Anxiety disorders are the most commonly occurring psychiatric condition in children, youth and adults. The COVID-19 pandemic further exacerbated the prevalence of anxiety disorders. About 11.6% of children and teens suffered from a diagnosable anxiety disorder in 2012, before COVID. During and after the pandemic, those numbers nearly doubled, such that 20.5% of youth worldwide now struggle with anxiety symptoms, according to a meta-analysis of 29 studies reported in JAMA Pediatrics (Vol. 175, No. 11, 2021). Youth from minoritized and LGBTQ+ backgrounds with mental health or learning disabilities that predated the pandemic are more vulnerable to experiencing anxiety disorders. Anxiety disorders are more common in teens (25%) and girls (2:1 rates of girls to boys).
Anxiety in children is expected and normal at specific times in development. For example, from approximately 8 months through the preschool years, healthy youngsters may show intense distress (anxiety) at times of separation from their parents or other people with whom they are close. Young children may have short-lived fears, such as fear of the dark, storms, animals, monsters, or a fear of strangers.
Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of a future threat. Anxiety disorders are associated with autonomic (fight, flight, freeze) reactions to a perceived threat, when there is no threat. Anxiety becomes a disorder when the individual is:
The US Preventive Services Task Force (USPSTF) recommends regular screening for anxiety in children ages 8 to 18.ve Services Task Force (USPSTF) recommends regular screening for anxiety in children ages 8 to 18.
Guidelines for Diagnosis
Occurs only when faced with the anxiety-provoking situation.
Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder
Agoraphobia
Occurs “out of the blue” without a known precipitant.
Generalized Anxiety Disorder
Panic Disorder
Post-traumatic Stress Disorder
Obsessive-Compulsive Disorder
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:
Psychological symptoms:
Risk Factors: The causes of Anxiety Disorders are Multi-factorial and Complex
Protective factors:
PCP Visit
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Guidelines for Screening and Assessment
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
Medical Workup
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).
If a patient is reporting suicidality, provide interventions (from less severe to more severe):
Anxiety Screening and Rating Scales
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
Guidelines for Treatment
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.
CBT: Cognitive Behavior Therapy
ERP: Exposure and Response Therapy
Family Interventions
Acute treatment of anxiety:
Treatment of anxiety:
In general, it is recommended to start low and go slow for medication treatment of 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:
Subclinical to Mild Anxiety | Moderate Anxiety | Severe Anxiety |
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Medication Guidelines
Evidence-based medications for Anxiety: Escitalopram*, Sertraline, Fluoxetine
At 4 weeks, re-assess symptom severity with SCARED or GAD-7
At 8 weeks, re-assess symptom severity with SCARED or GAD-7
At 12 weeks, re-assess symptom severity with SCARED or GAD-7
Provider Resources
YCSC Anxiety and Mood D/O Program – https://medicine.yale.edu/childstudy/research/clinical-innovations/anxiety-and-mood-disorders/
Yale Center for Emotional Intelligence – RULER https://medicine.yale.edu/childstudy/services/community-and-schools-programs/center-for-emotional-intelligence/ruler/
Hartford Health – Center for Cognitive Behavioral Therapy – https://hhcbehavioralhealth.org/programs-services/anxiety-disorders-center
Wheeler Clinic – Anxiety Treatment https://www.wheelerclinic.org/services/wheeler-services/depression-and-anxiety-treatment-connecticut
Lebowitz – SPACE/Accommodation – Ted Talk – https://www.youtube.com/watch?v=ExVvAn9hcjY
A Journey Though SPACE – documentary highlighting SPACE treatment
Inside Out II Teaching Resource Kit https://ymiclassroom.com/wp-content/uploads/2024/04/io2_kit-1.pdf
PBS Resources: https://www.pbs.org/parents/thrive/how-to-help-when-your-child-is-anxious#:~:text=It%20is%20normal%20to%20feel,Talk%20about%20concerns.
Arthur – anxiety – https://www.youtube.com/watch?v=qapngl9OgEU
Good Video on Co-morbid anxiety for children with LD and Neurodivergence: https://www.pbs.org/video/managing-anxiety-in-kids-with-ld-yuu90b/
ACCESS Mental Health for Youth Clinical Conversations Trainings
Family Resources
Coping Cat Parents: https://www.copingcatparents.com/Camp_Cope_A_Lot – not free but very good resource that could be used at PCP office/school/home
Calm (ages 7+)
Emergency Calm: How to calm down in 2 minutes:
myKinCloud: Family Mindfulness (ages 5+)
Headspace: Sleep and Meditation (ages 8+)
Mindshift: A free app that uses CBT to help teens and young adults cope with anxiety. It includes techniques like journaling, building fear ladders, and setting goals.
Clear Fear: A free app that uses CBT techniques to reduce anxiety.
SmartCAT: An app that uses evidence-based therapy to help kids manage anxiety. It can be programmed to launch at a specific location, such as school, to help kids with anxiety around school shootings.
Breathe, Think, Do with Sesame: A Sesame Street app that teaches breathing exercises, self-control strategies, and planning
Mightier: Ages 6-14 (free trial, then subscription)
Feder J, Tien E, Puzantian T: Child Medication Fact Book for Psychiatric Practice (2nd Edition); Carlot Publishing, 2023.
Shatkin J: Child and Adolescent Mental Health: A Practical All-In-One Guide (3rd Edition); Norton Publishing, 2024.
APA: DSM-5-TR. American Psychiatric Association, 2022.
Stahl M: Prescriber’s Guide: Children and Adolescents. Cambridge Press, 2019.
Galanti R: Anxiety Relief for Teens: Essential CBT Skills & Mindfulness Practices to Overcome Anxiety and Stress, 2020.
Lebowitz ER: Breaking Free of Child Anxiety and OCD: A Scientifically Proven Program for Parents. Oxford Press, 2021.
Lebowitz ER: Workbook for Breaking Free of Child Anxiety and OCD. Trinity Publishing, 2023.