Written by: Erin Mongiello
Let’s talk about the A word. Anxiety. It’s everywhere, and it seems like everyone has “anxiety.” But what is anxiety, really? There is a clear differentiation between normal nerves and fears and clinically diagnosable anxiety. So, how do we tell the difference in our kids, and when is it time to talk to a professional?
To start, the question clinicians ask themselves when determining if there is a diagnosis of anxiety is, does it impair the child’s ability to function physically, socially, and occupationally? i.e., school, daycare, and work for teens. When there is a diagnosable anxiety disorder, you will almost always see extreme distress and avoidance of the thing that makes them anxious. For example, a child may throw extreme tantrums and experience full-blown panic at the thought of separation from a caregiver (going to school, mom and dad leaving for work, etc) because of fear of harm coming to their loved one, or they may vehemently avoid attending birthday parties or participating in extracurricular activities because they fear embarrassment in social situations.
The Many Faces of Anxiety
There are many types of anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders (the manual used by clinicians to identify criteria for a diagnosis). We’ve broken down some of these disorders that are most common in children. Here are signs to look out for when determining next steps for your child.
Separation Anxiety, most often seen in younger children, can look like:
- Being very afraid when away from parents - panic or tantrums
- Constant thoughts and intense fears about the safety of parents and caretakers
- Refusing to go to school
- Frequent stomachaches and other physical complaints
- Extreme worries about sleeping away from home
- Being overly clingy
- Trouble sleeping or nightmares
Phobias look like extreme fear about a specific thing or situation, such as dogs, insects, or going to the doctor .
Social Anxiety, most often seen in older children, can look like:
- Being irrationally afraid of school
- Fears of meeting or talking to people
- Avoidance of social situations
- Few friends outside the family
General Anxiety Disorder (GAD) can look like:
- Being very worried about the future and bad things happening (general anxiety)
- Many worries about things before they happen
- Constant worries or concerns about family, school, friends, or activities
Panic Disorder is determined by the presence of manic attacks which look like:
- Having repeated episodes of sudden, unexpected, intense fear that come with symptoms like heart pounding, having trouble breathing, or feeling dizzy, shaky, or sweaty (panic disorder)
Post-Traumatic Stress Disorder (PTSD), Selective Mutism and Obsessive Compulsive Disorder (OCD) are also anxiety disorders but appear less often in children.
When Anxiety Is Good and When It Becomes Problematic
All children experience some anxiety. Anxious feelings can help children and teens learn to process the world around them and cope with life’s challenges. Anxiety in children is expected, normal at specific times in development and is considered appropriate rather than alarming. Children will have fears that come and go throughout their lives. Anxiety is healthy and normal in a situation where a child encounters a new situation, and they need some time to learn about it, work with it, and get used to it. For example, a child who has never met a dog before, for instance, might be fearful of interacting with even a friendly pup but given some time to observe the dog, learn about its behavior and understand that the dog is not a threat, the child’s anxiety level will lower.
Sometimes anxiety is valuable and can help both children and adults navigate dangerous scenarios. Feeling anxious or worried is necessary to be a human being. Normal levels of anxiety can help us stay vigilant and identify threats to safety. For example, If you didn't feel nervous when you got to the edge of the cliff, you’d be in trouble.
Anxiety can prove beneficial even in social situations. If a child witnesses a friend being teased, her anxiety over seeing such mistreatment may compel her to step in to comfort or defend her friend. We've gotten to a point where we think anxiety means that we, as parents, have done something wrong, but there are certain circumstances where we hope our kids will feel anxious.
However, some kids develop more severe or chronic anxiety, which can prevent them from performing well in school, maintaining social relationships, and developing normal, healthy functioning like consistent daily hygiene, good sleep habits, nutritious eating, and regular exercise. We recommend talking to your pediatrician or seeking a consultation with a child therapist at these points.
What Makes Kids Anxious?
And no, mom and dad, you don’t CAUSE your children to be anxious.
Both genetic and environmental factors contribute to the risk of an anxiety disorder. Research shows that biology, biochemistry, life situations, and learned behaviors play a role. Many anxious kids have anxious family members, and children model behaviors based on what they see. Parental behavior can exacerbate and worsen a child’s problems, but that’s not the same as saying that parents cause the child to have the problem in the first place. Much depends on the child’s nature, innate sensitivity, experiences, and family dynamics. Also, unusual stress, like moving, divorce, a death in the family, or other traumatic events such as witnessing a car accident or domestic violence, can set off an anxiety disorder.
What are signs that my child may have higher-than-normal levels of anxiety?
- Your child does not outgrow the fears and worries that are typical in young children
- Your child may exhibit fear and worry but also irritability and anger
- Your child has interruptions to their sleep patterns or trouble sleeping in general
- You child may complain frequently of physiological symptoms like fatigue, headaches, or stomachaches
Often, anxious children are overly tense or uptight. With toddlers and young children, parents may notice increased irritability, excessive crying, tantrums, and more difficulty self-soothing or self-regulating.
Children may also exhibit regressive behaviors such as bed-wetting (assuming the child is toilet-trained) or excessive clinginess.
In all age groups, Children with anxiety disorders may exhibit physical symptoms in addition to stomachaches and headaches like frequent bathroom urges, rapid breathing, chest pains, shortness of breath, nausea and vomiting, muscle aches and tension, and gagging or choking. They may also demonstrate a poor appetite.
Psychological and behavioral symptoms include frequent reassurance-seeking, needing things done precisely the same way and in the same order (rigidity), feeling irrationally threatened, experiencing overwhelm by new experiences, and avoiding any situation— school, people and places, events, social gatherings— that triggers or fuels their anxiety.
Children may also become hypervigilant, which means the child is on high alert, constantly monitoring their environment and keeping tabs on everything around them. Hypervigilant children often misinterpret innocuous cues as signs of danger. While surveilling the room is a helpful talent for spies, for a child, it’s exhausting.
Other symptoms of anxiety in children include repetitive, unwanted thoughts (obsessions) or actions (compulsions), fears of embarrassment or making mistakes, and low self-esteem and lack of self-confidence.
What are “appropriate” fears of children by age?
Infants and toddlers will typically experience anxiety around separation from caregivers, strangers, and loud noises. Two to three year olds will typically demonstrate fear of animals, darkness, thunder and lightning, fire and water. At four to five, children will frequently have fears of bugs, getting lost, monsters and death. Among the five to seven year old age range, we often see anxiety surrounding germs, illness, natural disasters and school. In the adolescent stage of seven to twelve, performance anxiety, social situations, burglars, kidnapping and war rank among common anxieties.
It is important to note that children with Attention Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) will often have a wider range of anxieties and are more prone to anxiety disorders.
Early Intervention is Key
If left undiagnosed and untreated, a child with an anxiety disorder is at increased risk of engaging in dangerous behaviors, such as self-harm, substance abuse, and bullying, as they often develop negative coping strategies.
Anxiety is not a life sentence. Most children diagnosed with anxiety disorders will outgrow them, provided they live in supportive environments and get appropriate treatment. Severe anxiety problems in children can be treated.
Early treatment can prevent future difficulties, such as loss of friendships, failure to reach social and academic potential, and feelings of low self-esteem. Treatments may include a combination of the following: individual psychotherapy, family therapy, medications, behavioral treatments, and consultation with the school.
Caregivers can be hesitant when it comes to taking a child to see a therapist. This is often due to not knowing what to expect. In the first session, the clinician simply builds a rapport with the child and gets to know them. Often, parents expect answers and solutions right away, but to provide the best treatment for the child, the clinician must first get to know the child and build a foundation to build trust. We advise parents to be patient and honest with the therapist. We are there to work in TANDEM with you and are a TEAM. Also, an initial assessment does not mean you must go again. We empower you to find a clinician that meets the needs of your child and family, even if it takes time.
Life is full of challenges, unexpected obstacles, and difficult moments. Teaching children how to manage anxieties around those experiences will enable them to adapt and be resilient, no matter what life throws at them. The goal is not to eliminate the anxiety but to instill healthy coping strategies for handling anxious thoughts and feelings.
What Can I Do To Help?
It is crucial to express positive but realistic expectations and encourage the child to tolerate their anxiety. Think things through with the child and model healthy ways of managing anxiety. Be honest with the child in an age-appropriate way and without overwhelming them with too much information. Children need information delivered in a way that doesn't leave gaps in their understanding. When there are gaps, kids fill them in with their beliefs, which may be inaccurate and anxiety-producing. Due to COVID, for example, some children now consider the world beyond their home as dangerous because they haven't been given enough information.
Provide children, especially young children, with structure and predictability. The need is heightened if your child has General Anxiety Disorder and worries constantly about everything. For example, the child may obsess about what happens if Mom gets sick and can't pick the child up from school. Rather than telling the child that Mom never gets sick, the parent can say, “I’m not sick, but if I ever got sick, I’d work very hard to get well. And if I can’t pick you up, Aunt Jane will be there.” Or when taking the child to the doctor to get a shot. Don’t say, ‘it won’t hurt.’ Instead, say, ‘it might hurt a little, but I know you’re brave and can handle it.”
Our Favorite Tips From the Pros and The Parents
Focus on healthy habits. Sleep, nutrition, hydration, and exercise are of utmost importance when dealing with an anxious child. Lack of proper amount of sleep and lack of quality sleep exacerbates stress. Adequate time to decompress counts as rest and is necessary for children that may need more processing time than others. Ensure your child gets enough exercise, as movement provides an outlet and combats stress hormones. Hydration is necessary for our bodies and brains to function normally.
It’s okay to get frustrated as a parent during your kid's tantrums or anxious times. Try to model the calm behavior you would like to see in your child during a tense moment.
- Take slow, deep breaths from your belly.
- Remind yourself that your child’s behavior is due to their anxiety.
- Step away from the situation, if need be, to take a few moments to breathe and engage in a grounding technique, such as identifying five things you can see, four things you can touch, three things you can hear, two things you can smell and one thing you can taste.
Develop an anxiety plan. Regardless of your child’s anxiety, we recommend having an anxiety plan. In an ideal world, this will involve the parent, the child, and the child’s teacher. Once the school year begins, contact your child’s teacher to discuss his anxiety. NOTE: Some children with diagnosed anxiety disorders qualify for classroom accommodations.
Establish things your child can do to reduce anxiety. For example:
- For little ones, it can look like deep breaths in and slow breaths out using the imagery of “smell the flower, blow out the candle; smell the soup, cool down the soup” and more.
- For older kids, it can look like ocean breathing, where you breathe in and imagine the wave rolling in, breathe out and visualize the wave rolling out. The 4-4-4 method also works; inhale for a count of four, hold for a count of four and exhale for a count of four.
Progressive muscle relaxation.
- Beginning with hands or feet, tense the muscles for a count of five and slowly release. Next, move on to the arms and legs and move up the body, repeating the tense/release pattern.
Using sensory objects like stress balls to relieve tension.
- Stress balls can help establish self-awareness, aid in grounding, and can be helpful when using techniques like deep breathing and teaching progressive muscle relaxation.
- Little kids can use techniques like identifying five colors they see, four shapes they see, three soft things they see, two people they see, and one book they see.
- For adolescents, ABC Around The Room is effective. The child looks around the room identifying an object for every letter of the alphabet.
- Teens can use versions of these, including the 5-4-3-2-1 method mentioned above for adults, which involves identifying, at that moment, five things you can see, four things you can touch, three things you can hear, two things you can smell, and one thing you can taste.
Other methods of relieving tension.
- These can include pulling on a theraband attached to a desk and doing wall pushups in the back of the room.
What Should I NOT Do?
We're so used to guiding our kids' behavior that we also try to guide their feelings. As we see time and time again, it doesn’t work—pressuring a child to feel a certain way may cause him to hide their real emotions, making it exponentially more challenging to recognize the seriousness of the problem. If our kids can't express their feelings to us and know they'll be heard, we will never know if they're experiencing genuine anxiety that needs attention.
Don’t avoid things just because they make the child anxious. This can backfire big time. Those limitations may add to their anxiety when children stop going to the pool with friends because they fear water or avoid sleepovers because they’re uncomfortable in the dark. It's really stressful not being able to do what other people do.
Don’t ask leading questions. We don’t want to provide new anxieties for the child that doesn’t exist already. For example, before the first day of school, don’t ask, “are you nervous about not having anyone to sit with at lunch?” or “are you feeling anxious because you don’t know your way around?” Questions like these can signal that the child should be anxious about these things.
Respect their feelings, but don’t reinforce fears. We talked about not dismissing fears or guiding the child to feel how we want them to, but we also don’t want to give positive reinforcement for these fears. We want to validate that our child is afraid because that feeling is very real to them. For example, if a caregiver stays home from work because a child is fearful of harm coming to them, this reinforces that there is something to be afraid of.
Avoid over-scheduling your child. Just like anxiety-free kids, anxious kids will feel pressured to join all the activities with their peers. It's good to encourage outside activities and time with friends. Still, teaching your child that part of managing anxiety is caring for yourself, knowing your limits, and setting boundaries are crucial. All kids, especially those with anxiety, need adjustment time to settle into routines and establish coping strategies for their anxious thoughts during the transition.
Where Do I Find a Therapist?
Your network is your best friend when searching for the right therapist. Ask your pediatrician or your child’s guidance counselor for referrals or ask your friends and family for recommendations based on personal experience. If you prefer to start from scratch, you can search for a therapist on Psychology Today or use the locator tool provided by the American Psychological Association.
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For more guidance on anxiety in your family, check out our All About Anxiety Course.