Anxiety in children: the signs most parents miss

Why anxious children do not look anxious

Parents who picture an anxious child often picture one who says they are worried, who wrings their hands, or who cries in an identifiable way. Real childhood anxiety is usually less obvious. A child who has recurrent stomach aches before school, who complains of headaches when asked to attend a party, who insists on sleeping in the parents' room long past the age when this is typical, or who seems to become angry and defiant at transition points may be showing anxiety in the way that children typically do.

Children lack both the vocabulary and the insight to identify their own emotional states reliably. A seven-year-old who feels a wave of anxiety on the bus to school does not think: I am experiencing anticipatory anxiety about the social environment of school. They think: my stomach hurts. They ask to go home. If the request is granted, the stomach ache resolves, and the pattern repeats and strengthens.

A 2009 study published in the Journal of Pediatric Psychology found that children with anxiety disorders had significantly higher rates of recurrent abdominal pain than children without anxiety. A separate prospective school-based study in the Journal of Pediatrics examined somatic complaints in children and found that stomach pain was among the most common, with emotional factors identified as a significant contributor in many cases. The body is expressing what the mind cannot yet name.

The most common anxiety disorders in children

Several specific patterns of childhood anxiety are well recognised and each presents differently. Separation anxiety is characterised by distress that is far beyond what is expected for a child's age when they are separated, or anticipating separation, from the people they are attached to. It is developmentally normal in toddlers and typically eases by school age. When it persists strongly into later childhood or adolescence, it has crossed into a clinical anxiety disorder.

Generalised anxiety disorder in children involves persistent, excessive worry about many different things: school performance, family health, whether the house door was locked, whether a parent's car will crash. The worrying is difficult to control, and it is accompanied by physical symptoms like muscle tension, poor sleep, fatigue, and difficulty concentrating. These children often appear diligent and conscientious to adults, which can mask how much effort they are expending just to function.

Specific phobias, such as fear of dogs, needles, vomit, or the dark, are common and often manageable. Social anxiety disorder involves an intense fear of scrutiny, embarrassment or humiliation in social situations, and leads children to avoid participation in class, speaking to peers they do not know well, or attending events. It is frequently confused with shyness, which is a temperament rather than a disorder.

Selective mutism, in which a child speaks normally at home but is consistently unable to speak in specific settings like school, is understood as an anxiety disorder rather than a behavioural choice or a developmental delay. It responds to treatment approaches similar to those used for other anxiety disorders.

School refusal: when avoiding school is more than laziness

School refusal, sometimes called school avoidance, describes a pattern in which a child resists or refuses to attend school, causing significant distress to the child and the family. It is not truancy, which involves leaving school without parental knowledge for the purpose of avoiding supervision. School refusal typically happens with the parents' full knowledge, the child is at home, and the family is often in considerable distress about it.

A 2024 review in The Nurse Practitioner noted that school refusal is driven by anxiety in the majority of cases, often involving a combination of separation anxiety, social anxiety, and specific fears related to the school environment. Other drivers include depression, bullying, learning difficulties, and a genuine traumatic event that took place at school. Getting to the underlying cause is essential before the response will work.

A StatPearls review updated in 2026 describes school refusal as requiring a multi-component response: rapid return to school as a therapeutic goal (not waiting until the child feels ready, because waiting reinforces the avoidance), involvement of the school in adapting the return, and addressing the underlying anxiety directly with professional support. The longer a child stays out of school, the harder it becomes to return, because the anxiety about the social situation of going back adds to the original anxiety.

Physical complaints that disappear on weekends and school holidays, that resolve if the child is allowed to stay home, and that have not produced any physical explanation after a medical review are a strong signal that anxiety is involved. This is not the child deceiving anyone. The physical symptoms are real. Anxiety produces genuinely felt physical sensations.

How reassurance can backfire

When a child is frightened, the natural parental response is to reassure them and remove what is frightening. This feels like the kind response and in a genuine emergency it is. In the context of anxiety disorders, it is one of the things that reliably makes anxiety worse over time.

Anxiety is maintained by avoidance. Each time a child is allowed to avoid the feared situation, they experience relief. That relief reinforces the belief that the situation was genuinely dangerous and that escape was necessary. The next time the situation arises, the anticipated anxiety is at least as high as before, and the pull toward avoidance is stronger.

This does not mean forcing a terrified child into the feared situation suddenly. Graduated exposure, which is the planned and gradual approach toward feared situations starting from the least frightening step, is the evidence-based approach. A child frightened of dogs might begin by looking at pictures of dogs, then at a dog in a video, then at a dog across the street on a lead, and progress from there. The process is supported by a therapist in formal treatment, but parents can apply the principle with mild everyday fears.

Excessive reassurance seeking is a related pattern. A child who repeatedly asks whether the plane will crash, whether there are germs on the door handle, or whether their parent will die, is not looking for information. They are looking for relief from anxiety. Providing detailed reassurance each time reinforces the seeking and does not reduce the anxiety. A more effective response is to acknowledge the feeling briefly and then redirect without providing the reassurance, which is a technique a therapist can help a family learn.

What anxiety looks like in different ages

At different developmental stages, anxiety presents differently and different levels of fear are developmentally expected. Toddlers who fear strangers and become distressed when separated from caregivers are within the normal range. Preschool children who are afraid of monsters, the dark, or animals are displaying very typical developmental fears. These become worth investigating if they are intense enough to significantly disrupt functioning or persist well beyond the typical age of resolution.

School-age children, roughly five to twelve years, most commonly present with worries about performance, health, family safety, and social acceptance. A child who needs constant reassurance about tests, who becomes physically ill before sports days or class presentations, or who cannot sleep because they are worried about something bad happening to a parent, may be showing signs of anxiety beyond the normal range.

Adolescents are more likely to present with social anxiety, sometimes combined with other mental health difficulties. A Lancet study published in 2026 comparing emotional distress in adolescents across multiple countries including Lebanon found significant rates of emotional distress, and noted that rates had increased between 2018 and 2022 across nearly all populations studied. Adolescents may describe anxiety as stress, may not identify it as anxiety at all, and are particularly likely to withdraw from family rather than seek help.

When to seek professional help for a child

Normal childhood fears do not generally require professional intervention. They are part of development, typically resolve with time, and respond to calm, consistent parenting that neither dismisses nor amplifies the fear. The signal that professional help is worth seeking is when the anxiety is significantly disrupting the child's daily functioning: missing school regularly, unable to participate in activities that peers manage without difficulty, unable to sleep alone for an age at which that is expected, or so distressed by the feared situation that they cannot be helped through it by the parents.

The duration and persistence matter. A child who is frightened before a specific event is different from a child who is frightened much of the time. A child who has refused school for three days after something difficult happened is different from a child who has refused school for three months with no clear precipitant.

Physical complaints that have been medically investigated and found to have no physical explanation are also a signal. This does not mean dismissing the child's pain. It means recognising that the physical symptoms are real but are being generated by an anxiety response rather than by a physical disease process, which leads to a different and effective treatment.

What treatment looks like: effective options

Cognitive behavioural therapy (CBT) adapted for children has the strongest evidence base of any treatment for childhood anxiety disorders. A 2017 review of the literature in Focus, the journal of the American Psychiatric Association, confirmed that CBT produces meaningful improvements across childhood anxiety disorder types, with most children showing significant improvement after eight to sixteen sessions. The child version of CBT involves helping the child identify anxious thoughts, challenge their accuracy, and gradually approach feared situations rather than avoid them.

For younger children, CBT is delivered through play and involves parents directly in the process. Parents are taught how to respond to anxious behaviour in ways that support progress rather than reinforcing avoidance. This parental involvement is not a side feature of childhood anxiety treatment. It is central to it, because the child's environment changes when parents change how they respond.

Medication is sometimes used alongside CBT when anxiety is severe, or when access to CBT is limited. Selective serotonin reuptake inhibitors (SSRIs) are the medication class with the best evidence in childhood anxiety. No medication should be started for a child without the involvement of a paediatrician or child and adolescent psychiatrist, and medication should not be the first or only treatment.

In many parts of the Arab world, access to trained child psychologists is limited and the stigma around mental health continues to deter families from seeking help. School counsellors, when available and trained, can provide a useful first point of contact. Paediatricians who are aware of the link between somatic complaints and anxiety can redirect families appropriately. The message that anxiety in children is common, is not a character flaw or a parenting failure, and responds well to treatment, needs to reach more families.

What parents can do at home

There is a great deal that parents can do that either helps or significantly worsens childhood anxiety, regardless of whether professional treatment is involved. Acknowledging the feeling without amplifying it is the central skill. Saying I can see you are nervous about this, that makes sense is different from saying Oh no, don't worry, everything will be absolutely fine. One validates the feeling; the other, despite its kindly intention, signals that the situation requires reassurance, which implies danger.

Helping a child develop a toolkit of self-management strategies has lasting value. Slow, deliberate breathing works physiologically because it activates the parasympathetic nervous system. Children as young as five can learn a simple breathing exercise: breathe in slowly for four counts, hold for two, breathe out slowly for six. This can be practised when calm so it is available when anxious.

Modelling calm response to difficult situations matters more than parents typically realise. Children are highly attuned to parental anxiety. A parent who visibly catastrophises, who talks about feared events as inevitable, or who arranges the family's life around avoidance of anxiety-provoking situations is providing a working model of anxiety that children absorb. This is not blame. It is a recognition that parents who struggle with anxiety themselves often benefit from their own support.

Maintaining routines, sleep schedules, and regular meals provides the physical foundation from which emotional regulation is possible. Anxiety and sleep deprivation amplify each other. A child who is chronically under-slept has a lower threshold for anxiety responses and less capacity to use coping strategies. Getting sleep right is not a soft intervention in childhood anxiety. It is fundamental.

Anxiety and Arabic cultural contexts

Mental health stigma remains a significant barrier to seeking help for children in many Arab families. Parents may attribute anxiety to the evil eye, to spiritual weakness, to spoiling, or to a child who simply needs discipline. These interpretations delay recognition and treatment. A child whose anxiety is interpreted as defiance or laziness will not receive the response that reduces it.

On the other hand, Arab family structures that maintain close extended family contact, that normalise communal problem-solving, and that provide a strong sense of belonging and identity, can be genuinely protective for children who are anxious. The question is not whether the cultural context helps or harms but where, in this particular family and community, the resources are and where the gaps are.

The experience of displacement, war, and loss, which is a reality for large numbers of children in the region, significantly increases the risk of anxiety disorders. A child who has experienced genuine danger, loss of home, separation from family members, or witnessed violence has an elevated biological threat response. This is an appropriate response to an inappropriate set of circumstances, and it needs to be understood in that frame. Managing anxiety in children who have experienced trauma requires specific expertise, and generic reassurance is insufficient.

Religion can be a source of comfort and meaning for anxious children and their families, and it is right to include it in a family's coping approach. It becomes problematic when it replaces rather than accompanies professional assessment, particularly when a child is suffering significantly and treatment-responsive conditions are going unaddressed.

Sources

• Dufton LM, Dunn MJ, Compas BE et al: Anxiety and somatic complaints in children with recurrent abdominal pain and anxiety disorders, Journal of pediatric psychology, 2009
• Freidl EK, Stroeh OM, Elkins RM et al: Assessment and Treatment of Anxiety Among Children and Adolescents, Focus (American Psychiatric Publishing), 2017
• Kawsar MDS, Yilanli M, Marwaha R et al: School Refusal, StatPearls, 2026
• Heuer B: School refusal: Considerations for the primary care NP, The Nurse practitioner, 2024
• Saps M, Seshadri R, Sztainberg M et al: A prospective school-based study of abdominal pain and other common somatic complaints in children, The Journal of pediatrics, 2009
• Casella CB, Kessler RC, Mneimneh Z et al: Emotional distress in adolescents in 2018 and 2022: a comparison of cross-sectional national probabilistic samples from six countries, The Lancet Child and Adolescent Health, 2026