Anxiety Disorders

Types of Anxiety Disorders

Situational Anxiety

Occurs only when faced with the anxiety-provoking situation.

Separation Anxiety Disorder

This condition happens when one feels excessive anxiety when separated from a loved one, usually a primary caregiver. While separation anxiety in babies and toddlers is a normal stage of development, separation anxiety disorder can affect children and adults.

Selective Mutism

This condition happens when one doesn’t talk in certain situations because of fear or anxiety. It usually affects young children, but it can also affect adolescents and adults.

Specific Phobia

A phobia is when a specific thing or situation causes one to feel fear or anxiety that’s so severe it consistently and overwhelmingly disrupts one’s life. There are hundreds of different types of phobias, and there’s one diagnosis for almost all of them: specific phobia. Only one phobia, agoraphobia, is a distinct diagnosis.

Social Anxiety Disorder

This condition (formerly known as social phobia) happens when one experience intense and ongoing fear of being judged negatively and/or watched by others.

Agoraphobia

This condition causes an intense fear of becoming overwhelmed or unable to escape or get help when in a community location. People with agoraphobia often avoid new places and unfamiliar situations, like large, open areas or enclosed spaces, crowds and places outside of their homes.

Unprovoked Anxiety

Occurs “out of the blue” without a known precipitant.

Generalized Anxiety Disorder

This condition causes fear, worry and a constant feeling of being overwhelmed. It is characterized by excessive, frequent and unrealistic worry about everyday things, such as school, performance, new situations, and health (self and loved ones).

Panic Disorder

This condition involves multiple unexpected panic attacks. A main feature of the condition is that the attacks usually happen without warning and aren’t due to another mental health or physical condition. About 1/3 of people with panic disorder also have agoraphobia.

Psychiatric disorders with prominent anxiety that aren’t categorized as an anxiety disorder.

Post-traumatic stress disorder

A mental health condition that’s caused by an extremely stressful or terrifying event — either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable. Young children who have experienced one or multiple traumas may present differently than adults, with more generalized irritability and dysregulated behavior.

Obsessive-Compulsive Disorder

This condition includes Obsessions: Unwanted and intrusive thoughts, feelings, images, or sensations & compulsions: Repetitive actions or behaviors that people perform to relieve the distress caused by their obsessions. Formerly categorized as an anxiety disorder, individuals with OCD may experience extreme distress if they are unable to perform rituals that they believe will decrease their distressing worries.

Presenting Complaints

Somatic symptoms are a common presenting complaint for children with anxiety. Symptoms of anxiety disorders vary depending on the type.

Common symptoms include:

Physical symptoms:

• restlessness
• stomachaches, nausea, GI complaints, change in appetite
• heart palpitations
• shortness of breath
• muscle tension
• dry mouth
• numbness or tingling in hands or feet
• difficulty falling asleep or staying asleep (insomnia)

Psychological symptoms:

• feeling panic, fear, dread and uneasiness
• feeling on edge or irritable
• uncontrollable, obsessive worries
• difficulty concentrating
• irritability and anger.
• being clingy
• reluctant or refusing to go to school

Etiology

Risk Factors: The causes of anxiety disorders are multi-factorial and complex

• Genetic: can run in families, suggesting that genes play a role. Heritability estimates are between 20-65%.
• Fear circuitry aberrations: either inborn or through adverse early life experiences
• Temperament: introversion, behavioral inhibition, and negative emotionality
• Medical: may be linked to an underlying health issue, such as diabetes, thyroid problems, respiratory disorders, etc. Children with severe food allergies have rational fears about eating that food, but may become anxious about ingesting other foods, as well.
• Medications: rule out drugs as the cause of anxiety as a side effect, such as drugs containing caffeine, corticosteroids, and some asthma medications
• Substances of abuse: rule out the use of nicotine, marijuana, abuse of sympathomimetics, and other illicit substances
• Environmental: stressful or traumatic life experiences can trigger anxiety disorders in people who are already prone to anxiety
• Psychological: cognitive factors, such as how people think about threatening events, play a critical role
• Gender and expectations: gender roles and societal expectations can lead to feelings of anxiety 
• LGBTQ+ identity: LGBTQ+ people are at increased risk of experiencing hostile environments and discrimination, which can lead to poor mental health
• Children of color: increased risk of experiencing discrimination and harsher expectations, leading to poor mental health
• Parental modeling: anxiety disorders in children may develop in context of high anxiety household
• Accommodation: chronic anxiety is exacerbated by accommodation (parents and others attempting to help the child avoid the situations that make them anxious)
• Cognitive factors: cognitive rigidity and/or being prone to catastrophizing

Protective factors:

• Strong community relationships: a supportive community
• Self-esteem: high self-esteem and self-confidence
• Parental involvement: parental involvement and appropriate supervision (without being overprotective “helicopter” parents)
• Parental warmth: parental warmth and caring
• Coping skills:  adaptive coping to stress or life challenges
• Social-emotional skills: good social skills, having friends
• Cognitive factors: cognitive flexibility and ability to put events or situations in context
• Problem-solving skills: good problem-solving and cognitive skills
• Resilience: demonstration of perseverance and “grit” 
• No discrimination: acceptance by peers, teachers, community

PCP Visit Screen for behavioral health problems Pediatric Symptom Checklist (PSC-17) Cut point 15 total: 5 Internalizing (Items 2, 6, 9, 11, 15) Item 15 is specific for anxiety If screen is positive, conduct focused assessment: focused symptom rating scales and clinical interview/medical workup (see below) If concern for potential for imminent danger—211 emergency crisis, Urgent Crisis Center for Children’s Mental Health, 911 for true emergency

The US Preventive Services Task Force (USPSTF) recommends regular screening for anxiety in children ages 8 to 18.  This may be done during a well-child checkup.  The PSC-17 or GAD-7 scales are the shortest and may be a good initial screener.  The Screen for Child Anxiety Related Disorders (SCARED) is 41 items (for parent and older children) and should be considered if the initial shorter screenings or patient interview suggests an anxiety disorder.  All of the following are validated screening tools in the public domain.

Rating Scales for Pediatric Anxiety

SCARED (parent and child): ages 8-18 (cut-point: 25 parent and child) orGAD-7: ages 12+ (cut-points: 10 moderate, 15 severe)

Clinical History

• assess acute or chronic stressors that may have precipitated or exacerbated anxiety
• family history of anxiety and other mental health disorders
• assess for other psychiatric symptoms — the most common co-occurring psychiatric diagnoses include ADHD, depression, and substance use disorders
• ask about substance use, including over the counter, medications, caffeine, and illicit substances nicotine, marijuana, pills, legal and illegal stimulants, etc)
  • the CRAFFT screening tool may be helpful (teen self-report and/or clinician questions) https://njaap.org/wp-content/uploads/2018/03/COMBINED-CRAFFT-2.1-Self-Admin_Clinician-Interview_Risk-Assess-Guide.pdf
• ask about chronicity (always an anxious child?) and severity (how impairing)
• assess for self-harm, suicidal ideation, suicidal planning, or history of suicidality. Anxiety disorders (especially panic), with or without depression, are a risk factor for suicidality.
• ask about avoidance, sleep, appetite, energy level, motivation, school performance, and friends

Medical Workup

• perform general standard medical assessment. Vital signs may suggest anxiety.
• assessment of medical conditions that can present with anxiety symptoms (i.e., thyroid abnormalities, cardiac arrhythmias, asthma, severe food allergy)
• consider other medications the child is taking which may increase anxiety (steroids, etc) and assess for drug-drug interactions
• pregnancy test for menstruating patients

Differential Diagnosis

Depression, ADHD, substance use, bullying or other traumas, PTSD, autism spectrum disorder, other mood disorders (bipolar).

Assessment of Risk

Anxiety disorders, especially with panic (with or without co-occurring depression) are a risk factor for suicidality. Screen for safety (self-harm or suicidality).

• Consider use of a suicide risk screening tool
  • Ask Suicide Screening Questions (ASQ). 5 question brief screener (ages 10-21) https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf
  • Columbia-Suicide Severity Rating Scale screener (brief and longer versions)
    https://www.cms.gov/files/document/cssrs-screen-version-instrument.pdf
    https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf
  • The PHQ-9 or PHQ-A (Question 9) is often used to assess for depression and many organizations use question #9 on this tool as their suicide screening tool. 

If a patient is reporting suicidality, provide interventions (from less severe to more severe):

• Safety Plan:
  • The Child Mind Institute provides a sample safety plan (please know that the safety hotline is 988). 
    https://childmind.org/wp-content/uploads/2022/09/MySafetyPlan-v1.pdf
• 988 Suicide Hotline
• 211 Mobile Crisis – crisis clinicians will go to the patient’s home, school or your office.
• Urgent Crisis Centers for Pediatric Mental Health
  • The Village for Families and Children in Hartford: 1680 Albany Avenue, Hartford. Hours: Monday – Friday, 7:00am – 11:00pm. Phone: 860-297-0520
  • Wellmore Behavioral Health in Waterbury: 141 East Main Street, Waterbury.
    Hours 24/7. Phone 203-580-4298.
  • The Child and Family Agency of Southeastern Connecticut in New London:
    255 Hempstead Street, New London. 
    Hours Monday-Friday 8:00 am -11:00 pm; Saturday 10:00 am-6:00 pm.
  • Yale New Haven Hospital in New Haven—pending in 2025.  Pediatric Emergency Department (open 24/7) available for crises.
  • 911 and Ambulance to Emergency Department

• Pediatric Symptom Checklist-17 (PSC-17): Q 15 (anxiety); Internalizing (Items 2, 6, 9, 11, 15).
  https://depts.washington.edu/dbpeds/Screening%20Tools/PSC-17.pdf
• Generalized Anxiety Disorder (GAD-7) Scale
  https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf
• Screen for Child Anxiety Related Disorders (SCARED)
  https://www.ohsu.edu/sites/default/files/2019-06/SCARED-form-Parent-and-Child-version.pdf
• Preschool Anxiety Scale, parent version
  https://novopsych.com.au/assessments/child/spence-childrens-anxiety-scale-parent-scas-parent/ https://www.scaswebsite.com
• NICHQ Vanderbilt Assessment Scale-PARENT: Questions 41- 47
  https://nichq.org/sites/default/files/resource-file/NICHQ-Vanderbilt-Assessment-Scales.pdf

Psychotherapy (especially cognitive-behavioral therapy, (CBT)), medication (typically antidepressants SSRIs or SNRIs) and family psychoeducation (to decrease potential accommodation to the patient’s anxiety symptoms) are the mainstays of treatment for pediatric anxiety disorders. With effective treatment, there is a good prognosis.

Psychotherapy:

CBT: Cognitive Behavior Therapy

ERP: Exposure and Response Therapy

Family Interventions

• Psychoeducation
• SPACE:  Supportive Parenting for Anxious Childhood Emotions: a parent-based treatment program (developed by Dr. Eli Lebowitz at the Yale Child Study Center). The treatment helps parents respond more supportively to their anxious child and to reduce accommodations they have been making to the child’s symptoms.
• https://www.spacetreatment.net/

Medications:

Acute treatment of anxiety:

• Antihistamines: Hydroxyzine (Atarax or Vistaril); Diphenhydramine (Benadryl): block the CNS histamines, as well as some serotonin receptors, which increases serotonin levels and creates a sedative effect. Recommended to reduce anxiety in children and teens for short periods of time. They work quickly, can help extremely anxious kids
• Benzodiazepines: Lorazepam (Ativan); Clonazepam (Klonopin); Alprazolam (Xanax): Benzodiazepines are only FDA approved for seizure disorders in children. These anxiolytics are addictive (particularly alprazolam). They may be helpful for children and youth for acute anxiety (such as to calm for a procedure), or for temporary (no more than 6 weeks) treatment of severe and disabling anxiety (while other medications and psychotherapies are implemented).

Treatment of anxiety:

In general, it is recommended to start low and go slow for medication treatment of anxiety.

• SSRI: Escitalopram* (Lexapro); Sertraline (Zoloft); Fluoxetine (Prozac): Although escitalopram has FDA indication for GAD, others have good data about effectiveness. SSRIs are the standard treatment for anxiety disorders (55% improvement), and, with CBT, have 81% improvement of symptoms.
• SNRI: Duloxetine* (Cymbalta); Venlafaxine (Effexor); Desvenlafaxine (Pristiq): SNRI medications are considered second line for anxiety, as they may have more side effects, such as physiological withdrawal, constipation, bp changes, nausea, or “brain zaps” (unpleasant shock-like feelings). However, they may be particularly helpful for someone with chronic pain, in addition to anxiety or if there is a history of biological family members having a positive response.  Duloxetine is FDA approved for the treatment of pediatric anxiety, although venlafaxine and desvenlafaxine likely have similar effectiveness.
• Alpha Agonists: reduce symptoms of anxiety by acting on the sympathetic nervous system, which regulates the body’s fight-or-flight response.
  • Guanfacine: Tenex (or long-acting Intuniv or generic): Is FDA approved for treatment of ADHD. However, at least two studies from 2013 and 2017 have shown that using it to treat anxiety and trauma-related disorders in children and adolescents may be effective and safe. It may be helpful for children and youth with co-occurring anxiety and ADHD.
  • Clonidine (or long-active Kapvay or generic): Is FDA approved for ADHD. It triggers the brain to relax blood vessels, which helps relax areas of the brain that may be causing stress. It is prescribed for anxiety, tics, and ADHD. It is more sedating than guanfacine and is used as a non-addictive sleep medication.
• Beta Blockers:  Propranolol is used off-label to relieve performance, social, or situational anxiety and panic. It works quickly, usually within 30 to 60 minutes to help relieve physical symptoms of anxiety such as flushing, shaking, sweating, trembling, and an elevated heart rate. It may be useful for school anxiety if panic symptoms are prominent.
• Buspirone (atypical anxiolytic):   Buspirone has little empirical evidence for effectiveness in children and youth. It is sometimes used as an adjunctive treatment for anxiety disorders and is non-addictive and with few side-effects.
• Atypical Antipsychotics Quetiapine (Sseroquel); Risperidone (Risperdal); Aripiprazole (Abilify):  All antipsychotic medications are off-label for anxiety. The negative side-effect profile (weight gain, possible dystonia, movements, sedation, cognitive blunting in some people), make these medications only suitable as an adjunct for serious anxiety.

Antidepressant “BOX WARNING”

Since 2004 antidepressants, including SSRIs and SNRIs, have carried an FDA “box” warning that they may increase the risk of suicidal thoughts and behavior in young people, especially in the first few weeks of starting on them, or when the dose is changed. But studies have shown that the warning, contrary to its intention, may have increased young suicides by leaving a number of suicidal young persons without treatment with antidepressants. 

It takes 2-4 weeks before an antidepressant begins to be effective in reducing symptoms of anxiety, and it continues to become more effective over the first 8 to 12 weeks.

It’s usually recommended that youth continue to take an antidepressant for a year after their symptoms have disappeared (or diminished to a manageable level). This allows the brain to build up the pathways that help manage anxiety and for the patient to build skills through therapy.

When antidepressant treatment is stopped, it should be done during periods of low stress, not when the child might be expected to be most anxious. For example, kids shouldn’t stop taking antidepressants at the start of a new school year or when they first leave for college. SSRIs are not addictive, but a child who stops taking them abruptly can experience withdrawal-like symptoms.

Talking to families about “Box Warning” for antidepressant medications

Talking to families about the “Box Warning” for an increase in suicidality in children and youth taking antidepressants may be difficult. The PCP must provide an honest and thorough explanation of the warning, without alarming families, particularly families that may already be reluctant to consider medications. The following pearls may be helpful:

• Review the assessment findings and the fact that the child is not functioning well. Sometimes letting parents know that “your child is only a child once. We want them to enjoy childhood and develop the skills they require to be a happy and productive adult. Right now, the anxiety is really interfering.”
• Briefly review the data that the studies showed a small risk that suicidal thinking may increase, but that there were no deaths. The positive effects of antidepressants over time have been shown to outweigh the possible adverse effects.
• Highlight the benefits: Example: Your child may be able to enjoy life again, get to school, and spend time with friends. Emphasize that anxiety disorders are very treatable and with the right medication and therapy, prognosis is good.
• Highlight that the potential side effect of suicidal thoughts is rare, but that we want to ensure safety, so will monitor closely.  In the rare situation that the patient has thoughts of self-harm, call right away or call 211 or 911. If the youth is depressed and depression worsens, or there is activation (talking fast, not feeling a need to sleep) make sure to contact prescriber right away. Some medications may increase the serotonin levels in the body and overdose on an SSRI can cause a serious effect of serotonin syndrome.
• For youth: Most people that start (name SSRI medication) don’t notice any negative effects at all. Some may have temporary stomach aches or dry mouth. Sometimes the medication may make your sleepier or sometimes more active or jumpy. If you ever have thoughts of harming yourself, we want to get you supports right away to be sure you are safe. Who will you tell if you ever feel that you want to hurt yourself?  Please let your family (and therapist if there is one) know right away. (For adolescents: If this is relevant to you, sometimes the medication may interfere with sexual desire. There may be some pregnancy risks, as well, so be sure to have safe sex (condoms even if on OCPs)).
• To family to enhance placebo effect: Most children and youth find that the anxiety begins to get better pretty quickly, although it may take 4-8 weeks for full effect.