What Does Anxiety in Children Look Like?

Anxiety is a common occurrence in children and adults alike. For children, it can surface with family responsibilities, schoolwork, extracurricular activities, and other typical environments that a child grows and operates in. The presence of anxiety can function at a healthy level that helps children develop through difficult, uncomfortable, or new experiences.

However, persistent or intense anxiety is abnormal, and when it interferes with, or adversely affects daily life, it can become a disorder requiring professional help (Foxman, 2004). Diagnosable anxiety disorders are estimated to be found in around one in ten children, with less extreme but still distressing fears being even more common (Rapee et al., 2008).

Some examples of anxiety that can be potentially harmful to children are an overdeveloped sense of responsibility, a prominent feeling of needing to please others, a rumination of perfectionism, unrealistic expectations of self or others, oversensitivity to criticism or rejection, a strong need for control, performance pressures, fears of abandonment, and an all-or-nothing pattern of thinking, among others (Foxman, 2004). At New York Behavioral Health (NYBH) all of our therapists are qualified to treat children and adults experiencing anxiety.

How To Help a Child With Anxiety 

Parents and caregivers are the most important agents of change that can be accessed in the child’s life when working through difficulties with anxiety (Creswell et al., 2017). The goal is not to change the child’s personality, but rather to manage the traits that cause stress and discomfort for the child (Foxman, 2004). The following list is not exhaustive, but contains valuable steps to consider in reducing your child’s anxious symptoms as well as developing their strengths to persist through symptoms that cannot be completely eliminated.

The psychological approaches that have been evaluated to appropriately treat anxiety often follow a cognitive-behavioral therapy (CBT) approach, which typically involves working with the child to address anxious thoughts, avoidant behaviors, and develop coping skills (Mychailyszyn et al., 2011). NYBH clinicians use a blend of CBT and other approaches to ensure they are meeting the needs of the individual in their care.

Various CBT techniques are blended into the following steps to help with symptom mitigation and continued care. Though the steps are sequential, many parents and caregivers will be working from situations that make some steps more pertinent than others. Though it is not recommended to skip steps entirely, It is ok to look through the following steps of care and select or combine the ones that are most salient for your child’s situation.

Preliminary Step: Dedicate Time and Attention to Helping Your Child with Their Anxiety

It is without question that a process of this nature will require a dedicated approach on behalf of the caregiver. As with any therapeutic implementation, there are several steps that need to be taken incrementally, and at the pace of the child, to achieve desirable outcomes. This also highlights the importance of a patient adult who can strategically use both encouragement and reasoning to help the child along in their efforts.

A systematic approach is recommended to work through the steps on a weekly basis. Each step should be blocked out to work through at a given time within the week, and practice implementing that step should be the focus of the week until the following session. These will be listed as “steps” and “homework” in the section following. Though a journal is not necessary, it is highly recommended for both you and the child to work through steps and homework together.

Step 1: Identify the Anxiety and Its Source 

It is important to start at square one, and that is “naming and claiming” the anxiety. You and the child together will work to identify what the anxiety is, and really process how to define it. Talking out what it feels like and what it looks like from their perspective is a great place to start. Identifying patterns of the anxiety and where/how it appears most often are also important places to take the conversation.

Homework: Spend the week “naming and claiming” the anxiety. If you have a journal, write down all the details around any instance of anxious behavior. Detailing the who, what, where, when, why, and how could be a useful tool here.

Step 2: Set Realistic and Measurable Goals Together

Setting goals is an extremely important step in any therapeutic process, and specifically in a CBT-framed guide. Both you and the child should set short and long-term goals that are specific enough so that they have direction, and measurable in a quantifiable way. Working with a 10-point scale might meet your specific needs, or developing your own “anxiety rating scale” at the level of the child could also be appropriate. Scalable goals can be tracked over time to help with understanding progress, and also provide a visual for comprehension.

Homework: You and your child should write out and display both of your short-term and long-term goals in a setting that is readily visible and accessible. Displaying your rating scale next to these goals is also strongly recommended.

Step 3: Educate Yourself and Your Child on Anxiety

It would be an incomplete guide without the incorporation of education to really understand what is taking place. The saying “the more you know the more you grow” is very pertinent in this situation. Without knowing what is really taking place and why it is taking place would leave you to tackle a problem that you don’t fully understand.

The goal is not to become an expert, but rather to have the tools to talk to your child about their experience in a way that is meaningful and can make sense to a young mind. Once you have taken some time to learn about the more nuanced details of anxiety, use this session to talk to your child about understanding their own anxiety. This can look like discussing why it might feel difficult to face our fears, what is happening in our bodies when anxiety starts to creep in, and what feels most challenging in anxiety-inducing situations.

Homework: Have your child write/discuss what they learned about anxiety that they didn’t already know, and how this might help them in reducing their anxiety. Spend the week looking for teachable moments that could further encourage and facilitate this rationale.

Step 4: Identify the Anxiety Triggers

Really pinpointing the ‘why’ here is important. Why is the anxiety happening in the first place? What is the cause of the anxiety arising? This might be a step that you already have a good grasp on (i.e. getting ready to go to school triggers the anxiety because the pressures of school work feel overwhelming). If you’re still working on pinpointing the trigger(s), and there could be several, try to map out all the most recent moments of anxiety and work from there.

This should be collaborative with the child since they are considerably the expert of their own distress. Once you understand what the triggers are and why they’re occurring, work through how your child feels, thinks, and acts when a trigger (and the following anxiety) occurs. Understanding these elements are going to be most important for the next step where working to alleviate some of these symptoms will be key to your child’s success.

Homework: Practice recognizing the “feel, think, act” of every triggering situation. See if you can pull out patterns, e.g., my child consistently pretends to “forget ” something in order to miss the bus, trying to get out of going to school. That will help you pinpoint such behaviors. The more precise you can be regarding what they feel, think, and do, the easier it will be to work to combat the behavior.

Step 5: Build Skills to Help Lessen the Triggers

If you’ve identified the triggers and the patterns that compliment them, you’re halfway there. Lessening the triggering responses is a proactive approach. In this step (which will be ongoing) you are going to make a plan with your child on how to move through the “tough stuff” with more ease. How do we do that? By practicing skills like realistic thinking, situational awareness, instilling confidence, renewing a sense of control, practicing social skills, and developing an assertive attitude.

Though this is a small list of many possible techniques, you need to understand what the trigger is telling you, and promote healthy behavior in response to it. Using the example from above, I would work with my child to instill a sense of control over his school day (rather than trying to control the day 5 minutes before they leave).

This might look like talking through the school day the night before, asking questions that will offer them more control. i.e., “What would help you feel more comfortable to take on the school day?” and then developing a plan around it. The key here is to put your child in the “driver’s seat.” What do they need to help get through these moments? How can you help to facilitate that happening?

Homework: Write down the skills that you and your child will work on together to help them feel better about anxiety inducing situations, and map out your proactive plan for the next triggering event. Work to practice these skills with a gradual progression towards fully “facing the fear.”

Step 6: Practice Mindfulness and Relaxation Techniques for Coping

As you continue to build skills that will combat the primary roles of fear in your child’s life, it is also important to help them develop coping skills that serve to “fill in” when fear and anxiety aren’t so easy to leave your child’s life. Mindfulness techniques are used to help orient your child to the present moment, which can serve to take their attention away from the anxiety inducing fear, and back into their body.

One way to do this is to have your child run through the 5 senses. What do I taste, smell, hear, touch and see, are the questions they can ask themselves. Another way to do this is through breathing exercises. Your child can focus on their breath and inhale for three seconds then exhale for three seconds). Think of these as “recentering” techniques to lead your child’s attention from fear to focus. Relaxation techniques can be just as effective and should be tailored to your child’s unique anxiety needs. Work with them to figure out what helps sooth, calm, and relax their nerves. These can be used for proactive or reactive relief.

Homework: Practice implementing a daily mindfulness routine into your lives. Work with your child to enhance these self-promoting skills so they can use them in moments of anxiety when you are not around for support.

Important Notes for Parents/Caregivers to Consider  

• Don’t believe that your child will “grow out of it;” anxiety can just as easily increase and escalate if left untreated.
• Modeling the qualities you are working on with your child is just as important as getting them to work on these independently; be the person you are hoping for them to grow into.
• Encourage play and environments that reduce stress; stimulating your child in non-anxiety inducing settings is an important factor in their independent development.
• Don’t expect progress to be linear; often progress is wavy, with many setbacks along the path.
• Helping your child with anxiety is about promoting independent and problem-solving behaviors; realistic messaging and confidence. These will all be critical in their progress. 
• Listen carefully to your child and their concerns; they are as much in the driver’s seat of this process as you are.
• Gradual process is the key to success; what is listed as 6 steps above might take 6 months or more and that’s OK!

When to Seek Therapy 

Seeking therapy is a good idea at the very least to help understand what your child might be experiencing. A mental health professional will be able to properly assess your child and let you know how to proceed to help mitigate excess worry. A professional can also help you apply specific strategies to your child’s circumstance, and get over difficult hurdles that are likely to present themselves (Rapee et al., 2008).

However, with given obstacles to therapy that include access and monetary value, it is understood that working with a counselor is not always the first-line action to take. There are important signs to look for in your child that can help you decide when to seek professional care. First, if the levels of anxiety are unmanageable for the child, seeking support is necessary. If the anxiety is interfering with the child’s eating or sleeping patterns, seeking professional care should also become a priority.

Additionally, if the anxiety is impeding the child’s ability to function in school or other areas outside of the specific “anxiety inducing events” therapy is highly recommended. If the child starts to experience unexplained physical medical symptoms (headaches, stomach aches, muscle tension, etc.) this would be an instance for seeking medical care where the doctor can refer you to a therapist if they deem the symptoms to be caused by the anxiety.

Serious trouble concentrating, irritability, restlessness, and fatigue could all be clinically significant symptoms, which should be assessed by a mental or behavioral health clinician. Finally, if extreme anxiety seems to be stemming from parent/caregiver separation, a specific phobia, a distinct social fear, or results in the child refusing to speak or notable panic, seeking therapeutic care would be necessary as these are qualifiers for potential disorder that should be assessed, diagnosed, and treated by a professional. If you are thinking about seeking treatment for you or your child, reach out to someone on our qualified NYBH team to help guide you through the next steps of the process.

References

Creswell, C., Parkinson, M., Thirlwall, K., & Willetts, L. (2017). Parent-Led CBT for Child 

Anxiety: Helping Parents Help Their Kids. The Guilford Press. 

Foxman, P. (2004). The Worried Child: Recognizing Anxiety in Children and Helping Them Heal. 

Hunter House Publishers. 

Mychailyszyn, M. P., Beidas, R. S., Benjamin, C. L., Edmunds, J. M., Podell, J. L., Cohen, J. S., 

& Kendall, P. C. (2011). Assessing and treating child anxiety in schools. Psychology in 

the Schools, 48(3), 223-232.

Rapee, R. M., Wignall, A., Spence, S. H., Cobham, V., & Lyneham, H. (2008). Helping Your 

Anxious Child: A Step-by-Step Guide for Parents (Second Edition). New Harbinger 

Publications.