Anxiety

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. 

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. 

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston.