Recently, a mother from Manhattan posted on Facebook that she was looking for recommendations for a child psychologist for her daughter:

“She has always been an anxious child, needing to be reassured of things, but recently it’s become increasingly worse. She becomes alarmed and scared if she doesn’t see someone at pick up right away, asks me constantly who will be picking her up from places, etc. When I try to talk to her about it, she gets very upset and begins to cry… I’m hoping someone can give me some tools to deal with this but also someone my daughter could speak to.” 

Facebook being the nirvana of crowdsourced-advice that it is, within a short time the post had attracted 40+ comments, many of them recommending pediatric mental health professionals, and some comments from the mental health professionals themselves.

Then came a comment from a woman (who happens to be our secretary):

“I work for a pediatric OT practice that deals with and treats child anxiety with those kind of symptoms on a regular basis.”

Occupational therapy? Child anxiety? What’s the connection? inquired a number of the comments on the post.

They were surprised to discover that OT can have everything to do with child anxiety… or nothing. It depends. This article will give you direction in determining the root of a child’s anxiety, and to which professional to turn.

Getting to the Root of Child Anxiety

Anxiety can have three different causes: emotional/psychological, neurochemical and physiological. Let’s go through them one by one.

Emotional/Psychological

When Emma was 4, she got lost in a shopping mall. Eventually a kind shopper noticed her crying hysterically and turned her over to a security guard, who brought her to the mall security office, which announced on the loudspeaker that a lost child had been found. By the time Emma’s frantic mother rushed to the mall security office and gathered Emma in her arms, Emma had been crying and frightened for 30 minutes.

Would you be surprised to know that for months afterward, Emma clung to her mother whenever they were in any public place, and that the sight of a shopping mall started an “I want to go home!” fit?

No, most of us would not be surprised. Emma had a very scary emotional experience. Anything that brings up a hint of that experience is understandably met with fear, distrust and aversion.

Sometimes we’re aware of the experience that triggered our child’s anxiety. Sometimes we may not be able to put our finger on any particular experience. When the anxiety appears suddenly and intensely, however, the first thing to investigate is if the child has had any emotionally disturbing experiences recently. 

You may be able to talk to the child directly about it, like in the case of Noah, the 6 year old son of a friend of ours who suddenly became fearful of going to sleep at night. He demanded that all doors be locked and all shutters be closed… and he still came out of bed too scared to go to sleep. Upon some questioning by his mother about exactly what he was scared of, Noah shared that he was scared of police officers coming to the house and taking him to jail. 

Why police officers? That information only came out a week later, after a long conversation where Noah was clearly reluctant to share, even as it was clear that it would make him feel better. Apparently Noah and a friend, on the way home from kindergarten, had intimidated an 8 year old girl by marching toward her with grim expressions on their faces. The next time they ran into the girl on their way home from kindergarten, she was with her mother, who told the boys off. “If you do that again,” she said, “I’ll call the police!”

Another child might have brushed off the comment. But Noah had taken it to heart and was now terrified of the police knocking at the door and carting him off to prison. He had gotten so worked up from the threat that no amount of reassurance or explanations – like how police officers would think that mother’s complaint was ridiculous, and that even if a child did a really bad thing like stealing, the police do not take them to jail; they talk to the child’s parents and figure out how to help the child learn to act better – worked to calm him. It took the efforts of Noah’s caring and creative kindergarten teacher, using stories and drama, to help him leave the fear behind.

In many cases, you may not be able to get a direct answer from the child. The child may be too embarrassed or frightened to share, or – more commonly – they may not be aware themselves to what they are reacting.

In these situations, bring in your detective skills and other resources in your child’s life. Talk to your child’s teacher or other staff members in your child’s school. What is happening to your child in the classroom – or at recess? Is there any bullying going on? If the teacher doesn’t know, ask him – or another staff member or older student whom you trust – to keep an eye out for your child and see if there is anything happening that could be emotionally disturbing your child.

On occasion – especially if you’re aware of what triggered the anxiety – you or other figures in your child’s life can help the child work through the issue. 

Often, however, you may need the help of a professional – in this case a child psychologist or other trained mental health professional. In some circumstances these professionals can figure out what the trigger issue was and address it. Even if they can’t, they may still be able to give the child the experiences and tools that he needs to move on.  

In short, the root of emotional/psychological anxiety is a trigger experience or series of experiences that made a highly emotionally disturbing impact on the child.

Neurochemical

The trigger of emotional/psychological anxiety is external. In contrast, the trigger of neurochemical anxiety is internal. 

Our brain and entire nervous system are exquisitely designed and delicately balanced. Over 100 different neurotransmitters operate to enable your brain and body to react appropriately to internal and external stimuli, with the majority of the work being done by seven main neurotransmitters: acetylcholine, dopamine, gamma-aminobutyric acid (GABA), glutamate, histamine, norepinephrine and serotonin. 

If something is off in the functioning of your neurotransmitters – in when they’re released, in how much is released – that will directly impact the smooth functioning of your nervous system. 

GABA and serotonin are the primary neurotransmitters responsible for the calming of the central nervous system. If your body doesn’t make the right amounts of GABA and serotonin, or doesn’t release and absorb them at the right times, anxiety will often be the result. 

Psychiatrists are the professionals that address neurochemical-based anxiety directly, primarily by using medications that affect the balance of GABA and serotonin in the body.  

While it’s wise to consult a child psychiatrist if you suspect neurochemical-based anxiety, pediatric psychologists and therapists can also be a valuable resource. Their expertise can give a child tools and methods to handle her anxiety and minimize the effect that anxiety has on her life. Sometimes the tools can be so effective that it doesn’t matter that the underlying issue is still present, because its presence isn’t felt. 

In short, the root of neurochemical-based anxiety is an imbalance or dysfunction of the nervous system, and specifically the neurotransmitters that are used by the body to calm the nervous system. 

Physiological

Similar to neurochemical-based anxiety, the trigger to physiological-based anxiety is also internal, but it stems from a different internal source. 

The two roots to physiological anxiety are found in the sensory system and in the part of the nervous system that deals with reflexes. 

To get an idea of how issues with the sensory system can cause anxiety, rate your feeling after the following events on a scale of 1-5, with 1 being completely relaxed and 5 being totally on edge.

  • Your neighbor is doing construction, and the sounds of jackhammering have been going on all day – for the past three days.
  • You walk into your friend’s house because you agreed to watch her toddler for a few hours… and stop, because there isn’t really anywhere to walk. Toys, books, crayons, clothes and cookies are strewn ALL over the floor.
  • You’re trying to get out of a sports stadium after a big game, and all the people pushed up against you are a head taller than you… and really need deodorant.

Add up your score. Did you score 12 or above? 

If so, you’re like most normal adults taking this poll. Intense sensory stimulation causes us to be overwhelmed by our environment. Dopamine levels go down, cortisol levels go up, and our physical and mental selves experience that state as anxiety. We are totally on edge, and can’t wait to get home (or for the construction workers to go home).

Let’s pretend for a moment we’re in the shoes of a child (or an adult) with Sensory Processing Disorder. The noise of children having a good time in the playground sounds like jackhammering. If your brother left a few Legos in the middle of your room, it feels like your entire toy closet was dumped out on the carpet. When you walk down the aisle in the supermarket, all the people passing by two feet away feel like they’re right next to you – and the food smells wafting out of their carts and off the shelves smell worse than an athlete after a summertime game.

And this might be happening all day, every day. Who wouldn’t be anxious?

When children with Sensory Processing Disorder have everyday interactions with their environment, everyday stimuli are felt as uncomfortable and/or overwhelming. The imbalance and fluctuation of neurotransmitters released cause our children to be uneasy and anxious.

Sensory integration issues aren’t the only physiological cause of anxiety. Sometimes reflex integration issues play a part.

Infants are born with certain reflexes, uncontrolled reactions to environmental stimuli. Any mother has seen these in action. Stroke your infant’s cheek – he turns and opens his mouth, trying to find something to suck. Slam a door – his arms fly wide open.

That last reflex is known as the Moro reflex, or startle reflex. A sudden change in the infant’s environment, most notably loss of physical support, causes the infant to fling her arms open, then retract them, often accompanied by crying. The Moro reflex – like all primitive reflexes – serves a purpose in infanthood (assisting in starting the breathing process when the newborn first emerges, clinging to and alerting the mother should she inadvertently lose her hold on the infant, keeping the baby alert to potential threats). It is, however, supposed to be integrated by 4 months, replaced with the adult startle reflex.

Sometimes, however, it sticks around. And like all guests who outstay their welcome, the Moro reflex starts to cause trouble. Sudden changes in a child’s environment trigger the Moro reflex and cause cortisol to cascade through their body, accompanied by the feeling of stress. 

Imagine you’re working on a project. You have 10 co-workers. Every time a co-worker says your name from outside your range of vision, you jump as if they had snuck up behind you and yelled BOO! straight into your ear. How productive will your day be? How will you feel after that day? 

While some children and adults with an unintegrated Moro reflex do actually physically startle, most have learned to compensate. The startle still occurs, but it’s mainly internal. 

These are the children who can’t cope well when things don’t go as expected. You’re a minute late to pick up your child in preschool, and he’s already started to lose it. Your 6 year old daughter has all her dolls lined up in a particular order on her bed, and Heaven help us if her little brother moves one half an inch out of place. Your 9 year old son needs to wear his Superman baseball cap on math test days. If it’s a test day and he can’t find it, he’ll burst out crying and refuse to go to school.

To deal effectively with physiological-based child anxiety, you would turn to a pediatric OT specializing in sensory integration and/or reflex issues. The goal is to address the sensory or reflex cause directly. When through occupational therapy the child is able to successfully integrate the sensory system or the immature reflex, the body will no longer be sending continual “there’s something wrong!” messages. 

No longer will the child feel so threatened in the face of a sudden change. No longer will she startle internally and feel the need to control her environment in order to protect herself. With her newly-gained physiological balance and stability, she’ll be able to acclimate appropriately to changes in her environment, actively engage in the dynamics of the relationships around her and look forward to new experiences.  

In short, the root of physiological-based anxiety is sensory processing issues or unintegrated primitive reflexes (or a combination!), which leads the child to feel stress from normal, everyday stimuli and interactions. 

How Do You Know Which it is?

Because there could be more than one factor at play, it is difficult (even for professionals, and all the more so for non-professionals) to identify the root cause of any given child’s anxiety with 100% certainty.

That said, here are some important guidelines to bear in mind when thinking about your child’s anxiety and how best to address it. 

If the anxiety appears suddenly and intensely, your first area of investigation should be centered on emotional/psychological anxiety. Has your child undergone a frightening, disturbing or traumatic experience? (And remember our friend’s son who took an adult’s “I’ll report you to the police!” much more seriously and literally than it was probably meant. Something an adult or an older child might brush off could still have a traumatic effect on a younger child.)

Talk with your child. Inquire with the other adults who are a part of his life (teacher, babysitter). Ask people you trust to keep an eye out in environments where you’re not around. 

Whether or not you can put your finger on the cause, a psychologist or an emotional therapist can often be a resource of choice in getting to the root and/or helping a child move past the anxiety-causing experience.

What if the anxiety isn’t a sudden development, but a slow, gradual one? In that case, look in the direction of physiological or neurochemical roots. Which one to focus on largely depends on how old the child is or was when you first noticed the anxiety. 

The diagnosis of neurochemical anxiety is not usually ascribed to children under the age of 6. If your child is under 6, physiological anxiety is likely to be the primary cause to investigate. The symptoms of this disorder may begin presenting at a slightly earlier age, yet due diligence should be done before establishing this diagnosis.

Even if your child is older than 6 – even if they are hitting adolescence – sometimes when you think back to how they were as a baby or young child, you’ll realize that there were undercurrents of anxiety symptoms. These are the babies who react intensely to sensory stimuli – who shy away from noise and from touch. These are the children who are constantly chewing – on their pencils, hair or clothing – or who grind their teeth at night. These are the children who lose it if everything isn’t “just so,” and break down over changes in plans.

Going back to our Upper East Side mother’s Facebook description of her daughter: “She has always been an anxious child, needing to be reassured of things…” While it sounds like the situation had intensified of late, the underlying issues and manifestations had been present for years. 

The manifestations themselves were also typical of physiological anxiety. The need to know exactly what to expect. The concern of expected events not happening as expected. Anticipatory anxiety and obsessive-compulsive issues often have physiological roots, as the child fears unexpected changes in his internal and external environment and he attempts to control that environment.

Another signal to look into a physiological root is if a child has been in emotional or behavioral therapy for a significant period of time without the desired effect. If the root of anxious behavior is truly emotional/psychological, therapy will more often than not help it disappear for the long-term. 

If the root is physiological, however, treating it as a psychological or behavioral issue will often help to minimize one particular manifestation of of the anxious behavior. But the physiological response, having lost an outlet of expression, will look for a different outlet of expression. Your anxious, thumb-sucking child stops sucking her thumb – but then she turns into an anxious, nail-biting child. Her unintegrated sensory systems or reflexes are looking for an outlet. And they will find one.

The Mind-Body Connection

Most of us are aware of how the mind affects the body. If we’re scared, for example, our heart starts beating faster and our breathing gets shallower.

Less common knowledge is how the body affects the mind. Internal physiological stimuli can have a powerful effect on our thoughts and emotions. One of the most simple examples is how you inevitably have less patience and more irritability and negativity when you’ve somehow made it all the way to mid-afternoon without managing to eat a normal breakfast or lunch. Hunger and thirst are internal physical stimuli… and they noticeably impact our mind and our mood. 

The relationship between the body and the mind is a constant, complex give-and-take. Child anxiety, when it occurs, may be caused by one, or the other, or an interplay between the two.  

We’ll end with the telling story of 7 year old Olivia, who, about two weeks after starting first grade, developed a sudden, intense fear of robbers. She refused to stay in bed, and would stand outside her parents’ door and cry hysterically unless they let Olivia sleep in their room, or unless one of them went to sit in her room until she fell asleep. 

Olivia had always expressed a preference for strong sensory stimulation and pressure. She liked to be “squished” in her bed by lots of blankets, pillows and stuffed animals. She chewed on her bottle as a baby and toddler, and still enjoyed chewing, usually limiting herself to gum. During the same time period that Olivia manifested her intense fear of robbers, her sensory desires also intensified. Gum didn’t cut it anymore. Olivia chewed on zip ties and waxed nostalgic for a particular baby toy that was made of a tough, rubbery material. Olivia requested that her bed be loaded with more blankets and bolsters so she could feel even more squashed. 

Her mother told us that the complexity of finding the root of the anxiety clicked one night when Olivia kept coming out of bed to talk to her mother (even though her father was sitting there in her bedroom). The first few times, Olivia said intensely, “I’m scared! I’m so scared of the robbers!” Each time her mother sent her back to bed, reminding her that her father was in the room with her. Then Olivia came out and, with identical intensity, “I need to chew! I need something to chew!”

It was the same intensity, the same urgency, the same tone. Except before Olivia had been complaining about a disturbance that was seemingly emotional, and now she was complaining about a disturbance that was clearly physiological. 

Which was it? her mother asked us. Was it that the fear of robbers was causing Olivia to feel more of an intense desire for sensory stimulation, so that she could calm herself (i.e. an emotional/psychological trigger exacerbating the physiological reaction)? Or had Olivia’s sensory system somehow become less regulated, causing her to feel intensely anxious, and Olivia had chosen to pin the anxiety on robbers (an intensification of the physiological trigger exacerbating the emotional reaction)?

The proximity to Olivia’s entrance into first grade could point to either answer. 

Because of the sudden appearance of the anxiety, it could be that Olivia was reacting to an emotionally disturbing experience. Maybe Olivia was being bullied by other students or intimidated – intentionally or unintentionally – by a teacher or staff member. 

On the other hand, the transition from kindergarten to first grade is a tough one in many aspects, particularly when it comes to children who are sensory seeking. In pre-school, art projects, toys and games abound. Every day students are hands-on with glue, scissors, paper-mache, modeling clay, fingerpaint and other sensory media. Jumping, running, rolling and other physical activities share equal time with sitting still.

In first grade, after the initial thrill wears off, the physical reality sets in. No more (or very little) modeling clay, fingerpaint and paper-mache. Jumping and running is restricted to recess, and the majority of time is spent sitting still. Olivia’s sensory-seeking stimuli craving body might be shouting for help, seeking to satisfy a physiological need that is not being fulfilled.

What should Olivia’s mother do? 

We advised her to make inroads in both directions. Definitely speak to Olivia, her teacher and any other parties who might give insight as to whether bullying or another emotionally disturbing occurrence is happening at school. If she gets clear information or hints that that is the right direction, then (in addition to addressing the problem directly, if possible) a child psychologist or therapist might help to alleviate Olivia’s emotional distress. 

At the same time, don’t ignore the physiological component. It might be wise to turn to an OT specializing in sensory integration issues for an evaluation. In parallel, Olivia’s mother can do her best to provide Olivia at home with the sensory stimulation she is now missing at school. She can invest in clay, modeling clay, kinetic sand, shaving cream and fingerpaint and make them available to Olivia every day for projects. She can also encourage games like jump rope and dodgeball, go to parks with climbing equipment and visit indoor play areas with trampolines and ball pits. 

Knowledge is Power

Watching your child struggle with anxiety is a frustrating and painful experience for a parent. The challenge is multiplied a hundredfold when you have no idea where the anxiety is coming from… or how to address it. 

We hope that this post has given you both insight and initial direction in how to approach child anxiety when it appears.  

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