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Key points
- Severe and frequent emotional outbursts have many possible causes, including anxiety disorders.
- Kids often don’t express their fears to adults for many reasons, including not even realizing that they are unusual.
- Validating children's fears is the first step to learning more about them.
My patient Harriet was 8 years old when we first met. Her parents were at their wits’ end because of her temper tantrums. The meltdowns seemed to happen all the time, without warning, but a common trigger was leaving the house—including for school. Harriet raged, threw things, called her parents terrible names, and sometimes pushed or kicked them if they tried to approach her. Ultimately, I diagnosed her with an anxiety disorder. Cognitive-behavioral therapy helped substantially, but she also eventually needed medication (an SSRI), and her symptoms got a lot better.
This angry, tantrum-driven presentation of anxiety can seem puzzling—especially to parents and teachers who usually think of outbursts as a "behavior" that kids use to get their way. But severe, persistent outbursts that don’t respond to typical strategies are symptoms that something is wrong. As a child psychiatrist, I consider a wide range of possible causes for persistent or severe meltdowns, and anxiety ranks high on my list.
Anxiety Keeps Us Alive
Anxiety serves important functions in our lives. When the brain detects a possible threat, it generates a full-body response to manage the threat—to keep us alive. Other parts of our brain typically help us take in and process other information to clarify the threat level and modify our responses. But, without more data, the "back of the brain," which manages survival processes, perceives a threat and mounts a "life-or-death" response.
Our brain and body respond to stressors in three fundamental ways—fight, flight, and freeze. Central to all of these responses is that blood is shunted away from the front of our brains, where complex thinking, relating, problem-solving, and other similar tasks occur. Those tasks are designated as not important when life or death is the stakes. Blood shifts to our lungs, our large muscles, and the parts of our brain that wake us up—keeping us alert and focused solely on evading the threat. Flight response is running from the threat. Freeze response is staying as still as possible to avoid detection. And fight response is just what it sounds like—getting ready to fight to take down the threat.
Anxiety Disorders Disturb Threat Detection and Response Systems
Children with anxiety disorders have hyper-attuned threat-detection monitors. Their brains and bodies are on high alert all the time, vigilant for danger—so much so that they may see danger in situations that aren’t objectively threatening. But their perception of the threat is what turns on their anxiety. So, if a child with anxiety is in a situation that their brain interprets as high risk, their brain and body go into fight, flight, or freeze mode.
The fight mode can trigger extraordinary meltdowns. Episodes range in severity, but the most extreme ones can look like your child has become something or someone else entirely. Even very young kids may curse like a sailor, tell their parents they hate them, threaten to do harm to their parents, destroy an entire room, kick and punch, and scream and yell at the top of their lungs. If it happens at school, it can cause a whole classroom to be cleared out.
The anxious child’s brain and body can respond to perceived threats with life and death energy. And kids don’t yet have well-established vocabularies for describing these feelings—or the fear itself keeps them from saying the worries out loud. If a demand is made that triggers or escalates their perception of threat, their little human selves go into full-on fight mode—because it (mistakenly) perceives the need to fight to stay alive.
These extreme meltdowns can come from anxiety because the brain has switched on life/death protocols. The child’s frontal lobes are in "low-power" mode, to reserve fuel for threat-survival actions. Understanding this changes everything about how we approach an anxious child who has extreme meltdowns. Detecting and treating the anxiety disorder is essential to helping the child get back to living their regular kid life.
Meltdowns Are a "Fight" Response
For Harriet, it gradually became clear that she had many worries about her family and her home. Harriet thought her mom might get sick or die when she was at school, or that robbers would come or that a fire would start. She had it in her head that staying home to keep an eye on things would help everyone stay safe. She had many of these fears at night, and she often had tantrums before going to bed. She was afraid that bad things could happen when she was asleep, too. So, not only was she anxious, but she was also exhausted,
She hadn’t talked about these thoughts with anyone, in part because she wasn’t really aware that they weren’t something that everyone thought about. She was also afraid that if she told someone, they would try to convince her that it was safe and would make her leave the house more. She felt bad that she was always causing so many problems at home and that her parents were so upset, but she didn’t know how to change things.
Harriet’s parents were deeply frustrated until they learned it was anxiety; they tried every parenting and behavioral program in the books and on the Internet—behavior charts, stickers, rewards, punishments, and countdowns. Family members and other parents suggested that Harriet was manipulating them and that they should just pick her up, kicking and screaming, and put her in the car—which they tried, and, which, predictably, escalated her distress and worsened her meltdowns.
Most days, Harriet would eventually get to school late once she was worn out and unable to fight anymore, but there were days she couldn’t get to school at all. Teachers and school were frustrated with Harriet and with her parents—wondering why they couldn’t control an 8-year-old child. In school, Harriet was distractible, irritable, and withdrawn. Multiple emails were exchanged and many meetings happened. The assumption was that her tantrums were under her control and were a “behavior” problem and that more behavior management was the solution. But the solutions were for the wrong problem.
How Do We Know It’s Anxiety?
So how do we know if a child’s tantrums or meltdowns are anxiety-driven? If you have concerns about patterns of explosive outbursts that seem unusual or are wearing everyone down, please speak to your pediatrician about it. It’s important to have a child medically evaluated to rule out medical causes of irritability and meltdowns. The pediatrician can also refer you to psychiatric evaluation.
At the same time, you can also begin to gather some intel on your child's level of anxiety. Listening to your child's chatter and watching your child's play and behaviors are the best places to start. Try not to ask too many direct questions—that tends to shut kids down—unless they have come to you with a worry. If they express a fear, most importantly, validate it. Let them know their fear is real—don't dismiss it as silly or not a real fear. Their feelings are quite real—and you will learn more about them if you are curious and don't dismiss them.
If you find out that your child does seem to have more worries than you were initially aware of, these worries may be contributing to their meltdowns. It can help you begin to shift your approach to their episodes of distress.
Preventing and Handling Anxiety Meltdowns Takes a Gentle Touch
How do we handle meltdowns that are anxiety-driven? The basics of managing kids with anxious outbursts are often different from typical recommendations. Remember that we are dealing with the “back of the brain” that is perceiving life/death stakes. So our response will be most effective when we keep that in mind. The approach includes the following:
- Try to detect the child’s escalating distress as early as possible.
- Once you note escalation, stop discussing the original demand.
- Check your own emotional tone—try to stay as even as possible.
- Use as few words as possible.
- Avoid commands such as “You have to calm down now.”
- Give the child some time and space to recover.
- Stay close by and connect with them if they choose.
- Model and encourage calming skills such as counting breaths or getting a snack or drink.
But Dr. Fink, you say, this all takes so long; we can’t do this every time. And it’s true that it does take some time—it shuts down the task-completion process. But meltdowns also shut down the task-completion process, and everyone gets emotionally wrung out in the process. Our typical responses escalate the perceived danger for a child who is anxious. We need to take the perceived threat level down before we can engage in problem-solving with the child.
Once the child is calm again, we can re-approach the task with an idea for addressing their fear, if they can express it, or moving more slowly and/or quietly to get through the transition. Angry kids often turn out to have substantial anxiety running just below the surface. Keeping an open mind about this and not getting into tunnel vision about angry kids is essential to relieving the child’s suffering.
