In my practice I am seeing a flurry of more youth, as well as adults, with untreated and misdiagnosed anxiety. Over the long-term, the results of this can be devastating. Just this past week, I met with a young father who recalled secretly exhibiting obsessive-compulsive behaviors as a child. His present symptoms have intensified and he currently self-medicates with alcohol and weed to avoid his racing mind. I also met with an adolescent girl who was distressed because she procrastinates working on and completing her school work and avoids new friendships because of fear of failure and rejection. All too often I see untreated and misdiagnosed anxiety leading to depression, missed opportunities in career and relationships, increased substance use, and a decreased quality of life.
Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older, or 18 percent of the population (NIH, 2017). It also affects one in eight children and upwards of 20 percent of children and adolescents over their lifespan (ADAA, 2017). Research shows that untreated children with anxiety disorders are at higher risk to perform poorly in school, miss out on important social experiences, and engage in substance abuse (NIH, 2017).
Because anxiety disorders also often co-occurs with other disorders such as depression, eating disorders, and attention-deficit/hyperactivity disorder (ADHD), it sometimes makes diagnosing youth complicated and confusing. It’s important to have a skilled diagnostician to properly evaluate youth and avoid misdiagnosing or overlooking anxiety which can negatively affect their treatment and prognosis.
Anxious youth are often intelligent, quiet and well behaved, and thus frequently don’t get flagged as anxious by their parents, teachers, and others they interact with. They tend to become masterful at overcompensating. They hold their anxiety secretive or deny it, and/or find calculated ways to avoid or distract from it. The feelings of hopelessness and shame are often so pronounced that the idea of “facing” themselves doesn’t even present as a viable option.
Alternatively, others who are overtly disruptive and act out, in part because of their anxiety, are easily labeled as having a conduct disorder, ADHD or just being a “troubled” kid. Because of a failure in evaluating or understanding what is at the root of and is negatively impacting the child’s behavior, we seek to “fix” the behavior/kid. The factors that are directly causing or influencing the behavior are sadly being overlooked. In either scenario youth slip through the cracks or get misunderstood and often fail to receive the help they desperately need.
Parents often say that from a very young age, they knew there was something different about their child, but, they thought their child was generally okay; that they themselves exhibited similar anxious behaviors and that they are fine; they thought their child would “grow out of it”; that they just accepted that’s the way their child is, and/or that they just didn’t quite know what to do about it.
Parents never expect or want their child to become more debilitated over time. Often, parents of anxious children and teens are often confused about what to do, and may additionally feel helpless, frustrated, and overwhelmed. This occurs especially if there are other siblings in the household, when parents are inundated with numerous responsibilities and/or there are a cluster of stressors.
Some symptoms and behaviors parents report include that their child: is clingy, cries easily and/or tantrums when they separate, has difficulty with transitions, exhibits excessive shyness, avoids social situations, socially isolates, is overly preoccupied with technology and or video games, constantly worries, overthinks things, avoids situations or places because of fears, frequently complains of stomachaches, headaches and/or difficulty sleeping, experiences sudden and frequent panic attacks, and/or engages in ritualistic behaviors, etc.
Anxiety differs from person to person based on the child or teens developmental level, the level of intensity of the anxiety, and how the anxiety manifests itself. It generally impacts in the following ways: (a) Emotionally and physically (e.g., rapid heart rate, heaviness in the chest, shaking, sweating, etc.); (b) Behaviorally (e.g., avoiding, seeking reassurance, etc.); (c) Cognitively (e.g., worrisome thoughts, racing thoughts, looping thoughts, etc.); (d) Dependence (e.g., relying too heavily on parents, friends, etc.), and (e) Functioning (e.g., compromised academically, limits or avoids social interactions, etc.).
Parents play an essential role in helping their child or teen manage anxiety. Some tips on helping kids include:
Be careful about modeling behavior. Be cautious about the way you act and react when you are faced with your own anxiety or worries. Kids pick up on cues which can exacerbate their own fears. Be cognizant of reinforcing self-soothing, personal reassurance, and self-monitoring accomplishments.
It is important for parents to work collaboratively and have a consistent way of managing their child's anxiety. It is very important that one parent not be "too easy" because the other parent “pushes too much.” Family dynamics can play out and may thwart progress and present as confusing to kids.
Encourage exercise, healthy nutrition, good sleep hygiene, and mindfulness. Practice mindfulness, meditation and stress management/relaxation exercises with your child. I highly recommend Transcendental Meditation (TM), the apps “Insight Timer,” “Take a Chill,” and “Stop, Breathe, and Think,” 10 teen meditations at: http://www.doyouyoga.com/10-cool-meditations-for-pre-teens-and-teens-67578/ and the book “The Mindful Teen” by Dr. Dzung X. Vo.
Don’t talk kids out of their thoughts and feelings. Don’t dismiss their concerns by saying, “You have nothing to be scared or worried about”, “Just don’t think about it”, etc. If they’re scared they can’t internalize those sentiments and explanations and often just feel misunderstood and dismissed. Ask kids about details of their fears and be there to respond to their questions and support them through their fears. Express to them that they are not their anxiety. Their anxiety doesn’t rule or define them. They get to define themselves. They also get to manage and rule their own life and can have the thoughts and feelings and act and react based on their values and what is meaningful to them.
Give kids an education on why worrying is useful, helpful and typical. Inform them that everyone experiences anxiety from time to time. It alerts us to threats, protects us from danger and helps us reach important goals. For example, it is normal to feel anxious when encountering a bear while camping, playing in a big game, or before taking an important exam. Although anxiety feels uncomfortable, it’s usually not dangerous. It is temporary and will eventually decrease. Anxiety is normal and part of our body’s natural response mechanism. Our body is smart enough to know when to “amp it up” and when to “calm itself down.”
Stop reassuring kids. It is okay to let your child experience some anxiety and discomfort. It helps them to build and strengthen their coping skills. Your child needs to know that anxiety is not dangerous but something they can effectively and successfully cope with. You can let your child know that all feelings are okay and it is alright to express what you feel. Anxious children sometimes have a hard time expressing strong emotions like anger or sadness because they are afraid people will be angry with them, they won’t be understood, or that others will think that there’s something inherently “wrong” with them.
To manage fears and anxiety, it involves helping kids face their fears, until anxiety decreases and there is a desensitization to the fear. It’s not helpful to avoid or deny kids fears and worries. Avoidance prevents kids from learning that their fears are not violent and/or dangerous. Try to keep the anticipatory period short and throughout the process anticipate pull back, resistance and an inclination to return to familiar and “comfortable” behaviors. Be patient throughout the process and recognize that they may be learning a new mental script and/or working on changing behavior which takes time and effort.
Also, let them know that as much as they desperately try to deny, distract or get rid of their anxiety, it comes back, and generally more intense than it had previously been. It’s worth working on so there is fundamental change, rather than just on the periphery.
Parents can directly help their children with this. Kids can list their specific fears and build a fear ladder (example of a fear ladder is shown at: http://youth.anxietybc.com/build-fear-ladder), from least scary to most scary and rate the fears from 0-5. Next, they can identify their goals, while considering the length of time, time of day, the environment, and who is with them (an example of an identification of goals can be found at: https://www.anxietybc.com/sites/default/files/Facing_Fears_Form.pdf).
They can start with the more innocuous fears and then work their way up to more frightening and are more anxiety provoking fears or worries. With this approach, over time their confidence will build and they’ll be able to challenge their fears and worries.
Keep in mind that parents are not expected to know how to help their child and it may not be feasible to assist because of the intensity of the anxiety, the extent of the challenges, and the child’s willingness to engage with parents. There is always help that parents can seek from professionals who specialize in treating anxiety and anxiety disorders.
Reward kids’ brave behaviors. There is a lot that parents can do to help build their child's competence, confidence, and personal strength. It's important to praise kids for facing challenges, trying something new or engaging in brave behavior. Search to find avenues where kids can exhibit their progress.
Engage in emotional and intellectual processing with kids. Identify kids’ thoughts, evidence toward or against those thoughts, and ask them to think about how else they can see things, thus challenging those thoughts. Help them go from “what if” to “what is.” Look to help them attach, new, more realistic beliefs about their thoughts and to notice patterns and trends of their thinking. Also have them talk back to their worried or anxious mind through self-talk. If the thoughts are legitimate, help kids to problem solve and strategize so the appropriate action can be taken to effectively help them through their dilemma.
I had a young adult client that had to come home from college because of intense levels of anxiety and secondary depression. He had a history of being symptomatic from anxiety since elementary school which went untreated. He recently left to a wilderness program and I wrote him a letter of support. Referencing the anxiety can be an empathic way of being reassuring and acknowledging.
It was nice to speak to your counselor and hear how much you’re putting into the program there. Yes, I’m sure I would be proud because I know that when you set your mind to something, you can accomplish anything. Being there will take a lot of effort, hard work and sticking it through, no matter what challenge or adversity presents itself. You were fully prepared and willing to take on that challenge. That was the first step.
I also want to remind you of what sometimes gets in your way and things to focus on and continue to work through while you’re there. You have hidden your thoughts and feelings since you were a child. No one ever challenged them and they just let you be because you always seemed perfectly okay. You did a masterful job at being secretive and withholding. You were never okay and suffered from intense anxiety. The way you dealt with it was to not deal with it. You distracted, denied and self-medicated. Yet with all of that you still managed to get by. I’ll rephrase that to say, just got by, but were not being your best self.
Now is a perfect time to open yourself to new experiences and to get to know the real you, not the one that had to be the perfectly “okay” guy. It’s okay to be flawed and imperfect. Welcome to the human race. We’re all flawed. What a boring place it would be – a world full of perfect people. Pretty dull if you ask me!
You don’t have to hide anymore. You will be liked and loved for who you really are because you genuinely are likeable and loveable. Your vulnerability is what makes you relatable and human. As much as it is uncomfortable to show others, it will get easier with time, if you’re willing to invest in the process. That means not thinking you’re immediately okay and recognizing that this is your go to default place. It’s familiar, “comfortable” and a place you will be prompted back to unless fundamental change happens. This doesn’t happen overnight or even in two months, but is rather a continual effortful lifestyle change.
You have to reframe the way you think about things, recalibrate the way you approach things and others, and rework the way you react and interact with others. I believe you can accomplish this with willingness, diligence, and significant effort. I know you want this more than anything, to witness yourself actually being your best you.
I believe in you, the real you, as does your family. We are genuinely here to support you and see you through this personal growth process. I wish you the best and offer you my help at any time.