By Miranda Milana, Psy.D.
Pediatric Neuropsychologist
When we hear the word anxiety, we often picture someone who is visibly worried – someone who says, “I’m scared,” asks a lot of “what if?” questions, or seems nervous about what might happen next. But anxiety doesn’t always present that way – especially in children. Anxiety can manifest as physical symptoms, behavioral challenges, emotional outbursts, sleep disruptions, school avoidance, or changes in relationships. A child may not have the words to say, “I’m anxious.” Instead, they may complain of a stomachache, become unusually irritable, refuse to go to school, have frequent meltdowns, or suddenly need much more reassurance.
It is also important to remember that a behavior or symptom that looks like anxiety isn’t automatically anxiety. Symptoms that may appear anxiety-related can have many possible explanations – and sometimes more than one diagnosis is present at the same time.
Anxiety in Young Children
Young children often don’t have the ability to identify and explain anxiety. Instead, adults may see it through behavioral challenges or physical complaints such as:
- Complaining frequently about a stomachache, headache, nausea, or feeling sick
- Becoming clingy or having difficulty separating from caregivers
- Resisting school, daycare, activities, or unfamiliar places
- Having trouble sleeping or experiencing nightmares
- Becoming irritable or emotional
- Having more frequent tantrums or meltdowns
- Asking for repeated reassurance
- Becoming upset when plans change
- Avoiding things that make them uncomfortable
- Seeming quiet, cautious, or tense
For example, a child who says, “My tummy hurts,” every Sunday night may not simply have a sensitive stomach. Their body may be responding to the anticipation of school the next morning.
It is important to note that physical symptoms are very real. Emotional distress can produce genuine physical sensations, and children may experience symptoms such as stomachaches, nausea, headaches, dizziness, or changes in appetite.
Anxiety in School-Age Children
As children enter elementary school, there are greater academic expectations, more complexities in friendships, increasing extracurricular activities, new environments, and often an increasing awareness of how other people perceive them.
Anxiety may begin to look more like avoidance or shut down/withdrawal.
You might notice:
- Frequent complaints of feeling sick before school
- Asking to stay home or repeatedly visiting the school nurse
- Difficulty separating from caregivers
- Worrying about making mistakes
- Perfectionism
- Reassurance-seeking, asking lots of questions about what is to come
- Difficulty falling asleep because of worries about the next day
- Irritability or large reactions
- Trouble concentrating
- Avoiding activities
- Becoming upset when plans change
Sometimes children who seem “defiant” are actually overwhelmed.
A child who refuses to participate in an activity may be avoiding something that feels scary. A child who melts down over homework may be overwhelmed by the possibility of getting something wrong. A child who says they hate school may be experiencing significant anxiety about academics, social situations, separation, bullying, or another aspect of the school environment.
Importantly, while avoidance can provide short-term relief, it can also allow anxiety to become more entrenched over time.
Anxiety in Teens
Adolescence brings a different set of challenges. Friendships become more complicated. Academic expectations increase. Social comparison becomes significant. Teens may be thinking more about who they are, their relationships, wanting more independence, and transitioning into adulthood. In teens, sometimes anxiety looks like:
“Leave me alone.”
“I don’t care.”
“I’m not going.”
“I hate everyone.”
“My stomach hurts.”
A teen experiencing anxiety may become more irritable, withdraw from others, have difficulty sleeping, struggle to concentrate, or avoid situations they once enjoyed. For teens, it may appear as though they have an “attitude problem” when what they actually are experiencing is internal distress.
With that said, that doesn’t mean every argument, eye roll, withdrawal, or change in mood is anxiety. Adolescence is marked by ever-changing hormones and a complicated period of development. To this end, irritability can have many causes. If you are noticing a significant change in behavior; however, it is worth paying attention to – especially when it persists or begins interfering with everyday life.
Anxiety in Adults
Adults may be better able to identify worry, but anxiety can still present in less obvious ways.
An adult may experience:
- Constant “what if?” thinking
- Irritability or feeling constantly on edge
- Difficulty relaxing
- Racing thoughts
- Trouble concentrating
- Insomnia or disrupted sleep
- Muscle tension
- Headaches
- Stomachaches or digestive symptoms
- Fatigue
- Avoidance
- Excessive reassurance-seeking
- Difficulty making decisions
- Feeling overwhelmed by ordinary responsibilities
In adults, anxiety can also feel so familiar that you may have thoughts such as:
“I’ve always been a worrier.”
“I’m just a perfectionist.”
“I just like to know what to expect so I can plan accordingly.”
“I’ve always been bad at relaxing as I prefer to stay busy.”
Not Everything That Looks Like Anxiety Is Anxiety
Something important to note about anxiety symptoms is that they often overlap with other possible conditions as well. This is where things can get complicated. For example, an upset stomach could be anxiety, but it could also be a gastrointestinal condition. Irritability could be anxiety, but it could also be related to sleep deprivation, depression, ADHD, hormonal changes, or learning difficulties. Difficulty concentrating could be anxiety, but it could also be ADHD, learning challenges, inadequate sleep, depression, or stress. School avoidance could be anxiety, but it could also be bullying, academic difficulties, social challenges, depression, or an environment that isn’t meeting the child’s needs.
Another important piece of the puzzle is that conditions don’t always exist in isolation. For example, ADHD and anxiety can occur together. Anxiety can also co-occur with learning disorders, sleep problems, depression, and other conditions, which can make it more difficult to determine what is driving a particular set of challenges.
For example, imagine a child who can’t complete homework. Is the child anxious about getting the answers wrong? Are they struggling to sustain their attention because of ADHD? Is the assignment particularly difficult because of an underlying learning disorder? Are they exhausted? Or maybe a few of these things are happening all at once. The answer matters because the most helpful support may look very different depending on what’s underneath the behavior. A good assessment looks beyond the most obvious symptom.
When Is It Time to Get Help?
Everyone experiences anxiety. Fear and worry are normal parts of development and everyday life. The concern is when anxiety (or the behaviors associated with it) becomes persistent or disruptive. Should symptoms persist, cause significant distress, or interfere with school, work, relationships, sleep, activities, or daily functioning, it is time to seek out an evaluation to better understand the root cause. An evaluation can also be particularly helpful when you’re unsure what you’re seeing. You don’t have to start the evaluation process knowing whether it’s anxiety, ADHD, autism, depression, a learning disorder, a medical issue, or something else. That’s precisely what an evaluation is for.
The bottom line is that anxiety doesn’t have one look. And sometimes what appears to be anxiety isn’t anxiety at all – or isn’t only anxiety. Understanding the whole picture matters. Through better understanding and an appropriate evaluation, we can begin on the road to providing supports that addresses the underlying need – not just what we see on the surface.
About the Author
Dr. Miranda Milana provides comprehensive evaluation services for children, adolescents, and young adults with a wide range of concerns, including
attention deficit disorders, communication disorders, intellectual disabilities, and learning disabilities. She particularly enjoys working with children and their families who have concerns regarding an autism spectrum disorder. Dr. Milana has received specialized training on the administration of the Autism Diagnostic Observation Schedule (ADOS).
Dr. Milana places great emphasis on adapting her approach to a child’s developmental level and providing a testing environment that is approachable and comfortable for them. She also values collaboration with families and outside providers to facilitate supports and services that are tailored to a child’s specific needs.
Before joining NESCA, Dr. Milana completed a two-year postdoctoral fellowship at Boston Children’s Hospital in the Developmental Medicine department, where she received extensive training in the administration of psychological and neuropsychological testing. She has also received assessment training from Beacon Assessment Center and The Brenner Center. Dr. Milana graduated with her B.A. from the University of New England and went on to receive her doctorate from William James College (WJC). She was a part of the Children and Families of Adversity and Resilience (CFAR) program while at WJC. Her doctoral training also included therapeutic services across a variety of settings, including an elementary school, the Family Health Center of Worcester and at Roger Williams University.
Dr. Milana grew up in Maine and enjoys trips back home to see her family throughout the year. She currently resides in Wrentham, Massachusetts, with her husband and two golden retrievers. She also enjoys spending time with family and friends, reading, and cheering on the Patriots, Bruins, Red Sox, and Celtics.
To book an appointment with Dr. Miranda Milana or another expert NESCA neuropsychologist, please complete our Intake Form today.
NESCA is a pediatric neuropsychology and related services practice in Newton, Plainville, and Hingham, Massachusetts; Londonderry, New Hampshire; and Coral Gables/Miami, Florida, serving clients from infancy through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.
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