Anxiety in Children: Signs, Symptoms, & Treatments

What Is Anxiety?

While occasional anxiety is a normal part of life, anxiety disorders are defined by intense feelings of worry that persist and sometimes worsen over time. These feelings can significantly interfere with a person’s life, preventing them from engaging in their daily routines, work commitments, and relationships. Anxiety disorders include generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and specific phobias.¹

How Many Kids Have Anxiety?

Millions of children are struggling with an anxiety disorder. According to the CDC, over 9% of all children ages 3-17 had diagnosed anxiety between 2016-2019.² Rates of anxiety have also increased steadily over time. The NIMH found that nearly 32% of adolescents have an anxiety disorder.³ With anxiety so prevalent in children and teens, it is important to know what signs to look for.

Signs of Anxiety in Children

Unfortunately, anxiety sometimes hides behind other behaviors that are often misdiagnosed as another disorder. For example, children with anxiety often struggle to stay focused, not paying close attention to detail. They may interrupt to get their worries out quickly and don’t appear to follow directions. 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.

Signs of anxiety in kids can include:^4,5

• 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 cause
• 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
• Crying
• Nightmares and/or night terrors
• A need for constant comfort and reassurance

Symptoms of Anxiety in Children

Anxiety is the brain confusing non-threatening situations with those that are actually dangerous, and the fight-or-flight response is activated. Each distinct anxiety disorder has its own set of symptoms; however, there is significant overlap among them.

The most common symptoms of anxiety in children 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 six 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. (like ADHD or autism).⁶

Types of Anxiety in Children

The most commonly diagnosed anxiety disorders include generalized anxiety disorder, social anxiety, and specific phobias. In younger children, separation anxiety is also very common.⁹

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 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).

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

Social anxiety involves 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.

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

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.

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.

Other Less Common Anxiety Disorders

Other anxiety disorders that children may experience include:⁶

• 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.”

What Causes 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.¹⁰

Genetics

Genetics and brain chemistry are considered two of the most common factors that contribute to a predisposition for anxiety. Anxiety’s genetic component means that 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 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.

Stressful Life Events

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.¹¹

Learned Behavior From Caregivers

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.

Managing Symptoms of Anxiety in Children

There are a number of methods to help an anxious child, including modeling healthy behaviors and helping them get to the bottom of what’s causing their anxiety. Children often learn and model directly from their caregivers, who have the opportunity to demonstrate and encourage effective coping strategies.

Here are several ways to help a child cope with anxiety:

Identify Their Triggers & Don’t Minimize Them

The first step in helping a child cope with anxiety is to identify their triggers. Noticing what seems to trigger your child’s anxious feelings can empower them to better understand their anxiety, and begin to think through their worries and find coping strategies that work for them. When parents validate their child’s worries, rather than dismiss or minimize them, it offers children much-needed understanding and compassion for their emotional experience, which is very real for them.

Preview Any Anxiety-Provoking Situations When Possible

For children who struggle with social anxiety or specific phobias, talking through anxiety-provoking situations before they happen can give a child a sense of control and mastery, easing their fears. For a child who is anxious about starting school, for example, visiting the classroom and the teacher ahead of time can be helpful, as can talking through their daily routine and what to expect. Role-playing situations together can also support a child through an anxiety-inducing scenario, equipping them with language and coping tools to help them in the moment.

Communicate Positive (But Realistic) Expectations

Giving your child a “just right” challenge to build self-esteem can communicate your faith in them. Using positive praise and affirmation to acknowledge their efforts helps your child feel supported and seen, regardless of the outcome. When they run into a problem, you can problem-solve together, helping them to build valuable skills.

Try to Limit an Anticipation Period

Anticipatory anxiety can be debilitating for some children, so reducing the anticipation period for triggering tasks or situations can help ease your child’s worries. One way of doing this is to break down big, overwhelming tasks into smaller ones, giving the child a sense of accomplishment and mastery along the way.

Don’t Ask Leading Questions

When you talk with your child about their anxiety, try to stick to open-ended questions that don’t lead a child to a yes or no answer, but instead open up a child-led discussion. Leading questions, like “does [this situation] make you anxious?” might cause your child to feel pressured, embarrassed, or self-conscious. By keeping questions open-ended, your child feels empowered to take the lead on better understanding and sharing their experience of anxiety.

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.

Help Them Think Through the Entire Anxiety-Provoking Situation

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?).

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.¹²

Allow Children 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!).

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, reminding them that you have complete confidence in their ability to handle what they are faced with (within reason), and letting them know what you will do to support them (other than allow them to avoid it). Celebrate victory. Reward success.

Take Extra Care of Their Physical Health

Regular, moderate exercise has been shown to decrease current anxiety and to prevent future episodes. 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.

Model a 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.

Help Them Have a Predictable Home Life

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.

When Is Child Anxiety a Problem?

While everyone experiences some anxiety in life, children suffering from severe, persistent anxiety need help to heal their worries. Parents might wonder how to know if their child’s anxiety is a problem requiring action.

The most important sign to look for when a child is struggling with anxiety is disruption in their daily activities. If a child is unable to maintain their daily lifestyle – personal hygiene, school attendance and performance, social relationships, personal interests, etc. – then it is important to seek professional help.

Here are a few other signs to look for indicating that your child may need professional help to deal with their anxiety:²

• Being very afraid to separate from parents
• Having intense fear about a specific thing or situation (e.g., spiders, doctor visits)
• Avoiding school, extracurricular activities, or playdates
• Expressing worries about the future or bad things happening
• Experiencing intense episodes of anxiety with somatic symptoms like heart pounding, chest pain, trouble breathing, dizziness, sweating or shaking
• Increase in anger or irritability
• Difficulty sleeping
• Ongoing fatigue, headaches, or stomachaches

Child Anxiety Treatment

There are a number of different approaches to treating anxiety in children and adolescents. For some, their anxiety may be so severe that only 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.

Therapy

The most common evidence-based form of psychotherapy for anxiety in children is CBT for kids. Although the exact structure of the therapy itself is tailored to the individual, manualized protocols for each anxiety disorder are often available to mental health providers.

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 3-6 months of weekly sessions.¹⁴

Medication

Medication is another intervention some caregivers might consider when attempting to alleviate their child’s anxiety. Anxiety medication is 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.

How to Get Help for Your Anxious Child

There are various ways to seek support for a child struggling with anxiety. 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 through an online therapist directory, 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.

School Support for Children 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.

Can Anxiety in Children Be Prevented?

While some factors that come to play in the development of childhood anxiety cannot be prevented, like biology and temperament, there are some things parents can do to help protect their children from anxiety. Research shows that children who are the victims of trauma, abuse, or chronic stress are more likely to experience anxiety. This includes children who experience bullying and social rejection from peers. Parental anxiety also puts children at risk of developing an anxiety disorder of their own. Protecting children from as many adverse childhood events as possible, while modeling healthy coping strategies when faced with stress or anxiety of their own, can empower parents to give their children the healthiest emotional advantage against anxiety.²

For children who are at risk, early intervention is key. Some parenting programs help those with young children to gain valuable insight and skills to prevent anxiety from developing later on.¹⁶ Seeking professional help right away for children who may be experiencing an anxiety disorder, and working together as a family to support them in identifying their anxiety triggers and practicing positive coping strategies in a supportive, nurturing home environment, will set any child up for success in managing their feelings of anxiety.

Childhood Anxiety Statistics

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.³

Overall, research has shown that with children in the United States aged 3-17:⁸

• 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