Is My Child Anxious or Is This Normal Stress?

Your teenager has been “fine” for weeks, and then one night she is sitting on her bed crying about a test that is three days away. Or your son has started skipping lunch because the cafeteria feels overwhelming, but he cannot explain why. Or you have noticed the stomachaches that show up every Sunday night, always gone by Tuesday, always back the following week.

You are not sure whether you are watching normal teenage stress or something that needs help. And you are not alone in asking. Anxiety disorders are the single most common mental health condition in American adolescents, affecting roughly one in three teens over their lifetime, with about 8 percent experiencing severe impairment.¹ That means in any given classroom, several kids are quietly struggling, and their parents are having the same conversation you are having with yourself right now.

Here is what the evidence actually says about the line between normal stress and clinical anxiety, what to look for in your own teenager, and when it is time to talk to someone.

01. Stress is normal. Constant dread is not.

Every teenager worries. Tests, social dynamics, college pressure, family conflict: adolescence is inherently stressful. A certain amount of worry is not only normal, it is adaptive. It is what gets your teenager to study for the exam instead of ignoring it.

What separates normal stress from an anxiety disorder is duration, intensity, and impairment. The DSM-5 criteria for generalized anxiety disorder require excessive worry occurring more days than not for at least six months, accompanied by physical symptoms and clinically significant distress or functional impairment.³ For children and teens, only one associated physical symptom is required, compared to three for adults, which reflects the reality that anxiety in young people often looks different than anxiety in adults.³

02. Anxiety in teenagers often looks like a body problem

One of the reasons parents miss anxiety is that it frequently presents as physical symptoms rather than expressed worry. In a study of 488 anxious youth from the Child/Adolescent Anxiety Multimodal Study (CAMS), more than half reported at least one somatic complaint, most commonly headaches, stomachaches, sleep difficulty, and fatigue.⁴

Your teenager may not say “I feel anxious.” They may say “my stomach hurts” or “I could not sleep” or simply “I do not feel good.” The Sunday night stomachache that vanishes by Tuesday is a classic pattern. So is the teenager who is suddenly exhausted all the time, or who has started getting headaches before social events they used to enjoy.

If your teen is seeing the pediatrician frequently for physical symptoms that do not have a clear medical explanation, anxiety is one of the things worth screening for.²

03. Watch what they start avoiding

Anxiety does not just feel bad. It changes behavior. A systematic review found that adolescents with anxiety disorders show significantly lower social competence, more difficulty in relationships, and higher rates of school refusal compared to healthy peers.⁵

In your own home, this might look like a teenager who used to love soccer but now finds reasons to miss practice. A student who is suddenly “sick” on presentation days. A kid who has stopped texting friends back or who gets irritable and withdrawn before family events.

The key word is avoidance. Normal stress might make your teenager complain about the party, but they still go. Anxiety starts making them not go, and the world gets smaller over time.

04. One in three is not a small number

If you are reading this and thinking “this sounds like my kid,” you are not overreacting. The National Comorbidity Survey found that 31.9 percent of adolescents aged 13 to 18 met criteria for an anxiety disorder at some point, with a median age of onset of just 6 years old.¹ And in 2022, the U.S. Preventive Services Task Force issued its first ever recommendation for universal anxiety screening in children and adolescents aged 8 to 18, a Grade B recommendation that the American Academy of Pediatrics has since incorporated into its preventive care schedule.²

That screening recommendation exists because anxiety in teenagers is both very common and very treatable, but also very commonly missed. Your pediatrician should be screening for it. If they have not brought it up, you can.

05. What actually works

The treatment evidence for pediatric anxiety is strong, and it is reassuring.

Cognitive behavioral therapy (CBT) has the deepest evidence base of any treatment for pediatric anxiety. The landmark RCTs by Kendall in the 1990s first showed that roughly two thirds of children no longer met criteria for their anxiety disorder after CBT, and follow up studies found those gains held six years later.¹³ In more recent studies, kids who received CBT were roughly three times more likely to recover than those who received supportive therapy alone.¹⁴ In controlled trials, about half of children with anxiety no longer met criteria for their diagnosis after CBT.⁶

When anxiety is moderate to severe, the evidence supports combining CBT with an SSRI. The CAMS trial, the largest randomized study of pediatric anxiety treatment, found that combination therapy produced an 80.7 percent response rate, significantly better than CBT alone (59.7 percent) or medication alone (54.9 percent).⁷ Based on a federal systematic review of this evidence, the American Academy of Child and Adolescent Psychiatry recommends both CBT and SSRIs as first line treatments, with combination therapy for moderate to severe cases.⁸¹⁵

In my own practice, I always emphasize therapy as the foundation. When we do add medication, the goal is not to put your teenager on a pill indefinitely. The goal is to help them reach a place where therapy can do its work more effectively, where they can actually engage with the skills instead of being overwhelmed by the anxiety itself. Over time, as your teen builds those coping skills through therapy, we evaluate whether medication is still needed, and in many cases, we work toward tapering off. The combination is powerful precisely because one treatment supports the other, and the long term plan is for the skills to carry the weight.

One practical note: treatment helps, but anxiety in young people often follows a relapsing course. A long term follow up of the CAMS trial found that roughly 48 percent of participants experienced a relapsing course over the following years.¹² That is not a reason to skip treatment. It is a reason to stay connected with your care team and to think of anxiety management as an ongoing skill, not a one time fix.

06. Something you can do tonight

While professional treatment is important for clinical anxiety, research on family accommodation offers something parents can start thinking about right now. Family accommodation is when parents change their own behavior to help a child avoid anxiety triggers: answering reassurance questions over and over, letting them skip school on hard days, speaking for them in social situations.

It is completely natural, and most parents do it out of love. But research shows that accommodation maintains and worsens anxiety over time. A randomized trial of the SPACE program (Supportive Parenting for Anxious Childhood Emotions) found that working with parents alone, without any direct child therapy, was as effective as individual CBT for reducing childhood anxiety.⁹ The mechanism is straightforward. When parents gradually stop accommodating avoidance, the child gets the opportunity to learn that they can tolerate distress, which is exactly what anxiety keeps telling them they cannot do.

This does not mean being cold or dismissive. It means warm, steady, gradual reduction of the workarounds that keep anxiety in charge.

07. When to talk to someone

You do not need to wait for a crisis. If any of the following is true, it is reasonable to bring it up with your teenager’s pediatrician.

• Worry or physical symptoms have been present most days for several weeks and are not tied to a single, temporary stressor.
• Your teenager has started avoiding activities, social situations, or school because of anxiety.
• Sleep, appetite, grades, or friendships have noticeably changed.
• You are regularly accommodating their anxiety (answering the same reassurance questions, allowing them to skip events, doing things for them that they used to do independently).
• You are also noticing signs of depression: persistent sadness, irritability, loss of interest, or withdrawal. Anxiety and depression co-occur in 15 to 62 percent of affected youth, and the combination carries higher risk for suicidality and worse overall outcomes.¹⁰

Here is what makes this worth doing sooner rather than later. The research consistently shows that anxiety disorders in young people tend to persist without treatment, and that early intervention improves outcomes.¹¹ A longitudinal study following children into their mid-twenties found that all childhood anxiety disorders predicted adverse outcomes in health, social functioning, and employment.¹¹ Treating anxiety early does not just help your teenager now. It changes the trajectory.

What you are doing right now, paying attention, asking the question, taking it seriously, is the right first step. Most teenagers with anxiety do well with the right support. The hard part is recognizing that the stomachaches and the avoidance and the “I am fine” might be anxiety talking, not your kid.

Griff Motes, MD is a board-certified pediatrician and the founder of Resonate Pediatrics.