Anxiety disorders are characterized by fear, worry, or dread that greatly impairs the ability to function and is out of proportion to the circumstances.
All children feel some anxiety sometimes. For example, 3- and 4-year-olds are often afraid of the dark or monsters. Older children and adolescents often become anxious when giving a book report in front of their classmates. Such fears and anxieties are not signs of a disorder. However, if children become so anxious that they cannot function or become greatly distressed, they may have an anxiety disorder. At some point during childhood, about 10 to 15% of children experience an anxiety disorder.
People can inherit a tendency to be anxious. Anxious parents tend to have anxious children.
Anxiety disorders include acute stress, generalized anxiety, obsessive-compulsive, panic, posttraumatic stress, and separation anxiety disorders, social phobia, and agoraphobia. Acute stress disorder is similar to posttraumatic stress disorder except that symptoms occur less than 1 month after the traumatic event. Agoraphobia—the fear of being trapped in places with no way to escape easily—often accompanies or results from panic disorder (see Anxiety Disorders: Panic Attacks and Panic Disorder).
Many children with an anxiety disorder refuse to go to school. They may have separation anxiety, social phobia, panic disorder, or a combination.
Some children talk specifically about their anxiety. For example, they may say “I am worried that I will never see you again” (separation anxiety) or “I am worried the kids will laugh at me” (social phobia). However, most children complain of physical symptoms, such as a stomachache. These children are often telling the truth because anxiety often causes an upset stomach, nausea, and headaches in children.
Many children who have an anxiety disorder struggle with anxiety into adulthood. However, with early treatment, many children learn how to control their anxiety.
Doctors usually diagnose the disorder when the child or parents describe typical symptoms. However, doctors may be misled by the physical symptoms that anxiety can cause and do tests for physical disorders before an anxiety disorder is considered.
If anxiety is mild, behavioral therapy alone is usually all that is needed. Therapists expose children to the situation that triggers anxiety and help the children remain in the situation. Thus, children gradually become desensitized and feel less anxiety. When appropriate, treating anxiety in parents at the same time often helps.
If anxiety is severe, drugs may be used. A type of antidepressant called a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine, is usually the first choice (see Table on Mood Disorders: Drug Therapy).
Generalized Anxiety Disorder
Generalized anxiety disorder involves excessive, persistent nervousness, worry, and dread about many activities or events.
Children's worries are general and encompass many things and activities. Stress worsens the anxiety. These children often have difficulty paying attention and may be hyperactive and restless. They may also sleep poorly, sweat excessively, feel exhausted, and complain of physical symptoms, such as stomachache, muscle aches, and headache.
The diagnosis is based on symptoms: excessive worries that do not focus on a particular activity or situation or that include many activities and situations. The disorder is diagnosed when symptoms last more than 6 months.
If anxiety is mild, relaxation training or other types of counseling may be all that is needed.
If anxiety is severe or counseling is not effective, drugs that can reduce anxiety, usually selective serotonin reuptake inhibitors or sometimes buspirone, may be needed.
Obsessive-compulsive disorder is characterized by recurring, unwanted, intrusive ideas, images, or impulses (obsessions) and unrelenting urges to act on the impulses (compulsions). The obsessions and compulsions cause great distress and interfere with school and relationships.
What causes obsessive-compulsive disorder (OCD) is unclear. However, streptococcal infections may be involved in a few cases. In these cases, the disorder is called pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS).
Typically, symptoms develop gradually, and most children can hide their symptoms at first.
Children are often obsessed with worries or fears of being harmed—for example, of contracting a deadly disease or of injuring themselves or others. They feel compelled to do something to balance or neutralize their worries and fears. For example, they may repeatedly do the following:
Some obsessions and compulsions have a logical connection. For example, children may wash their hands to avoid disease. However, some are totally unrelated. For example, children may count to 50 over and over to prevent a grandparent from having a heart attack. If they resist the compulsions or are prevented from carrying them out, they become extremely anxious and concerned.
Most children have some idea that their obsessions and compulsions are abnormal and are often embarrassed by them and try to hide them. In most children, the disorder tends to be chronic.
Diagnosis and Treatment
Diagnosis is based on symptoms.
Behavioral therapy, if available, may be all that is needed if children are highly motivated. If needed, a combination of behavioral therapy and an SSRI is usually effective, enabling most children to function normally. Treatment usually needs to be continued indefinitely. A few children do not respond to treatment and remain greatly impaired.
If streptococcal infection is involved, antibiotics are used.
Panic disorder is characterized by panic attacks that occur at least once a week. A panic attack is a brief (5- to 20-minute) episode of intense anxiety that is usually accompanied by physical symptoms, such as a rapid heart beat, sweating, chest pain, and nausea.
Panic disorder is much more common among adolescents than among younger children. Sometimes children have separation anxiety or generalized anxiety when they are younger and then develop panic disorder as they go through puberty.
Panic attacks (see Anxiety Disorders: Panic Attacks and Panic Disorder) can occur in any anxiety disorder, usually in response to the focus of that disorder. For example, children with separation anxiety may have a panic attack when a parent leaves. Children who fear being trapped in places with no way to escape easily (agoraphobia) may have a panic attack when they are seated in the middle of a row in a crowded auditorium. Many children who have panic disorder also have agoraphobia. Physical disorders, such as asthma, can also trigger panic attacks.
During an attack, children feel great anxiety, which causes physical symptoms. The heart beats rapidly. Children may sweat profusely and feel short of breath. They may have chest pain or feel dizzy, nauseated, or numb. Children may feel like they are dying or going crazy. Things may seem unreal to them. Children worry about having other attacks. Panic attacks and the associated worries interfere with relationships and schoolwork.
In panic disorder, panic attacks usually occur on their own, with no specific trigger. But over time, children begin to avoid situations that they associate with the attacks. This avoidance can lead to agoraphobia, which makes children reluctant to go to school, visit the mall, or do other typical activities.
Panic disorder often worsens and lessens for no apparent reason. Symptoms may disappear on their own, then recur years later. Occasionally, adolescents with panic disorder may drop out of school, withdraw from society, and become reclusive and suicidal.
Diagnosis and Treatment
Usually, doctors do a physical examination to check for physical disorders that may be causing the symptoms. Doctors also consider other anxiety disorders, which may also cause panic attacks.
Usually, a combination of drugs and behavioral therapy is effective. In children, drugs are usually needed to control the panic attacks before behavioral therapy can begin. Benzodiazepines are the most effective drugs, but SSRIs are often preferred because benzodiazepines cause drowsiness (sedation) and may interfere with learning and memory. Behavioral therapy is especially useful for agoraphobia symptoms. However, drugs rarely help children with agoraphobia because children often continue to fear that they may have a panic attack, even long after attacks have been well controlled by drugs.
Posttraumatic Stress Disorder
Posttraumatic stress disorder causes recurring, intrusive memories of an overwhelming traumatic event as well as emotional numbness and increased tension or alertness (arousal).
Posttraumatic stress disorder (PTSD) may develop after children witness or experience an event that threatens their own or another's life or health. During the event, they typically feel intense fear, helplessness, or horror. These events include acts of violence, such as child abuse, school shootings, car accidents, attacks by a dog, fires, wars, natural disasters (such as hurricanes, tornados, or earthquakes), and deaths. In young children, domestic violence is the most common cause. Not all children who experience a severe traumatic event develop a stress disorder.
In posttraumatic stress disorder, symptoms may not appear until months or years later, and they last more than a month. If symptoms occur within a month of the stressful event and last less than a month, the disorder is called acute stress disorder. Children with acute stress disorder usually fare better than those with posttraumatic stress disorder, but they still benefit from early treatment.
Children constantly feel anxious. They usually fail in their attempts to avoid remembering the event. They may reexperience the traumatic event while they are awake (flashbacks) or asleep (as nightmares). Flashbacks are usually triggered by something associated with the original event. For example, seeing a dog may trigger a flashback in children who were attacked by a dog. During a flashback, children may be terrified and unaware of their surroundings. They may desperately try to hide or escape, acting as though they are in great danger. Less dramatically, children can reexperience the event in thoughts, mental images, or recollections, which are nonetheless greatly distressing.
Feeling emotionally numb is common. Children may lose interest in their usual activities, withdraw from other people, and worry about dying at a young age. They may feel extremely tense (called hyperarousal), making them jittery and unable to relax. They have difficulty sleeping.
Children may also feel guilty—for example, because they survived when others did not or because they could do nothing to stop the event.
Diagnosis and Treatment
Diagnosis is based on a history of a frightening, horrifying traumatic event followed by characteristic symptoms.
Supportive psychotherapy may help. Therapists reassure children that their response is valid but encourage them to face their memories (as a form of exposure therapy). Behavioral therapy can be used to systematically desensitize children to situations that cause them to reexperience the event.
SSRIs (a type of antidepressant) may help relieve some symptoms.
Separation Anxiety Disorder
Separation anxiety disorder involves persistent, intense anxiety about being away from home or being separated from people to whom a child is attached, usually the mother.
Some degree of separation anxiety is normal and occurs in almost all children, especially in very young children (see Symptoms in Infants and Children: Separation and Stranger Anxiety). Children feel it when a person to whom they are attached leaves. That person is usually the mother, but it can be either parent or a caregiver. The anxiety typically stops as children learn that the person will return. In separation anxiety disorder, the anxiety is much more intense and goes beyond that expected for the child's age and developmental level. Separation anxiety disorder commonly occurs in younger children and is rare after puberty.
Some life stress, such as the death of a relative, friend, or pet or a geographic move or a change in schools, may trigger the disorder. Also, people can inherit a tendency to feel anxiety.
Children experience great distress when separated from home or from people to whom they are attached. Dramatic scenes commonly occur during goodbyes. Goodbye scenes are typically painful for both parent and child. Children often wail and plead with such desperation that the parent cannot leave, prolonging the scene and making separation even more difficult. If the parent is also anxious, children become more anxious, creating a vicious circle.
After the parent has left, children fixate on being reunited. They often need to know where the parent is and are preoccupied with fears that something terrible will happen to them or to their parent.
Traveling by themselves makes these children uncomfortable, and they may refuse to attend school or camp or to visit or sleep at friends' homes. Some children cannot stay alone in a room, clinging to a parent or shadowing the parent around the house.
Difficulty at bedtime is common. Children with separation anxiety disorder may insist that a parent or caregiver stay in the room until they fall asleep. Nightmares may disclose the children's fears, such as destruction of the family through fire or another catastrophe. Children often develop physical symptoms.
Children usually appear normal when a parent is present. As a result, the problem may seem less severe than it is. The longer the disorder lasts, the more severe it is.
Doctors base the diagnosis on a description of the child's past behavior and sometimes on observation of goodbye scenes. The disorder is diagnosed only if symptoms last at least a month and cause substantial distress or greatly impair functioning.
Behavioral therapy is used. It involves teaching parents and caregivers to keep the goodbye scenes as short as possible and coaching them to react to protestations matter-of-factly. Individual and family psychotherapy is also useful.
Enabling children to return to school is an immediate goal. It requires doctors, parents, and school personnel to work as a team. Helping children form an attachment to one of the adults in the preschool or school may help.
When the disorder is severe, drugs that can reduce anxiety, such as an SSRI, may help.
Children are prone to relapses after holidays and breaks from school. Thus, parents are often advised to plan regular separations during these periods to help children remain accustomed to being away from them.
Social phobia (social anxiety disorder) involves a persistent fear of being embarrassed, ridiculed, or humiliated in social situations.
Sometimes social phobia develops after an embarrassing incident.
Usually, this disorder is first noticed when children or adolescents refuse to go to school. The reason they give is often a physical symptom, such as stomachache or headache.
Children are terrified that they will humiliate themselves in front of their peers by giving the wrong answer, saying something inappropriate, becoming embarrassed, or even vomiting. When the fear is excessive, children may refuse to talk on the telephone or to leave the house.
The diagnosis is based on symptoms
Behavioral therapy is used most often. It involves not allowing children to miss school. Absence makes them even more reluctant to attend school.
If behavioral therapy is ineffective or children will not participate in it, a drug that can reduce anxiety, such as a selective serotonin reuptake inhibitor may help. The drug may reduce anxiety enough to enable children to participate in behavioral therapy.
Last full review/revision February 2009 by Hugh F. Johnston, MD