7 Things To Know About Children & Anxiety

Sometimes when I look at my Laurel -- now 13 years old and remarkably steady and self-assured –- I can’t believe how stressed I used to be about her social/emotional development. I mean, she was a happy, sweet kid, but her elementary school transition was so incredibly difficult…for all of us.

I hear from so many parents who are fretting similarly about different issues with their kids and anxiety often comes up. So as part of an ongoing editorial partnership, I’m happy to share some wisdom today from Karen Saroca MD, a Child and Adolescent Psychiatrist at Floating Hospital for Children at Tufts Medical Center. Dr. Saroca answers questions about anxiety in children and how parents can respond to it.

1. What is the difference between reasonable anxiety and an anxiety disorder?

Anxiety disorders are the most common psychiatric disorders with childhood onset, with an estimated prevalence of 10-30%. While it is natural for a child to have worries and/or fears, this becomes a disorder if it is persistent and/or excessive and impairs daily function.

It’s important to note that anxiety is not necessarily a bad thing; there is a purpose of day-to-day life anxiety in children. Anxiety is a biological “wiring” that has a protective function against perceived dangers. Anxiety can be a driving factor that helps motivate kids to achieve goals (i.e., fear of not doing well on a test can drive a kid to study, or fear of not performing well during a game can drive a kid to put effort into sports practices). The key is to be able to maintain an optimal level of anxiety to drive optimal function. In other words, function can be impaired if anxiety is excessively high or excessively low.

It’s important to note that anxiety is not necessarily a bad thing; there is a purpose of day-to-day life anxiety in children. Anxiety is a biological “wiring” that has a protective function against perceived dangers.
— Dr. Karen Saroca, Tufts Medical Center

2. How does anxiety manifest itself in children?

Anxiety can manifest in children in many different ways. A common theme is avoidance; anxious kids often will avoid certain situations that make them uncomfortable, and this can result in school refusal or avoidance of various social situations. In younger children, social anxiety can manifest as selective mutism (not speaking in certain situations or to certain individuals).

Anxiety can also manifest physically; typically children with anxiety may complain of stomachaches or headaches. When kids feel anxious, they may also feel additional physical symptoms including feeling their heart beating fast, having discomfort or pain in the chest, feeling hot or dizzy, feeling that their muscles are tight, or feeling numbness or tingling. Sometimes these physical sensations heighten the worry and can lead to feelings of panic, or a worry that they are sick or dying.

Behaviorally, anxiety can have a lot of impact. Anxiety in kids often is accompanied by what we call cognitive rigidity, or a need to have fixed rules or structure and a difficulty with unexpected change or transitions. Due to this, anxious kids can often present as oppositional or irritable at home or school, sometimes having “explosive” behavior due to difficulty managing anxiety. Also, anxious children may seek reassurance frequently. In order to relieve anxiety, kids may repetitively ask parents to reassure them that their fear will not happen, and they may remain distressed if they do not receive this reassurance. Children with anxiety also may have trouble falling asleep, often due to excessive worry thoughts at bedtime, or they may also wake up during the night due to anxiety.

Anxiety can have an impact on executive functioning, and this can manifest with poor school performance due to problems paying attention, or problems finishing tests or assignments on time.

3. What are signs that it is becoming more severe?

Signals that anxiety is becoming more severe is when worry and fears are persistent or excessive and negatively impact function. Children are expected to perform academically and socially according to their appropriate developmental stage. This means school attendance, expected school performance, ability to socialize appropriately with peers and with family, ability to eat and sleep without issue. Worsening anxiety often leads to decline in these domains. Another consideration is suicidal thinking. Some children have anxiety so severe that it leads to thoughts that they would like it to end, and this can manifest in the form of suicidal thoughts. Younger children do not yet understand death as permanent, but such statements should still be taken seriously as they reflect a high level of distress. Any suicidal thinking should be urgently evaluated.

4. Are there simple questions that might tease out the underlying issue/ease day-to-day anxiety?

Anxiety is often internalized, and a child can feel distressed due to worry but may not know how to express this. It is always important to have a conversation with your child with a stance of curiosity with intent to better understand them. Some questions you may ask your child are:

  • Do you have any worries or fears?
  • What do you worry about? Why?
  • How much do you worry?
  • When you worry, do you feel anything in your body, like stomachaches or headaches, or any other pain?
  • Does your worry prevent you from doing things you wish you could do?
  • Does anything help you to feel less worried?

It is important when you talk with your child that they feel reassured that they are safe and that you are there to protect them. If the worry is excessive and impairing function, or if reassurance seems to be reinforcing the worry and causing it to persist, it is then important to seek professional help from a doctor or therapist.

5. What are some ways I can help my kid cope with their anxiety?

Exercises in relaxation and mindfulness can be very helpful. The key is to establish a daily practice of relaxation techniques which are to be done while your child is calm. These can be exercises such as practicing taking long, slow breaths for 1 minute each day. The goal with this practice is to train your body to be able to relax. The same way that you get “muscle memory” when learning to ride a bike, you can train your breathing muscles to learn to breathe in a way that facilitates relaxation. That way, when your child is feeling anxious, it will be easier for them to access the relaxation technique during a time of distress.

The key is to establish a daily practice of relaxation techniques which are to be done while your child is calm.
— Dr. Karen Saroca, Tufts Medical Center

There are several books that can be helpful to read for anxiety management. One book I recommend is: What To Do When You Worry Too Much: A Kid’s Guide to Overcoming Anxiety by Dawn Huebner, Ph.D. This can be a book that you and your child read together, and it is a workbook style “what to do” guide with illustrations and kid-appropriate language.

6. At what point should a parent or caregiver seek professional help?

You should seek professional help when anxiety is more than natural, day to day worry or fear. If worries are excessive, persisting, and impairing function, you should talk with your pediatrician to discuss management of anxiety and referrals for a therapist. You can also call your insurance company to request a list of providers for cognitive behavioral therapy for anxiety for children. Potential treatment with medication can be discussed with your pediatrician, or with a child psychiatrist. Start by talking with your pediatrician about treatment options.

7. How does medication fit into the picture? What are effective treatments?

I typically prescribe medication when anxiety is affecting function in multiple domains, such as school and home life, and medication is always prescribed in combination with behavioral therapy. For children, treatment of anxiety in the form of cognitive behavioral therapy combined with medication has been found to be most effective. Rather than a “cure” for anxiety, the goal of medication is to facilitate a lower level of anxiety so that engagement in therapy and learning coping mechanisms can be done more optimally. When a child is too anxious, it can be too difficult to learn to manage anxiety and distress in the moment. Medication can help “take the edge off” and facilitate more ease in engaging in coping strategies and relaxation techniques.

First line medications for children with anxiety are SSRI’s, or selective serotonin reuptake inhibitors. These are medications such as fluoxetine (Prozac) or sertraline (Zoloft). In children, we start with a low dose and increase the dose gradually, until an effective dose is reached. These medications are taken daily and can take up to 4-6 weeks to build up in the system and take effect. You should have a discussion with your doctor about medications and potential side effects.


Floating Hospital for Children is the full-service pediatric hospital of Tufts Medical Center, an internationally respected academic medical center. A major academic medical institution with innovative programs in clinical care, research, education and health care delivery, Floating Hospital offers a full range of inpatient and outpatient services in every area of pediatric specialization for infants through adolescence.

We strive to heal, to comfort, to teach, to learn and to seek the knowledge to promote health and prevent disease. Our patients and their families are at the center of everything we do. At Floating Hospital for Children, our patients are our inspiration, and they prove to us every day that you don’t have to be big to be strong.

To learn more about Floating Hospital for Children and how inspiring our patients are, visit www.floatinghospital.org/strong.

things-to-know-about-children-anxiety.jpg

Disclosure: This post reflects a compensated editorial partnership with Tufts Medical Center. Featured photo by Michał Parzuchowski on Unsplash