Anxiety is universally defined as an emotion that elicits fear, nervousness, and worry. Anxiety occurs as a mental and physical response to what our brain perceives as a threat. Anxiety can be helpful when threats are real and rational. For example, when a child is walking home from school and a large dog runs towards them, their anxiety signals their flight response to protect them from danger. Anxiety can also present as harmful when it becomes excessive and triggered during situations in which there is no real threat. This is when the emotion can manifest into a disorder.
Anxiety can occur across the lifespan. In fact, the prevalence of childhood anxiety is growing. The Centers for Disease Control and Prevention (CDC) estimated that in 2016-2019, approximately 9.4%, 5.8 million, children between the ages of three to seventeen years old were diagnosed with anxiety. (3) Anxiety disorders can present as highly distressing to children and lead to disruptions in their functioning across their home, school, and play environments. Anxiety can negatively impact a child’s self-esteem, emotional wellness, behavior, sleep, eating, and mood.
What Causes Childhood Anxiety?
Research suggests that both nature and nurture likely play a part in the manifestation of anxiety in children. (8) Children who have parents with anxiety or who are part of a family with a transgenerational pattern of anxiety may be more at risk to develop it as well. (8) In addition to genetics and heredity, environmental stressors may also present as risk factors for the development of childhood anxiety. Stressors that are commonly associated with childhood anxiety and that may increase risk include frequent exposure to parental conflict, bullying, the death of a loved one, having an injury or illness, being involved in an accident, and a history of trauma, abuse, or neglect.
Anxiety is a diagnosis that often presents with high comorbidity, meaning that many children who have anxiety also have a co-occurring diagnosis. Research supports that children diagnosed with attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and depression are more likely to have a comorbid diagnosis of anxiety. (4,5,6)
Symptoms of Anxiety in Children
Common symptoms of childhood anxiety may include:
Excessive worry, fear, and nervousness that feels uncontrollable
Avoidance of stimuli or situations that elicit fear
Heightened startle response
Crying or tantrums
Upset stomach or nausea
Increased heart rate
For a child to be formally diagnosed with an anxiety-related disorder, the presentation of their symptoms must cause distress, take place during at least two daily activities, feel uncontrollable, be persistent, impair functioning, and impact development. (1)
Types of Anxiety That are Most Prevalent Among Children
Separation Anxiety Disorder
Marked by a significant pattern of distress that occurs when a child is separated from their caregivers to who they are attached. The act of separation leads to the child exhibiting excessive fear and anxiety. Common worries include persistent fears that are often related to their personal safety and the safety of their caregivers. The child may express worry that their caregivers will never return or that something bad will happen to their caregiver. Children diagnosed with separation anxiety disorder typically will display refusal behaviors to go to school, leave their home environment, or go to playdates. When separation does occur, it is often met with the child becoming hysterical, clingy, and emotionally dysregulated. Separation anxiety is typically seen as a developmentally appropriate experience during infancy and for children under the age of three years old. Clinical assessment is recommended when symptoms prolong beyond this age and continue to have a debilitating impact on the child’s functioning due to the possible manifestation of a diagnosable separation anxiety disorder. Separation anxiety disorder is most prevalent among children between the ages of seven to nine years old. (2)
Social Anxiety Disorder (Social Phobia)
Marked by high anxiety and fear of social situations. Children with social anxiety disorder often present with low self-esteem when they are around others and become self-conscious. They fear being judged, embarrassed, or humiliated by others. A diagnostic feature that must be present for children to be diagnosed with social anxiety disorder is that the anxiety must be present in interactions with peers, not just in situations that involve interactions with adults. Children with social anxiety disorder often avoid busy environments such as the playground or a birthday party. Even simpler social interactions, such as being called on to answer a question or having to choose a partner in their classroom trigger immense anxiety.
Marked by excessive worry and anxiety related to a specific fear of an object or situation. Common specific phobias that children develop include fears of thunderstorms, flying, animals, heights, and seeing blood. Children with specific phobias often perseverate on this fear and make diaristic attempts to avoid the stimuli or situations that they are fearful of. For example, a child who has a specific phobia of flying on an airplane may experience nightmares about flying, refuse to go on a family vacation to avoid flying, avoid playing with airplane toys, and become distressed when they notice an airplane flying above them while outside playing.
Generalized Anxiety Disorder
Marked by excessive worry and anxiety that occurs across multiple settings and impairs the child’s functioning. There is not one specific trigger to the anxiety, but instead, the anxiety persists during various unpredictable times.
Ways Parents Can Help with Childhood Anxiety
Externalization: Externalization is the process of separating anxiety from the child’s identity. Parents can help their children understand that anxiety is something they experience but it does not define who they are. Reframing the narrative of what anxiety is can help children feel more in control of it. This reduces the negative effects anxiety can have on a child’s self-esteem.
Catch the triggers: Parents can work alongside a therapist to help their child build awareness of what triggers their anxiety. They can learn to become familiar with their body’s signals of anxiety, such as helping them notice their heart beating faster or their palms becoming sweaty when anxious, and their brain’s signals of anxiety, such as noticing when ruminating thoughts are occurring or difficulty with concentration. Once they develop an understanding of what makes them feel so worried, they become more readily able to notice when it’s a beneficial time to practice a coping strategy.
Coping strategies: Common coping strategies that focus on regulation that are helpful for anxious children include breathing exercises, progressive muscle relaxation, guided imagery, meditation, yoga, stretching, mindfulness, and grounding exercises. Additionally, providing child-friendly ways for children to communicate and process their anxiety is helpful. Techniques to encourage this include drawing or journaling about their worries, writing a letter to their anxiety, or creating a comic about them defeating their anxiety. Children often feel supported when parents join them in practicing these coping strategies.
Model bravery: Parents can model being brave in worrisome situations and share stories with their children about their experiences facing their fears and how they worked through them. This can boost their child’s confidence.
Practice pre-living: Often the anticipation is the most anxiety-provoking for children. To ease this uneasy feeling, parents can pre-live situations in advance to help their children know what to expect. Children thrive with predictability.
Gentle exposure involving play: Exposure therapy is one of the primary and most effective interventions to treat anxiety. It aims to rewire the brain’s fear response by exposing the child to their fear in small manageable steps. With repetition, the fear can reduce and eventually subside. Exposure therapy should be prescribed and led by a professional therapist, however, parents can provide their children with gentle exposure to what they are afraid of through play. For example, if a child is afraid of spiders they could read the book “Charlotte’s Web” with their parents and then role-play parts from the story that depict a spider in a positive way rather than a scary way. This is a form of imaginary exposure.
Allow Distress: As parents, it is normal to want to shield your child from experiencing negative emotions and the easiest way to do this is avoidance. Although allowing your child to avoid what makes them anxious may provide temporary relief it won’t cure their anxiety. Instead, parents should help their child build a tolerance to being exposed to what makes them anxious with guided support from a therapist, allow them to have a natural emotional reaction, and then praise them for their courage.
When to Seek Help
Don’t wait for your child’s anxiety to grow before reaching out for support. Cognitive Behavioral Therapy (CBT) and play therapy are utilized most frequently to treat anxiety in children. At Heritage Counseling and Consulting, there are therapists who specialize in providing quality care that integrates both therapeutic approaches to treat children with anxiety.
At Heritage, we know the power of partnership and working with the family system. We have made a vow to include parents in the process of helping their child overcome their anxiety. In addition to individual child therapy sessions, parent consultations are scheduled routinely after every four individual child therapy sessions to reflect on progress, introduce parenting interventions, and help generalize psychoeducation and skills learned to treat their child’s anxiety diagnosis. To schedule a consultation at Heritage Counseling we invite you to call 214-363-2345.
Three, Z. T. (2016). DC: 0-5: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.