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, multiple somatic complaints, and exhaustion. Diagnosis is based on clinical criteria. Treatment is often with relaxation therapy, sometimes combined with drug therapy.
Generalized anxiety disorder in children and adolescents is characterized by excessive, persistent worry about various aspects of daily life, such as school performance, social interactions, and health. It is diagnosed when symptoms persist for 6 months or more, and is often accompanied by physical symptoms like restlessness, fatigue, and difficulty concentrating. It is much more commonly diagnosed in late adolescence and early young adulthood; 8% of cases start by age 14, 20% by age 18, and 33% by age 25, with a median age of diagnosis of 20 years (1).
Reference
1. Solmi M, Radua J, Olivola M, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry. 2022;27(1):281-295. doi:10.1038/s41380-021-01161-7
Symptoms and Signs of Generalized Anxiety Disorder
Children with generalized anxiety disorder may have multiple and diffuse worries, which are exacerbated by stress. These children often have an intolerance to uncertainty, difficulty paying attention, and may exhibit hyperactivity and restlessness. They may sleep poorly, sweat excessively, feel exhausted, and complain of physical discomfort (eg, stomachache, muscle aches, headache). Anxious children may also exhibit perfectionist behaviors, and perceived poor school performance may directly contribute to their anxiety.
During the COVID-19 pandemic, the abrupt and dramatic disruption in routines increased anxiety in approximately 20% of children (1) with greater risk incurred by those infected with COVID-19 (2).
Symptoms and signs references
1. Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis. JAMA Pediatr. 2021;175(11):1142-1150. doi:10.1001/jamapediatrics.2021.2482
2. Lu Y, Tong J, Zhang D, et al. Risk of neuropsychiatric and related conditions associated with SARS-CoV-2 infection: a difference-in-differences analysis. Nat Commun. 2025;16(1):6829. Published 2025 Jul 24. doi:10.1038/s41467-025-61961-1
Diagnosis of Generalized Anxiety Disorder
Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria
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 or panic disorder (1). Generalized anxiety disorder is also an appropriate diagnosis for children who have a specific anxiety disorder, such as separation anxiety, but also exhibit additional significant anxiety symptoms that extend beyond those associated with the specific disorder.
Specific criteria include the presence of each of the following:
Excessive anxiety and worry that patients have difficulty controlling
Symptoms present on more days than not for ≥ 6 months
Symptoms cause significant distress or impair functioning socially or at school
In addition, the above criteria 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, the symptoms of generalized anxiety disorder can be confused with those of attention-deficit/hyperactivity disorder (ADHD) 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.
Diagnosis reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Washington: American Psychiatric Association, 2022.
Treatment of Generalized Anxiety Disorder
Relaxation training
Breathing exercises
Sometimes anxiolytic medications, usually selective serotonin reuptake inhibitors (SSRIs)
Because the focus of symptoms is diffuse, generalized anxiety disorder is especially challenging to treat with behavioral therapy. Relaxation training and breathing exercises are often more appropriate.
Patients who have severe generalized anxiety disorder or who do not respond to psychotherapeutic interventions may need anxiolytic medications. As with other anxiety disorders, SSRIs are typically the drugs of choice (see table Medications For Long-Term Treatment of Anxiety, Depression, and Related Disorders). Buspirone is sometimes used for children who cannot tolerate SSRIs; however, it is much less effective (). Buspirone is sometimes used for children who cannot tolerate SSRIs; however, it is much less effective (1). Gastrointestinal distress or headache may be limiting factors in dosage escalation.
Treatment reference
1. Strawn JR, Mills JA, Cornwall GJ, et al. Buspirone in children and adolescents with anxiety: A review and Bayesian analysis of abandoned randomized controlled trials. J Child Adolesc Psychopharmacol. 28(1): 2-9, 2018. doi: 10.1089/cap.2017.0060
Key Points
Children with generalized anxiety disorder have multiple and diffuse worries, rather than a single, specific one.
Diagnose generalized anxiety disorder when symptoms cause significant distress to the child or impair social or academic functioning and the child has ≥ 1 specific symptoms (eg, restlessness, a "keyed-up" or "on-edge" feeling).
Relaxation therapy may help; if children have severe anxiety or do not respond to psychotherapeutic interventions, consider anxiolytic medications (preferably SSRIs).
Drugs Mentioned In This Article
