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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.
Some anxiety is a normal aspect of development, as in the following:
Such difficulties should not be viewed as evidence of a disorder. However, if manifestations of anxiety become so exaggerated that they greatly impair functioning or cause severe distress, an anxiety disorder should be considered.
At some point during childhood, about 10 to 15% of children experience an anxiety disorder (eg, generalized anxiety disorder, social phobia, separation anxiety disorder, obsessive-compulsive disorder, specific phobia, panic disorder, acute and post-traumatic stress disorders).
Etiology
Etiology seems to have a genetic basis but is heavily modified by psychosocial experience; heritability is polygenetic, and only a small number of the specific genes have been characterized thus far.
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 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 phobia, 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 phobia). 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.
Diagnosis
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
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
Anxiety disorders in children are treated with behavioral therapy (using principles of exposure and response prevention), sometimes in conjunction with drug therapy.
In 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 (see Table 1: Mental Disorders in Children and Adolescents: SSRIs for Treating Children ≥ 12 Yr ).
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Table 1
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| SSRIs for Treating Children ≥ 12 Yr |
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Drug
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Starting Dose
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Maintenance Dose*
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Comments or Precautions†
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Citalopram
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20 mg once/day
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40 mg once/day
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Very similar to escitalopram
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Escitalopram
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10 mg once/day
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20 mg once/day
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Most selective SSRI
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Fluoxetine
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10 mg once/day
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40 mg once/day
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Long half-life
Most activating SSRI
Accumulation of active metabolites in some patients
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Fluvoxamine
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50 mg once/day
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100 mg bid
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May elevate caffeine and other xanthine levels
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Paroxetine
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10 mg once/day
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50 mg once/day or 25mg bid
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Most sedating SSRI
Withdrawal effects in some patients
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Sertraline
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25 mg once/day
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50 mg once/day or 25mg bid
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Approved for OCD in children ≥ 6 yr
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*Dosing is oral. Dose ranges are approximate. Interindividual variability in therapeutic response and adverse effects is considerable; starting dose is increased only if needed. This table is not a substitute for the full prescribing information.
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†Behavioral side effects (eg, disinhibition, behavioral activation) 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 side 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.
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OCD = obsessive-compulsive disorder.
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Most children tolerate SSRIs without difficulty. Occasionally, upset stomach, diarrhea, or insomnia may occur. Some children have behavioral side effects (eg, activation, disinhibition—see Mental Disorders in Children and Adolescents: Depressive Disorders in Children and Adolescents).
Generalized Anxiety Disorder
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
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 phobia or panic disorder. 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.
Occasionally, GAD can be confused with attention-deficit/hyperactivity disorder (ADHD—see Learning and Developmental Disorders: Attention-Deficit/Hyperactivity Disorder (ADHD, ADD)) because GAD can cause difficulty paying attention and can also result in psychomotor agitation (ie, hyperactivity). A key difference is that children with ADHD tend to be no more prone to worries than children without ADHD, whereas children with GAD have many distressing worries.
Treatment
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 1: Mental Disorders in Children and Adolescents: SSRIs for Treating Children ≥ 12 Yr) are typically the drugs of choice. Buspirone is a useful alternative, especially for children who cannot tolerate SSRIs; starting dose is 5 mg po bid and 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.
Social Phobia
(Social Anxiety Disorder)
Social phobia is a persistent fear of embarrassment, ridicule, or humiliation in social settings. Typically, affected children avoid situations that might provoke social scrutiny (eg, school). Diagnosis is by history. Treatment is with behavioral therapy; in severe cases, SSRIs are used.
School refusal is often the initial presentation of social phobia, particularly in adolescents. Complaints often have a somatic focus (eg, “My stomach hurts,” “I have a headache”). Some children have a history of many medical appointments and evaluations in response to these somatic complaints.
Affected 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. In some cases, social phobia emerges after an unfortunate and embarrassing incident. In severe cases, children may refuse to talk on the telephone or even refuse to leave the house.
Treatment
Behavioral therapy is the cornerstone of treatment. Children should not be allowed to miss school. Absence serves only to make them even more reluctant to attend school.
If children and adolescents are not sufficiently motivated to participate in behavioral therapy or do not respond adequately to it, an anxiolytic such as an SSRI may help (see Table 1: Mental Disorders in Children and Adolescents: SSRIs for Treating Children ≥ 12 Yr). Treatment with an SSRI may reduce anxiety enough to facilitate children's participation in behavioral therapy.
Separation Anxiety Disorder
Separation anxiety disorder is a persistent, intense, and developmentally inappropriate fear of separation from a major attachment figure (usually the mother). Affected children desperately attempt to avoid such separations. When separation is forced, these children are distressfully preoccupied with reunification. Diagnosis is by history. Treatment is with behavioral therapy for the child and family and, for severe cases, SSRIs.
Separation anxiety is a normal emotion in children between about age 8 mo and 24 mo (see Approach to the Care of Normal Infants and Children: Separation anxiety); it typically resolves as children develop a sense of object permanence and realize their parents will return. In some children, separation anxiety persists beyond this time or returns later; it may be severe enough to be considered a disorder. Separation anxiety disorder commonly occurs in younger children and is rare after puberty.
Symptoms and Signs
Like social phobia, separation anxiety disorder often manifests as school (or preschool) refusal.
Dramatic scenes typically occur at the time of separation. Separation scenes are typically painful for both the child and attachment figure (usually the mother but can be either parent or a caregiver). Children often wail and plead with such desperation that the parent cannot leave, resulting in protracted scenes that are difficult to interrupt. When separated, children fixate on reunification with the attachment figure and are often worried that this person has been harmed (eg, in a car accident, by a serious illness). Children may refuse to sleep alone and may even insist on always being in the same room as the attachment figure.
Children often develop somatic complaints.
The child's demeanor is often normal when the attachment figure is present. This normal demeanor can sometimes give a false impression that the problem is minor.
Separation anxiety is often compounded by a parent's anxiety, which exacerbates the child's anxiety; the result is a vicious circle that can be interrupted only by sensitive and appropriate treatment of parent and child simultaneously
Diagnosis
Diagnosis is by history and by observation of separation scenes.
Treatment
Treatment is with behavioral therapy that systematically enforces regular separations. The goodbye scenes should be kept as brief as possible, and the attachment figure should be coached to react to protestations matter-of-factly. Assisting children in forming an attachment to one of the adults in the preschool or school may be helpful.
In extreme cases, children may benefit from an anxiolytic such as an SSRI (see Table 1: Mental Disorders in Children and Adolescents: SSRIs for Treating Children ≥ 12 Yr). However, separation anxiety disorder often affects children as young as 3 yr, and experience with these drugs in the very young is limited.
Successfully treated children are prone to relapses after holidays and breaks from school. Because of these relapses, parents are often advised to plan regular separations during these periods to help the child remain accustomed to being away from the parents.
Obsessive-Compulsive Disorder (OCD)
Obsessive-compulsive disorder (OCD) is characterized by obsessions, compulsions, or both. Obsessions are irresistible, persistent ideas, images, or impulses to do something. Compulsions are pathologic urges to act on an impulse, which, if resisted, result in excessive anxiety and distress. The obsessions and compulsions cause great distress and interfere with academic or social functioning. Diagnosis is by history. Treatment is with behavioral therapy and SSRIs.
Most cases of OCD have no clear etiology. However, a few cases are thought to be associated with group A β-hemolytic streptococcal infections. This syndrome is called pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). PANDAS should be considered in all children with a sudden onset of severe OCD-like symptoms because early antibiotic treatment may prevent or attenuate long-lasting impairment. Research in this area is ongoing, and if PANDAS is suspected, consultation with a specialist is strongly recommended.
Symptoms and Signs
Typically, OCD has a gradual, insidious onset. Most children initially hide their symptoms and report struggling with symptoms years before a definitive diagnosis is made.
Obsessions are typically experienced as worries or fears of harm (eg, contracting a deadly disease, sinning and going to hell, injuring themselves or others). Compulsions are deliberate volitional acts, usually done to neutralize or offset obsessional fears; they include checking behaviors, excessive washing, counting, or arranging, and many more. Obsessions and compulsions may have some logical connection (eg, hand washing to avoid disease) or may be illogical and idiosyncratic (eg, counting to 50 over and over to prevent grandpa from having a heart attack). If children are prevented from carrying out their compulsions, they become excessively anxious and concerned.
Most children have some awareness that their obsessions and compulsions are abnormal. Many affected children are embarrassed and secretive. Common symptoms include
Diagnosis
Diagnosis is by history. Once a comfortable relationship with a nonjudgmental therapist is established, the child with OCD usually discloses many obsessions and related compulsions. However, usually several appointments are needed to first establish trust. Children with OCD often have symptoms of other anxiety disorders, including panic attacks, separation problems, and specific phobias. This symptom overlap sometimes confuses the diagnosis.
Prognosis
In about 5% of children, the disorder remits after a few years, and treatment can be stopped. In the others, the disorder tends to be chronic, but normal functioning can usually be maintained with ongoing treatment. About 5% of children do not respond to treatment and remain greatly impaired.
Treatment
If streptococcal infection is not involved, treatment is usually a combination of behavioral therapy and an SSRI. If appropriate services are available and children are highly motivated, behavioral therapy alone may be adequate.
PANDAS is treated with antibiotics.
Panic Disorder and Agoraphobia
Panic disorder is characterized by recurrent, frequent (at least once/wk) panic attacks. Panic attacks are discrete spells lasting about 20 min; during attacks, children experience somatic symptoms, cognitive symptoms, or both. Panic disorder can occur with or without agoraphobia. Agoraphobia is a persistent fear of being trapped in situations or places without a way to escape easily and without help. Diagnosis is by history. Treatment is with benzodiazepines or SSRIs and behavioral therapy.
Panic disorder is much less common among prepubertal children than among adolescents. Panic attacks can occur alone or in other anxiety disorders (eg, OCD, separation anxiety) or certain medical disorders (eg, asthma). Panic attacks can trigger an asthma attack and vice versa.
Symptoms may be cognitive, somatic, or (usually) both (see Anxiety Disorders: Symptoms and Signs).
Panic attacks usually develop spontaneously, but over time, children begin to attribute them to certain situations and environments. Affected children then attempt to avoid those situations, which can lead to agoraphobia. Avoidance behaviors are considered agoraphobia if they greatly impair normal functioning, such as going to school, visiting the mall, or doing other typical activities.
Diagnosis
Panic disorder is diagnosed based on history, usually after a physical examination is done to rule out physical causes of somatic symptoms. Many children undergo considerable diagnostic testing before panic disorder is suspected. The presence of other disorders, especially asthma, can also complicate the diagnosis. Thorough screening for other anxiety disorders (eg, OCD, social phobia) is needed because any one of these disorders may be the primary problem causing panic attacks as a symptom.
In adults, important diagnostic criteria for panic disorder include concerns about future attacks, the implications of the attacks, and changes in behavior. However, children and younger adolescents usually lack the insight and forethought needed to develop these features, except they may change behavior to avoid situations they believe are related to the panic attack. As compared to those in adults, panic attacks in children and adolescents are often more dramatic in presentation (eg, with screaming, weeping, and hyperventilation). This display can be alarming to parents and others.
Prognosis
Prognosis for children and adolescents who have panic disorder with or without agoraphobia is good with treatment. Without treatment, adolescents may drop out of school, withdraw from society, and become reclusive and suicidal.
Panic disorder often waxes and wanes in severity without any discernible reason. Some patients experience long periods of spontaneous symptom remission, only to experience a relapse years later.
Treatment
Treatment is usually a combination of drug therapy and behavioral therapy. In children, it is difficult to even begin behavioral therapy until after the panic attacks have been controlled by drugs. Benzodiazepines are the most effective drugs, but SSRIs are often preferred because benzodiazepines are sedating and may greatly impair learning and memory. However, SSRIs do not work quickly, and a short course of a benzodiazepine (eg, lorazepam 0.5 to 2.0 mg po tid) may be helpful until the SSRI is effective.
Behavioral therapy is especially useful for agoraphobia symptoms. Drugs are rarely useful for these symptoms because children often continue to fear that they may have a panic attack, even long after attacks have been well controlled by drugs.
Acute and Posttraumatic Stress Disorders (PTSD)
Acute stress disorder (ASD) is a brief period (about 1 mo) of intrusive recollections (eg, flashbacks and nightmares), dissociation, avoidance, and anxiety occurring within 1 mo of a traumatic incident. Posttraumatic stress disorder (PTSD) causes recurring, intrusive recollections of an overwhelming traumatic incident that persist > 1 mo, as well as emotional numbing and hyperarousal. Diagnosis is by history and examination. Treatment is with behavioral therapy, SSRIs, and antiadrenergic drugs.
Because vulnerability and temperament are different, not all children who are exposed to a severe traumatic event develop a stress disorder. Traumatic events commonly associated with these disorders include assaults, sexual assaults, car accidents, dog attacks, and injuries (especially burns). In young children, domestic violence is the most common cause of PTSD.
Symptoms and Signs
ASD and PTSD are closely related and are distinguished primarily by duration of symptoms. ASD is diagnosed within 1 mo of the traumatic event, and PTSD is diagnosed only after 1 mo has passed and symptoms have persisted. In a few cases, onset of PTSD symptoms may be delayed months or even years after the traumatic event.
Emotional numbing and hyperarousal are common. Emotional numbing includes the following:
Hyperarousal symptoms include the following:
Typically, children with ASD are in a daze and may seem dissociated from everyday surroundings.
Children with PTSD have intrusive recollections that cause them to reexperience the traumatic event. The most dramatic kind of recollection is a flashback. Flashbacks may be spontaneous but are most commonly triggered by something associated with the original trauma. For example, the sight of a dog may trigger a flashback in children who experienced a dog attack. During a flashback, children may be in a terrified state and unaware of their current surroundings while desperately searching for a way to hide or escape; they may temporarily lose touch with reality and believe they are in grave danger. Some children have nightmares. When children reexperience the event in other ways (eg, in thoughts, mental images, or recollections), they remain aware of current surroundings, although they may still be greatly distressed.
Diagnosis
Diagnosis of ASD and PTSD is based on a history of severely frightening and horrifying trauma followed by reexperiencing, emotional numbing, and hyperarousal. These symptoms must be severe enough to cause impairment or distress.
Prognosis
Prognosis for children with ASD is much better than for those with PTSD, but both benefit from early treatment. Severity of the trauma, associated physical injuries, and the underlying resiliency of children and family members affect the final outcome.
Treatment
SSRIs often help reduce emotional numbing and reexperiencing of symptoms but are less effective for hyperarousal. Antiadrenergic drugs (eg, clonidine, guanfacine, prazosin) may help relieve hyperarousal symptoms, but supportive data are preliminary.
Supportive psychotherapy may help children who have adjustment issues associated with trauma, as may result from disfigurement due to burns. Behavioral therapy can be used to systematically desensitize children to situations that cause them to reexperience the event. Behavioral therapy is clearly effective in reducing distress and impairment in children and adolescents with PTSD.
Last full review/revision April 2009 by Hugh F. Johnston, MD
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