Anxiety & Anxiety Disorders
If you are a parent, or spend time with children or adolescents, you are probably familiar with at least one of the following statements:
- “My stomach hurts. I can’t go to school today.”
- “I can’t take the test. What if I fail?”
- “I’m too tired to go to my friend’s house.”
- “I’m scared! Please lie down with me until I fall asleep.”
- “I don’t want to go in my room. There’s a spider in there!”
Children and adolescents often say these kinds of things when they are anxious. Anxiety is a natural response to stressful or potentially dangerous situations. For most of us, some anxiety is helpful and necessary. For example, it is important for young children to fear unfamiliar people. Also, for many older children and adolescents, being a little worried about performance on a test can be helpful in motivating them to study and do well. However, for roughly 10–30% of children and adolescents, anxiety can be so severe that it gets in the way of day-to-day activities or becomes difficult to manage.
To learn more about anxiety and anxiety disorders, use the links below.
Anxiety can present itself in a variety of ways and in response to different triggers. Internal thoughts and physical sensations can provoke anxiety, as can external objects like certain animals, places, or situations. A common source of anxiety for toddlers and younger children is separation from a parent or caregiver. Younger children might also express fear of a specific object, such as snakes or thunder. As a child gets older, fear of specific objects continues to be common, while fears of death, harm, germs, social evaluation, and school performance can become more prevalent. For instance, traveling on an airplane or touching the handle of a bathroom door can trigger anxious feelings. In adolescence, social anxiety is quite common, as are worries about academic performance and the future.
Anxiety can present itself:
- physically (e.g., stomachaches, headaches, heart racing, trouble breathing, sweating, restlessness);
- mentally (e.g., worries, nightmares, intrusive thoughts or images);
- behaviorally (e.g., avoidance, clinging, crying, cautiousness); or
- as a combination of any of the above.
In younger children, anxiety is most often expressed with physical symptoms (e.g., stomachaches or headaches) or distressed behaviors (e.g., avoidance or crying).
A five-year-old might get butterflies in her stomach before her first day of school, and a teenager might feel nervous about his performance in a play, sporting event, or interview. These are normal feelings that we have all experienced at some time or another. However, when such anxious feelings: 1) occur frequently over an extended period of time, 2) significantly impact a child’s ability to function, or 3) cause significant distress, they can be signs of a specific anxiety disorder. The main anxiety disorders in children and adolescents—in order, from most to least common—are:
- fear of coming into contact with specific objects or specific situations (specific phobia);
- feeling anxious or embarrassed in social situations (social anxiety disorder);
- anxiety when separated from a primary caregiver (separation anxiety disorder);
- sudden, unexpected surges of anxiety (panic disorder);
- fear of being in crowds or open spaces (agoraphobia);
- worry about a variety of issues, such as day-to-day matters, being sick, being perfect, or about things that can happen in the future (generalized anxiety disorder); and
- significant reluctance or refusal to speak in front of others (selective mutism).
Sometimes, it might be difficult to distinguish between what is typical and developmentally appropriate and what might be an anxiety disorder. Consider the following questions:
- Does the child’s anxiety, worry, or fear occur consistently (more than a few times) over a long time period (e.g., six months or longer)?
- Do these feelings or worries significantly impact how the child functions on an ongoing basis, or affect those interacting with the child? For example, if a child doesn’t want to sleep alone at night for more than one night, does that disturb the sleep of the child or those who care for the child?
- Does the child become significantly bothered almost every time he or she comes into contact with or experiences what he or she fears? For example, does the child cry, scream, yell, freeze up, or shut down?
Answering yes to any of the above questions doesn’t automatically indicate that the child has a diagnosable disorder or condition, but it does mean that it might be useful to seek help.
When a child’s or adolescent’s anxiety becomes so severe that it causes difficulties, stops him or her from participating in everyday activities, or causes extreme distress, it might be time to get help. Difficulties that can arise in school due to anxiety include: trouble concentrating on or completing assignments, nervousness when taking tests, avoiding asking a teacher a question or for help, fear of working with other classmates, avoiding eating in front of others or in the school cafeteria, not wanting to use the school bathroom, or even refusing to go to school. Difficulties that can arise at home due to anxiety include: not wanting to sleep alone at night, fear of leaving the house or being away from caregivers, avoiding certain objects or doing certain things (e.g., sleeping in the dark or using public transportation), and having significant trouble deciding what to wear. Difficulties that can arise with friends or in social situations due to anxiety include: refusing to play with friends or to go to parties, extreme nervousness when speaking with others, needing to be surrounded by familiar people in order to go to places or do things, and avoiding crowded places.
Decades of research have identified two types of effective treatment for anxiety disorders:
- cognitive-behavioral therapy (CBT) and
- medication, with the most commonly prescribed medication for anxiety being selective serotonin reuptake inhibitors (SSRIs).
CBT is a type of talk therapy that focuses on guiding a child to think and act more flexibly and to approach feared situations more consistently. A CBT therapist helps the child successfully engage in activities that he or she has been avoiding or that have caused distress, while teaching new skills to help manage the difficult-to-cope-with feelings. Treatment is typically structured so that exposure to the fear is gradual and not overwhelming.
SSRIs are currently the frontline medication treatment for anxiety in children and adolescents. SSRI medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). This type of medication can be prescribed by a psychiatrist, psychiatric nurse practitioner, or pediatrician.
In research studies, the combination of CBT and SSRI medications has been shown to be more effective in reducing anxiety than using medication or CBT alone, although both CBT and SSRI medications are considered effective treatments on their own. It is often recommended that a child or adolescent first try CBT before medication, but it depends on the specific circumstances of the patient.
Depending on the situation and age of the patient, family members might be involved in certain stages of the treatment process. The family’s understanding of—and impact on—a child’s behaviors is key, especially when children are younger.
If you think your child has an anxiety disorder, it is important to seek help from a trained professional such as a psychiatrist, psychologist, or social worker who can evaluate your child’s symptoms and make recommendations for effective treatment. If your child sees a primary care doctor or pediatrician, you can also raise your concerns with him or her. If it is suspected that your child has an anxiety disorder, the pediatrician or primary care doctor will likely refer your family to a mental health professional. As some of the symptoms of anxiety can be physical, consulting a physician is also recommended to rule out any existing medical or physical illness.
Other ways to get help include speaking to someone at your child’s school, contacting your insurance provider, or looking for support services through your city or town. In New York City, for example, NYC.gov publishes a list of child and mental health services.
At the Columbia University Medical Center and at CUCARD–Manhattan and CUCARD–Westchester, there are highly-trained specialists dedicated to the mental and emotional well-being of children and young adults with anxiety and related disorders. Call (212) 305-6001 to get more information and—if appropriate—a referral. In addition to clinical care, the Columbia University Pediatric Anxiety and Mood Research Clinic runs a limited number of treatment research studies focusing on treatment for mood and anxiety disorders. Call (646) 774-5793 to find out more and whether your child is eligible to participate in a treatment study.
If you are not located near the Columbia University Medical Center or in the New York metropolitan area, here are some online tools to find a mental health care provider:
- Psychologist Locator, a service of the American Psychological Association (APA) Practice Organization.
- Child and Adolescent Psychiatrist Finder, a research tool from the American Academy of Child and Adolescent Psychiatry (AACAP).
- Find a CBT Therapist, a resource provided by the Association for Behavioral and Cognitive Therapies.
Here are some additional resources about anxiety and anxiety disorders. These external links are not necessarily specific to child and adolescent anxiety, and are being provided for informational purposes only. They do not constitute an endorsement or an approval by the Division of Child and Adolescent Psychiatry at Columbia University.
Articles and Fact Sheets
- Anxiety and Children (y en Español a El Niño Ansioso), from the American Academy of Child and Adolescent Psychiatry (AACAP)
- Anxiety Disorders and Effective Treatment, from the American Psychological Association (APA)
- Anxiety Disorders in Children, from NewYork-Presbyterian Hospital
- Child and Adolescent Anxiety and Depression, from the Centers for Disease Control (CDC)
- Childhood Anxiety Disorders, from the Anxiety and Depression Association of America (ADAA)
- Generalized Anxiety Disorder (en Español tambien), from NewYork-Presbyterian Hospital
- How to Spot and Treat Anxiety in Children, from Scholastic Parent and Child.
- How to Spot Stress and Anxiety in Children, from Verywell (part of About.com)
- Panic Disorder (en Español tambien), from NewYork-Presbyterian Hospital
- Phobias (en Español tambien), from NewYork-Presbyterian Hospital
- Screening for an Anxiety Disorder: Children, from the Anxiety and Depression Association of America (ADAA)
- Separation Anxiety in Children, from HelpGuide.org
- Social Anxiety Disorder, provided by the Columbia University Clinic for Anxiety and Related Disorders (CUCARD)
- Andrew Kukes Foundation for Social Anxiety: A website dedicated to understanding and helping people with social anxiety. It features facts, current events, professional resources, personal stories, organizations, and other helpful materials.
- Anxiety and Depression Association of America (ADAA): A website featuring news and updates, guidelines for help and other resources, and blogs by mental health professionals.
- Anxiety Disorders Resource Center: Information, resources, facts for families, and videos from the American Academy of Child and Adolescent Psychiatry (AACAP).
- CBT Therapist Finder: A tool from the Association for Behavioral and Cognitive Therapies (ABCT) for finding a CBT therapist based on one’s insurance, location, and mental health needs. The association’s website also includes symptom checklists, self-help book recommendations, and guidelines for choosing a therapist.
 Frequency of symptoms depends on the specific issue and can vary. If you feel your child’s concerns are excessive, consult with a healthcare professional.
 Note that these online locators are provided as a convenience. However, by providing links to these third-party tools, neither the Division of Child and Adolescent Psychiatry, nor any associated entity at Columbia University, is endorsing any specific provider.
Paula Yanes-Lukin, PhD, is an assistant professor of clinical psychology in the Columbia University Division of Child & Adolescent Psychiatry at the Columbia University Medical Center. She is also director of psychology at the Columbia University Pediatric Anxiety and Mood Research Clinic (PAMRC). Dr. Yanes-Lukin’s research interests focus on avoidance that occurs within mood and anxiety disorders, and she has several publications on this topic in peer-reviewed journals.