Mental illness is twice as common in children as asthma, notes child and adolescent psychiatrist Dr. Susan Swick. And yet many parents find it harder to grasp the best ways to address, prevent, and access treatment for mental illness in children.

Prior to the COVID-19 pandemic, one in six children in the United States had a diagnosed mental illness, according to the U.S. Centers for Disease Control, a number that rose sharply over the past decade, exacerbated as the pandemic wore on.

“There are emergency flares going up on the mental wellbeing of our children, teenagers and young adults,” said Swick, who works with children, teens and their families as director of Ohana Center for Child and Adolescent Behavioral Health in Monterey County, Calif. “Parents and teachers and other caring adults in the orbits of children are asking for support on this, and we need to listen.”

While much attention has been paid to the decline in mental health among teens, elementary-age children are also struggling.

The average age of onset for an anxiety disorder – the most common type of mental illness that crops up in childhood – is 7, said Swick.

Catching early signs of a mental health issue in childhood can prevent it from spiraling into a crisis during adolescence or young adulthood

“In my heart of hearts, I am very hopeful that although the current situation is concerning, I think good news is hidden in there: If we see rates of mental illness can go up, that means a lot of those are preventable and can come down,” said Swick.

“With early identification and evidence-based treatment (for mental illness), around 75% of kids will go into remission and not need treatment again.”

Reckon spoke with Swick about how parents should think about mental health in elementary-age children, warning signs to look for, how to seek treatment, and how parents can improve their children’s mental fitness before they enter adolescence.

The interview has been condensed and edited for space and clarity.

Q: What’s behind the increase in mental illnesses in children?

In the 10-24 age range, rates of diagnosable anxiety and depression have gone up nearly 50% since about 2011. We’ve been noticing a lot more distress since COVID.

But really some of these problems started a decade before the pandemic. The jury is out on why, but there’s substantial evidence to say one big factor is the emergence of social media. It looks like there may be some vulnerable developmental windows in ages 10-12 and 14-16, particularly in girls, where social media seems to have such a potent addictive potential that it ends up supplanting the real-life work that kids should be doing to build their full adult selves: exploring the world, cultivating complex relationships, identifying and managing strong or uncomfortable feelings. If they’re down the rabbit hole of looking for likes and followers, they miss out on some of that.

I don’t want to say that it’s all social media because there have been a number of other forces at work: growing economic disparities, violence in schools, undeniable environmental changes. It all can contribute to the feeling in young people of foreclosing possibilities. Covid just poured lighter fluid on that. The pandemic diminished settings where kids would normally explore the world and build relationships and have other caring adults around them outside the home – that was all eradicated for a year and a half or more. And parents were stressed, under the strain of trying to navigate jobs or job loss while schooling their kids.

All of those forces contributed to a moment where the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, they’re all sounding alarms about youth mental health being an emergency.

Q: Before we dive into this issue, what do we need to know about how elementary-age kids are experiencing the world?

The years of ages 6-12 are wonderful and rich developmental years for kids but I sometimes refer to that time as an age of anxiety. Children in those years are cognitively and physically developing very quickly. They’re looking for opportunities to learn new things and master them, whether it’s the rules of social engagement at recess or how to play soccer or how to do math. They come to something they don’t know how to do, and they do it again and again until they start to master it.

There’s a lot of failure there. Kids are built to withstand failure but they benefit from having a big cheering section of parents, teachers, coaches. They benefit from parents who can show up, watch, and bear it with them when the outcome isn’t a success – not parents who swoop in and solve the problem. They need parents who can comfort them, help them lean into something challenging and even a little scary, while helping them know in their bones that they can do it.

With each effort like that, kids are building emotional regulation skills. They’re learning to tolerate failure, to stay curious even when things are uncertain or uncomfortable – those are enormously powerful skills.

Things that are unfair also really bother this age group. Parents need to know that when kids are coming to them in distress about something unfair, that’s really normal. The parents’ job is not necessarily to fix it for them, but to listen, bear it with them and help them think aloud about what they could to do make it right.

I would love for parents to know the stress, worry, anxiety and even sadness about unfairness is not just normal in this age group – it’s actually critical to mental health development.

Our kids are building their capacity to face challenges, to manage new emotions, new cognitive skills and social challenges. With that comes discomfort, distress and difficulty as they’re building those skills.

Q: You’ve said the elementary school years are a peak age for anxiety disorders to emerge. Why is that, and what warning signs should parents look for?

The thing that’s challenging about anxiety disorders is that they are very internal experiences. A lot of kids who have what we’d call an anxious temperament tend to be superstars at school, very detail-oriented, very responsible, scrupulous, sensitive to the emotional needs of others, perceptive. But when the volume of worry is higher than anyone notices, they sometimes won’t talk about it, or they may not notice it because they don’t know what other people’s level of worry is. Or they may not want to bother their parents or teachers or friends, or might not want people to notice this about them, which keeps them from asking for help.

So sometimes we don’t notice our kids are struggling with that worry until they get to the point where they’ll go no further. They seem like high performers and then all of the sudden, they have an explosive meltdown where they say, ‘I can’t go to school’ or ‘I won’t get out of the car.’

Or some kids will say, ‘I have a headache’ or ‘I have a stomachache, so I don’t think I can go to school, or to that party, or to practice.’ Often, that’s a stress response.

What parents should watch for are any blunt refusals to engage in areas like school, social relationships or new hobbies. If they suddenly drop that, that should be a red flag for parents.

Q: If parents notice one of these red flags, what can they do to help?

Parents need to validate to their kids that it feels crummy to be worried about things that matter a lot to you. That acknowledgment is incredibly powerful for kids. Parents need to help their kids notice what feelings they’re having, and how to find words to describe those. This models for kids what to do in response to distress, that you don’t have to jump in and get the fire extinguisher; you can slow down and pay attention. When parents don’t try to swoop in and solve the problem, that shows the child they are confident that the child is going to be able to manage this, even if that doesn’t happen today and even if it’s not going to be easy. Maybe it means making a plan together for how to deal with the situation. That can be enough for a child to face a challenge and to try again.

You want to give the child the right amount of support so they don’t avoid the problem, because avoidance creates its own cascade of problems. It makes them feel discouraged about themselves, less confident, less likely to try any type of challenge, and their anxiety goes up when they try things that are hard. Whereas, if they try and it doesn’t go well, they can still feel good about themselves for having tried. Having parents who applaud that effort will help a child to keep trying again so they don’t fall back into avoidance.

Kids also need to learn it’s also OK to take a break or do something different when you have a setback; you don’t have to keep at a problem relentlessly.

Q: If parents feel like their child needs more help than they’re able to give, where should they start?

I suggest parents start with their pediatrician. Pediatricians are wonderful experts on development, but they are also often trusted adults, if you and your child have known them for a while. Pediatricians can use screening tools to figure out if the issue is something that’s going to need treatment, and they can partner with parents to map out a plan.

Ideally the child would be evaluated within two weeks by (a physician) who can make recommendations about treatment and either deliver it or point toward someone skilled in the needed area. And ideally, parents would get ongoing support in how to help their child while the child is building the skills they need.

Parents may feel a sense of shame (if their child is struggling with mental health). But I tell parents they are the experts on their own children. When something is not going well, they should ask for help because that’s what they would do if their child fell and broke a bone. They wouldn’t say, ‘I have to figure out how to mend this bone.’ Parents need to feel similarly empowered in their right to ask for clinical support and guidance in mental health.

The bad news is the healthcare system is fragmented and under resourced. There are barriers to accessing all parts of our health system depending on where you live and what resources you have, and there are enormous barriers to accessing effective and evidence-based treatment for mental health illnesses in children and teens.

With telehealth, diagnostic assessments and treatments like psychotherapy can be more accessible, though it helps to meet with a therapist in person initially because it creates more trust and a more nuanced understanding of the parent and child.

If you seek help and it feels like things aren’t getting better, keep pushing. Push your pediatrician, seek out a child psychiatrist at a local university or a nearby federally qualified health center. Access information on trustworthy websites like the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and Psychology Today.

Finally, you can go to your local emergency room if you’re worried about your child’s safety or if your child has attempted to seriously hurt themselves.

Q: What do you think parents get wrong in their understanding about mental health issues in children?

The big one for me is that a lot of parents feel as if mental health is passive, just a landscape we have, and that a few unlucky people develop an illness.

Mental health is not something that’s your passive inheritance; it’s something we build. I like to talk instead about ‘mental fitness’ because ‘mental health’ doesn’t quite illustrate the idea that we have control. In the same way that how physically fit we are is a function of what we do – our activity level, how well we sleep, how well we eat – it’s the same with mental fitness. We have to invest in it.

For children, the building blocks of mental fitness include getting comfortable with being uncomfortable, becoming experts in managing the give and take of their thoughts and feelings, and understanding that failure is part of developing their knowledge and skills. This creates resilience, deep knowledge of themselves, successful relationships and meaningful work.

It’s not that parents need to be driving their kids to mental fitness classes like they drive them to swim team practice. It just means that any time their child experiences discomfort or distress is a wonderful opportunity for the parent to sit next to their child, to be curious about what’s going on, see if you can help them describe the problem and figure out what to do next without rushing to solve the problem for them.

This is not a project where you master it in one day and get it right. Just like with physical fitness, it takes some doing every day.