First there were temper tantrums. Then uncooperativeness and failure to follow instructions.
“She couldn’t transition between activities well either—like if they were coloring, she wouldn’t follow the instructions, or she wouldn’t stop it to go outside for recess,” says Keri Stoner Davis of Lewisville, whose daughter Kaylee was in preschool at the time. “She wasn’t defiant, but she also wasn’t compliant. She would just continue to do what she wanted to do.”
The list of incidents grew, and Davis and her husband were mystified. They simply weren’t seeing any of these behaviors at home.
And there was more. “They told us she would hang onto her anger for days,” Davis recalls, “and that’s age-inappropriate for a 3 ½-year-old child.”
Jennifer Nintzel, a Mansfield mother of five, has spent the past year dealing with a completely different set of behaviors that are attached to the same diagnosis: anxiety.
Her son Liam, who was 12 at the time, seemed increasingly apprehensive about situations he knew were safe. He had never been particularly shy, but suddenly sleepovers became a nightmare. He’d want to be with his friends, but then in the middle of the night Nintzel would get a panicked plea for an instant pickup.
“And even at home, when new people were invited over to the house, he’d ask all these questions about who they were and why they had to come over anyway,” Nintzel reveals. “It’s just any kind of new situation. Anything unfamiliar, and he bolts or freezes up.”
Nintzel brought her concerns to their family pediatrician but says the doctor “pretty much discounted the whole situation and labeled it just a phase.” Meanwhile, Liam’s behavior started affecting his grades. One project, for example, required him to interview 13 administrators, “and he just couldn’t do it,” his mom says. He got a failing grade.
“He’s always been a good student and well-adjusted otherwise,” Nintzel says. “But he’s just crippled when it comes to meeting new people. … And it’s hard because other people don’t understand it. It’s sort of like an invisible thing.”
Instincts on Overdrive
Invisible though it may be, anxiety is shockingly pervasive: According to the Anxiety and Depression Association of America (ADAA), anxiety disorders affect 25 percent of children ages 13–18, and the National Institute of Mental Health puts this figure closer to 32 percent. If untreated, experts say, these kids are at higher risk of performing poorly in school and engaging in substance abuse as well as missing out on important social experiences, like slumber parties.
Statistics for younger kids aren’t readily available, possibly because diagnosis is difficult. Nicholas Westers, a clinical psychologist at Children’s Health and assistant professor at University of Texas Southwestern Medical Center, says anxiety is one of the most common mental health disorders among children and adolescents, but parents often miss it because anxiety can manifest differently in children than in adults. He and his colleagues provide a psychotherapy treatment called cognitive behavioral therapy at the Children’s Health Specialty Center Bass Center, and he says parents frequently arrive at his clinic seeking answers about their child’s behavioral problems only to be surprised by a diagnosis of anxiety disorder.
“Because younger children don’t have the emotional vocabulary yet to express when they’re anxious or scared, the child might be acting physically aggressive or breaking things at home, or even hiding under to bed when it’s time to go to school,” he explains. “Parents might think the child is experiencing anger and aggressiveness, but it might be anxiety that’s the underlying issue of the behavior.”
Ardis Lo, a counselor and play therapy specialist at Therapy on the Square in McKinney, says children commonly exhibit signs of separation anxiety as early as ages 3 to 4, while generalized anxiety disorder may appear among 7- to 9-year-olds.
“By the time they’re in second to third grade, changes happen at school and kids start becoming more aware of and anxious about the academic expectations that are placed on them,” she explains. “We tend to see social anxiety becoming more of an issue for pre-adolescents, although that can start younger too.”
And anxiety in and of itself “is not a bad thing,” Westers adds. “Emotions serve functions, and our fight-or-flight response can keep us safe. If a human is standing on a cliff and gets scared and feels cautious, he backs up—and that’s good.” A certain amount of anxiety can help kids focus and perform well in the classroom or on the sports field too.
Some children are generally anxious by nature, but this isn’t synonymous with an anxiety disorder.
“Anxiety is only too much if it begins to impair a child’s functioning—when it’s an ongoing, persistent response in multiple situations,” Westers explains. “So it impairs functionality in their life.”
Anxious Parents, Anxious Kids
How, then, does that natural, keep-me-safe instinct graduate to an anxiety disorder? Researchers note that both nature and nurture play a role. Someone with a parent or sibling diagnosed with social anxiety disorder is reportedly two to three times more likely to develop the same than someone without this family history. And some studies have found causal links between anxiety and factors like brain chemicals and certain chromosomes.
Other experts say that anxiety disorders may give the appearance of running in the family because of passed-on anxious behaviors.
“When parents are hypervigilant, anxious, worried and on edge, kids are too,” explains Kathryn Everest, director of counseling services for the Fort Worth Independent School District. “So, if Mom gets stressed out when she watches politics on TV or is always complaining about drama with friends or co-workers, that rubs off on the children.”
Given the typical modern family’s packed lifestyle, the fact that both kids and parents get stressed out is no surprise.
“When parents are hypervigilant, anxious, worried and on edge, kids are too.”
“For a lot of families, there’s just hardly any quiet time, and the busier you stay the more stress you create,” says Everest. “It gets crazy, and it takes a toll.”
Everest also theorizes that screens have a lot to do with anxiety in kids. “Just think about all the gadgets and electronics our kids have—from infancy on up—and everything lights up and talks to us,” she says. Even the intensity of modern-day movies may contribute. “Everything’s louder, and screens are larger and the action is fast, fast, fast,” she explains. “It just gets way more intense than what previous generations dealt with, and I think kids don’t know how to come down from all of that.”
Westers says a child might be genetically predisposed to shyness or anxiety and then begin to experience “clinical levels of anxiety” as a result of a stressful event—bullying, perhaps, or some kind of trauma.
Davis believes that her daughter Kaylee’s anxiety was precipitated by a sudden life change and period of transition as a family.
“That caused a lot of changes in our schedules and she was with sitters a lot, and she was too little to understand why,” Davis explains. “She probably just felt very out of control of her world.”
That doesn’t mean it’s possible to avoid anxiety disorders by avoiding stressful situations. Westers says that by rescuing kids from a stress-provoking event, well-meaning parents may inadvertently reinforce the child’s anxious response to it.
“When you do rescue them from stressful situations, that only helps in the short-term,” he says. “Total avoidance isn’t the goal. We want to empower them, not just rescue them. … A better strategy is to help them learn to tolerate and have strategies in place for dealing with stressful situations that cause anxiety.”
On the other side of the coin, Everest says parents sometimes struggle to understand when to take kids’ complaints seriously. “They think, ‘What do you have to be anxious about? I feed you, I clothe you, I get you where you need to be. You’ve got nothing to be stressed about,’” she explains.
Parents may also attach a stigma to a diagnosis of anxiety disorder and be reluctant to seek professional treatment, or they might simply view the anxiety as a phase.
“It’s not uncommon for parents or even teachers to say things like, ‘Everybody has emotions like that’ or ‘He’ll grow out of it,’” Westers says, adding that adults sometimes try to reassure or comfort an anxious child by saying, “Don’t worry. Just relax.” This may help a child who’s nervous in the moment, but for a child who has an anxiety disorder, such phrases can invalidate their feelings. “Even if what’s making a child anxious isn’t following a rational thought, it’s still caused by feelings, so you don’t want to invalidate that,” he says.
Adding to the Mix
Keri Stoner Davis, the Lewisville mom, took the complaints from her daughter’s preschool teachers seriously and consulted a friend, Tiffany Smith, who is a partner with Flower Mound Counseling. This led the family to Smith’s colleague Denise Butler for play therapy.
Five years later, Davis talks about anxiety disorders like an expert—and notes that now that Kaylee is in third grade, the triggers of her anxiety are different.
“She’s more aware of other kids and social situations and she also wants to do well in school,” Davis explains. “And when you’re nervous and not processing well, then you worry about not doing what you’re supposed to be doing, so anxiety is kind of ever-present.”
Davis reports that play therapy was incredibly helpful, both for their daughter and for the couple’s understanding of how she expressed her anxiety. Now Kaylee is doing cognitive behavioral therapy (CBT), which Westers describes as a process of “helping individuals to recognize how their thoughts, behaviors and emotions affect each other.”
“That sounds something like, ‘I know you’re scared. That’s OK. We can get through this. It’s not fun, but that’s the anxiety talking,’” he says. “Then the next step is to teach them how to talk back to the anxiety. … It doesn’t stop a child from having anxious feelings, but it helps them become aware of them and they have some strategies in place and ways of coping with it when it appears.”
Davis believes that in addition to helping Kaylee develop coping skills for her anxiety, the CBT made it possible to delay starting her daughter on medication for attention deficit hyperactivity disorder (ADHD)—a newer, secondary diagnosis.
Kaylee’s dual diagnosis is not unusual; anxiety often co-exists with ADHD, depression and similar disorders. In fact, of the 40 million U.S. adults affected by depression in the U.S., the ADAA says half are diagnosed with a co-occurring anxiety disorder. Westers says the frequency of coexisting conditions often compounds the difficulties of diagnosing anxiety in children too because symptoms can overlap.
Take Garland couple Christina and Michael—by the time their son was 4, he had been diagnosed with three conditions, including anxiety disorder. (The couple requested their surname and their son’s name be omitted due to a policy at Christina’s workplace.) “He had classic symptoms of Asperger’s and ADHD, and was quick-tempered when things wouldn’t go his way,” Christina says. “The anxiety was just part of the mix.”
Anxiety wasn’t new territory for the mom, since her 16-year-old daughter—“a high-strung, high-performing student”—had taken medication for anxiety in the past. Still, Christina admits that anxiety added “a whole new layer of difficulty” to the challenges of advocating for her son and making sure his special needs were addressed in school.
“It was so stressful in those early years—even just doing homework was a combative situation,” she recalls. “And then, we’d be getting calls from the school almost every day because he would either withdraw, act out or freak out. So I was practically having anxiety attacks of my own every day.”
A Bumpy Road Ahead
Christina reports that her son, now 11, has been much happier since moving from a public school to Great Lakes Academy, a small, private school in Plano that specializes in serving students with these types of conditions.
“It’s been so much better this year,” she says. “A big source of his stress is that he zones out during the lesson, then freaks out when it’s time to do the work. That used to get him in a lot of trouble, but here, they know how to deal with situations like this and they let him step away when he’s stressed out.”
He’s also medication-free, although in the past they’ve tried three different prescription drugs. “Those either aggravated his symptoms or he was totally out of it,” Christina reports. “He was too young to understand, but he felt bad from the meds and we could see it. So we stopped those.”
The Nintzels started Liam on a very low dose of anti-anxiety medication this year. His mother says they’re keeping an eye on this component because antipsychotics and antidepressants, which are often prescribed for anxiety, can make the symptoms worse or cause other health problems. Meanwhile she reports that a year of counseling has helped immensely. Still, she anticipates a “bumpy road ahead” since it’s an ongoing struggle to keep coping strategies in place as kids age and their anxiety triggers change.
“He’s working to be an Eagle scout, and campouts are going to be a part of that, so we worry for him—a lot,” she reports. “And it’s distressing that he also thinks there’s something wrong with him and we have to constantly tell him there’s nothing wrong with him—it’s just who he is.”
The couple has coined a phrase that seems to help their son cope: “Anxiety just doesn’t make any sense.”
“The fear is irrational and he knows it is, and we know it is, but that doesn’t matter,” Nintzel says. “It’s how he feels, so it’s very, very real.”