Alert, Alarm, Assessment, and All Clear
Sometimes we can cajole her into trying something new, but other times she is just a shaking, sobbing mess.
—Mother of a seven-year-old
The Faces of Anxiety
A typical day at a community pool is filled with swimming lessons and diving competitions. Amid the laughter, splashing, and chatter, each group of children probably includes one or two who struggle with some form of anxiety. Perhaps in the youngest class a three-year-old boy sits in his mother’s lap, thumb in his mouth, face buried in her shirt, while a teacher patiently tries to coax him into the water. In another class, a six-year-old girl steps happily into the pool, splashes her feet, then bursts into angry tears when a few drops of water land on her face. In the hallway a nine-year-old boy engages in a fierce debate with his mother:
“You know you’ll have a good time as soon as your class starts. You enjoyed swimming last week.”
“I just want to go home, I hate swimming!”
A twelve-year-old realizes as she begins her dive that one of her competitors is the top-ranked diver in their age group. She feels butterflies in her stomach and hesitates, spoiling her well-practiced dive.
The youngest child at the pool is anxious about separation from his mother, while the six-year-old is scared by the physical sensation of water in her face. The boy in the hall is eager to swim when he imagines it at home, but gets scared and tries to avoid it once he is at the door. Ashamed of his fear, or perhaps unaware of it, he covers it up with anger. The oldest child has performance anxiety marked by worried “what if” thoughts: What if I mess up? Each of these children is anxious, yet each is anxious in a different way.
So what is anxiety? That’s a tough question, because we use so many different words with overlapping meanings to describe it. Anxiety is sometimes regarded as milder or vaguer than fear, but an anxiety attack is the same as a panic attack, and that can be quite severe. Anxiety can be an emotion, a physical state, or troubling thoughts and beliefs. Stress usually refers to prolonged anxiety, while worries and obsessions are anxious thought patterns. Nervous habits and compulsions are anxious behaviors. Dread and terror suggest extreme anxiety, but these words are also hard to precisely define. Most children get anxious once in a while; others are anxious most of the time. Some are anxious and don’t even know it. It’s confusing! We’ll have to settle for a rough guide rather than a precise definition.
You may have noticed that my imprecise definition of anxiety is not based on a list of anxiety disorders. That’s because I don’t think diagnosis is especially useful in childhood anxiety. I’d rather understand the impact of anxiety on children’s thoughts, bodies, emotions, relationships, and behaviors. The opposites of worry, anxiety, and fear are also hard to define. The opposite of danger is safety, and the opposite of anxiety is security—or is it confidence? Or relaxation? What’s the opposite of fear? Fearlessness, courage, or calmness? The opposite of worry is trust that all is well. Again, it’s confusing.
The Positive Side of Anxiety
Whatever words we use, we usually focus on the painful side of anxiety, the side that makes children miserable and leaves parents helpless. But anxiety has a positive side as well. A little bit is necessary for our mental health, our success in life, and even our survival. A healthy dose of anxiety drives us to avoid danger, take effective action, and perform at our peak. Complete relaxation isn’t very useful for activities that require alertness and muscle control, like taking a test or diving into a pool. Anxiety only becomes unhealthy when there is excessive distress or excessive avoidance, like the anxious children at the pool.
Too much anxiety and you’re “worried sick.” Too little and you get nothing done, or you fail to take necessary precautions. We need fear when we are in danger, because fear galvanizes us to call for help, run, hide, or fight for our lives. Of course, that only helps us when our lives are really in danger. Fear when a tiger is actually chasing you is crucial for survival. Fear of a tiger in a zoo is excessive. Fear of a story about a tiger is really excessive.
Healthy anxiety also keeps us from acting immorally. Our conscience uses anxiety as a reminder that we will get in trouble or feel guilty if we do something morally wrong. Again, this anxiety can get out of hand, creating guilt or shame when we haven’t done anything wrong.
We don’t have time to think things through carefully when we are in real danger. We need a fast system, and anxiety is faster than the speed of thought. If that sounds impossible, consider that we often feel uneasy before we know why. We all have a little bit of “Spider-Sense,” the superpower of the comic book hero Spider-Man, which warns us when something feels wrong before we have time to process all the information carefully. Spider-Man wouldn’t call it anxiety, but that’s basically what it is: a signal to look around carefully for danger and prepare for action. Healthy anxiety shows up really fast, does its job, and then steps aside to let slower and more logical thought take over. With excess anxiety, that reasonable side has trouble stepping in.
Too much anxiety doesn’t kill us; it just makes us miserable. Well, it doesn’t kill us right away. Stress has terrible effects on health, but in a dangerous situation it’s safer to have too much anxiety than too little. That may be why so many children have excessive anxiety. As parents it’s hard to get the balance just right. We want our children to worry enough about a test that they study for it, but not so much that they refuse to go to school. We want them to check their homework for errors, but not to be such perfectionists that their papers are in tatters from repeated erasing. We want them to wash their hands, but not for five minutes at a time. We want them to know what to do in case of fire, but we don’t want them preoccupied with the possibility of a fire every time they enter a building.
Many anxious children worry that they aren’t smart, because they know they act irrationally at times. I always remind them that it wouldn’t be very smart to have no anxiety. Intelligence doesn’t protect a person from troubling emotions. In fact, many anxious children are highly intelligent—it takes a lot of brainpower to think of the things they worry about! Anxious children also need to know that they have emotional strengths. It’s common in childhood for vulnerabilities in one area to be balanced by strengths in another.
I met recently with the parents of Constantine, a boy with significant anxiety. They described him as imaginative, creative, joyful, and funny, with a long attention span—when not in his anxious state. This list is quite typical of children with high anxiety. Their parents and teachers often say they are mature for their age, verbally precocious, sensitive, and able to relate well to adults. We often encourage anxious children to take more risks in life, but on the bright side, we don’t have to worry that they will be extreme risk-takers and thrill-seekers.
The Suffering Caused by Anxiety
When anxiety reaches too high a level, the suffering can be intense. Rob, a nine-year-old boy, sent me an email between therapy sessions: “Lately I’ve been getting very worried about dying and that hurricanes will reach here. I’m having a really hard time dealing with it and I wanted to tell you before Thursday. I’m getting really, really worried. I feel really tense inside. I’m having trouble falling asleep and just enjoying life. I wish that there is a way to solve this. I’m urgent to find a solution quickly. Can you help me find any solution?”
Anxiety causes a range of suffering from mild to moderate to severe, and from occasional to frequent to nearly constant. The distress of childhood anxiety can take many forms:
• Physical sensations, such as pounding heart, shallow breathing, tense muscles, butterflies or churning in the stomach, trembling and sweating, hot or cold skin.
• Frequent urination, gastrointestinal distress, or incontinence.
• Anxious thoughts, pessimistic beliefs, and worries. What if something bad happens? If only I had done something differently. I know my teacher hates me.
• Rumination, in which the same thoughts or images are repeated over and over with no resolution.
• Cognitive inflexibility, which involves a fear of risks, avoidance of anything new, or an intense reaction to changed routines.
• Nervous habits such as nail biting, hair pulling, fidgeting, or chewing on clothes.
• An emotional state of alarm, apprehension, panic, dread, or always feeling on guard.
• Fears of specific things—real or imaginary—such as dogs, bugs, or monsters under the bed.
• A tendency to perceive the world as generally threatening or dangerous.
• Avoidance of anything that arouses fear or anxiety, and extreme emotional upset when avoidance is impossible.
• Behavior patterns such as shyness, clinginess, indecisiveness, perfectionism, compulsions, or an attempt to completely control one’s environment.
• Escalating demands for reassurance, with increased feelings of desperation. When reassurance is given, however, it is often rejected.
You can see that anxiety can affect children’s bodies, thoughts, emotions, behaviors, and relationships. This means that every child’s anxiety will look different and feel different.
Consider two children, Mara and Cal, in a movie theater. Mara sits with her parents. Suddenly a picture of a shark fills the screen, along with scary music. Mara feels strong physical sensations in her body; that is anxiety. She thinks, I have to get out of here and What if that shark comes after me? Those thoughts are anxiety. She runs for the exit; that is anxiety. She has trouble falling asleep that night and when she does she wakes up with nightmares—more anxiety. The next time her family goes to a movie she doesn’t want to go, even though she understands there will be no sharks in it. That avoidance is also anxiety, and it may spread to other activities that Mara used to enjoy.
Excerpted from The Opposite of Worry by Lawrence J. Cohen, Ph. D.. Copyright © 2013 by Lawrence J. Cohen. Excerpted by permission of Ballantine Books, a division of Random House LLC. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.