What Does Anxiety in Childhood Look Like?
A 9-year-old is the perfect student but destroys his bedroom and screams at his siblings after school. An 11-year-old snaps at her mother constantly, criticizing just about everything she does. A 10-year-old cries every morning before school and clings to his parents each time they attempt to drop him off at school, sports events or birthday parties. A 9-year-old experiences headaches that make it difficult to get out the door on time. An 8-year-old can’t fall asleep at night. Though all of these behaviors appear unrelated and present different challenges, they have one common thread: anxiety.
Anxiety disorders are on the rise among children, and anxiety tends to spike during the school year. A study published in the Journal of Developmental and Behavioral Pediatrics estimates that approximately 2 million American children and adolescents have a diagnosable anxiety disorder.
One of the difficult parts of getting help for children suffering from anxiety is that anxiety often presents as a constellation of negative behaviors. Parents and educators are quick to spot the behavior problem, but they don’t always see the underlying anxiety that drives it. “We tend to think of anxious children as these delicate little butterflies, but when kids are scared, they can be ferocious about trying to escape or avoid anxiety-provoking situations,” explains Eileen Kennedy-Moore, child psychologist and author of “Kid Confidence.”
The challenge often lies in the fact that kids might experience these emotions for the first time, without warning. They don’t necessarily know how to connect the dots between a racing heart, a stomach ache, feeling dizzy and anxiety.
“Children today are stressed on so many fronts: challenged socially, academically, having to cope with physical changes and development, the demands and influence of social media, trying to fit in and be accepted. It’s no wonder they show evidence of anxiety,” says Susan Newman, psychologist and author of “The Book of No.” “Parents should ask questions about anything they notice or want to understand to show their interest and love for their child. Children want to be heard and listened to, even if they tell you to stop being nosy.”
The good news in all of this is that child anxiety is very treatable, especially with early intervention. In learning to spot the sneaky signs of child anxiety, identify triggers of anxiety and teach kids coping skills, parents and educators can empower kids to manage their anxious feelings independently and thrive in social and academic settings.
Kids will respond differently to various triggers and events. To that end, it’s important to understand your child’s baseline. Most kids experience some anxiety at times.
Anxiety becomes problematic when it interferes with a child’s daily functioning. If anxiety makes it difficult for your child to get to school each day, focus, socialize and function within the family, it might be an anxiety disorder.
Anxiety often has a genetic component, but it can also be triggered by a number of factors.
- Genetics: Just like your child can inherit your eyes or your complexion, anxiety can also be transmitted from parent to child.
- Academic/achievement pressure: Sometimes pressure is self-prescribed; sometimes kids feel pressured by the adults in their lives.
- Learned anxiety: Children can learn anxious responses from the people in their homes. A perfectionist parent, for example, might unintentionally send the message that everything needs to be perfect.
- Bullying/social issues: Kids who experience chronic bullying can develop symptoms of anxiety. This includes cyberbullying, which is reaching younger and younger children. Kids who struggle with social anxiety can be triggered by large and unfamiliar social situations.
- Transitions: New homes, new schools and even new teachers can trigger an anxious child.
- Loss: Divorce, death of a loved one or death of a pet can result in symptoms of anxiety.
- Violence or abuse: Kids who experience child abuse or witness domestic violence or other acts of violence in the home can experience anxiety disorders.
How to help kids cope
When children experience symptoms of anxiety that interfere with their daily life (symptoms occur more often than not during at least a two-week period), it’s important to seek professional help. A pediatrician is a good first stop to rule out or diagnose possible medical issues and to refer a licensed mental health practitioner who specializes in working with children. Cognitive behavioral therapy and dialectical behavioral therapy can be very effective treatment options for children with anxiety.
Types of Anxiety Disorders
The onset of clinical anxiety is typically around six years old, usually at the same time children start school full-time; symptoms can escalate around age 10. Generalized anxiety disorder (or GAD) affects about three to five percent of youth and often occurs with one or more of the other types of anxiety (such as separation anxiety, obsessive-compulsive disorder, or social anxiety). More girls than boys struggle with anxiety disorders. Payton and I characterize her anxiety a “worry bully,” who sits in the corner and is always telling her to expect the worst. But the good news is that today we have a better understanding of children’s anxiety than we have ever had before, and there are ways to help our children wrestle it into submission.
Symptoms of anxiety in children take on many forms and several other types of anxiety disorders also impact children:
- Body-Focused Repetitive Behaviors (BFRBs) are related to self-grooming, anxiety management, or sensory stimulation. The most common BFRBs are trichotillomania (hair pulling), dermatillomania (skin picking), onychophagia (nail biting), dermatophagia (skin biting), rhinotillexomania (nose picking), as well as cheek biting and joint cracking.
- Obsessive-compulsive disorder (OCD) causes children to experience pervasive, unwanted obsessions or worries. Sometimes, they work to relieve this anxiety through repetitive physical or mental behaviors called compulsions.
Among kids and teens with OCD, common obsessions include:
- fear of dirt, germs or contamination
- a need for symmetry, order, and precision
- religious obsessions
- lucky and unlucky numbers
- sexual or aggressive thoughts
- fear of illness or harm coming to oneself or family
- intrusive sounds or words
These compulsions are also common among kids and teens with OCD:
- grooming rituals, including hand washing, showering, and teeth brushing
- repeating rituals, including going in and out of doorways, needing to move through spaces in a special way, or rereading, erasing, and rewriting
- checking rituals to make sure that an appliance is off or a door is locked, and repeatedly checking homework
- ordering or arranging objects and cleaning rituals around the house
- counting rituals
- hoarding and collecting things of no apparent value
Panic Disorder is characterized by the sudden onset of intense fear, called a panic attack, followed by weeks of worry about having another similar attack. Symptoms include: difficulty breathing, racing heart, sweating, needing to escape, sense of danger or doom, and chest pain, among others.
- Post Traumatic Stress Disorder is an anxiety disorder that can develop after involvement in or exposure to a frightening, traumatic event. Symptoms include ongoing upsetting memories, nightmares, flashbacks, feeling overly jumpy or irritable, and avoiding reminders of the incident.
- Social Anxiety Disorder causes children and teens to fear social and/or performance situations because they worry about doing something embarrassing or being negatively judged by others. The extreme manifestation of this is the rare condition Selective Mutism.
- Separation Anxiety Disorder causes children to worry excessively about being separated from primary caregivers or from the home.
- Specific Phobias involve persistent, over-the-top fears of an object or situation that is beyond the child’s control and significantly impacts life. Common phobias include insects, heights, dogs, and loud noises.
Common Symptoms of Generalized Anxiety Disorder for Children at Home
If you notice the following warning signs, schedule an appointment with your child’s doctor:
- Trouble falling asleep
- Fear of being alone
- Picking at skin
- Nail biting
- Strong startle response
- Being overly self-critical
- OCD-like behaviors (e.g. checking and rechecking the door to make sure it is locked or arranging objects “just so”)
- Suddenly avoiding social contact
- Frequent urination
Common Symptoms of Generalized Anxiety Disorder for Children at School
According to Child Mind Institute, your child’s anxiety may manifest at school in several ways. Keep an eye out for these signs:
- Refusing to go to school or having a hard time at school drop-offs
- Difficulty participating in class and interacting with peers
- Excessive worry about everyday things
- Trouble answering questions when called on by the teacher
- Disruptive behavior
- Frequent trips to the nurse (with complaints of headaches, nausea, stomachaches, or even vomiting)
- Avoiding socializing or group work
- Not turning in homework
Symptoms of Anxiety In Children
(6 – 12 years old)
Unlike in aAdults, anxiety in children does not present as a parent or caregiver might expect. There are symptoms that overlap:
- Fears of impending doom
- Difficulty concentrating
- Constant concern/worry
- Fidgety, tense
Just as in adults, when a child displays excessive fear, has difficulty focusing, is tense, or simply looks worried – it is fair to assume they are experiencing anxiety.
There are symptoms not often seen, or at least rarely associated with anxiety in adults. Anxiety in children often looks like, or takes on the following common features:
- Questions focused on a singular topic, examples could include death, global warming (this has become more and more common due to the recent focus in school curriculum), kidnapping, isolation, not fitting in, or personal/family safety.
- Difficulty sleeping, protest around bedtime, attempts to avoid being alone while falling asleep, and bad dreams
- Becoming easily irritable or quick to lose their temper – this may include more frequent outbursts or tantrums
- Questions focused on “when you were my age,” or “when daddy was my age, did he ever…”, especially when the subject of the inquiry is negative, or involves impending doom, harm or unpleasant feelings
- Not eating properly, having little to no appetite during the day – when the anxiety is rooted in or around the child’s school, you may notice your son or daughter often returning to school having eaten very little lunch.
- In younger children, being clingy – wanting to be with familiar adults more often, or being more comfortable with an adult the child considers ‘safe.’
- Questions surrounding a large number of ‘what if’s,’ or a discussion of unlikely scenarios
- Stomach aches, headaches, feeling off, often surrounding a specific event or situations with a common theme
As is expected, these symptoms could very well be associated with a perfectly well adjusted girl or boy, but they can be useful tools to identify unusual, or odd behavior as being the result of anxiety.
What does anxiety look like with children who have a learning disability, or ADHD:
What does child anxiety look like?
The word “anxiety” may conjure images of a quiet worrier, but childhood anxiety wears many different masks. More often than not, symptoms of child anxiety fall into the following categories:
- Psychosomatic complaints: Kids don’t usually come home from school saying, “I felt really anxious at school today,” but they do say things like, “I have a terrible stomachache; I can’t go back to school tomorrow.” Frequent stomachaches, headaches and unexplained muscle aches and pains can all be symptoms of anxiety. It’s also important to watch for complaints of chest pain, racing heart, difficulty breathing, dizziness and difficulty swallowing. These can all be symptomatic of a panic attack.
- Anger and irritability: Most kids have meltdowns at times when they feel exhausted and overwhelmed. Frequent meltdowns that are lengthy and fueled by anger and irritability, on the other hand, are worth taking a second look. Child anxiety often looks like intense anger and a complete lack of emotional regulation.
- Sadness: Anxious kids can appear clingy, overwhelmed and sad. They are likely to burst into tears without explanation.
- Isolation and avoidance: Anxious children often engage in social isolation. They avoid additional social interaction beyond school, choosing the safety and comfort of home to recover. They are also master procrastinators and tend to avoid challenges.
- Fatigue: Coping with anxiety can be exhausting. Chronic fatigue in a previously active child can be a sign of anxiety.
- Poor concentration: Anxiety can make it difficult to focus.
- School refusal: School can feel like an exercise in survival for kids with anxiety, and school refusal is often the first red flag parents and educators notice.
- Frequent questions: Anxious kids tend to be concerned with personal safety and the safety of family and friends. They ask the same questions repeatedly and seek validation from adults often.
Treating Anxiety in Children
(6 – 12 years old)
If you, or someone in your family, is concerned your child might be suffering from symptoms consistent with anxiety, early intervention is essential. Learning how to cope with uncomfortable or uncontrollable worry is something everyone will suffer with, at some point in their lives, but for children, learning how to develop appropriate coping skills can be challenging. Children often have difficulty identifying a specific situation as the source of anxiety, and therefore struggle to develop methods to control their fear.
Treatment is highly specific, but always begins with an interview with the parents. Typically, the first interaction occurs without the child being present. For younger children, there can often be resistance to meeting someone new – for this reason, I will often ask parents to refer to “Dr. Heafey” often, prior to the first meeting.
Let your child know you are going to meet a “very nice man, who asked if “you” would [show them] or [teach them] ________” (the blank should be filled with ‘drawing’, a ‘board game’, ‘meeting the pet turtle’, or exploring the local pond, anything the child is energetic about, and enjoys sharing with others). When in doubt, let your child know Dr. Heafey knows where to find a 3 foot koi fish and a turtle as big a hula hoop!
Once I am able to meet with, and ‘play’ with the child, I typically have a good idea of what is going on, and will then discuss treatment options. Trust is an essential feature whenever you work with children, and one I take very seriously. While difficult to sit with, it is ok for a child to experience some discomfort. The benefit of therapy is discovering nuanced qualities of the child, and then guiding them towards self-discovery using evidence-based therapy techniques. The specific interventions often depend on the nature of the child’s anxiety.
Just like with everyone I work with, I am available to both my patients and their families, in between sessions. If you or your child is experiencing a particularly difficult situation, I encourage you to reach out so we may discover, together, the best way to address, and hopefully resolve the situation.
Growing up in Piedmont or Pacific Heights does afford great privilege, but this does not diminish a person’s subjective psyche suffering. Many families struggle with the concept their child experiences worry or concern, since they are afforded so many luxuries.
This is a completely natural concern, just as is a child’s worry about what could happen if a fire destroys their neighborhood, like it did Santa Rosa, or if there could be some act of violence they could not predict or prevent. Learning how to control one’s anxiety is often what directly shapes personality the most – let your child explore their fears in a safe space so they do not feel inhibited or limited in the world.