Overview of anxiety disorders in children and adolescents

By Josephine Elia, MD, Nemours/A.I. duPont Hospital for Children Last complete revision/change Apr 2021 Anxiety disorders are states of fear, worry, or dread that are disproportionate to the situation and that impair a child's normal functional abilities. Anxiety can result from physical problems. The diagnosis is clinical. Treatment is with behavior therapy and drugs, usually antidepressants (SSRIs). Some degree of anxiety is a normal aspect of development: Most young children show some fear of being separated from their mothers, especially in unfamiliar environments. Between 3 and 4 years old, fear of the dark, monsters, insects and spiders is common. The shy child reacts to new situations, first with fear or withdrawing. In older children, the most common fears are of aggression or death. Older children and teenagers are often anxious when they have to present a book in front of their peers. Such difficulties should not be regarded as evidence of disturbance. However, if these manifestations of anxiety become exaggerated to the point that they significantly impair function or cause severe distress and/or avoidance, anxiety disorder should be considered. Anxiety disorders arise in about 3% of 6-year-olds and about 5% of adolescent boys and 10% of adolescent girls (1–3). Children with anxiety disorder are at increased risk for depression(4), suicidal behavior (5, 6), drug and alcohol dependence (7), and academic difficulties (8) later in life. Anxiety disorders that occur in children and adolescents include Agoraphobia generalized anxiety disorder panic disorder separation anxiety disorder social anxiety disorder specific phobias

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 Adolescent 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 later. 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 the fear response. In mice, loss of serotonin 1A receptor (5-HT1AR) expression in the forebrain during early development results in dysregulation of the hippocampus and leads to anxiety behaviors (1). Heredity studies indicate that genetic and environmental factors play a role. No specific genes were identified; many genetic variants are likely involved. Anxious parents tend to have anxious children and have the unwelcome potential to make the children's problems worse than they really could be. Even a normal child finds it difficult to remain calm and calm in the presence of anxious parents, which becomes a challenge for the child who is already genetically predisposed to anxiety. In up to 30% of cases, it is helpful to treat the parent's anxiety in conjunction with the child's anxiety (see Anxiety Disorders). Reference on etiology 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

Signals and symptons Perhaps the most common manifestation of an anxiety disorder in children and adolescents is school avoidance. The term “school rejection” has largely supplanted the term “school phobia”. Actual fear of school is extremely rare. Most children who refuse to go to school likely have separation anxiety, social anxiety disorder, panic disorder, or a combination of these. Some have specific phobias. Consideration should be given to the possibility that the child is being bullied. Some children openly complain about their anxieties, describing the reason, eg. eg, “I'm afraid I'll never see you again” (separation anxiety) or “I'm afraid I'll be made fun of” (social anxiety disorder). However, most children express their discomfort by citing somatic complaints: “I can't go to school because I have a stomachache”. These complaints are often true because stomach upset, nausea, headache, and trouble sleeping often develop in anxious children. Several long-term follow-up studies confirm that many children with somatic complaints, especially abdominal pain, have an underlying anxiety disorder.

Diagnosis clinical evaluation The diagnosis of anxiety disorder is through a clinical evaluation (1). Confirmation can come from the psychosocial history. Rating scales can be useful for tracking. Several validated scales are freely available: Screen for Child Anxiety-Related Emotional Disorders [SCARED], Spence Children's Anxiety Scale [SCAS], Preschool Anxiety Scale ( Preschool Anxiety Scale) [PAS] and General Anxiety Disorder-7 (General Anxiety Disorder 7) [GAD-7] ). The physical symptoms that anxiety causes in the child can complicate the assessment. Many children undergo physical examinations before a doctor considers an anxiety disorder. Diagnostic 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 The prognosis depends on the severity, the availability of appropriate treatment and the receptivity of the child. In most cases, children carry anxiety symptoms into adulthood. However, with early treatment, many children learn to control their anxiety.

Prognosis The prognosis depends on the severity, the availability of appropriate treatment and the receptivity of the child. In most cases, children carry anxiety symptoms into adulthood. However, with early treatment, many children learn to control their anxiety. Treatment Behavioral therapy (exposure therapy, cognitive behavioral therapy [1]) Parent-child and family interventions Drugs, usually selective serotonin reuptake inhibitors (SSRIs) and, to a lesser extent, serotonin noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressants (2) for long-term treatment, and sometimes benzodiazepines to relieve acute symptoms (3). Many of these disorders are treated with behavioral therapy (using exposure and reaction preventive principles), sometimes associated with drugs (4). In exposure-based cognitive-behavioral therapy, the child is gradually exposed to anxiety-provoking situations. By helping the child stay in the anxiety-provoking situation (preventive reaction), therapists enable children to gradually become desensitized and feel less anxious. Behavior therapy is most effective when an experienced therapist who is knowledgeable about the child's development individualizes these principles. In mild cases, behavioral therapy alone is sufficient, but drug therapy may be necessary in more severe cases or when access to a behavioral therapist is limited. SSRIs are often the first choice for long-term treatment (see table Drugs for Long-Term Treatment of Anxiety and Related Disorders). SSRIs combined with CBT are more likely to improve 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 tolerated by pediatric patients (aged 6 to 17 years) with generalized anxiety disorder (1) but two randomized controlled trials did not demonstrate greater efficacy than placebo; these studies failed to detect small effects. Reports of improvement in developmental disorders such as Williams syndrome (5) and autism (6) require well-controlled clinical trials.

Most children tolerate SSRIs well. Occasionally, stomach upset, diarrhea, insomnia, or weight loss may occur. Some children have adverse behavioral effects (eg, disinhibition or agitation); these effects are usually mild to moderate. Patients generally respond to a minor dose adjustment or a drug switch. Rarely, adverse behavioral effects (eg, aggression, increased suicidality) are severe. Adverse behavioral effects are idiosyncratic and can arise with any antidepressant and at any time during treatment. As a result, children and adolescents taking these drugs should be closely monitored. References about treatment 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 Adolescent 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 System 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 can be school avoidance; most children feel their discomfort in terms of somatic complaints. Only consider anxiety a disorder in children when the anxiety becomes so exaggerated that it greatly impairs functioning or causes severe distress and/or avoidance. The physical symptoms that anxiety causes in the child can complicate the assessment. Behavior therapy (using exposure and response prevention principles) is most effective when an experienced therapist, knowledgeable about child development, individualizes these principles to the child. When cases are more severe or when access to an experienced child behavior therapist is limited, drugs may be necessary. Commercially available panels for testing CYP variants remain limited. Additional Information The following English resources may be helpful. Please note that The Handbook is not responsible for the content of these resources. CPIC — Clinical Pharmacogenetics Implementation Consortium: This international consortium facilitates the use of pharmacogenetic tests to treat patients. The website provides access to guidelines to help clinicians understand how genetic test results should be used to improve pharmacological treatment. 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 guidance on the psychosocial and psychopharmacological treatment of anxiety and aim to improve treatment quality and clinical outcomes for children and teenagers.

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