Anxiety in Children: When to Worry About Your Child's Worries
All kids have fears, whether they’re scared of a dark bedroom, a new school year, or the neighbor’s dog. Most will simply complain about these worries and move on. But about 7 percent of children aged 3-17 have an anxiety disorder, according to the Centers for Disease Control and Prevention (CDC), and these seemingly trivial things can be debilitating for them.
Indeed, for children with anxiety, worries generally get more intense over time instead of naturally fading away. "No matter how much you answer an anxious child's questions or tell her things are fine, she can't absorb your reassurances," explains Tamar Chansky, Ph.D., author of Freeing Your Child From Anxiety. In severe cases, kids with anxiety may stop eating, sleeping, or going to school. At the very least, their instability can set them apart from their peers—often at an age when fitting in is crucial.
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If you think your child has anxiety, read on to learn more about the causes, symptoms, and treatment options for the common disorder.
What Causes Childhood Anxiety?
Your child’s anxiety is "just the luck of the genetic draw," explains psychologist Steven Kurtz, Ph.D., president of Kurtz Psychology Consulting in New York City, who specializes in childhood anxiety. "There's a sort of smoke detector in your head that's supposed to go off when the brain perceives danger, and it triggers the fight-or-flight response," says Dr. Kurtz. "In anxious kids, their smoke detector is set to a much more sensitive level, and they also have a much more dramatic reaction." In fact, research has shown that differences in stress response can be detected in babies as young as 6 weeks old, proving that nature is at least as important as nurture when it comes to anxiety.
There's a family connection too: Kids with an anxious parent are up to seven times more likely to have an anxiety disorder compared with kids whose parents are not anxious. The link is both biological and behavioral, explains Golda Ginsburg, Ph.D., professor of psychiatry at the University of Connecticut. "There is an inherited risk, but when parents are overprotective or model their own fears, they increase their child's risk of anxiety."
Difficult situations—like the death of a relative, moving, or even the stress of having an unemployed parent—can also push manageable anxiety into a full-blown disorder. "A major event can sometimes make a child feel like everything in life is changing and nothing is predictable," explains Dr. Chansky.
Signs of Anxiety in Children
Even happy-go-lucky kids tend to worry more once they hit age 7 or 8, as they gain a greater understanding of the world around them and realize how much isn't in their control. "At this age, there's a shift from monster-under-the-bed kind of worries to real-life ones, whether it's that a natural disaster will strike or that they'll let the baseball team down," says Jenn Berman, Psy.D., Parents advisor and author of The A to Z Guide to Raising Happy, Confident Kids.
The difference between normal worry and an anxiety disorder is severity. A young child may not realize her worries are unrealistic or exaggerated, and she may only express them through behavior. If he's anxious that something might happen to a parent, for example, 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 avoid triggers. If a child refuses to participate in activities other children enjoy, throws a tantrum before every appointment with the dentist or doctor, gets sick on Sunday nights, or spends a great deal of time in the school nurse's office, serious anxiety may be the culprit.
Other anxiety symptoms in children include headaches or stomachaches without medical origin, trouble sleeping, and acting out. Your child might also ask fear-driven questions that get worse over time. For example, it's perfectly normal for a child to ask, "Can that happen to us?" after seeing a news report about a house fire; it's not normal to obsess about that fire several months later.
Types of Anxiety Disorders in Children
Anxiety in kids can manifest as several different disorders, and many children have a combination of the following conditions.
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is excessive worry about everyday things, as well as a tendency to imagine the worst-case scenario. GAD often focuses 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.
Kids with GAD worry incessantly about their ability to meet expectations. They often 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. Their stress can lead to physical symptoms, including fatigue, stomachaches, and headaches.
Social Anxiety Disorder
A child with social anxiety fears meeting or talking to people. Most children are occasionally shy or self-conscious, but when a kid is excessively worried about doing something embarrassing or being judged negatively, she may have this disorder. Social anxiety 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—for example, speaking in class or ordering in restaurants. Others may get anxious even when they're not in the spotlight, which makes them fear going to school, eating in public, and using public restrooms.
A child with selective mutism talks easily with family and friends, but she gets so anxious in front of others that she can't speak at all. Peers, teachers, and authority figures sometimes interpret this silence as willful, but the child is actually paralyzed by extreme self-consciousness.
Selective mutism can cause a child severe distress, since she can't communicate even if she’s in pain or needs to use the bathroom. It can also 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, children with selective mutism may fall silent when anyone other than a family member is present.
Separation Anxiety Disorder
If separation from parents or caregivers causes extreme distress, your child 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 extreme difficulty 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. Separation anxiety could also trigger stomachaches, headaches, and dizziness in anticipation of the separation.
Obsessive-Compulsive Disorder (OCD)
If a child is plagued with intense fears, and feels compelled to perform repetitive rituals to make them go away, she may have obsessive-compulsive disorder (OCD). Children with OCD are overwhelmed by unwanted thoughts and fears (obsessions), which they defuse by repetitive actions (compulsions). For example, a girl might be afraid of burglars robbing the house, but someone with OCD believes burglars will come unless she touches everything in her room.
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. Children 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.
A phobia is an illogical, all-consuming fear about a particular object or situation (dogs, clowns, loud noises, water, insects, the dark, etc.) This crippling fear will manifest when your child is confronted by the trigger directly or indirectly, such as seeing an image or hearing a song about it.
Children with specific phobias will anticipate and avoid their trigger, 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.
Diagnosing Anxiety in Kids
Anxiety in toddlers and children often goes undiagnosed. "Many parents think that their child will grow out of his issues or that it's normal for a child to be nervous," says Wendy Silverman, Ph.D., director of the Program for Anxiety Disorders at the Yale School of Medicine.
However, anxiety disorders make children's lives harder and limit the experiences they can have. "It's unlikely that a child will outgrow an anxiety disorder," says Rinad Beidas, Ph.D., associate professor of psychology at the Perelman School of Medicine at the University of Pennsylvania. "When it's left untreated, she'll have a higher risk of substance abuse later."
If you think anxiety is interfering with your child's ability to function, seek services early instead of waiting it out. Ask your pediatrician or school guidance counselor for a referral to an expert and schedule an evaluation. The clinician you see should have diagnostic expertise and should explain the sources of information she's going to use. We recommend a board certified child and adolescent psychiatrist, or a licensed psychologist.
Treat this meeting with the same matter-of-fact attitude as you would when taking your child to the doctor for a sore throat, says Dr. Kurtz. Explain the visit to your child using the same words he uses to tell you about his problems: "We're going to talk to someone who can teach you how not to worry at bedtime," for example. It's also a good idea to keep track of worrisome behaviors and when they occur, which might help identify possible triggers.
How to Help Your Anxious Kid
Fortunately, anxiety is one of the most treatable psychological disorders in kids. The most common treatment options are cognitive behavioral therapy and medication.
Cognitive Behavioral Therapy
For many kids, especially those in the early stages of an anxiety disorder, cognitive behavioral therapy (CBT) can improve symptoms within a few weeks or months. While CBT won't eliminate anxiety completely, it teaches children to recognize what they're feeling and manage those reactions.
A child who has an obsessive fear of germs, for example, may learn to notice when his heart beats faster at the sight of someone coughing and to take deep breaths to calm down. He'll also learn coping techniques, such as telling himself, "Millions of people touch things every day and don't get sick." Finally, he'll be exposed little by little to his fear—going with the therapist to a public bathroom and touching the sink and then the toilet handle.
How often and how long your child receives CBT depends on the severity of his disorder.
Drug therapy might be recommended when a child isn't making progress with talk therapy alone, or if the anxiety is severely impacting eating and sleeping. Medication makes many parents uncomfortable, but doctors urge them to look at the big picture. "If a child's symptoms have overwhelmed her capacity to cope and her parents' ability to help her, then it's appropriate to consider every option available," says Anthony Charuvastra, M.D., assistant professor of child and adolescent psychiatry at NYU Langone Health. In fact, certain medications can often be an essential part of a child's treatment, he adds.
For children with severe anxiety, two types of medication have been found to be especially effective: SSRIs and benzodiazepines.
Selective serotonin reuptake inhibitors (SSRIs): These antidepressants increase levels of serotonin, which is a naturally occurring chemical in the brain that regulates moods. Examples are Prozac and Zoloft.
Benzodiazepines: These anti-anxiety drugs also work, but they’re used less frequently because they’re linked to hyperactivity in young kids. They can also become less effective over time, says Dr. Charuvastra.
Common side effects for all anxiety medications include mild headaches, nausea, irritability, or sedation. If symptoms don’t subside within a few weeks, the prescription or dosage can be adjusted, Dr. Charuvastra says. Talk to your doctor if you find that your child's behavior or personality seems drastically (and negatively) different after starting medication.
Anxiety Treatment at Home
If your child seems anxious but it's not interfering with his everyday life, you might try helping at home first. Here are some tactics.
Help your child confront his fears. All parents instinctively want to protect and comfort their kids; if your child screams hysterically whenever a dog walks by, for example, you might try to keep him far away from canines. However, "doing that may make things easier in the short run, but it reinforces his fear," says Dr. Ginsburg. "Instead, he needs to confront the fear and work on his skills to manage it." You can help your child take small steps, like watching dogs from a distance and then petting a puppy on a leash. With each victory, celebrate your child's bravery with a small reward, like ten extra minutes on the Xbox.
Find out what’s causing the anxiety. Before reassuring your child in anxious situations, find out specifically what he's fretting about first, says Dr. Chansky. Consider a child who’s anxious about starting school in a new city. "You may be tempted to say, 'Don't worry. No one is going to be mean to you at school,' when in reality he was really worried about finding his way around. Now you've given him something new to worry about." To figure out his specific concern, ask, "What do you think is going to happen?" Then think of several things that the two of you can do ahead of time to help ease his fear.
Establish a bedtime routine. At bedtime, develop a calming ritual. Rather than allowing TV or other screens, have your child read a calming book or do relaxation exercises.
Teach him to self-soothe. Tell your child about self-soothing techniques he can practice whenever his stomach is in knots, like deep breathing, counting backwards, or visualizing what he wants to happen. "I tell kids that the worry in their head is one channel on the radio station in their brain, but they can change it whenever they want," says Jeremy Schneider, a family therapist in New York City. "If they're worrying about not making the baseball team, they can just change the station to their own voice and focus on last year's vacation or they can think about the people who love them."
Evaluate your own mental health. Consider how your own anxiety might be affecting your child. Screaming at the sight of a bug in your room, for example, will teach him to be afraid of bugs too. So if you've been waiting for a good reason to seek help for your own anxious behavior, this may be it.