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Fear is an emotional response that is a normal part of development and essential to human survival. It is both protective and adaptive. In times of danger or anticipated risk, the sympathetic nervous system is activated and prepares the body to fight or flee the dangerous situation. Fear is short lived, which makes it different from mood states such as anxiety. Anxiety is often thought of as a secondary emotion in response to a primary emotional reaction (eg, fear). For example, people become anxious if they are fearful about a specific event, object, or situation and anticipate negative outcomes. Anxiety requires more cognitive capacities than fear. The fight-flight response may be activated when anxiety and fear appear even when there is no real danger but negative outcomes are anticipated. Such anticipatory fear, when persistent and pervasive, extends beyond normative levels of fear and anxiety and can be debilitating.

The focus of fear and anxiety changes over time as children explore their world and encounter new situations and stimuli. During infancy, fear is usually expressed as crying and limb reactivity to loud noises and novel stimuli. As infants begin to discriminate known faces from unfamiliar ones, stranger anxiety emerges (usually by 7–9 months of age). During this stage, the infant becomes very reactive (crying, muscle tension, flailing limbs, etc) to unfamiliar people. Simultaneously, bonds with primary attachment figures are typically being strengthened, and eventually separation anxiety becomes predominant (ie, child may cry when parent or other primary attachment figure is away even in the presence of other familiar adults). Separation fears are common between 1 and 3 years of age and gradually resolve by age 5 with experience that parents return after separations and a newfound awareness that objects continue to exist even when you cannot see them. From about 4 to 7 years of age, as children continue to become acquainted with their surroundings and more imaginative in their thinking, fears of new and unfamiliar situations as well as real and imagined dangers (eg, spiders, monsters, ghosts, the dark, dogs) become more prominent.

With increased learning and exposure to information obtained at school, children’s fears often become more reality based. For example, fears of fires, storms, natural disasters, kidnapping, illness, plane crashes, and crime are common during this stage. Preadolescence and adolescence are characterized by increasing autonomy and individuation from parents as well as greater emphasis on peer relationships. Social comparisons, peer status, and social acceptance become increasingly important during this time, resulting in more social fears. Abstract thinking also becomes more developed during adolescence, which allows the teenager to worry about many hypothetical situations as well as issues regarding self-identity, morality, and the future. Substantial deviations from this developmental sequence may signify the presence of problematic anxiety.

Fears and anxiety are manifested in various ways. Some children may appear visibly nervous. Others may hide their feelings, freeze in a situation, or express their anxiety as anger or ...

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