When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.
It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.
Dr. Susan D. Swick
Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.
From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.
Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.
Michael Jellinek
Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.
There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.
School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?