If I have a specialty, it is anxiety disorders in children and adolescents. Most of the young people I see have Social Anxiety Disorder (impairing shyness and avoidance), Obsessive-Compulsive Disorder (obsessive worries and/or repetitive behaviors), Phobias (specific impairing fears), and/or Generalized Anxiety Disorder (excessive and unrealistic worries). Some of them may not have an actual anxiety disorder but are reacting to a stressor with anxiety symptoms such as worry and trouble falling asleep.
Individuals with anxiety are fun to work with because they tend to work hard in therapy and because a great deal is known about effective treatments for this group of disorders. There are, of course, challenges as well. The challenges I encounter most frequently in my work with anxious young people involve two related parent factors. First, because anxiety is both a highly heritable and learned condition, one or both of the parents often suffer from anxiety. In turn, parents’ own anxiety can make it difficult for them to respond to a child’s anxiety in the most effective ways.
Based upon a lot of research and a lot of experience with families of children with anxiety, I have developed a brief set of guidelines that can help parents through the difficult parenting dilemmas. To help parents remember the guidelines, I refer to them as the 3 A’s and an I:
A1: Avoidance. Avoidance is one of the most powerful factors that maintain anxiety. Think about a child with a phobia of dogs. Dana arrives at the house of a relative who has a dog. She reacts with anxiety, cries, and clings to her mother. Out of compassion, the relative puts the dog into the backyard. Dana relaxes and enjoys her visit.
Imagine a child with multiple, school-related worries such as using a public restroom, being called on in class, and doing poorly on a test. Scott wakes up complaining of a stomach ache but has no fever and no overt signs of illness. Out of uncertainty, Dad lets him stay home from school. Scott feels better and enjoys a day off.
In both of these examples, avoidance (sending the dog to the backyard, staying home from school) leads to relief of anxiety. Here’s what these hypothetical children are learning: if I avoid the things that scare/worry me, I don’t have to feel anxious.
A2: Attention. Anxious behaviors like the ones exhibited by Dana in the example above pull at a parent’s heartstrings, especially if the parent knows firsthand how uncomfortable anxiety can be. Imagine a child who has a fear of choking. Mom is understandably concerned about Chauncey’s nutrition, so she has been preparing special foods for her son (avoidance). Because Chauncey loves to cook, they have been spending lots of time together in the kitchen making homemade smoothies, soups, mashed potatoes, and puddings.
Think about a teenager with a compulsive need to check the window and door locks as well as all the appliances before she goes to bed. Cheryl has trouble falling asleep because she lies in bed worrying that an intruder will come into the house or that an appliance left on will start a fire. Dad has begun going through the checking ritual with Cheryl because it helps her get to bed earlier.
In both of these examples, parental attention (cooking together, checking locks and appliances together) is serving as a reward (positive reinforcement) for Chauncey and Cheryl’s anxiety and avoidance. Here’s what these young people are learning: anxious behaviors are an effective way to get attention from a parent.
A3: Assurance. When young people share their worries, it is natural for parents to want to assure them that there is nothing to fear. It is important that parents do not offer their children empty assurances such as “Tornadoes don’t happen in this part of the country” or “Children don’t get cancer.” Kids see right through this. In fact, I once had an anxious child say to me, after her parents assured her that “nothing can go wrong during a tonsillectomy”:
I let my parents think I believe them so that they can stop worrying so much about me. Amber, age 11
It is also important that parents limit assurance to brief, matter-of-fact, statements of truth, and that they don’t repeat their assurances. I encourage parents to “Assure, but don’t reassure.” It is fine to say, for example, “It is very rare for earthquakes to happen in this part of the country” or “Children sometimes do get cancer, and thankfully there are lots of effective treatments available.” Repeating these assurances results in too much attention for anxious behavior.
When parents offer empty assurances or too many reassurances, this is what their children learn: the situation is so bad that my parents have to lie to me or try to convince me that there is nothing to worry about.
I: Independence. Perhaps the greatest risk for children and adolescents with anxiety disorders is interference with the normal, developmental drive toward independence. The natural tendency for a worried or fearful child is to turn to an adult for support. A parent’s natural tendency is to try to alleviate his or her child’s discomfort. Unfortunately, these tendencies often translate into a child’s excessive dependence on a parent. The goal for parents is to find ways to support their anxious children that also encourage independence.
Picture a teenager who has an intrusive worry about cheating on a test. This causes her anxiety to rise during tests and interferes with her performance. As Wanda is about to get out of the car to go into school, she says to her mom, “I’m going to call you at lunch so you can help me calm down before my Spanish test.”
Imagine a shy child who wants very much to go to birthday parties but becomes so anxious beforehand that he begs not to go. When Pablo’s parents encourage him to go, he tells them he will go if one of them will stay at the party with him.
Both of these hypothetical young people are turning to parents to help them cope with their anxiety. Often, because parents want their children to succeed (to get a good grade, to go to a party), they will give in to such demands. It would be much better for parents to encourage more independent coping. In the examples above, this might look like Mom helping Wanda write down some true, assuring statements that Wanda can review before her test, statements such as “I studied hard for this test and I know the material,” “I worry about cheating before every test, and yet I have never cheated,” and “I can use deep breathing to calm myself down.” Or, it might mean Mom or Dad agreeing to stay at the party for a few minutes until Pablo gets involved in an activity and then leaving until the end of the party.
Parenting a child with anxiety presents a unique set of challenges. The follow-your-gut parenting approach, which really works just fine for the vast majority of children, is counter-productive for parents with anxious kids. Our maternal and paternal guts tell us to help our kids out, alleviate their stress and worry, calm them down, make things easier, etc. In other words, if we follow our natural instincts as parents, we may be parenting in ways that maintain, reinforce, even worsen anxiety and that interfere with our children’s development of independence. Allowing the 3 A’s and an I to guide you will lessen these risks and help you help your child learn effective coping strategies and develop age-appropriate levels of independence.
[Names and identifying information have been changed to protect privacy.]