Positive and negative events in childhood can influence development and affect future physical and mental health outcomes. All children may experience some form of worry from time to time. Anxiety is a normal part of life as children encounter new situations and master new tasks. As the child learns to master the situation or task, anxiety around the activity will typically resolve. However, when worry or anxiety begins to affect the ability of a child to function, the diagnosis of anxiety disorder must be considered. Anxiety disorders are one of the most common psychiatric conditions affecting adolescents. The National Comorbidity Survey: Adolescent Supplement1 estimated that 31.9% of adolescents age 13 to 18 years had an anxiety disorder of some type and of those approximately 8.3% had severe impairment according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition,2 criteria. Although the prevalence was similar across age groups, the prevalence in adolescent girls (38%) was higher than that for adolescent boys (26.1%).3 Anxiety disorders can also be associated with other negative outcomes such as mood disorders, difficulty in school, and substance abuse.4 The lifetime prevalence of anxiety disorders has been reported to be from 38%.5 In children who have been exposed to trauma or with chronic medical illness, anxiety can precede the event, be caused by the event, or may simply coexist. Several somatic symptoms are found in children with anxiety disorders. Some of the most common symptoms are restlessness, stomachaches, blushing, palpitations, muscle tension, sweating, and trembling/shaking.6 Sequela of anxiety can include reluctance to go to school, difficulty sleeping, tantrums, difficulty with concentration and decision-making, and nausea and vomiting.
Conventional Approach to Anxiety
The conventional approach to anxiety may include some combination of selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) and cognitive-behavioral therapy (CBT). The Agency for Healthcare and Research Quality published a report7 that compared the safety and efficacy of psychotherapy and or pharmacology in the treatment of childhood anxiety disorders. The review included 206 randomized and nonrandomized comparative studies. Based on child, parent, and clinician reports, CBT was found to improve function and reduce symptoms. There was moderate to high evidence that SSRI and SNRIs were effective in improving primary anxiety symptoms; however, the studies that were reviewed in the report were not adequate to assess the risk of suicidality with the use of the medications except for one that showed a statistically insignificant increase in suicidal ideation with venlafaxine. They also concluded that more research is needed “to evaluate components of CBT, effect modifiers of treatment, and long-term safety of drugs, and needs to be more inclusive of underserved populations and minorities.”7 In 2007, the US Food and Drug Administration black box label warning for SSRIs that was written to cover children in 2004 was expanded to include young adults age 18 to 24 years.8 This warning was for the potential for increased risk of suicidal ideation and completion particularly in the first few months of antidepressant use. In addition to the concern for potential suicidal ideation, medication side effects may include headache, nausea, drowsiness, weight gain, and agitation. There is also the risk of serotonin syndrome when SSRIs are combined with medications or substances that can increase serotonin in the central nervous system. Both St. John's wort and ginseng may precipitate this reaction.
It is important to note that some pediatric patients may self-medicate with illegal substances, which may include cannabis. An in-depth discussion of medical marijuana and hemp oil are beyond the scope of this article, but it is paramount that the provider obtains a complete history including all medications—traditional, complementary, and alternative.
The American Academy of Pediatrics has developed a clinical toolkit to assist with treatment decision-making called “Addressing Mental Health Concerns in Primary Care” ( https://www.aap.org/en-us/Documents/resilience_anxiety_interventions.pdf). The toolkit lists CBT and CBT with medication as having level 1 support or excellent support. Integrative techniques such as cultural storytelling, hypnosis, and relaxation have level 2 or good support.
Integrative treatments in the setting of anxiety and stress management can be used along with conventional approaches and in many cases may improve symptom management. In addition, integrative approaches are particularly useful because they can empower patients and their families by giving them tools that they can use to manage symptoms. Unaddressed anxiety in childhood can affect quality of life and lead to disability that can be persistent into adulthood. Teaching children tools to help manage their anxiety may improve their quality of life in adulthood as well as in childhood.
Integrative approaches can decrease stress by invoking the relaxation response. Some commonly used integrative approaches to relaxation, stress, and anxiety management include mindfulness, hypnosis, and aromatherapy/essential oils.
The Role of Stress in Chronic Illness and Disease
In times of stress or anxiety, the sympathetic nervous system is in a state of heightened alert. This heightened sympathetic activation, which is also known as the fight or flight response, can have important physiologic impact. The fight or flight response has an important lifesaving function. It prepares the body to ensure survival by being able to either address a threat head on and fight or to flee away from danger as swiftly as possible. Although fear resides in the amygdala, it is the sympathetic nervous system that does the heavy lifting. When a threat is perceived, the sympathetic nervous system kicks into gear increasing the heart rate and cardiac output and diverting blood flow away from nonessential functions such as digestion. The stress response is mediated by the sympathetic nervous system. In times of heightened anxiety, the sympathetic nervous system is activated. Intentional activation of the parasympathetic nervous system has been shown to improve balance in the autonomic nervous system which, in turn, can influence chronic pain, anxiety, and depression. This activation of the parasympathetic system can counteract the stress response. Many integrative techniques are powerful inducers of the parasympathetic nervous system and the relaxation response.
Many integrative approaches have a wide safety margin and are well tolerated in pediatrics. Health care providers who understand the risks and benefits of integrative approaches as well as the evidence basis are best able to counsel patients and their families on the most appropriate treatment regimens. There are many strategies that can be used to assist with coping with anxiety. Establishing predictable routines can cause less distress for the child with anxiety. Additional important considerations include proper sleep hygiene, balanced diet with adequate protein and plenty of water throughout the day, exercise for at least 20 minutes a day, 4 days a week, and setting concrete achievable goals. Helping children expand their social support network and giving them chores can contribute to the development of confidence and resilience.
Filling the Toolbox and Building Resilience
Worry is a normal part of life. Developing the confidence to approach new situations and bounce back from unforeseen circumstances helps build resilience. Integrative approaches and a focus on healthy lifestyle can help build the strong foundation that children need to be able to face adversity later in life.
The importance of a healthy diet cannot be overstated. To have sufficient fuel for clear thinking throughout the day, a protein-rich breakfast is important. Children who are not appropriately nourished can find that they have increased jitteriness, nervousness, and difficulty with concentration throughout the day. Excessive caffeine and stimulant use may increase anxiety and depression in children and adolescents.9,10 A whole healthy food approach should be taken when discussing diet and nutrition with patients and their families. In general, it is recommended that most children get their nutrients from a healthy diet that includes natural, whole foods.
Studies on the impact of exercise on anxiety are limited, particularly, in children. In a 2006 Cochrane review,11 16 studies that included 1,191 youth age 19 years and younger were examined to determine whether exercise interventions were effective in the reduction and/or prevention of anxiety and depression. The authors concluded that “there appears to be a small effect in favor of exercise in reducing depression and anxiety scores in the general population of children and adolescents.” They noted that their conclusions were limited because of a small number of studies and the lack of diversity of interventions and measurements in the studies.11 The Centers for Disease Control and Prevention and the AAP recommend at least 60 minutes of exercise a day for all children older than age 6 years.12 Except when contraindicated, for example in the care of anxiety associated with body image dysmorphism and eating disorders, exercise should be considered a component of the integrative approach to anxiety management. Another consideration for the use of exercise in anxiety management is that the sympathetic nervous system is activated during vigorous exercise and the same signs might occur during a panic attack. Teaching patients to understand the activation of their body to stimuli and the similarities to the responses during times of stress may be a useful approach.13
Sleep disturbance is a well-known phenomenon in children with anxiety disorder. However, research regarding causality and the underlying mechanisms are lacking.14 Literature does support that sleep problems may serve as a marker for the development of anxiety.15 As a part of their complete history, patients should be asked about their sleep quality and efforts should be made to improve sleep and sleep hygiene when possible. Recommendations for improved sleep quality include no screen time 30 or more minutes before bed, child-directed bedtime routine, and dimming the lights in the house slightly. Relaxation practices such as calming aromatherapy and progressive muscle relaxation may be an enjoyable part of the bedtime routine.
Aromatherapy is the use of essential oils for a therapeutic purpose. Certain essential oils such as bergamot, orange, and lavender are often used for relaxation and stress management.16 Studies on efficacy are mixed.17 Orange essential oil has been shown to have a measurable effect on anxiousness in children with one study showing a decrease in salivary cortisol in children who are undergoing dental procedures.18 A recent study of 20 women, who were university students, demonstrated that nasal inhalation of rose or orange oil induced a decrease in oxyhemoglobin concentration in the right prefrontal cortex and a subjective increase in comfortable and relaxed feelings.19 Limitations of the study include lack of blinding of the participants.
Progressive Muscle Relaxation and Biofeedback
Progressive muscle relaxation consists of isolating a muscle group at a time and allowing 8 to 10 seconds of tension, allowing the muscle group to relax, and then moving on to the next. Children can be taught this technique in the office and if the session is recorded, they can listen to the recording as a refresher prior to going to bed as an aid to sleep. Progressive muscle relaxation can be used for stress management and has been used in the treatment of anxiety.20 Progressive muscle relaxation can be used as a standalone treatment or with biofeedback. Another approach to biofeedback is to have the patient practice deep breathing while connected to a monitor that gives them real-time feedback to help them learn to better control the responses of the autonomic nervous system, thereby reducing stress and anxiety.
Botanical and Supplements
The most commonly used complementary health approaches by children are natural products defined as nonvitamin, nonmineral dietary supplements.21 Chamomile, lemon balm, and fennel are herbal supplements that have a wide safety margin and are generally well tolerated. Fennel is often used to ease digestion or as a component of some of the over-the-counter colic remedies such as gripe water for babies. Fennel may also have anti-anxiety properties based on the results of in vivo and in vitro animal studies.22 There are several studies that lend evidence to chamomile having efficacy in generalized anxiety disorder with the primary adverse effects being lingering herbal taste or drowsiness.23 Cautions for chamomile use include those with allergies to related plants such as ragweed and possible interactions with cyclosporine and warfarin.
Jon Kabat-Zinn, the founder of Mindfulness Based Stress Reduction (MBSR), defined mindfulness as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.”24 Anyone who has seen a child intently focus on a toy, ignoring the world around them has witnessed the ability of children to remain focused in chaos. Mindfulness can be taught to young children25 and there are online resources26 for families that explain mindfulness in developmentally appropriate ways. MBSR has been adapted for anxiety management in children as young as age 7 years.27 In addition to the promise that mindfulness holds as a standalone intervention, mindfulness and hypnosis have been successfully combined for anxiety management and this is an area that would benefit from additional study.28
For procedural-related anxiety as well as pain there is increasing interest in the use of virtual reality. Virtual reality is an artificially created three-dimensional environment that is typically computer generated. This immersive experience places users in a virtual world with which they are encouraged to interact. Recent studies show that passive distraction, active distraction, and virtual reality can all modulate the anxiety and pain experience.29
Daylight lamps or light boxes are often prescribed for seasonal affective disorder as well as other conditions to help ease symptoms. It is now known that learning and mood can be affected by light and that there is a dedicated area of the brain that mediates that effect in vivo. This area is found within the hypothalamus.30 Although more research is needed, bright light therapy has been shown to significantly reduce symptoms of anxiety and depression in those with epilepsy.31 When using a light box some find that symptoms improve in a few days and for other it may take weeks. Typical recommendations are for 2,500 lux light box for approximately 1 hour or more or a higher intensity light for 20 to 30 minutes per day.32 It is important to note that while it is necessary for the light to hit the retinas, it is imperative that the patient be advised not to look directly into the light as it might damage the eyes. Side effects are minimal and usually short lasting and may include eyestrain, headache, or nausea.33 It is also possible that in people with bipolar disorder, light therapy may trigger mania.34,35
Stress and anxiety are prevalent in both the pediatric and adult population. Parental anxiety may predict how children respond to stress. A detailed history including family stressors are an important component of the evaluation. Early detection and treatment can help avoid some of the later sequela and impact of chronic stress and anxiety.
- Kessler RCHarvard Medical School. National Comorbidity Survey: Adolescent Supplement (NCS-A), 2001–2004. https://www.icpsr.umich.edu/icpsrweb/HMCA/studies/28581. Accessed May 22, 2019.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Arlington, VA: American Psychiatric Publishing; 2000.
- Pine DS, Cohen P, Gurley D, Brook J, Ma Y. The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry. 1998;55(1):56–64. doi:. doi:10.1001/archpsyc.55.1.56 [CrossRef]
- Woodward LJ, Ferguson DM. Life course outcomes of young people with anxiety disorders in adolescence. J Am Acad Child Adolesc Psychiatry. 2001;40:1086–1093. doi:. doi:10.1097/00004583-200109000-00018 [CrossRef]
- Merikangas K, He J, Burstein M. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980–989. doi:. doi:10.1016/j.jaac.2010.05.017 [CrossRef]
- Ginsburg GS, Riddle MA, Davies M. Somatic symptoms in children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2006;45(10):1179–1187. doi:. doi:10.1097/01.chi.0000231974.43966.6e [CrossRef]
- Agency for Healthcare Research and Quality. Anxiety in children. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cer-192-revised-anxiety-report.pdf. Accessed May 15, 2019.
- Kondro W. FDA urges “black box” warning on pediatric antidepressants. CMAJ. 2004;171(8):837–838. doi:. doi:10.1503/cmaj.1041507 [CrossRef]
- Richards G, Smith A. Caffeine consumption and self-assessed stress, anxiety, and depression in secondary school children. J Psychopharmacol. 2015;29(12):1236–1247. doi:. doi:10.1177/0269881115612404 [CrossRef]
- Distelberg BJ, Staack A, Elsen KD, Sabaté J. The effect of coffee and caffeine on mood, sleep, and health-related quality of life. J Caffeine Res. 2017;7(2):59–70. doi:. doi:10.1089/jcr.2016.0023 [CrossRef]
- Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;3:CD004691. doi:10.1002/14651858.CD004691.pub2 [CrossRef].
- Hagan JF Jr, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017
- Martinsen EW. Physical activity in the prevention and treatment of anxiety and depression. Nord J Psychiatry. 2008;62(suppl 47):25–29. doi:. doi:10.1080/08039480802315640 [CrossRef]
- Brown WJ, Wilkerson AK, Boyd SJ, Dewey D, Mesa F, Bunnell B. A review of sleep disturbance in children and adolescents with anxiety. J Sleep Res. 2018;27(3):e12635. doi:. doi:10.1111/jsr.12635 [CrossRef]
- Leahy E, Gradisar M. Dismantling the bidirectional relationship between paediatric sleep and anxiety. Clin Psychol. 2012;16:44–56. doi:. doi:10.1111/j.1742-9552.2012.00039.x [CrossRef]
- Stewart MT, Misra SM, Weydert JA, et al. Integrative therapies to support pediatric palliative care: the current evidence. Curr Pediatr Rep. 2018;6:150–157. doi:. doi:10.1007/s40124-018-0167-6 [CrossRef]
- Kiecolt-Glaser JK, Graham JE, Malarkey WB, et al. Olfactory influences on mood and autonomic, endocrine, and immune function. Psychoneuroendocrinology. 2008;33(3):328–339. doi:. doi:10.1016/j.psyneuen.2007.11.015 [CrossRef]
- Jafarzadeh M, Arman S, Pour FF. Effect of aromatherapy with orange essential oil on salivary cortisol and pulse rate in children during dental treatment: a randomized controlled clinical trial. Adv Biomed Res. 2013;2:10. doi:. doi:10.4103/2277-9175.107968 [CrossRef]
- Igarashi M, Ikei H, Song C, Miyazaki Y. Effects of olfactory stimulation with rose and orange oil on prefrontal cortex activity. Complement Ther Med. 2014;22(6):1027–1031. doi:. doi:10.1016/j.ctim.2014.09.003 [CrossRef]
- McClafferty H. Complementary, holistic, and integrative medicine: mind-body medicine. Pediatr Rev. 2011;32(5):201–203. doi:10.1542/pir.32-5-201 [CrossRef]
- Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL. Use of complementary health approaches among children aged 4–17 years in the United States: National Health Interview Survey, 2007–2012. Natl Health Stat Reports. 2015;78:1–19.
- Ghazanfarpour M, Mohammadzadeh F, Shokrollahi P, et al. Effect of Foeniculum vulgare (fennel) on symptoms of depression and anxiety in postmenopausal women: a double-blind randomised controlled trial. J Obstet Gynaecol. 2017;38:121–126. doi:. doi:10.1080/01443615.2017.1342229 [CrossRef]
- Short-term chamomile treatment for generalised anxiety disorder. Austral J Herbal Med. 2017;29(1):41.
- Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract. 2003;10(2):144–156. doi:. doi:10.1093/clipsy.bpg016 [CrossRef]
- Burke CA. Mindfulness-based approaches with children and adolescents: a preliminary review of current research in an emergent field. J Child Fam Stud. 2010;19:133–144. doi:. doi:10.1007/s10826-009-9282-x [CrossRef]
- Sesame Street in Communities. Breathe, think, do with Sesame. https://sesamestreetincommunities.org/activities/breathe-think-do/. Accessed May 22, 2019.
- Semple RJ, Reid EFG, Miller L. Treating anxiety with mindfulness: an open trial of mindfulness training for anxious children. J Cogn Psychother. 2005;19(4):379–392. doi:. doi:10.1891/jcop.2005.19.4.379 [CrossRef]
- Kaiser P, Kohen DP, Brown ML, Kajander RL, Barnes AJ. Integrating pediatric hypnosis with complementary modalities: clinical perspectives on personalized treatment. Children. 2018;5(8):e108. doi:. doi:10.3390/children5080108 [CrossRef]
- Arane K, Behboudi A, Goldman R. Virtual reality for pain and anxiety management in children. Can Fam Physician. 2017;63(12):932–934.
- Fernandez DC, Fogerson PM, Lazzerini O, et al. Light affects mood and learning through distinct retina-brain pathways. Cell. 2018;175(1):71–84. doi:. doi:10.1016/j.cell.2018.08.004 [CrossRef]
- Baxendale S, O'Sullivan J, Heaney D. Bright light therapy for symptoms of anxiety and depression in focal epilepsy: randomised controlled trial. Br J Psychiatry. 2013;202(5):352–356. doi:. doi:10.1192/bjp.bp.112.122119 [CrossRef]
- Huang SY, Sung HC, Su HF. Effectiveness of bright light therapy on depressive symptoms in older adults with non-seasonal depression: a systematic review protocol. JBI Database System Rev Implement Rep. 2016;14(7):37–44. doi:. doi:10.11124/JBISRIR-2016-002990 [CrossRef]
- Terman M, Terman JS. Bright light therapy: side effects and benefits across the symptom spectrum. J Clin Psychiatry. 1999;60(11):799–808. doi:10.4088/JCP.v60n1113 [CrossRef]
- Chan PK, Lam RW, Perry KF. Mania precipitated by light therapy for patients with SAD. J Clin Psychiatry. 1994;55:454
- Schwitzer J, Neudorfer C, Blecha HG, Fleischhacker WW. Mania as a side effect of phototherapy. Biol Psychiatry. 1990;28(6):532–534. doi:10.1016/0006-3223(90)90489-O [CrossRef]