Supporting parents of pre-teen children with mild-moderate anxiety
Catherine Murphy and Elly Robinson - Parenting Research Centre, Australia, October 2019
- Pre-teen children (9-12 years) experience lots of changes; in physical appearance, friendships, school environment and family relationships.
- Children at this age tend to have a heightened awareness of local, national and global events/concerns, and increasingly use social media to connect with others. This can make them worry and put them at risk of anxiety.
- Parents often seek guidance about parenting during this time. Practitioners in generalist services can play an important role in promoting children’s health and wellbeing.
- It is important that practitioners in generalist services effectively support parents who have a child (9-12 years) experiencing mild-moderate anxiety.
- By being aware of anxiety in the pre-teen years and responding early to their experience of anxiety, practitioners may prevent pre-teens from developing severe and/or persisting anxiety or other mental health concerns in the future.
- What's happening for pre-teens?
- What are the signs of anxiety?
- What does anxiety involve?
- Is this 'just a phase' or are support services needed?
- How can you learn more about the child’s experience of anxiety?
- What can practitioners do to support a parent who has a pre-teen experiencing mild-moderate anxiety?
- When and how can you make an effective referral to a specialist service?
- Other resources & references
What is this resource about?
This practice guide provides information about anxiety in the pre-teen years (9-12 years). It aims to help practitioners in generalist services to better support parents who have a child experiencing mild-moderate anxiety.
For the purposes of this guide, pre-teens are defined as aged between 9-12 years, although slightly older or younger children may also face challenges that are relevant to this age group (e.g. early puberty). Parents are defined as a person undertaking the role of parenting and includes caregivers (e.g. grandparents, foster carers, kinship carers).
The resource covers:
- What is anxiety?
- What is happening for pre-teens?
- What are the signs of anxiety?
- What does anxiety involve?
- Is this ‘just a phase’ or are support services needed?
- How can practitioners support a parent caring for a pre-teen with anxiety?
- When and how can practitioners make effective referrals to a mental health service?
- How can parents support a child experiencing anxiety?
Who is this resource for?
This resource is for practitioners working with the parents of pre-teens who may be experiencing mild-moderate levels of anxiety. Practitioners may work in adult-focused agencies such as welfare, family support, health, drug and alcohol services, or other relevant services (e.g. GPs and paediatricians). These services can play a significant role in promoting children’s wellbeing and health by supporting parents in their parenting.
The two parent guides attached to this resource (Gathering information about your child’s experience of anxiety and Supporting your child) include specific strategies that can be employed by parents to identify and support mild-moderate anxiety.
If the parent (or child) tells you that the child:
- has experienced child abuse
- has experienced bullying
- is currently thinking or has recently had thoughts of ending their life or hurting themselves
- is currently or has previously attempted to harm themselves or other people
- has experienced a traumatic event
refer to your agency’s mandatory report guidelines, talk to your supervisor and/or refer this family to a child mental health service. If the child is in immediate danger, contact emergency services on 000.
What is anxiety?
Anxiety is our body’s natural response to a potential stress or threat. Anxiety can be useful – for example, someone feeling anxious about missing an early morning flight might pack their bag the night before and set an early alarm to avoid missing their flight.
There are also times when feeling anxious can protect us from danger. For example, when someone notices a snake nearby, feeling anxious will mean that they move far away from the snake to protect themselves.
Experiencing anxiety every now and again is a normal part of the human experience and most of the time these feelings come and go, and do not last long. Anxiety becomes a problem when it impacts on our wellbeing and prevents us from doing things that are important to us.
Children also experience anxiety. When children have worries that don’t go away, get worse or interfere with their daily life, it could be a sign of anxiety. Children may experience anxiety about different things as they develop. Young children may be anxious about separating from their parents and spending time with unfamiliar people. In the early school years, children may feel anxious about the dark, animals, monsters and ghosts.
There are a number of significant changes in a pre-teen’s life that can cause anxiety, such as primary to secondary school transition and the physical changes associated with puberty. While most children will adapt and cope well with these feelings, for others the experience is distressing and has significant impact on their wellbeing and that of their family. The way parents, and the services around families, respond to and support pre-teens with anxiety can make a positive difference for these children.
What's happening for pre-teens?
The pre-teen years have historically been considered a ‘latent’ period or a quiet time for development. Recent research, however, has drawn attention to the many physical, neurodevelopment and social changes that occur in these years (Evans-Whipp, Mundy, Canterford & Patton, 2017). Successful navigation of these changes, both by parents and children, positively influences later wellbeing.
Physical development at this age is highly variable. We often think of puberty as beginning with outwardly physical signs, such as breast development and growth of body hair. In fact, recent evidence points to puberty beginning as early as 6-8 years with the onset of the first, less visible pubertal processes (Dorn & Biro, 2011). The pubertal transition can result in increased body dissatisfaction in both males and females, especially those who mature earlier than their peers. Brain development is also highly active at this age, with a rapid period of reorganisation in the years leading up to adolescence (Hughes, Mundy, Romaniuk, Sawyer, Wake, Williams et al, 2018).
Primary to secondary school transition
Wellbeing in the middle years matters for learning and school engagement. Approximately 1 in 8 Year 7 students find the transition to secondary school difficult, in terms of academic studies, peer and teacher relationships and daily routines (Evans-Whipp et al, 2017). Children report that making new friends and missing old ones are the most difficult aspects of transition, and those prone to anxiety or worry are also at greater risk (Maguire & Yu, 2014). Parents report less confidence in managing the primary to secondary school transition than the transition from home/child-care into primary school (Wade, Almendingen & Robinson, 2019).
The transition from primary to secondary school usually means an adjustment from smaller, caring school environments with few teachers, to large and relatively impersonal ones with multiple teachers. This can create a developmental mismatch at a time when relationships with close, supportive adults are needed (Luthar & Ciciolla, 2016). The secondary school environment is also tailored to a student’s independence and personal responsibility, which may be confronting to parents who have been active participants in the primary school community.
Changes in family relationships
The pre-teen years herald a shift from dependent relationships with parents to an increasing desire for separation and individuation (Luthar & Ciciolla, 2016). Research suggests that this is the most challenging time for mothers as well, with maternal distress peaking and wellbeing reaching its lowest point when children are in the pre-teen phase. This is especially the case if parents are unfamiliar with developmental changes for this age group (Luthar & Ciciolla, 2016).
Pre-teens spend an increasing amount of time with peers and engaging in social events outside of the home, but parents are not replaced by peers. They continue to play a key role in guidance, advice, physical support and nurturing well into the young adult years (Vassallo, Smart & Price-Robertson, 2009).
Changes in social relationships
During the pre-teen years, children start to become highly concerned about their status in relation to peers (Luthar & Ciciolla, 2016) and interactions become more complex. Friendships are important but they can also be a source of anxiety and stress, and friendship instability is common in early adolescence (Poulin & Chan, 2010). School transition may involve the separation of friendship groups if children attend different schools.
Bullying is also highly prevalent in this age group – around 1 in 6 children aged 8-14 report at least one form of bullying weekly (Redmond et al, 2016). Exposure to bullying has a direct impact on children’s mental health (Singham, Viding & Schoeler, 2017).
Increasing use of technology
The use of devices in childhood is seen by parents as an increasing problem as their children become older. In a recent Victorian study, just over half of parents with 10-12 year old children felt they spend too much time on electronic devices, compared to just over a third for 6-9 year old children, and parents were moderately less likely to monitor or limit use (Wade, Almendingen & Robinson, 2019).
Social media use increases in the pre-teen years. One in six primary school-aged children have at least one social media account, and 1 in 8 use social media almost every day (Rhodes, 2017). Increasing use of social media brings both positives (e.g. feeling more connected to friends, more diverse friendships) and negatives (e.g. overwhelmed by the drama, pressure to look good to others, cyberbullying) (Anderson & Jiang, 2018). While prevalence of cyberbullying is difficult to determine, estimates indicate approximately 1 in 5 children have experienced it (Rhodes, 2017; Spears et al., 2014). Cyberbullying, like offline bullying, is associated with many mental health problems for children, including anxiety, depression and suicidal behaviours (Elgar, Napoletano, Saul, Dirks, Craig, Poteat et al., 2014).
Increasing awareness of and exposure to adverse events
As a result of cognitive growth and greater exposure to global issues via technology, pre-teens become increasingly aware of events both in their local and national (e.g. homelessness) and global communities (e.g. effects of climate change). Exposure to extreme weather events (e.g. drought) and the family stress and displacement that often accompany them, can increase children’s risk of mental health problems such as anxiety, depression and sleep disorders (Burke, Sanson & Van Hoorn, 2018). In-depth interviews with 10-12-year-olds in the US showed that more than 80% expressed strong feelings of fear, sadness and anger when discussing environmental problems (Strife, 2012).
How common is anxiety in pre-teens?
It is difficult to know the prevalence of anxiety in childhood. There is limited data, particularly on a national level. The 2015 Young Minds Matter survey on the national prevalence of mental health difficulties in children showed that of those aged 4-17 years, 7% of boys and 6.8% of girls had experienced an anxiety disorder in the previous 12 months (Lawrence, Johnson, Hafekost et. al., 2015). However, there is little insight regarding the prevalence of mild-moderate anxiety other than anecdotal evidence.
Studies show that some individuals inherit a temperament that makes them vulnerable to anxiety in later years. In one study, infants classified as ‘highly reactive’ (showing a combination of vigorous, frequent motor activity and frequent crying) were more than twice as likely to show anxious symptoms at 11 years old than those classified as ‘low reactive’ (infrequent motor activity, minimal crying) (Kagan, 2002). In other words, children who are prone to anxiety in later years may show indicative signs in infancy.
The combination of prevalence, developmental and psychosocial changes in the pre-teen years means that there is a rationale for greater awareness of and improved responses to anxiety signs and symptoms. Where anxiety is mild-moderate, there are simple strategies that universal services can adopt to support a child and their parent/s. This guide outlines these strategies.
What are the signs of anxiety?
When we experience anxiety, our body, feelings, actions and thoughts are affected. Pre-teens experience anxiety in a range of ways and at first it can be hard for adults to recognise anxiety in children of this age. Learning about how a child experiences anxiety will give their parents clues as to ways they can support their child, as well as when additional help may be needed.
The boxes below provide some examples of how children may experience and show anxiety.
“Am I normal?”
“I can’t do this. Why can’t I do this like everyone else? They’re going to think I’m hopeless.”
- “…the other kids don’t talk to me?”
- “…I can’t get through the speech?”
- “…I can’t get off the bus in time?”
- “…I fail this exam?”
- “…Dad is late dropping me off at school?”
- “…I don’t have the right clothes for school camp?”
- “…I don’t respond to Sarah’s message in time?”
“If (situation/event – above) happens then (something terrible – below) will happen.”
- “…I’ll never make any friends.”
- “…the teacher will yell at me and everyone will laugh.”
- “…I’ll have to move schools.”
- “…I’ll be late and get a detention.”
- “…my parents will ground me forever.”
- “…I’ll cry in front of everyone.”
- “…Sarah won’t invite me to the party and I’ll never make any friends.”
- “…I won’t get into the soccer competition.”
- Breathing fast (hyperventilating).
- Racing heart.
- Difficulty concentrating.
- Need to use the toilet.
- Stomach aches.
- Difficulty getting to sleep.
- Suddenly feeling hot or cold.
- Butterflies in the stomach.
- Vague and confused.
Common characteristics of anxious actions
- Avoiding or withdrawing from situations, objects or people that bring on anxious feelings.
- Seeking re-assurance from adults.
- Trying to control people or the situations that bring on feelings of anxiety.
- Saying they cannot participant in activities or events because they feel sick or are in pain (when there is no medical explanation).
- Refusing to do some activities that other children their age feel comfortable and confident doing (e.g. a short talk in their class, catching public transport independently, joining a club or interest group without knowing everyone else), even when encouraged to.
- Preferring to watch others do activities, rather than participate, even in familiar situations and with people the child knows.
- Asking other people to do an activity/task they don’t want to do for them.
- Making attempts or creating reasons to leave activities/situations early.
- Crying or showing aggressive behaviour (e.g. hitting, slamming doors, throwing or kicking things, yelling or swearing) when others insist the child participate in an activity/task.
- Holding their feelings together while at school or in public, then letting them out when at home. The way these emotions are expressed can vary, including: withdrawn behaviour (i.e. spending most of their time alone in their room); spending all their time with others (i.e. following their parent/s or sibling/s around the house); strong emotional behaviour (i.e. fighting with siblings or parents, swearing, yelling, crying).
- Repeatedly seeking assurance from adults by asking lots of questions, such as, “What’s going to happen?” and “What are we going to do if… happens?”
- Appearing to overstudy for exams and/or overpreparing for upcoming events.
- Frequently sharing worries they have about other people, their community and social issues.
What does anxiety involve?
How we think about an event, situation, person or object significantly influences our emotional experience and how we act. The image below illustrates how our thoughts, feelings, physical sensations and actions are linked to the experience of anxiety.
Example 1: Components of anxiety
Example 2: Peer group example
Example 3: Academic example
Is this 'just a phase' or are support services needed?
Anxiety occurs across a long continuum, from occasional ‘butterflies’ before a test, to feelings of panic which can be recurring and disabling. Even though most pre-teens who experience mild or occasional anxiety or worry will not need to see a mental health professional, parents’ responses to their child’s anxiety can make a big difference. Support and guidance from parents early on may mean that their child will not need to see a mental health professional in the future.
For children whose anxiety is significantly impacting their relationships, school achievement, wellbeing, and/or family functioning, seeking specialist support may be necessary. Learning more about the child’s experience of anxiety helps practitioners to decide when support from a mental health professional may be required.
This next section covers what practitioners can do or say with parents to gain a better understanding of their child’s experience, before deciding what action to take.
How can you learn more about the child’s experience of anxiety?
It’s important to gather information about the child’s experience of anxiety before making any decisions about the type of support. This information will help the practitioner and the parent to work through the decision tree in the next section. It’s important to ask questions about the:
- level of avoidance
- impact on the child.
Example questions practitioners can ask parents include:
- “Can you describe for me what happens when your child is feeling anxious? What sorts of things do they say or do?”
- “How often does your child get anxious?”
- “Do you think your child’s worries or fears are stopping them from pursuing activities or interests that they enjoy, spending time with their friends, going to school, or doing things as a family?”
- “If you were to rate the intensity of your child’s experience of anxiety on a scale of 0–10, with 0 being calm and relaxed with no anxiety, and 10 being terrified, how would you rate your child’s usual experience?”
- “How long does it take for your child to feel calm again after feeling anxious?”
- “How long has your child experienced anxiety?”
- “Do you know of any other children your child’s age who have similar experiences?”
It is important for children to share their experience of anxiety. Some parents may benefit from guidance about how to have these conversations with their child. You could say something like:
“Sounds like we need to get a better understanding of what’s happening for Ricky when he’s feeling anxious. I’ve got a handout here which outlines some tips about how you, or you and I together could get a better understanding from Ricky. Would you be interested in us working through this together?”
What do you do now?
Once you and the parent have an understanding of the child’s experience of anxiety, use the decision tree as a guide for what to do next.
This decision tree covers:
- when this resource is helpful for practitioners to gain an understanding of what is happening for the child, but no further action is required at that moment
- when this resource is helpful for practitioners in supporting a child with mild-moderate anxiety
- when parents should seek a GP referral to a mental health professional.
It should be worked through in collaboration with the parent.
What can practitioners do to support a parent who has a pre-teen experiencing mild-moderate anxiety?
You do not need to be an expert in parenting or anxiety to help a client whose pre-teen is experiencing anxiety. By building a trusting, collaborative relationship and familiarising yourself with the information in this guide, you can make a positive impact. This section covers some ways that practitioners can:
- invite a parent into a conversation about anxiety
- explore the impact of anxiety on the child and the family
- understand how parents have been supporting their child
- offer strategies for how a parent may be able to help their child (see Parent Guide 2: Supporting your child for information)
- provide support to the parent.
15 ways practitioners can help
- See your role as a coach to the parent.
As mentioned, you don’t need to be an expert in parenting or anxiety. Taking an interest in your client’s child, following up on their parenting concerns, offering strategies and working collaboratively with the parent to work through this issue can all have a big impact.
- Once you have been through the decision tree and have some understanding of the pre-teen’s anxiety experience, invite the parent to explore this issue further with you.
- As part of your sessions with a parent, ask them how their child with anxiety is going. In particular, ask questions to determine the intensity and impact of the anxiety.
For example: “Tell me how Alex felt about going to the birthday party last week without you?”
“Do you think his experience of anxiety is better, worse or the same as last week?”
Checking in with the parent shows that you are interested in their child’s wellbeing, and it gives you the opportunity to monitor any changes. If the anxiety does not get any better or becomes worse, refer back to the decision tree to decide next steps.
- Ask the parent what difference it would make to their life and their child’s life if the anxiety was reduced or no longer there.
“How would things be different for you and Mohammed if he was not feeling so anxious?”
“What do you think Eden would be doing if she was not experiencing anxiety?”
- Ask the parent what they have tried already to help their child and what impact (if any) it had. “What have you tried in the past that seemed to make a difference?”
“What do you think about trying that strategy again?”
“Has anything you’ve tried seemed to make things worse? Can you tell me what happened?”
- Share information about evidenced-informed options to help children with anxiety.
Some great places to start are:
Emerging Minds’ ‘Supporting your child’ parent guide
Raising Children Network
- Ask the parent if they would like to implement any of the options available.
“Of these options, are there any you think might help or are worth trying?”
- Share knowledge you have about anxiety and invite the parent’s responses.
“Gradually doing the things they feel anxious about helps children to learn that things may not be as bad as they thought, and that they can cope with those anxious feelings. To do this, it can be helpful for children to have some strategies for how to cope with anxious feelings. Would you be interested in us talking through some of those strategies?”
- Explore what will help the parent to use one of the strategies.
If the parent decides they are going to try a strategy, check:
– how the parent feels about giving that strategy a go
– if they need other types of support to help them use the strategy
– when they plan to start using the strategy.Exploring this will highlight any barriers that may get in the way of the parent following through on their intentions.“How do you expect this conversation with your son will go? I’m wondering if you’d find it helpful to talk through how you might raise this with him?”
“What might get in the way of you giving this a go?”
“When you have tried new parenting strategies in the past, what seemed to help?”
“Ok great, you seem pretty keen to check out these websites and learn more about anxiety. When do you think you can fit this in?”
- Prepare the parent for changes in the child’s actions. When parents start responding to their child differently and trying some of the strategies in the ‘Supporting your child’ parent guide, their child may in turn change how they act and respond to the parent and other family members. It’s important to let parents know that when they start using the strategies, children’s experience of anxiety may get worse before it gets better.Talk with the parent about how they can prepare for this likely initial increase in anxiety by thinking about:- the timing of starting the strategies (e.g. it may not be a good idea to start when family members are unwell or starting a new job)
– identifying people who can support the parent and child while they are first trying the new strategies
– involving the child in establishing a plan and deciding on strategies
– how the parent can be kind and compassionate to themselves while they are trying the new strategies.
- Check in with the parent in the next session. If a parent said that they were going to try one of the strategies, check in with them about how it went at their next session. “Did you end up practising the relaxation activity with Mohammed last week?”“Last time we spoke, you were planning to talk to Declan about writing down his anxious thoughts. How did you go with that?”
- If the parent did complete the action, explore with them the outcome it had and what their next steps are.
“That’s great that you and Mohammed developed a list of anxious situations that he’s going to gradually do. What was it like for you to do this?”
“What did you both learn from this?”
“What did Mohammed learn about anxious thoughts?”
“What’s next for you both now?”
- If the parent did not implement the strategy, gently ask what changed or got in the way. “Okay, last week you seemed pretty committed to talking with Jelesha and getting a better idea of when she feels anxious. What changed after you left our session?”
“What got in the way of practising the relaxation strategies?”
“Is reducing the reassurance you provide Jelesha still something that you want to do?”
“What could help you to do this next week?”
“Is there a support person who could help with this?”
“Is there anything I can do that may help?
- Parenting a child experiencing anxiety can be tiring, so it’s important to check in with the parent about how they are coping. “Alex’s anxiety is reducing; he is no longer asking you to travel with him on the bus to school. How are you going? You mentioned feeling pretty worn out the last time I saw you.”“While you have been trying to talk with Bree about this, it sounds like she’s still avoiding talking with you. I have to say, good on you for persisting. How are you feeling about things not improving as well as you would have liked? What do you think are the next steps?
- Involving the child. Parents may bring their child along to an appointment so that you and the parent can talk with the child together. When seeking information about the child’s experience, ask the child directly rather than asking the parent to respond for the child. Pre-teens are the experts on their internal experience of emotions and can give you and the parent helpful insights into what may help.The ‘Gathering information about your child’s experience of anxiety’ and ‘Supporting your child’ parent guides outline ways adults can talk with children to understand their experience.
What if parent anxiety is contributing to child anxiety?
It’s not uncommon for parents to be experiencing anxiety at the same time as their children. When parents are anxious around their children, it’s usually about the parent seeking to control the environment or situation in an effort to protect their children and to keep them safe.
By working with parents to understand how anxiety works, they may gain greater insight into their own experience, as well as that of their child. In some cases, parents reducing their anxiety response and demonstrating positive coping strategies may be important factors in reducing their child’s own experience of anxiety.
If the parent is experiencing a consistently high level of anxiety, a referral to mental health professional is advised.
What to do if child anxiety is contributing to parent anxiety
Children who experience anxiety can develop very convincing reasons why they should not do the things that they are anxious about. This can lead parents and other family members to feel anxious about those situations too, and then avoid doing those things that are anxiety-provoking. Over time, this increases child anxiety as they do not learn how to cope in those situations.
It is important for parents to keep encouraging and supporting their child’s gradual efforts to do the activities they feel anxious about. If the parent is experiencing a consistently high level of anxiety themselves, a referral to a mental health professional is advised.
When and how can you make an effective referral to a specialist service?
Some children and parents may need mental health support due to their unique circumstances and the nature and level of anxiety. In these situations, your role is to support the family to engage with another service. The decision tree you saw earlier steps through some scenarios of when it’s important to refer to a specialist mental health provider. Here are some additional tips:
- Inform the family early on that you can provide some information and suggestions about anxiety, but that if their child is experiencing high or distressing levels of anxiety, they should seek advice from a mental health professional.
- If you feel that the family’s needs are outside of your professional expertise and it’s not possible to have regular supervision, refer the family to another service.
- Provide options to the family so they can decide the course of action that best suits them. Options include seeking a referral to a psychologist via their GP; referral to a psychologist at their school (some schools have visiting psychologists); contacting their local community health centre; or accessing services through Headspace (if the child is aged 12 or over).
- When sharing information or options with parents, ensure it is evidence-based. Helpful and reliable websites include Beyondblue, Raising Children Network, Headspace and ReachOut. A full list of resources can be found at the end of this guide.
- Family circumstances can change quickly. As you build a trusting relationship with a parent, they may share more information with you. If you have a reasonable belief that the parent or child are at risk of harm, seek guidance from a supervisor and follow your agency’s policies regarding mandatory notification to child protection, the police, child mental health services or adult mental health services.
Other resources & references
More from Emerging Minds
- Why it is difficult for parents to talk with practitioners about their children’s mental health
- Sharing information with parents about children’s social and emotional wellbeing
- Child mental health (e-learning course)
- Building blocks for children’s social and emotional wellbeing (e-learning course)
Apps and websites for relaxation, mindfulness and thought-tracking exercises
Support services for pre-teens
Mental health and wellbeing screening tools
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