Generalized Anxiety Disorder in Children and Adolescents

Children with generalized anxiety disorder 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). The abrupt and dramatic disruption in routines during the COVID-19 pandemic—such as school closure and isolation from extended family, peers, teachers, cultural and religious groups—increased anxiety in nearly all children. Living in constrained spaces with family members for weeks to months, parental job loss, and general uncertainty about the future increased stress as well (1 Symptoms and signs reference Generalized anxiety disorder is a persistent state of heightened anxiety and apprehension characterized by excessive worrying, fear, and dread. Physical symptoms can include tremor, sweating... read more ).

Generalized anxiety disorder 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 Social Anxiety Disorder in Children and Adolescents Social anxiety disorder is a persistent fear of embarrassment, ridicule, or humiliation in social settings. Typically, affected children avoid situations that might provoke social scrutiny ... read more or panic disorder Panic Disorder in Children and Adolescents Panic disorder is characterized by recurrent, frequent (at least once/week) panic attacks. Panic attacks are discrete spells lasting about 20 minutes; during attacks, children experience somatic... read more . Generalized anxiety disorder is also an appropriate diagnosis for children who have a specific anxiety disorder, such as separation anxiety Separation Anxiety and Stranger Anxiety Separation anxiety is fussing and crying when a parent leaves the room. Some children scream and have tantrums, refuse to leave their parents' side, and/or have nighttime awakenings. Separation... read more , but also have other significant anxiety symptoms above and beyond those of the specific anxiety disorder.

Specific criteria include the presence of each of the following:

In addition, the above criteria must be accompanied by ≥ 1 of the following:

Occasionally, generalized anxiety disorder can be confused with attention-deficit/hyperactivity disorder (ADHD) Attention-Deficit/Hyperactivity Disorder (ADD, ADHD) Attention-deficit/hyperactivity disorder (ADHD) is a syndrome of inattention, hyperactivity, and impulsivity. The 3 types of ADHD are predominantly inattentive, predominantly hyperactive/impulsive... read more because generalized anxiety disorder 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.

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

Patients who have severe generalized anxiety disorder 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 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 orally twice a day; the dose may be gradually increased to 30 mg twice a day (or 20 mg 3 times a day) as tolerated. Gastrointestinal distress or headache may be limiting factors in dosage escalation.