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Anxiety

Anxiety

Anxiety disorders are among the most common pediatric psychiatric disorders, affecting 15-20% of youth. They are characterized by excessive and difficult to control worry, leading to distress and impairment in daily life.  Common symptoms include the constant need for reassurance, sleep issues, avoidance of activities, shutting down or outbursts when pushed to engage in group settings.  Frequently, a child with anxiety may appear to be shy, worried, home sick or nervous.

Early identification and treatment of anxiety by a healthcare professional is vital. Untreated anxiety places youth at higher risk for other challenges, including difficulties in school, strained relationships with adults and peers and substance abuse.

Common Types of Anxiety Disorders:

Generalized Anxiety Disorder: Generalized Anxiety Disorder may be indicated when a child worries too much about too many things. In children, this anxiety often focuses on performance in school or sports. It may drive the child to strive for perfection, creating extreme studying habits or practice routines. Children with this disorder can be very hard on themselves and may seek constant approval or reassurance from others. 

Panic Disorder: Panic Disorder may be indicated when a child suffers from brief, but intense, unexpected panic or anxiety attacks. These attacks often have components of both physical sensations and psychological distress. Additionally, the onset of the attack is often sudden and without an apparent trigger. Children with panic disorders often find little relief in-between attacks; they are instead consumed with worry of another impending episode, and fear losing control, or “going crazy”. Panic attacks are seen in other anxiety disorders, but when they occur without clear triggers they may be classified as panic disorder. 

Separation Anxiety Disorder: Separation Anxiety Disorder may be indicated when a child (as old as 9)  cannot bear to be separated from a parent or other family member. Separation anxiety is typically normal for children aged 3 and under. Older children who struggle with separation anxiety may refuse to go to school, camp or sleepover at a friend’s house. They may also demand that someone stay with them at bedtime. 

Social Anxiety Disorder: Social Anxiety Disorder is characterized by an intense fear of social and performance situations. The child may experience persistent “stage fright” that can significantly impair school performance and attendance. It can also hinder a child’s ability to socialize and develop friendships among peers. 

When to Seek Treatment?

Fear and worry are normal, and in some cases, can even be healthy reactions. However, further assessment by a healthcare professional is needed when a child experiences symptoms that are developmentally inappropriate, out of proportion, last > 6 months, impair day-to-day functioning or interfere with quality of life.

 

Clinical Pearl: Misdiagnosis and Comorbidity

Outbursts surrounding refusal to comply with a request or engage in a task can be caused by anxiety. These outbursts can be mislabeled as defiance or oppositional behaviors. 

Reports of active suicidal planning or intent increase safety risk, and should prompt re-evaluation for comorbid disorders such as depression, anxiety and PTSD.

Myths vs. Facts

Anxiety can happen independent of stress.

Fact: While love and support are important, there are evidence-based treatments available to help alleviate anxiety symptoms. Continual reassurance, or removal of the anxiety provoking task, can perpetuate anxiety.

There may not be an easily identifiable cause of anxiety.

Ignoring anxiety, or thinking only positive thoughts, will not help the symptoms go away.

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Meet John

John is an 8-year-old boy presenting to his primary care practitioner's (PCP) office because of his school’s referral. According to his school administration, John frequently takes trips to the school nurse for stomachaches and headaches, and he demands to be sent home during these nurse visits. He is also noted to be avoidant in the classroom, and often gets agitated and tearful when asked any questions. His mom reports that he gets clingy during school drop offs, and this makes it difficult to leave him at the school. When John is sent home early, he does not show any physical symptoms and is often engaged in his own activities. His mom shares that the school has cautioned her about John’s frequent absence despite his academic performance being strong.  All his past medical history has been unremarkable.

Family history

His mother has a history of anxiety, and his father has a history of alcohol dependence.

Social history

John lives with his mother, older sister, and stepfather. He witnessed domestic violence at a young age. 

Screening and Assessment

Screening and Clinical Evaluation

Anxiety disorders require a clinical diagnosis, which is typically initiated by collecting information from the child and caregivers. Assessment begins by ruling out other medical conditions that may be causing the symptoms. Next, a comprehensive assessment is completed, which may include a combination of a clinical interview and the use of standardized rating scales. Standardized rating scales are neither definitively diagnostic, nor a definitive indication of a specific condition. The intent is to determine if the symptoms experienced by the child are contributing to their social, emotional, behavioral, academic, or work challenges.  
 
There are several rating scales validated for the screening of anxiety (SCARED, GAD-7, MASC). The Screen for Child Anxiety-Related Emotional Disorders (SCARED) is one of the most commonly used tools to help diagnose and monitor anxiety disorders in children and adolescents.  The SCARED is a 41 item Likert scale assessment that is delivered to both the child or adolescent and parent(s). A score of 25 or above is indicative of a possible anxiety disorder, however the scale can be scored in parallel with various specific anxiety disorders listed in the DSM-5. Depending on how various items are scored, the assessment can indicate if the child or adolescent is possibly presenting with panic disorder, significant somatic symptoms, generalized anxiety disorder (GAD), separation anxiety disorder, social anxiety disorder, and/or school avoidance. This information can thus be used to individualize treatment plans. Practitioners are encouraged to use the instrument to help with initial diagnosis, monitoring, response to medication, and evaluating for symptom remission.

SCARED Screen

Clinical Pearl: Cycle of Avoidance

Avoidance of activities or situations are often the most disabling aspect of anxiety, but youth and parents may feel unable to break a cycle of avoidance, or unintentionally reinforce avoidance. For example, an anxiety disorder can lead to physical symptoms and school avoidance. It is therefore important to work through avoidance by encouraging patients set small, manageable goals towards the desired behaviors, like going to school or leaving the house.

 

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John

Upon clinical evaluation, John’s mom reports that he has been a good student and that he loved school until about two years ago. His family had to move after the divorce of John’s biological parents and the subsequent marriage with his stepfather a year later. John had difficulty adjusting to the new environment and has been worried about ‘everything going wrong’. John has been even more nervous lately, with worry about the possibility of his mother and sister getting sick with COVID-19. He scored a 36 on the SCARED parent rating scale, and on the youth rating scale he scored 45. It was ultimately discerned by his PCP that he met criteria for GAD and school avoidance. 

Diagnostic Features

Common Diagnostic Features of Anxiety Disorders for Children and Adolescents include the following. For more complete diagnostic criteria, see DSM-5 Anxiety Disorders Diagnostic Features.

Generalized Anxiety Disorder (GAD)

Excessive anxiety or worry occurring nearly every day for at least six months, the anxiety or worry is difficult to control, and the anxiety or worry is associated with three or more of the following: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbances. Furthermore, the anxiety or worry causes clinically significant distress in educational, occupational, or other important facets of life, the anxiety or worry cannot be better explained by substance use or another medical condition, and the symptoms cannot be better attributed to another mental disorder. 

Social Anxiety Disorder

This disorder is characterized by excessive fear or anxiety that arises in one or more social situations, including fear or anxiety within peer settings and not just in the presence of adults. Furthermore, the child or adolescent fears that their anxiety will be negatively evaluated by others, the social situations almost always provoke fear or anxiety (which may be expressed via crying, tantrums, freezing, clinging, shrinking, or failing to speak), the feared social situations are avoided or attended to with fear or anxiety, the fear or anxiety is disproportionate to the posed situation, the fear or anxiety or avoidance last for at least six months, and cause clinically significant distress, the symptoms cannot be explained by  substance use or another medical condition, the symptoms cannot be explained by another mental disorder, and if another medical condition is also present the fear or anxiety is unrelated to the medical condition.

Panic Disorder

Repeated and unexpected panic attacks, with at least one of the panic attacks having been followed by one month (or more) of persistent fear of another panic attack and/or maladaptive behavior change related to the panic attacks, the panic attacks cannot be explained by substance use or another medical condition, and the symptoms of this disorder cannot be explained better by another mental disorder.

Separation Anxiety Disorder

Excessive fear or anxiety regarding separation from those that the individual is attached as indicated by three of more of the following: frequent distress when separated or anticipating separation from major attachment figures, excessive worry about losing a major attachment figure, persistent worry about an event that would cause separation (e.g. having an accident, becoming ill, getting lost, etc.), refusal or reluctance to leave the home for fear of separation, excessive fear about being alone at home or in other settings, refusal or reluctance to sleep away from home or to go to bed without major attachment figure near, persistent nightmares around the theme of separation, and repeated physical ailments (e.g. headaches, nausea, vomiting) when separation from major attachment figure occurs or is anticipated.

Selective Mutism

Persistent failure to speak in social settings in which is it expected (e.g. school) despite speaking in other settings, disturbance interferes with educational achievement,  occupational achievement, or social communication, failure to speak has occurred for at least one month (not limited to the first month of school), the failure to speak is not due to lack of knowledge of spoken language, and the disturbance cannot be better explained by a communication disorder, nor does it occur exclusively during the course of ASD, schizophrenia, or another psychotic disorder.

Specific Phobias

A key diagnostic feature for this disorder is fear or anxiety surrounding a particular object or situation. Further diagnostic criteria include the object or situation provoking fear in an almost immediate manner, the object or situation is purposely avoided on a regular basis, the fear or anxiety is disproportionate to the danger posed, the fear or anxiety or avoidance is persistent for 6 months or more, there is clinically significant distress in social, occupational, or other important areas of life, and the fear or anxiety cannot be explained by another mental disorder.

 

Differential Diagnosis

Since many symptoms of anxiety resemble those of other behavioral health disorders, it is important to assess these to ensure an accurate diagnosis. Some of the common differential diagnoses and distinguishing symptoms of anxiety are listed below:

  • Common Comorbidities – The most common co-occurring diagnoses include ADHD, Depression, Substance Use Disorder.
  • Anorexia Nervosa or Bulimia Nervosa – Anxiety or worry associated with fear of gaining weight.
  • Bipolar Disorder, Depressive Disorders and Schizophrenia – Anxiety occurring as an associated feature but includes other specific symptoms characteristic of a mood or psychotic disorder.
  • Obsessive-Compulsive Disorder – Repetitive anxiety provoking thoughts that are experienced as intrusive, unwanted, inappropriate along with a compulsion to reduce anxiety.
  • Panic Disorder: Anxiety and worry about having additional panic attacks.
  • Post-Traumatic Stress Disorder or Acute Stress Disorder – Anxiety occurring to internal or external triggers that resemble an aspect of traumatic event, hyperarousal, reactivity to an event.
  • Separation Anxiety Disorder – Excess anxiety and worry focused exclusively on separation from major attachment figures.
  • Social Phobia – Excess anxiety and worry focused exclusively on social situations. 
  • Somatic Symptom Disorder/Illness Anxiety – Focused exclusively on health, becoming ill, or seriousness of symptoms.
  • Substance/Medication Induced – Onset during intoxication or withdrawal or occurring as a side effect.

Treatment

A multi-modal approach involves management strategies that include non-medication interventions and medication interventions. 

Shared decision-making encourages children, teens, and caregivers to have a voice in their care.  The Ohio Minds Matter Shared Decision-Making Toolkit is a guide for youth and families to take an active role in their treatment, prepare for their appointment, consider treatment options, document their symptoms, and describe their goals.
 

Shared Decision Making

 

 

Non-medication interventions

Psychotherapeutic Treatment is the recommended first line treatment. The goal is to help the patient identify and change emotions, thoughts, and behavior. 

  • Psychotherapy:
    • Cognitive Behavioral Therapy assumes that thoughts, feelings, and behaviors have a reciprocal relationship with one another. This modality is particularly useful for anxiety as it teaches a child to moderate and combat unhelpful or disruptive thoughts, thus improving their mood and increasing positive behaviors.
    • Parent -Child and Family Interventions involve parent(s) or other relevant family members in the treatment of a child’s anxiety. This approach focuses on what other members of the family can do to support the child in their recovery from anxiety disorder.
  • School Interventions:
    • School interventions include teacher and classroom interventions and accommodations, such as identifying a trusted staff member to speak with or a safe place to go when anxious.
    • Individual Education Plan (IEP) can be requested for accommodations in classwork and homework.
    • See the Ohio Department of Education for school resources and Individualized Education Program (IEP).

 

Clinical Pearl: Psychotherapeutic Considerations

Psychotherapeutic treatment of anxiety typically involves graded exposure to anxiety-provoking stimuli, which can lead to short-term increases in distress. Primary care providers play a vital role in reinforcing the value of psychotherapy, even when it is difficult.

Cognitive behavioral therapy for youth with anxiety is effective but is less effective if there is comorbid ADHD that is untreated or if CBT is administered late in the day after ADHD medication has worn off.

 

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John

The diagnostic impressions of John were communicated with the school upon his parent’s request.  His care plan included engaging in therapy to explore the reasons for his current symptoms, including the discussion of any traumatic experiences related to witnessing domestic violence.  After ruling out any concerns of PTSD, John continued to engage in cognitive behavior therapy.  His therapist also worked with his school on a behavior plan to support him in staying at school.

Medication Management

When psychotherapy alone results in a partial or no response, medications should be considered. SSRIs are the first line pharmacological treatment. These are the most well studied and most effective medications, even though they may not have FDA approval for pediatric anxiety disorders.

4/4

John

After about 8 weeks of therapy, John’s parents reported that he was progressing well with some residual anxiety around separation at the time of school drop off. He was performing well academically and has been implementing coping skills with the help of a school counselor. During the follow-up with his PCP, his parents expressed interest in starting John on medication for his current symptoms. The SCARED instrument was repeated, and John showed a 30% reduction in his score. His PCP suggested continuing with therapy and monitoring his progress before starting a trial of Fluoxetine.

For SSRI prescribing guides see Antidepressant Medication Aid.

See the Ohio Department of Medicaid Unified Preferred Drugs List for information about prescription coverage for children enrolled in Medicaid.

Medicaid Unified Preferred Drugs List

 

Prescribing Principles

When starting an SSRI medication in a patient who has never taken this type of medication, it is important to start at a low dose for the patient’s age and weight.  

This allows clinicians to assess the patient’s tolerability of the medication. After two weeks, the medication should be increased in regular intervals (2 to 4 weeks) until the patient’s symptoms are significantly improved or they cannot tolerate a dose high enough to achieve symptom relief or the maximum dose of the medication is reached. 

SSRIs carry a Black Box warning due to a rare but significant risk of increased suicidality in the initial stages of treatment. It is important to talk about the boxed warning with families during medication management visits and direct them to notify a provider if suicidal thoughts or behaviors develop or intensify. Most studies suggest that the potential benefits of adding SSRI treatment for moderate to severe anxiety or depression treatment far outweigh the minimal potential risk that patients will experience increased suicidal ideation.

Typical Starting Doses of SSRI’s:
Medication Pre-pubertal Children Peri-pubertal Children Post-pubertal adolescents
Fluoxetine 2.5- 5 mg 5-10 mg 10 mg
Escitalopram 1- 2.5 mg 2.5 mg 5-10 mg
Sertraline 12.5 mg 12- 25 mg 25- 50 mg

For more information see Antidepressant Medication Aid.

 

"Failure" of an SSRI Medication

To say that a patient has failed a trial of an SSRI, they must have reached a maximum tolerated dose for four weeks and have been on medication for a total time of over eight weeks without receiving meaningful benefit.

Example: 12 y/o patient started on fluoxetine 5 mg and titrated up to 20 mg without side effects or symptomatic relief over 12 weeks. This is not a treatment failure as they did not reach a maximum dose, either by tolerability or dosing threshold. This patient should have the fluoxetine increased. 

Example: 16 y/o patient started on escitalopram 10 mg and increased to 20 mg over eight weeks. Patients had significant somnolence and GI symptoms at the higher dose and did not achieve symptom relief. Escitalopram should be discontinued due to treatment failure.

 
Cross Tapering

When a patient has failed their first SSRI, the next step is to switch to another SSRI. This can be done by cross tapering or starting a second medication and increasing its dose at the same time the first medication is being weaned down. One can think of this as going up on the dose of a new medication in a stepwise manner while going down on the dose of the ineffective medication in the same stepwise manner. This approach reduces potential side effects that can emerge at the time of SSRI discontinuation and allows clinicians to achieve dose equivalence of the newly started SSRI relatively quickly.

There are no agreed upon time intervals for dose adjustments during a cross taper. In general, dose changes can take place after a few days or a week. The longer a patient has been on a medication, the longer it should take to wean.

Example of a Cross Tapering Schedule: patient currently on fluoxetine 40 mg and switching to sertraline -week 1: decrease fluoxetine to 20 mg and start sertraline 25 mg -week 2: decrease fluoxetine to 10 mg and increase sertraline to 50 mg, check in with clinician -week 3: stop fluoxetine and increase sertraline to 100 mg

Approximate Dosing Equivalents
SSRI Step 1 Step 2 Step 3 Step 4
Fluoxetine 10 mg

20 mg

 40 mg 60 mg
Sertraline 25- 50 mg 50- 100 mg 100-150 mg 200 mg
Escitalopram 5 mg 10 mg 20 mg 30 mg
Side Effects
  • Common Side Effects Include:
    • Nausea, diarrhea- resolve in several days, typically transient. 
    • Sleep disruption without or without intense dreams. 
    • Increased blood pressure for SNRIs. 
  • Black Box Warning: There is a rare but significant risk of increased suicidality in the early stages of starting antidepressants. See the Clinical Pearl: Black Box Warning

When in doubt, decrease dose and consult with a psychiatrist.

 

Clinical Pearl: Black Box Warning

The discussion of the boxed warning about suicidal thoughts and behaviors may cause some patients and families to be nervous about pharmacotherapy. It is better for them to have the topic broached by a provider they can trust instead of obtaining information from less reliable sources. Some of theses resources may have an anti-medication agenda and spread false information. In discussing the boxed warning with patients and families, it can be helpful to link the discussion to the need to notify a provider if suicidal thoughts or behaviors develop or intensify, regardless of the reason. For instance: “I bring this up not because I think the medication will cause you to be suicidal – that does not seem at all likely to happen – but because if you were having suicidal thoughts (or more frequent or intense suicidal thoughts), it would be important for you to talk with an adult you trust, like me, your therapist, or your caregiver about them.

 

Managing Side Effects
Patient Reports Clinical Description Action to Consider
Uneasy restless feeling, need to move legs/walk around, diaphoresis Akathisia Lower dose, titrate slowly
Restlessness, increased impulsivity, difficulty falling asleep Activation Lower dose, titrate slowly
Dizziness, nausea/emesis, h/a, gait instability, myalgias, fatigue Withdrawal syndrome  Restart or reinstate low to moderate dose
Clonus, disorientation, increased blood pressure, fever Serotonergic toxicity Reduce drug interactions, seek consultation in severe cases
Bizarre behaviors, not sleeping for days, rapid speech, extreme irritability Mania (rare) Stop medication and consult with psychiatrist

 

SSRI Discontinuation

The goal of treatment with SSRIs is to achieve symptom remission. Once a patient has significant improvement in their symptoms, an SSRI should be continued for 12 months before it is weaned off. In this instance, the SSRI should be weaned slowly to allow for adequate monitoring of potential symptom recurrence.

Example of discontinuation schedule: 15 y/o patient has been on fluoxetine 40 mg for 12 months with symptom remission

  • Month 1: fluoxetine 30 mg daily and follow up visit to monitor symptoms 
  • Month 2: fluoxetine 20 mg daily and follow up visit to monitor symptoms
  • Month 3: fluoxetine 10 mg daily and follow up visit to monitor symptoms
  • Month 4: stop fluoxetine 

Ongoing Management

  • Monitor medication compliance and side effects.
  • Continue to monitor for 6 – 12 months.
  • Titrate medicine within therapeutic dose range.
  • Provide anticipatory guidance including interventions to build resilience.
  • Seek consultation or refer to a specialist if any of the following occur: suicidal Ideation, prior suicide attempts, significantly impaired functioning, or serious trauma.
  • Provide family psychoeducation

Frequently Asked Questions

Anxiety disorders tend to be chronic unless treated. Kids can successfully manage or overcome anxiety with professional guidance, treatment, and family support.

With proper treatment, Improvements in symptoms usually start within two to six weeks. If you do not see progress after this time, talk to your child health care provider or therapist about other options or medication changes.

Health care providers recommend that initial treatment should be continued at least 6-12 months after symptoms have become much more manageable or completely resolved, however this varies with each child.

While no medication is risk free, make sure to review side effects before starting any medication. Side effects should also be monitored at each visit.

References

  1. Anxiety Disorders Association of America (n.d). Anxiety Disorders in Children. https://adaa.org/sites/default/files/Anxiety%20Disorders%20in%20Children.pdf
  2. Child Mind Institute. (n.d.) Parenting anxious kids. https://childmind.org/topics/anxiety/#parenting-anxious-kids
  3. Compton, S. N., Walkup, J. T., Albano, A. M., Piacentini, J. C., Birmaher, B., Sherrill, J. T., Ginsburg, G. S., Rynn, M. A., McCracken, J. T., Waslick, B. D., Iyengar, S., Kendall, P. C., & March, J. S. (2010). Child/adolescent anxiety multimodal study (CAMS): Rationale, design, and methods. Child and adolescent psychiatry and mental health, 4. https://doi-org.proxy.lib.ohio-state.edu/10.1186/1753-2000-4-1
  4. Dulcan, M. K. (2015). Dulcan's textbook of child and adolescent psychiatry (2nd ed.). American Psychiatric Association Publishing
  5. Dulcan, M. (2022). Dulcan's textbook of child and adolescent psychiatry (3rd ed.). American Psychiatric Association Publishing
  6. Feder, J., Tien, E., & Puzantian, T. (2018). Child medication fact book for psychiatric practice. Carlat Publishing, LLC
  7. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A., Edwards, V., Poss, M.P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4) 774–786. https://doi.org/10.1016/s0749-3797(98)00017-8
  8. First, M. B. (2014). Dsm-5-Tm Handbook of differential diagnosis. American Psychiatric Publishing
  9. Foy, J.M., Green, C.M., Earls, M.F, & Committee on Psychological Aspects of Child and Family Health, Mental Health Leadership Work Group. (2019). Mental health competencies for pediatric practice. Pediatrics, 144(5). https://doi.org/10.1542/peds.2019-2757
  10. Massachusetts Child Psychiatry Access Program. (n.d.). Anxiety “clinical pearls” for primary care providers. https://www.mcpap.com/pdf/AnxPearls.12.05.18.pdf
  11. University of Pittsburgh. (n.d.). Screen for child anxiety related emotional disorders (SCARED). https://www.pediatricbipolar.pitt.edu/resources/instruments