Anxiety disorders are characterized by fear, worry, or dread that greatly impairs the ability to function normally and that is disproportionate to the circumstances at hand. Anxiety may result in physical symptoms. Diagnosis is clinical. Treatment is with behavioral therapy and medications, usually selective serotonin reuptake inhibitors (SSRIs).
(See also Overview of Anxiety Disorders in adults.)
Some anxiety is a normal aspect of development, as in the following:
Most toddlers become fearful when separated from their mother, especially in unfamiliar surroundings.
Fears of the dark, monsters, bugs, and spiders are common in 3- to 4-year-olds.
Shy children may initially react to new situations with fear or withdrawal.
Fears of injury and death are more common among older children.
Older children and adolescents often become anxious when giving a book report in front of their classmates.
Such difficulties should not be viewed as evidence of a disorder. However, if manifestations of anxiety become so exaggerated that they greatly impair function or cause severe distress and/or avoidance, an anxiety disorder should be considered.
Anxiety disorders emerge in about 3% of 6-year-olds and in about 5% of teenage boys and 10% of teenage girls (1–3). Children with an anxiety disorder have an increased risk of depression (4), suicidal behavior (5, 6) drug and alcohol addiction (7), and academic difficulties (8) later in life.
Anxiety disorders that can occur in children and adolescents include
General references
1. Merikangas KR, He JP, Burstein M, et al: Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Study – Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 49(10): 980-989, 2010.
2. Dalsgaard S, Thorsteinsson E, Trabjerg BB, et al: Incidence rates and cumulative incidences of the full spectrum of diagnosed mental disorders in childhood and adolescence. JAMA Psychiatry, 77(2):155-164, 2020. doi: 10.1001/jamapsychiatry.2019.3523
3. Merikangas KR, He JP, Brody D, et al: Prevalence and treatment of mental disorders among US children in the 2001–2004 NHANES. Pediatrics 125(1):75-81, 2010. doi: 10.1542/peds.2008-2598
4. Cummings CM, Caporino NE, Kendall PC: Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull 140(3):816-845, 2014. doi: 10.1037/a0034733
5. Boden JM, Fergusson DM, Horwood LJ: Anxiety disorders and suicidal behaviours in adolescence and young adulthood: Findings from a longitudinal study. Psychol Med 37(3)431-440, 2007. doi: 10.1017/S0033291706009147
6. Husky MM, Olfson M, He J, et al: Twelve-month suicidal symptoms and use of services among adolescents: Results from the National Comorbidity Survey. Psychiatr Serv63(10):989-996, 2012.
7. Zimmermann P, Wittchen HU, Hofler M, et al: Primary anxiety disorders and the development of subsequent alcohol use disorders: A 4-year community study of adolescents and young adults. Psychol Med 33(7);1211-1222, 2003. doi: 10.1017/s0033291703008158
8. Van Ameringen M, Mancini C, Farvolden P: The impact of anxiety disorders on educational achievement. J Anxiety Disord 17(5):561-571, 2003. doi: 10.1016/s0887-6185(02)00228-1
Etiology
Evidence suggests that anxiety disorders involve dysfunction in the parts of the limbic system and hippocampus that regulate emotions and response to fear. In mice, loss of expression of the serotonin 1A-receptor (5-HT1AR) in the forebrain during early development results in dysregulation of the hippocampus and leads to anxiety behaviors (1). Heritability studies indicate a role for genetic and environmental factors. No specific genes have been identified; many genetic variants are probably involved.
Anxiety symptoms among youth doubled during the COVID-19 pandemic, especially in girls (2), and mental health visits for anxiety increased 43% (3). These study results were controlled for gender, age, and presence of pre-COVID anxiety symptoms and showed that poor connectedness to caregiver, poor sleep hygiene, and high amounts of screen time were reported to be significant predictors of the child's COVID-19 anxiety symptoms (4).
Anxious parents tend to have anxious children; having such parents may make children’s problems worse than they otherwise might be. Even normal children have difficulty remaining calm and composed in the presence of an anxious parent, and children who are genetically predisposed to anxiety have even greater difficulty. In as many as 30% of cases, treating the parents’ anxiety in conjunction with the child’s anxiety is helpful (for anxiety disorders in adults, see Anxiety Disorders ).
Etiology references
1. Adhikari A, Topiwala M, Gordon JA: Synchronized activity between the ventral hippocampus and the medial prefrontal cortex during anxiety. Neuron 65:257-269, 2010. doi: 10.1016/j.neuron.2009.12.002
2. Racine N, McArthur B, Cooke J, et al: Global prevalence of depressive and anxiety symptoms in children and adolescence during COVID-19: A meta-analysis. JAMA Pediatr 175(11):1142-1150, 2021. doi: 10.1001/jamapediatrics.2021.2482
3. Dvir Y, Ryan C, Straus JH: Comparison of use of the Massachusetts Child Psychiatry Access Program and patient characteristics before vs during the COVID-19 pandemic. JAMA Netw Open5(2):e2146618, 2022. doi:10.1001/jamanetworkopen.2021.46618
4. McArthur BA, Racine N, McDonald S, et al: Child and family factors associated with child mental health and well-being during COVID-19. Eur Child Adolesc Psychiatry Jul 24;1-11, 2021. doi: 10.1007/s00787-021-01849-9
Symptoms and Signs
Perhaps the most common manifestation of an anxiety disorder in children and adolescents is school refusal. “School refusal” has largely supplanted the term “school phobia.” Actual fear of school is exceedingly rare. Most children who refuse to go to school probably have separation anxiety, social anxiety disorder, panic disorder, or a combination. Some have a specific phobia. The possibility that the child is being bullied at school must also be considered.
Some children complain directly about their anxiety, describing it in terms of worries—eg, “I am worried that I will never see you again” (separation anxiety) or “I am worried the kids will laugh at me” (social anxiety disorder). However, most children describe their discomfort in terms of somatic complaints: “I cannot go to school because I have a stomachache.” These children are often telling the truth because an upset stomach, nausea, headaches, and sleep problems often develop in children with anxiety. Several long-term follow-up studies confirm that many children with somatic complaints, especially abdominal pain, have an underlying anxiety disorder.
Diagnosis
Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM 5-TR) criteria
Diagnosis of an anxiety disorder is through a clinical assessment (1). A thorough psychosocial history can usually confirm it.
Rating scales can be useful for screening. Several validated scales are freely available (Screen for Child Anxiety-Related Emotional Disorders [SCARED] , Spence Children's Anxiety Scale [SCAS] , Preschool Anxiety Scale [PAS] , and General Anxiety Disorder-7 [GAD-7]).
The physical symptoms that anxiety can cause in children can complicate the evaluation. In many children, thorough testing for physical disorders is done before clinicians consider an anxiety disorder.
Diagnosis reference
1. Walter HJ, Bukstein OG, Abright AR, et al: Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 59(10):1107-1124, 2020. doi: https://doi.org/10.1016/j.jaac.2020.05.005
Treatment
Behavioral therapy (exposure-based cognitive-behavioral therapy)
Parent-child and family interventions
Medications, usually selective serotonin reuptake inhibitors (SSRIs) and to a lesser degree, serotonin-norepinephrine reuptake inhibitors (SNRI) and tricyclic antidepressants for long-term treatment and sometimes benzodiazepines to relieve acute symptoms.
Anxiety disorders in children are treated with behavioral therapy (using principles of exposure and response prevention) (1), sometimes in conjunction with drug therapy (1–4).
In exposure-based cognitive-behavioral therapy (CBT), children are systematically exposed to the anxiety-provoking situation in a graded fashion. By helping children remain in the anxiety-provoking situation (response prevention), therapists enable them to gradually become desensitized and feel less anxiety. Behavioral therapy is most effective when an experienced therapist knowledgeable in child development individualizes these principles.
In mild cases, behavioral therapy alone is usually sufficient, but drug therapy may be needed when cases are more severe or when access to an experienced child behavior therapist is limited. SSRIs are usually the first choice for long-term treatment (see table Medications for Long-Term Treatment of Anxiety and Related Disorders). SSRIs combined with CBT have the highest likelihood of improving symptoms (45). Reports of improvement in developmental disorders such as Williams sydrome (6) and autism (7) have generated ongoing investigations.
Medications for Long-Term Treatment of Anxiety and Related Disorders*
Medication | Uses | Starting Dose† | Dose Range | CYP/Precautions/Comments‡ |
|---|---|---|---|---|
OCD children ≥ 7 years | 10 mg | 10–40 mg/day | 2C19 | |
GAD in children 7–17 years | 30 mg | 30–120 mg/day | 2D6 – SNRIs have noradrenergic activity and can increase risk of hypertension¶ | |
Major depression in children ≥ 12 years | 10 mg | 10–20 mg/day | 2C19 | |
OCD, GAD, separation anxiety, social anxiety, major depression in children > 8 years | 10 mg | 10–60 mg/day | 2D6 – Long-half life | |
GAD, separation anxiety, social anxiety, OCD in children > 8 years | 25 mg (titrated up as needed) | 50–200 mg/day | 2D6 – For doses > 50 mg/day, divided into 2 doses a day, with the larger dose given at bedtime | |
OCD in children > 6 years | 10 mg | 10–60 mg/day | 2D6 – Increased weight | |
OCD, GAD, separation anxiety, social anxiety in children ≥ 6 years | 25 mg | 25–200 mg/day | 2C19 | |
Depression in children ≥ 8 years | 12.5 mg | 12.5 mg twice a day to 25 mg 3 times a day | 2D6 SNRIs – Limited data about dose and concerns about increased suicidal behavior; not as effective as other drugs, possibly because low doses have been used | |
GAD in children > 7 years | 37.5 mg | 37.5–225 mg once a day | ||
* The medications listed are used clinically for all the anxiety disorders, OCD, and depression. FDA approval has been obtained for some conditions; the lack of FDA approval for other conditions is due to a lack of sufficient studies. There is no evidence that one SSRI is better than or not as effective as the others (Varigonda AL, Jakubovski E, Taylor MJ, et al: Systematic review and meta-analysis: Early treatment responses of selective serotonin reuptake inhibitors in pediatric major depressive disorder. J Child Adolescent Psychopharmacol 54(7):557-564, 2015. doi: https://doi.org/10.1016/j.jaac.2015.05.004). | ||||
† Unless otherwise stated, dose is given once a day. Starting dose is increased only if needed. Dose ranges are approximate. Interindividual variability in therapeutic response and adverse effects is considerable. When stopping a medication, taper gradually by 25% weekly. This table is not a substitute for the full prescribing information. Behavioral adverse effects (eg, disinhibition, agitation) are common but are usually mild to moderate. Usually, decreasing the dose or changing to a different medication eliminates or reduces these effects. Rarely, such effects are severe (eg, aggressiveness, increased suicidality). Behavioral adverse effects are idiosyncratic and may occur with any antidepressant and at any time during treatment. As a result, children and adolescents taking such medications must be closely monitored. | ||||
‡ Genetic testing for enzymes that metabolize the SSRIs have shown interindividual differences in pharmacokinetic parameters and treatment outcomes associated with CYP2D6 and CYP2C19 polymorphisms. The CPIC (Clinical Pharmacogenetics Implementation Consortium) guidelines indicate poor response for CYP2C19 and D26 rapid metabolizers and risk for adverse effects for poor metabolizers, recommending starting at 50% of the recommended dose. Ethnic variations show that 7 to 15% of White, 2% of Asian, and 2% of African Americans lack the gene for 2D6 while 10% of White people and 50% of Asians have genetic variants that reduce 2D6 function (Droll K, Bruce-Mensah K, Otton SV: Comparison of three CYP2D6 probe substrates and genotype in Ghanaians, Chinese and Caucasians. Pharmacogenetics 8(4)325-333, 1998. doi: 10.1097/00008571-199808000-00006). As newly discovered genetic variants and copy number variants get incorporated into the CYP2D6 biomarker panels, predictions of metabolizer status will become more accurate. (For the former, see Ray B, Ozcagli E, Sadee W, et al: CYP2D6 haplotypes with enhancer SNP rs5758550 and rs16947 (*2 allele): Implications for CYP2D6 genotyping panels. Pharmacogenet Genomics 29(2):39-47, 2019.) doi: 10.1097/FPC.0000000000000363; for the latter, see Beoris M, Wilson JA, Garces JA, et al: CYP2D6 copy number distribution in the US population. Pharmacogenet Genomics 26(2):96-99, 2016. doi: 10.1097/FPC.0000000000000188. Clinicians who order these tests need to help families interpret the results. | ||||
¶ Strawn JR, Prakash A, Zhang Q, et alJ Am Acad Child Adolesc Psychiatry 54(4):283-293, 2015. doi: 10.1016/j.jaac.2015.01.008. | ||||
Most children tolerate SSRIs without difficulty. Occasionally, upset stomach, diarrhea, insomnia, or weight gain may occur. Some children have behavioral adverse effects (eg, agitation, disinhibition); these effects are usually mild to moderate. Usually, decreasing the medication dose or changing to a different medication eliminates or reduces these effects. Rarely, behavioral adverse effects (eg, aggressiveness, increased suicidality) are severe. Behavioral adverse effects are idiosyncratic and may occur with any antidepressant and at any time during treatment. As a result, children and adolescents taking such medications must be closely monitored.
Treatment references
1. Brent DA, Porta G, Rozenman M, et al: Brief behavioral therapy for pediatric anxiety and depression in primary care: A follow-up. J Am Acad Child Adolesc Psychiatry 59(7):856-867, 2019. doi: 10.1016/j.jaac.2019.06.009
2. Strawn JR, Welge JA, Wehry AM, et al: Efficacy and tolerability of antidepressants in pediatric anxiety disorders: A systematic review and meta-analysis. Depress Anxiety 32(3):149-157, 2015.
3. Ipser JC, Stein DJ, Hawkridge S, et al: Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev (3):CD005170, 2009. doi: 10.1002/14651858.CD005170.pub2
4. Walkup JT, Albano AM, Piacentini J, et alN Engl J Med 359:2753-2766, 2008. doi: 10.1056/NEJMoa0804633
5. Strawn JR, Mills JA, Cornwall GJ, et alJ Child Adolesc Psychopharmacol 28(1): 2-9, 2018. doi: 10.1089/cap.2017.0060
6. Thom RP, Keary CJ, Waxler JL, et alJ Autism Dev Disord 50(2):676-682, 2020. doi: 10.1007/s10803-019-04301-9
7. Ceranoglu TA, Wozniak J, Fried R, et al J Child Adolescent Psychopharmacol, 29(1):28-33, 2018. doi: 10.1089/cap.2018.0021
Prognosis for Anxiety Disorders in Children and Adolescents
Prognosis for anxiety disorders in children depends on severity, availability of competent treatment, and the child’s resiliency. Many children struggle with anxiety symptoms into adulthood. However, with early treatment, many children learn how to control their anxiety.
Key Points
The most common manifestation of an anxiety disorder may be school refusal; most children couch their discomfort in terms of somatic complaints.
Consider anxiety as a disorder in children only when anxiety becomes so exaggerated that it greatly impairs functioning or causes severe distress and/or avoidance.
The physical symptoms that anxiety can cause in children can complicate the evaluation.
Behavioral therapy (using principles of exposure and response prevention) is most effective when done by an experienced therapist who is knowledgeable about child development and who tailors these principles to the child.
When cases are more severe or when access to an experienced child behavior therapist is limited, medications may be needed.
Commercially available panels testing for CYP variants remain limited.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
CPIC—Clinical Pharmacogenetics Implementation Consortium: This international consortium facilitates use of pharmacogenetic tests for patient care. The site provides access to guidelines to help clinicians understand how genetic test results should be used to enhance drug therapy.
American Academy of Child and Adolescent Psychiatry Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders: These guidelines summarize expert-based guidance about the psychosocial and psychopharmacologic treatment of anxiety and aim to enhance quality of care and clinical outcomes for children and adolescents.
