Anxiety in children: how to recognise it and how to help

“Mum, my tummy hurts again.”

Monday, ten to seven. An eight-year-old girl sits on the edge of her bed, still in her pyjamas; her school bag waits by the door, her cocoa is going cold on the table. Her mother feels her forehead — no temperature. Last night everything was fine; she watched cartoons and laughed. Over the weekend nothing hurt. The pain always arrives at the same hour: the moment it is time to leave for school. And her mother stands in the hallway with the keys in her hand, not knowing whether to send her and risk that she really is unwell, or keep her at home and risk the same thing happening tomorrow.

This is one of the most common scenes parents describe when they start looking for help with their child’s anxiety. It often takes months before anyone connects the tummy with fear — because a child does not say “I’m scared”, but “it hurts”. This piece is for parents who are wondering whether what they see in their child is anxiety, and what they can do about it themselves. I will write about how anxiety shows itself at different ages, about something researchers call family accommodation, and about when it is time to look for professional help.

Fear is part of growing up, anxiety is something more

First, something reassuring: fear is normal in children. Around eight months a baby starts crying at unfamiliar faces, a toddler clings to their mother when she leaves, a preschooler checks whether there is a monster under the bed, a schoolchild worries that something will happen to their parents. These fears come and go like phases. They help a child learn what is safe and what is not, and most of them fade as the child grows out of them.

We speak of anxiety that needs more attention when the fear is stronger than we would expect for the child’s age, when it lasts for weeks or months, and when it takes something important away from the child — school, friends, sleep, play, joy. What matters is not what the child is afraid of, but how much room the fear takes up in their life and in the life of the family.

Anxiety disorders in children and adolescents are more common than we tend to think. A large meta-analysis by Guilherme Polanczyk and colleagues, which brought together studies from more than twenty countries, estimated that around 6.5 per cent of children and adolescents worldwide have an anxiety disorder. That was the most common group of mental disorders at this age — more common than depression and more common than attention disorders. In a class of twenty-five children, that is one or two on average. And many more live with anxiety that does not reach the threshold of a disorder, yet still sours their days.

How anxiety shows itself at different ages

Anxiety at three looks different from anxiety at thirteen. Small children cannot name fear, so they show it through their bodies and their behaviour. Older ones can describe it, but often hide it because they are ashamed.

Toddlers (up to three) most often show anxiety around separation: inconsolable crying when a parent leaves the room, clinging, waking at night, refusing a babysitter. Some of this is entirely expected developmentally. It deserves more attention when the child stays inconsolable long after the parent has gone, or when the distress grows rather than eases over the years.

Preschoolers have vivid imaginations, so their fears like to settle in the dark, monsters, animals and storms. Anxiety in them often hides behind stubbornness and outbursts: a child who screams every morning that they will not put on their shoes may not be protesting against the shoes, but against nursery, where they will be left without their mother.

School-age children begin to worry about more abstract things — that someone will fall ill, that there will be an accident, that they will make a mistake in front of the class. This is the age when tummy aches and headaches without a physical cause appear, along with resistance to school. If a child fears that something will happen at home while they are away, we speak of separation anxiety; if the fear is tied to school itself — the teacher, marks, classmates, speaking in front of others — of school anxiety. The two are often intertwined.

Teenagers most often experience anxiety in relationships with their peers: fear of what others will think, shame, avoiding company, missing lessons, and for some, panic attacks. From the outside this can look like laziness, rebellion or “just puberty”. If you would like to know how conversation can open up again at home during such a time, I wrote about it in When a teenager goes quiet: how family therapy opens the conversation.

The body speaks first

In children, anxiety is very physical. Tummy aches, nausea, headaches, needing the toilet often, trouble falling asleep, nightmares, loss of appetite — all of these can be the language of fear. It is not “made up”: when an alarm goes off in the body, the heart speeds up, digestion tightens and muscles tense. The child genuinely feels the pain. I described what happens in the brain, and why the body reacts before the child has even had a thought, in What happens in the brain during anxiety.

That is why the first step is always a visit to the paediatrician. Not because the child is making excuses, but because physical causes need to be ruled out — from coeliac disease to infections. When the results come back normal, the pain does not disappear; it gets a new explanation. I wrote about how it feels to be told everything is fine while it still hurts in “The tests are normal, but it still hurts”. It matters to tell your child that you believe them — and that together you will work out what their tummy is trying to say.

Why my child?

Parents often ask this with guilt in their voice. There is no single answer. Some children are born with a more cautious temperament — the developmental psychologist Jerome Kagan called it behavioural inhibition: babies who respond to the new and unfamiliar with more tension and withdrawal are somewhat more likely to be anxious later on. Part of this is heredity. Part is experience: moving house, parents separating, illness in the family, bullying, the death of someone close. And part is what happens between people in the family.

From relational family therapy, in which I am training, I bring the view that a child’s anxiety rarely lives in the child alone. Children are extraordinarily sensitive to tension between the adults around them; sometimes their anxiety gives voice to a worry nobody else in the family puts into words. This is not an accusation — it is an invitation not to see the child as a “problem” to be fixed, but as part of a system in which a great deal can shift.

And here is something that is hard to hear, yet freeing: anxious parents more often have anxious children — partly because of genes, partly because children learn from us what the world looks like. Guilt helps nobody here. If you recognise yourself in this, I recommend Mother’s guilt: why the most devoted mothers are the ones who feel they do too little. Looking after your own anxiety is one of the best gifts you can give your child.

Family accommodation: when love unwittingly feeds fear

When a child is frightened, we want to protect them. It is one of the deepest parental reflexes, and it is a good one. But with anxiety something unusual can happen: the very thing that eases a child’s distress today keeps the fear alive in the long run.

Eli Lebowitz, a psychologist at Yale University, calls this family accommodation. It covers all the changes a family makes to spare a child anxiety: a parent sleeps beside the child because they cannot fall asleep alone; orders for them in a restaurant; answers the same question, “Will everything be all right?”, twenty times a day; keeps them away from a birthday party because they would be there without their mother; lets them stay at home whenever their tummy hurts. Lebowitz and his colleagues found that accommodation occurs in the great majority of families with an anxious child, and that it is linked to more severe symptoms.

Why? Because a child who avoids fear every time with a parent’s help never learns two things: that the situation is safer than it seems, and that they can bear the discomfort on their own. Each time a parent takes over, the child’s world shrinks a little. I wrote more about how avoidance works in adults in Anxiety and avoidance — in children the mechanism is the same, except that they avoid with our help.

An evening in such a family might go something like this (a composite, not a real person):

“Mum, will you stay until I fall asleep?”
“I stayed yesterday. And the day before.”
“But tonight I’m really scared. Please.”
“All right, but only ten minutes.”
(An hour later, Mum is still lying on the edge of the bed, answering messages in the dark.)

The mother has done nothing wrong. She responded with the love every parent knows. But if this evening repeats itself for two years, both of them are caught — the child in the belief that they cannot manage alone, and the mother in an exhaustion that leaves no room either for herself or for her relationship with her partner.

The SPACE programme: support instead of protection

From these findings Lebowitz developed the SPACE programme (Supportive Parenting for Anxious Childhood Emotions). What makes it distinctive is that the child does not take part at all — the work is done with the parents only. This is valuable, because many anxious children refuse therapy, and because it is easier to empower parents than to force a child into something they fear.

The programme rests on two pillars.

The first pillar is supportive statements. A parent learns to express two things in one sentence: acceptance of the child’s fear and confidence in their ability. For example: “I can see you’re scared, and I understand it’s hard for you. I know you can do it.” Not “there’s nothing to be scared of” (that denies the fear), and not “I’ll sort it out for you” (that denies the child’s strength). Both at once.

The second pillar is a planned reduction of accommodation. Parents choose a single accommodation — sleeping next to the child, say — and make a plan to let it go gradually. They announce it to the child in advance, calmly and without punishment: “From now on I’ll sit by your bed for five minutes, then I’ll be in the living room. If you call me, I’ll call back that I’m here, but I won’t come in.” And then they stick to it, even when the child protests.

In a randomised trial Lebowitz and colleagues published in 2020, SPACE proved as effective as cognitive behavioural therapy with the child. That is an important message for parents: you are not helpless onlookers waiting for your child to be “ready” for therapy. You can start yourselves. The programme is also described in a book for parents, Breaking Free of Child Anxiety and OCD.

The picture below shows how the two paths part in the very first minutes after fear takes hold of a child.

Exercise: one supportive sentence and one accommodation less

You can start this exercise this week. The aim is not to “toughen up” your child overnight, but to see how they respond to a small change.

1. Write down every accommodation you notice. For a week, note everything you do or stop doing because of your child’s fear — from sleeping beside them to answering the same questions. The list can be surprisingly long.
2. Choose just one. Ideally one that happens every day and that you will genuinely manage to let go of. Not the hardest one.
3. Put together your supportive sentence. Keep acceptance and confidence in mind: “I know it’s hard for you, and I know you can do it.” Say it out loud before you need it.
4. Announce the change at a calm moment. Not in the evening when your child is already frightened. Say what will change, from when, and what you will do instead.
5. Stick with it and observe. For the first few days your child will probably protest more loudly — this is expected and does not mean it isn’t working. Note what happens after three, five and ten days.

If there are two parents in the family, it is crucial that you agree together. A child quickly finds the one who will give in — not out of malice, but because they are scared.

What else helps day to day

Your calm is your child’s regulation. Small children cannot yet soothe themselves; they learn it with us, as a calm adult soothes them again and again. We call this co-regulation. You do not have to be free of fear. It is enough for your child to sense, beside you, that fear can be borne.

Talk about the fear, not around it. It helps children when fear gets a name and a shape — when they draw it, name it, talk to it. “What is your Worry Bug whispering to you today?” A fear you can watch from the outside is less all-powerful.

Do not promise that nothing bad will happen. You cannot guarantee it, and children sense that. It is better to say: “I don’t know how it will go, but I know you’ll manage, and I’ll be here when you come home.”

Keep routines. Sleep, meals, time moving outdoors and a predictable day are like a handrail on the stairs for an anxious child. They do not prevent fear, but they make sure everything does not collapse around it.

Allow other feelings too. Children who are not allowed to be angry or sad at home often pour all their distress into anxiety, because it is the only feeling that is “allowed”. I wrote about what such a child carries into adulthood in How a child who wasn’t allowed to be angry becomes an adult who can’t say no. And about how our own way of attaching passes on to our children in Attachment and parenting.

When reducing accommodation is not enough

It would be unfair of me if all this sounded as though parents simply need to “stop giving in”. Here are the limits of the idea.

Sometimes the fear is realistic. A child who will not go to school because classmates are bullying them is not anxious for no reason — they are in a dangerous situation. Before you start reducing accommodation, make sure the environment really is safe. A conversation with the class teacher and the school counselling service is often the first step, not the last.

Sometimes there is something else behind the fear. For autistic children, noise and crowds can be genuinely unbearable because of sensory sensitivity; for children with learning difficulties, fear of school can be a response to failing every day; after a traumatic event, avoidance has a different meaning. In these cases the cause has to be understood first.

SPACE is not pressure. Reducing accommodation does not mean throwing a child in at the deep end or punishing them for being afraid. If a step turns out to be too big, we break it into smaller ones. And some forms of anxiety — severe panic attacks, obsessive-compulsive disorder, refusing food, self-harm — always need a professional alongside.

Parents are not to blame. Accommodation is not proof of bad parenting. It is proof that you love your child and that you are tired. You can begin to change without blaming yourself.

When to see a professional and where to turn

Look for help when:

• the anxiety has lasted several weeks and is not easing;
• your child is missing school or cannot separate from you;
• they have frequent physical complaints the doctor cannot explain;
• they have panic attacks, are not sleeping or eating, or are withdrawing from friends;
• family life has become subordinate to their fear.

The first port of call is your child’s paediatrician, who can rule out physical causes and advise on next steps. Schools have a counselling service. In Slovenia there are also centres for the mental health of children and adolescents, staffed by clinical psychologists, child psychiatrists and other specialists. For anxiety in children, cognitive behavioural therapy has the strongest research support; in the large CAMS study, the combination of therapy and medication was the most successful, but decisions about medication are always made by a child psychiatrist, never by a parent alone. Because a child’s anxiety always lives within a family, family therapy also makes sense — there you can look together at what is happening in the family around the fear.

Children and young people in Slovenia can call TOM telefon on 116 111 anonymously. If your child talks about wanting to hurt themselves, or if anyone is in danger, call 112 in Slovenia.

What to remember

• Fear is part of growing up; we speak of anxiety when it is stronger than expected, lasts for weeks and takes away everyday life.
• In children, anxiety often speaks through the body — the tummy, the head, sleep. Paediatrician first, then explanation.
• Family accommodation eases a child’s distress today but keeps the fear going in the long run.
• The SPACE programme works with parents only: supportive statements (acceptance + confidence) and a planned reduction of one accommodation at a time.
• When the fear is realistic, or the anxiety persists or is severe, get help — the paediatrician, the school counselling service, children’s mental health specialists.