Barry Sarvet, MD, is Chief, Division of Child and Adolescent Psychiatry; and Vice Chairman, Department of Psychiatry, Baystate Health; and Associate Clinical Professor, Tufts School of Medicine. Sara Brewer, MD, is Child and Adolescent Psychiatrist, Behavioral Health Network, Division of Child and Adolescent Psychiatry, Baystate Health; and Assistant Clinical Professor, Tufts School of Medicine.
Drs. Sarvet and Brewer have disclosed no relevant financial relationships.
Address correspondence to: Barry Sarvet, MD, Division of Child and Adolescent Psychiatry, Baystate Health, 3300 Main St., 4th Floor, Springfield, MA 01199; fax: 413-794-7140; email: firstname.lastname@example.org.
Primary care providers are likely to see many children with anxiety disorders because of their high prevalence in community samples.1 Indirect presentations, such as somatic symptoms, are common. For instance, 80% of children with recurrent abdominal pain were found in one case series to have a diagnosable anxiety disorder.2 Parents of children with anxiety disorders also frequently suffer from their own anxiety and exhibit excessive worry about their child’s health, resulting in frequent utilization of primary care services and requests for specialist consultation and ancillary testing.3 A high index of suspicion for the presence of an anxiety disorder is appropriate for children who have frequent, unexplained somatic symptoms.
Anxiety disorders are among the most common psychiatric disorders, affecting up to 20% of children and adolescents during the course of their development.4 By definition, the symptoms of anxiety disorders must be persistent and severe enough to cause significant distress and/or impairment in functioning. Therefore, common phase-specific periods of anxiety (Table 1, see page 501) are considered to be part of normal child development and are not classified as anxiety disorders. Similarly, appropriate levels of anxiety or even panic associated with threatening circumstances or situational stressors would also be considered normal.
Table 1. Normal Phase-Specific Transitory Anxiety in Child Development
Although feelings of anxiety, fear, nervousness, and panic are the hallmark internal symptoms of anxiety disorders, the habitual patterns of behavior and cognitive phenomena associated with these symptoms (Table 2, see page 502) may be more debilitating than the internal experience.
Table 2. The Three Clinical Domains of Anxiety Disorders
Anxiety may be so unpleasant that anything which momentarily provides relief gets reinforced and may become a habit. For example, children with separation anxiety disorder can temporarily alleviate their discomfort by sleeping in their parents’ bed. However, if this avoidant behavior is permitted to continue, the parents inadvertently give the message that feeling safe can occur only in their presence, thus reinforcing the behavior.
Much of the disability associated with anxiety disorders is related to this compensatory-avoidant behavior, manifested in a lack of interest and a refusal to participate in activities necessary for normal development. In some instances, children and parents may be so successful at avoiding and preventing exposure to anxiety triggers, that the symptom of anxiety itself may no longer be clinically apparent. As activities become more restricted in response to the anxiety trigger, developmental delays may arise from social isolation and under-stimulation.
Types of Anxiety Disorders
Anxiety disorders have many different psychiatric syndromes (Table 3, see page 503). Although these syndromes have distinct clinical features, it is relatively common for children to have more than one anxiety disorder concurrently. The criteria for the assignment of these diagnoses are published in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition, Text Revision (DSM-IV-TR).5 Anxiety disorders are distinguished from each other according to the nature of the feared object, among other factors.6 Correct identification of the diagnosis within the broad category of anxiety disorders can have important implications for treatment planning.
Table 3. Clinical Features of Anxiety Disorders
Separation Anxiety Disorder
Separation anxiety disorder (SAD) is characterized by intense and persistent anxiety in the context of impending or actual separation from an attachment figure such as the parent or other caregiver. Diagnostic criteria require that the onset be before the age of 18 years and must be persistent for at least 4 weeks.5 Most commonly, symptoms initially present during the early grades of elementary school. Although many children experience some degree of emotional distress associated with early separation experiences, such as being dropped off at school at the beginning of the school year, these symptoms are ordinarily handled by experienced teachers and resolve quickly. Children with SAD, however, do not readily respond to the usual support and encouragement by parents and teachers. Their distress is more severe, prolonged, and extends outside of school to include worrying about future separations, anxiety regarding sleeping alone in their room, frequent worries that terrible accidents or tragedies may befall their parents or they manifest physical symptoms at times of impending or actual separation.
New onset of SAD in older children and adolescents may be triggered by stressful events, such as seeing a parent injured in an accident. Parents of children with SAD frequently have anxiety disorders themselves, which creates a tendency for these parents to communicate a fearful view of the world to their child, which in turn further reinforces the child’s own worries.6 Ongoing avoidance of separation experiences in lieu of treatment may result in poor school attendance, as well as delays in social development.
SAD occurs in approximately 4% to 5% of children. Some children experience a chronic course and may have other co-occurring anxiety disorders.7 Although SAD is usually limited to childhood and adolescence, children with SAD are at risk for panic disorder and depression during their late adolescence and adulthood.8
Generalized Anxiety Disorder
Children with generalized anxiety disorder (GAD) have an unlimited range of worries about potential dangers and practically any harm that can possibly befall themselves or their loved ones. GAD is distinguished from other anxiety disorders by the indiscriminate focus of the anxiety. All of the dangers children with GAD worry about are plausible; however, these children have an unrealistic estimation of the probability of their fear’s actual occurrence and imagine these things actually happening. For example, a child with GAD may cry inconsolably as she contemplates the demise of her parent from a rare disease that she has only heard about in passing on television. Children with GAD are constantly “on alert” and tense. For some, this state of hyperarousal is associated with restlessness, defensiveness, impulsive aggression, irritability, and other disruptive symptoms. For others, behavioral inhibition is more prominent; however, disruptive behavior can still erupt unexpectedly in the context of overwhelming anxiety when the child finds that avoidance is not possible. The anxiety may also result in refusal to follow directions and stubborn behavior that results in negative relationships with parents and teachers.
GAD is estimated to occur in 3% to 6% of children.9 Although co-occurrence with other psychiatric diagnoses such as depression, attention-deficit disorder, and oppositional defiant disorder is quite common, these additional diagnoses should not be made if all of the depressive and/or disruptive symptoms can be directly attributed to the anxious distress and behavioral inhibition associated with GAD.10 Teenagers with GAD are also noted to have an elevated risk for substance abuse.11
A panic attack is an experience of extreme anxious distress of relatively sudden onset, usually associated with a variety of frightening physical symptoms of autonomic arousal. Panic attacks commonly include feelings of being out of control, “going crazy,” or impending death that may lead to a dramatic scene or an emergency department presentation. Panic attacks may be triggered in the context of overwhelming exposure to a feared object or situation, and may occur in patients with or without any anxiety disorder. For patients with panic disorder, however, panic attacks can occur “out of the blue,” with no apparent trigger, and are associated with a great deal of worry about the possibility of having a future panic attack.5 Ironically, this worry about panic attacks is often discovered to be the trigger of further attacks, resulting in a progressive increase in symptom frequency and severity. Children with panic disorder may seek to avoid public settings where the embarrassment of losing control during a panic attack would seem intolerable. Gradual worsening of this avoidant behavior may lead children to become housebound, or agoraphobic.
In pediatric populations, panic disorder most frequently begins between the ages of 15 and 19 years, and there is a female predominance. Prevalence rates have been reported between 0.5% and 5% of children and adolescents.12 Most patients with panic disorder have additional anxiety disorder diagnoses and/or depression.13 Panic disorder often shows a waxing-and-waning chronic course, and may become a persistent disability in adulthood if not effectively treated.
Specific phobia is characterized by unreasonable and intense fear and apprehension related to a particular object or situation.5 This fear must be persistent for more than 6 months and cause significant distress or be severe enough to interfere with the child’s functioning. If a child has a phobia regarding bees, for example, the child might refuse to participate in picnics because of apprehension about encountering a bee; or the child might worry for hours or days beforehand. Fears of specific types of animals or insects, flying on an airplane, injections, thunderstorms, water, heights, and blood are typical examples of phobias. When confronted with the object of their fear, children may have inconsolable crying, agitation, or a panic attack. As with other anxiety disorders, individuals with phobias overestimate the risk associated with the feared object and therefore may not recognize that these fears are unreasonable. For example, a child with a fear of thunderstorms may picture in his mind the devastation that happened from the worst hurricanes in history and react as though his life were in danger whenever he sees rain clouds in the sky.
Phobias that begin during childhood may gradually remit over time; however, for a subset of children, phobias may continue throughout adulthood. Specific phobias are estimated to occur in 7% to 10% of children and are slightly more common in girls than boys.14
Social Anxiety Disorder
Often misidentified as the trait of shyness, social anxiety disorder (also known as social phobia) is characterized by high levels of fear and avoidance of interactions with unfamiliar people. Children with social anxiety disorder are perfectly sociable and comfortable with members of their family and close family friends; however, they resist participation in group activities with peers. Anxious distress in social situations can lead to awkward behavior, thereby attracting unwanted attention, teasing, or concern, which in turn triggers additional anxiety.
Children with social anxiety disorder may be extremely quiet and withdrawn, and in the most extreme cases, may have selective mutism. The social anxiety is often traced to a fear of public humiliation; therefore, the anxiety may be most apparent during activities that involve performance or competition such as sports, giving oral presentations, participation in classroom discussion, or expressive arts. The inhibited behavior of children with social anxiety disorder frequently results in delayed social skill development and impoverished peer relationships. Consequently, they may have progressive difficulty negotiating more complex social relationships as they advance toward adolescence and young adulthood.
Social anxiety disorder is one of the most common of all psychiatric disorders, with a lifetime prevalence of 14% in adults.15 Prevalence is much lower in children, although many adults with social anxiety disorder recall that symptoms began during childhood. Childhood-onset social anxiety disorder tends to be chronic, associated with high levels of distress, and frequently associated with other anxiety disorders, depression, and disruptive behavior disorders. Genetic factors appear to play a significant role in the etiology along with environmental factors such as parental anxiety.16 The importance to long-term health and well-being of satisfactory interpersonal relationships underscores the importance of identifying and treating children with social anxiety before delays in social skill development become severe.
Children with obsessive-compulsive disorder (OCD) are plagued with characteristic types of preoccupations, worries, urges, and obligations that occupy an inordinate amount of time, activity, and mental life. The hallmark of OCD is repetition: repetitive checking, cleaning, washing, praying, counting, organizing, and thinking. The preoccupations or obsessions are often disturbing ideas that generate feelings of shame, guilt, or even horror.
For example, a perfectly well-behaved and compassionate 12-year-old boy with OCD could become disturbed with recurrent thoughts that he might become a murderer or rapist. Compulsions are repetitive behaviors or mental acts associated with a strong feeling of necessity that goes far beyond any real need to perform the behavior, such as re-locking the front door 20 times. The characteristic obsessions and compulsions of OCD tend to be associated with contamination, sexuality, fears of predators (including criminals), accidents/safety issues, and/or religious purity. Although adults typically are aware of the irrationality of their symptoms, children commonly are not. Children with OCD may experience feelings of anxiety associated with their obsessions and compulsions. This anxiety may surge to extreme levels at times when they are unable to perform their compulsions “just right.”
OCD occurs in approximately 2% of children.17 Children frequently attempt to hide their symptoms, perhaps because of the feelings of shame and guilt associated with the obsessions, or perhaps out of anxiety that they would be prevented from carrying out their compulsions if discovered. Comorbid psychiatric illness is quite common among children with OCD, notably depression, disruptive behavior disorders, and tic disorders. Pediatric autoimmune disorder associated with streptococcal infection (PANDAS) has been theorized to be a causal factor for some patients with combined OCD and Tourette’s syndrome18 whose symptoms appear to correlate with episodes of group A beta-hemolytic streptococcal infection; however, this syndrome has remained controversial since its description in the mid-1990s, and the relationship to group A streptococci is unproven.
Approach to Assessment
Because pediatric anxiety disorders frequently go unrecognized, providers are advised to use a formal anxiety disorder screening instrument at the well-child visit. Because anxiety disorders may be associated with other psychiatric disorders, pediatricians should begin with a more broadband mental health screening tool. For example, the 35-question Pediatric Symptom Checklist,19 with self-report (Y-PSC) and parent-report (PSC) versions, surveys a broad overview of psychiatric symptoms and is free, available in multiple languages, easy to administer and score, and takes very little time to complete. The actual responses on the completed form can be reviewed by the clinician and serve as a guide for more focused inquiry during the visit. Isolated positive responses are considered normal, but anxiety symptoms in the context of an overall positive score on a “broadband” screening tool, such as the PSC, indicate a high likelihood of the presence of an anxiety disorder; however, a positive general screen is not tantamount to a diagnosis of an anxiety disorder, and therefore it should be followed by further assessment.
Anxiety disorders, similar to all psychiatric disorders, are diagnosed clinically through the careful application of DSM-IV-TR criteria on the basis of careful history (from parents, child, and collateral sources) and examination. Although familiarity with the common clinical characteristics and diagnostic criteria of the various anxiety disorder syndromes can help the clinician develop a diagnosis, more specific anxiety assessment tools can help to clarify a diagnosis further. The Screen for Anxiety Related Emotional Disorders (SCARED)20 is an example of an anxiety-specific questionnaire; it is free, and available in both self-report and parent-report versions. The total score, as well as sub-scores for specific anxiety disorders, can be counted easily. As with the PSC, individual positive responses on the SCARED can be used to efficiently direct the clinician’s attention to the most prominent anxiety-related symptoms that need to be confirmed and more fully described during the clinical exam.
Differential Diagnosis and Comorbidity
An important aspect of the assessment of anxiety symptoms is the consideration of physiological problems that could mimic an anxiety disorder. These include thyroid disorders, Cushing’s disease, hypoglycemia, medication side effects (especially sympathomimetic), recreational drug intoxication, asthma, and cardiac arrhythmias, among many others. Excessive laboratory testing for medical disorders in the absence of suggestive clinical evidence can be both costly and generate additional family anxiety, and therefore should be pursued only when indicated.
DSM-IV diagnostic criteria indicate that a mental health diagnosis should not be made if the symptoms are better accounted for by another medical or psychiatric illness.5 For example, a child with an autistic spectrum disorder (ASD) may appear anxious in social situations; however, these symptoms may be due to poorly developed social reciprocity and inability to interpret social cues. In this instance, the social anxiety symptoms can be fully attributed to the ASD and the diagnosis of social anxiety disorder is not made.
At other times, by carefully considering the context of symptoms, a child may be diagnosed appropriately as having concurrent psychiatric diagnoses. For example, if a child with longstanding anxiety is now observed to be restlessness and hyperactive, these new symptoms could be due to the same anxiety problem, making a separate diagnosis of attention-deficit/hyperactivity disorder (ADHD) unlikely. On the other hand, if the patient has a long history of hyperactivity, inattention, and impulsiveness with a seemingly independent course, then both ADHD and anxiety are likely diagnoses. Depression, ADHD, oppositional defiant disorder, ASD, adolescent substance abuse disorders, and posttraumatic stress disorder are common examples of psychiatric syndromes that should be considered both in the differential diagnosis for children with presumed anxiety disorders, and also as candidates for comorbid psychiatric illness.
Preparation for Treatment
Careful assessment and subsequent psychoeducation for the parent and child about the anxiety disorder diagnosis can be inherently therapeutic and key to effective treatment. Such a psychoeducational intervention begins with identification of the diagnosis. The act of recognizing the diagnosis as a familiar entity is reassuring because many patients with anxiety disorders imagine that their symptoms are incurable and/or inexplicable. This intervention also serves to shift the patient’s attention to the anxiety symptoms themselves, rather than concern about the feared situation or object — an early-phase intervention similarly employed by cognitive behavioral therapists.
Parents should be informed at the time of diagnosis that anxiety disorders are eminently treatable. Primary care providers can convey positive expectations that the symptoms can improve; handouts describing anxiety disorders and their treatments can assist with providing this information.21 Helping children to understand the nature of their condition and envision a pathway to recovery can instill the hope and confidence these children will need as they proceed with their treatment.
- Chavira DA, Stein MB, Bailey K, et al. Child anxiety in primary care: prevalent but untreated. Depress Anxiety. 2004; 20(4):155–164. doi:10.1002/da.20039 [CrossRef]
- Campo JV, Bridge J, Ehmann M, et al. Recurrent abdominal pain, anxiety, and depression in primary care. Pediatrics. 2004; 113(4):817–824. doi:10.1542/peds.113.4.817 [CrossRef]
- Riley AW, Finney JW, Mellits ED, et al. Determinants of children’s health care use: An investigation of psychosocial factors. Medical Care. 1993; 31(9):767–783. doi:10.1097/00005650-199309000-00002 [CrossRef]
- Costello EJ, Egger H, Angold A. 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. J Am Acad Child Adolesc Psychiatry. 2005;44(1):972–986. doi:10.1097/01.chi.0000172552.41596.6f [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision. Washington, DC: American Psychiatry Association, 2000.
- Feigon SA, Waldman ID, Levy F, et al. Genetic and Environmental Influences on Separation Anxiety Disorder Symptoms and Their Moderation by Age and Sex. Behavior Genetics. 2001; 31(5):413–411. doi:10.1023/A:1012738304233 [CrossRef]
- Foley DL, Pickles A, Maies HM. Course and Short-Term Outcomes of Separation Anxiety Disorder in a Community Sample of Twins. J Am Acad Child Adolesc Psychiatry. 2004; 43(9):1107–1114. doi:10.1097/01.chi.0000131138.16734.f4 [CrossRef]
- Lewinsohn PM, Holm-Denoma JM, Small J, et al. Separation Anxiety Disorder during Childhood as a Risk Factor for Future Mental Illness. J Am Acad Child Adolesc Psychiatry. 2008; 47(5):548–555. doi:10.1097/CHI.0b013e31816765e7 [CrossRef]
- Schaffer D, Foisher P, Dulcan MD, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3: Description, acceptability, prevalence rates, and performance in the MECA study. J Am Acad Child Adolesc Psychiatry. 1996; 35(7): 865–877. doi:10.1097/00004583-199607000-00012 [CrossRef]
- Masi G, Mucci M, Favilla L, et al. Symptomatology and comorbidity of generalized anxiety disorder in children and adolescents. Compr Psychiatry. 1999;40(3):210–215. doi:10.1016/S0010-440X(99)90005-6 [CrossRef]
- Woodward LJ, Fergusson DM. Life course outcomes of young people with anxiety disorders in adolescence. J Am Acad Child Adolesc Psychiatry. 2001; 40(9):1086–1093. doi:10.1097/00004583-200109000-00018 [CrossRef]
- Whitaker A, Johnson J, Shaffer D, et al. Uncommon troubles in young people: prevalence estimates of selected psychiatric disorders in a non-referred adolescent population. Arch Gen Psychiatry. 1990; 47(5):487–496.
- Biederman J, Faraone SV, Marrs A, et al. Panic disorder and agoraphobia in consecutively referred children and adolescents. J Am Acad Child Adolesc Psychiatry. 1997; 36(2):214–223. doi:10.1097/00004583-199702000-00012 [CrossRef]
- Lichtenstein P, Annas P. Heritability and prevalence of specific fears and phobias in childhood. J Child Psychol Psychiatr. 2000; 41(7):927–937. doi:10.1111/1469-7610.00680 [CrossRef]
- Weiller E, Bisserbe JC, Boyer P, et al. Social phobia in general health care: an unrecognized undertreated disabling disorder. Br J Psychiatry. 1996; 168(2):169–174. doi:10.1192/bjp.168.2.169 [CrossRef]
- Bögels SM, Van Oostern A, Muris P, et al. Familial correlates of social anxiety in children and adolescents. Behav Res Ther. 2001;39(3):273–287. doi:10.1016/S0005-7967(00)00005-X [CrossRef]
- Zohar AH. The epidemiology of obsessive-compulsive disorder in children and adolescents. Child Adolesc Psychiatr Clin N Am. 1999;8(3): 445–460.
- Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998;155(2):264–271.
- Jellinek MS, Murphy JM, Robinson J, et al. Pediatric Symptom Checklist: Screening school-age children for psychosocial dysfunction. J Pediatr. 1988;112(2):201–209. doi:10.1016/S0022-3476(88)80056-8 [CrossRef]
- Birmaher B, Khetarpal S, Brent D, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry. 1997; 36(4):545–553. doi:10.1097/00004583-199704000-00018 [CrossRef]
- Massachusetts Child Psychiatry Access Project: mcpap.org. Accessed Sept. 20, 2011.
Normal Phase-Specific Transitory Anxiety in Child Development
|Age||Type of Anxiety|
|6 to 10 months||Stranger anxiety.|
|8 months to 2 years||Separation anxiety.|
|3 to 6 years||Fear of dark, imaginary figures (monsters, ghosts).|
|6 to 12 years||Fear of illness or death of family member or self, natural disaster.|
|11 to 17 years||Fear of failure, criticism, humiliation.|
The Three Clinical Domains of Anxiety Disorders
Exaggerated assessment of risk, dangers
Aggression (if flooded or cornered)
Habits: picking, nail biting
Repetitive reassurance seeking
Clinical Features of Anxiety Disorders
|Anxiety Disorder||Feared Object(s)||Prominent Symptoms|
|Separation anxiety disorder (SAD)|
Harm befalling parent
Refusal of separation
May include panic
|Generalized anxiety disorder (GAD)||Unlimited variation including:|
Loss of interest
Having a panic attack
Panic attacks without apparent trigger
|Social anxiety disorder|
Loss of interest in group activities
Impaired social skills
Specific things, animals, or situations
Inadvertently hurting others or being responsible for others being hurt
“Bad luck” or fate
Being accused of sexual deviancy or criminality
Repetitive mental acts