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Overview of Anxiety Disorders in Children and Adolescents

by Josephine Elia, MD

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.

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 (eg, generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, obsessive-compulsive disorder, specific phobia, panic disorder, acute and post-traumatic stress disorders). Children with an anxiety disorder have an increased risk of depressive and anxiety disorders later in life.

Anxiety disorders include generalized anxiety disorder (see Generalized Anxiety Disorder in Children and Adolescents), social anxiety disorder (see Social Anxiety Disorder in Children and Adolescents), separation anxiety disorder (see Separation Anxiety Disorder), panic disorder (see Panic Disorder in Children and Adolescents), and agoraphobia (see Agoraphobia in Children and Adolescents).


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 (see Overview of Anxiety Disorders for treatment of anxiety in adults).

Symptoms and Signs

Perhaps the most common manifestation 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, 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 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 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.


  • 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



Starting Dose*

Dose Range




10 mg

10–40 mg/day


Major depression

5 mg

5–20 mg/day


OCD, GAD, separation anxiety, social anxiety, major depression in children > 7 yr

10 mg

10–40 mg/day

Long-half life


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

25 mg (titrated up as needed) §

50–200 mg/day


OCD in children > 6 yr

10 mg

10–40 mg/day

Increased weight


OCD, GAD, separation anxiety, social anxiety

25 mg

25–200 mg/day



37.5 mg

37.5–225 mg/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, 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, β-blockers, clonidine, lidocaine).

§ When the fluvoxamine dose is more than 50 mg/day, it should be divided into 2 doses/day, with a larger dose given at bedtime.

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—see Depressive Disorders in Children and Adolescents).

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