Anxiety in Children

Anxiety is a normal and adaptive part of being human. We rely on anxiety to alert us to potentially dangerous or adverse situations. An adult who is anxious about losing her job may find ways to improve her performance at work, and keep her job. Feelings of anxiety while walking down a dark street alone may keep us alert to an approaching threat. Anxiety becomes a problem when it is present in situations which are not threatening. Worrying that each person who approaches us intends us harm, as we walk down the street in broad daylight, is not reasonable. Excessive anxiety can prevent us from fully participating in life, and make normal routines a struggle. When anxiety becomes a problem that affects daily functioning and impinges on the ability to experience happiness and satisfaction, it may meet the criteria for an anxiety disorder.

Even very young children experience anxiety. Separation anxiety is observed in infants as young as 8 months. As with adults, some anxiety in children is a normal part of development. Young children are changing at a rapid rate, and must integrate new abilities and knowledge quickly. Simply learning to walk can create a worrisome situation for a toddler. He can suddenly move around on his own, and leave the proximity of his caregiver to explore the world. On the one hand, the world looks inviting and fascinating; on the other hand, leaving the safety of a parent’s immediate vicinity is potentially perilous. It is not uncommon to see an increase in anxiety in children as they struggle to reconcile competing desires for autonomy and security. Normal anxiety that accompanies the developmental process tends to fade when children adjust to new experiences and abilities.

Some children seem to be born worriers. They approach most situations with anxiety, especially new situations. They hang back when other children charge ahead; they cling to parents; they cry or tantrum when their routines are upset; they have many worries and fears – of the dark, monsters, robbers, germs, etc. Anxiety seems to be part of their personalities, and is always present to some degree. Sometimes children with anxious temperaments can find ways to manage their anxiety so that they function well at home, school, and with peers. Other children need help developing coping skills so that their anxiety does not prevent them from pursuing and enjoying the activities of childhood.

Young children cannot always tell us when they feel anxious. They just know that they feel terrible. Anxiety in young children can manifest in many ways:

1. An excessive need for routine and structure.
2. Refusing to participate in activities that should be enjoyable.
3. Tantrums when events do not unfold according to the child’s expectations.
4. Unreasonable fears and/or frequent thoughts about danger in the environment.
5. Panic when separated from caregivers.
6. Clingy and demanding.
7. Cannot be alone in a room, even when a parent is nearby.
8. Sleep difficulties – trouble falling asleep, nightly awakenings, nightmares.
9. Need for control in most situations.
10. Aggression towards others.
11. Difficulties with focus and concentration.
12. Over reacts to environmental input.
13. Moody and/or irritable.
14. Physical complaints with no medical origins, such as stomachaches, headaches, etc.
15. School refusal.

Keep in mind that many of these behaviors can be present in other mental health disorders as well, and are not unique to anxiety.

If you think that anxiety is preventing your child from fully participating in and enjoying appropriate activities, or interfering with school performance or peer relationships, it is advisable to bring your child to a mental health professional for an evaluation.

An appropriate evaluation involves the clinician spending time with parents or caregivers to get a developmental history and address specific concerns, and spending time with the child. This may happen at the same session, or at different sessions. A thorough evaluation will assess your child in many developmental arenas – physical development, cognitive strengths and weaknesses, emotional health, social development, attachment to caregivers, behavior, coping skills, language skills, and sensory processing. The clinician will also want to know about any family history of anxiety or other mental health problems, and any major life events or traumas experienced by the child.

If your child is diagnosed with an anxiety disorder, there are a range of treatment options to consider with your mental health provider. These may include therapy, medication, behavior plans, and strategies parents can implement at home to help their child cope.

Raising a child with anxiety is challenging. On the one hand, parents don’t want to validate unreasonable fears by always accommodating the child’s worries. On the other hand, parents don’t want to overwhelm their child and send him or her into a panic. Setting appropriate expectations, while providing empathy and support, can be difficult for parents of anxious children.

While each child is different, and responds to different strategies, below are some general guidelines for helping your child manage anxiety.

1. Create a daily routine for your child, and try to stick to it as much as possible.

2. Spend some time either the night before or in the morning rehearsing the day with your child. Go over what will happen that day, when it will happen, and anticipate any possible changes in plans or challenges the day presents.

3. If you anticipate that events or tasks during the day will be difficult for your child to manage, make an action plan so your child has some strategies to help her get through the challenge. For example, if you expect your child will have a hard time getting on the school bus in the morning, your action plan might look like this: Let’s get to the bus stop five minutes early so we aren’t rushed and tense. If Anna is there you can talk to her and ask her to sit next to you. If Anna isn’t there, you and I will take turns telling each other a story. When you see the bus coming, you will take 5 slow breaths and say, “All my friends ride the bus, and I can too. I am strong and brave.” Just before you get on the bus, I will give you a note (or picture) that you can look at when you are in your seat. Then you can talk with your friends or look out the window and tell yourself what a good job you did.

4. Give your child a five minute warning before transitioning to the next activity.

5. Give your child choices whenever possible. For example: would you like to do your homework now, or have a snack and do your homework in 15 minutes? Don’t give choices that will backfire, like, “Do you want to do your homework or watch TV first?” There will surely be a battle about turning off the TV to get homework done. Appropriate choices give your child a sense of control over his life.

6. Rather than give in to unreasonable worries, present your child with options: i.e. “The rest of the family wants to go to the amusement park, but if you are too worried to go with us, you can stay home with a sitter.” Or: “I know you get worried about going upstairs without me, but there is really nothing bad up there. You can take this whistle with you and blow it if there is really any trouble upstairs, and I’ll race right there.”

7. Give your child coping statements to say to herself when she is anxious, like “nothing bad is happening” or “I can do it even though I’m worried.”

8. Help your child practice relaxation techniques, such as deep breathing, muscle relaxation, and visualizing a calming place. Invest in a meditation tape for children to help your child learn to control runaway worries, and inhibit the adrenaline rush that accompanies fear.

9. Help your child make a “worry box” to put her worries into. Give her five minutes a day to be her “worry time” when she can talk about whatever worries are on her mind. Write the worries down and put them in the worry box when the time is up. Close the lid, and instruct your child to leave the worries in the box until the next worry time.

10. Help your child develop self-awareness about his anxiety. Talk with him about his tendency to worry more than he needs to. Be empathic about how uncomfortable this is for him. Don’t criticize – he can’t help it. Reassure him that everyone worries, and although it doesn’t feel good, worries aren’t dangerous.

11. Teach your child to think logically about worries. Identify the fear underlying the worry. If your child is worried about getting on the school bus, explore what she is afraid of – is she worried she will be bullied, or that the bus will have an accident, or that she will get off at the wrong stop? Then think logically about her fears. How likely is the situation that is causing the anxiety to occur? If it does occur, how much damage will there be? What can she do if the situation occurs? Most of the time the things that make us anxious are either unlikely to happen, or unlikely to result in serious consequences like injury or death. Keeping anxiety in perspective is an important skill for a child to learn.

If you work on these strategies with your child, and anxiety still interferes with his or her functioning, it’s time to seek counseling. Most children who struggle with anxiety are relieved to be getting help, once they get over their anxiety about what therapy will be like. It’s important to find a therapist whose personality and approach feel comfortable to both you and your child.

Anxiety does not usually go away completely, but your child can develop coping skills that help manage anxiety so that it does not affect the quality of your child’s life.

Libby Robbins, Ph.D