ANXIETY IN CHILDREN
FROM: PSYCHOLOGY TODAY
Katherine Nguyen Williams Ph.D.
The Modern Child
Katherine Nguyen Williams Ph.D.
The Modern Child
When Your Child Experiences Anxiety
Helping your child manage worries and fears
Helping your child manage worries and fears
Anxiety is normal, adaptive, and crucial to our survival. It is an evolutionary trait designed to elicit the "fight-or-flight" stress response to aid in responding quickly to life-or-death or other dangerous situations. For example, when a child is walking home from school and an aggressive, unleashed dog jumps out at him, his natural stress response allows him to respond quickly to avoid danger.
In this modern age, there are many false alarms that signal danger when it doesn't exist. Unfortunately, the stress response continues to kick in during false alarms. The anxious child, who once had an aggressive dog interaction, is now fearful of all other dogs he encounters. Thus, the child begins to experience persistent stress responses when no real danger exists. When this happens repeatedly, it can cause the child to develop chronic anxiety that disrupts his normal functioning.
Anxiety disorders have become the most common mental health issue in the United States. Many anxiety disorders start in childhood and if untreated, they may persist into adulthood. Children may have more than one kind of anxiety disorder. Up to 6% of children and youth have an anxiety disorder severe enough to need treatment.
How do you know if your child is developing a problem with anxiety? Here are some common behaviors that indicate when anxiety should be worrisome:
When your child avoids activities they would otherwise prefer or enjoy doing.
When your child begins to avoid school, often by saying that they have a stomachache or headache.
When you see behavioral concerns (e.g., “meltdowns,” “tantrums”) especially in younger children, especially when they arise suddenly.
When the child experiences difficulty concentrating and/or changes in sleep, energy, appetite, and mood.
Pay attention to physical symptoms. Anxiety often co-occur with and mimic physical symptoms (gastritis, stomach pain, nausea, acid reflux, increased heart rate, heart attack).
If you find yourself spending a lot of time comforting your child.
If you feel like your family functioning is being disrupted by your child’s repeated fears and worries.
When your child persistently worries about embarrassing herself, leaving the house, getting sick, doing poorly in school, or separating from parents.
Why do children develop anxiety?
Often, there is a family (genetic) predisposition to anxiety. If a family member has a history of anxiety, the child does not necessarily develop anxiety, but rather, she has a higher probability of developing anxiety. The environment also plays a significant role. Anxious parents can unwittingly model anxious behaviors for children. In addition, children who live with too much stress can become anxious, such as chronic stressful situations in the family (e.g., contentious divorce), school/academics (e.g., learning problems, bullying), or neighborhood (e.g., high-crime) environment.
Studies show that children who experience traumatic or stressful events (e.g., car accidents, death of a loved one, abuse/neglect, hospitalizations) may develop an anxiety disorder. In addition, individual characteristics such as a shy temperament or perfectionist tendencies can be associated with anxiety. Further, lifestyle choices such as caffeine, alcohol, and drug use are contributing factors.
There are many types of anxiety:
Generalized Anxiety Disorder: Characterized by over 6 months of excessive worry about a variety of issues, and coupled with irritability, muscle tension, difficulty sleeping, low energy, restlessness, and/or difficulty concentrating. In children/teens, common fears include death, school, future (e.g., career, college), and peer/social interactions.
Social Anxiety: The child has a significant fear of being judged by others or negatively evaluated by others, including fear of embarrassing himself. Often coupled with the fear that others will be able to perceive he is feeling anxious. Usually, unfamiliar strangers are the trigger but this kind of anxiety can also be triggered by familiar peers and adults, such as teachers. Social anxiety can result in school avoidance or avoidance of extracurricular activities (e.g., sports, church, tutoring), and further, can result in avoidance of preferred activities (e.g., sports, birthday parties).
Separation Anxiety: The child experiences intense fear of leaving her parents, which is often coupled with the fear of harm befalling the parents. This type of anxiety is associated with the fear of going anywhere without the parents and the child asking for her parents to come with her everywhere. Often, the child may have nightmares of harm being caused to her parents.
Panic: Children who have panic disorder experience recurrent and unexpected panic attacks. They often develop a fear of recurring panic attacks. Symptoms often include: heart palpitations, difficulty breathing, sweating, fear of going crazy, and chest pain.
Other types of anxiety include: agoraphobia (fear of going outside), obsessive-compulsive disorder, specific phobias, selective mutism, and post-traumatic stress disorder.
What you can do to help your child when he is experiencing anxiety:
Help your child “avoid avoidance” with planned gradual exposure to things they fear.
Teach your child positive self-talk.
Teach your child basic relaxation strategies such as belly breathing and muscle relaxation.
Be patient and calm; try to not raise your voice or use a sharp tone.
Be positive about his ability to manage the situation (with support).
Help your child succeed by doing “small steps.”
Reward and praise your child’s efforts as well as successes.
Be a model for your child – manage your own anxieties.
Teach your child to visualize or imagine a pleasant and relaxing “happy place,” such as the beach, their room, or toy store.
Keep stress low or manageable at home. Avoid parental conflict when the children are present. Be calm and positive as much as possible.
Deal appropriately with external situations that require adult intervention, such as bullying.
Healthy living: sufficient sleep, regular routines, balanced diet, exercise.
Take time to have fun and relax with your child.
What to avoid doing when your child is feeling highly anxious:
Criticize or yell at your child.
Ignore the problem or wait for the child to get over it.
Make it easy for your child to avoid anything that scares them.
Tell the child to “toughen up.”
Tease or make fun of your child for anxiety.
Pressure your child to do more than she can do.
Have unrealistic expectations.
When to seek professional help:
If your child is having significant problems with school, missing a lot of school, or having other problems with daily functioning, you should talk to a child/adolescent psychologist who specializes in childhood anxiety. Contacting any general mental health provider is usually not enough. Be sure to find a mental health provider who has significant experience with anxious youth, who has training in evidence-based therapies in anxiety for children and adolescents, and who you and your child feel comfortable talking with during your first session. The good news is that anxiety disorders are highly treatable. The gold-standard, evidence-based treatment is cognitive behavior therapy with gradual exposures (CBT with EX). In CBT with EX, children/teens learn relaxation/mindfulness and stress management, more helpful ways of thinking about their fears/worries, and participate in gradual exposure to things that make them anxious in order to decrease their specific fears/worries.
In therapy, children and teens also learn constructive coping strategies to manage their anxious/stress response. Your child and adolescent therapist should also work with parents/caregivers and relevant school personnel to maximize treatment efficacy. While CBT is first-choice treatment, medication may be needed in severe situations. In this case, it is strongly recommended for children/teens to be treated by a psychiatrist who specializes in children and adolescents.
Anxiety and Depression Association of America
Association for Behavioral and Cognitive Therapies
Psychology Today Therapist Finder
Evidence-Based Parent Online Resource
Blankstein, K. R., & Dunkley, D. M. (2002). Evaluative concerns, self-critical, and personal standards perfectionism: A structural equation modeling strategy.
Goodyer, I. M., & Altham, P. M. E. (1991). Lifetime exit events and recent social and family adversities in anxious and depressed school-age children and adolescents—I. Journal of Affective Disorders, 21(4), 219-228.
Krohne, H. W. (1990). Developmental conditions of anxiety and coping: A two-process model of child-rearing effects. Psycholog. Inst., Abt. Persönlichkeitspsychologie.
About the Author
Katherine Nguyen Williams, Ph.D., is the Director of Strategic Development and Clinical Innovations at Rady Children's Hospital–San Diego and Associate Clinical Professor of Psychiatry at UC San Diego.