When Anxiety Becomes a Problem: A Guide for Parents & Carers

All children and young people experience anxiety. Feeling nervous before an exam, worrying about meeting new people or feeling frightened about being away from home can all be normal parts of growing up. Anxiety can even be useful: it helps us notice potential danger, prepare for challenges and respond when something feels threatening.

The difficulty is when anxiety becomes too intense, happens too often, lasts for too long, or starts getting in the way of everyday life. At this point, it may have become an anxiety disorder rather than an understandable response to a particular situation.

Anxiety disorders are common in children and young people and can affect family life, friendships, school attendance and achievement, sleep, activities and confidence. They can also occur alongside other difficulties, including depression, ADHD and autism.

Anxiety does not always look like someone saying, “I'm worried.”

A child or young person may:

• worry excessively about a range of things
• repeatedly seek reassurance
• avoid school, social situations, activities or particular places
• become very upset when separated from parents or carers
• find it difficult to speak in particular situations
• have intense fears about specific things, such as vomiting, animals, injections or travelling
• experience panic attacks or sudden episodes of intense fear
• become irritable, angry, tearful or emotionally overwhelmed
• complain of headaches, stomach aches, nausea, dizziness or muscle tension
• have difficulty sleeping
• appear restless or constantly 'on edge'
• struggle to concentrate
• become increasingly dependent on parents or carers
• freeze or seem unable to act when anxious.

Sometimes anxiety presents primarily through avoidance or behaviour rather than obvious worry. A child who repeatedly refuses school, for example, may be experiencing significant anxiety even if they cannot explain what they are frightened of.

The important question is not simply whether a child is anxious. It is how severe the anxiety 

is, how long it has been present, and what impact it is having.

Anxiety is more concerning when it:

• is much greater than would normally be expected for the child's developmental stage
• is persistent or increasingly difficult to manage
• causes significant distress
• interferes with school attendance or learning
• affects friendships or family relationships
• prevents the child doing things they would otherwise enjoy
• leads to increasing avoidance
• affects sleep, eating or physical wellbeing
• results in frequent reassurance-seeking or reliance on parents
• is becoming progressively more restrictive.

Avoidance can provide short-term relief, but it can unintentionally make anxiety stronger over time. The child learns, “I escaped that situation, so it must have been dangerous.” This is one reason psychological treatment often focuses on gradually facing feared situations rather than continually avoiding them.

There are several different anxiety disorders. A young person may experience one or more of them.

This involves excessive and difficult-to-control worry about several areas of life, such as school, health, family, friendships or the future.

This involves excessive distress about being away from a parent or other important attachment figure. It may lead to difficulties sleeping alone, going to school or attending activities independently.

This involves marked fear of being judged, embarrassed or negatively evaluated by other people. A young person may avoid speaking in class, meeting new people, eating in front of others or participating in social activities.

These involve intense fear associated with a particular object or situation—for example, animals, injections, flying, vomiting or heights. The fear can be much greater than the actual level of danger and may lead to significant avoidance.

This involves recurrent unexpected panic attacks together with persistent concern about having further attacks or changes in behaviour because of them. Panic attacks can involve a racing heart, breathlessness, dizziness, shaking, sweating, chest discomfort or a feeling of losing control.

This involves significant fear of situations where escape might feel difficult or help might not be available if panic-like symptoms occur. This can lead to avoidance of public transport, shops, crowds, school or being away from home.

Selective mutism involves a persistent inability to speak in particular social situations despite being able to speak in other settings. It is not simply shyness or a child choosing not to talk and requires a sensitive, specialist approach.

There is rarely one simple explanation.

Anxiety is thought to develop through an interaction between biological vulnerability, temperament, learning, family factors and life experiences.

Factors that may contribute include:

• a family history of anxiety
• an inhibited or highly cautious temperament
• sensitivity to uncertainty or perceived threat
• stressful or difficult life experiences
• bullying or difficulties at school
• changes in family circumstances
• difficulties within relationships
• learning to avoid situations that feel frightening
• other mental health or neurodevelopmental difficulties.

It is important not to think of anxiety as being caused by one particular parenting style. Parents can, however, unintentionally maintain anxiety—for example, by repeatedly providing reassurance, allowing extensive avoidance or doing things for a child that they could gradually learn to manage themselves.

This is not about blaming parents. Anxiety can be difficult to understand and respond to, and parents often do exactly what feels helpful in the moment. The aim is to help families recognise patterns that may inadvertently keep anxiety going.

One of the most helpful things a parent can do is to communicate:

“I know this feels frightening, and I believe you can learn to handle it.”

Try to:

• listen without immediately trying to remove the anxiety
• acknowledge the feeling without confirming that the feared outcome will happen
• encourage age-appropriate independence
• notice and praise brave behaviour, not just successful outcomes
• avoid repeatedly providing reassurance
• help the young person gradually approach rather than continually avoid feared situations
• maintain predictable routines around sleep, school and activities
• work with school when anxiety is affecting attendance or learning
• allow the young person to have an active role in deciding what support they need.

It can be tempting to say, “Don't worry—nothing bad will happen.” However, reassurance often provides only temporary relief. A more helpful response may be:

“I can see you're worried. Let's work out what you're afraid might happen and what you could do if it did.”

Cognitive behavioural therapy (CBT) is one of the best-established psychological treatments for anxiety disorders in children and young people.

CBT can help a young person understand the relationship between thoughts, feelings, physical sensations and behaviour. Treatment commonly involves gradually approaching feared situations, reducing avoidance and developing practical ways of managing anxiety.

Depending on the child's age and circumstances, CBT may involve:

• individual sessions
• parents or carers
• family-based work
• guided self-help
• group treatment
• online or computer-supported programmes.

For younger children, parents often have an important role in treatment.

Medication is not usually the first treatment for anxiety in children and young people. Psychological treatment, particularly CBT, is generally preferred.

Medication may sometimes be considered when anxiety is severe, persistent, significantly impairing or has not responded sufficiently to psychological treatment. Where medication is considered, this should be discussed with an appropriately qualified clinician and usually forms part of a broader treatment plan.

SSRIs such as fluoxetine or sertraline have the strongest evidence base among medications studied for childhood and adolescent anxiety disorders. Benzodiazepines are not routinely recommended for anxiety disorders in children and young people and there is limited evidence supporting their effectiveness in this population.

Medication decisions should always take account of the individual young person's age, diagnosis, physical health, other medication and potential adverse effects.

Consider seeking professional advice when anxiety is:

• persistent or worsening
• interfering with school attendance
• affecting friendships or family life
• significantly restricting activities
• causing frequent panic attacks
• associated with significant physical symptoms
• resulting in substantial avoidance
• affecting sleep or day-to-day functioning
• causing significant distress to the young person or family.

A professional assessment should also consider whether other difficulties are present, including depression, obsessive-compulsive symptoms, ADHD, autism, eating difficulties, trauma-related symptoms, substance use or physical health problems.

There is no single test for anxiety. Assessment usually involves understanding the young person's symptoms, development, circumstances and functioning, often alongside information from parents, school and other professionals.

Questionnaires such as the RCADS, SCARED, SCAS and MASC can be useful in assessing symptoms and monitoring change, but they do not by themselves establish a diagnosis.

Anxiety is real, but an anxious child is not a broken child.

The goal is not to eliminate every anxious feeling. Anxiety is part of life and learning to tolerate some uncertainty, discomfort and nervousness is an important developmental skill.

The aim of treatment is to help a young person become less controlled by anxiety—so they can do the things that matter to them even when anxiety turns up.

With appropriate support, children and young people can learn that feeling anxious does not necessarily mean they are unsafe, incapable or unable to cope.

MindAlign

Child & Adolescent Psychiatry

Practical advice for young people and families.