The irritable child: Anxiety in disguise?

As a child and adolescent psychiatry fellow, I often see young patients whose parents describe them as “irritable”. Consider the case of a 7-year-old boy who regularly hits his peers, is rude to teachers at school, and often has tantrums at home. But the boy also regularly worries about his family and grades and these worries keep him up at night and often lead him to feel restless. Is the boy’s behavior a result of improper parenting? Probably not.

He suffers from a type of anxiety known as Generalized Anxiety Disorder. According to a recent study of national health data for mental health issues in children ages 3-17 years, 7.1 percent of children suffer from current anxiety issues while only 59.3 percent of those children received treatment for the anxiety in the last year. A study examining lifetime prevalence of various mental health disorders found the median age of onset for anxiety to be 11 years.

Although some degree of worrying is normal, anxiety becomes a concern when it prevents an individual from getting through their day or causes significant distress for at least six months. While many different types of anxiety exist, Generalized Anxiety Disorder is most common. For a child to be diagnosed with Generalized Anxiety Disorder, he or she must have uncontrollable and excessive worries in many areas (school, health, home, etc.) with at least one of the following: restlessness, fatigue, lowered concentration, irritability, muscle tension, or trouble sleeping.

Many factors can lead a child to have a pathological degree of anxiety. Anxiety disorders tend to run in families, and a parent of an affected child may also be overly anxious. Stressful life events like losing a loved one, starting a new school, or bullying can often be triggers. For a child with anxiety, having a parent that reacts by being too controlling and overprotective can lead a child to be more dependent on their parent in stressful situations such that they do not develop coping skills themselves. Anxious children sometimes model their behavior after anxious parents and use the same problematic coping strategies they have seen their parents use.

Young children often lack the vocabulary and understanding to express how they feel so actions take over. Sometimes, anxiety presents as physical complaints, like headaches, trouble sleeping, or upset stomach. Some children act out or become aggressive to avoid the thing that worries them. Other children refuse to go to school, skip class, or frequently visit the nurse when anxiety leads to physical issues.

If anxiety is left unchecked, children become at higher risk for developing other types of anxiety, depression, or later substance use. Anxious children often have lower self-esteem and see ambiguous situations from a negative perspective.

If you are concerned that your child might be suffering from excessive anxiety, contact your pediatrician or schedule an appointment with a child and adolescent psychiatrist, psychologist, or social worker. The pediatrician will screen for anxiety, and if the screen shows significant anxiety, often a more formal evaluation will follow. If a comprehensive evaluation confirms significant anxiety, a treatment plan will be created.

Therapy might be recommended so that your child can talk to someone about his or her feelings and develop better coping strategies for dealing with stress. Therapy also involves meeting with parents to develop more effective parenting strategies. For more severe anxiety that does not respond to therapy, or if your child has another disorder in addition to anxiety (like depression), medication might be necessary to help treat the symptoms. The clinician might recommend talking with your child’s school to make accommodations to decrease anxiety in the classroom setting.

Don’t let anxiety fester; seek help for your child.

Julie Furst, M.D., is a child and adolescent psychiatry fellow under the guidance of James Luebbert, M.D., a child and adolescent psychiatry attending at Thomas Jefferson University Hospital.