Researcher explains why children struggle with anxiety more than ever

For children and adolescents with anxiety, going to school can feel like a nightmare. Anxiety is the most common mental health disorder in adults in the United States. And since the COVID-19 pandemic, anxiety that disrupts daily life has increased among young people, making everyday activities like going to school and socializing difficult and more stressful.

In Massachusetts, the rising trend in anxiety-related disorders has led to increased school absences, sometimes referred to as chronic absenteeism or school refusal, among students. This leaves parents, families, and caregivers scrambling for solutions such as educational accommodations and mental health services, all of which are limited, with long wait lists to even see a health care provider.

“The mechanisms underlying anxiety, like intolerance of uncertainty, change, and stress, all increased in 2020 and haven’t returned to pre-COVID levels,” said Alyssa Farley, a research assistant professor of psychology and brain sciences in the BU College of Arts & Sciences. “This raises the question of whether kids have truly recovered from the experiences of those years.”

Farley is a clinician and supervisor in BU’s Center for Anxiety & Related Disorders (CARD) Child & Adolescent Program, where she and her colleagues treat children ages 3 to 17 for a variety of clinical anxiety disorders, including separation anxiety, phobias, and selective mutism, in which a child cannot speak in certain situations, such as school, but can speak in others. The clinic also provides counseling to caregivers to help children succeed.

“I think a lot of the things we recommend can be counterintuitive to parents,” Farley says. “For example, instead of addressing avoidance or enabling children to escape a situation that is causing them anxiety, we say work with them gradually to face their fears.”

Farley wishes there was more understanding of anxiety, both at home and at school, because it can be overlooked until a child starts skipping school.

The Brink spoke with Farley about why anxiety in children gets in the way of school life, why it’s so hard for parents and children to access resources, and how to support an anxious child.

Based on your work at CARD, how do you explain the increased anxiety among children and the increase in school absenteeism?

There are a lot of different factors that contribute to that. There was the COVID pandemic period, from 2020 to 2021, where kids weren’t in school and they weren’t exposed to things that would be challenging for them under normal circumstances. So for example, a child who is predisposed to social anxiety may have spent critical developmental years without playdates and without physically going to school.

Now that school is back to normal, some children have missed out on important opportunities to practice dealing with social challenges. Children who were in their preschool years during the COVID lockdown would have started practicing talking to teachers and other children, and they have really struggled because they missed that time.

Another element is screen time. I hear a lot of parents say that their child is completely addicted to their phone or tablet, and it’s really hard to get them to do other things. During that same period of COVID, screen use during the day has become normalized. I think that can also contribute to school absences now. If school is a factor that makes a child feel extreme and anxious, then of course they want to avoid it and stay home instead.

Screen time is just another tool to avoid anxiety: it can be really hard to put it aside and go to school instead. Often when we’re trying to get families to help their kids get into school more regularly, we have to ask them to remove that reinforcement at home.

How does the clinic deal with truancy and what options do families have?

Often, we work with families to remove the patterns that contribute to school refusal and build skills to help the child attend school more consistently. For example, an anxious child may say that they have a stomachache every week and are staying home a lot because of it. Over time, we may realize that anxiety is causing the child to feel physically unwell, or that there is something that is really making the child nervous about school that the child is trying very hard to avoid. The source of this anxiety needs to be addressed and the family needs to help the child attend school as consistently as possible.

We always try to prevent school refusal from becoming a more persistent pattern, because the longer you don’t do something, the harder it is to jump back into it. When we see children with persistent school refusal, we often recommend more intensive treatment than standard outpatient therapy, because that is usually not enough for a child who has long-term, chronic school refusal.

There are reports of parents having difficulty getting accommodations and support for their children who refuse to go to school due to restrictive anxiety. Why do you think that is the case?

It is usually thought of in terms of internalizing versus externalizing. Externalizing disorders cause behaviors that disrupt the classroom and interfere with the teacher’s daily routine. Internalizing disorders such as anxiety and mood disorders cause internal distress and are less likely to impact the classroom.

For example, we treat children who are very perfectionistic and afraid of making mistakes. They are in school every day and turn in perfect assignments, which may be viewed positively by teachers and school staff. But that may actually be caused by a significant underlying fear, one that does not elicit a need for help.

Another example is that a student with social anxiety or selective mutism may have difficulty participating or speaking in class. While these are signs of impairment, they can still be easily overlooked because they are not disruptive in nature.

Is there a fear that these students will be left out because it is not their behavior that disrupts the lesson?

Absolutely. In school refusal, it is common for schools to intervene and make plans when it gets to the point where there are concerns about educational neglect. Then the measures and steps that need to be taken can seem quite punitive to families. I have worked with children who have gone to court because they missed too many days of school. But that is not addressing the underlying problem.

How would you most like to see schools improve student support?

I wish there was more awareness of what anxiety looks like and the ways it can interfere. Anxiety can really be debilitating and prevent a child from reaching their potential in many ways. I would like to see more training on how to recognize signs of anxiety for both families and school staff. There is a lot of misidentification and misunderstanding of anxiety disorders that — until a child is not showing up for school — can cause them to be overlooked.

Teachers are often well-positioned to identify a mental health issue. To address this, we’ve made an effort to support them, including through the development of online trainings designed in collaboration with Jennifer Greif Green, a professor of special education and child psychologist in BU’s Wheelock College of Education & Human Development. The trainings help with identifying the different signs that a child is struggling with their mental health and how to reach out to them in an effective and supportive way, as well as how to refer them to school-based or community-based mental health services if needed.

Is there a similar training available for parents and caregivers of a child struggling with anxiety?

That’s something I’d like to develop. In the clinic, we educate parents on the ways they interact with their child so that they can be more effective in helping their child overcome anxiety. And often it’s not intuitive. They might be reassuring their child all the time, or they might step in when they see their child starting to get a little anxious, or they might bail them out of difficult situations or let them avoid them. We call that the “parent trap” because that’s what parents often do naturally when they have the best intentions. It’s in an attempt to protect your child and it might be helpful in the short term, but it can perpetuate and exacerbate anxiety in the long term.

If you had to give some general tips to parents and caregivers, what would they be?

Validate your child’s feelings and express confidence in their ability to do difficult things. There can be a tendency to minimize fear by saying things like, “Oh, it’s going to be so easy, nothing to worry about, relax, it’s okay” — but that language isn’t really helpful. We encourage parents to label their child’s feelings, show empathy for their emotions, and encourage them. You might say, “I see that you’re feeling really scared, and I get it. I know this is really hard. But you can do this. You can do it.”

I would also say, help your child challenge their own fearful thoughts. Support your child to gradually face their fears. Notice and praise examples of courage and practice modeling courage – children pick up all the cues from their parents.