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Overview of Anxiety Disorders in Children and Adolescents

By Josephine Elia, MD, Professor of Psychiatry and Human Behavior, Professor of Pediatrics;Attending Physician, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

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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 drugs, usually 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-yr-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 often emerge during childhood and adolescence. At some point during childhood, about 10 to 15% of children experience an anxiety disorder. Children with an anxiety disorder have an increased risk of depressive and anxiety disorders later in life.

Anxiety disorders that can occur in children and adolescents include

Etiology

Evidence suggests that anxiety disorders involve dysfunction in the parts of the limbic system and hippocampus that regulate emotions and response to fear. Heritability studies indicate a role for genetic and environmental factors. No specific genes have been identified; many genetic variants are probably involved.

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 Overview of Anxiety Disorders).

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 couch 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, and headaches 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

  • Clinical evaluation

Diagnosis of an anxiety disorder is clinical. A thorough psychosocial history can usually confirm it.

The physical symptoms that anxiety can cause in children can complicate the evaluation. In many children, considerable testing for physical disorders is done before clinicians consider an anxiety disorder.

Prognosis

Prognosis 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.

Treatment

  • Behavioral therapy (exposure-based cognitive-behavioral therapy)

  • Parent-child and family interventions

  • Drugs, usually SSRIs 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), sometimes in conjunction with drug therapy.

In exposure-based cognitive-behavioral therapy, 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: Drugs for Long-Term Treatment of Anxiety and Related Disorders). Benzodiazepines are better for acute anxiety (eg, due to a medical procedure) but are not preferred for long-term treatment. Benzodiazepines with a short-half life (eg, lorazepam 0.05 mg/kg to a maximum of 2 mg in a single dose) are the best choice.

Drugs for Long-Term Treatment of Anxiety and Related Disorders

Drug

Uses

Starting Dose*

Dose Range

Comments/Precautions

Citalopram

OCD

children ≥ 7 yr

10 mg

10–40 mg/day

Duloxetine

GAD in children 7–17 yr

30 mg

30–100 mg/day

Escitalopram

Major depression in

children ≥ 7 yr

5 mg

5–20 mg/day

Fluoxetine

OCD, GAD, separation anxiety, social anxiety, major depression in children > 8 yr

10 mg

10–60 mg/day

Long-half life

Fluvoxamine

GAD, separation anxiety, social anxiety, OCD in children > 8 yr

25 mg (titrated up as needed)

50–200 mg/day

For doses > 50 mg/day, divided into 2 doses/day,with the larger dose given at bedtime)

Paroxetine

OCD in children > 6 yr

10 mg

10–60 mg/day

Increased weight

Sertraline

OCD, GAD, separation anxiety, social anxiety in children ≥ 6 yr

25 mg

25–200 mg/day

Venlafaxine, immediate-release

Depression in children ≥ 8 yr

12.5 mg

25–75 mg/day bid or tid

Limited data about dose and concerns about increased suicidal behavior; not as effective as other drugs, possibly because low doses have been used

Venlafaxine, extended-release

GAD in children > 7 yr

37.5 mg

37.5–225 mg/day

*Unless otherwise stated, dose is given once/day. Starting dose is increased only if needed. Dose ranges are approximate. Interindividual variability in therapeutic response and adverse effects is considerable. 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 drug dose or changing to a different drug 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 drugs must be closely monitored.

Fluoxetine and paroxetine are potent inhibitors of the liver enzymes that metabolize many other drugs (eg, beta-blockers, clonidine, lidocaine).

GAD = generalized anxiety disorder; OCD = obsessive compulsive disorder.

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 drug dose or changing to a different drug 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 drugs must be closely monitored.

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, drugs may be needed.

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