Helping Children With Anxiety in the Pandemic

Yes, this is an anxious time, and yes, everyone is anxious, but it is particularly hard to be an anxious kid in an anxious time. Anxiety disorders are the most common mental health disorders in children and adolescents (and this was true before the pandemic), and they can be linked to other mental health issues, notably depression.

Anxiety can bring children into emergency rooms, and into psychiatric hospitalizations, and in a time of generally heightened stress and anxiety, parents with anxious kids find themselves worrying especially about the worriers, wondering how to talk with them about the complexities of life in 2020, and trying to assess when worry is, well, worrisome enough to need professional help.

At Boston Children’s Hospital, during the first months of the pandemic and the general shutdown, the volume of children and adolescents coming in to the emergency room with mental health issues decreased, said Dr. Patricia Ibeziako, the associate chief for clinical services in the hospital’s department of psychiatry and behavioral sciences.

It picked up in June, and has increased from the summer through the fall, with more coming in for mental health reasons and also who come to the hospital for other reasons and have anxiety issues. Stress and anxiety may manifest as worsening health, especially for children with underlying medical conditions.

“The highest volume we’re seeing during the pandemic of children presenting to the hospital setting with mental health issues are those with suicidal ideation and suicide attempts — many have anxiety as well, sometimes underlying anxiety disorders,” Dr. Ibeziako said. Adolescents who come in with eating disorders often have anxiety. Children with developmental disabilities have been coming in with agitation and disruptive behaviors reflecting anxiety as the pandemic has disrupted their regular routines.

Even in an anxious time, anxiety is treatable. Dr. Ibeziako said, “First-line management for anxiety is therapy; cognitive behavioral therapy is what we use for children and adolescents.” It involves understanding the thought process of anxiety, she said, and how that affects emotions and behaviors, and helping the child reframe or change problematic thoughts.

Some children, depending on the severity of their symptoms, may require medication as well. Children who are severely affected may need therapy in a day program, or a hospital, at least to begin with, while others will do fine with a weekly appointment.

Ideally, children get therapy and medication, if needed, before the anxiety becomes so intense or debilitating that parents consider an emergency room visit. “It would really be great if parents could make outreach to a pediatrician or primary care provider and try to get linked up with a counselor or therapist, start to address this early,” Dr. Ibeziako said.

During this difficult time, some families are thinking, “help is for the people who really need it, but not my kid,” said Rachel Busman, the senior director of the Anxiety Disorders Center at the Child Mind Institute in New York, who sees many younger children in her clinical practice. The expansion of telehealth in the pandemic has increased the availability of mental health services for children, she said.

Dr. Carolina Zerrate, an assistant professor of psychiatry at Columbia who also works in a school-based mental health program, said that while these are stressful times for all families, “Black and Latinx families have been hit by the virus harder.” She noted that “some families were already in a stressed situation.”

Dr. Zerrate suggested that parents model how to express emotions and ask for help and support. Do check-ins by asking open-ended questions, such as: “How are you feeling? Why are you feeling that way?” Don’t dismiss their concerns, she said; don’t tell them they’re too young to be worrying. “You’re opening up space for communicating, it’s OK to talk about your feelings, it’s OK to share with your family.”

Seek help, Dr. Zerrate said, if you see patterns that significantly interfere with a child’s day-to-day functioning, or if a child seems to be in distress over time and getting worse, and of course, if a child says anything at all about self-harm or suicide.

Rebecca Berry, a clinical psychologist at Hassenfeld Children’s Hospital at N.Y.U. Langone, said parents often know that a child tends toward anxiety, and perhaps had separation issues around the age of 4 or 5. She described anxious children as having “what I call a worry brain, a sticky brain, worrying, when is the second wave going to come?”

“There’s so much a parent can be doing to model brave, nonanxious and resilient behavior,” Dr. Busman said. Parents tend to want to rush in and protect their children from distress, she said, and may unintentionally send the message that yes, the child is in danger and needs protecting. “You want to be able to convey a message, ‘I know it’s a little scary to get into bed on your own, but I know you can do it,’” she said, a message like, “We can do hard things.”

Before the pandemic, Dr. Ibeziako said, school-related anxiety was a common problem, but what they are seeing now is “tinged with pandemic implications,” reflecting the changes in the school year and the general uncertainty about how long this will go on.

Routines and structure are important, and can help us all handle anxiety — they matter for young children, for school-aged children, for adolescents, and for adults as well.

“Young children are not likely going to say, ‘Mom, Dad, I’m feeling anxious, and this is how I’m manifesting that anxiety,’” Dr. Busman said. And many older kids, and even adults, she said, don’t necessarily connect their sensations and behaviors to the underlying anxieties that may be shaping them.

Younger children may show their anxiety by being more clingy, Dr. Busman said, “either metaphorically or literally,” and they may have trouble with sleep. But they may also be angry and disruptive, “when we’re threatened, we go into fight or flight mode,” she said. “Children might retreat and hide or they might protest.” So despite the stereotype that an anxious child will be fearful or inhibited, the worried child may actually be the tantrum-throwing child, the defiant child, the oppositional child.

Dr. Ibeziako suggested parents monitor what children encounter in what is often now more time spent looking at screens. Similarly, Dr. Busman recommended parents be mindful of their own conversations, understanding that children may pick up incomplete information, or adult worries. When children ask about what is going on in the world (or in the family), she said, take time to understand what the child already knows, and what information is being requested.

Don’t have those conversations late at night. “Bedtime is a lovely time,” Dr. Busman said, “but not the best time to have lengthy conversations about things that are on your kid’s mind.” Try calming exercises, she suggested, or visualization, like a mental vacation to a place the child has been before.

“Don’t get into bed with your child — you will fall asleep, and when you move they wake up,” she said. Sit next to the bed, rub the child’s back — but model that bedtime is not a time for talk. She suggested picking a “worry time” or even setting up a “worry box” where the worry can be written down and put away for later discussion.

Remind kids that they have power and agency, Dr. Zerrate said, “There are things they can do to keep themselves and their family safe, wash your hands, wear your mask, and we’re good to go.”

The message should be, “this is really hard and really complicated, and as a family, we’re going to be able to cope with this and be OK.”

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