Anxiety Disorders

Anxiety Disorders pdf


Children who have anxiety tend to look scared a lot. They may often make comments, such as, “what if,” because they fear something bad happening in the future. These kids are often afraid of multiple things and may have intense fears of dogs, insects, or the dark. They may be very nervous around people and may avoid social events. They often avoid being the center of attention and get very nervous if people are looking at them too long. Children with anxiety often have trouble sleeping. They may have physical symptoms like tummy aches and headaches that have no clear health origin. Sometimes, they get so nervous that they cannot focus at school. It may appear that the child has ADHD or an attention problem, when actually he or she is too nervous to stay on-task for very long. Loud sounds or bright lights may easily overwhelm them. Some children with anxiety have behavioral tics, such as eye blinking, grimacing, or head nods. They may think about things with a “catastrophizing” perspective, always predicting the worst-case scenario. The glass is often half-empty. They might “make mountains out of mole hills,” in other words, making little problems into big problems. Some children with anxiety have compulsions, which are repetitive behaviors that are used to bring down anxiety. For example, the child may be constantly checking that the stove is turned off or even checking that toys are arranged just so. These kids get very upset if things are moved around in their rooms. They may be very overwhelmed by unexpected changes in their routine.


Children who have significant problems in this area may have any of the following potential disability. *Note, this does not serve as a diagnosis in any way. See Where to Go for Help With Anxiety for professionals who can diagnose or provide a referral.

Anxiety Disorders include a number of disorders that are marked by significant anxiety that causes an impact on day-to-day functioning. Anxiety symptoms must be observable and cause clinically significant distress. Here, we wish to introduce and differentiate a few anxiety disorders that may be common in children and teenagers. These disorders are Generalized Anxiety Disorder, Separation Anxiety Disorder, Social Anxiety Disorder and Specific Phobia

In children, anxiety is characterized by general worry or worry about a specific stressor. Worry may manifest in physical symptoms, such as restlessness, irritability, inability to focus, stomachaches, headaches, or nausea. It can lead to challenges with sleep or to avoidance of certain places or situations. Times or situations that produce uncertainty or unpredictability can be hard for an anxious child because these types of environment promote a lack of control. As adults, it is important to realize that worry and anxiety are readily contagious. Often when a parent worries, a child will too.


Generalized Anxiety – symptoms include significant worry more days than not about a variety of topics or situations. Adults have insight that this worry is unrealistic, but children may not. The worry is not better explained by a specific type of worry (like social anxiety), and it is not explained by another mental health condition. Other symptoms include restlessness, irritability, challenges with focus and concentration, challenges with sleep and muscle tension. This disorder can occur from childhood all the way to adulthood.

Separation Anxiety – symptoms include significant difficulty separating from a primary caregiver. Children may have nightmares and physical symptoms like bedwetting. Children may fear sleeping alone or refuse certain daily activities. They will avoid going places like school or friend’s houses because their caregiver will not be present. Children have an unrealistic and lasting fear that something bad will happen to the parent or child if they are separated. This form of anxiety could develop after a stressful event or situation, such as a hospital stay for the child or an unexpected parental illness. Other times, parent challenges, such as parents separating, can impact the child. This disorder is most common in school-aged children from ages 7 to 11.

Social Anxiety – symptoms include an excessive fear of social situations in which a person may be judged or embarrassed. A fear of making mistakes or looking bad can lead to avoidance of social settings, such as school or peer activities, and to the onset of physical symptoms, such as headaches, stomachaches, nausea or panic symptoms like difficulty breathing, feeling dizzy, or hyperventilating. This disorder is most common in adolescence and adulthood.

Specific Phobia – symptoms include a specific worry or fear that is lasting and unreasonable about a certain stimulus or situation. The most common fears in children are fear of the dark, of animals (often dogs) and of inclement weather (like storms). Fears of heights or of medical procedures are also common. Adults know their fear is excessive but struggle with it anyway; children may not realize how excessive the fear is. Fear leads to avoidance of situations in which the stimulus may be encountered. A child may refuse to sleep alone in his bedroom (fear of the dark), go outside on a cloudy day (fear of storms) or visit the park (fear of dogs). This diagnosis is more common in adolescents than children but does seem to be a frequent challenge for children on the Autism Spectrum.


CBT with use of Exposure and Response Prevention as appropriate. Cognitive Behavioral Therapy (CBT) is a modality with considerable research to support its effectiveness. With anxiety, often strategies can be taught and practiced in a setting that may be time limited. Eight to 10 sessions may be sufficient in building confidence and coping skills. CBT can be paired with exposures, which are response prevention treatments that are slowly introduced in a gradual manner, giving anxiety time to dissipate within the situation. For example, a child with Separation Anxiety may work to gradually separate a few feet at a time from mom or dad during therapy sessions until gradually the child can be in the therapy room with a parent in the waiting room. Then, CBT work focusing on understanding anxiety, recognizing worry, and the fears associated with separation can be accomplished. Anxiety treatment is often individual therapy, but it may also be delivered in a group setting. “Facing Your Fears” is a curriculum that is delivered in parent and child groups and is geared at treating phobias in children who also have Autism Spectrum Disorders.

Some goals of CBT include the following:

Increase Emotional Awareness. Activities to help your child recognize emotions may include drawing emotion faces, role playing and acting out different emotions, and recognizing them in the therapist. If CBT is offered in a group setting, emotions are recognized through engagement with group members. Practice recognizing emotions at home, starting with positive ones and moving to anxiety, sadness, and other negative emotions. Children learn about the benefits of anxiety and when worries are too much. Journaling and completing homework assignments related to the emotional awareness goals can help some children remember and practice their skills at home.

Improve Coping Skills. CBT often teaches and helps kids identify and practice coping skills, such as deep breathing, relaxation, reading, listening to music, taking a walk, jumping on the trampoline, or talking to a friend. Children learn to stop and identify their feelings and use a coping skill or to try an anxiety-producing task with support. They work with a therapist to recognize the antecedents, behaviors and consequences associated with their thoughts and feelings.

Work to improve self-confidence. CBT focuses on identifying thoughts that lead to certain behaviors and determining whether those thoughts are valid or whether they are cognitive distortions. Children learn to combat negative thoughts and to see actions and experiences not as global and uncontrollable but as singular instances and under a child’s control.

Mindfulness. Mindfulness involves recognizing and accepting feelings and allowing them to just be. This practice involves scanning the body to notice any tension and working to let that tension go. Awareness of the present time and accepting thoughts and feelings are important in Mindfulness.

Relaxation and Meditation. Breathing and relaxation are encouraged in mindfulness and can make a big difference in reducing anxiety and the presence of negative, distorted thoughts.

Accepting Thoughts. Mindfulness focuses on acceptance and not the immediate push to change and criticize ourselves.

Play Therapy. For young children, play therapy utilizes toys and art to allow a child a safe setting to act out their feelings and experiences. Guided play therapy can introduce coping skills and emotional awareness into the play themes. This guided time may involve exploring the origins of the anxiety and processing these feelings.


Many tests and measures may be part of a psychological evaluation to determine whether anxiety is a relevant diagnosis and to better understand the contributing factors. This process can be hard with children who are sometimes less able to report on their anxiety directly. Some children are very unaware of their own feelings. Using a mix of parent report, self-report, observation and projective measures is often helpful.

Projectives. Questions, open-ended sentences, and drawing tasks can allow a child to express his or her emotions and experiences indirectly. Themes can emerge related to worry or rejection, and some insight may be derived from the collection of these measures.

Story Telling. Tests like the Roberts or TAT involve presenting story cards to an individual and having him or her tell a story about the vague card. Again, themes and emotional content are noted as well as support of self and support from others.

Rating Scales. Sometimes it is easier for children to express their feelings by answering questions. Parents and teachers can also complete questionnaires to provide a sense of how each child appears and performs in different settings. This perspective adds to the data because an evaluation is conducted in one setting that is not natural to the individual.

Play observation. Watching a child play with toys can provide insight into his or her feelings of sadness by attending to themes introduced by the child.

Observation during testing. Looking for restlessness, shy behavior, giddy laughter, noting negative self-statements, noting affective states of the body that indicate tension or discomfort, body language and noting interactions with examiners can provide insight into anxiety.

Executive functioning and processing speed measures. Often, anxious individuals have diminished performance on tasks. A child tested when anxious may have difficulty with planning, problem-solving, attention, etc. A year later, after treatment, some of these areas may be vastly improved.


A referral for a comprehensive neuropsychological evaluation may be warranted to confirm anxiety and to better understand your child’s strengths and weaknesses. This type of assessment includes an evaluation of your child’s cognitive ability, adaptive skills, language skills, social skills, mood and anxiety. Other areas may be evaluated as concerns arise. Referrals may include psychotherapy, group therapy, parent consultations, and an IEP or a Section 504 plan.

Psychotherapy. Psychotherapy occurs in an office with a psychologist or therapist and is often focused on improving emotional awareness, teaching coping skills, and restructuring negative thoughts. The psychotherapy modality that has the most research for treating anxiety is cognitive behavioral therapy (CBT). Other modalities that may be helpful include modular CBT with exposure and response prevention [1], play therapy (for young children) and mindfulness, which teaches awareness of emotions, acceptance, relaxation, and meditation.

Parent Consult. Parent consultation can follow a CBT or a Family Systems model and can provide guidance to parents on strategies to use to hear and support their child and to help them feel understood. It also may focus on principles of reinforcement, noting that punishment is not effective for most children. Consultation can also focus on the parent’s experience and emotional well-being.

School Services. School-based supports like an IEP or a Section 504 plan can help your child receive accommodations and modifications that they may require to access learning in the classroom setting. Taking a comprehensive neuropsychological report to any of these professionals will help them to get an understanding of your child. It will be important to think about how these therapies fit together and about how different skills are being built and addressed to best support your child. Anxiety can impact school performance and social skills. Individual meetings with the school counselor or school psychologist may provide emotional support, assignment of a peer buddy or mentor at school can help as positive event scheduling, and a lunch bunch or social group may also help build peer support. In order to write a formal plan, your school team will need to find an educational impact of anxious symptoms in some aspect of your child’s education. It may be easier to obtain support through a Section 504 plan if your child’s grades and test scores are not at all impacted. A 504 Plan requires a medical condition that impacts functioning, but academics and test scores need not be directly impacted. An IEP is a more detailed document that does require a clear educational impact of symptoms. In addition to emotional supports, goals in an IEP would also address challenges in reading, writing, math or communication. Ask your school about both an IEP and a 504 to determine which plan would best serve your child.

Psychiatrist. Sometimes, children with anxiety do take medication prescribed by a psychiatrist. Keep your pediatrician in the loop about your child’s mental health, and request a referral to a child psychiatrist to learn more about the benefits and side effects of medication if your child’s symptoms are not appropriately alleviated in therapy or if the severity of symptoms constitutes a multimodal approach.


Anxiety is a common diagnosis and can be treated. Taken together, it is valuable to obtain a diagnosis and to engage in the appropriate therapies as early as is feasible. With these supports in place, it is possible to see improvement in anxious symptoms, less avoidance, more engagement in life, fewer physical symptoms, better coping skills and emotional awareness, and the potential to live a happy life.


[1] Chorpita PhD, Bruce (2007) Modular Cognitive Behavioral Therapy for Childhood Anxiety Disorders


[2] Reaven PhD, Judy (2011) Facing Your Fears


[3] Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.

[4] Huebner, Dawn (2005). What to do when you worry too much: A kid’s guide to overcoming anxiety (What to do guides for kids).


[5] Peters, Daniel B. (2013). From worrier to warrior: A guide to conquering your fears.


[6] Culbert, Timothy &  Kajander, Rebecca (2007). Be the boss of your stress (Be the boss of your body®).


[7] Foxman, Paul (2004). The worried child: Recognizing anxiety in children and helping them heal.


[8] Meiners, Cheri J. (2003). When I feel afraid (Learning to get along).


[9] Green, Andi (2011). Don’t feed the worrybug.


[10] Freeland, Claire A. B. & Toner, Jacqueline B. (2016). What to do when you feel too shy: A kid’s guide to overcoming social anxiety.


[11] Bender, Janet M. (2004). Tyler tames the testing tiger


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