For parents
Anxiety in children and teenagers
Anxiety in children and teenagers usually responds well to treatment, and it is usually easier to treat early. This page explains what it looks like at home, including separation anxiety, why reassurance stops working, and what helps.
What anxiety looks like at home
Very few children say that they are anxious. Younger children cannot name the feeling and teenagers often will not, so what you see is behaviour, and much of it does not look like fear. Parents usually notice stomach aches that arrive on Sunday evening and clear by Monday afternoon, the same question needing an answer however often it has been answered, invitations turned down, or homework that never gets started in case it is wrong. Sudden anger on a school morning over a sock is often fear coming out in the only form the child can manage. Anxiety in children takes several forms, often more than one at once, including general worry, fear of being apart from you, social anxiety about being watched or judged, specific phobias and panic, and the way it keeps going is much the same in each.
How anxiety keeps itself going
Anxiety predicts that something bad is going to happen. Your child avoids the situation, or you step in and make it easier, and the feeling drops. That drop teaches your child’s brain that the situation was dangerous and that avoiding it kept them safe. Because the prediction is never checked, the range of things that feel manageable keeps shrinking.
Why reassurance stops working
You reassure a frightened child, it works, so you do it again, and a month later the same question needs answering four times a night. Clinicians call the changes a family makes to keep a child’s anxiety down family accommodation, for example sitting with them until they fall asleep, ordering for them in cafes or emailing the teacher on their behalf. It is what any loving parent does, and it works in the short term, which is why it is hard to stop. It also keeps the anxiety going, because each time it happens your child learns that the situation could not have been managed without your help. Reducing it gradually and warmly is a central part of treatment, and the family accommodation tracker is a free way to note what happens in your house across a week.
- Trigger: A birthday party, or bedtime in the dark
- Your child: Gets upset, clings, or asks to stay at home
- You step in: You stay close, answer again, or let them skip it
- Relief for you both: The distress drops quickly
- What it teaches: It was too much, and they could not have managed alone
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: School trips, sleepovers, you going out for the evening, A different teacher.
Where treatment steps in. Treatment works on this step. You stay warm and supportive, say that you are confident they can cope, and step back from rescuing them a little at a time.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
Separation anxiety
Separation anxiety is a fear of what will happen when you are not there, most often that something bad will happen to you, such as a car crash or an illness, or that you will not come back. Younger children rarely say this. What you see instead is a child holding on to your coat at the school gate, a bedtime that ends with you on the floor of their room until they fall asleep, and tears or a stomach ache whenever you plan an evening out. In a teenager it looks more like constant messages during the day, distress if you do not reply, and turning down residential trips and sleepovers. Distress at separation is expected in toddlers and preschool children, and it becomes a problem when it lasts beyond the age you would expect and limits what your child and the family can do.
Treatment builds up time apart in planned steps, starting with one your child can manage and repeating each on different days until it becomes ordinary. For a seven-year-old the steps might run from you being in another room, to you in the garden, to ten minutes at the shop, to a grandparent doing bedtime. While you are apart you respond supportively rather than calling the separation off, saying that you know it feels hard and that you know they can cope, without promising that nothing bad will happen. Goodbyes become short, warm and the same each time, and slipping away unseen is best avoided, because a child who learns that you might disappear watches you more closely. With younger children, much or all of this work can be done through the parents. A bereavement, a parent’s illness or a house move can set separation anxiety off, and it lies behind much school avoidance in primary school and Year 7.
What treatment involves
The psychological treatment with the most trial evidence is cognitive behavioural therapy in which your child gradually faces what they fear (Walkup and colleagues, 2008). We first map what sets the anxiety off, what your child does to stop the feeling, and what the family does to help. Then we write a list of steps, rated from manageable to hard, and your child practises each one without the usual way out, such as leaving early or asking you for an answer. Each step is agreed with your child in advance, is a stretch but manageable, and becomes easier with practice. The anxiety often eases while they stay, and even when it does not, your child finds out that they can handle the feeling. With an eight-year-old this looks like games and charts, and with a fifteen-year-old it is closer to adult treatment, with parents stepping back. Most of the change happens between sessions, so much of my work is showing you what to say when the same question comes for the fifth time and how to step back without a confrontation.
If your child will not attend
SPACE, Supportive Parenting for Anxious Childhood Emotions, is a treatment developed at Yale in which you attend and your child does not. In one randomised trial, SPACE was not inferior to CBT delivered to the child (Lebowitz and colleagues, 2020), so it is an option where a child or teenager has refused therapy.
When it can be worth getting help
Plenty of childhood worry passes on its own, but where avoidance is building it can be worth getting things looked at sooner. Signs that it is worth acting now include attendance slipping, a child’s world visibly shrinking, sleep going, physical symptoms every morning, a child who says they hate themselves, or a family quietly rearranged around one person’s fear. Take it seriously too in a child or teenager who seems to be coping, because in a high-achieving young person anxiety can show only as perfectionism and exhaustion.
Sources
- Lebowitz, E. R., Marin, C., Martino, A., Shimshoni, Y., & Silverman, W. K. (2020). Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: a randomized noninferiority study of Supportive Parenting for Anxious Childhood Emotions. Journal of the American Academy of Child and Adolescent Psychiatry, 59(3), 362-372. doi.org/10.1016/j.jaac.2019.02.014 (opens in a new tab)
- Walkup, J. T., Albano, A. M., Piacentini, J., et al. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359(26), 2753-2766. doi.org/10.1056/NEJMoa0804633 (opens in a new tab)
- Lebowitz, E. R., Woolston, J., Bar-Haim, Y., et al. (2013). Family accommodation in pediatric anxiety disorders. Depression and Anxiety, 30(1), 47-54. doi.org/10.1002/da.21998 (opens in a new tab)
Common questions
How do I tell normal worry from an anxiety disorder?
Every child worries, and some worry is expected at every age. It becomes a problem when it starts costing your child things they would otherwise have, such as sleepovers, clubs, lessons and friendships, and when it takes up a real part of the day. I look at how much distress there is, how much time it takes up, and how much of family life has been rearranged around it.
My child says they have a stomach ache every morning. Is it real?
Yes, your child really feels it. Anxiety produces physical symptoms, including nausea, stomach pain, headaches, needing the toilet and a racing heart, because the body’s alarm system also acts on the gut. It is worth a GP appointment early to rule out a physical cause. Once that has been done, the symptoms usually ease as the anxiety is treated.
What if my child refuses to come to therapy?
That is common, particularly with teenagers, and it does not mean nothing can be done. SPACE (Supportive Parenting for Anxious Childhood Emotions) is a treatment in which only the parents attend. We work on how the family responds to the anxiety rather than on persuading your child to take part, and it has trial evidence behind it.
Free 20-minute call
Not sure whether this is the right fit?
Start with a free 20-minute call. We talk through what is going on, I answer any questions you have, and I tell you whether I think I can help. If I cannot, I will try to point you to someone who can. The call is free and there is no obligation to book.
Weekdays, 9am to 5pm. No GP referral needed.