All kids have fears. Your baby may panic if a stranger picks her up. Your toddler may be afraid of dogs. Your third grader may get a stomachache the day he's starting a new school. But some kids worry a lot more than others. It's always painful to watch a child suffer from anxiety, but it's especially difficult if you're not sure whether she's worrying too much and might need help.
The difference between normal worry and an anxiety disorder is severity. Although feeling anxious is a natural reaction to a stressful or dangerous situation, a child may need help if his anxiety is out of proportion, if it persists, or if it interferes with his life and healthy development.
Signs That a Child Is Anxious
A young child who is overwhelmed by worries may not realize that those worries are unrealistic or exaggerated, and he may not express them, except by his behavior. If he's anxious that something might happen to a parent, he may have trouble separating, or falling asleep. If he can't stop worrying about getting sick, he might seek constant reassurance, or wash his hands obsessively.
Children who have severe anxiety will also try to avoid the thing that triggers it. If a child refuses to participate in activities other children enjoy; if she throws a tantrum before every appointment with the dentist or doctor appointment; if she gets sick on Sunday nights, or spends a great deal of time in the school nurse's office, serious anxiety may be the culprit.
Separation Anxiety Disorder
If the prospect of being separated from parents or caregivers causes a child extreme distress, she may have separation anxiety disorder. Difficulty separating is normal in early childhood; it becomes a disorder if the fear and anxiety interfere with age-appropriate behavior, whether it's letting a parent out of her sight at 18 months or being dropped off at school at age 7.
A child with separation anxiety might have an extremely difficult time saying goodbye to her parents, being alone on one floor of the house, or going to sleep in a darkened room, because she is terrified that something will happen to her or her family if they are separated. She might avoid playdates and birthday parties; at home, she might "shadow" one parent constantly. She might experience stomachaches, headaches, and dizziness in anticipation of the separation.
Generalized Anxiety Disorder
If a child seems to worry too much, in a pervasive way, about ordinary, everyday things, he might have something called generalized anxiety disorder. This kind of anxiety is often focused on performance in school or sports -- Will I pass the test? What if I don't play well? Will I get into a good college? It may drive extreme studying or practicing, making the child "his own tyrant," in the words of one Child Mind Institute clinician.
Kids with GAD worry incessantly about their ability to meet expectations. They tend to seek reassurance in an attempt to assuage their fears (Will we get there on time? What if I can't fall asleep the night before the test?) and they can be rigid and irritable. The stress they experience can lead to physical symptoms, including fatigue, stomachaches, and headaches.
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If a child isn't anxious in general, but is excessively fearful of a particular object or situation, he may have a specific phobia. This crippling fear will manifest when he's confronted by the thing -- dogs, clowns, loud noises, water, insects, the dark -- either directly or indirectly, such as seeing an image or hearing a song about it.
Children with specific phobias will anticipate and avoid the thing that triggers their fear, which can severely limit their activities. They may cry or throw tantrums to avoid the object of their distress, or experience physical symptoms like trembling, dizziness, and sweating.
Social Anxiety Disorder
Most children are occasionally shy or self-conscious, but when a child (usually a teenager) is excessively worried about doing something embarrassing, or being judged negatively, she may have social anxiety disorder. Fear of doing something that may cause humiliation may prompt a child to avoid school or other social situations, and to cry or throw tantrums when pressured to go.
Some children have social anxiety focused on performing -- speaking in class, for instance, or ordering in restaurants and shopping in stores. Others also have anxiety in social situations even when they're not in the spotlight, which makes them fear going to school, eating in public, and using public restrooms.
If a child is talkative in the privacy of home but unable to speak in school and other social situations, she may have selective mutism. Parents and teachers sometimes interpret this silence as willful, but the child is actually paralyzed by extreme self-consciousness.
Selective mutism can cause a child severe distress -- she can't communicate even if she is in pain, or needs to use the bathroom -- and can prevent her from participating in school and other activities. Some children seem frozen, like deer in the headlights, when they are called upon to speak. Others will use gestures, facial expressions, and nodding to communicate without talking. Even at home, some will fall silent when anyone other than a family member is present.
Selective Mutism: How Shy Is Too Shy?
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Obsessive-Compulsive Disorder (OCD)
If a child is plagued with intense fears, and feels compelled to perform repetitive rituals to make them go away, he may have obsessive-compulsive disorder. Children with OCD are overwhelmed by unwanted thoughts and fears (obsessions), which they defuse, or neutralize, by repetitive actions (compulsions).
Common obsessions are fear of contamination, fear that they or someone close to them will be harmed, and fear that they themselves will do something terrible. They may compulsively wash their hands, lock and relock doors, or touch parts of their bodies symmetrically to neutralize the fear and make themselves comfortable. They may also repeatedly ask questions and seek reassurance, and they may insist that others participate in their rituals.
What to Do If Your Child May Need Help
The first step in seeking help for a child is an evaluation. The clinician you see should have diagnostic expertise and should explain the sources of information she's going to use. It's a good idea to keep track of the behaviors that worry you and when they occur, to help identify possible triggers. A brief office visit with your child is not sufficient for a diagnosis.
In choosing a professional to treat your child, it's best to find someone trained to work with children -- a board certified child and adolescent psychiatrist, or a licensed psychologist. The clinician should explain clearly what a therapy entails, what it's effective for, why he recommends it, and the extent of his training and experience with it.
For a list of child and adolescent psychiatrists around the country, go to AACAP.org.
For more on signs of childhood psychiatric and learning disorders, the latest treatments, and strategies for parenting anxious kids, go to childmind.org.
Published with permission of the Child Mind Institute, 2011.