For many children, the start of school also is the start of a lot of anxiety.
According to child psychiatrist Dr. Carl Ratliff with Community Howard Regional Health, it’s not only normal but also expected that children experience some levels of anxiety at specific times in development, including at the start of a new school year.
“All children experience anxiety, and I think that is a really important piece,” said Ratliff.
One of the most common questions he receives at his practice is in regards to how much anxiety is normal for a child. What he tells families is that fears and worries in kids can be common, and they also are developmentally-appropriate.
Ratliff noted several examples of anxiety that are considered developmentally-appropriate. For toddlers, these include a fear of the dark, imaginary creatures, or being separated from their caregivers. For school-aged kids, typical fears include fear of injury, death, and natural events, such as storms. For preadolescent and adolescent kids, they typically experience anxiety around school performances, he said.
While these fears are common, Dr. Ratliff noted that parents shouldn’t disregard them.
“Developmentally-appropriate fears, they can become problematic. If they don’t subside with time—or if they’re severe enough to impair the child’s day-to-day functioning—what I’m expected to do is distinguished between ‘normal’ anxiety and an anxiety disorder that requires further intervention and treatment,” he said.
When treating children with generalized anxiety disorders, which he said are “very common” psychiatric disorders in children and adults, he looks for the signs and symptoms in order to distinguish which type of anxiety a child has.
According to the psychiatric, children can experience chronic or excessive anxiety about multiple areas of their lives, their family, their school, their school situations, their health. Children with separation anxiety can experience excessive fear of being separated from their home and caregivers. Children with a phobia can fear a specific object or situation, which could include spiders or riding in elevators. Children with social phobias can experience anxiety in social situations or performance situations.
Children with a panic disorder can experience “unexpected or brief episodes of intense anxiety without any kind of trigger.” This can be characterized by the physical symptoms, shortness of breath or increased heart rate or sweating. Obsessive compulsive disorder is more of a trauma-related anxiety disorder, he said. Children who have it can perform repetitive mental acts or behaviors, called compulsions, to alleviate anxiety. Finally, the most common trauma-related disorder is post-traumatic stress disorder, and patients can experience anxiety symptoms, feeling of attachment, or an increased startle response following exposure to a traumatic event.
Ratliff noted that there’s no specific cause for most anxiety disorders.
“The development of anxiety disorders typically results from an interaction between, really, genetics biology and the environment, specifically risk factors that are unique to each individual. So genetics play a role in determining who will develop an anxiety disorder,” he said.
So too does a child’s temperament, or what Ratliff called a child’s innate personality style.
“We do have studies that show, for example, children who are innately cautious and quiet and shy are more likely to develop an anxiety disorder, and environmental factors—and this is very important—such as parenting style, combining with the biological risk factors of genetics and temperament, make a child more or less predisposed to developing an anxiety disorder,” he said.
When children are experiencing these issues, one piece of advice Ratliff tells parents is to not be overbearing.
“They may want to try to help the child by doing this, but you actually will be worsening the anxiety symptoms,” he said.
Families typically bring in their children for evaluation when they feel the anxiety is hindering the child’s ability to perform day-to-day tasks or when it begins to affect multiple areas of their lives. When it comes to treating the child, Ratliff said there isn’t one single treatment, and all treatment plans are individualized.
The first-line treatment for anxiety disorders of mild severity, he said, is psychotherapy, as well as one that’s widely used and evidence-based for anxiety disorders, which is called cognitive behavioral therapy (CBT). When a child’s anxiety symptoms are severe or when the child responded only partially to the therapy and psychotherapy is when adding medications may be helpful, he said.
“One of the medications we’ll use is called selective serotonin reuptake inhibitors, and these are the first-line medications to treat children with anxiety disorders. Parents, what I tell them is that they should discuss the risk and the benefits of these medications with their child’s clinicians. That can either be a child psychiatrist like me or a pediatrician or family practice doctor,” he said.
Ratliff said anxiety disorders typically aren’t outgrown. As such, he encouraged parents to consider treatment if the anxiety appears to be outside the realm of what’s considered “normal” for their age.
“There are certain anxiety fears that are normal for the child. It’s just when we cross that threshold and get into some of the more pathologic anxiety symptoms is when we get really, really concerned,” he said. “What I just tell parents is be mindful of the child. Again we want to really work with families on parents not being overbearing. Again, I know that doesn’t sound great, but let the child learn to experience some of the anxiety. However, if the symptoms don’t appear to be getting better, you need to get some extra help.”