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Overview of Anxiety Disorders in Children and Adolescents

By

Josephine Elia

, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Last full review/revision Apr 2021| Content last modified Apr 2021
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Topic Resources

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 selective serotonin reuptake inhibitors (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-year-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 emerge in about 3% of 6-year-olds and in about 5% of teenage boys and 10% of teenage girls (1–3). Children with an anxiety disorder have an increased risk of depression (4), suicidal behavior (5, 6) drug and alcohol addiction (7), and academic difficulties (8) later in life.

Anxiety disorders that can occur in children and adolescents include

General references

  • 1. Merikangas KR, He JP, Burstein M, et al: Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Study – Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 49(10): 980-989, 2010.

  • 2. Dalsgaard S, Thorsteinsson E, Trabjerg BB, et al: Incidence rates and cumulative incidences of the full spectrum of diagnosed mental disorders in childhood and adolescence. JAMA Psychiatry, 77(2):155-164, 2019. doi: 10.1001/jamapsychiatry.2019.3523

  • 3. Merikangas KR, He JP, Brody D, et al: Prevalence and treatment of mental disorders among US children in the 2001–2004 NHANES. Pediatrics 125(1):75-81, 2010. doi: 10.1542/peds.2008-2598

  • 4. Cummings CM, Caporino NE, Kendall PC: Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull 140(3):816-845, 2014. doi: 10.1037/a0034733

  • 5. Boden JM, Fergusson DM, Horwood LI: Anxiety disorders and suicidal behaviors in adolescence and young adulthood: Findings from a longitudinal study. Psychol Med 64:1180, 2007. doi: 10.1017/S0033291706009147

  • 6. Husky MM, Olfson M, He J, et al: Twelve-month suicidal symptoms and use of services among adolescents: Results from the National Comorbidity Survey. Psychiatr Serv63:989-996, 2012.

  • 7. Zimmermann P, Wittchen HU, Hofler M, et al: Primary anxiety disorders and the development of subsequent alcohol use disorder: A 4-year community study of adolescents and young adults. Psychol Med 33(7);1211-1222, 2003. doi: 10.1017/s0033291703008158

  • 8. Van Ameringen M, Mancini C, Farvolden P: The impact of anxiety disorders on educational achievement. J Anxiety Disord 17(5):561-571, 2003. doi: 10.1016/s0887-6185(02)00228-1

Etiology

Evidence suggests that anxiety disorders involve dysfunction in the parts of the limbic system and hippocampus that regulate emotions and response to fear. In mice, loss of expression of the serotonin 1A-receptor (5-HT1AR) in the forebrain during early development results in dysregulation of the hippocampus and leads to anxiety behaviors (1). 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 Anxiety Disorders ).

Etiology reference

  • 1. Adhikari A, Topiwala M, Gordon JA: Synchronized activity between the ventral hippocampus and the medial prefrontal cortex during anxiety. Neuron 65:257-269, 2010. doi: 10.1016/j.neuron.2009.12.002

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, headaches, and sleep problems 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 through a clinical assessment (1). A thorough psychosocial history can usually confirm it.

Rating scales can be useful for screening. Several validated scales are freely available: Screen for Child Anxiety-Related Emotional Disorders [SCARED] , Spence Children's Anxiety Scale [SCAS] , Preschool Anxiety Scale [PAS] , and General Anxiety Disorder-7 [GAD-7]).

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.

Diagnosis reference

  • 1. Walter HJ, Bukstein OG, Abright AR, et al: Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 59(10):1107-1124, 2020. doi: https://doi.org/10.1016/j.jaac.2020.05.005

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 [1])

  • Parent-child and family interventions

  • Drugs, usually selective serotonin reuptake inhibitors (SSRIs) and to a lesser degree, serotonin- norepinephrine reuptake inhibitors (SNRI) and tricyclic antidepressants (2) for long-term treatment and sometimes benzodiazepines to relieve acute symptoms (3) .

Anxiety disorders in children are treated with behavioral therapy (using principles of exposure and response prevention), sometimes in conjunction with drug therapy (4).

In exposure-based cognitive-behavioral therapy (CBT), 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). SSRIs combined with CBT have the highest likelihood of improving symptoms (4). 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. Buspirone was found to be well tolerated in pediatric patients (ages 6 to 17) with a generalized anxiety disorder (1) but 2 randomized, controlled trials did not demonstrate greater effectiveness than placebo; these trials were underpowered to detect small effects. Reports of improvement in developmental disorders such as Williams syndrome (5) and autism (6) require well-controlled trials.

Table
icon

Drugs for Long-Term Treatment of Anxiety and Related Disorders*

Drug

Uses

Starting Dose†

Dose Range

CYP/Precautions/Comments‡

Citalopram

OCD

children 7 years

10 mg

10–40 mg/day

2C19

Duloxetine

GAD in children 7–17 years

30 mg

30–120 mg/day

2D6 – SNRIs have noradrenergic activity and can increase risk of hypertension¶

Escitalopram

Major depression in children 12 years

10 mg

10–20 mg/day

2C19

Fluoxetine§

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

10 mg

10–60 mg/day

2D6 – Long-half life

Fluvoxamine

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

25 mg (titrated up as needed)

50–200 mg/day

2D6 – For doses > 50 mg/day, divided into 2 doses a day, with the larger dose given at bedtime

Paroxetine§

OCD in children >6 years

10 mg

10–60 mg/day

2D6 – Increased weight

Sertraline

OCD, GAD, separation anxiety, social anxiety in children 6 years

25 mg

25–200 mg/day

2C19

Venlafaxine, immediate-release

Depression in children 8 years

12.5 mg

12.5 mg twice a day to 25 mg 3 times a day

2D6 SNRIs – 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 years

37.5 mg

37.5–225 mg once a day

* The drugs listed are used clinically for all the anxiety disorders, OCD, and depression. FDA approval has been obtained for some conditions; the lack of FDA approval for other conditions is due to a lack of sufficient studies. There is no evidence that one SSRI is better than or not as effective as the others (Varigonda AL, Jakubovski E, Taylor MJ, et al: Systematic review and meta-analysis: Early treatment responses of selective serotonin reuptake inhibitors in pediatric major depressive disorder. J Child Adolescent Psychopharmacol 54(7):557-564, 2015). doi: https://doi.org/10.1016/j.jaac.2015.05.004.

† Unless otherwise stated, dose is given once a day. Starting dose is increased only if needed. Dose ranges are approximate. Interindividual variability in therapeutic response and adverse effects is considerable. When stopping a drug, taper gradually by 25% weekly. 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 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.

‡ Genetic testing for enzymes that metabolize these drugs is available. The CPIC (Clinical Pharmacogenetics Implementation Consortium) guidelines indicate poor response for CYP2C19 and D26 rapid metabolizers and risk for adverse effects for poor metabolizers, recommending starting at 50% of the recommended dose. Ethnic variations show that 7 to 15% of white, 2% of Asian, and 2% of African Americans lack the gene for 2D6 while 10% whites and 50% of Asians have genetic variants that reduce 2D6 function (Droll K, Bruce-Mensah K, Otton SV: Comparison of three CYP2D6 probe substrates and genotype in Ghanaians, Chinese and Caucasians. Pharmacogenetics 8(4)325-333, 1998. doi: 10.1097/00008571-199808000-00006). As newly discovered genetic variants and copy number variants get incorporated into the CYP2D6 biomarker panels, predictions of metabolizer status will become more accurate. (For the former, see Ray B, Ozcagli E, Sadee W, et al: CYP2D6 haplotypes with enhancer SNP rs5758550 and rs16947 (*2 allele): Implications for CYP2D6 genotyping panels. Pharmacogenet Genomics 2019:29(2):39-47; for the latter, see Beoris M, Wilson JA, Garces JA, et al: CYP2D6 copy number distribution in the US population. Pharmacogenet Genomics 26(2):96-99, 2016. doi: 10.1097/FPC.0000000000000188. Clinicians who order these tests need to help families interpret the results.

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

Strawn JR, Prakash A, Zhang Q, et al: A randomized, placebo-controlled study of duloxetine for the treatment of children and adolescents with generalized anxiety disorder. J Am Acad Child Adolesc Psychiatry 54(4):283-293, 2015. doi: 10.1016/j.jaac.2015.01.008.

FDA = Food and Drug Administration; GAD = generalized anxiety disorder; OCD = obsessive compulsive disorder; SSRI = selective serotonin reuptake inhibitor

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.

Treatment references

  • 1. Brent DA, Porta G, Rozenman M, et al: Brief behavioral therapy for pediatric anxiety and depression in primary care: A follow-up. J Am Acad Child Adolesc Psychiatry 59(7):856-867, 2019. doi: 10.1016/j.jaac.2019.06.009

  • 2. Strawn JR, Welge JA, Wehry AM, et al: Efficacy and tolerability of antidepressants in pediatric anxiety disorders: A systematic review and meta-analysis. Depress Anxiety 32(3):149-157, 2015.

  • 3. Ipser JC, Stein DJ, Hawkridge S, et al: Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev (3):CD005170, 2009. doi: 10.1002/14651858.CD005170.pub2

  • 4. Walkup JT, Albano AM, Piacentini J, et al: Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 359:2753-2766, 2008. doi: 10.1056/NEJMoa0804633

  • 5. Thom RP, Keary CJ, Waxler JL, et al: Buspirone for the treatment of generalized anxiety disorder in Williams syndrome: A case series. J Autism Dev Disord 50(2):676-682, 2020. doi: 10.1007/s10803-019-04301-9

  • 6. Ceranoglu TA, Wozniak J, Fried R, et al: A retrospective chart review of buspirone for the treatment of anxiety in psychiatrically referred youth with high-functioning autism spectrum disorder. J Child Adolescent Psychopharmacol, 29(1):28-33, 2018. doi: 10.1089/cap.2018.0021

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.

  • Commercially available panels testing for CYP variants remain limited.

More Information

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

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