10-year-old boy named James has an outburst in school. Upset by something a classmate says to him, he pushes the other boy, and a shoving-match ensues. When the teacher steps in to break it up, James goes ballistic, throwing papers and books around the classroom and bolting out of the room. He is finally contained in the vice principal\u2019s office, where staff members try to calm him down. Instead, he kicks the vice principal in a frenzied effort to escape. The staff calls 911, and James ends up in the Emergency Room.<\/p>\n\n\n\n
To the uninitiated, James looks like a boy with serious anger issues. It\u2019s not the first time he\u2019s flown out of control. The school insists that his parents pick him up and take him home for lunch every day because he\u2019s been banned from the cafeteria.<\/p>\n\n\n\n
But what\u2019s really going on? \u201cIt turns out, after an evaluation, that he is off the charts for social anxiety,\u201d reports Jerry Bubrick, PhD, a child psychologist at the Child Mind Institute. \u201cHe can\u2019t tolerate any \u2014 even constructive \u2014 criticism. James is terrified of being embarrassed, so when a boy says something that makes him uncomfortable, he has no skills to deal with it, and he freaks out. Flight or fight.\u201d<\/p>\n\n\n\n
James\u2019s story illustrates something that parents and teachers may not realize \u2014 that disruptive behavior is often generated by unrecognized anxiety. A child who appears to be oppositional or aggressive may be reacting to anxiety\u2014anxiety they may, depending on their age, not be able to articulate effectively, or not even fully recognize.<\/p>\n\n\n\n
\u201cEspecially in younger kids with anxiety you might see freezing and clinging kind of behavior,\u201d says Rachel Busman, PsyD, a clinical psychologist, \u201cbut you can also see tantrums and complete meltdowns.\u201d<\/p>\n\n\n\n
Anxiety manifests in a surprising variety of ways in part because it is based on a physiological response to a threat in the environment, a response that maximizes the body\u2019s ability to either face danger or escape danger. So while some children exhibit anxiety by shrinking from situations or objects that trigger fears, some react with overwhelming need to break out of an uncomfortable situation. That behavior, which can be unmanageable, is often misread as anger or opposition.<\/p>\n\n\n\n
\u201cAnxiety is one of those diagnoses that is a great masquerader,\u201d explains Laura Prager, MD, director of the Child Psychiatry Emergency Service at Massachusetts General Hospital. \u201cIt can look like a lot of things. Particularly with kids who may not have words to express their feelings, or because no one is listening to them, they might manifest their anxiety with behavioral dysregulation.\u201d<\/p>\n\n\n\n
The more commonly recognized symptoms of anxiety in a child are things like trouble sleeping in their own room or separating from their parents, avoidance of certain activities. \u201cAnyone would recognize those symptoms,\u201d notes Dr. Prager, co-author of Suicide by Security Blanket, and Other Stories from the Child Psychiatry Emergency Service. But in other cases the anxiety can be hidden.<\/p>\n\n\n\n
\u201cWhen the chief complaint is temper tantrums, or disruption in school, or throwing themselves on the floor while shopping at the mall, it\u2019s hard to know what it means,\u201d she explains. \u201cBut it\u2019s not uncommon, when kids like that come in to the ER, for the diagnosis to end up being a pretty profound anxiety disorder.\u201d<\/p>\n\n\n\n
It\u2019s not uncommon for children with serious undiagnosed anxiety to be disruptive at school, where demands and expectations put pressure on them that they can\u2019t handle. And it can be very confusing to teachers and other staff members to \u201cread\u201d that behavior, which can seem to come out of nowhere.<\/p>\n\n\n\n
Nancy Rappaport, MD, a Harvard Medical School professor who specializes in mental health care in school settings, sees anxiety as one of the causes of disruptive behavior that makes classroom teaching so challenging. \u201cThe trouble is that when kids who are anxious become disruptive they push away the very adults who they need to help them feel secure,\u201d notes Dr. Rappaport. \u201cAnd instead of learning to manage their anxiety, they end up spending half the day in the principal\u2019s office.\u201d<\/p>\n\n\n\n
Dr. Rappaport sees a lot of acting out in school as the result of traumaat home. \u201cKids who are struggling, not feeling safe at home,\u201d she notes, \u201ccan act like terrorists at school, with fairly intimidating kinds of behavior.\u201d Most at risk, she says, are kids with ADHD who\u2019ve also experienced trauma. \u201cThey\u2019re hyper-vigilant, they have no executive functioning, they misread cues and go into combat.\u201d<\/p>\n\n\n\n
When a teacher is able to build a relationship with a child, to find out what\u2019s really going on with them, what\u2019s provoking the behavior, she can often give them tools to handle anxiety and prevent meltdowns. In her book, The Behavior Code: A Practical Guide to Understanding and Teaching the Most Challenging Students, Dr. Rappaport offers strategies kids can be taught to use to calm themselves down, from breathing exercises to techniques for distracting themselves.<\/p>\n\n\n\n
\u201cWhen a teacher understands the anxiety underlying the opposition, rather than making the assumption that the child is actively trying to make her miserable, it changes her approach,\u201d says Dr. Rappaport, \u201cThe teacher is able to join forces with the child himself and the school counselor, to come up with strategies for preventing these situations.\u201d<\/p>\n\n\n\n
If it sounds labor-intensive for the teacher, it is, she notes, but so is dealing with the aftermath of the same child having a meltdown.<\/p>\n\n\n\n
Anxiety also drives a lot of symptoms in a school setting that are easily misconstrued as ADHD or defiant behavior.<\/p>\n\n\n\n
\u201cI\u2019ll see a child who\u2019s having difficulty in school: not paying attention, getting up out of their seat all the time, asking a lot of questions, going to the bathroom a lot, getting in other kids\u2019 spaces,\u201d explains Dr. Busman. \u201cThe behavior is disrupting other kids, and is frustrating to the teacher, who\u2019s wondering why they ask so many questions, and why they\u2019re so wrapped up in what other kids are doing, whether they\u2019re following the rules.\u201d<\/p>\n\n\n\n
People tend to assume what\u2019s happening with this child isADHDinattentive type, but it\u2019s commonly anxiety. Kids withOCD,mislabeled as inattentive, are actually not asking all those questions because they\u2019re not listening, but rather because they need a lot of reassurance.<\/p>\n\n\n\n
\u201cIt probably occurs more than we think, either anxiety that looks disruptive or anxiety coexisting with disruptive behaviors,\u201d Dr. Busman adds. \u201cIt all goes back to the fact that kids are complicated and symptoms can overlap diagnostic categories, which is why we need to have really comprehensive and good diagnostic assessment.\u201d<\/p>\n\n\n\n
First of all, good assessment needs to gather data from multiple sources, not just parents. \u201cWe want to talk to teachers and other people involved with the kid\u2019s life,\u201d she adds, \u201cbecause sometimes kids that we see are exactly the same at home and at school, sometimes they are like two different children.\u201d<\/p>\n\n\n\n
And it needs to use rating scales on a full spectrum of behaviors, not just the area that looks the most obvious, to avoid missing things.<\/p>\n\n\n\n
Dr. Busman also notes that a child with severe anxiety who\u2019s struggling in school might also have attention or learning issues, but they might need to be treated for the anxiety before they can really be evaluated for those. She uses the example of a teenager with OCD who is doing terribly in school. \u201cShe\u2019s ritualizing three to four hours a day, and having constant intrusive thoughts \u2014 so we need to treat that, to get the anxiety under control before we ask, how is she learning?\u201d<\/p>\n\n\n\n
Acting out can be a symptom of anxiety in a child because some anxious children feel an overwhelming need to get out of a situation that\u2019s making them anxious. Their behavior may look like anger or defiance, lashing out, throwing tantrums, seeming distracted, moving around a lot, or arguing with others.<\/p>\n\n\n\n
Anxious kids who act out may be misdiagnosed with ADHD or a behavior disorder. That\u2019s why it\u2019s important to have a careful evaluation by a mental health professional, like a psychologist, psychiatrist, or social worker, to find out what\u2019s causing the behavior.<\/p>\n\n\n\n
Anxiety in kids can be treated very successfully with cognitive behavior therapy, or CBT. Medication is sometimes recommended, too.<\/p>\n\n\n\n