Anxiety Disorder

Worries and fears are a natural and adaptive part of childhood development. Anxiety and fear meet the criteria for a clinical anxiety disorder when the concerns are persistent and excessive, causing notable distress or impairment in day-to-day life.

Anxiety disorders are the most common childhood-onset psychiatric disorders. Anxiety disorders in children (up to 12 years old) and adolescents (13 to 18 years old) are associated with educational underachievement and co-occurring psychiatric conditions, as well as functional impairments that can extend into adulthood.

The DSM-5 includes seven anxiety disorders seen in children:

Clinical Symptoms

Children can present with a variety of symptoms or behaviors that may signify an anxiety disorder. They, their parents, or teachers may report:

• Avoidance – Academic and social activities may be avoided, such as school, parties, camp, sleepovers, or talking to safe strangers.
• Somatic symptoms – As examples, headaches, stomach aches, or dramatic presentations of pain
• Sleep problems – Difficulty falling asleep or waking up in the middle of the night
• Excessive need for reassurance – The child may seek excessive or repetitive reassurance prompted by bedtime, storms, school time, or more generally related to fears of bad things happening.
• Poor school performance – As examples, demonstrating inattention in class or having difficulty completing tests within the allotted time
• Explosiveness and oppositional behavior – Such outbursts may be triggered by an anxiety-provoking stimulus, for example, at home or school. 
• Eating problems – Eating insufficiently or overeating to cope with anxiety. Research suggests a significant proportion of children, children with selective eating or weight concerns, report anxious behavior. 
• Suicidal thoughts or behavior – Many studies suggest anxious youth may report suicidal thoughts or behavior in the absence of depression. These studies suggest that between 22 and 58 percent of anxious youth report suicidal ideation. 

Anxiety symptoms may be pervasive, but they may alternatively occur in some settings and situations and not others. Individual anxiety disorders can be distinguished by the nature of the stimuli that trigger anxiety, the cognitions experienced, and/or the resulting behaviors, as described below:

Generalized anxiety disorder — A child presenting with generalized anxiety disorder (GAD) will typically present with a host of worries that he or she finds difficult to stop or control. Many children with GAD discuss preoccupation with academic performance. The preoccupations often manifest in perfectionism and an “all or nothing” cognitive bias, wherein they perceive that they must perform perfectly or they are no good. These children and adolescents tend to focus on mistakes they have made, rather than successes. Other children with GAD discuss a number of personal safety or health concerns, relating to themselves and their loved ones. They may have difficulty sleeping due to worry about someone breaking into their home, or report a preoccupation with contracting a feared disease.

Social anxiety disorder — Social anxiety disorder is often observable on presentation because the child may be shy or withdrawn during the assessment interview, exhibiting poor eye contact or providing limited answers to questions until they have had time to warm up. Children and adolescents with social anxiety disorder will often describe a fear of saying or doing the wrong thing, being laughed at, or being embarrassed, resulting in avoidance of social and performance situations. Their worries focus more on what others think of them, rather than on their own perceptions of their performance.

Panic disorder — Youth with panic disorder will describe experiencing panic attacks as the primary presenting problem, and a fear of having another attack which is contributing to distress, avoidance, and/or impairment. The cognitions they describe often focus on the uncomfortable physical symptoms and fears of what these symptoms might signify (eg, “I feel like I’m having a heart attack; I feel like I’m going crazy; I worry that I will lose control and something bad will happen”). Often the sense of uncontrollability revolves around not knowing when an attack may occur. Youth will often report avoiding a variety of different settings or situations for fear of triggering a panic attack.

Agoraphobia — Agoraphobia is marked by pronounced fear in particular environments or situations, such as large open spaces (parking lots, bridges), crowded places (shopping malls, theater, ballpark), small enclosed areas (elevator), public transportation (planes, trains, cars), or generally being outside of the home, especially alone. The focus of the fear, and subsequent avoidance, of these places or situations is related to thoughts of being unable to escape or cope with physical symptoms (such a panic) or other debilitating or potentially humiliating symptoms. Youth with agoraphobia will avoid developmentally important situations, such as school or common social experiences due to this fear, or will require the presence of a “safe” person, such as a parent or close friend, in order to participate.

Specific phobias — Children and adolescents will often describe a number of different phobias, particularly when asked. Only some that they describe result in functional impairment. As an example, a child who is fearful of dogs may report a wish to avoid the park or the home of friends with dogs, which becomes socially interfering. Parents may describe that the child runs to the other side of the road when a dog is approaching, which presents a safety concern. Many children display some anxiety during thunderstorms, but a child with a specific phobia of storms may describe a marked preoccupation with the weather and avoid going outside when it is raining. In contrast to adult diagnostic criteria, it is not necessary for children to judge their fear or phobia as excessive or unreasonable in order to diagnose a specific phobia.

Separation anxiety disorder — Separation anxiety disorder is often observable when the child presents for an initial assessment. The child may have trouble separating from their parent in order to participate in their portion of the interview. Parents may also display anxiety about being separated from their child. When separated, the child may frequently wish to check in with the parent, or vice-versa, increasing the time needed to complete the assessment. The child will typically report worries about something bad happening when they are separated from their parents. Parents will often describe difficulty getting the child to sleep on their own. Families may report that the child often sleeps with their parents or requires a parent to lay down with him or her in order to fall asleep.

Selective mutism — A diagnosis of selective mutism is readily observable if the child refuses or is reluctant to speak in the assessment setting. Parents report that the child readily talks at home, and/or around select family or friends, but does not speak in school or other settings.

Research studies suggest a developmental progression of anxiety disorders in childhood and adolescence.

• Selective mutism typically develops prior to age five, with age of onset ranging from two to four years of age.
• The age of onset for separation anxiety and specific phobias is approximately seven years of age.
• School refusal has a bimodal age of onset between the ages of five to six and ten to eleven years.
• Generalized anxiety disorder typically presents in school age years, with a typical age of onset around seven years.
• Social anxiety disorder is most common in early adolescence.
• Panic disorder has a typical age of onset in later adolescence

Childhood anxiety disorders are associated with educational underachievement, increased risk for depression, substance abuse and/or dependence and suicide, as well as other significant functional impairments that can extend into adulthood. 

Assessment:

Psychiatric assessment for anxiety disorders includes a diagnostic interview of the child and parents. Collateral information from school personnel is often needed. Teachers can describe how children respond to separation, interact with their peers, and respond to other stimuli.Some children, particularly those with social anxiety disorder and separation anxiety disorder, may have difficulty participating in the psychiatric assessment. It may be helpful to spend some time building rapport, answering any questions, and providing a description of the assessment experience so the child knows what to expect and what will be expected of them. With younger children, playing a game to build rapport can be helpful. Children may not endorse symptoms due to embarrassment, oppositionality, or a wish to give a desirable response. Some children or adolescents may feel more comfortable endorsing symptoms of anxiety and related impairment in a questionnaire rather than in an interview. Children may also display symptoms in some contexts but not others, contributing to differing reports from informants. A multi-informant approach with careful clinician interpretation will yield the most comprehensive and accurate assessment.

Assessment instruments — Clinician-assessment instruments and child/parent self-report instruments are used to assess the presence, type, and severity of anxiety symptoms. These tools alone cannot be used to diagnose an anxiety disorder, but can be useful for screening and for monitoring the severity of symptoms over time.

1. The Pediatric Anxiety Rating Scale (PARS) is a 50-item, clinician-rated instrument that assesses symptoms of generalized anxiety disorder, separation anxiety disorder, and social anxiety disorder in children. The PARS has demonstrated high reliability and good validity in initial testing.
2. The Screen for Child Anxiety-Related Emotional Disorders (SCARED) is a parent and child self-report instrument that assesses clinical symptoms of anxiety broadly in children. Advantages to the SCARED for clinical practice include no cost for use and short (five-item) version for screening purposes. The SCARED discriminates anxiety from other conditions, including depression, and is sensitive to changes in treatment. Clinical cut-offs on the SCARED have been established as a tool for clinicians or researchers to determine treatment response and symptom remission.
3. The Youth Anxiety Measure for DSM-5 is a new self- and parent-report questionnaire developed to assess anxiety disorder symptoms in children and adolescents according to the current classification system 

Treatment

Psychotherapy: 

Cognitive-behavioral therapy (CBT) focuses on the interplay between cognitions, behaviors and emotions, helping patients to recognize and modify maladaptive anxiety-provoking thoughts and to change patterns of avoidance. The content of CBT programs can vary but typically includes psychoeducation and exposure to anxiety producing stimuli and situations, couched within an active and collaborative patient-therapist relationship, and reinforced by the use of patient-centered homework assignments.

Exposure treatment is central to all efficacious CBT for pediatric anxiety disorders; this involves the child gradually but repeatedly experiencing the feared situation with the intent of reducing the associated anxiety, or learning to tolerate and manage normal, expected levels of anxiety.

There are multiple semi-structured, manualized CBT programs for pediatric anxiety disorders that have been found to be efficacious when delivered by a trained clinician. 

The most well-researched and prominently used program for treating anxiety is the Coping Cat program, which was developed for children ages 7 to 13 diagnosed with generalized anxiety disorder, social anxiety disorder, or separation anxiety disorder. The C.A.T. Project adapts this program for use with adolescents ages 14 to 17 with the same disorders. Both programs help teach youth the following core skills:

• Psychoeducation to the child/adolescent and caretakers
• Somatic management skills
• Cognitive restructuring techniques
• Problem-solving skills

Once these skills are taught, treatment focuses on gradual exposure to feared situations

Medications:

First-line treatment with a selective serotonin reuptake inhibitor (SSRI). Serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants have also shown efficacy in the treatment of pediatric anxiety disorders. Because they are associated with less easily tolerated side effects compared with SSRIs, these drugs are generally used second- or third-line.

SSRI/SNRI — Serotonin reuptake inhibitors (SRIs) used in the treatment of pediatric anxiety disorders include SSRIs, SNRIs, and clomipramine. 

Efficacy — SSRIs and SNRIs, as a class, are considered effective for pediatric anxiety disorders A meta-analysis of 16 randomized trials on published between 1992 and 2008 found a number of SSRI and SNRI medications – fluoxetine, sertraline, fluvoxamine, paroxetine, and venlafaxine – to be superior to placebo in the treatment of pediatric anxiety. Among the SNRIs clinical trials suggest that venlafaxine SR, in particular, is effective for these disorders. A 2015 trial suggested that duloxetine may benefit youth with GAD. Some children experienced weight loss, increased cholesterol, and changes in vital signs while taking the medication.

Adverse effects: SSRIs have been associated with psychiatric adverse events, such as disinhibition, agitation, and worsening of anxiety symptoms. Physical side effects most commonly include headaches, gastric distress, and sleep disturbance. Antidepressant medications are associated with an increased risk of suicidality in children. Some children receiving venlafaxine have been reported to experience weight gain, elevated cholesterol, and hypertension. 

Augmentation: Evidence from clinical trials suggests that augmentation of pharmacotherapy with cognitive behavioral therapy (CBT) may be effective in pediatric anxiety disorders. Several medications including buspirone, benzodiazepines, stimulants, a second SSRI, atypical antipsychotics, and tricyclic antidepressants (TCAs) have been proposed for augmentation of SSRI/SNRI treatment of pediatric anxiety disorders; however, there is minimal to no evidence to support these strategies.