Uncomfortable as it is, anxiety is a normal human emotion that serves important functions, including protecting people and motivating them to solve problems. Children are vulnerable to feeling anxious as they don’t know much about the world and rely on adults for security.
Learning to manage anxiety productively, including developing the ability to differentiate between reasonable and unreasonable fears and ways to calm down, is a valuable and important life skill.
Many adults assume that children with high levels of anxiety will outgrow the problem, but it's somewhat the opposite, says Wendy Silverman, PhD, director of the Yale Medicine Child Study Center's Anxiety & Mood Disorders Program. Substantial research links untreated childhood anxiety with mental illness in adulthood, including not only ongoing anxiety but also depression and substance abuse. She adds that anxiety is the most common mental health problem in children and adults and the median age of onset is 11.
How can parents distinguish between "normal" childhood anxiety and a problem that should be treated?
It’s normal for a child to be anxious about changes in life, such as the start of a new school year or alterations in family status (such as birth of a new sibling, a move, or a separation, divorce or remarriage of parents), or in the face of loss. Temperament is a factor too. Some kids (and grownups) are naturally anxious, while others are easygoing.
Silverman suggests that parents pay close attention to anxiety that begins to interfere with a child’s ability to engage in the activities that are normal and age-appropriate, including school, birthday parties and sports. “If a child is anxious every day or most days, if the anxiety is intense and severe, and if it goes on for an extended period of time—certainly if for as long as six months—that’s of concern,” she says.
What are the most common types of anxiety in children and adolescents?
Children with anxiety disorders commonly experience one or several of the following types.
- Separation anxiety: Anxiety about being away from a parent or caretaker is a normal developmental phase for toddlers, but it’s of greater concern if a school-age child has difficulty with separation, at home or in the larger world. “We see children who can’t be left alone in a room for even a few minutes,” Silverman says. Such children may follow parents from one room to the next, insist they can’t sleep alone or even have difficulty attending school. Some express fear that they or the parent may be harmed or kidnapped if they aren’t together.
- Social anxiety: Typically around the third grade or later, as social awareness increases, children may feel intense anxiety about how they appear to others. They may express worries about being embarrassed or humiliated, or about being evaluated in a harsh or negative way. This may be related to performance (at school or in extracurricular activities) or social situations, such as at parties.
- Generalized anxiety disorder: If a child’s anxiety spills into many different situations, with an emphasis on the worst possible outcome, he or she may have what’s called generalized anxiety. “This brings general, uncontrollable worries about lots and lots of things,” Silverman says. “Hearing parents argue might turn into excessive worry that they’ll break up. They may worry about the family finances, fearing that if there isn’t enough money, they’ll become homeless. They may have constant, uncontrollable worry about the occurrence of natural disasters, such as an earthquake.” She adds, “Some children have physical symptoms, like headaches and stomachaches, literally making themselves sick from worrying.” Perfectionism is also a common issue linked to generalized anxiety among young people.
There are other types of anxiety too, Silverman says. The onset of specific phobias begin as early as the preschool years, where children develop intense, irrational fears with excessive avoidant behavior about particular objects (such as dogs) or events (such as loud noises). Panic attacks, with physical symptoms such as racing heartbeat and shortness of breath, may develop, more typically in adolescence. It’s rare, she says, that children have just one type of anxiety. “For kids who are vulnerable, we typically see two or three anxiety-related conditions,” she says.
How is anxiety diagnosed?
The Anxiety & Mood Disorders Program offers comprehensive evaluations for children with anxiety problems. An essential element of effective treatment is a thorough evaluation, and we ensure that an accurate and correct differential diagnostic workup is conducted on all referred children. Physician referrals aren’t necessary; parents can request an appointment. As with all psychological assessments at the Child Study Center, the process begins with parents filling out a detailed medical history. Parents and child are interviewed, separately and together, and structured measurement tools are used to identify the nature and extent of a child’s anxiety and to determine whether treatment would be helpful—and, if so, what type.
According to Eli Lebowitz, PhD, a specialist in childhood anxiety, a child’s anxiety doesn’t exist in isolation; it has to be understood in the context of the parental relationship. “As mammals, we are born defenseless, but we can signal distress to our caregivers,” he says. “The caregiver, usually the parents, takes steps to protect or soothe their child when in distress. But if a child has an anxiety disorder where they constantly feel threatened or distressed, then the parent’s response will be constantly triggered.” Unlike a toothache, which is contained in a child’s mouth, anxiety actually exists “in the space between the parent and child,” Lebowitz says.
How is childhood anxiety treated?
Treatment of childhood anxiety is always individualized to address the particular needs and situation of the child and family, Lebowitz says. Lebowitz adds that the more typical treatment is psychotherapy to address the child’s anxious symptoms, and the parents’ response.
“We focus on what we call ‘accommodations,’” he says. “These are the well-intentioned changes parents make to their own behavior in response to their child’s anxiety.” Helpful in the short-term, accommodations end up fueling a child’s anxiety, Lebowitz says. “If your child has social anxiety and stays in this room all the time,’ he says, “and you stop inviting people over to your house, how can the child learn to be less afraid?” Accommodating a child’s anxiety also reinforces it, he says. “It maintains the model of ‘When I am scared, I need someone else to fix the problem for me,’” he says.
At the Anxiety & Mood Disorders Program, we emphasize the use of treatments that are evidence based. The two most commonly used approaches are cognitive behavioral therapy (CBT) and Supporting Parenting for Anxious Childhood Emotions (SPACE), which can be done together or separately:
- Cognitive behavior therapy: This form of psychotherapy, used with the child, teaches children skills to help them identify and modify thoughts that lead to anxiety, while also coaching them through the situations that make them anxious through gradual exposure. For instance, a child who fears sleeping alone in her room at night might start by naming and dismantling her fears and then, gradually, altering the bedtime routine so she can learn to overcome them.
- Supporting Parenting for Anxious Childhood Emotions: This approach is directed at helping the parents to recognize and reduce their accommodating behaviors. “Kids get pretty annoyed when parents start to change their response,” Lebowitz says, “so we have to give them tools to cope as we help them move from a protective stance to a supportive one. They learn to acknowledge that their child is in distress but communicate that they believe in the child’s ability to cope.” Lebowitz adds that SPACE can be particularly helpful if a child is resistant to therapy, because parents can do it on their own.
What makes Yale Medicine’s approach to treating childhood anxiety unique?
The Child Study Center offers unique strengths in the diagnosis and treatment of childhood anxiety. The “whole child” philosophy emphasizes treating all issues in the full context of a child’s life. This is particularly relevant in addressing anxiety, which, as noted, involves not only the child’s feelings but also the parents’ reaction. Also, with longstanding and widely recognized expertise in mental health in children, we offer access to resources and treatment for other issues that may be related to the anxiety, such as trauma, learning disabilities and autism.