By Steven Schlozman, MD, Dina Hirshfeld-Becker, Ph.D., Paula K. Rauch, M.D. and Aude Henin, Ph.D.

Posted in: Patriots' Day Project

Topics: Anxiety, Mental Illness + Psychiatric Disorders

How can we best handle the stress that this year’s marathon and the upcoming memorials of last year’s events might engender? In answering this question, we first need to remember that everyone is unique.  If we try to apply a one-size-fits-all recipe for when we need to broaden our support, we’re bound to miss some individuals who very much need more attention, and at the same time, worry unnecessarily about others who are in fact doing fine.

To this end, we can be guided by what our survey showed in terms of how parents perceived the reactions of their children during last year’s marathon. About 20% of the parents surveyed felt that their children had noticeable behavioral changes for the first few weeks after the bombing and lockdown. That number decreased to around 11% in the months that followed. Of note is that these symptoms were primarily characterized by anxiety. Given these findings, it is important to ask the following questions:

How do we define anxiety in children, and how does anxiety manifest in different age groups?

When should parents worry that their child’s anxiety is excessive, and when should they appreciate it as mild, transient and likely to be minimally disturbing?

Anxiety is a normal, healthy emotion, and nearly all children experience periods of worry, fear or hesitancy. Anxiety can present differently at different ages. Toddlers and preschoolers, more limited in their language while more concrete in their thinking, may tantrum, exhibit oppositional behaviors when entering a feared situation, and cry, fret or cling to parents. As children mature, they may verbalize their fears and express their worries through play or drawings. They may experience physical symptoms, such as stomachaches and headaches, attempt to avoid situations in which they feel anxious, or have repeated nightmares and difficulty sleeping. They may have trouble concentrating on their schoolwork or other activities, and exhibit behaviors more typical of young children (for example, suddenly wanting to sleep in their parents’ room). Adolescents may also appear withdrawn, apprehensive and less engaged in daily activities. Children of all ages may repeatedly seek reassurance, and complain that they have repetitive or distressing thoughts.

We consider anxiety to be problematic when it interferes in a child’s life. Signs that anxiety is becoming problematic include the following:

• The child begins to routinely avoid situations or activities in which he previously participated. For example, he attempts to avoid going to school, doesn’t want to go to a friend’s house or won’t go upstairs by himself.
• The child is too anxious or distressed to enjoy daily activities.
• The child spends a significant amount of time worrying most days of the week.
• The child experiences physical symptoms that have no medical basis, and which get in the way of participating in activities.
• The child’s anxiety persists for a prolonged period of time (weeks to months).

In thinking about whether anxiety is interfering in your child’s daily life, it can be helpful to think about what the expectations are for the child’s developmental level, and examine whether he is struggling to meet any of those demands. For example, in preschool children, anxiety may get in the way of their going to school, separating from parents, sleeping independently and maintaining toileting routines. Older children or adolescents may have difficulty attending school or completing schoolwork; they also may withdraw from friends and social activities, become more oppositional, or display less interest or involvement in their usual hobbies.

Recall, however, that anxiety can be triggered by any of a number of troubling events—but, it can also occur in the absence of any known trigger. Nevertheless, when anxiety DOES occur, regardless of the trigger (or lack thereof), we need to determine what to do. Once we determine that a child is suffering—that the anxiety is significant—what is the best course of action? Several strategies may help a child manage the stress of these events:

• Limit the child’s exposure to media coverage of the bombing and other disturbing or graphic images. For young children, viewing repeated recaps of an attack or disaster may make them think it is happening again and again.  Avoid watching news coverage of these events when children are in the room.
• Answer your child’s questions in a straightforward, neutral manner. Children will sense if parents are anxious in discussions, which can further escalate their concerns. Your child will also guide you as to how much information to provide; in general, start by providing a minimum of information. If he asks no additional questions, he has had enough, and is ready to move on. Keep your child’s developmental stage in mind when discussing these events.  Younger children will benefit from more concrete, limited information: “Two guys set off a bomb and some people got hurt, but the police caught the guys so this won’t happen again.” Older children who realize that future attacks are possible may benefit from being reminded of how uncommon these events are, and how unlikely they are to happen to them (“How many times have we been to Boston? How many times did we get hurt?”). It can also be helpful to remind older children about all of the people who helped out in the aftermath of the bombing, thereby emphasizing that there are many, many more helpful than hurtful people in the world. Adolescents may also have more complex questions about motivations and bigger picture issues that you should be prepared to answer.
• Encourage your child to verbalize her concerns to normalize the experience of anxiety. It’s OK to provide reassurance initially, although remember that repeated reassurance is generally unhelpful—it inadvertently rewards, and therefore increases, the likelihood of expressions of worry.
• Encourage your child to actively cope with anxiety. Ask him what he could say to himself to manage worried thoughts. Rather than simply telling them how to cope, parents should work collaboratively with their children to think of a plan that they can use to manage anxiety. A coping plan could include a brief strategy to manage physical symptoms of anxiety (e.g., take a few deep breaths), a helpful self-statement (“The bad guys were caught and can’t hurt anyone else”) and a plan for facing their fears (“I can be brave and go upstairs by myself.  I’ve done it before”).
• If your child is worried about harm coming to the family, encourage her to have a plan for dealing with this harm and the associated anxiety (“What could you do if….?”).
• As difficult as this may be, do not allow avoidance behaviors to continue.  Although it is instinctual to try to help your child feel better, the more he avoids situations that trigger anxiety, the less safe and more anxious he will feel. Instead, encourage him to gradually face his fears. Reward and praise any attempts he makes to do so.
• Let other adults know that your child has been feeling more anxious so that they can implement similar coping strategies. For example, checking in with school staff, coaches and other important adults may be helpful in creating a supportive network for your child.
• If your child experiences significant, persistent anxiety that is interfering in her life, seek help. There are many trained professionals who can help her cope with anxiety, and there are several excellent treatment options that may help her master anxious feelings.
  • There are some helpful resources online that can provide additional information and guidance:
    • Anxiety Disorders Association of America (ADAA): www.adaa.org
    • Association of Behavioral and Cognitive Therapies (ABCT): www.abct.org
    • National Institute of Mental Health (NIMH): www.nimh.nih.gov

With the support of parents, teachers and others in our community, most children will cope well with the upcoming marathon and reminders of last year’s bombing, but for those who do show prolonged symptoms of anxiety parents should seek help.