Jeffrey R. Strawn, MD, talks with host Lorenzo Norris, MD, about assisting children and adolescents with anxiety and anxiety disorders, particularly during the COVID-19 pandemic. Dr. Strawn, a previous Psychcast guest, discusses ways for mental health clinicians to think about proportionate anxiety versus anxiety that is severe, continual, and persistent. He is director of the anxiety disorders research program at Cincinnati Children’s Hospital Medical Center and an associate professor of psychiatry at the University of Cincinnati. Dr. Strawn has received research support from several pharmaceutical companies and from the National Institute of Mental Health. He also has received royalties from Springer. Dr. Norris is assistant dean of student affairs, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He has no conflicts of interest. Take-home points Anxiety is a normal emotional reaction critical to survival. Yet, when the emotions become extreme, anxiety can negatively affect day-to-day functioning. With any event that may cause stress, the anxiety should be expected and proportional to the event. Clinicians and parents can support children and adolescents by pointing out different emotional reactions and discussing them to promote self-awareness, as well as maintaining routines while also acknowledging the loss of normalcy. Clinicians should keep in mind several dimensions of the child-parent relationship and how they interact with the ever-changing home and schooling environment. The dimensions to be considered include: Flexibility versus control, which is a spectrum that ranges from rigid to chaotic, and cohesion and support, which ranges from disengaged to enmeshed. Summary If the triggering event is severe, persistent, and uncertain, such as the COVID-19 pandemic, the anxiety may last and become an anxiety disorder, which results in functional impairment. Anxiety (not yet a disorder) may provoke changes in emotions and behaviors, such as irritability, frustration, poor sleep, and so on, that are proportional and expected to the major changes produced by the pandemic. So, parents and clinicians need to monitor for impact on functioning. Clinicians and parents can support children by pointing out different emotional reactions and discussing them to promote self-awareness. Adults should acknowledge that children are going through loss and trauma and be open to discussing how life is different now but not lose sight of the future. Parents will have to balance trying to keep normalcy in place where possible and discussing when life feels far from the norm. In his clinical practice, Dr. Strawn has noticed more reports of irritability and frustration. These emotions need to be evaluated but not necessarily pathologized. Those emotions likely arise from the drastic changes in home environment. Also parents now have more opportunity to observe their children in the learning environment. The pandemic has come with certain benefits, such as more time at home together allowing families time to slow down and engage in different, more fulfilling activities. Yet, the pandemic has created chronic and variable stressors that can negatively affect physical and mental health. This combination of the dark and light has the potential to foster resilience as we reflect on our vulnerabilities and strengths. But we must also think about how to inoculate ourselves against loneliness, and the risks of how social distancing and societal discord may fray our social fabric. References Strawn JR. Current Psychiatry. 2020 May;19(5):9-10. Brooks D. The pandemic of fear and agony. New York Times. 2020 Apr 9. Delgado SV, Strawn JR. Difficult Psychiatric Consultations: An Integrated Approach. New York: Springer, 2013. Strawn JR et al. Depress Anxiety. 2012;29(11):939-47. Strawn JR et al. Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-39. Show notes by Jacqueline Posada, MD, who is associa