What Could Anxiety Look Like?

*All children (and adults) experience fear and worry from time to time. How do you know when it’s a problem for your child?

• Intensity: Your child’s worry causes uncomfortable symptoms or significant distress
• Length of time: The symptoms last beyond the immediate anxiety-inducing situations (e.g., consistent worry about something that happened in the past or that is going to happen in the future).
• Consistency: Your child’s worry lasts for weeks or months and/or the fear or worry is not getting better or is worsening.
• Interference: The worry or fear is impacting your child’s ability to complete their daily activities, to attend or fully participate in school, or engage with family/friends.

Common signs and/or situations that lead to anxiety include the following:

Preschool ages: 

• Extreme fear (Phobia): excessive and irrational fear of a situation, thing, activity, or person that leads to avoidance and upsetting behaviors
  • Examples of common childhood fears: the dark, bugs, animals such as dogs
  • Examples of unusual childhood fears seen in autistic children: fears of balloons, the happy birthday song, toilets, ceiling fans, and loud noises

• Separation anxiety: extreme stress or worry when separated from caregivers that prevent your child from participating in their usual activities; your child may become worried or upset just at the thought of being separated
  

• Managing change
  • Examples:  worry that there will be a change in the regular routine, handling unexpected changes, doing activities or routines  in a different order

Example of a toilet flushing fear: A 4-year-old can only go to the bathroom in their own home because they are afraid of loud toilets flushing. When they hear a loud toilet flush, they cover their ears, scream, and hit their parents.  Their parents don’t know how to handle the fear and in order to prevent meltdowns, they rarely leave their home for long periods of time. As a result, the family doesn’t go on family outings to places like the zoo or the pool because they would need to be away from home for more than a few hours

School-aged:

• Worry about performance: too much worry or fear about their ability to perform a specific activity in front of others
  • Examples: school performance (e.g., being in a play or musical performance); answering questions in class; eating in public; talking in front of a group of people.

• Generalized worry: extreme, constant, or unusual worry about everyday life events that are out of proportion with the actual event or situation
  • Examples: fears of making mistakes; having the teacher be mad at you; getting in trouble; coming late for something;  too much worry about breaking the rules.

• Social worry: too much or unusual worry about being judged by others, concern about embarrassment, or saying or doing the “wrong thing”
  • Examples: avoiding certain people or groups of people; worry about talking to new people; fear of rejection; avoidance of talking on the phone; fear of asking for help

• Managing change:
  • Examples: change in teacher (e.g., having a substitute teacher)  or going on a field trip; canceling activities due to an unexpected situation such as bad weather; small changes in routines such as a different caregiver doing school pick-up; parties or other special events are unexpectedly canceled

• Worry related to special interests: significant fear about not having enough time to engage in one’s special or focused interest; often interferes with one’s ability to complete daily tasks and responsibilities
  • Examples: difficulty completing homework assignments because time spent doing homework may limit the time they have to play with legos

Example of managing change: An 8-year-old child constantly asks their parents about plans, the schedule, and who is picking them up from school.  Even when they know the answer, they consistently ask questions for reassurance. The child is always anticipating something unexpected happening and asks questions like “what happens if traffic is bad on the way to school and we are late?” Their parents often have to warn them weeks in advance of doctors appointments to avoid meltdowns, or alternatively, they don’t tell them about upcoming changes until the day before to prevent too many questions. The family doesn’t talk about the future or going to new places because of the amount of questions that can occur.

Adolescence:

• Social worry: too much or unusual worry about being judged by others; concern about embarrassment; or saying or doing the “wrong thing”
  • Examples: fear of giving presentations in class; worry about attending social activities like parties or school dances; too much concern about not fitting into a group of peers

• Generalized worry: extreme, constant, or unusual worry about everyday life events that are out of proportion with the actual event or situation
  • Examples: worry about future events such as what if something bad happens to my parents; worry about growing up; worry about past events

Example of social worry: A 17-year-old often gets stomach and headaches before hanging out with friends after school. They ask questions such as “What if my friends don’t actually like me?” They beg their parents to call the school and say they are sick when there are parties or big school social events so they don’t have to go. They spend a lot of time worrying about past social events and if they said anything offensive. Recently, they spend more and more time alone and don’t participate in any extracurricular activities.

Example of a dog fear (adolescent with developing language): A 13-year-old avoids playing outside or going to the park because they are afraid of seeing or hearing a dog. They don’t watch any TV shows or movies that have dogs. When they hear a dog bark, they cover their ears, jump up and down, and scream. Their parents notice that they sweat and shiver when they are close to dogs. They try to run away from dogs which causes safety concerns if they’re in an open area. To make sure they don’t run into dogs, they rarely go outside where other people or pets may be. Therefore, the family does not go to the park, on walks in the neighborhood, or on camping trips.

Consider the following behaviors:

* It is important to pay close attention to physical symptoms and changes in behavior or mood in children and teens where high levels of fear/worry may be suspected. For children who have developing language, changes in behavior are especially important because it may be hard for them to express their worry in other ways.

• Physical symptoms may include: sweating, feeling flushed, shaking or shivering, dry mouth, complaints about stomach or headaches, excessive tiredness, restlessness, and/or difficulties with paying attention
  

• Behavioral symptoms may include avoidance of or refusal to do certain activities, fearful anticipation of certain situations or events, constant reassurance-seeking, and/or difficulty falling asleep. Sometimes stimming, jumping, or other repetitive motor movements may also be in response to worry.
  

• Changes in mood may include: increased irritability, quick to anger, and/or crying for unknown reasons.

*For verbal children, it is also important to listen to how they talk about past or upcoming events.  See below:

• Examples of negative thoughts or self-talk may sound like: “I can’t do this!”; “This is really scary!”; “What if no one likes me?”
  

• The continuous reliving of a past event or conversation or continuous worry or discussion about a future event may sound like: “I wish I hadn’t made that joke. No one thought it was funny. If only I had thought ahead and said something different.” or “What if no one likes my costume at the party? I don’t think I will wear a costume. But then what if I don’t fit in because everyone else is wearing a costume?”   

How To Help Your Child With Anxiety At Home

It is important to remember that everyone experiences fear or worry as a part of life. The goal is not to get rid of worry or fear completely, but to help your child manage their feelings. It can be helpful to share with your child that we all worry sometimes and they are not alone in their feelings. Because too much worry/fear gets in the way of daily life and the things that your child wants to do (e.g., attend birthday parties, ask for help at school), you will need to find ways to keep these feelings in check so that they do not interfere with everyday life.

Cognitive Behavior Therapy (CBT) is an effective treatment for anxiety and helps children understand the connection between thoughts, feelings, and behaviors. Below are ideas for self-care as well as how to help your child recognize their physical signs of anxiety, their negative thoughts, and then develop ways to help decrease their symptoms. There are also ideas for how to change their thinking patterns when faced with situations that cause worry.

Self-Care

• Below is a list of general self-care strategies that may be helpful for your child to stay regulated and may help in reducing their level of worry.
  • Regular exercise
  • Good sleep routine
  • Eating a well-balanced diet
  • Engaging in a range of hobbies or activities

Managing Physical Symptoms

• A good first step is helping your child understand that when they feel worried or afraid, they may feel it in their bodies. It will be helpful for your child to make the connection between their worries (thoughts) and the changes in their body.
  

• People experience worry in their bodies in different ways. It may be helpful to work with your child to identify “where in their body” they experience their worry (e.g., butterflies in their stomach, sweaty palms, tingling in their arms and legs).
  

• The goal is for your child to notice when they begin to feel these physical signs so they can eventually manage them.
  

• Deep breathing (slowly breathing in and out) and progressive muscle relaxation (systematically tensing and relaxing muscles throughout the body) can be helpful to decrease physical signs of worry.
  

• It may also be useful to identify other activities your child can do when feeling worried. For example, taking a break, moving their body, or engaging in hobbies, music, or art can useful tools to calm down.
  

• It will be important to practice these skills and activities when your child is in a calm state before trying them when they are in a state of worry.

Identifying Our Patterns of Negative Thinking

• Negative thoughts may often lead to more worry.

• The goal is for your child to identify these negative thoughts and substitute their thinking with facts or positive thoughts. The below recommendations are typically used in CBT for youth; youth with ASD may or may not find these specific approaches helpful. 
  

• It may be helpful to ask your child the following:
  • How likely is it that my fear/thought will come true?
  • What is the worst thing that could happen?
  • Can I control what happens in this situation?

• It may be helpful for your child to manage fears with facts:
  • For example, if your child is afraid of getting stung by a bee so they don’t want to go to the park, they could use facts such as “I’ve been to the park many times and I’ve never been stung so I probably won’t get stung this time!”, “It is winter, bees don’t come out in the winter”, or “Even if I do get stung by a bee, it will hurt a little, but I’m not allergic so I’ll be okay!”.

• Positive self-talk may be helpful:
  • Instead of “I can’t do this” phrases like “I will do my best!” or “I can give this a try!” are helpful.
  • Instead of “This is really scary!” phrases such as “I can try new things!” or “This is a false alarm” are useful.  For the bee example listed above, you might help your child say: “I want to go to the park because it is fun; I don’t want my worry to get in my way” or “I can be brave and go to the park.” 

Facing Fears a Little at a Time (Graded Exposure)

• The goal of facing a gear a little at a time is to gradually and repetitively face the feared situation or thing. Ultimately the goal is to decrease the worry and help your child learn to manage their feelings. Exposure is important because avoidance of anxiety-provoking situations or things may often lead to worsening or longer-lasting worry.

• It is important to remember that the goal is not necessarily to eliminate worry altogether but to decrease the impact of the worry and increase your child’s ability to handle the situation.
  

•  Facing fears of a toilet flushing phobia (described above) may include the suggested steps.
  • Look at pictures of toilets.
  • Watch videos of toilets flushing without any sound or low sound.
  • Look at toilets in-person without flushing from a distance. Slowly decrease the distance between your child and the toilet with the eventual goal of touching the toilet without flushing.
  • Softly listen to the toilet flushing sound for a short period of time (e.g., 10 seconds). Increase the amount of time your child listens at a soft volume.
  • Slowly increase the volume of the flushing.
  • Stand outside the bathroom and listen to a toilet flush.
  • Decrease the distance between your child and the toilet as it flushes.
  • Your child flushes the toilet.

Considerations for Minimally Verbal Youth

• Managing physical symptoms will be particularly important. In addition to deep breathing (mentioned above), squeezing small bean bags or other objects and chair yoga (e.g., yoga that you can do in your chair or standing next to your chair) may be helpful.
  

• Encouraging phrases from caregivers or providers such as “I can do it” or “I did it” may be helpful. The goal is for your child to then repeat the phrase themselves.
  

• Facing fears will be similar for all youth.

Other At-Home Activities to Manage Worry

• Label the worry
  • For some children, labeling their worry can be helpful because it is hard to express their emotions or fears. Labeling the worry can also help when developing useful ways of coping.

• Coping Cards or Coping “Toolbox”
  • These activities are most helpful when they are completed ahead of time so your child can use them in the moment when they are experiencing worry or stress.
  • Making “coping cards” can be a fun and useful activity to develop ways your child can calm down when feeling worried or upset. Your child can draw or write down activities on note cards. Activities such as coloring, going for a walk outside, reading a book, listening to music, or calling a friend may be helpful.
  • Other kids like to have a “toolbox” with ways of coping. For example, your child can decorate a shoebox and put items inside such as playdoh, crayons, a squishy ball, or other items that may be useful to use when feeling worried and trying to calm down.

• Start Small and Use Rewards
  • Facing worries is hard work! It can be very helpful to use rewards to increase motivation. It is important to begin with small goals so that your child meets their goal and feels successful from the start. Talk with your child about what they want to earn when they meet their goal. Earning tokens, stickers, or marbles that they can then turn in for a special treat, or for more time doing a favorite activity can be helpful. For older children or adolescents, earning extra screen time, a trip to get ice cream, a movie night, or even money may be motivating.

University of Colorado Anschutz Campus Programs

Facing Your Fears

• This is a 14-week intervention group program for children with ASD who need help managing their symptoms of anxiety. The program is based on Cognitive Behavior Therapy (CBT) principles and includes a parenting component. 

Facing your Fears IDD Group

• This is currently a research study evaluating an adapted Facing Your Fears intervention group program for children with ASD and intellectual disability who need help managing their symptoms of anxiety. The program is based in Cognitive Behavior Therapy (CBT) principles and also includes a parenting component.

Children’s Hospital Colorado Pediatric Mental Health Institute (PMHI) 

• The PMHI provides mental health services to children, adolescents, and families for a range of conditions. Providers at PMHI deliver evidence-based, family-focused services and often include interdisciplinary teams.