There isn’t one way to be anxious so when we look for child anxiety symptoms, we need to be aware that they will manifest differently in different kids.
This is a very (very) broad overview of the kinds of anxiety disorders seen in kids. And remember, it goes from regular worry to a concerning disorder when the anxiety gets in the way of functioning.
Most Common Anxiety Diagnoses
- Generalized Anxiety Disorder
- Kids with generalized anxiety have excessive worry across a variety of situations. They worry about missing the bus, about whether the kids at camp will like him, or about the laundry getting done in time to wear her new shirt tomorrow.
- They may worry about things that didn’t happen, too. (“But what if last night’s thunderstorm DID turn into a tornado?”)
- You may feel like your child is always humming, always looking for something to worry about. You may start to feel like any television show, book or movie is a potential worry generator and you may even find yourself editing things ahead of time because you don’t want to trigger a new round of anxious “What ifs?” before bedtime.
- For these kids, the worry is pervasive and ongoing. If you find yourself constantly trying to reassure your child (often without success) then she may be struggling with generalized anxiety.
- Separation Anxiety Disorder
- Almost all kids go through a developmentally appropriate phase of separation anxiety when they’re toddlers and sometimes when they’re preschoolers. Kids who still have trouble separating by age seven should be evaluated.
- Kids who have separation anxiety are usually worried about something bad happening — often to the people and pets they love — while they’re away. Sometimes separation anxiety appears after a difficult event — a parent who was ill, a threat in the neighborhood, etc.
- For some kids, this will result in them refusing to go to school.
- NOTE: I work with a lot of attachment parenting proponents who co-sleep and homeschool and make other parenting choices that keep kids close and I think that these decisions need to be respected and understood when therapists are evaluating kids for separation anxiety. A child who is happily ensconced in the family bed at an age where our culture expects them to be out is not necessarily struggling with separation. I start looking for anxiety when their reluctance to leave mom or dad goes beyond preference. If a child is truly crippled by his anxiety — if he wants to go to a sleepover but can’t, if he wants to join his friends at the movies but can’t unless you to come, too, and sit in the back row where he can know you’re close, then separation anxiety may be an issue. I mention this because some of the assessments that therapists use are not culturally sensitive to parenting choices outside the mainstream.
- Social Anxiety Disorder
- It can be tricky to differentiate social anxiety from natural introversion. In both cases kids may have a hard time around new people and may be reluctant to join groups (at birthday parties, soccer teams). The difference is that the socially anxious child may worry more after the fact (“I probably said something stupid and won’t get invited again”) and will usually want to want to do the things that scare her while the introvert may be perfectly happy avoiding social events.
- Social anxiety is common as kids head into adolescence. Part of this is that the middle school years are HARD. Social groups start to split apart and come together in new confusing ways. Hormonal changes have everyone turned topsy-turvy. And kids start trying on new personas. An introvert may wish she was more extroverted and so she may push herself past her comfort zone. Kids become more self-critical and more worried about what other people think. Again, it’s normal but that doesn’t mean it doesn’t deserve attention and support.
- Selective Mutism (a child who won’t speak to people outside his or her family or who will only speak to friends but not adults) is a form of Social Anxiety Disorder and is usually diagnosed once a child heads to school and people notice she isn’t speaking up.
Less Commonly Diagnosed
- Obsessive-compulsive disorder (OCD)
- People tend to be confused about OCD as evidenced by the casual, “Oh your collar is crooked. I know I’m so OCD but let me straighten it.” True OCD is magical thinking run amok. It’s believing that if you don’t straighten the collar then your friend will die. We all do a little magical thinking and children in the tween years may flirt with it an awful lot (that’s the age of “don’t step on a crack or you’ll break your mother’s back”). The difference is that kids with OCD get stuck. They have Obsessions (“What if mom’s car crashes?”) and Compulsions (“If I skip every other step coming down the stairs her car won’t crash.”).
- Kids who have OCD are slaves to their rituals, which become more and more complex as a simple compulsion no longer quiets the obsession. Compulsions are like drugs — they become less effective the longer one uses them. So the staircase needs to be traversed twice. Then four times. Then eight. If they aren’t allowed to complete a compulsion, these children may fall apart.
- Children with developmentally typical magical thinking can more or less roll with it if you tell them to quit walking on just the white tiles because you need to get home before lunch; kids with OCD can’t. They don’t want to be stuck in the bank stepping on white tiles while you’re fuming but they truly can’t help it.
- Children with OCD may be constantly checking, cleaning and ordering things a certain way. They may hang their obsessions on superstitions (“I saw a black cat and now I need to walk backwards the rest of the way to school so I don’t die.”)
- OCD can be very complex. Some kids will struggle with intrusive thoughts (“What if I killed my dog”) and then have rituals to “counteract” the thoughts. Other children will hoard things because they become obsessed with the idea that they might need the candy wrappers later.
- Parents may become part of ritualized behavior without realizing it, having to repeat things in a certain way or reassure their child with particular words or phrases or to do the bedtime routine in a very specific order.
- OCD is usually diagnosed around age 10 and interestingly is more commonly seen in boys before puberty, and more commonly seen in girls after puberty.
- Panic Disorder/Somatic Symptoms
- Panic Disorder is generally diagnosed in older children but younger children may display somatic symptoms like stomach aches and headaches. Older children may have full blown panic attacks — heart racing, fear of passing out or dying. Kids are unlikely to connect their pain with worry and parents may believe they’re faking to get out of something — a test, a visit outside the home — but the children genuinely feel sick.
As you’re looking at this list you may think, “Wait, my kid does that! Should I be concerned?” My answer is that you should be aware but note whether or not the worry is getting in the way of your child’s happiness. Remember, a diagnosis depends on interference with a child’s everyday functioning.
That said, learning skills to manage anxiety is useful no matter who you are. We all have times in our life where we’re dealing with more stress than usual and learning anti-anxiety tools certainly never hurt anyone.
First in the series: Anxiety in Kids
Last in the series: Helping Kids with Anxiety
There’s no getting around the fact that therapy can be expensive. Sure, you may pay less than you would for a hair cut and color or just a little more than you would for a massage, but most people don’t get their hair cut as often as they’re likely to go to therapy. I mean a dye job lasts what, six weeks? And most people see their counselors about four times a month.
The reasons therapy costs so much are:
- Schooling. In order to offer psychotherapy, your counselor needs an advanced graduate degree. Generally Counselors, marriage & family therapists and social workers need a masters and psychologists need a PhD.
- Licensing fees. Ongoing expenses include paying for our license and certifications as well as our professional memberships in organizations like the American Counseling Association or the National Association of Social Workers.
- Continuing education. Therapists need to have continued training to be sure we’re up on the latest research and that we’re staying abreast of what our professional ethics and the law require of us. States vary in their demands and the costs of training differs a lot, too, but most of us sink a few hundred a year into making sure we’re up to date. If we have other certifications — in, for example, hypnotherapy — we will need to take classes to maintain that certification, too.
- Insurance. We pay for professional liability insurance the same way that doctors do (fortunately our costs are a lot less). Most of us need the insurance to maintain our licenses.
- Rent and utilities. Even if we’re not in practice for ourselves, part of our income goes to keeping the office open and the lights on. Bigger cities, naturally, charge bigger rents and thus more expensive therapy. For those of us in private practice, rent is likely our biggest expense (I know it’s mine).
- Phones. Some therapists also pay for an answering service.
- The cost of doing paperwork. Those of us who take insurance (I do not) generally negotiate rates with each contracted insurance company. So you pay your co-pay and the clinician bills the insurance company for the rest of the rate initially agreed upon (and this is usually something the insurance company dictates; therapists can either agree or not). The paperwork required for insurance eats up a lot of time. Insurance companies differ in what they require and when and keeping track of it, submitting the billing, following up on payment (because insurance companies don’t always pay in a timely manner) and going back to the client if there’s something sticky takes up a great deal of office time, which could go to seeing clients so therapists bundle that time into their fees. Some of us farm these tasks out and pay a biller, which also obviously adds to the cost of therapy. For those of us who don’t take insurance, the paperwork demands are a lot less but ethically and legally we are required to keep certain documentation up-to-date. After a session with a client, we have to write up the session and again, our pay for this is bundled into the fee we charge the client. Note: Those of us who take insurance generally charge more than those of us who don’t because of the cost of doing business with the insurance company but most of us end up making about the same amount. People who take insurance spend more time on maintaining paperwork and those of us who don’t spend more time on marketing (since insurance companies do much of the marketing for you, giving your information to consumers who use their plan). A full-time therapist (i.e., someone who works a 40-hour week) isn’t seeing clients for all of those forty hours. Some of those hours are doing paperwork, getting training, meeting with supervisors or getting peer support, marketing, talking to insurance companies, printing out worksheets for the next session, reading research, calling to coordinate care with other providers, following up with clients who missed appointments or have questions or emergencies; etc.. Client fees have to also cover the invisible work of being a therapist.
- Miscellaneous supplies and fees. Therapist need to print out worksheets and forms, keep our furniture in reasonably good shape (and replace broken down chairs and sofas), maintain a working supply of pens and paper, and Kleenex. Most of us also need to pay for a web site and/or for inclusion in membership directories so clients know how to find us. If we work with kids, toys and art supplies need to be available and in good repair. Then of course there’s stuff like bank fees, the cut the credit card company takes, etc.
After all of these expenses are taken from our hourly rate the rest goes toward our salary. Part-time and contract workers at agencies and practices as well as those in private practice for themselves also have to pay taxes (about a third of their income), health insurance and retirement (not to mention banking for sick or vacation days) out of that what they take in.
And that’s why therapy costs so darn much.
There are options to make therapy more affordable:
- Use your insurance. Not all insurance plans offers mental health benefits and not all insurance plans that do make it more affordable. (Plans with high deductibles may take a lot of time and money before you see any savings.) You will need to find a therapist who takes your insurance and then you will need to receive a mental health diagnosis that your insurance company will cover. Once you get that diagnosis, your insurance company will need to approve the treatment plan your therapist gives. All of this sounds very complicated but therapists who take insurance generally understand how to make it work for you. Make sure you are clear about what the diagnosis and treatment plan mean and what exactly will become part of your health record. Also note that most insurance plans do not cover couple or family counseling and may not cover certain diagnoses. Sometimes you won’t find this out until your bill gets denied so take some time to make sure it all makes sense to you and your therapist.
- Use your Health Savings or Health Spending Account. If you have a HSA card, see if it will cover counseling and if your therapist is able to charge HSA cards. Most of the time these plans will only need you to submit a monthly or quarterly receipt but check first to see.
- Seek out a practice or agency that uses a sliding scale. Sliding scales tend to be needs based and different therapists and practices require different documentation; some will want proof of income and others will not. Not all therapists will advertise their sliding scale so if there’s someone you’d really like to see and you’re not sure if a sliding scale is available, call and ask.
- Explore group therapy. Groups tend to be much less expensive than individual therapy (that’s one reason I decided to create the Parenting Challenging Children group — it’s a more affordable way for parents to get help) and research shows they can be be just as effective. I especially like groups because I feel that community can be incredibly healing for those of us who feel isolated in our struggles.
- Seek out a publicly funded agency since they often have more generous sliding scales. Depending on your income, using a county agency (in Central Ohio those are agencies funded by the ADAMH board, a list of which you can find here) may allow you to pay very little and sometimes nothing for counseling. Because they receive outside grants to fund mental health support for underserved clients they can subsidize their services. There may be a wait list and depending on where you live, it may be long but check in regularly since cancellations do happen and sometimes the intake person can get you in more quickly than originally promised. (Sometimes if you call in the morning they may have a last minute slot open up in the afternoon.)
- See your therapist less often. While meeting every week may be ideal (it’s easier to create and stick to change when you can devote an hour each week to working on it), you can go every other week or even less often if your therapist agrees.
- See an intern at the practice. Not all agencies or practices hire interns but those that do sometimes charge less since those practitioners have less experience. Interns are supervised by other counselors with specialized supervisory training although what this means will depend on the practice. If you’re using this option, ask them what this will mean exactly so you know what you’re agreeing to. (Note: Research shows that new therapists can be just as effective as more experienced therapists in part because newbies have lots of enthusiasm, which can make up for their lack of real world experience.)
- Do the work. Counseling is not a race and how long it takes will depend a lot on individual factors but the more energy you put into therapy, the more you’ll get out of it, the more quickly you can create change and the sooner you’ll be leaving therapy. This means showing up for appointments (and avoiding the no-show fees! another way to cut costs), being honest with your therapist and reflecting on what you’ve learned between appointments.
Parental involvement is a key ingredient in kid client success in therapy. What this looks like will depend on your child and his/her treatment plan, your practical ability to be involved (are you a noncustodial parent? Is your child receiving services at school?) and the therapist. But at the very least, you and your child’s therapist should be communicating regularly.
Depending on the child, the parents and the treatment goals, I include parents in the following ways:
- Parents attend sessions with their child (this is common with young children and with children who are struggling with attachment);
- Parents come in for the first or last few minutes of session;
- Meeting with parents separately before or after the child’s session;
- Scheduling separate sessions with parents when needed and appropriate;
- Arranging for phone calls to check in.
I like kid feedback for how parents should be involved, particularly with teenagers who are navigating the developmentally appropriate need to separate along with the necessary support from parents. Sometimes this means helping the teen figure out how they want to talk to parents about something and then inviting parents to session to help mediate a discussion.
I go over confidentiality with parents and teens in session with the understanding that we will all respect the teen’s privacy in the counseling relationship but that the adults will keep her safety paramount in decision-making around what to share. When kids are struggling in a gray area, I always encourage them to invite parents to the discussion but I won’t go over their heads and tell secrets unless I’m concerned for their safety.
Here’s the Ohio ACLU publication about minors and their rights. The part about counseling (this is a PDF file) starts at page 40: Your Health and the Law: A Guide for Teens.
From the file:
A minor who is at least 14 years old can request outpatient care without notifying a parent as long as the treatment does not include medication. However, such care is limited to six sessions or 30 days, whichever comes first. After that, the care must stop or the parents must be informed and must consent in order for treatment to continue. During the first six sessions or 30 days, the parents will not be informed of the treatment unless the teen consents or the care provider feels the minor is likely to harm someone. Still, before the parents can be informed, the care provider must first tell the teen that the parents will be notified.
I have not had a teen call and ask for counseling on her own but I have had other loving adults (relatives or family friends) call me to find out if they can bring the teen to counseling without parental consent. I always explain how the law works and explain that except in cases where parental involvement would be dangerous to the child, it’s really best to have parents be a part of counseling.
There are guidelines around counseling teens and maintaining confidentiality. As a counselor practicing in Ohio, my ethical guidelines come from Ohio’s Counselor, Social Worker, and Marriage and Family Therapist board and my professional organization, the American Counseling Association. Both these entities recognize that teen confidentiality is a gray area. The ACA and their sister organizations for social workers and other therapists regularly publish articles and papers on the topic.
Here’s a handful for you to check out:
As you can see, there are not definitive answers because these topics are complex and so very individual. How I might, for example, handle it if a client tells me s/he is sexually active will depend on many things including but not limited to:
- Why the teen is in counseling in the first place;
- With whom they are being sexually active (is it consensual? Is it legal?);
- How old the teen is (there’s a big difference between a 13 year old and a 17 year old);
- The family’s values around sexual activity;
- The circumstances surrounding the sexual activity (are there pressing concerns about safety?).
My first priority is always first and foremost safety but I recognize my ideas about safety may be different than the families. For example, say I learn that a 17-year old after careful consideration and planning decides to access birth control and have sex with her long-term partner. Perhaps she comes from a strict, conservative family whose religious beliefs condemn premarital sex. I am unlikely to break confidentiality under those circumstances.
I say this to encourage parents to talk to their teen’s counselor to make sure that they understand each other. If you want a counselor who would break confidentiality then I’m not the right person to work with your teen. It’s best we all know this ahead of time.
That said, I do not ever encourage teens to lie and I do not side with them against parents.
Finally, when confronted with a sticky situation I seek supervision, meaning I go to my peers and my mentors to get feedback when I’m not sure. While maintaining confidentiality about the individual and the family, I ask for help and document these efforts accordingly. It’s dangerous for any therapist to operate in a vacuum and I am fortunate to have great counselors available to me to answer questions and help me examine ethical practice as it applies to the complicated reality that is counseling kids and teens.
So you’ve decided your child needs counseling. How do you explain to them what counseling is and why they’re going?
1. Tell them that a counselor is a person who helps people who are feeling stuck.
Many children (and adults) who are in therapy believe that they — their inherent selves — are problematic. Lots of children (and adults) have already been through the wringer by the time they come see me and their self-esteem is suffering for it. They may be feeling like they are root of all of their family’s problems. They may think that the people who love them really hate them. They may believe that they are in someway defective and that’s why they’ve got to come and see me. What I emphasize is that counselors help people who are feeling stuck. If your child is anxious you can say, “A counselor helps kids who are feeling stuck in their worrying.” If your teen is depressed you can say, “We’re seeing a counselor who helps people who are feeling stuck in their depression.” If your middle grade child is raging you can say, “The counselor will be able to help us figure out how to help you get better at managing your anger.” After all, your child is NOT her worrying or her depression or her challenging behavior. Your child is a whole, complicated person who is struggling. Counselors help with the struggle; they help people get unstuck from the struggle.
2. Let them know that the counselor will help everyone in the family do a better job with each other.
If I’m working with a child then I’m also working with her parents. As I said, sometimes the children who see me think they are at the root of all of their family’s problems. Kids are naturally self-centered (it’s a developmentally appropriate part of growing up) and so the divorce, the fighting, the tension — they think it all comes back to them. And if it is their behavior driving the decision to get counseling then they’re partially right. But kids don’t exist in a vacuum and if a child is struggling then the parents surely are, too. Counseling is meant to help everybody, which means helping the child be her best self and helping the parent be his best parenting self, too.
3. Explain that they will get to set the pace.
Kids who come to see me don’t always want to talk to me. That’s fine. Being guarded with a new person — particularly a new person who’s been enlisted to help the child over a sensitive topic — is appropriate. We can play Uno, we can play with the kinetic sand, I can watch the child build block towers or create art or otherwise orient herself to our relationship. I do not make children talk to me and even most reluctant teens will come around if we have time and space to learn how to work together. (Note: Once we’ve established rapport I will push when pushing makes sense but at the beginning we take it slow.)
4. Don’t insinuate that therapy is a punishment.
If children get the idea that seeing a counselor is one step away from being sent to juvenile detention it makes it awfully hard to build rapport. It goes back to #1 up there; if people believe that only screwed up people go to counseling then the threat of counseling might get seen as a weapon. “If you don’t get it together I’m taking you to a therapist to get your head on straight!” Or to other people, “He’s gotten so bad that we’ve had to start seeing a counselor!” Ugh. Not a great message. Even if you’re feeling discouraged and even if you feel like counseling is your last ditch effort, please remember that coming to therapy is a really smart and positive move.
5. It’s OK to acknowledge the problems that got you there.
No, you don’t want to make your child feel like the problem. No, you don’t want to put the whole burden of change on her either. But you can be frank about why you’re going. Sometimes parents will say, “Is it all right to talk about his tantrums here? In front of him?” Yes, it is. After all, he’s the one having them and he knows they’re an issue, trust me. There are some topics that aren’t for tender ears (or at least aren’t until we’ve made them age appropriate) but getting the problem out into the open without judgment and in the spirit of moving forward is a good thing.
If you’re still not quite sure how to talk to your child about it, bring it up with the therapist you’ve chosen to work with your child.
At the anxiety workshop we talked a lot about what’s normal and what isn’t normal and needs intervention. Sometimes it’s clear — your child absolutely refuses to go to school or your teen tells you she’s depressed and is thinking about hurting herself. But other times it’s more ambivalent. Are these tantrums normal? Is your reaction to them making things worse? Can counseling help your 7-year old’s struggles in school?
Here’s how to figure it out.
Are you or your child missing out?
Is the issue — sadness, anxiety, anger — getting in the way of your everyday lives? Do you find yourself spending more and more time trying to move from one place to another? Is she expressing frustration or sadness with how things are going? Are you?
This is the number one way to know that it’s time to get help. If you or your child are avoiding things, if the problem is disrupting the normal events in your lives, that’s the very definition of troubled. It’s one thing to be scared of dogs; it’s another thing to be so scared of dogs that your child won’t leave the house. It’s one thing to want to stay home from second grade; it’s another thing to scream and hold onto the door frame when your dad tries to move you out the door to the bus stop. It’s one thing to have a lousy day where your child falls apart at the zoo; it’s another thing when you can’t go to the grocery store because of your child’s tantrums in the cereal aisle.
If you find yourself living around your child’s challenges, it’s time to get help.
Are you at your wit’s end?
Do you dread confronting your child or dealing with transitions? Do you find yourself unhappy with your child more often than not? Are you losing sleep because you’re worried about her? Do you find yourself asking friends, relatives, strangers for advice?
Parenting is no endless ball of fun but most of the time it’s pretty good. We can all have bad days and even bad weeks but if you aren’t enjoying your child and your child isn’t enjoying you, you both deserve help. Parenting is hard but it shouldn’t be so hard that you find yourself crying or yelling at the end of the day. Counseling can help you have fun being a parent again.
Are other people expressing concern?
Is your child’s teacher sending lots of notes home? Are there people you trust who are worried? Do you find yourself constantly defending your child?
Sometimes other people can see what we can’t. I’m not saying that every kid who’s not clicking with her teacher needs help but if the teacher’s concerns ring true or she’s the last in a line of concerned people, it might be time to get a new perspective. If you’re not sure — is your mother-in-law’s criticism valid or not? — a counselor can help you figure it out.
It’s hard to know when we can handle what’s happening for our kids and when we need professional help. Fortunately you can call a therapist and ask her. Does this sound like a concern? How will I know when it is? What might it look like if we come in right now? Further, you can get help simply because you want it. If you use your insurance to pay for counseling you (or your child) will need a diagnosis but if you don’t use your insurance then you don’t need a diagnosis. (I do not take insurance and so I do not give a diagnosis unless it’s warranted and will serve the client. I’d say most of my caseload is made up of people who don’t necessarily qualify for a mental health diagnosis but do deserve and benefit from professional help. You can speak to the therapist you’re working with to learn more about diagnosis and treatment.)
You don’t have to figure this all out on your own.
(I’ll be writing more about kids and therapy this week. Stay tuned!)
I remember when I was in my early 30s and seeing a therapist to process my experience with infertility. At the beginning I had so much to say that I didn’t know how I would make it between sessions. Then after (I thought) I had said it all, I would worry before appointments that she’d be disappointed because I didn’t have an idea about what we should talk about.
I used to plan our topics. All week I would store up events or musings and I’d have them neatly prepared. I would continue to do this even after I realized that during most of our appointments we’d end up talking about something completely different. She’d ask about something we discussed the session before or in our casual opening we’d end up on a subject I hadn’t even considered. But I’d wrench us back around to the topic I had planned even if it fell flat because I thought I was supposed to.
I didn’t know then that it was more than OK to just show up. I didn’t have to have a topic prepared. I didn’t have to know what we were going to talk about. I could let the conversation happen organically and trust her to help me figure out what I wanted to say.
Therapy is a lot like writing. Sometimes you come to the page with a plan and sometimes you don’t. Sometimes you have it all outlined and mapped out and sometimes you’re free writing whatever comes into your head no matter how messy and disorganized and ungrammatical it might be.
You can’t have too much of one or too much of the other. Yes, you do need to have goals and you need to pay attention to your goals but you also need time when you’re sitting in the chair riffing on whatever comes up.
You and your therapist are working in collaboration. You don’t have to come up with every topic and she’s not going to always lead the way. The two of you will discover what it is you’re working on through the course of your conversations. If you do too much editing (especially if you’re not bringing things up because you are afraid she will be upset or bored) then she’ll be working with less material than she needs. If you try to plan your topics because you’re afraid that she will be annoyed if you sit there blankly saying nothing then you may lose the opportunity to see what the silence will bring to you.
(Sitting in silence with a person who is wholly tuned in to you can be very powerful. Try it sometime.)
Therapy is collaborative creation and growth. Trust the process and give yourself permission to allow the session to unfold however it will.