Often overlooked: Illness anxiety in children and adolescents

The fear of becoming ill often develops in childhood and adolescence - but is often only detected retrospectively in adulthood. Psychologist Vera Özak investigates how and why this fear occurs at an early age.

The fear of becoming ill often develops in childhood and adolescence - however, this is often only detected retrospectively in adulthood. This issue will change in the near future: Vera Özak, a graduate psychologist at the Goethe University (Frankfurt am Main, Germany), wants to research how and why illness anxiety occurs at a young age as part of the KaiKiJu study (In German: Krankheitsangst im Kindes- und Jugendalter. In English: “Illness Anxiety in Childhood and Adolescence). In this interview, Ms Özak talks about the study’s background, lists "warning signs" for paediatricians, and gives an outlook on which psychological long-term consequences could be observed more frequently after the COVID-19 pandemic.

esanum: Ms. Özak, within the framework of the KaiKiJu project you want to research how and why illness anxiety develops at a young age. What is the current state of research on this?

Özak: The current state of research is exactly the problem. Most research relates to adulthood, for example on the topics of illness anxiety or hypochondria. Retrospective studies then often report that the illness anxiety has existed since childhood and adolescence. However, there is comparatively little research from actual childhood and adolescence. Whatever little there is, it shows that these fears do occur in children and adolescents, that illness anxiety occurs in a very chronic way, or that they also recur. This means that this is a disorder that is only really well researched in adulthood, although the symptoms actually already occur in childhood and adolescence.

There could also be different reasons why this research approach has been neglected so far. It could be that children do not name illness anxiety specifically enough until a certain age, and that these then simply disappear into other anxiety disorders. In childhood, there are often anxiety disorders that are less clearly delineated than in adults, because the fears may still jump from one area to another, depending on what developmental task a child is facing at the time. Somatic fears in particular can also be less clearly named by children. There can still be illness anxieties that show up for the child more in the direction of somatisation or the fear of dying from it. This may then be interpreted more in the form of separation anxiety. It is very unclear at this stage whether there are individual symptoms that merge into other childhood anxiety disorders.

esanum: What was your motivation to shed more light on the topic of childhood anxiety?

Özak: Actually, some years ago, Professor Weck, at the Goethe University did some research on illness anxiety in adulthood. Among other things, there were reports from patients who suffer from illness anxiety in adulthood who reported retrospectively that they had already noticed these symptoms in childhood. When we checked the state of research, we found that there has been very little research on this topic in childhood. Especially in the German-speaking world, where there was not even a questionnaire for children that covered the topic. So far, it only exists in English. That was the impetus to deal with the topic in more detail.

esanum: Do you see the possibility that children get early illness anxiety "from home" - that is, from the way their parents deal with the subject of illness?

Özak: There are definitely connections. Of course, there are also general connections between parental and child psychological problems, where various factors play a role. However, there are results from illness anxiety research that focus on aspects such as parental overprotection, insecure attachment styles or certain genetic factors that can be influential on certain anxiety types. Of course, as with all psychological disorders, we assume that a large proportion could be due to "model learning" from the parents.

esanum: Can you explain the study design in more detail? Who can participate in it?

Özak: The study was actually conceived and planned before the COVID-19 pandemic. We had already started with the first data collection in school classes before COVID-19 started. Questionnaire surveys were conducted class by class, in which we only recorded the pupils. For our now modified online version, we have also put together a questionnaire package for the parents. We are looking for participants between the ages of 8 and 19. We start with the age of 8 because this is the earliest age at which children can be trusted to complete questionnaire surveys, but also because from this age onwards the concept of health and illness is slowly becoming more tangible. We go up to 19 years because this is the age when many finish school. We wanted to address students in particular, but not leave out the adults, because many (students) are still based at their parents' home until they finish school, and therefore have role model influences there.

We currently have an online format in which both children and parents can participate. Of course, it is best if both parties take part, because then the similarities between parents and children can also be examined. We survey different areas of psychological stress with different established questionnaires, both for the children and the parents. These include illness anxiety questionnaires, questionnaires on somatic symptoms, on general psychological stress, on depressive symptoms, or also surveys on fears and compulsions in the children - i.e. patterns that can be strongly featured as a comorbidity to illness anxiety. Basically, it has been shown that illness anxiety usually involves at least one other clinically significant mental disorder as a comorbidity. They rarely occur alone and in isolation.

esanum: Until when does the survey run?

Özak: We would like to run the survey in the general population until the end of April 2021. Possibly (depending a bit on the school situation) we would extend the survey period a bit more, because many children spend a lot of time in front of the computer at the moment anyway. The willingness to fill in something extra might not be very high. However, the current deadline is April 30th 2021. In case of doubt, the extension should run until the end of May, 2021.

At the same time, the project is being surveyed at our Centre for Psychotherapy in Frankfurt (in German: Zentrum für Psychotherapie in der Ambulanz für Kinder und Jugendliche), at the outpatient clinic for children and adolescents, so we still have a clinical sample for comparison. These are children who are being treated for various psychological disorders. In this setting, the survey will run until the end of June 2021.

esanum: Are there "warning signs" that paediatricians, for example, could use to recognise that their paediatric patients are about to develop particularly pronounced illness anxiety?

Özak: I think this is particularly apparent in the form of the classic "visiting the physician particularly often" to reassure themselves that a symptom does not perhaps mean something bad. This is essentially the same as in adults, but perhaps less obvious in children. Frequent visits to the doctor without any actual reasons being apparent would definitely be such a warning sign. But the same can also apply to the complete avoidance of visits to a physician, i.e. just not wanting to know what might be wrong. In general, illness anxiety can manifest itself in both directions. For the aspect of strong reassurance, it is also particularly important to involve the parents of paediatric patients: How often does the child ask the parents for an assessment of the physical symptoms? How often is parental reassurance needed to give guarantees to the child that nothing is wrong? 

esanum: Due to the ongoing COVID-19 pandemic, do you see an increased risk that more children will suffer long-term psychological consequences and develop, for example, severe forms of illness anxiety?

Özak: Stressful life events are definitely a possible predisposing factor or triggering factor for illness anxiety. We assume a model in which early experiences with diseases or medical treatment play a role, and in which a stressful or critical life event is then added - in addition to various other factors.

The current COVID-19 pandemic already fulfils both. The children have many more experiences with illness and medical treatment, either in the family environment or through the media. Critical events include measures such as quarantine or contact restrictions, which have already been shown to have a strong impact on children's psychological stress. This means that it can definitely be assumed that a different way of dealing with disease symptoms could occur, which may also be maintained in the longer term.

The Hamburg COPSY (Corona & Psyche) study shows, being the first large German children's Corona, for example, that fears already occur significantly more frequently and often have a recurrent or chronic course. Therefore, it can be assumed that the COVID-19 psychological effects will be felt for quite some time. At the same time, the study shows that the stress in the family system has a great influence and families in which the parents have a low level of education or who live in a confined space are particularly burdened. There, too, the consequences of the COVID-19 pandemic are not at all fully foreseeable. However, these are all factors that have an impact on children's mental health. Therefore, it can be assumed that the issue is not suddenly over with the end of the lockdown or the pandemic, but will have an impact on children’s everyday lives and their psyche.