What are Anxiety and OCD?

Children with anxiety or OCD are likely to exhibit symptoms in the school setting. For this reason, it's important to understand the signs and symptoms of anxiety and OCD and to be able to differentiate between normal and abnormal behavior.

Anxiety in Kids

Everyone experiences anxiety at some point in their lives, from the very young to the very old. In school, students may get nervous during a fire drill, before a test or presentation, or when saying goodbye to their families in the morning. It is normal and common for students to get anxious in situations like these. When a student’s anxiety starts to creep out of specific situations and into their everyday life, they might have an anxiety disorder.

Anxiety is defined as chronic and/or generalized worry, fear, or nervousness that students express a lot of the time. In other words, the anxiety the student feels is not driven by specific situations. They feel anxious most of the time, regardless of what is happening in their life. In these cases, anxiety noticeably impacts a student’s behavior in school and at home, their ability to participate in class, their learning, and/or their ability to perform assigned tasks.

For BIPOC youth, experiences of racism and discrimination, social determinants of health, current and historical stressors, and the resulting internalized stress may contribute to increased anxiety and mental health concerns. Further, youth living within a racially oppressive context may feel as if they are constantly in a state of hypervigilance. This contributes to increased anxious arousal or generalized worry, fear, or nervousness.

Types of Anxiety Experienced by School-age Children

There are many types of anxiety and anxiety-related disorders that school-age youth can experience, including:

Generalized Anxiety Disorder

What is it?

Generalized anxiety disorder (GAD) is characterized by extreme and constant worry about any number of things. It lasts for at least six months and interferes with daily activities.

What does it look like?

Symptoms of GAD in children include reassurance-seeking from teachers and loved ones, difficulty concentrating in class or while doing homework, and even avoiding going to school.
Children with GAD can also be overly self-critical. This can lead them to avoid activities they think they may not excel at.

How common is it?

GAD is less common in younger children. From ages 4–11 years old, it occurs in less than 1% of youth.
In older children/teens, around 12–15 years old, the rate of GAD grows to 1.1%, or around one in 100 older children/teens.

How is it treated?

Cognitive behavioral therapy (CBT)
Medication

Panic Disorder

What is it?

Panic disorder is characterized by repeated feelings of severe fear that occurs randomly due to a perceived imminent danger. These intense feelings are also called panic attacks.
Panic disorder may also be accompanied by agoraphobia. This involves avoiding conditions, locations, and situations that may cause one to panic.

What does it look like?

The symptoms of panic disorder are heart palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, heat sensations, chills, and feelings of choking.
They may also include an extreme untriggered fear of dying, losing control, or going crazy. The person experiencing this may feel detached, or as if they are outside themselves.
Research shows that 13–14 year-olds who suffer from panic attacks are two times more likely to have attempted suicide.

How common is it?

Panic disorder is not very common in children. Research shows that among 8–15 year olds only 0.4% have the disorder. But in comparing children to teens, there’s an increased rate from 0.3% in children to 0.5% in teens.
Overall, the lifetime prevalence of panic disorder is 4.7%. Twenty-five percent of those who develop a panic disorder will do so by the age of 16.
Comorbidity, or having more than one diagnosis, is very high with panic disorder. The majority of youth with panic disorder, between 50-90%, will also experience a mood or anxiety disorder.

How is it treated?

A form of cognitive behavioral therapy (CBT) called panic control treatment for adolescents (PCT)
Medication

Separation Anxiety Disorder

What is it?

Separation anxiety disorder is the experience of great distress caused by fear of being separated from home or from a loved one.
It can also be characterized by constant worry that a loved one will be harmed or will die.

What does it look like?

Symptoms of separation anxiety disorder in children often includes throwing emotional tantrums, crying, holding on to the parent/caregiver, refusing to participate in activities that involve separation, not wanting to sleep alone, and refusing to go to school.

How common is it?

Among the children that will develop this disorder, 75% will do so by age 10 and 90% by age 13.
Separation anxiety disorder is diagnosed less frequently the older youth get — 4.1% of 9–10-year-olds have it, down to 0.6% of 12-year-olds, and even lower in older adolescents.

How is it treated?

Cognitive behavioral therapy (CBT)
Parent child interaction therapy (PCIT)
Medications can be used in treatment of separation anxiety

Social Anxiety Disorder

What is it?

Social anxiety disorder is characterized by the fear and avoidance of social performance situations. Symptoms last for at least six months.
Usually symptoms occur when the person is exposed to new or unfamiliar people or situations. They fear they might act in an embarrassing way.

What does it look like?

Social anxiety disorder may look like a fear of going to a new school, going through social situations with great distress or avoiding them altogether, fear of being embarrassed or judged, self-consciousness, avoiding eye contact, and avoiding other people.
In more severe cases, children may refuse to go to school, or get physically aggressive if forced to do so.

How common is it?

Social anxiety disorder is one of the more common anxiety disorders in youth in the USA. Five to 15% of adolescents have, or have previously had, social anxiety disorder.
Although symptoms usually start around 15 years old, they have been known to occur in children as young as eight years old.

How is it treated?

Cognitive behavioral therapy (CBT)
Group therapy
Medication

Selective Mutism

What is it?

Selective mutism is when a person is unable to speak in certain social situations, lasting for at least one month, despite the fact that they are able to speak in more familiar situations.

What does it look like?

Some of the symptoms of selective mutism include inability to speak, timidity, social anxiety, struggle with speech and language, being easily frustrated, developmental delays in some children, nervousness, and fear.

How common is it?

Selective mutism occurs in 0.11–2% of children.
Selective mutism usually appears when youth are between two and four years old, but children typically don’t receive treatment until they are 6–9 years old.

How is it treated?

Cognitive behavioral therapy (CBT) and behavioral therapy are first-line treatments.
Social communication anxiety therapy
Medication

Specific Phobias

What is it?

Specific phobias are devastating individualized fears that a person experiences regarding an object or a situation that poses little to no danger. Some examples include fear of heights, airplanes, animals, blood, needles, or clowns. The individual will then avoid these situations or objects in order to not experience the immense anxiety.

What does it look like?

Symptoms of specific phobias include sweating, nausea, difficulty breathing, and feeling powerless when exposed to whatever the specific trigger might be (object or situation).
Children with specific phobias may cry, throw tantrums, and hold on to their parents when faced with their specific feared object or situation.

How common is it?

The average age of onset for specific phobias is 9–10 years old.
Specific phobias affect 5–10% of children and adolescents, according to community samples. However, research done with parents shows that this number may be higher — 17.6% of children experiencing childhood fears may fit the criteria for specific phobia.

How is it treated?

Exposure-based cognitive behavioral therapies
Medication

Post-Traumatic Stress Disorder

What is it?

Post-traumatic stress disorder (PTSD) occurs when a person has experienced, been threatened by, or has witnessed serious injury, death, or sexual violation.
The individual with PTSD will experience dreams, flashbacks, memories, and/or other physical reactions that are upsetting and unwanted for over a month after the incident.

What does it look like?

In children, some symptoms may include acting helpless, angry outbursts, or reliving/recreating the incident through play.
Other symptoms may include negative self-image or emotional state, detachment, hypervigilance, or memory and sleep troubles.

How common is it?

Studies show that about 14–43% of youth go through at least one trauma. Of those children and teens who have had a trauma, 3–15% of girls and 1–6% of boys develop PTSD.

How is it treated?

Trauma-focused cognitive behavioral therapy (TF-CBT)
Prolonged exposure therapy (PE)
Relationship-based therapy
Group therapy
Medication

Each of these conditions have different symptoms. But the common thread between them is that they cause severe, chronic disruption in a child's life.

OCD in Kids

Obsessive compulsive disorder (OCD) is one of the more common mental health disorders among school-age youth. However, it is not widely understood and is rarely included in discussions of mental health in the classroom. OCD involves both obsessions and compulsions that take a lot of time, get in the way of important activities — such as school and extracurricular activities, developing friendships, and self-care — and can cause severe anxiety in those affected.

Obsessions are intrusive and unwanted thoughts, images, or urges that occur over and over again and feel outside of the child’s control. These obsessions are unpleasant for the child and typically cause a lot of worry, anxiety, and distress.
Compulsions (also referred to as rituals) are behaviors the child feels they must do in order to get rid of the upsetting feelings caused by the obsessions. A child may also believe that engaging in these compulsions will somehow prevent bad things from happening.

In general, OCD is diagnosed when these obsessions and compulsions become so time-consuming that they negatively interfere with the child’s daily life. Typically, the obsessions and compulsions become gradually more severe over time until they get to this point.

Among racial and ethnic minorities, OCD symptoms may be influenced by negative stereotypes, racism, or one’s racial identity. For example, fear of validating false racial stereotypes may contribute to OCD-related anxieties. For more information about how experiences of racism may influence and/or exacerbate symptoms of OCD for racial and ethnic minorities, please view this video by Monnica Williams, PhD, ABPP, Jenny Yip, PsyD, ABPP, and Valerie Andrews.

Is it Anxiety/OCD or is it Typical Behavior?

It is common for students to have anxiety/fears, and to have certain routines/rituals for certain times. What makes anxiety and OCD different from these common fears and behaviors is the frequency and intensity at which they occur, and whether or not they get in the way of the student’s daily life. The following chart can help distinguish between fears and behaviors that are developmentally and culturally appropriate, and those that might constitute anxiety and/or OCD.

Typical Fears/Routines	Anxiety/OCD
The content is usually commonplace (e.g. fear of thunderstorms, wanting to eat the same breakfast every day, etc.)	May seem bizarre or unusual, out of sync with what is happening. May be extreme or disproportionate responses to the situation.
Age-appropriate (e.g. wanting to be tucked in at night).	The student may have fears that are not typical to their age group (e.g. sexual/violent intrusive thoughts).
Do not consume an inordinate amount of time nor interfere with daily functioning.	Experience of fears and/or performance of rituals is excessive, time consuming, and has a negative impact on the student’s functioning.
Associated with enjoyment or satisfaction; the student wants to do them, or likes doing them.	Students find their behaviors distressing and/or overwhelming.
Responsive to logic or reason.	Reason or common sense do not stop or help the student’s fears or behaviors. Students often cannot be comforted or reassured. NOTE: Younger students may not realize that their fears are bizarre or unusual (i.e. they may lack insight).
Are able to be stopped or interrupted at will.	The student feels they cannot control their fears or stop doing their behavior(s). Interrupting the behavior will cause the student a lot of distress.

Adapted from “Students with OCD: A Handbook for School Personnel” by Gail B. Adams, EdD

Anxiety disorders and OCD are not something a student can simply “snap out of.” Students with anxiety that is disproportionate to the situation find it difficult to manage their feelings. Likewise, students with OCD typically have little control over the obsessions they suffer from and the compulsions they perform to try to get rid of their bad feelings.

Signs/Symptoms of Anxiety and OCD in School

What are the signs and symptoms of anxiety and OCD that a child may exhibit in school?

In this video, Eric Storch, PhD, talks about the different ways that children may exhibit signs and symptoms of anxiety and/or OCD in the school setting.

Read below for additional information about the signs and symptoms of anxiety and OCD in school.

Anxiety Signs/Symptoms in School

When it comes to OCD in a school setting, you may notice some of the following signs/symptoms:

Anxiety may make a student appear to be cautious, nervous, shy, or fearful.
Anxious students may express their fears by crying or throwing tantrums. It may be very difficult for them to calm down.
Some students may seek constant approval or reassurance from others.
Students may describe feeling physical symptoms, like headaches, stomachaches, racing heartbeat, or difficulty breathing.
You may notice that they are sweating, or that they are trembling/shaking. In some cases, students may experience full-blown panic episodes or panic attacks.

OCD Signs/Symptoms in School

OCD compulsions

When it comes to OCD in a school setting, you may notice some of the following compulsions:

Repeated lining up, checking, ordering, or arranging items on desks, in backpacks, or lockers
Wanting to complete assignments “perfectly,” checking, and re-doing it
Sloppiness or carelessness in completing assignments, which is not typical for the child
Erasing repeatedly until the paper has holes in it, the ink is smudged, and the writing or drawing is illegible
Reading letters, words, or sentences repeatedly, repeating syllables until they sound right
Incomplete assignments or homework, although the child is capable of doing them
Frustration or anger when things are disorganized, interrupted, or routines change unexpectedly
Asking the teacher or other students the same questions repeatedly even though the child knows the answer
Frequent trips to the bathroom either to use the toilet or wash hands
Refusing to touch others’ books, pencils, the ball in gym, etc. or getting upset if own personal items are touched by others
Sudden avoidance of familiar things or reluctance to try new things
Odd behaviors such as walking in specific patterns through doorways, counting tiles or syllables, touching or tapping in symmetry, or sitting and standing repeatedly
Opening doors, lockers, desks, or books with elbows or with tissue in hand, holding hands in the air to avoid physical contact, refusal to shake hands, share pencils, or other supplies
Excessive reassurance seeking (e.g., always asking “Are you sure I’m going to be okay?”)

OCD Obsessions

Common obsessions that fuel these compulsions may include:

Worrying about germs, getting sick, or dying
Extreme fears about bad things happening or doing something wrong
Feeling that things have to be “just right”
Disturbing and unwanted thoughts or images about hurting others*
Disturbing and unwanted thoughts or images of a sexual nature*

* PLEASE NOTE: Students who have sexual and/or violent intrusive thoughts find them to be very upsetting and distressing. The experience of these thoughts does NOT mean these students have any desire or intention to act on them. It can be scary for school personnel to hear about these thoughts, but it is very important to note that these students are not at risk and should not be confused with students who may have a history of or intent to perform antisocial, aggressive, or otherwise violent behavior.

What is Racial Trauma?

While all students are susceptible to anxiety or OCD symptoms in the school setting, students from racial minority groups are also vulnerable to symptoms of racial trauma. Therefore, it's essential to understand the signs and symptoms of racial trauma to differentiate between normal vs. abnormal behavior, particularly when considering anxiety or OCD among students of color.

Racial Trauma in BIPOC Children

Traumatic events that occur due to experiencing racism or discrimination can profoundly impact mental and physical well-being. Racial trauma, or race-based traumatic stress, refers to the mental and emotional impact of one’s experiences of racism and discrimination. Signs of racial trauma appear in students ranging from infancy to adulthood.

When it comes to racial trauma in a school setting, you may notice some of the following signs/symptoms:

Racial trauma may contribute to students reporting increased physical symptoms, like headaches, stomach aches, tension in the chest, or a racing heartbeat.
Students may report increased negative emotions, such as depression or anxiety, within the context of discrimination.
Exposure to chronically stressful race-related conditions may make some students feel detachment or numbness.
Racial trauma may elicit feelings of helplessness, hopelessness, and worry for students about their skin tone and ethnic-racial identity.
Some students may become preoccupied with their safety or the safety of peers/family members.
Students may experience decreased academic motivation or have difficulty concentrating in the classroom.
Incomplete assignments or homework, although the child is capable of doing them.
Some students may seek reassurance or validation from others.

What Now?

If you’re a school personnel and you’ve read all of this, you’re probably asking yourself, “OK, what now?” Here’s the simplest answer to that question: Being informed about anxiety and OCD, and how culture and diversity may affect anxiety and OCD symptomatology, is important for school personnel because it helps better serve the students in your classrooms. This information allows you to be aware of how anxiety and OCD can affect your students. It also allows you to be prepared when your students are experiencing symptoms. This is not asking you to step out of your role, but to simply be in the know regarding anxiety and OCD in the classroom.

The qualifications needed to assign any mental health diagnosis can vary, but below are some examples of what school personnel can advise parents to look for when seeking the right therapist:

Therapists

This is a broad term that covers a variety of mental health professionals. They typically provide traditional outpatient therapy in one-on-one settings in their office.
Psychologists

This mental health professional holds a doctoral degree in clinical or counseling psychology. A psychologist will have PhD (training in both research and therapy), PsyD (training mostly in therapy), or EdD (training in therapy through a school of education).
Psychiatrists

This mental health professional has completed a doctoral degree in medicine (MD) and has specialized in psychiatry and mental illness. They can prescribe medicine and also do therapy.
Psychiatric Nurse

This mental health professional has a degree in nursing (typically a registered nurse, or an RN) with a special emphasis on psychiatry and working with people with mental illness. Nurse practitioners (with a masters-level nursing degree) may also be able to prescribe medication.
Social Workers

This mental health professional has a master’s degree in social work (MSW), and has training in therapy. Once they are independently licensed — meaning they are able to provide therapy without any supervision — they will have an LMSW, LCSW, or LICSW after their name. The exact title of a licensed social worker varies by state, but each means they are qualified to provide you therapy.
Counselors

This mental health professional has a master’s degree in counseling psychology (MA or MS) and has training in therapy. Once they are independently licensed, meaning they are able to provide therapy without any supervision, they will have an LMHC or LPC after their name, depending on their specific degree and focus. They may also have an MFT, or master’s degree in family therapy, and have an LMFT once they are independently licensed. The exact title of a licensed counselor varies by state and by degree, but each mean they are qualified to provide you therapy.

How Can Anxiety and OCD Impact School Performance?

Anxiety and OCD can have a significant impact in the school setting. These conditions can affect a student's classroom behavior, academic performance, and social interactions. Learn more about the potential impact of anxiety/OCD at school.

What are Anxiety and OCD?

Anxiety in Kids

Types of Anxiety Experienced by School-age Children

OCD in Kids

Is it Anxiety/OCD or is it Typical Behavior?

Signs/Symptoms of Anxiety and OCD in School

Anxiety Signs/Symptoms in School

OCD Signs/Symptoms in School

OCD compulsions

OCD Obsessions

What is Racial Trauma?

Racial Trauma in BIPOC Children

What Now?

Therapists

Psychologists

Psychiatrists

Psychiatric Nurse

Social Workers

Counselors

How Can Anxiety and OCD Impact School Performance?