Signs of anxiety in children

Can children have anxiety?

Yes, children can have anxiety. In fact, anxiety disorder is the most common mental health condition in U.S. adolescents. It also has the earliest onset: Anxiety starts, on average, at just 6 years old.

The number of kids with depression and anxiety was already heading up when the COVID-19 pandemic hit. Between 2016 and 2020, more than 9 percent of children and teens were diagnosed with anxiety, up from 5.5 percent in 2007 and 6.4 percent in 2012.

The pandemic sent these numbers even higher, as kids and teens dealt with disruption in their lives; social isolation; and reduced support from teachers, coaches, and others. A 2021 meta-analysis estimates that worldwide, 20 percent of kids are experiencing symptoms of anxiety and 25 percent are experiencing symptoms of depression.

COVID also led to a rise in mental health crises and suicide attempts among kids and teens. Hospitals reported a 24 percent increase in mental health emergencies among children ages 5 to 11, and a 31 percent increase for kids and teens ages 12 to 17. Suspected suicide attempts among girls ages 12 to 17 jumped by more than 50 percent in early 2021 (compared to the same time period in 2019).

In October of 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association declared a national state of emergency in child and adolescent mental health.

Anxiety in kids isn't always a crisis. Some anxiety is a normal part of your child's behavioral and emotional development. Toddlers can become anxious about being separated (however temporarily) from their parents, and young grade-schoolers often worry about school, getting along with classmates, and pleasing their parents. Other causes of anxiety in children include family stress – divorce, financial troubles, illness – or upsetting news in the wider world.

Although it's difficult to see your child feeling anxious, it's important to remember that it's usually normal. For most kids, occasional worries are a manageable fact of life. Anxiety can even have some benefits, like keeping kids alert to potentially dangerous situations and encouraging positive behavior to meet the challenges of daily life. Confronting mild stresses in life can help them build resilience and learn to problem-solve. But chronic or extreme anxiety can become a major stumbling block for children and their families.

An anxiety disorder means that a child feels long-lasting worry or unease that interferes with their everyday functioning. It might prevent them from playing with friends or going to school, for example.

Untreated, an anxiety disorder can cause low self-esteem, problems with friendships and other relationships, and failure to reach social and academic potential. Children with untreated anxiety disorders can eventually become withdrawn and depressed.

Causes of anxiety in kids

There's no one cause of anxiety disorders. A combination of genetic risk factors and a child's environment are thought to contribute to the likelihood of developing an anxiety disorder.

Experts think that a child may inherit genes that make them prone to anxiety. A child with certain genes and temperament may be more likely to develop an anxiety disorder under certain circumstances (during times of economic uncertainty for the family, serious illness, difficulty at school, abuse, or the loss of a loved one, for example).

Also, if people around a child are anxious and afraid, the child may become anxious and afraid as well. Since March 2020, 27 percent of parents reported worsening mental health for themselves, with food insecurity, insurance worries, and loss of childcare cited as major concerns. As parents get more anxious and stressed, this unfortunately can affect their kids.

What does anxiety in children look like?

Anxiety disorders can be difficult for parents to identify in their children. For one thing, children have developmentally appropriate fears and worries at different stages, and it can be hard to distinguish a child's normal, to-be-expected anxiety from problematic worry.

It's also easy to miss an anxiety problem because many children with anxiety are quiet and eager to please – what might be considered "well behaved." That makes it easy to assume all is well.

Look at the intensity and longevity of your child's reactions. If your child seems tense or worried for long periods of time (several weeks or more) or has fears that seem beyond what's normal for their age and the situation, ask their doctor for an evaluation and/or referral to a mental health specialist. Without treatment, anxiety disorders tend to get worse. 

Anxiety disorders in children include:

Separation anxiety disorder (SAD)

Fear of separation from a parent or caregiver is common among infants and toddlers, and it may surface again when it's time to start school. But if your child has separation anxiety disorder, there's no getting past it. They may refuse to go to school and be very clingy or resistant. They may worry about their parents' or caregiver's safety and have trouble sleeping. This disorder is specific to children, not something adults have.

Generalized anxiety disorder (GAD)

A child with generalized anxiety disorder is overly worried about something bad happening. They have anxiety about everyday things rather than something specific. They may feel restless, angry, and tired, and have trouble concentrating and sleeping.

Social anxiety disorder (SAD)

Children with social anxiety are extremely self-conscious and overly worried that they might do something embarrassing. As a result, they don't like to meet or talk with people, and they don't want to be the center of attention. Their anxiety can prevent them from having many friends and from doing well in school.

They might not raise their hand in class, for example, and they may become extremely fearful if they're called on by the teacher, especially if they don't know an answer. They may feel shaky or lightheaded in school, and their face may get red and hot. Physical symptoms may even prevent them from going to school. In young children, social anxiety may result in crying and tantrums.

Children with social anxiety are often afraid that others will see that they're afraid and criticize them for it.

Panic disorder

Children with panic disorder suffer from unexpected panic attacks.

Panic attacks can happen anytime, but they're more common in teens than younger children. A child having a panic attack will have physical symptoms, such as trembling, a racing heart, and shortness of breath. They may fear having another attack, and they may avoid places and things that remind them of past panic attacks.

Selective mutism

A child with selective mutism can talk (at home or with those close to them, for example), but they can't speak in certain situations – such as at school or other places where they're fearful. They're not shy, and they don't have a communication disorder; they're just so anxious that they're unable to speak. As a result, they may have problems with friendships and school.

Phobias

Fears aren't uncommon in children. Children who are 2 or 3 years old are commonly afraid of thunder and lightning, fire, water, darkness, nightmares, and animals, for example. At 4 to 5 years old, they often fear monsters, ghosts, serious illness or germs, disasters, and traumatic events. School anxiety and performance anxiety are normal at this age, too.

From 5 to 8 years old, kids often worry about things they've seen, done and not enjoyed, heard about from friends, studied at school, or learned about in the media. These fears can run the gamut from shots at the doctor's office to vampires, meteors, clowns, or a scary show they watched. As they develop an understanding of death – often around age 6 or 7 – kids may have worries about the possible death of a family member or themself.

A child with a phobia, though, has a more extreme, persistent, longer-lasting fear of the specific thing and is difficult to comfort. A tornado drill at school can blossom into a fear of natural disasters. Likewise, a child may develop a fear of flying after hearing about a plane crash on the news. Some kids become phobic about dogs if they've been bitten or growled at.

A child with a phobia might go out of their way to avoid whatever it is they're afraid of. For example, a kid with a phobia about dogs may refuse to go on a walk because they might come across one. Kids with phobias may become extremely shy and withdrawn and have feelings of shame.

Obsessive-compulsive disorder (OCD)

Children with obsessive-compulsive disorder have obsessions (unwanted, upsetting thoughts) and/or compulsions (rules they think they have to follow to make the obsession go away). A child might have the idea that they have to repeat something over and over (silently or out loud), for example, and then they're compelled to do it. Or they might have the idea that they need to wash their hands many times an hour, and they feel that doing it will make them feel better.

These thoughts and compulsions happen over and over, making the child very anxious.

Anxiety signs and symptoms in children

An anxiety disorder may affect a child's mood and behavior. They may have very real physical symptoms, too.

Some signs and symptoms of anxiety in children include:

• Physical symptoms like headaches, stomachaches, sweating, racing heart, shortness of breath, clammy hands, hot face, dry mouth, dizziness or shakiness, fatigue, and fidgeting. Anxious children are more likely to have physical symptoms than adults with anxiety.
• Emotional problems such as long-term, persistent worry, irritability, anger, excessive crying, regression (bedwetting, for example), excessive sadness, worry about things before they happen, fear of making mistakes or being embarrassed, lack of confidence, low self-esteem, obsessions or compulsions, tantrums
• Performance difficulties like poor academic performance at school, difficulty with attention and concentration
• Social difficulties such as avoidance of friends and activities they enjoyed in the past, clingy behavior, extreme self-consciousness, lashing out, aggressive behavior, argumentativeness, disruptive behavior at school
• Sleep problems like nightmares and terrors, and trouble getting to sleep. These symptoms are also more likely in children than adults.

Keep in mind that some children who are anxious try to cover up their feelings, and their symptoms may not be obvious.

The American Academy of Child and Adolescent Psychiatry recommends that healthcare providers routinely screen children for behavioral and mental health problems at their well-child checkups.

How is anxiety in kids treated?

Talk to your child's doctor or a mental health specialist if your child has persistent signs or symptoms of an anxiety disorder. Pay special attention if your child's anxieties keep them from everyday activities (like making friends, going to school, and sleeping well), result in compulsive behavior, or cause physical symptoms.

Treatment options include psychotherapy and medication.

Psychotherapy

Your child may benefit from individual therapy, family therapy, and/or group therapy.

Cognitive behavioral therapy (CBT) is the psychotherapy treatment most often used for anxiety in children. It helps children change their negative thoughts and unlearn avoidant behavior (avoiding a fear makes it stronger). It also gives them tools – such as relaxation exercises and breathing techniques – to cope with their anxiety. As a result, the child may feel less fearful, more confident, and less likely to act out.

If your child has a phobia, gradual exposure to the fear may teach them that they're safe. CBT can include a technique called exposure and response prevention, which helps kids face their fear a little bit at a time, in small amounts, in a safe space. If they're afraid of a specific animal, for example, the therapist may talk with them about it, look at photographs or videos of the animal, then look at the animal behind glass. Eventually, the child can learn to be in the same room with the animal.

Family therapy (with parents and siblings, for example) may be helpful for your child. With your permission, your child's school may be consulted, too.

Your child may also benefit from group therapy with other children (usually a group of fewer than 10) who suffer from an anxiety disorder. Using fun activities (spontaneous or structured play, role playing, drawing, and board games) and targeted goals, a group setting is helpful for working on social skills and problem solving.

Being part of a group teaches children that other kids have similar problems, which helps them feel understood and validated. It encourages kids to share feelings (which may be easier to do with other children than with adults), and teaches positive social interaction. Groups can work together to come up with coping skills. Children are encouraged to help others in the group, which is therapeutic and boosts confidence and self-esteem.

Children can receive both group and individual therapy at the same time, or they may have one or the other.

To find a mental health professional, ask your child's doctor for a referral. You can also use online tools, such as those provided by:

• The American Academy of Child and Adolescent Psychiatry provides a Child and Adolescent Psychiatrist Finder to help you find a physician in your area. They also have a resource library with information on relevant issues.
• The American Psychological Association provides a Psychologist Locator where you can search for a psychologist by location and specialty.
• Anxiety & Depression Association of America offers a Find a Therapist Directory. They also provide a state-by-state list of ADAA telemedicine health providers.
• The Association for Behavioral and Cognitive Therapies offers a CBT Therapist Directory to help you find psychologists, psychiatrists, and clinical social workers trained in cognitive and behavioral techniques.
• Psychology Today's website offers a Find a TherapistOpens a new window link to help you find mental health professionals in your areas.

Medication

Medications are sometimes used as part of a treatment program (along with therapy) to ease a child's anxiety. Studies have shown that children who receive a combination of medication and therapy for anxiety do best.

The most common medications used for treating anxiety in children are antidepressants. These include serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs). These medications work by increasing the effects of serotonin and norepinephrine, which help regulate mood, anxiety, and social behavior.

Medications that are used for anxiety disorders include citalopram (Celexa), escitalopram (Lexapro), duloxetine (Cymbalta), sertraline (Zoloft), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil) and venlafaxine ER (Effexor XR).

Children sometimes start showing improvement within a week or two of starting medication, but it generally takes 2 to 4 weeks, with additional improvement over 8 to 12 weeks. Keep in mind, though, that your child's doctor may need to try more than one medication – or more than one dosage – to find the right prescription for your child. A child often responds to one medication after not responding to another.

For short-term use (for an intense bout of anxiety), benzodiazepines are sometimes given, but these aren't considered effective for long-term treatment of anxiety in children. They may require increased dosaging over time, and some patients suffer withdrawal symptoms when they stop the medication.

Talk with your child's doctor about the recommended medication – including its effectiveness (how long will it take to see results, and what can you expect to see in your child's behavior) and side effects.

How to help a child with anxiety

In addition to the treatments above, there are things you can do at home to help your anxious child. Emphasize healthy habits so they can feel their best – by eating well, enjoying plenty of physical activity, and getting enough sleep. Many children with anxiety especially benefit from routine (set bedtimes, mealtimes, activities, etc.) because it helps them know what to expect and feel more secure.

When your child is anxious, be sure to comfort them. But don't stop there – find creative ways to help them overcome their fears and worries. The overall message you want to convey is that you understand and empathize with how they feel, you're there to support them, and you know they can feel better in time.

These tips may help:

Acknowledge the fear. Don't dismiss your child's fears as silly – they may be entirely normal and reasonable. Be sympathetic and explain that many children have fears. Tell them that they can learn to deal with them.

If they're afraid of losing you in a store, for example, tell them that this idea scares you as much as it does them. Explain that's why you watch them so closely, and teach them what to do if they ever do become separated from you.

If they're worried they're not mastering their schoolwork as quickly as their peers, remind them that each child learns at their own pace. Let them know that as long as they make their best effort, neither of you can be disappointed.

Encourage your child, but don't force them to confront a fear. If your child is afraid of the dark, for example, don't make them go to sleep with the lights out. Instead, find a solution together – such as a nightlight or flashlight, or a door that's propped open to a lit hallway, for example.

Teach your child to separate themselves from the anxiety. Getting distance from their anxiety enables a child to better control it (rather than it controlling them). One way to do this is to tell them to think about their anxiety as an annoying creature or a bully. Your child can name the creature, and you can help them develop skills to handle it – by telling it off or laughing at it, for example.

Talk it out. Simply discussing a fear may make it less overwhelming. By talking about it, your child might be able to get a healthier perspective – and they may give you the information you need to help them manage their fear.

If someone said something mean on the playground, for example, you can help your child plan what to do if it happens again. Let them know that you're confident they can handle anxiety-provoking situations.

Write it down. Keeping a journal is a simple and private way for your child to work through anxiety. Or they could use a sketchpad to draw pictures of their worries. A journal can be especially helpful if your child doesn't realize they worry about the same things repeatedly – seeing the same concerns come up again and again could give them (and you) some perspective.

Lighten the load. Your anxious child may be trying to tell you that they're overwhelmed by the demands of school, music lessons, and sports. Consider whether your child is overscheduled with too many extracurricular activities or chores. Ask them how they'd like to lighten their load, or suggest that maybe Scouts or the swim team could wait until next year.

Use humor. Laughter goes a long way toward easing anxiety. If your child is worrying over an upcoming recital or their role in a school play, tell them the old trick of imagining the audience in their underwear. Funny stories put things in perspective, and if they learn to laugh at those awkward moments, they won't seem so awful.

Engage your child in problem solving and brainstorming. Thinking about solutions will engage your child's thinking brain (frontal lobe) instead of their emotional brain (amygdala). "I see you're feeling worried about school tomorrow," you might say. "Let's start a list together of things you can do to feel better."