Back-to-school season is upon us, and while some kids look forward to returning to class, others are a bundle of nerves. Parents may reassure and soothe, but they may also worry: Does my anxious child have a real problem?
“Anxiety is a normal, healthy human emotion,” says John Walkup, a psychiatrist at Lurie Children’s Hospital in Chicago.
That’s because there are plenty of things in our lives, and our children’s lives, to worry about, and worry can activate an appropriate response. A middle school student worried about an upcoming test should be motivated to study. A first-grader worried about a bee on the playground will move away to avoid being stung.
But what about a third-grader who’s worried that something terrible will happen to her parents while she’s at school? That’s a worry that’s hard to quell and may leave the child in no state to learn the new math lesson.
So there’s normal, functional anxiety, but also there’s the kind that’s severe, persistent and pathological. There are different kinds of anxiety disorders, including generalized anxiety disorder, specific phobias, separation anxiety disorder, social phobia and panic disorder.
More than 2 million American children have been diagnosed with anxiety disorders, including 3.5 percent of those between ages 6 and 11, says Walkup, who was part of a new study with researchers from the Centers for Disease Control and Prevention.
An in-depth survey of more than 10,000 teens used face-to-face interviews conducted between 2001 and 2004 to screen for psychiatric conditions and found that anxiety disorders are the most common in this age group, far outnumbering behavioral, mood and substance use disorders. One teen in 4 met diagnostic criteria for an anxiety disorder.
Walkup, who speaks widely for the American Academy of Child and Adolescent Psychiatry, says anxiety disorders are underrecognized and underdiagnosed. Anxiety disorders typically emerge between ages 6 and 12. Because of this early onset, symptoms of anxiety may be downplayed, seen as just the child’s temperament or personality.
So how can parents recognize the line between normal worrying and an anxiety disorder?
It can be a matter of frequency and intensity, says Mary Alvord, a psychologist at George Washington University. “Is it interfering with normal life? Does it get in the way? How much are you, as a parent, accommodating it?”
“Normal anxiety has very predictable triggers,” Walkup says, such as a test at school or a bee in the backyard — things that stress most people out to a degree. Pathological anxiety is often triggered by everyday experiences that are not typically stressful, such as going to bed or ordering in a restaurant. In addition, with pathological anxiety, he says, “the reaction is excessive and disproportionate.”
For instance, a 6-year-old might get very anxious about separating from their parents to go to school. A 9-year-old might worry excessively about going to a sleepover. “They worry that something bad is going to happen to their parents while they’re gone,” Walkup says.
Kids with anxiety disorders often worry about the past and the future. They might worry about their grandparents dying, even though they are healthy. “Most kids don’t think a lot about life or death. Anxious kids think about life or death all the time,” he says.
Children with anxiety are hypervigilant and overreactive, and they tend to feel threatened a lot. When Walkup describes classic scenarios to parents or to pediatricians he is training, they often respond with surprised recognition. Parents will blurt out: “That’s my kid!”
There’s another category of anxious kids: those whose everyday environment — at home or at school — is persistently stressful. A dysfunctional family or a crime-ridden neighborhood may present anxiety triggers that are severe and pervasive. Walkup says these are normal reactions to predictable triggers, but because they are constant, the anxiety is chronic.
Separation anxiety is more common in younger children, while social phobia tends to show up later in childhood “as peers become more important,” Alvord says. She stresses that anxiety doesn’t necessarily go away as kids age: “Don’t assume that they’ll grow out of it.”
In avoiding their anxiety triggers, kids might withdraw so much that they exhibit signs of clinical depression. (Anxiety and depression can occur together.) Children with anxiety disorders are at increased risk of depression, substance abuse and suicidal behavior later in life.
How to help your anxious child? Parents can do a lot to support their kids. Most important might be helping them face their fear, helping them adapt to a situation. The key, Alvord says, is to do this gradually. She recommends asking the child about their anxiety and learning what their “self-talk” is: “When this happens, what do you think?”
“As therapists, we challenge negative self-talk,” Alvord says. (Self-talk is the monologue that goes on inside our heads.) Someone with anxiety might imagine a worst-case scenario, which in turn exacerbates feelings of stress. “A therapist might work with the kid directly but also might work with parents to help them help their kid.”
One difficulty for parents is recognizing anxiety in children who can’t describe their thoughts and feelings. “Young children don’t say, ‘I’m anxious,’ ” Alvord says, but they will show avoidance behavior — or physical symptoms such as stomachaches, headaches, not eating much or trouble sleeping. Adolescents show physical symptoms of anxiety as well, such as headache, nausea and irritability. Alvord recommends looking for patterns — when do symptoms arise? — and looking for possible triggers.
For help, start with your pediatrician, who can screen your child for anxiety disorders and help you find professional help. Online resources, such as the Association for Behavioral and Cognitive Therapy, are good for finding specialists versed in anxiety disorders in kids.
Treatment options include cognitive behavioral therapy, or CBT, which can be effective in young people. CBT might include exposing the child to their triggers to desensitize their anxiety.
Medications can help, too, particularly the class of antidepressant drugs known as selective serotonin reuptake inhibitors, or SSRIs.
Books specifically written for families with anxious children include “Keys to Parenting Your Anxious Child” by Katharina Manassis, and “Conquer Negative Thinking for Teens” by Alvord and Anne McGrath.
Walkup lists things that anyone can do to manage stressful situations, such as slow down, take a break, exercise, breathe deeply. Problem-solving approaches can be helpful: Begin by calming down, then identify the problem, brainstorm solutions and try the one that seems best.