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Generalized Anxiety Disorder in Children and Adolescents

by Josephine Elia, MD

Generalized anxiety disorder (GAD) is a persistent state of heightened anxiety and apprehension characterized by excessive worrying, fear, and dread. Physical symptoms can include tremor, sweating, multiple somatic complaints, and exhaustion. Diagnosis is by history. Treatment is often with relaxation therapy, sometimes combined with drug therapy.

Symptoms and Signs

Children have multiple and diffuse worries, which are exacerbated by stress. These children often have difficulty paying attention and may be hyperactive and restless. They may sleep poorly, sweat excessively, feel exhausted, and complain of physical discomfort (eg, stomachache, muscle aches, headache).

Diagnosis

  • Clinical criteria

GAD is diagnosed in children and adolescents who have prominent and impairing anxiety symptoms that are not focused enough to meet criteria for a specific disorder such as social anxiety disorder (see Social Anxiety Disorder in Children and Adolescents) or panic disorder (see Panic Disorder in Children and Adolescents). GAD is also an appropriate diagnosis for children who have a specific anxiety disorder, such as separation anxiety, but also have other significant anxiety symptoms above and beyond those of the specific anxiety disorder.

Specific criteria include excessive anxiety and worry that patients have difficulty controlling and that is present on more days than not for ≥ 6 mo. The symptoms must cause significant distress or impair functioning socially or at school and must be accompanied by ≥ 1 of the following:

  • Restlessness or a keyed-up or on-edge feeling

  • Being easily fatigued

  • Difficulty concentrating

  • Irritability

  • Muscle tension

  • Sleep disturbance

Occasionally, GAD can be confused with attention-deficit/hyperactivity disorder (ADHD—see Attention-Deficit/Hyperactivity Disorder (ADHD, ADD)) because GAD can cause difficulty paying attention and can result in psychomotor agitation (ie, hyperactivity). However, in ADHD, children also have difficulty concentrating and feel restless when they are not anxious. Some children have both ADHD and an anxiety disorder.

Treatment

  • Relaxation therapy

  • Sometimes anxiolytic drugs, usually SSRIs

Because the focus of symptoms is diffuse, GAD is especially challenging to treat with behavioral therapy. Relaxation training is often more appropriate.

Patients who have severe GAD or who do not respond to psychotherapeutic interventions may need anxiolytic drugs. As with other anxiety disorders, SSRIs (see Table: Drugs for Long-Term Treatment of Anxiety and Related Disorders) are typically the drugs of choice. Buspirone is sometimes used for children who cannot tolerate SSRIs; however, it is much less effective. The starting dose for buspirone is 5 mg po bid; the dose may be gradually increased to 30 mg bid (or 20 mg tid) as tolerated. GI distress or headache may be limiting factors in dosage escalation.

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