Anxiety

Anxiety disorders are among the most common types of mental illness in children and adolescents. The estimated prevalence in the pediatric population ranges from 6% to 20%, with 9.4% of children and adolescents aged 3-17 years having ever received an anxiety disorder diagnosis per the 2016-2019 National Survey of Children’s Health (NSCH).

However, fears and worries can also be developmentally appropriate and should not be confused with a disorder. Anxiety disorders often are missed diagnostically and can cause significant distress and impairment throughout the life span. The origin of anxiety disorders is multifactorial, with contributions from inherent biological risk factors (family history, medical illness, and temperament) and the environment (parental anxiety; parent-child interactions; adverse childhood events, including exposure to neighborhood violence or bullying).

Types of Anxiety Disorders

Multiple subtypes of anxiety disorders exist. In children, symptoms of anxiety often manifest as somatic complaints or functional impairment and are often not labeled as anxiety by parents. Some children may be characterized as “worriers.” Many children who develop anxiety disorders demonstrate evidence of behavioral inhibition at an early age, or the predisposition to feel overwhelmed and withdraw from unfamiliar situations, individuals, or settings. Anxiety disorders can evolve over time, often starting with a narrow area of anxiety (e.g., social anxiety) that broadens.

Diagnostic criteria for anxiety disorder in children differ from the criteria for adults, often requiring fewer presenting symptoms or shorter duration, reflecting the difference in expected resilience to distress by age.

Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by chronic excessive worry in multiple domains (e.g., school, family, health or safety, world events, natural disasters). The key factor for generalized anxiety disorder is that the worry is diffuse rather than associated with specific situations (e.g., social anxiety disorder) or a narrow, defined trigger (e.g., specific phobias).

Separation Anxiety Disorder

Separation anxiety disorder (SAD) refers to excessive fear and distress associated with separation from home or significant attachment figures. Historically, SAD was only considered in children, but this diagnosis was recognized in adults in the DSM-5 (adults require 6 months of symptoms versus 1 month in children and adolescents). Mean age of onset is 8 years old, with symptoms often arising with introduction to a new setting or time away from an attachment figure (e.g., the start of school or overnight at summer camp).

Social Anxiety Disorder

Social anxiety disorder (formerly social phobia) refers to significant feelings of fear, worry, and discomfort in social settings or performance. Although the typical mean age of diagnosis is 12 years, symptoms of behavioral inhibition and feelings of self-consciousness often present earlier. In children, anxiety due to interactions with adults only is not considered social anxiety unless it occurs with peer interactions. Further, symptoms can occur only when the individual is expected to perform (e.g., public speaking or other public social activity, including acting, singing, dancing, participating in sporting events, and giving a school presentation). When symptoms are only associated with performance (commonly referred to as stage fright), the specifier “performance only” is added to the diagnosis.

Specific Phobias

Specific phobias refer to fear of particular stimuli (e.g., spiders, heights) and are the most common form of anxiety disorder across all ages. Yet, patients with specific phobias are the least likely to present for mental health care because they often can adapt by avoiding the trigger. Patients typically present when they are unable to avoid the trigger, avoidance leads to functional impairment, or both. An individual can have multiple phobias, but the anxious response should be specific to each specific trigger.

The mean age of onset is approximately 6 years, but symptoms can arise at any time if the individual is exposed to a fear-inducing trigger. It is important to separate such events from a source of trauma. This can often be accomplished by identifying if the event was associated with potential loss of life or severe injury and the individual was directly involved in the event. For example, developing a fear of sharks or open water after watching a horror film involving shark attacks would constitute a specific phobia, whereas anxiety and avoidance of open water after involvement in a shark attack would likely reflect a trauma response.

Selective Mutism

Selective mutism involves failing to speak, read aloud, or sing in some situations while being able to do so in other situations. It is often associated with a high social anxiety component but can also reflect negativism or oppositional behavior. While selective mutism can interfere with communication, it does not itself reflect a language disorder, as the mutism arises due to anxiety rather than a neurocognitive impairment. Most children with selective mutism have normal language skills, although comorbid communication disorders are possible, and assessment can be limited until selective mutism is addressed. It is most common in preschool- and early-grade-school-aged children.

Panic Disorder

Panic disorder is characterized by recurrent intense panic attacks (e.g., pounding heart, sweating, shaking, difficulty breathing, chest pressure or pain, nausea, and dizziness) that occur without warning or trigger (see Diagnostic Criteria for Panic Attacks below). Patients’ fear of having another panic attack can heighten anxiety and predispose them to further panic episodes. Symptoms of panic attacks occur outside the context of other anxiety symptoms; if episodes primarily occur in the context of symptoms that meet criteria for another mental health disorder, the specifier of “with panic attacks” is added to the relevant disorder (e.g., the diagnosis in a patient with symptoms consistent with generalized anxiety and episodes of panic would be generalized anxiety disorder with panic attacks).

Panic Attacks

Panic attacks are episodes marked by sudden fear or significant discomfort that peak within minutes and are accompanied by a mix of physical and cognitive symptoms (see table below). Panic attacks are distinct from anxiety because of the sudden and rapid escalation, discrete nature, and greater severity.

Panic attacks have two typical manifestations: expected and unexpected.

• Expected panic attacks occur when there is clear cause, such as a high-stress scenario or situation where panic attacks have occurred previously.

• Unexpected panic attacks can occur at any time without a clear trigger, sometimes even when the affected individual is calm or relaxing. A subtype of unexpected panic attacks is nocturnal panic attack, marked by a panic attack that wakes an individual from sleep.

Panic attacks are the primary feature of panic disorder but can occur with any anxiety disorder, other mental health disorders (including but not limited to depressive disorders, trauma disorders, and substance use disorders), and some medical conditions (including but not limited to cardiac and neuroendocrine disorders). Additionally, panic attacks can occur in isolation in patients who do not meet criteria for panic disorder or other conditions. As such, it is important to identify if the patient presents with symptoms that meet criteria for other mental health conditions, including panic disorder. If panic attacks occur primarily in the context of another disorder, the “with panic attacks” specifier should be used in the diagnosis.

Evaluation

Screening

Children and adolescents should routinely be screened for symptoms of fear, worry, and anxiety. Youth might underreport their symptoms or impairment in functioning. Therefore, parents can provide useful screening information. The Generalized Anxiety Disorder screening tool (GAD-7) is commonly used by clinicians and can quickly be completed in the office setting. However, GAD-7 is not validated for use in children younger than 13 years and primarily screens for generalized anxiety disorder symptoms.

Differential Diagnosis

The differential diagnosis for anxiety symptoms is broad and includes:

• attention deficit-hyperactivity disorder (ADHD): restlessness, inattention

• psychotic disorders: restlessness, social withdrawal

• pervasive developmental disorders (especially autism spectrum disorder): social awkwardness and withdrawal

• learning disabilities: persistent worries about school performance

• depression: poor concentration, difficulty sleeping, somatic complaints

• medical conditions: hyperthyroidism, caffeine intoxication, migraine, asthma or other breathing difficulties, seizure disorders, lead intoxication

• prescription medications: bronchodilators, sympathomimetics, glucocorticoids, selective serotonin-reuptake inhibitors (SSRIs), antipsychotics (akathisia), stimulants

• nonprescription drugs: diet pills, antihistamines, cold medications, drugs of abuse

• trauma: ongoing or historical abuse, neglect, and other adverse childhood experiences — unsurprisingly, can cause fear and anxiety (see the section on Attachment, Trauma, and Other Stressor-Related Disorders in this rotation guide)

Comorbidity

Youth with anxiety disorders have high rates of comorbid anxiety, depression, substance use disorders, and educational underachievement as adults. In children, depression and neurocognitive disorders (e.g., autism spectrum disorder and ADHD) are common comorbid conditions associated with anxiety disorders.

Management

Medication and therapy are effective treatments for anxiety disorders. Therapy (e.g., cognitive behavioral therapy or psychodynamic psychotherapy) is the primary treatment modality in children. For example, mild anxiety disorders can be managed with therapy, parental intervention, or both. Moderate-to-severe disorders may require a combination of therapy and medication. Selective serotonin-reuptake inhibitors (SSRIs) are the mainstay of medication management.

Nonpharmacologic Treatment

Engagement in avoidance behaviors reinforces and typically worsens anxiety and anxious behaviors. Although exposure to stressors or engagement in anxiety-provoking situations induces distress and symptoms, one of the most important aspects of management of anxiety symptoms is reducing and preventing avoidance. Parents often facilitate avoidant behaviors to minimize their child’s distress. However, engaging in avoidance conditions future avoidance by providing rapid relief, reinforcing the distress associated with the trigger, and driving functional impairment. In contrast, exposure to sources of anxiety can lead to conditioned tolerance and reduction of stress response.

Primary care providers can start to address anxiety by educating parents about anxiety and supporting their efforts to curb their child’s avoidant behaviors. It is important to assess for sources of harm (e.g., bullying or abuse) that can lead to avoidant behavior. In some cases, parental education and support can be sufficient to reduce symptoms without medication or directly engaging the child in therapy.

Several therapy modalities can provide benefit for children with anxiety disorders, including the following:

• Cognitive behavioral therapy (CBT) works, in part, by helping youth identify and challenge negative thoughts, gain new coping and problem-solving skills, and reduce avoidance behavior while increasing exposure to the feared stimuli.

• Insight-oriented psychotherapy focuses on identifying problematic patterns of behavior and potential underlying causes; the most effective therapies often incorporate elements of both modalities.

• Family therapy is also a useful intervention, especially to address parental anxiety.

Pharmacologic Treatment

Selective serotonin-reuptake inhibitors (SSRIs) are commonly used and well tolerated in the treatment of pediatric anxiety. Although talk therapy is appropriate first-line treatment in children with mild anxiety, SSRIs should be considered in children who experience moderate or severe anxiety, when therapy yields only a partial response, or when barriers to initial therapy cannot be overcome. Adverse effects are generally benign and include gastrointestinal symptoms, sleep changes, restlessness, diaphoresis, headaches, akathisia, changes in appetite, and sexual dysfunction. An SSRI should be stopped if akathisia (restless movement) or activation (restlessness, lability) occur after drug initiation.

Patients prescribed SSRIs should be screened regularly for risk of suicidality at follow-up visits. Current evidence suggests a favorable risk/benefit ratio for SSRI use with careful monitoring in pediatric patients and does not support withholding medication treatment. For more details on the risk of suicidality with SSRI use in young people, see Depression in the Mood Disorders section in this rotation guide.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) are not prescribed as often as SSRIs in the pediatric population. Data indicate that SSRIs are more efficacious and that SNRIs are associated with a broader adverse effect profile. Adverse effects of SNRIs include those of SSRIs as well as tachycardia and hypertension, leading to an increased risk of discontinuation and antidepressant-induced activation. Therefore, SNRIs could be considered in children with poor tolerance or lack of response to SSRIs. The SNRI duloxetine has specifically been approved for generalized anxiety disorder in children aged 7 and older. Children prescribed SNRIs should be monitored for suicidality and adverse effects as well as blood pressure and heart rate.

Other Medications

• Buspirone is a well-tolerated antianxiety medication that can be prescribed for adolescents. However, results of some studies have raised questions about efficacy, suggesting that it is no better than placebo.

• Sedating antihistamines, beta-blockers, gabapentin, and alpha-adrenergic-agonist medications are sometimes used as adjuncts to SSRIs.

• Propranolol has been shown to be effective as an as-needed medication in individuals with performance-associated social phobia, but evidence has otherwise not adequately shown benefit in pediatric anxiety disorders.

• Gabapentin lacks sufficient evidence in pediatric populations for management of anxiety.

• Benzodiazepines are sometimes prescribed as an adjunctive short-term treatment for anxiety disorders but carry risks for sedation, dependence, and misuse. Although benzodiazepines are effective for acute management of anxiety in pediatric populations, studies suggest limited-to-no benefit in long-term management of pediatric generalized anxiety disorder, separation anxiety disorder, and social anxiety disorder. Some data suggest that benzodiazepines are associated with increased suicidality as compared to placebo, but further study is needed to confirm the possible association.

Prognosis

The more severe a child’s anxiety disorder and the greater the functional impairment, the more likely it is to persist. Additionally, the presence of parental mental health disorders, family accommodation of anxiety, and limited engagement with treatment predict both increased severity and duration of symptoms. The presence of comorbidities also affect prognosis.

However, treatments for anxiety are often quite effective, and can alleviate the patient’s symptoms and lead to remission. Patients with a history of one anxiety disorder are more likely to develop other anxiety disorders, even if the original disorder is resolved.