Anxiety can be a fascinating emotion. In moderation, it’s a useful tool; in excess, it’s a burden and can be debilitating. It’s one of the most commonly diagnosed mental disorders in children and adolescents and can take many forms or be misdiagnosed as a behavior problem. There are several means of managing anxiety, both therapeutically and through lifestyle modifications.
Types of Anxiety in Children
The Yerkes-Dodson Law1 states that there is an optimal amount of nervousness or anxiety that motivates us. After that, however, it begins to get in the way of our ability to think clearly and be successful. What happens when someone’s anxiety creeps up and starts impeding their success? Usually, we see an anxiety disorder start to develop.
According to the Centers for Disease Control and Prevention (CDC), just over 7% of children in the United States between the ages of 3 and 17 have been diagnosed with an anxiety disorder, a statistic that has been increasing over time.2 Anxiety also masquerades as other potential diagnoses, like Attention-Deficit Hyperactivity Disorder (ADHD) or Oppositional Defiant Disorder (ODD). It’s important to understand and distinguish between these presentations to provide the best possible support for your child. The most commonly diagnosed anxiety disorders include Generalized Anxiety Disorder, Social Anxiety, and Specific Phobias. In younger children, Separation Anxiety is also very common.3
Generalized Anxiety Disorder
Children with Generalized Anxiety Disorder (GAD) are often described by others as general “worriers” and sometimes “perfectionists.” Their worry transcends across various situations, settings, and circumstances and occurs more often and with more intensity than same-aged peers. They often like to have control and may organize their belongings or develop their own lists, schedules, etc. They also may not always understand that they are “anxious,” but may only be able to notice that they feel better when things are within their control (removing as much ambiguity as possible so they can be prepared). The life of the child or the functioning of the family is impaired by the anxiety.
Evenings and sleep are typically most difficult for children with GAD, as it’s the time of day where there are fewer distractions and their minds have the time and space to focus more directly on worries: Did I say/do the wrong thing earlier? What if things go horribly wrong tomorrow? They may look for excess comfort and reassurance and prefer co-sleeping with caregivers or siblings over sleeping alone, though the relief from these accommodations is usually only temporary. Children with GAD also typically report more physical manifestations of anxiety, such as headaches or stomach issues.
Social Anxiety is focused worry about social interactions. Rather than nervousness about a variety of topics like in GAD, the socially anxious child or adolescent attends exclusively to the judgments of others. They are typically terrified of embarrassing themselves in some way, resulting in others perceiving them negatively and/or ridiculing them. A child who is socially anxious will typically defer to others, refrain from having an opinion (lest it be “wrong”), and may potentially avoid social interaction altogether. After all, you can’t be judged negatively if you’re not judged at all, right?
It is possible for someone who is socially anxious to engage with others, speak in front of groups, or perform among a crowd, but they often do so under extreme distress. They may sweat excessively, stutter when trying to speak or perform, experience dry mouth, or appear shaky. In younger children, social anxiety may present as Selective Mutism, which consists of a child’s failure to speak in certain situations despite the expectation for them to do so. They will, however, speak openly and fluently in more comfortable settings.
Specific Phobias are what people refer to when they say that they have “something-something-phobia” (e.g., triskaidekaphobia/fear of the number 13, arachnophobia/fear of spiders, etc.). Children are expected to be afraid of things they first encounter or that are largely unfamiliar to them, especially those that we evolved as a species to fear naturally (e.g., dangerous animals, insects, heights, etc.). However, with an appropriate amount of reassurance and modeling from trusted caregiver(s), and with increased understanding, these fears typically subside.
For some children, however, they do not. Further, when a child experiences a severe negative event (e.g., being bit by a dog), they are more likely to develop a fear related to the experience. When the idea of being near a feared stimulus (e.g., a bee, medical shot/needle, thunderstorm) is even so much as mentioned and the child reacts with significant distress or upset, they may be exhibiting signs of a specific phobia. They will often go to great lengths to avoid coming into contact with the feared stimulus, which inadvertently reinforces their fear: they are unable to experience any successful coping of exposure to the feared object. That, combined with a temporary feeling of relief from their avoidance of it, ultimately strengthens the phobia.
Other Less Common Anxiety Disorders
Other anxiety disorders that children may experience include:
- Separation Anxiety occurs when a child experiences the distress symptoms of anxiety (as listed above) in response to being apart from their caregiver(s)/attachment figures.
- Selective Mutism is a child’s refusal to speak in certain contexts, despite showing the ability to and freely doing so in more comfortable environments.
- Panic Disorder captures a purely physical manifestation of anxiety, when a child experiences panic attacks and becomes fearful of their continued occurrence.
- Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, and Adjustment Disorder include an anxiety component in their presentation, but are not, in fact, considered anxiety disorders. They are now viewed as “Trauma- and Stressor-Related Disorders.”4
Signs of Anxiety in Children: What It Looks Like
Unfortunately, anxiety sometimes hides behind other behaviors that are often misdiagnosed as another disorder. For example, children with anxiety struggle to stay focused. As a result, they don’t pay close attention to detail. They may interrupt to get their worries out quickly and don’t appear to follow directions. They could also have “nervous energy,” frequently failing to remain seated or still when expected to do so.
A child with these behaviors might meet the diagnostic criteria for ADHD, but when the source of their behavior is explored further, an anxiety disorder could more accurately capture their experience. Treatment goals can therefore be tailored to the root of the behavior.
Other common behaviors that may reflect anxiety in children include:
- Avoidance or extreme panic or distress when encountering feared stimuli (e.g., racing heart, clammy hands, sweating, dry mouth, shaky hands/body, warm/hot face)
- Psychosomatic symptoms (e.g., headaches, stomachaches, gastrointestinal issues, chest pain, dizziness) without any known medical cause5
- A persistent and unrelenting need for control and/or perfection
- An unwillingness to be flexible when plans change, sometimes resulting in tantrum-like behavior
- Difficulty falling or staying asleep
- Nightmares and/or night terrors
- A need for constant comfort and reassurance6
Symptoms of Anxiety in Children
Each of the anxiety disorders has its own set of symptoms; however, there is significant overlap among them. Anxiety is the brain confusing non-threatening situations with those that are actually dangerous, and the fight-or-flight response is activated.
The more common symptoms of anxiety include:
- Persistent and excessive panic or distress when either directly experiencing or anticipating a feared stimulus, situation, or circumstance
- Worries and/or fears feel impossible to control
- Extreme irritability, especially in response to non-structured settings
- Fear is out of proportion to the actual threat posed
- Recurrent avoidance of the object or experience
- Presence of symptoms for an extended period of time (often more than 6 months)
- Experience must cause significant distress or impairment in areas of functioning (e.g., academic, social)
Symptoms must not be better accounted for by a medical condition or other diagnosable mental/behavioral health disorder. (e.g., Autism Spectrum Disorder)4
Causes & Triggers of Anxiety in Children
The causes of anxiety disorders are considered a combination of both nature and nurture. One popular theory involves what’s called the “diathesis-stress” model, which suggests that there is an underlying genetic or developed irregularity (“diathesis”) that puts a child at risk. This, in combination with an inability to cope with an acute life event (“stress”), is what leads to the development of an anxiety disorder. Therefore, without the predisposition and/or with successful coping of aversive life stressors, there is less of a chance of acquiring an anxiety disorder.7
Genetics and brain chemistry are considered two of the most common factors that contribute to a predisposition for anxiety. Children with close family members who also have an anxiety disorder are more likely to experience one themselves. Genes can also impact the production of certain neurotransmitters (chemicals) in the brain that, when in excess, short supply, or are not functioning properly, can also cause an extreme anxiety response. Children with a behaviorally inhibited temperament or who appear shy may also be at an increased risk.
Significant life events and reinforcement of avoidance behavior can trigger and/or exacerbate existing anxiety.
Life events that can increase a child’s risk for developing an anxiety disorder include:
- Loss of a loved one or attachment figure
- Changes in familial structure
- Witnessing or experiencing violence or abuse
These are typically more challenging to cope with and therefore may place a child at an increased risk. However, even seemingly insignificant situations can trigger an anxiety response, such as experiencing pain when receiving a shot or being stung by an insect.8
In addition, caregivers often inadvertently reinforce their children’s avoidance of anxiety producing triggers. When a child is acting shy and their caregiver continually speaks for them, a pattern may develop that prevents them from building their confidence in managing their anxiety, perpetuating it instead. Being overprotective, keeping excessive control over their children, and struggling to manage their own anxiety are a few other ways that caregivers can negatively impact their child’s experience of anxiety.
Treatment of Anxiety in Children
There are a number of different approaches to treating anxiety in children and adolescents. For some, their anxiety may be so severe that only pharmacotherapy (i.e. medication) will reduce their symptoms enough to be able to engage in psychotherapy. Although medications show some effectiveness in treating anxiety, they often do not independently lead to the same long-term effects that psychotherapy and lifestyle changes can produce.
The most common evidence-based form of psychotherapy (i.e. talk therapy) for anxiety in children is Cognitive Behavior Therapy (CBT). Although the exact structure of the therapy itself is tailored to the individual, manualized protocols (e.g., Coping Cat) for each anxiety disorder are often available to mental health providers.
The cognitive component of CBT challenges negative automatic thoughts and assumptions (e.g., I’m going to fall on my face; I’ll never be able to handle it if I don’t do well on the test). This is done through identifying, analyzing (e.g., what’s the actual probability of the event occurring the way it’s anticipated?), and developing more balanced and rational thinking, called reframing.
The behavioral component typically includes learning and mastering various relaxation strategies, followed by engaging in planned and gradual exposures. The relaxation techniques are designed to help control any physical symptoms of panic or upset, which are most effective when practiced in tandem with reframed thoughts. These are especially important during exposures to feared objects or situations.
Exposures can either be gradual or all at once for an extended period (known as “flooding”), both of which have been supported as efficacious in research. In a gradual exposure, the child and therapist create a hierarchy of feared situations, objects, etc., ranking them on a 1-10 scale with easier items low on the scale. One by one the child is introduced to the feared stimuli while engaging in relaxation and cognitive reframing. Once a low-ranked item is “mastered,” the next item on the tiered list is tackled. Over time, this creates a new association with each of the feared circumstances, and the child learns that the threat they had perceived is not actually any danger to them.9
Therapy is most successful when caregivers are involved, reinforce the skills being learned, encourage practice between therapy appointments, and model and support the use of the skills without compensating for the child’s efforts. Each child and their presentation will differ; however, CBT is generally intended to be a short-term therapy approach with initial results often seen between 3 and 6 months of weekly sessions.10
Medication is another intervention some caregivers might consider when attempting to alleviate their child’s anxiety. These are most often prescribed through a primary care pediatrician or psychiatrist. Although a few lesser-prescribed medications (e.g., stimulants, alpha-two agonists, antipsychotics) show some effectiveness in treating specific symptoms, they are less likely to address anxiety as a whole.
There are two more commonly prescribed medications that have research support:
In particular, Selective Serotonin Reuptake Inhibitors (SSRIs) and/or Selective Norepinephrine Reuptake Inhibitors (SNRIs). Both of these work on the chemical neurotransmitters in the brain, blocking their disposal so they remain in the brain longer. Improvement is often seen within a few weeks for more severe forms of anxiety, and for some individuals this relief supports better engagement in more long-term strategies such as CBT. There is significant scientific support for the combination of medication and therapy for the most successful outcomes.
These function as a sedative, acting by increasing the effects of the chemical Gamma Amino Butyric Acid (GABA). Although also effective, particularly for severe anxiety, benzodiazepines can become addictive. Further, people often build up a tolerance to this type of medication, leading to continual increases in dosage. There is stronger scientific support for the longer-term effectiveness of Antidepressants, making those the preferred pharmacotherapeutic intervention over Benzodiazepines.11 Many pediatric providers will be reluctant to prescribe this category of medication to their patients.
Lifestyle changes may also produce a reduction in anxiety, including:
- Diet & exercise: The 8th edition (2015-2020) of the Dietary Guidelines for Americans outlines the appropriate amount of physical activity and nutrition for the best overall health outcomes. Regular, moderate exercise has been shown to decrease current anxiety and to prevent future episodes.
- Sleep: Anyone who has suffered from too little sleep knows the impact it can have on mood, concentration, and ability to tolerate everyday tasks and events; this is exacerbated in someone who also suffers from anxiety.
- Social support: Feeling validated and having a place to release stress is invaluable. There is evidence to suggest that having just one close attachment figure may be enough to limit the effects of negative life events.
- Positive outlook and gratitude: Practicing gratitude can help shift a negative experience into at minimum a neutral one. When a child is encouraged to notice and appreciate little things on a regular basis, they develop resilience when faced with challenges.
- Structure and organization: The more predictable something is, the easier it is to prepare for, both literally and mentally. Having a regular schedule posted somewhere for all family members to see, keeping living and work spaces tidy with labeled places for items, and getting things ready in advance (e.g., packing a backpack the night before) are just a few ways to provide some relief at home.12
How to Get Help for Your Child With Anxiety
There are various ways to seek support for a child struggling with anxiety. At times, a teacher will notice anxious behavior and reach out, either directly or through a school counselor. Some schools provide adjustment counselors for children who struggle with mental health challenges in the academic setting. Many schools promote social and emotional learning to help children build confidence and manage interpersonal relationships, which can result in decreased symptoms of anxiety. If they feel a child would benefit from additional interventions, they typically reach out to the caregiver(s) to discuss options.
Some families choose to begin with their primary care provider or pediatrician. They may prefer to rule out medical causes for their child’s symptoms and trust the referrals provided by their family physician. Others will ask close family members or friends for referrals to a therapist or agency. Some folks will simply conduct an internet search, looking for specific criteria in a person they choose to work with their child.
Regardless of the means to get to a clinician, what’s most important is the fit between the provider and the family. Not every therapist will connect well with the child or be the most effective for their needs. Request consultations, ask questions that are important to you, set up a meeting between the clinician and the child, if possible, and don’t be afraid to “shop around” until a good fit is found.
Practical Ways to Help Your Child Cope With Anxiety
In addition to the lifestyle changes listed above, there are a number of methods to help an anxious individual through the caregiver-child relationship. Children often learn and model directly from their caregivers, who have the opportunity to demonstrate and encourage effective coping strategies.
Five ways to help a child cope with anxiety include:
1. Help Them Relax
Anyone told to “calm down” isn’t likely to do so by command alone; they need to actually be calm before they can make sense of the world. The same is true for children. Sit with them and take deep breaths together. Use a grounding technique and ask them to name all of the things in the room that are one color. Or have them identify 5 things they can see, 4 things they can feel, 3 things they can hear, 2 things they can smell, and 1 thing they can taste. These techniques should be practiced regularly so that the child feels comfortable trying them when they are anxious.
2. Discuss What Upset Them
Rather than providing logical responses to their fears, ask them to consider these themselves (e.g., what do you think is really likely to happen if you make a mistake when presenting in front of the class?)
3. Validate Their Worries and Concerns
Even if it’s difficult for you to understand their logic, find their truth. For example, “I know the loud sound of the thunder scares you. It’s a big boom, it really can be startling!” It’s much easier to tell a child why they don’t need to be afraid, but it can leave them feeling like they can’t trust themselves, which can have negative effects.13
4. Allow Children the Illusion of Control Whenever Possible
If they need to clean up a big mess, ask them which they’d like to clean up first, the crayons or the Legos. Instead of feeling like they have no control over having to clean, they focus on which choice they prefer, giving them a sense of control. When it’s difficult to find two options, resorting to “would you like to do it yourself, or would you rather I help you?” is an easy way to build in a choice (and often gets the job done faster!).
5. Help Children Approach (Not Avoid) Feared Stimuli
Provide them with support by letting them know you love them very much, acknowledging that what they have to do is difficult for them, remind them that you have complete confidence in their ability to handle what they are faced with (within reason), and let them know what you will do to support them (other than allow them to avoid it). Celebrate victory. Reward success.
Childhood Anxiety Statistics
As we learn more, the statistics on anxiety in children and adolescents are constantly changing, with recent spikes as a result of the COVID-19 pandemic, particularly among teenagers.14
Overall, research has shown that with children in the United States aged 3-17:2
- 7.1% (approximately 4.4 million) experience an anxiety disorder
- Of those with anxiety, more than 1 in 3 experience behavior issues (37.9%) or depression (32.3%)
- Being diagnosed with an anxiety disorder has been increasing over time (5.5% in 2007; 6.4% in 2011-2012)
- When broken down by age, only 1.5% are age 3-5, just over 6% are age 6-11, and more than 10% are between the ages of 12 and 17
- Six out of ten (59.3%) receive treatment for their anxiety
The National Institute of Mental Health (NIMH) estimates that close to 32% of adolescents (age 13-18) experience an anxiety disorder at one point during their adolescent years, with a higher rate for females (38%) than males (26.1%). Of all psychiatric diagnoses among this population, anxiety is the most common.15
For Further Reading
For more information and resources related to anxiety in this population, visit the following sites:
- Mental Health America offers screening tools for both parents and youth.
- The Child Anxiety Network provides information and direction specific to anxiety in children and adolescents, including coping items, strategies, and resources for both caregivers and professionals.
- Freedom From Fear offers a comprehensive information and resource guide for individuals affected by depression, anxiety, and other related disorders.
- The Anxiety and Depression Association of America provides a full page of information and resources related to child and adolescent anxiety and depression.
- Recently, the CDC and The National Academies of Science, Engineering, and Medicine formed an alliance in response to the COVID-19 pandemic to create web-based cognitive-behavioral tools for parents, children, and adolescents to reduce stress and anxiety. This project is in-process, but more information can be found here. Check back regularly for updates.
- Art Therapy for Children & Teens: How It Works, Examples, & Effectiveness