December 24, 2021
Cindy Lopez:
Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen. Young children usually experience some fear, separation, darkness, strangers, loud noises and probably more. Listen in to this podcast episode as we talk with two of our experts here at CHC, both psychiatrists, Dr. Natalie Pon and Dr. Glen Elliott. We’ll discuss how anxiety presents in young children, what is typical and what’s not and how socialization or lack of it in this past year can contribute to children’s fears. For this episode our conversation focuses on young children six years old and younger.
Welcome Dr. Pon and Dr. Elliott.
Thank you so much for joining us today. As we get started, I’m just wondering if there’s anything you’d like to share with our listeners.
Dr. Natalie Pon:
Thank you so much for having us here today Cindy. I’m Dr. Pon, I’m a child psychiatrist at CHC, and I specialize in working with young children in the age range of 0 to 6 and so I see a lot of kids presenting with anxiety.
Cindy Lopez:
Thank you Dr. Pon, we’re so glad that you are here with us today and Dr. Elliott.
Dr. Glen Elliott:
Very good to be here. I’ve raised two boys who are well into their thirties. Neither of them were particularly anxious, but have a grandson who’s just five and his anxiety level is pretty high. So, it’s both personal experience and training. I’m also a child and adolescent psychiatrist recently retired.
Cindy Lopez:
Let’s talk about how anxiety presents itself in young children, and maybe even talk a little bit about how parental anxiety plays into that.
Dr. Natalie Pon:
Anxiety is really the most common thing we see in this age group. Young children can present with anxiety in a really wide variety of ways, and I like parents to really think about all the behaviors that you’re seeing in your child that could possibly have an anxious etiology.
Sometimes kids present what we typically imagine as anxiety, which is really, having more avoidance, tearfulness, withdrawal, saying that they’re scared, clingingness, but sometimes young children also present with what we think of as externalizing symptoms such as outbursts, prolonged frequent or severe temper tantrums, oppositionality, or aggression even.
Dr. Glen Elliott:
I would just add to that a lot of times and it can be perfectly normal, but it shows up at transition times. So, kids are often reluctant to go from one activity to the next activity, which could be problematic at school, it can also be problematic at home: I don’t want to stop TV, and parents often get frustrated. There’s a reason that we talk about the terrible twos and sometimes the terrible threes. The kids are sort of learning the world, and it’s a big strange place out there, and not every child, but many children have a feature of anxiety which isn’t necessarily at a level of, something needs to be done, but it is important to sort of recognize that that may be what’s going on.
Cindy Lopez:
So how might parents be seeing that anxiety in their kids? What does that look like?
Dr. Natalie Pon:
Well, you know, Cindy, if we think about anxiety in terms of stress and fear, your fight or flight response is highlighted, then some level of anxiety is indeed appropriate for us all. It’s something that we just can’t get rid of, and it is really typical for children to have fears that come and go throughout their life. What happens when a child encounters a new situation is that they need a little bit of time to learn about it, to work with it and get used to it.
A child who’s never met a dog before, might be fearful of interacting with a little puppy, even if the puppy is very friendly, and what we don’t know tends to bring us anxiety, this goes for all of us, and so this goes back to what Dr. Elliot was talking about with transitions. Transitions means I’m going from something familiar to something new and unknown, and that’s why we see anxiety often showing up during those points between dinner and bedtime or from the morning to get into the car to go to school.
Dr. Glen Elliott:
Another way of looking at this is that anxiety can be transmitted by the parents sometimes consciously and sometimes unconsciously. We often see this in doctor’s visits where the parent is saying, “Don’t be worried, don’t be worried. Everything’s going to be fine.” And that tends to actually rev up the child. So, if a parent is sort of by nature of themselves a little anxious, sort of recognizing that and adding that factor in can be really useful and helpful in understanding why the child is reacting the way he or she is.
Cindy Lopez:
So you were just mentioning the doctor visit, Dr. Elliott. Is it true that sometimes it’s helpful to talk through, like what they can expect at the doctor? Does that make sense?
Dr. Glen Elliott: Makes a lot of sense if it’s the right child. There are some children knowing what is coming up well in advance can be enormously beneficial. There are other children where that just heightens their anxiety much much higher and parents they’ll know that about their child. So the idea of going to Disneyland for some kids planning on that and thinking about it is great. For other kids, as soon as they learn about it, that’s all they’re going to think about, and that’s all they’re gonna obsess over and so you have to tailor it to the child. They teach us pretty quickly what works best for them.
Dr. Natalie Pon:
I totally agree with that I’m thinking about one of my patients, as you mentioned, Disneyland here, I had at one point a three-year-old child who is coming to see me for anxiety, and she got a surprise trip to Disneyland on the day of her birthday, and she loves frozen, loves Elsa and Anna and everybody just could not understand why the plane ride there and all the time there, she was in tears not wanting to do anything, and it was really that surprise transition, and not knowing aspect of anxiety that this family was seeing.
Cindy Lopez:
Yeah and appreciate the reminder that every child is different and so as we think about that, are there typical kinds of fears in childhood?
Dr. Natalie Pon:
Yeah, there was definitely typical fears that we see at different ages. When kids are babies and at the toddler age, we see a lot of anxiety about separation from caregivers or strangers or loud noises, or even things like the blow dryer in the ladies bathroom or the mens bathroom. When they get to, you know, two to three years old, we see a lot of anxiety about like thunder and lightning, animals, new scary animals, the dark, fire or water and then when we get to kind of four to five, I see a lot of anxiety with like bugs or getting lost, monsters, death and potties is a big thing that a lot of kids are scared of, potties and flushers in that three to five year old range. So there’s a lot of anxieties and fears that we do expect at different developmental stages.
Dr. Glen Elliott:
The way things are framed sometimes makes an enormous difference.
Cindy Lopez:
I wonder when then does the anxiety become a problem?
Dr. Natalie Pon:
You know, I, I like to think about every child relative to what we expect for the typical range of development of that age. So what is the information that we have of what’s typical at this age, not necessarily comparing your child to yourself at that age or to other peers or to siblings, but really looking at developmental milestones, which are available on the CDC website, and when anxiety becomes more of a problem or a concern is really when the worries or fears interfere with functioning or normal daily activities or when we see a significant decline in the functioning of the child, such as, maybe previously they were going to play soccer and now they’re refusing to get out of the car.
We also see anxiety becoming problematic when there’s a lot of persistent distress, despite a parent or caregivers reassurance, when there’s trouble eating or sleeping, when there’s physical symptoms like headaches or stomach aches, or if a child for some reason is talking about, you know, not wanting to be here or wanting to hurt themselves.
Dr. Glen Elliott:
Another period of time when anxiety can really begin to interfere has to do with nighttime, well separation in general. We didn’t specifically mention separation anxiety, but it’s a real thing. Parents get to experience it when they drop their kid off to daycare. Usually it settles much more quickly than parents believe. They think their child was going to continue crying all day long and in actuality as soon as the parents are out of sight, things settle down, but there are kids where it becomes problematic and the preschool will let the parents know about that.
Mike:
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Cindy Lopez:
What other kinds of common anxieties might we see in children?
Dr. Natalie Pon:
Yeah, I think we see a lot of what we kind of think of or frame as adjustment anxiety and this may be something like the birth of a new sibling, starting at a new daycare, preschool, having a new nanny or new living situation with family, moving to a new home.
Dr. Glen Elliott:
And there are some kids who are just temporarily very shy. So, putting them into a place or situation where they’re expected to interact with other kids may not go so well initially and may require some structuring and encouragement.
Dr. Natalie Pon:
We also see a lot of toileting anxieties in this age group, fear of the toilet, really getting to the point of interfering, such as withholding or not going to the bathroom all day at preschool or only using one bathroom in the house, or continuing to avoid toilet training and using diapers. We also see a lot of sleep anxieties.
The final thing that we feel a lot I think in young children is trauma and things that are or can be traumatic to young children are some of the same things that adults or teens may experience, but they could also be something that could be a little bit less obvious to the parent, such as, I’ve had a kid who before got lost in Target for about 10 minutes. The mom was obviously looking for him, but this turned into a lot of separation anxiety, clingingness not letting mom go get the mail right outside the door, had to be with her, had to be like right next to her all the time in the bathroom shower, and this child was five years old. So you can see there how that level of anxiety with being separated just in the house for a 5 year old would be out of what we would expect in typical development.
Dr. Glen Elliott:
It can show up in all sorts of ways. With families that have two-storey houses and the bedrooms are upstairs there are some kids who get afraid to go up those stairs and what’s hard sometimes is differentiating. I don’t want to go to bed, so, if I don’t go up the stairs, I don’t have to go to bed,but it can be very real as well, up to the point of, I can’t go to sleep unless one of the parents lays with me until I go to sleep, which some parents were fine with, but other parents I think find difficult and need help in figuring out how to wean themselves out of the bedroom.
Dr. Natalie Pon:
Well I’m so glad that we’re mentioning sleep because I really like to tell families every bedtime or nighttime is the separation and every morning is a reunion and this really is the truth for young children who are bouncy and can’t wait to open your door in the morning and then at bedtime, they’re just clinging and crying and really don’t want to go to bed because they’re saying goodbye to you for that day.
Dr. Glen Elliott:
The severity of it again may last a few days to a week to you know months and parents, depending on what else is going on with them they may give in, or they may insist on sort of working it through, and Natalie, you can correct me because you spend more time with kids this age, but it probably has to do with that sort of increased recognition of being separate. The relationship has been cleaved and that really seems to sort of kick in Dr. Pon what would say two and a half to three?
Dr. Natalie Pon:
Yeah developmentally I’d say from two to three, really experiencing that separateness that mommy or daddy goes off and does something else while I am here.
Cindy Lopez:
I wonder too about anxiety, does it run in families?
Dr. Glen Elliott:
Yes, and there’s two parts to this. There’s almost certainly a biologic component, it does tend to run in families. There’s also a behavioral environmental component. If your parents are anxious, likely that’s going to get transmitted just by sheer imitation.
If they’re afraid to try things, the kids are going to sort of get that. I had a good friend who was terrified of mice, and we happened to be there one night when she saw a mouse in the hallway, and she didn’t quite leap up under the table, but it was very close. And then her two year old daughter had exactly the same reaction and she couldn’t understand why in the world, her daughter would have reacted so extremely, but essentially she was imitating her mother.
Dr. Natalie Pon:
Yeah, definitely young children are really emotional sponges and really biologically wired to be in tune with their caregivers. That’s why we see them just really being so in sync with what mommy or daddy feels much more so than at 12 or 10 year old even, and you know, children pick up on their parents fears, whether they are verbalized or not just like, as Dr. Elliott was saying. So because mom or dad or so-and-so did this, that’s how I should feel about this situation.
Cindy Lopez:
Let’s switch gears a little bit and talk about play and socialization. We know that play is really the work of young children and in this COVID time that we’ve been living in, I’m wondering how that has impacted play for kids.
Dr. Glen Elliott:
It’s really an interesting issue.
Dr. Natalie Pon:
Yeah, definitely, and I think the other factor these days is really the kind of devaluation of play and of that process. And really when I tell parents the first thing to do, whatever they’re concerned with their child is, is to play and to have that special play time. Play is like date night for a couple. So if you are concerned at all about your young child, I would say sit down, play, really let them be in charge of the play, and this really helps anxious children and that they get to be in control. And so I would say with parents, you know, working from home and not being able to play and the lack of opportunities to play where you have to be close to somebody else and feel safe in that play environment has been lacking, non-existent for some children over this past year and a half and that has been really challenging. The thing that we know though is that young children are incredibly resilient and so if this has made it a priority for them or they’re in a safe environment to do so, then they can build these skills.
Dr. Glen Elliott:
I completely agree. There are sort of key periods when it’s probably easier to begin to socialize, and if the child happens to have been that age while the pandemic was occurring, it’s probably going to be a little harder. They may need a little more guidance and structure and help in learning to socialize.
Dr. Natalie Pon:
I agree and I think we’re seeing a lot of that actually. You know the development that occurs between when you are three and four years old, is a lot more than an adult and even more than, you know, from 9 to 10 years old. There’s a lot of things that are happening then, and it’s been important for all of us to make children’s mental health and getting back to school a big priority so that they can socialize.
Dr. Glen Elliott:
Hopefully this will eventually pass, but what Dr. Pon was talking about earlier, if there’s nobody else to play with making sure that you as a parent spend time helping them play and develop their imagination and those kinds of things and giving them leadership responsibility in directing the play.
Cindy Lopez:
Can anxiety impair social interaction with kids?
Dr. Natalie Pon:
Absolutely. And I think it falls into some children just fear the interaction itself, whether there is COVID or not, and then a lot of times anxiety presents within the child in a way that can be very off-putting to other children or even adults, you know, a child who really insists on being in control of all of the play: you be this, I be this, no you can’t ever play with this doll, I have to be him or her, and anxiety in young children can also present like excessive talking or a lot of hyperactivity or kind of intrusiveness physically that can be off putting to other kids.
Dr. Glen Elliott:
I would say most kids this age are drawn to being social with other kids, often is what’s called parallel play; they play, but they’re sort of playing by themselves, close to somebody, but unfortunately there are some kids who can be aggressive, can do what Dr. Pon was just talking about, no, you can’t play with that, it’s mine. And if you’ve got a kid who’s already inherently shy or more prone to anxiety, that can be pretty traumatic and off-putting, and need some pretty close supervision for adults to help sort of make sure that that doesn’t happen in a prolonged way.
Dr. Natalie Pon:
Yeah, a lot of scaffolding and kind of graded exposure to situations. Some anxious kids present with selective mutism or being basically nonverbal in certain settings and being very talkative, usually in very familiar settings, like at home or with parents. So this is definitely, primary presentation of anxiety in younger kids, and often they’re seen as kind of just shy, but then they hear from preschool or kinder teacher that they haven’t spoken at all during the year. So they can’t even assess if they know their letters or colors. The other thing that young children can present with are features of OCD or doing, like, repetitive hand-washing or tapping or being excessively concerned with germs.
Dr. Glen Elliott:
And it could be all of the senses, there are some kids who love to be spun around or some kids who love to swing. There are other kids where that is not at all pleasurable, are some kids a who like to be tickled, there are other kids who find that to be torture, and I guess my caution to parents is sometimes it’s tempting to push with the assumption that if I just push hard enough that whatever that is will go away, and it is a fine line, I mean, giving in quickly probably doesn’t make any sense, but continuing to push if the child is getting worse rather than better, really suggest that you need to take a different tact.
Cindy Lopez:
What advice do you have for parents? If their child has some anxiety, how should they respond or not respond?
Dr. Natalie Pon:
It’s definitely individual to the child and at the same time, we kind of have these guiding ideas as mental health specialists. And really one thing we talk to parents about is the goal is not to eliminate anxiety, but to really help a child become aware and manage it because like we mentioned, stress and anxiety is part of life. And then we’re always walking this balance as Dr. Elliott had mentioned about not avoiding things that make the child anxious, but not pushing them to the point that they’re experiencing extreme symptoms of panic.
We really encourage parents to listen and hear out their child about what it is that they’re scared about, and I really encourage parents who their child says that they don’t know, or they just don’t answer that question to play out this scenario.
I have one patient who just loves to play we don’t want to go to bed, just like we were talking about before, and this has helped her have a seamless bedtime. So she sets up the animals, and they all talk about not wanting to go to bed, and they all talk about how the mommy’s and daddy’s want to make them go to bed, and they want to keep playing, but also they’re afraid of the dark. They don’t like the sounds, they don’t like the door closed, they are worried about monsters underneath the bed. So I really encourage parents to set up a play-based situation of what is going on for their child so that their child can show them with the play and that they can better understand, and this gives the child also an opportunity to express what they’re feeling and experiencing when they don’t have the words. Play is the language.
Dr. Glen Elliott:
In general, routines can be really, really helpful, particularly nighttime rituals, bathtime if that’s you know part of the family tradition, toothbrushing, book reading, things that are gradually designed to help the child settle down, and then hopefully be able to go to sleep, rather than letting them play until five minutes or two minutes before it’s bedtime and then say, okay, you’ve got to stop that now and go to bed, that doesn’t work so well.
Cindy Lopez:
So then when should parents seek additional help? And what kinds of specialists might they see?
Dr. Glen Elliott:
There’s no single answer to that. It depends a bit on what symptoms they’re seeing. I think the first person to go to is the pediatrician, hopefully the pediatrician will have information that can reassure them if this seems like normal development or talk with them about what specific concerns they’ve got and where they should go.
If it’s sensory kinds of things, getting really upset over the vacuum cleaner or fire engines going by or those kinds of things, sometimes an occupational therapist may be really helpful. Some kids are extraordinarily fussy about eating and sometimes that really does have to do with taste, sort of over sensitivity. If it’s more behavioral things like meltdowns, those kinds of things, I would say the most easily accessible are usually psychologists and hopefully trained specifically in working with young children. There sadly are not as many Dr. Pons around as we’d like. There are some psychiatrists who do specialize in young children, but I’d say objectively there’s more child psychologists who do that. The other thing is, is that if the parents are feeling like they’re just not working well as parents, then a social worker who’s designed to help work with them in terms of parenting techniques or frankly what we call bibliotherapy that is finding some good books about child-rearing practices, can be very reassuring, both in normalizing what’s going on and sort of suggesting to parents what they might do differently.
Dr. Natalie Pon:
For sure and I agree with all of those. I also think that the preschool or school can be helpful too in naming some resources and also as another set of eyes in a different environment, if you are concerned.I think the most important thing with this age group is really making sure that if you do seek out a provider that they really are experienced with working with this age group cause there’s a lot of people who treat children and adolescents and generally will treat eight years old and older, however, the treatment really looks different for younger kids, and there are several evidence-based interventions for specific issues and these are things like PCIT also known as parent child interaction therapy, which is very highly evidenced in the field for behavioral struggles and anxiety, or, you know, child-parent psychotherapy for trauma and anxiety. I think the one thing parents can think about is that every intervention will include them because as we’ve talked about, it really is a bi-directional process with the child and with the parent.
Dr. Glen Elliott:
I think you can’t overemphasize that particularly with young kids, when we’re talking with 2, 3, 4 year olds, we need to see what’s happening with the child, but the parent often is the one that has to adapt. Not because they’re bad parents, but because their style doesn’t fit well with that particular child, and much as we’d like to say, well, the kid has to change and accommodate, it’s easier, typically to help the parents figure out what’s going on and help the child to feel more comfortable. They may have to change some of their behaviors too and that gets really weird when you’ve got two children and one’s highly anxious and requires a lot of reassurance and the other one is, eh, not so much. So it can be really frustrating for parents. They find themselves wondering, you know, what did I do wrong. And the answer is that there’s just kind of a mismatch between their style and what that particular child needs.
Cindy Lopez:
Thank you so much both Dr. Elliott and Dr. Pon for being with us today.
Dr. Glen Elliott:
My pleasure.
Dr. Natalie Pon:
Yeah, thank you so much for having us.
Cindy Lopez:
And to our listeners thank you for joining us, and we hope you’ll tune in again next week for a new episode.
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