One of the most gratifying parts of my job is working with children and families to navigate the challenges of growing up in our modern world. This is never more true than when it comes to managing anxiety and stress. For parents, it’s really important to know that every child can be anxious from time to time, and it’s a very natural and normal part of growing up. At each age and stage of development, we can probably name common situations that provoke anxiety: big changes in daily routines, the first day of school, a new family member joining the household, the first sleep-away camp experience, taking final exams, talking in front of a group of people.
Where it gets trickier is when anxiety seems to be a more chronic, consistent part of each day; that’s when we as parents and clinicians need to pay attention. More persistent anxiety could be situational, caused by something going on at school or at home that is very manageable over time, but it could also be a sign of a larger issue.
So what might be causing stress or anxiety in children? What can parents do to reduce it? And how can parents tell if anxiety is growing beyond what the family can handle on their own, and outside help is needed? Our first step as parents and pediatricians is to become detectives and look at every aspect of a child’s environment to determine what factors may or may not be affecting them, and then remove or reduce the impact of those factors when possible.
Here are some things to evaluate and consider in your child’s life.
#1: Going back to the basics
The modern lifestyle is not necessarily easy for children, given its pace and number of transitions every day. Sleep – the quantity and the quality of it – is often compromised, and not just for teenagers but for children of all ages. You can have a child who’s acting out or who seems stressed, or who has inattention or hyperactivity, and it may be simply because they are not getting the amount of sleep needed for their age and developmental level. If you’re not sure how much sleep your child needs or how to establish a good sleep routine, this blog written by my colleague may help.
Then there’s food and diet. What a child eats as well as when a child eats can affect mood. A child who eats a lot of sugar may have mood and behavioral changes when they get a sugar high, and/or when their sugar level drops back into the normal range after a high. Having 3, protein-containing meals and 1, protein-containing snack per day and avoiding snacks that contain only carbohydrates can make a huge difference in your child’s behavior. Having those meals and snacks at around the same times each day also helps maintain a good energy balance and minimizes food-related mood changes. I can really empathize with the challenge of regulating and monitoring teen eating habits, but anything parents can do to encourage a regular eating routine and well-balanced diet can go a long way. Family mealtimes built into the daily or weekly schedule are one place that parents can have a big impact on children’s eating routines.
#2: Screens and screen time
As pediatricians, we are concerned about the effects that electronic devices are having on our children. I am seeing some parents use screens to distract and comfort their children as early as 6-9 months. Distraction is an invaluable tool for parents when children are upset or bored. Things like singing songs, reading a book, saying “Look at that truck!” or “Can I have a hug?” or “Where’s the doggy?,” moving to a different part of the room, or bouncing up a down are all great forms of distraction. Distraction and comfort given in the form of a video, however, does not help a child learn self-soothing skills, and we think that it may actually promote eventual dependence on devices to regulate emotions. Those children who are shown screens when they are worried or upset are not getting the opportunity to have that experience of crying, seeing their parent is calm, then eventually taking some deep breaths and moving on. That whole natural process of learning is hijacked.
Into middle and high school, pre-teens and teens are constantly bombarded by our online culture. With the advent of TV, we saw lots of images of certain body types, certain ways of talking or dressing that set a norm for “that’s how you should be.” These standards of behavior and attractiveness were already setting some kids up for depression and anxiety. Today, kids can not only look at images of people with abnormally attractive bodies, they can also share images of themselves and their peers, AND, they’re able to compare, comment, and judge each other through the interactivity of social media. The level of sharing and comparing on social media, not just about body image but about all aspects of daily life, from grades to where you went on vacation to what you are doing with whom, can leave many kids feeling like they are not measuring up somehow.
#3: The need for predictability and routine
People of every age, including a majority of adults, like to be prepared for what’s next. While humans love novelty and surprise at times, we depend on certain things happening at certain times and in certain ways. A preschooler could be having Exorcist-like tantrums for days to weeks before the family realizes she is confused by the fact that her pick-ups and drop-offs are done by different caregivers on different days. Making a picture chart of who will be picking her up can solve this problem. A school-aged child may be acting out and saying really negative things, but a closer look at his schedule could reveal that, due to parents’ schedules or his activities, he gets home and has a different dinner and bedtime routine every night of the week. When children sense uncertainty or unpredictability, they are uncomfortable and often push against the limits, which can look like willful misbehaving when it’s actually a form of anxiety. Because the demands of teen life, with school and activities, can become really complex, they also benefit from having certain parts of the week structured in ways they can count on.
#4: School, homework, and grades
I wish I had a solution for this one, but sadly I don’t know how to combat today’s absolutely pervasive academic pressures. As a pediatrician I’m just overwhelmed by the number of hours that I’m hearing high school and even middle school kids are spending on homework: as many as 3-5 hours on a typical night. Add extracurricular activities to that load, which are important and worthwhile, in my opinion, and we know sleep is taking a hit to get it all done. I really encourage my patients and families to do their best to balance achievement with mental health. If the difference between a B and an A is two full hours of sleep per night? I believe the healthiest option is to go for the B. Our kids live in an extremely competitive world where even a 4.0 GPA and 1600 on their SATs may not get them into the school of their choice. They are feeling disheartened. I therefore encourage parents to try and shift the emphasis to a love of learning, intellectual curiosity and freedom, and a healthy regimen for mind and body, which are the best tools to be successful over the long term.
#5: Parents’ mental health
There is no getting away from the Elephant in the Room: if a parent or other caretaker suffers from anxiety, a child can be significantly impacted by it. A parent’s reaction to their child’s anxiety can either be very soothing or worsen it. Parenting is not easy in the first place, and we all have good days and bad. Some parents avoid self-care in the name of “putting the children first” but this can be counterproductive. Self-care for some can mean just one hour of alone time per week, for others they are able to fit in some exercise. Also, do not be afraid to ask for help. Talking to a therapist, keeping up with a group of friends every few months, going to bed instead of watching one more episode…doing these things can help you personally as well as help you be a better parent.
When to Call
First of all, I do want to state it’s never too early to speak with a therapist. I don’t see it as potentially harmful, and I certainly don’t see it as an indicator that you’ve “failed” as a parent, as I’ve heard some of my parents say. Having somebody with whom you and your child (or your teen on his/her own) can bounce things off of and talk things through can be really important. We naturally look to our friends or family to fulfill that role, but they don’t always have the expertise to tease out what’s really going on like a trained therapist can. And a skilled therapist may see or even head off a larger issue before it gets unmanageable. So if you’re wondering about seeing a therapist, just calling or emailing to ask your pediatrician their opinion is always reasonable, regardless of the specific symptoms.
As for when therapy is truly needed, pediatricians and mental health professionals really want to look closely when a child’s functioning is being impacted. What might this look like? A child is troubled or acting out a home, they’re less interested in activities they used to enjoy, they don’t want to play with their friends as much or at all, grades are dropping, teen peer relationships are falling apart, or sibling or parent relationships feel difficult all of the time, not just some of the time. No matter the age of your child, when something is impacting their functioning more than half of the days, we’d want to see them. I often see patients before they call a therapist, but if you have access to a therapist you can directly seek them out.
Obviously, we always take concerns about anxiety or stress seriously, regardless of age, but teens who have a strong family history of a mental health issue can start to manifest symptoms of the illness as they get closer to adulthood. For this age group, therefore, I’m listening for signs and cues of possible issues like depression that may need therapy or medication.
My bottom line: just call us! If your instincts are that something is not right, or even with your best attempts to reassure and soothe you feel your child is struggling with anxiety, make an appointment with your pediatrician. We are partners in caring for all aspects of your child’s health and well-being.