Anxiety in Children and Teens with Cancer

What is anxiety?

Anxiety is the experience of fear, distress, or worry, often felt in response to a stressful situation.

Thoughts and feelings of stress and worry are common for any person facing the challenges of a serious illness. In most cases, children and adolescents are resilient and cope well.

Less often, anxiety causes ongoing distress or interferes with daily life. This may indicate a specific anxiety disorder.

A variety of resources and services are available to manage symptoms, improve mental health, and promote quality of life. Remember that these resources can help you improve your quality of life during difficult times even if you have not been diagnosed with anxiety.

Signs and symptoms of anxiety

Each person experiences anxiety differently. This is especially true for children and teens. Younger children may have trouble identifying feelings of anxiety. Older children and teens may not want to talk about their worries because they don’t want to upset their parents or make things more stressful.

Signs and symptoms of anxiety may include:

• Feeling stressed, worried, or scared
• Irritability or getting upset easily
• Trouble thinking or concentrating
• Restlessness, not able to settle down
• Crying more than usual
• Not wanting to be left alone, clinging to loved ones
• Avoiding activities or situations that cause thoughts or feelings of anxiety
• Increased need for reassurance
• Signs of self-harm
• Problems sleeping
• Increased heart rate or fast breathing
• Tense muscles
• Headaches
• Loss of appetite or change in eating habits
• Upset stomach, stomach pain, constipation, or diarrhea

Many of these symptoms can occur due to physical illness or as a side effect of living with a difficult medical diagnosis. A mental health provider can help families understand anxiety symptoms and how to best manage them.

Anxiety disorders in children and teens

An anxiety disorder is ongoing fear or worry that interferes with a person’s daily life or causes extreme distress. 

Usually, what we consider anxiety is part of a normal range of thoughts and emotions. However, symptoms of anxiety may also indicate an anxiety disorder or other mental illness that needs specific treatment. Talk to your care team if a child’s anxiety symptoms get worse, interfere with daily activities, or continue even after the stressful event is over.

Each type of anxiety disorder has a collection of symptoms that lead to a specific diagnosis. Some anxiety disorders may have similar symptoms and treatments. However, an assessment by a trained professional is important to make sure anxiety is treated in the best possible way.

Types of anxiety disorders

Managing anxiety is important. High levels of anxiety can:

• Cause health problems and physical symptoms like headaches, stomach pain, nausea, or diarrhea
• Interfere with medical care and procedures
• Affect personal relationships 
• Make it hard to function at school or work
• Impact nutrition, sleep, physical activity, and other health behaviors
• Increase risk for other problems such as depression, alcohol or substance use, smoking, self-harm, or eating disorders

Anxiety treatment for children and teens

Managing symptoms of anxiety is important for health and quality of life. It is best to use several different strategies to deal with anxiety. Care team members that can help include psychologists, psychiatrists, social workers, counselors, mental health nurses, child life specialists, music therapists, art therapists, and chaplains.

Psychological therapies for anxiety

• Cognitive behavioral therapy (CBT) – CBT is a type of psychotherapy or “talk therapy” that teaches how to change negative thoughts and react to situations in a more helpful way. The therapy may focus on how to cope with specific objects, places, events, thoughts, or objects that usually cause fear or anxiety.
• Distraction techniques – Distraction is an important tool in managing anxiety. However, it is not as simple as not thinking about your stress. Children can be distracted from anxiety-provoking thoughts or situations by engaging in enjoyable activities.Art therapy, music therapy, and play therapy are important activities that can help manage anxiety.
• Mindfulness and relaxation strategies – Your child can learn specific techniques to manage and lessen the effect of stress and anxiety. They can be done almost any place or time. Examples of relaxation techniques include deep breathing, guided imagery, autogenic training, and progressive muscle relaxation.
• Mind/body therapies – Some children find help from mind/body therapies including biofeedback, massage therapy, yoga, and physical exercise. Research shows that these therapies can change nerve signals and chemical messages in the brain to help improve anxiety.

In addition to reducing anxiety, many of these therapies have other benefits including helping with pain, nausea, and depression.

Anxiety medicines for children and teens

A doctor may prescribe medicine to help with symptoms of anxiety. 

Sometimes, a medicine may be given to help your child relax before a procedure. These medicines tend to work quickly, and the effects go away after a short time.

Some patients may need anti-anxiety medicines that work over time to treat an anxiety disorder. These medicines take longer to work. Some patients may need a combination of medicines. 

Medicines used to treat anxiety disorders in children may include:

• Fluoxetine (Prozac®)
• Escitalopram (Lexapro®)
• Sertraline (Zoloft®)
• Venlafaxine (Effexor®)
• Duloxetine (Cymbalta®)
• Fluvoxamine (Luvox CR®)
• Benzodiazepines including diazepam (Valium®), alprazolam (Xanax®), and clonazepam (Klonopin®)

Patients taking medicines for anxiety need regular doctor visits to make sure the medicines are working properly. They will also monitor any side effects. 

It is important to follow dosing instructions carefully. Do not take more than prescribed. Do not stop taking the medicine without medical supervision. Be sure to let your child’s care team know if anxiety does not improve.

Questions to ask when your child is prescribed an anti-anxiety medicine:

• When should anxiety symptoms begin to improve?
• Are there any medicines or supplements that my child should not take while taking this medicine?
• Are there any activities that my child should avoid?
• What are the common side effects?
• What side effects should we be particularly concerned about?
• What should we do if my child misses a dose?
• How long will my child need this medicine?
• Medicines used to treat anxiety can be unsafe if:
• Taken more often than prescribed
• Taken in greater amounts than prescribed 
• Stopped too quickly

Please ask your child’s care team before making any dose changes. Also, be sure to store medicines safely. Keep them out of the reach of children.

Coping with anxiety

• Talk openly. It can be hard for parents and caregivers to talk with children about fears and worries.
  • Look for natural opportunities to talk about thoughts and feelings on a regular basis. This makes it easier to have hard conversations when they come up.
  • Use a variety of feeling words to help children process emotions and talk about anxiety.
  • Ask instead of assuming. Use open-ended questions and take an interest in really understanding their point of view.
  • Recognize and respect their concerns, even when you don’t agree.
  • When true and appropriate, acknowledge that you sometimes have similar thoughts and feelings. This helps them know that they are not “crazy” or alone.
  • Keep a journal to track thoughts and feelings.
• Reach out to friends and family. Social support is important for patients and families facing serious illnesses. Help children and teens stay connected to friends and find ways to focus on “normal” things.
• Consider support groups. Patients and families often find that it is easier to share about their experience with someone who has been there. Joining a support group, participating in group activities, or just making new friends within the hospital can provide patients a safe place to talk about anxiety and find ways to cope.
• Use a variety of resources to help manage anxiety. Make it a habit to use coping skills even when things are going well. This will make the strategies easier to use when they are needed. Having more than one method to deal with anxiety is also important. There may be times when a usual coping strategy can’t be used or is not helping.
• Manage your own anxiety and stress. Stay calm when your child is anxious. Children sense the moods of those close to them. They also learn coping strategies from watching others. Parents and caregivers need to take care of their own mental health. Find ways to manage your own anxiety so that your child can know he or she can do it too.
• Encourage your child to face their fears rather than avoid. Children and teens with anxiety often avoid situations they fear. Allowing children to avoid fearful situations may initially decrease their anxiety, but in the long run, avoidance helps maintain or even worsen anxiety. Praise and reward your child or teen for their efforts in facing or getting through an anxiety-provoking situation.
• Offer security without being overprotective. Parents want to protect their children from hurt, both physical and emotional. When living with a serious illness, parents must take extra care to offer children opportunities to be independent in age-appropriate ways. This helps children develop confidence in their own abilities to adapt and solve problems.
• Seek help for your child (or yourself) if anxiety symptoms get worse. Mental health often takes a back seat to medical needs when a child is seriously ill. However, anxiety can have a negative impact on health and medical outcomes. Asking for help is not a sign of weakness. Talk to your care team or mental health provider.

Resources for more information

• Anxiety Disorders - National Institute of Mental Health
• Children and Mental Health - National Institute of Mental Health
• Anxiety and Depression Association of America 
• WorryWiseKids.org
• The Child Anxiety Network