Treating anxiety in children

By Lisa R. Rhodes

August 2023

Childhood is quickly becoming a time of increased worry and emotional distress. According to a Department of Health and Human Services study published in the Journal of the American Medical Association in March 2022, the number of children aged 3 to 17 diagnosed with anxiety grew by 29% between 2016 and 2020. In fact, medical and mental health professionals have become so concerned about the increase in childhood anxiety that last October the U.S. Preventive Services Task Force called for health care professionals to begin screening for anxiety in children aged 8 to 18.

Counselors who treat children for anxiety, specifically those aged 6 to 12, say the rise in childhood anxiety is due in part to the fast pace of modern society as well as the onset of COVID-19. “Our culture [is one] of busyness, constantly moving with lots of good opportunities, but almost too many good opportunities, keeping kids busy with structured learning instead of learning through observation and play,” says Hannah Pitman, a licensed professional counselor (LPC) at Abundant Life Counseling Services in Austin, Texas. “Kids are forced to make so many more microdecisions every day that their brains get on overload. They are constantly in communication and contact with everyone … at any time.”

A child’s life used to be less complicated, she continues. They went to school, played during recess, came home, ate dinner and went to bed. But today, there are more activities for children and more decisions to make. For example, after school, do they go to gymnastics, play soccer, attend piano lessons or chat with friends on social media?

“As our culture has [evolved], decisions and opportunities have grown,” Pitman says, noting that a child’s brain needs these opportunities to be given by parents in smaller doses so there will be less psychological stress for them.

Pitman and Aileen Elsaesser, an LPC at Sunstone Counseling in Alexandria, Virginia, note that genetic and environmental factors both play a role in children developing anxiety and displaying anxiety-related symptoms (e.g., feeling nervous, having temper tantrums, catastrophic thinking). Elsaesser says children who grow up in an environment where parents or caregivers display anxious behaviors or who have experienced a stressful event (e.g., moving to a different state, being in a car accident, losing a loved one to a terminal disease, being bullied) may develop a tendency toward anxiety.

Children want to play and have fun, but anxiety takes away their ability to play uninhibited and enjoy life, says Pitman, who treats children and adolescents with anxiety disorders. “Normal levels of worry and stress impact us, but not in a way that they make our daily lives overly difficult,” she explains. “When anxiety starts to impact a child’s ability to function and enjoy life, that’s when it’s time to make a change.”

Assessing for anxiety

Parents play a pivotal role when assessing children for anxiety. Elsaesser recommends counselors have parents participate in the intake process because they know their children best and can be helpful in answering questions about the child’s emotions and behavior.

“Clinicians will perform a detailed intake evaluation with the parents to discuss symptoms, severity and functioning of the child,” says Elsaesser, who specializes in treating children struggling with anxiety and phobias. “We ask for physical symptoms, anxious thought patterns, behaviors indicating anxiety and how it is affecting functioning in different areas of the [child’s life].”

Elsaesser recommends counselors use the Screen for Child Anxiety Related Emotional Disorders Assessment with both parents and children during intake. This self-report assessment screens for general anxiety disorder, separation anxiety disorder, panic disorder and social phobia in youths aged 8 to 18. The assessment statements for children (e.g., “When I feel frightened, it is hard to breathe,” “I don’t like to be with people I don’t know well”) and parents (e.g., “My child worries about other people liking him/her,” “When my child gets frightened, he/she feels like passing out”) are rated on a scale of 0 (not true or hardly true) to 2 (very true or often true).”

Elsaesser says the assessment gives her insight into a child’s understanding of their own anxiety and what parents may notice but the child does not recognize. The information from these assessments helps her formulate a treatment plan, but she notes that screening is not the sole determining factor for diagnosis.

Pitman often asks her clients’ parents if they have noticed any changes in their child’s behavior or if it is affecting the child’s daily functioning. To determine this, she tells parents to ask themselves the following:

• Is my child having trouble going to school every day?
• Is my child unable to enjoy fun events?
• Is my child obsessing over something or someone?
• Is my child feeling afraid more often?
• Is my child irritable every day and unable to control their emotions?

For example, if a child refuses to attend school, has trouble concentrating in school, avoids sleepovers and parties or doesn’t try new things or if their physical symptoms (such as stomachaches or headaches) cause them to be impaired, then the parents should consider having their child assessed for anxiety. Jena Jozwicki, a licensed associate counselor at Elevate Counseling in Glendale, Arizona, says she uses her own checklist of questions to screen children for generalized anxiety disorder. These questions include:

• How long have you been feeling this way?
• How often do these anxiety attacks occur?
• When do you notice the symptoms most?
• How do you know you are experiencing anxiety?

These questions allow Jozwicki to understand the severity and frequency of the child’s anxiety symptoms so she can best classify and make a diagnosis.

Determining an effective treatment plan

The counselors interviewed for this article agree that cognitive behavior therapy (CBT) is an effective treatment for anxiety disorders because it helps children become familiar with their distressing thoughts and learn how to replace them with healthy thinking patterns. It can also help them learn to become more aware of their emotions and how they influence their behavior.

Counselors should also consider working with parents during therapy because family members can be helpful in teaching children how to recognize anxiety and implement the coping skills and behaviors they learn in treatment.

Pitman devotes the first few sessions of therapy to helping children build emotional and relational skills and determining what modality will work best for the child and their family. She often finds CBT, trauma-focused CBT, eye movement desensitization and reprocessing, internal family systems and trust-based relational intervention work well for her clients. She also uses the information she gleans from these first few sessions to help her later assess if the child is progressing or regressing.

During the first therapy session, Pitman meets only with the parents to establish rapport and learn more about what the child is struggling with, without having to use age-appropriate words or timing. Pitman asks parents, “What are you hoping I can help you with?” and “What have you tried already?”

Pitman wants to know if the parents have a good understanding of anxiety or if this is their first time encountering it. This helps her determine how much psychoeducation about anxiety is needed at the start of therapy. She also discusses the importance of parents spending quality time to connect with their child and to be empathetic to validate the child’s experience and let them know the parent is there to help them manage their anxiety.

Pitman devotes the second session to helping the child and parent(s) build rapport for the work they will do together in session. She says she usually begins this session by asking the child and parent(s) to play a trust-based relational intervention connection game to increase co-regulation between the child and parent and build communication to disarm shame and confusion around anxiety in the home.

“When a child’s home is an open place to talk about their needs, they are better able to manage their anxiety,” Pitman adds.

One connection game she often has her clients play involves the use of Band-Aids. Pitman asks the parents and child to share a happy and a sad thing that happened to them during the week. Then the parents put a Band-Aid on the child for their sad thing, which shows empathy and care, and the child puts a Band-Aid on the parent for their sad thing. This activity is one of Pitman’s favorite games because it helps children build emotional and communication skills, allows parents to model how to talk about positive and negative feelings, and lets parents and children practice giving and receiving care. Even the simple act of asking where the person would like them to place the Band-Aid helps build the skill of asking permission and negotiating emotional needs.

After playing the game, Pitman works with the child alone, if they are comfortable, to build rapport, and she incorporates psychoeducation to teach them about the purpose of therapy and normalize their experience with anxiety. For example, she may ask, “What do you know about counseling?” and “Sometimes kids worry and feel like they can’t stop. Have you ever felt that way? Did you know that a lot of other kids often feel that way?”

Pitman continues to meet with both the parents and child during the third and fourth sessions and keeps her focus on building rapport and introducing the child to breathing exercises, which can be fully implemented in later sessions.

“These [early] sessions give you time to build rapport and determine the severity of the child’s anxiety,” Pitman explains. “Once you have seen that, you are able to see if there is something deeper the child needs to process, like trauma, or if it is general anxiety.”

Pitman says a counselor can also learn where the family stands in terms of the child’s treatment. Are the parents able to complete the assigned activities at home? Can the parents help the child manage their anxiety or are they dealing with their own anxiety and are not able to help? The answers to these questions help counselors determine a treatment plan for the client, she notes.

Learning to handle distress

Elsaesser recommends teaching clients distress tolerance skills because they can use these skills throughout their lifetime whenever they encounter stress. She provides a hypothetical example to illustrate how counselors can help children struggling with anxiety learn to manage physical symptoms and de-escalate anxious thoughts by evaluating and reframing them.

Eric is 9 years old and has been struggling with separation anxiety for several years. His parents are not aware of any specific incident that caused his anxiety, but his mother’s side of the family has a history of anxiety disorders. When Eric begins counseling, he presents with several anxiety symptoms, including worrying that something bad might happen to his parents. He becomes nervous and stressed if his parents are not near him. He calls his parents multiple times throughout the day to check on them. Every time they leave, even when he knows where they are and when they will be home, he asks repetitive questions for reassurance, such as “Where are you?” “When will you be home?” “Are you going out tonight?” “Who will put me to bed?”

He tells the counselor he is experiencing stomachaches, a rapid heartbeat, fast breathing, shakiness and muscle tension, and he has a difficult time concentrating when he is worried or nervous about his parents’ whereabouts.

In therapy, Elsaesser says she would teach this client relaxation and coping techniques to handle his physical symptoms. She would first ask him to draw a picture of his body and to point out all the places where he experiences physical symptoms. Then she would normalize his experience by telling Eric that the symptoms are common in people who struggle with anxiety.

Once Eric knows what anxiety looks and feels like in his body, Elsaesser would encourage him to name these bodily symptoms when they arise. For example, he may say, “My stomach hurts because I am worried about being alone.” She would also have him practice relaxation techniques, such as deep breathing and tensing and releasing his body through progressive muscle relaxation.

Elsaesser would use CBT techniques to help him get control of his thoughts. She would discuss thoughts versus facts and helpful/useful worries versus unhelpful/useless worries. “I would explain that helpful worries keep us safe, like how worrying about getting injured by a car makes us look both ways, but unhelpful worries keep us from living joyfully or doing the things we want to do,” she explains.

Elsaesser says she would then ask Eric to imagine the worst-case scenario for his parents. He may say that his parents could fall and get hurt when they are walking the dog, and if no one knows, they would be stuck there alone. She would also ask him how likely it is that would happen. He may admit that it is not likely but insist that it could still happen.

Elsaesser says she would then shift the focus to how he would handle the situation by asking, “OK, so it’s not very likely, but would you be able to handle it if that happened?” Eric may respond by saying, “No, because they’d be hurt, and I’d be so worried and sad.” She would validate that Eric is probably right that he would feel that way, but she would also ask him what he means when he says he couldn’t handle it.

“Usually when kids say they can’t handle it, they just mean that it would be difficult to deal with,” she explains. “But they will get through it because they have to and they have gotten through difficult things before.”

To help Eric put his fear and anxiety into perspective, Elsaesser would also use Socratic questioning and ask him, “If your parents did fall, then what would happen?” or “If others helped you, what would happen?” By taking this approach, Eric may respond to the scenario by saying, “Yeah, it has never happened before, but they always walk on the sidewalk in our neighborhood so a neighbor could see them.”

“Lots of times worries feel very big and overwhelming, but once we say them out loud and question them, we see they are not likely to occur or are that difficult to manage,” Elsaesser says.

Setting children up for success

With treatment, children can learn to feel more at ease with themselves and the world around them. Helping clients build a strong social network outside their family and school is pivotal in helping them learn how to better manage anxious thoughts and emotions, Jozwicki says.

“For those presenting with anxiety disorders, a strong social network may also serve as another outlet for them to share their concerns with their peers,” she explains. “Social networks, such as friendships, allow children to feel safe, which is the opposite of feeling anxiety.”

Elsaesser says when children learn what anxiety is, how it shows up in their bodies and what skills they can use to manage their anxious thoughts and behaviors, it sets them up for success in handling anxiety throughout their lifetime.

Pitman agrees. “When children can recognize what is happening in their body and build new neural pathways that take them to deep breathing, calm problem-solving skills and regulated ability to think, they can become adults who are no longer consumed with anxiety,” she says. “And instead, they can live peacefully and enjoy their life, no matter what comes their way.”  

Lisa R. Rhodes is a senior writer at Counseling Today. Contact her at lrhodes@counseling.org.

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.