Many children experience an occasional bout of shyness, anxiety when left alone, or a stomach ache the first day of school or camp. These are normal and common anxiety reactions that typically lessen as the child matures. However, if a child or adolescent experiences persistent and excessive anxiety that interferes with their academic, behavioral, emotional and social development, they may have an anxiety disorder. It is important for both parents and teachers to be aware of the signs and symptoms of childhood anxiety disorders, which are serious, yet treatable conditions. With the school year recently underway, the symptoms of certain anxiety disorders, such as separation anxiety disorder and social anxiety disorder (also called social phobia), might become more apparent. Read on to learn more about recognizing and treating anxiety and related disorders in children.

What are the main types of anxiety disorders and associated features in children?

Separation Anxiety Disorder - Many children experience separation anxiety between 18 months and three years of age. At this time, it is normal for children to feel anxious or upset when a parent is out of sight, leaves the room or drops them off at daycare for the first time. Children can generally be distracted from these feelings and often will not feel distressed once they become engaged in their surroundings. Typically, children are able to leave their parents without becoming upset around four years of age. If a child is still distressed at this age without his or her parents, the child might have separation anxiety disorder. This disorder affects approximately 4 percent of children and occurs when a child experiences extreme anxiety when removed from familiar people or surroundings. For example, children with separation anxiety disorder often have difficulty leaving their parents to attend school. In this case, the desire to be in contact with the missed person(s) is excessive. While separated, it is not uncommon for these children to have fears regarding the health and safety of their parents. The onset of separation anxiety disorder can occur any time, but it is most common in children between the ages of seven and nine.

Signs of separation anxiety disorder in children may include:

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Social Anxiety Disorder - Social anxiety disorder (social phobia) is characterized by an intense fear of social and performance situations. Initiating conversations, participating in peer activities, performing in front of others, speaking in class and inviting others to social activities are some of the most commonly feared situations for children with social anxiety disorder. Children with social anxiety are not just shy. When faced with their feared situation(s), children with the disorder might suffer from symptoms such as sweating, racing heart, stomach ache, dizziness and crying. They may avoid situations where they may have to engage in such activities, which can significantly interfere with their lives. School performance and attendance, as well as the child's ability to socialize with peers and develop relationships, can all be impaired as a result. While social anxiety disorder can develop at any time, onset usually occurs during adolescence, when independently establishing and managing relationships plays a key part in healthy development.

Signs of social anxiety disorder in children may include:

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Selective Mutism - Many children become shy when faced with strangers or when speaking in front of a large group. However, children who refuse to speak in situations where speech is expected or necessary, to the extent that this refusal interferes with school and making friends, might be suffering from selective mutism. The onset of selective mutism, a condition that can in some cases represent a severe form of social anxiety disorder, is usually before the age of five, but it often becomes most noticeable when children enter school. Although diagnosis generally occurs between ages four and eight, children with selective mutism often exhibit "extreme shyness" at an earlier age. In sharp contrast to their school/outside behavior, children with selective mutism can be talkative and even boisterous when at home or in a place where they feel comfortable.

Children with selective mutism may:

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School Refusal/Avoidance. School refusal or avoidance is not an anxiety disorder. However, anxiety in children with conditions such as separation anxiety disorder or social anxiety disorder can manifest as a refusal to attend school. Because this is particularly distressing for families, issues of school refusal warrant careful scrutiny. It is common for children to suffer from "school jitters," particularly on the first day of school or before a test or presentation. However, school refusal is diagnosed when a child refuses to go to school on a regular basis or has problem staying in school once there. It is usually marked by certain fears related to school such as being separated from caregivers, riding the bus, interacting with classmates or teachers or being picked on by peers or older students. School refusal is often a symptom of a deeper problem and, if not treated, can have a negative impact on socialization skills, self-confidence, coping skills and education. Anxiety-based school refusal affects 2 to 5 percent of school-aged children. It is most often found in children between the ages of five and six and ten and 11. School refusal is common during times of transition, such as graduating from elementary to middle school and middle to high school. It is important for parents to keep a child with school refusal or avoidance in school, as allowing him or her to miss days reinforces the anxiety instead of relieving it.

Signs of school refusal/avoidance in children include:

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Can children also have any of the anxiety disorders that adults may suffer from, such as obsessive-compulsive disorder or generalized anxiety disorder?

Like adults, children can also suffer from all the major recognized anxiety disorders, including generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD) and specific phobias (as well as social anxiety disorder, already described above). A brief description of each disorder and how they may manifest in children is included below:

GAD in children is characterized by excessive worry or apprehension about everyday events in multiple settings (school, home, social events, extracurricular activities, etc.). Sources of worry may include grades, athletic performance, punctuality and health concerns. Children with GAD tend to be very hard on themselves, striving for perfection and sometimes redoing tasks repeatedly in an effort to do them "perfectly." These children may also seek constant approval or reassurance from others. For more information, click here.

OCD is characterized by unwanted and intrusive thoughts that people can't seem to get out of their heads (obsessions) and strong urges to repeatedly perform ritualistic behaviors and routines (compulsions) to try and ease their anxiety. While many forms of anxiety can lead to intrusive thoughts or actions, the thoughts and actions in OCD are very stereotyped in nature. For example, a child might have a stereotyped thought that "I am dirty" and this might lead to a stereotyped pattern of hand washing. These obsessions and compulsions take up a great deal of time and can cause significant distress. Some children and adolescents with OCD spend hours performing complicated rituals involving hand-washing, counting or checking in order to ward off persistent, unwelcome thoughts, feelings or images. Others live in terror that they will accidentally do something wrong, such as harm someone or throw something out by mistake. The peak age for diagnosis is ten years old, although OCD can affect children as young as two or three. For more information, click here.

Panic Disorder in children is diagnosed when they suffer at least two unexpected panic attacks (the abrupt onset of an episode of intense fear or discomfort that might include trembling, heart palpitations, shortness of breath, dizziness and/or feeling the need to escape), followed by at least one month of concern over having another attack, losing control or "going crazy." Panic disorder is not common in young children, but can begin in adolescence. For more information, click here.

PTSD can occur in children who are exposed to an extreme stressor such as a natural disaster, the sudden death of a parent or other loved one, an accident or physical assault, or witnessing of a traumatic event. Symptoms of PTSD may include not sleeping or eating; excessive clinging; re-experiencing the event through nightmares, recollections or play; emotional numbing; or persistent fears about the event happening again. While many children will experience these symptoms following a traumatic event, they will pass within a few weeks. Children with PTSD, however, will continue to experience such symptoms weeks or months later, interfering with their home, school and social functioning. Some children with PTSD may have a delayed onset of symptoms, which can occur several weeks or even months after the trauma. For more information, click here.

Specific Phobias are intense, irrational fears of specific objects, places or situations. Common childhood phobias include animals, heights, storms, water, blood, medical procedures and "the dark." These fears often go away on their own. If a child's fear persists for at least six months and interferes with his or her daily life, the child may have a phobia. Children with a phobia may throw a tantrum, freeze, cling, cry or suffer stomach aches/headaches when confronted with their fear. Unlike adults with phobias, children do not usually recognize that their fear is irrational. For more information, click here.

At what age do anxiety disorders develop in children?

While children of almost any age can suffer from anxiety, certain disorders are more common during specific stages of development. Separation anxiety disorders and specific phobias tend to occur between the ages of 6 to 9. Generalized anxiety disorder (GAD) and social anxiety disorder generally occur during middle childhood and adolescence. Panic disorder sometimes begins in adolescence.

How are anxiety disorders in children different than in adults?

While children often experience the symptoms of anxiety disorders in ways similar to adults, children might display and react to symptoms differently (i.e., crying, tantrums, clinging). They also may not understand that their anxiety is irrational, as most adults with anxiety disorders recognize, and may not be able to verbalize their feelings. This makes it important for parents and other adults to pay close attention to a child's symptoms.

What affect can an anxiety disorder have on a child?

If left untreated, anxiety disorders can lead to academic, behavioral, emotional and social problems that may include:

When is it time to seek help?

Many physical and emotional signs can suggest an anxiety disorder or other mental health problem. It may be time to seek help if your child exhibits changes or problems in the following areas:

How do I find help for my child?

If you suspect your child may suffer from an anxiety disorder, click here to complete a test for your child. Print out the results and discuss them with your child's doctor. He or she may refer you to a mental health professional for diagnosis and treatment. Only a trained professional can diagnose an anxiety disorder. If you would like to search for mental health professionals in your area, click here.

Seeking mental health care for your child can be a difficult process if you don't know what to ask. Parents should consider the following issues and questions when deciding on a professional and a type of treatment:

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What treatment options are available for children?

Therapy, medication or a combination of both are treatment options for children with anxiety disorders. Specific options include the following:

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What should I know about medication as a treatment option?

The use of medication is one of the many treatment options available in managing the symptoms of anxiety disorders. Parents are understandably hesitant about putting their children on medication without knowing which ones are appropriate, how they will affect their child, and if and when medications are safe to use. It is important to weigh the benefits versus the risks of medication, potential side effects and a number of other issues. Click here for a more complete discussion of medications and children.

What else can I do as a parent?

It is important to let children know that their anxiety is not their fault. Other ways parents and the entire family can help include:

How can I help a child in college who is suffering from anxiety?

It can be more difficult to recognize a disorder and help a child who is away from home. However, there are things parents can do, including:

Additional Resources

American Academy of Childhood & Adolescent Psychiatry

Massachusetts General Hospital's School Psychiatry Program & MADI Resource Center

National Institute of Mental Heath

National Mental Health Information Center

Nemours Foundation

Obsessive-Compulsive Foundation

Obsessive-Compulsive Foundation of Metropolitan Chicago

Selective Mutism Foundation, Inc.

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