Mental Health Series: Anxiety

In this episode—the third in our series on mental health in children & teens—our topic is anxiety. What triggers it in kids? What are the signs? And what can parents do to help a child struggling with anxiety? Children’s behavioral health experts are here to offer their guidance and perspective.

Topic Breakdown

1:19 – What is anxiety?
3:51 – Anxiety changes with age
5:46 – Common types of anxiety
9:12 – Anxiety in teenagers
10:31 – Evaluating and treating anxiety
15:10 – Learning to cope with anxiety rather than eliminate it
17:48 – Medication for anxiety
22:13 — Positive things can cause anxiety, too
23:38 – Getting help for your child with anxiety


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In this episode—the third in our series on mental health in children & teens—our topic is anxiety. What triggers it in kids? What are the signs? And what can parents do to help a child struggling with anxiety? Children’s behavioral health experts are here to offer their guidance and perspective.

Dr. McWilliams: Hi, I’m Dr. Jennifer McWilliams and I’m a child and adolescent psychiatrist here at Children’s Hospital and Medical Center, here with my partner in crime, Sean Akers, to talk about anxiety.

Dr. Akers: Hi, I’m Dr. Sean Akers. I’m the psychologist here at Children’s Hospital and Medical Center in the Behavioral Health Department and yeah, anxiety is our topic today, Dr. McWilliams. So, you know, the thing about anxiety is, it’s such a vague term.

So how about we first, kind of, define it, narrow it down a little bit, so we can talk in a little bit better detail.

What is anxiety?

So when we, when we say anxiety, what does that really mean?

Well, that’s a great question, and that’s something that, depending on who you ask, you’re going to get five different answers on.

Dr. McWilliams: It’s important to remember that anxiety is very normal. We all have some degree of anxiety. It exists on a spectrum. And anxiety is really protective and helpful it’s what — it’s what keeps us from walking down the middle of Dodge Street in the middle of the night with our eyes closed.

But at a certain point, that anxiety, that discomfort and fearful reaction that we all experience in certain circumstances, can cross a line and become over the top. Can become something that’s more extreme than you would expect for the average person at that age and stage in their life. And then when that starts impairing their ability to function, whether it be, you know, talk to friends, go to school, etc., then that’s where it crosses that line and becomes what we consider a problem, and something that needs to be treated and addressed.

Is that similar to how you define it?

Dr. Akers: Right. We use the terms “excessive anxiety.” Now, there’s some subjectivity in there, but it really just — like some of the other things we’ve talked about, is it — does it affect functioning right? Is it affecting their day to day life or their ability to enjoy socializing with other kids, or being able to attend school or be separated from parents?

And so everybody gets anxious, I don’t know anybody who doesn’t. And, and like you said, it’s a good thing to have some anxiety. You know, we talked about safety. It keeps us from, you know, kind of — watching out for things that are unsafe.

The other thing I’ll add is, is that a certain amount of anxiety helps us, helps us function. It helps us prepare for things. You know, before this talk, you and I talked a little bit and we prepared a little bit, so it doesn’t make us quite anxious to, to talk about something like this. And, you know, whether you’re in the theater or music or taking a test — a little anxiety helps our performance. It’s when it gets excessive and becomes problematic, we want to address it.

Dr. McWilliams: Exactly. In residency, one of my teachers showed us a bell curve of anxiety. Too little, and you didn’t get things done, and too much, you didn’t get things done. And so the goal was to help people get in that sweet spot, the right amount of anxiety.

Anxiety changes with age

Now, we know that anxiety changes as you get older, that what little kids are anxious about is different from what grade school kids are anxious about, is different from what high school kids are anxious about. Thinking about normal anxiety first — what we would expect kids to have, how would you describe the idea of those different stages?

Dr. Akers: It’s a good question and you’re right. Again, we want a certain amount of anxiety, because, let’s say kids are bonding to their parents and they’re — especially little kids — are typically in a relatively sheltered place. You know, in their home and cared for by relatively few caregivers. So we want to get a sense of what’s going on. What is the context of their life, and are there new things, are there new people going on?

One thing that we see a little bit more in younger kids is something like separation anxiety. You know, those first days of kindergarten or preschool. When it’s a very new situation and experience, and they don’t understand what’s going on. And obviously they’re — they’re not little adults, these are children with a different way of thinking about the world. And so that’s going to be different than the child who’s just starting puberty, right around that 11 to 12-year-old, when their brain is functioning, a little bit differently and they’re becoming much more aware of the social world. You know, versus a high school kid.

Dr. McWilliams: Right, exactly. I still remember, sending my daughter off to kindergarten and her, you know, clinging onto my leg crying, which, of course, made me cry. It was reassuring because it was normal for somebody her age. Now this year when she heads off to sixth grade and doesn’t look back over her shoulder, I’m still gonna cry. But I’m reassured that she’s not. Exactly, it changes over time.

Common types of anxiety

Dr. Akers: But that also talks about it that there’s not just one anxiety that fits everybody. There’s different diagnoses, there’s different types of anxiety. Maybe we ought to talk just a little bit about that. Like when people say “anxiety,” oftentimes, they’re really talking about what we call “generalized anxiety.” It’s about anxiety about a variety of things, it’s not just one specific, “I’m only anxious about roller coasters.” They may be anxious about performance and the weather and teachers, or, being judged. I mean, there may be a lot of things that go into that anxiety versus — and then there’s other diagnoses. What other ones come to your mind?

Dr. McWilliams: I see a lot of kids with generalized anxiety, where they worry about a whole range of things. I also see a lot of kids that have very specific social anxiety, so they worry about being around new people, being in crowds, being in situations where they feel like they’re being observed or judged. And that can be really problematic because it makes them not want to go to school and impairs their ability to, kind of build those social skills that we expect kids to be, you know, working on. So social anxiety is one that’s been one that I’ve seen a lot.

And then you mentioned separation anxiety, that’s another type of anxiety that I see fairly frequently. You know, whereas it’s normal for my kindergarten daughter to be nervous about leaving me — if she was in high school and was nervous about that and was constantly fearful about my welfare and her welfare, and didn’t want to leave the house, then that would be problematic. That would be excessive.

So those are the couple of the types that I see the most. There are also specific phobias — you mentioned roller coasters. I personally hate snakes, but I don’t know that I’m at the level where I’m phobic of them. But those are one type.

Oftentimes, we clinically see kids that have very specific fears about things like needles or different medical procedures which, you know, oftentimes are a necessary part of our life and they have to be addressed. I can avoid boa constrictors, I can’t avoid the flu shot. Those are some of the kinds that I see the most commonly. How about you?

Dr. Akers: Yeah, the only thing I would add — I totally agree, is that in phobias — one of the things that I’ll see a little bit more since we work at Children’s Nebraska, is a few phobias around, say blood, or, you know, those types of things. So there are times when we have to work on areas where medical procedures, needles, blood, that have to be addressed, especially in cases where kids are getting procedures or they have a new diagnosis where they’re going to have to face those types of things.

Dr. McWilliams: There are a couple of diagnoses that technically, if you read the psychiatric textbooks, have been put into their own category. So they’re no longer considered anxiety, although historically we’ve thought of them as such. And those are obsessive compulsive disorder, or OCD, and post-traumatic stress disorder, or PTSD.

So again, depending on how strict your definition of an anxiety disorder is, those two can also fit in there and oftentimes can be quite impairing and require treatment as well.

Anxiety in teenagers

Dr. Akers: Right, right. So, let’s go toward, we talked about, you know, separation anxiety — what about teenagers? What do we see a little bit more with teenagers, the high schoolers, that might come out? One of the things that I see a lot of is, is maybe kids who are hard on themselves, kind of, you know, really perfectionistic. What are your thoughts on that?

Dr. McWilliams: Yeah, that can, you know, really morph into, you know, a generalized anxiety or some of the social anxiety, but these kids can become very hard on themselves. To the point that they have expectations that no mere mortal can live up to. So, you know, trying to help them recognize that, “You know what? Getting a ‘B’ on a test is okay” is sometimes really a challenge for these kids. And it can spiral into depression and a whole bunch of other things. And that’s one thing that I always keep a close eye on with anxiety, is that anxiety can lead to other disorders and can cause more problems like depression, eating difficulties, and sleep problems, and stuff like that.

So when I’m doing my evaluation, even if someone comes in and says that they’re having problems with anxiety, I’m gonna ask a whole range of questions about a whole bunch of other stuff to make sure I’m not missing anything.

Evaluating and treating anxiety

Do you want to talk a little bit about the process for evaluation?

Dr. Akers: Yeah, it’s very similar to the other evaluations that we do. Typically, when people come into our office, it’s us asking lots of questions, and really trying to narrow things down. Because certainly kids and families will come in and it’s usually — they’re distressed, and they’re going to say, you know, there’s an anxiety issue. And we want to get a real good idea, what is the context? What is going on that’s distressing?

You know, we’re gonna take developmental level into account — what their age is, what their environment is, what their demands are on them, and how it’s affecting their functioning. So really start with clarifying and identifying what is distressing to them, because, again, a lot of things can look alike, you know, we don’t want to just automatically jump to generalized anxiety, when maybe it’s a mood issue or there’s other things.

Because some things can look alike. For example, some kids who are very hard on themselves can come across very irritably. They — they’re — because they’re angry that things aren’t going that way because — but it’s really, the root is, they want to be perfect. Or they got a “B” on a test or they didn’t do as well in a performance, and that’s what’s affecting mood. So just like you said, we want to make sure that we’re catching everything. That it’s not just anxiety, but there’s often a lot of other things going on.

So it’s really a lot of questions. And then toward the end — clarifying, “This is what we see going on,” and then coming up with a treatment plan. Basically saying, “You know, if this is identifying anxiety, this is what we want to do about it.”

Dr. McWilliams: Exactly. Perfect.

So thinking about treatment. You know, when we talked about some of the other disorders, and we talked about medications, as well as therapy. And for most of the research that I’ve looked at, it really pretty heavily favors focusing on therapy first. Saving medication for only kind of more severe cases. Has that been your experience, and can you kind of walk us through some of the different types of psychotherapy treatment that we use for anxieties?

Dr. Akers: Absolutely. For me, when we’re working to say, “We’re gonna focus on anxiety. We have a generalized anxiety.” It really starts with anxiety education, right? And what I feel like is most helpful in my practice is a team effort to begin with. So when I do anxiety education, I want to talk through with the child, as well as the parents, because they’re in — the child is in the context of their family. And we know that with anxiety, we often really need that, that help in a lot of ways.

So my first step is always going to be anxiety education and it’s going to — there’s a number of things I’m going to talk about. I won’t go through every one of them, but it really starts with — one of the rules of therapy is going to be that we work on managing anxiety, not necessarily eliminating it. Right?

Dr. McWilliams: Right. Again, that bell curve.

Dr. Akers: Yeah. And because we want to normalize that some anxiety is good. And we’ve gone through that, and we don’t want to eliminate anxiety, because that would be unrealistic and unhelpful.

Dr. McWilliams: There was actually a study done at the University of Iowa about a woman who had a very unique stroke that took out parts of your brain on either side that control anxiety. So she had no anxiety. You wouldn’t believe the amount of trouble that she got into, confronting people and doing things that one would just not advise that someone would do.

Dr. Akers: Right, and that is kinda scary if something like that happened.

So we’re gonna talk about what — if there’s a body’s response, we often have a physical response to anxiety. Everybody’s a little bit different. When I get anxious, my hands sweat. It’s just how I know. Other people get anxious in a nauseous kind of manner. I don’t, but that’s certainly true for others. It can affect your pulse, it can affect your breathing, it can affect a lot of different things. So we certainly want to go through that. Are they experiencing those kinds of physical symptoms?

Learning to cope with anxiety rather than eliminate it

And then, one of the things I think is really important for kids and families to both understand is — the number one thing that most all of us do for things that make us anxious is avoid. Avoidance is huge. And you mentioned the child who might have that separation anxiety, or social anxiety, not wanting to attend school. And that’s avoidance behavior. And the reason that we have to involve parents oftentimes with this, is because we want to make sure that we’re — so part of the treatment is working on not avoiding, but coping. We want to learn, “How do we cope with these things that make us uncomfortable and anxious?” and not just use one coping technique of avoidance.

Dr. McWilliams: Exactly, exactly. And that’s hard, that’s really hard work. And as a parent, if my kid is afraid of something and anxious about something to say, you know, “Come on, you know, buck up little camper, you got to go” — that takes some major mom strength and it’s not easy.

Dr. Akers: It really does and we — because we tend to want to validate our children and comfort them. And, “How do I take your distress away?” And that’s typically our immediate response is, “You’re distressed. How can I help that distress?”

That’s the one thing that, for me — I love working with kids with anxiety for a number of reasons. But one of the things that I think is important, that I do explain, is that motivation is important. And part of that is that because the treatment is being willing to say, “We have to work on going toward things that make you uncomfortable,” and knowing that it’s going to be uncomfortable, and not just keeping in that comfort zone of avoidance, and not doing those things.

Dr. McWilliams: It’s also important to recognize that we don’t make people go cold turkey into what they’re trying to avoid. We start by looking at pictures of snakes before just making you walk into the snake section of the zoo. I mean, right? It’s kind of a graduated approach?

Dr. Akers: Right. And to me, that’s where it’s very individual. We want to make sure that we treat every child and every family individually and how, what is going to be in their best interest. And typically, gradual — a gradual process — is much more tolerable to all of us. You know, we don’t necessarily go full-on, from zero to a hundred, because that’s just going to be too distressing. That would actually be more, oftentimes, yucky to people and may create more resistance rather than being helpful..

Dr. McWilliams: Exactly. For some kids that we work with, it’s really hard for them to make even that first step. And they have such severe anxiety that even going in and working with a therapist on it can be quite difficult.

Medication for anxiety

Dr. McWilliams: So, those are the cases that I often step in at, and look at medications. Most of the medications that we use for anxiety are very similar to the ones that we use for depression. Very similar neurobiological pathways so the medications can overlap. And so those are things in the selective serotonin reuptake inhibitor family that you’d see for a lot of different things like Zoloft or Prozac and those medicines.

Like when we’re treating depression, those medicines don’t work overnight. And they have to be taken every single day. And so they take a while to be effective. But for some kids, it can decrease some of that baseline anxiety just enough that then they can engage in the therapy. But I always want to emphasize to families that medication alone is just a band aid. It’s not gonna solve the root problem.

There are some other medications that people use that are very short-acting and very temporary, that people use for situational anxiety, like having panic attacks and such. For kids and for teenagers, we really try to avoid those as much as possible, for a couple reasons. Some of them can be addictive and habit-forming. We don’t always know how they affect the growing brain. And finally, and probably most importantly — if I’m giving you a medicine that immediately makes you feel calm and dulls that anxiety, then that is very counterproductive to the work of therapy of teaching you how to become comfortable with that anxious feeling and cope with it and move on. We don’t want you taking a pill when, you know, taking a deep breath would be more effective in the long term.

Dr. Akers: And those are really good points. When we do add in medication — I think it’s often — we’ve tried these techniques, and the medication is really meant to be an adjunct, an assist. And what we do often see is that when that tension level moderates a little bit, they can actually use some of these techniques a little bit better. And that’s what we really want to see is that they can — they can use the relaxation or the better coping techniques. But the ideal from my end is that they feel — and this is one of the reasons why I feel I really like seeing these kids — is they feel more in control. They feel more powerful. Again, it’s not about eliminating the anxiety, but we want to be able to see kids who say, who come in your office and say, “I gave that talk in front of the class and I was anxious, but I got through it, and it was so much better.” And they’re often very excited that they didn’t panic as much as they expected or they didn’t freak out. And when they feel like they have that ability to do that, it feeds on itself. Then they can really start using these techniques and they can see that with more practice, the brain kind of resets a little bit. They’re realizing that it’s not as dangerous as we think, that fears are often worse than reality, and that the more you practice and face these things, it’s really not that bad. And that’s where I think the longer-term management really helps.

Dr. McWilliams: Absolutely. I think taking a step back then and looking at kind of long-term prognosis with anxiety, that’s important to remember. That if we all consider that anxiety exists on a spectrum, and that some people just a little bit more anxious of a temperament — a little more anxious personality than others, then we’re going to see some ups and downs throughout the course of people’s lives. Stressful situations, you know starting grad school, you know, moving to a new city, could cause anxiety to flare back up again. But the more you have at managing that anxiety appropriately, the easier it gets each time.

Positive things can cause anxiety, too

Dr. Aker: Right. Even positive things can be anxiety-provoking — getting married or having a child, as we get older, those are wonderful things, but they can also be stressful.

Dr. McWilliams: Exactly, exactly. Like I said, you know, anything — as a personal story, I was very introverted and shy as a little kid and really probably could have been diagnosed with social anxiety when I was little. But my parents were fantastic and helped me kind of get over that and practice talking to people. Now I bet it would surprise you to know that it still sometimes makes me a little bit anxious to talk to people I don’t know. But I’m getting better at it, every year, get a little better each time.

Dr. Akers: Wow, you’re really not shy anymore! (laughs).

Dr. McWilliams: They did a really good job.

Dr. Akers: I was going to say the same thing. I was much more quiet and shy and I’m, by nature, soft-spoken, and giving presentations like this 30 years ago would have been very anxiety-provoking for me. And the way I was getting through it was using actually some of the techniques and practicing. It really doesn’t bother me anymore.

Dr. McWilliams: Yeah, exactly. Wonderful.

Well, Sean, any last thoughts that you can think of about anxiety or any unique particularities that you run into in the hospital, or with sick kids, that relates to anxiety?

Getting help for your child with anxiety

Dr. Akers: My only last thought, my last takeaway, is — as a parent, sometimes — I’ve raised three kids — we don’t always have that objective view of where things are. And just, you know, talk to your child. And then I think it’s always going to be good to talk to your pediatrician and your team. Again, that’s the person who’s going to know you guys over time. And ask those questions and say, “This is what we’re seeing.” You know, we have wonderful pediatricians here at Children’s Hospital & Medical Center, and our pediatrician was wonderful with my kids growing up. Whether — regardless of the issue, anxiety is there and, you know, they have a good sense of helping screen a little bit to say, “No, this is within normal limits, we do see separation issues in a toddler. Or, “No, this is excessive, let’s get you to the appropriate folks.” And ask questions. There’s help out there.

Dr. McWilliams: No matter what, at the end of the day, snakes are always gross. So, there you go. Well, thanks everybody for listening. A lot of times, I know that our talks generate more questions than they even have answered. So if you have any concerns or questions, feel free to reach out to our team and we’d be happy to help you.

Dr. Akers: Yeah, I sure do appreciate everything, and thanks a lot for listening.

Thanks, everybody.


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