Are the Kids Alright in Rhode Island?

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Anxiety has quietly become a major health condition among kids and adolescents. But with the myriad silver bullets that trigger anxious feelings and behaviors — screens, personal traumas, genetics and society — the journey from diagnosis to treatment can be long and laden with land mines. Here, some pathways for parents to find solutions in this growing epidemic.

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Quintin is standing in the mudroom, yelling that he doesn’t want to go to school. The seven-year-old is visibly frustrated and upset, and stalls getting ready, so much so that he only musters enough willpower to get partly dressed — one shoe on, one shoe off, his jacket and backpack strewn by the door.

His mother, Maggie Pearson, waits patiently nearby. She has seen this before, and knows every parent has. But in the moment, when it’s time for Quintin to go to school, the internal stress level hits its highest point. The seemingly simple act of getting out their Riverside door becomes an insurmountable, anxiety-laden battle because he’s afraid of the what-ifs.

“It could be related to safety, like ‘What if we’re stuck out there?’ or ‘What if you don’t come get me?’” she says. “He’s sad. Sometimes he’ll have outbursts and needs a lot of reminders to put his shoes on because he gets distracted, almost like self-sabotage. He’s not having these emotional meltdowns at school. It’s with us, because it’s a safe space.”

Moments like this are common among families whose kids struggle with anxiety. Anxiety disorders affect about 15 to 20 percent of children and adolescents, the Cleveland Clinic reports, while nearly one in three adolescents between the ages of thirteen and eighteen has anxiety. Since 1990, the global incidence of anxiety disorders between the ages of ten and twenty-four has risen 52 percent, reports the journal Frontiers in Psychology.

“We’re seeing a rise in the need for children’s behavioral health; there’s an increase in anxiety and depressive disorders, and also an increase in the acuity of these illnesses,” says Stephanie Lujan Rickerman, division director of children’s services at Newport Mental Health.

Rhode Island’s children are part of this wave of mental health depressions and they struggle to get a diagnosis and help. While resources are available, local experts as well as the International OCD Foundation warn that 95 percent of youth don’t get the appropriate care due to lack of access and may struggle in what they think is a solitary prison.

“I think anxiety has always been a problem. We’re just better at recognizing it,” says Jennifer Freeman, director of the Pediatric Anxiety Research Center at Bradley Hospital and professor of psychiatry and human behavior at Brown University. “Something changed post-pandemic, where we have a lot of data to show that these already incredibly troubling rates of youth anxiety and depression have doubled. That’s remarkable in a bad way.”

The Anxiety Umbrella

There is a vast spectrum of mental health conditions nestled within an anxiety diagnosis. Generalized anxiety disorder, panic disorder, separation anxiety disorder, social anxiety disorder, selective mutism and specific phobias are the main syndromes. Obsessive-compulsive disorder, once considered an anxiety disorder, is now its own category, explains Ryan Glode, a licensed mental health counselor and founder and vice president of OCD Rhode Island.

“People with OCD often have a secondary anxiety disorder, and … the likeliness of having a third increases,” Glode says. “Anxiety is a big component of OCD, because usually it’s based on some type of feared outcome. Children worry that something bad is going to happen, and the mind tricks them into thinking they have to engage in some type of repetitive behavior in order to prevent the feared outcome from occurring, or to reduce their distress.”

Many kids with OCD have a specific phobia in childhood or separation anxiety that doesn’t interfere in their functioning or isn’t diagnosed or treated, he adds. Many others also have social anxiety or general worries. A common phobia experienced in childhood is emetophobia, or a fear of vomiting, which can result in fears of germs and certain illnesses, and can build into OCD if the child engages in compulsions or reassurance-seeking to prevent themselves from getting sick.

“But they’re two separate conditions that are highly comorbid,” he says. “Children can also feel guilt, shame and an uncomfortable feeling of incompleteness if things aren’t performed the right way. So, some just need things to be organized or arranged in a particular way, otherwise their brain doesn’t shut off.”

Other disorders often accompany anxiety too, which can complicate diagnosis and treatment, like attention deficit hyperactivity disorder or post-traumatic stress disorder. Zara’s* journey with anxiety and PTSD started with a trauma that led to self-harm. She was hospitalized before coming into the temporary foster care of Shariyah and Daniel Rhone* in North Kingstown. Now working through her emotions and finding stability, she remains sensitive to even the slightest change, like a delay in a scheduled pickup time or place. She fears her peers will taunt her or that she’ll experience the trauma again, Shariyah says.

“She typically goes into her room and is quiet, and she will talk to her mom, which is very helpful. Mom is one of her coping skills,” Shariyah says. “We go on walks and let her know that she can come to us. Talking about what happened helps, but she is very closed off because of what she’s been through.”

*Names changed to protect privacy.

Anxiety vs. Anxiety Disorder

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Anxiety in itself is actually not a bad thing, explains Marcy Shyllon, interim executive director for Boys Town New England in Portsmouth. We all have it and need it to a certain extent so we can function in our daily lives.

For example, your child has a big test coming up and they need to prepare. If they weren’t nervous about it, they wouldn’t study and would score poorly or fail, Shyllon hypothesizes. Additionally, if they’re joining a new school, playing a new sport or flying for the first time, it’s natural to feel some trepidation. Those without anxiety push through that initial fear and move on, and in doing so, learn they can face the hard thing that frightened them.

Anxiety disorder, however, is an excessive, persistent and often uncontrollable apprehension that interferes with normal functioning. Those with anxiety disorder are unable to mentally forge ahead and often talk themselves out of whatever scares them because not doing it is easier than facing it and failing. The fear dominates their thoughts and actions, paralyzing them in the moment and making them think they can’t persevere.

“When anxiety becomes debilitating and starts to prevent us from engaging in life in a way that we thrive,” Shyllon says, “that’s when anxiety is a problem and needs to be labeled, diagnosed, acknowledged and treated.”

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Triggers

There is not one specific cause of anxiety in children, Freeman says. For each child, there is a different trigger or triggers and subsequent behavior or series of behaviors, so it looks and sounds different depending on the child and the stressors. This complexity, and why it’s so prevalent now, she adds, feels like navigating a labyrinth.

“Stress covers a lot, because that could be a social stressor between kids, family stressors, societal stressors like the pandemic, violence and scary things happening in schools and communities. Illness, like a family illness and being sick yourself, can be a trigger,” Freeman says. “There’s no right way to be a kid, but if they don’t get to practice things, like talking to other kids, that builds upon the next layer of anxiety. So I really do think there is a cascade effect that if anxiety is getting in the way of developmental milestones, it really disrupts typical kid functioning.”

Personal trauma and fear of missing out, family genetics and easy access to the internet are all common origins. A trauma, like abuse or the loss of a loved one, often impacts kids’ functioning and feelings of security, which may make them skittish or angry because they assume another parent will leave them behind or they’ll be judged.

Social pressures remain a chief instigator of anxiety among children, experts agree. They are afraid they’ll be ridiculed, judged, ignored, bullied or any combination of consequences that children must navigate.

“Academic pressures, puberty, exposure to peers’ highlight reels on social media — all can play a role in creating anxiety,” says psychologist and author Chelsea Tucker, of the New England Center for Anxiety in Westerly. “Kids start comparing themselves by thinking things like, ‘Oh, they’re hanging out without me,’ or ‘They have more followers than me.’ In middle school, they’re suddenly dealing with tryouts and auditions for activities they love. Those new barriers can really provoke anxiety. In high school, the next set of triggers includes identity formation, navigating romantic relationships and future plans. There’s something new to navigate at every stage.”

Genetics also impacts anxiety from generation to generation, so if parents have an anxiety disorder, children are predisposed to it, too, though it will manifest differently. It also looks different between anxious siblings — one may be outgoing and need strict processes to focus their frenetic nerves, while another may be shy and go with the flow in order to disappear.

“There are some kids whose anxiety is produced because of an unfamiliar situation,” Shyllon says, “and that’s very different than a child who is experiencing anxiety because of fear of missing out.”

Screen Time

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Experts agree that screens are one of many culprits. “People are trying to pigeonhole technology, phone use or screen time. But it’s not that those things are causing anxiety. It’s how people are using them,” Glode says.

For example, if an anxious adolescent cuts themself, they may think, ‘What if I have an infection?’ So they’ll search in Google, pore over Reddit threads and TikTok videos, and spend hours each day researching their symptoms. Their search algorithm learns what they’re worried about, feeds them misinformation and shares advice that they shouldn’t follow, Glode says. “That makes them worry more and research more; maybe they start engaging in more compulsions or avoiding more situations because they start to believe that what they’re worried about will be true,” he says.

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Behaviors

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Because there are so many triggers, each person’s behavior looks completely different and complicates the diagnoses and treatments. Glode says the time from the age of onset of obsessive compulsive symptoms in children and when they are formally diagnosed is between seven to twelve years. And the time between diagnosis to an effective, evidence-based treatment is twelve to fourteen years.

“They retreat from activities they enjoy or stay away from peers, avoiding the things that cause them anxiety. The avoidance reinforces their fear — because they feel OK, they continue to avoid social situations that provoke fear and anxiety,” Lujan Rickerman says. “Younger children might cry. They might throw temper tantrums, they might freeze or not move, or be clingy, regress or act younger than they really are. They might have trouble sleeping at night, complaining about stomach aches, headaches or a sore throat. It’s easier for a kiddo to say, ‘This hurts,’ which elicits a response from a parent, rather than say, ‘I don’t want to because I’m scared.’”

Parents should look for patterns, suggests Tucker: Is a child worried or trying to avoid school on mornings when there’s a test or presentation, or is it every time there’s gym class or music? Evaluate what day it is, what’s going on at school and over time to see if the child’s reaction occurs around a specific event.

“Parents can help children learn their unique somatic signs of anxiety, so they can begin to recognize, ‘When I feel hot and sweaty and my heart is beating fast and my throat is dry, that’s me feeling anxious, not sick,’” Tucker says.

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Case Study No. 1

Kasha Cooper’s* daughter Saraya* exhibited signs of intense anxiety at a young age and would often withdraw, shut down or become mute. Saraya insisted on being early to family outings, sports practices and games for fear of being judged. She had a phobia at school and would vomit for weeks before a new school year began, eventually developing a habit of vomiting every morning before school. In her teenage years, it became more dominant, often paralyzing, affecting every aspect of her life. She put excessive pressure on herself to achieve academically, but it became so acute that she eventually withdrew from high school completely. She never graduated, and now at twenty-three, still struggles to meet and maintain friends because she fears their judgment, suffers debilitating self-doubt because she thinks she’s never as good as them, and can’t be proactive because she fears failure.

“She wasn’t going to school. She wasn’t coming out of her room, she wasn’t eating. She wouldn’t answer text messages or phone calls because she was overthinking everything,” Cooper says. “She didn’t have the coping skills, thought therapy was dumb, and just didn’t want to put the work in. No one knew how to help, and everyone thought she was just quirky.”

Cooper says layers of treatments have worked for Saraya over the years, including therapy at Newport Mental Health, behavioral assessment at Butler Hospital, and now mood-stabilizing medications. “Patience and compassion are essential when dealing with a loved one with anxiety,” she says.

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Solutions

There are various treatments that can help an anxious child confront their fears with confidence. But because fears, the unknown and anxiety will always exist, the objective is not to cure them, Freeman says, but rather to teach them how to manage their reaction to it.

“The goal is to help them feel like they’re in control of their anxiety. They can take steps and ask for help. They can overcome whatever their excessive fear and worry are and set it aside to do what gives them pleasure and what they need to do to get through life,” Lujan Rickerman says.

Positive coping skills from Newport Mental Health therapist Dawn Iacobbo, a licensed clinical social worker:

• Drawing or journaling, meditation and even a cold shower or ice pack will settle the nervous system.
• Playing with a fidget spinner, stress ball or other device will manually focus energy and attention. The key is to have these tools available when anxiety attacks strike.
• Practice box breathing: Inhale for four seconds, hold for four seconds, exhale for four seconds, hold again for four seconds. This will ground the anxious person and calm panicked thoughts.
• Monitor and limit screen time, and beware of physical, emotional and digital bullying.
• Keep them physically active with sports, dance, horseback riding or any exercise they enjoy and look forward to.
• Be a safe space by practicing routines that show empathy (“I’m here for you” or “I’m listening”) but require accountability (“It’s hard but you can do it with my help”). This may sound like, “I under- stand you’re feeling anxious right now. That’s OK and really hard. Would you like a hug or some space to figure it out on your own?”
• Kids have big feelings, so if your child tells you how he/she feels, listen to them.
• Negative coping mechanisms, like cutting, pulling out hair or other visible signs of self-harm should be addressed with a medical professional.

“We’re in a new climate of parenting where parents are being overprotective and overly involved, with good reason. Post-pandemic mental health has become a major focus of attention, and parents are eager to protect and help kids. One of the ways they do so is by protecting them from any kind of dysphoric emotion, and they inadvertently leave kids a little less prepared to handle challenges in life,” says Ellen Flannery-Schroeder, director of the Child Anxiety Program at the University of Rhode Island, and co-director of  the New England Center for Anxiety. “Kids need to learn that it’s not as scary as they think it is, gather the data they need to see that they can handle anxiety-provoking situations, and practice coping skills to develop their own confidence.”

Exposure Therapy

Freeman and PARC are conducting research to discover further impacts of and expand access to exposure therapy on pediatric anxiety, and comorbidities like depression and autism. Exposure therapy is a strategy to target the thing that children fear and change the exposure over time so they gradually learn coping mechanisms, Freeman says. Partnering with community health centers across the state, including
Lujan Rickerman’s Newport Mental Health, they are testing the effectiveness of different delivery methods and how it can affect youth with anxiety and OCD.

“Exposure therapy is an effective treatment for children and adolescents with OCD and anxiety and it’s far superior than medication alone,” Glode says. “It’s basically a face-your-fears model.”

Exposure therapy:

• Identifies the different situations that trigger intrusive thoughts and the
  emotions the child experiences in that situation.
• Acknowledges the response: Perhaps it’s compulsive behaviors or avoiding the situation.
• Overcomes this by exposing them to the situation in a controlled way while resisting engaging compulsions and safety behaviors, so they learn to respond differently with their anxious thoughts and feelings.

“There is stigma around mental health disorders and treatment,” Freeman says. “One of the missions of our work is to increase equitable access to care for all kids and also fight stigma. We want to help kids and families know this is something we can talk about together. Those are messages we need to send our kids loud and clear.”

The Pearson family got the message, and Quintin stays busy with sports to redirect his anxiety, loves coloring, and talks openly about how he’s feeling. “We’ll keep doing the things he’s afraid of,” Pearson says, “and hopefully that will change the narrative in his mind.”

Sleep

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Getting enough rest plays such a leading role in our well-being that Flannery-Schroeder and Tucker co-authored Banish Bedtime Battles: The Ultimate Six-Week Plan to Help Your School-Aged Child Sleep Independently.

“It’s very common for children who present with any anxiety or anxiety-related issues to also have difficulties going to bed independently,” says Tucker. “When we address the bedtime issues in treatment, the child can use their new coping skills to become more independent at night, supporting their ability to be independent, competent and confident.”

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Case Study No. 2

Andres Rosario’s* nine-year-old son Tomas’* biggest challenge is what they refer to as anticipatory anxiety, where he builds up a situation in his mind based off his expectation of what will happen. “Early on, I feared that a lot of this was caused by me, because I have always lived to a high standard that I hold for myself, and I started holding my child to a very high standard, and I fear that pressure becomes overwhelming for him,” Rosario explains. “But I learned that I will not screw up my child’s life if he doesn’t brush his teeth right one night.”

Tomas gets jittery when anxious, and defiant, emotionally and physically refusing to do what’s asked of him. In these moments, Rosario says the biggest benefits have been breaking things down step by step, and not letting the end goal be intimidating. Instead, he says, “‘You don’t want to go to school today? Let’s just start by getting out of bed. Start by walking downstairs. We will address going to school when we’re actually through the morning routine of getting food into our system, getting dressed. Take one step at a time,” Rosario says. He adds that occupational therapy also helped Tomas tackle stressful school projects, find strategies for being more efficient in the classroom, improve things like handwriting and physical strength, and learn how to combat anxious moments while limiting disruption. “It really helps to break it down for him so the end goal is not nearly as daunting.”

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Resources

New England Center for Anxiety
North Kingstown and Westerly, 236-7096, newenglandanxiety.com

Newport Mental Health
Middletown, 846-1213, newportmentalhealth.org

Butler Hospital
Providence, 844-401-0111, butler.org

Obsessive Compulsive Disorder Rhode Island
info@ocdri.org, ocdri.org

Pediatric Anxiety Research Center at Bradley Hospital
Riverside, 432-1469, parcanxiety.org

High Performance Parenting
info@highperformance-parenting.com, highperformance-parenting.com

Brine Occupational Therapy
843-069-0856, brineot.com

Camp

Courage Quest Summer Camp for ages eight through twelve, held at the University of Rhode Island. childanxietyprogram.com/summer-camp

Books

Banish Bedtime Battles: The Ultimate Six-Week Plan to Help Your School-Aged Child Sleep Independently
by Ellen Flannery-Schroeder and Chelsea Tucker

Pride and Joy: A Guide to Understanding Your Child’s Emotions and Solving Family Problems by Kenneth Barish

Freeing Yourself from Anxiety by Tamar Chansky

Breaking Free of Child Anxiety and OCD by Eli Lebowitz

Happy Families: How to Protect and Support Your Child’s Mental Health by Beth Mosley

Websites

my.clevelandclinic.org/health/diseases/anxiety-in-children

nimh.nih.gov/health/topics/anxiety-disorders

Editor’s Note: This article is not intended as a medical diagnosis or treatment. A licensed medical professional, through a neuropsychological evaluation, must diagnose anxiety disorder or OCD. If you suspect anxiety in your child, consult a medical professional.