Overview of Anxiety Disorders in Children and Adolescents

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.

Anxiety symptoms among youth doubled during the COVID-19 pandemic, especially in girls (2), and mental health visits for anxiety increased 43% (3). These study results were controlled for gender, age, and presence of pre-COVID anxiety symptoms and showed that poor connectedness to caregiver, poor sleep hygiene, and high amounts of screen time were reported to be significant predictors of the child's COVID-19 anxiety symptoms (4).

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 ).

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 describe 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.

• Psychiatric assessment

• Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM 5-TR) criteria

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, thorough testing for physical disorders is done before clinicians consider an anxiety disorder.

• Behavioral therapy (exposure-based cognitive-behavioral therapy)

• Parent-child and family interventions

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

Anxiety disorders in children are treated with behavioral therapy (using principles of exposure and response prevention) (1), sometimes in conjunction with drug therapy (1–4).

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 Medications for Long-Term Treatment of Anxiety and Related Disorders). SSRIs combined with CBT have the highest likelihood of improving symptoms (45). Reports of improvement in developmental disorders such as Williams sydrome (6) and autism (7) have generated ongoing investigations.

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 medication dose or changing to a different medication 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 medications must be closely monitored.

Prognosis for anxiety disorders in children 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.

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

1. CPIC—Clinical Pharmacogenetics Implementation Consortium: This international consortium facilitates use of pharmacogenetic tests for patient care. The site provides access to guidelines to help clinicians understand how genetic test results should be used to enhance drug therapy.

2. American Academy of Child and Adolescent Psychiatry Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders: These guidelines summarize expert-based guidance about the psychosocial and psychopharmacologic treatment of anxiety and aim to enhance quality of care and clinical outcomes for children and adolescents.