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, such as pediatric cancer. In most cases, children and adolescents are resilient and cope well during and after cancer.

Less often, anxiety causes ongoing distress or interferes with daily life. This may indicate a specific anxiety disorder. Research shows that children with cancer are not more likely to have an anxiety disorder compared to other children. However, all pediatric cancer patients can benefit from strategies to help with anxiety. A variety of resources and services are available to manage symptoms, improve mental health, and promote quality of life during and after cancer.

Signs and Symptoms of Anxiety in Children and Teens

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 cancer treatment. 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

In separation anxiety disorder, a person has intense anxiety about being separated from another person. In the case of a child, this is often the fear of being separated from one or both parents. The child may worry that something bad will happen if mom or dad leaves. The idea of being separated causes extreme distress. Other symptoms of separation anxiety disorder may include clinging behavior, nightmares, and avoiding being alone.
A person with a specific phobia has an intense fear of a specific object or situation. This often leads a person to worry about the phobia and take steps to avoid the object or event.
In social anxiety disorder, a person has extreme fear or anxiety about social situations or performing in front of others. A person might worry about being embarrassed and may avoid certain settings. This can often lead to problems in school or work. A child with social anxiety disorder may appear shy or withdrawn.

Social Anxiety Disorder - NIMH
In panic disorder, a person has repeated, sudden panic attacks. The attacks are very distressing but usually last only a few minutes. They may be unexpected or be triggered by a feared object or event. During a panic attack, a person may have increased heart rate, sweating, and trembling. The person may have shortness of breath or a feeling of being smothered. The panic attack is accompanied by feelings of intense fear and a sense of being out of control or that something bad is going to happen.

Panic Disorder - NIMH
In generalized anxiety disorder (GAD), symptoms of anxiety occur almost daily and continue for at least 6 months. Symptoms include uncontrolled feelings of worry, irritability, restlessness, problems concentrating, fatigue, muscle tension, and sleep problems. Symptoms are severe enough to interfere with a person’s ability to function at school, work, or home.

Generalized Anxiety Disorder - NIMH
In obsessive-compulsive disorder, a person has repeated disturbing thoughts or worries. The person may have an intense need to do certain things (compulsions) to relieve distress. Examples of rituals or compulsive behaviors include hand-washing, counting, checking, or specific routines. OCD usually develops in teens or young adults and may run in families. The person often knows that the thoughts and behaviors are not rational but is not able to control them.

Obsessive-Compulsive Disorder - NIMH
Post-traumatic stress disorder may develop after a person experiences a scary, threatening, or emotionally traumatic event. PTSD includes symptoms of re-experiencing the event, avoiding reminders of the trauma, and being on edge or easily startled. The person may have trouble remembering details of the event or have negative thoughts and feelings such as guilt, sadness, or hopelessness.

Post-Traumatic Stress Disorder - NIMH

Managing anxiety is important, whether or not a patient has a diagnosable anxiety disorder. High levels of anxiety can:

Cause health problems and physical symptoms like headaches, stomach pain, nausea, or diarrhea
Interfere with cancer-related 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

In general, pediatric cancer patients are resilient and no more likely to develop an anxiety disorder than their healthy peers. Almost all cancer patients can benefit from strategies to reduce anxiety, whether in the context of cancer treatments or in survivorship.

Dr. Niki Jurbergs, pediatric psychologist

Treatment of Anxiety in Children and Teens

Managing symptoms of anxiety is important for health and quality of life during and after cancer. 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, or thoughts 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. For children with cancer, art therapy, music therapy, and play therapy are important activities that give patients control over anxiety.
Mindfulness and Relaxation Strategies – Patients can learn specific techniques to manage and lessen the effect of stress and anxiety. A benefit of many of these strategies is that 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 – Many patients 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 for children with cancer including helping with pain, nausea, and depression.

Medicines for Anxiety in Children and Teens

A doctor may prescribe medicine to help with symptoms of anxiety. Sometimes, a medicine may be given to help a patient 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 and to monitor any side effects. It is important to follow dosing instructions carefully. Patients should not take more than prescribed and should not stop taking the medicine without medical supervision. Be sure to let a doctor know if anxiety does not improve.

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

When should anxiety symptoms begin to improve?
Are there any medicines or supplements that I should not take while taking this medicine?
Are there any activities that I should avoid?
What are the common side effects?
What side effects should I be particularly concerned about?
What should I do if I miss a dose?
How long will I need this medicine?

Medicines used to treat anxiety can be unsafe if taken more often or in greater amounts than prescribed or if stopped too quickly. Please ask your doctor before making any dose changes. Also, be sure to store medicines safely, and keep out of the reach of children.

Coping with Anxiety: Tips for Parents and Caregivers

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 assume. 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 childhood cancer. 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 the cancer experience with someone who has been there. Joining a cancer 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. The cancer experience is stressful. 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. During cancer, parents have to 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 during cancer. 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.