children who experience GAD within middle childhood face behavioural inhibition, negative affectivity (neuroticism) and harm avoidance – leading to quite debilitating implications for an individual’s functioning within various settings, if undiagnosed and symptoms not addressed (APA, 2013b). Persistent and excessive anxiety and worry about various realms in life impairs an individual’s capacity to do things efficiently and causes a range of physical symptoms: muscle tension, headaches, nervous feelings, restlessness, frustration, irritability, difficulty concentrating and sleep disturbance (APA, 2013; Wicks-Nelson & Israel, 2015). All these symptoms can impact a child’s ability to confidently function and cope with everyday activities within various settings such as home and school. Tension and conflict can arise, as well as social withdrawal and avoidance of situations (APA, 2013b; Barrett and May, 2007; Wicks-Nelson & Israel, 2015).

Suggested Interventions

The phase of childhood presents great opportunity for intervention to address GAD – anxiety prevention should start early (Barrett & May, 2007). A Guidance Officer (GO) cannot diagnose GAD but they can work alongside the student, teachers and parents to gather information and, through observation and anecdotal notes, identify potential indicators towards a case of anxiety within a student of concern. This data will assist in assessing whether a referral to an external specialist is required and to assess what intervention and support is required in the classroom (Wicks-Nelson & Israel, 2015).

In the school context, a GO can work alongside a student to develop their skills and abilities to cope with challenges. Much research suggests that Cognitive-Behavioural Treatment (CBT), that includes a range of potential behavioural and cognitive-behavioural strategies, is effective for anxiety disorders (Silverman et al., 2008; Wicks-Nelson & Israel, 2015). CBT targets changing behaviour and positively influences emotional feelings (Geldard et al., 2019). Example of therapeutic strategies, cited by Wicks-Nelson and Israel, include: “education about anxiety and emotions”, “teaching awareness of bodily reactions and physical symptoms”, relaxation techniques, “recognition and modification of anxious self-talk and anxious cognitions”, “role playing and contingent reward procedures”, “teaching problem-solving models”, “use of coping models”, “exposure to anxiety-provoking situations” and “practice in using newly acquired skills” (2015, p. 137; Kendall, 2012)

One example of a program that a GO could implement, either as a universal program across certain year levels, or as more targeted tier 2, small group intervention is the FRIENDS program (Barret & May, 2007). Barrett and May, describe this as an effective and sustainable, cognitive-behavioural evidence-based intervention program addressing “cognitive, psychological and behavioural processes that are seen to interact in the development, maintenance and experience of anxiety” (2007, p. 4). The program is designed to be implemented as both a treatment and a school-based universal prevention program targeted at ages 10-12 and age 15-16 years. It aims to teach children how to cope with, and manage, anxiety both now and later in life. Both a GO or teacher can implement this in a group setting following a one-day training session. According to Wicks-Nelson and Israel, the goal is to teach the child to: “recognise the signs of anxious arousal, identify the cognitive processes associated with anxious arousal, and employ strategies and skills for managing anxiety” (2015, p. 136). In severe cases, a child diagnosed with GAD, through an external specialist, such as a child psychologist, may be prescribed pharmacological treatment. Psychological treatments that address coping skills may be implemented alongside pharmacological intervention (Wicks-Nelson & Israel, 2015).